■r<hxe i-7^"'
<•>>.*.-:*::
w
■&& 
SINUIVJ3VH  J(_( AOVOSII IVrJUUVIN
JIU3"  3VJ  AOVOMII  IVINUI1VIN      jmjlUi»V  JU  A3VaUI
  H080T.I£0t>
&S8SM oox r/w
NLM052012356 
JINIJIUiW i\J AOVOOI
iNijiuin su Aavaoii ivrNuuviN     jNijiuirv JU AavaHIl TVNOUVN
3NI3IQ3W jo Aavaan tvnouvn
3NiDia3w jo Aavaan tvnouvn
3NOia3w jo Aavaan tvnouvn 
 
GENITO-URINARY SURGERY
AND
VENEREAL  DISEASES.
               BY

      J. WILLIAM WHJXE, M.D,
   PROFESSOR OF CLINICAL SURGERY, UNIVERSITY OF PENNSYLVANIA,
               AND
       EDWAED MARTIN, M.D,
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES, UNIVERSITY OF PENNSYLVANIA.
ILLUSTRATED WITH TWO HUNDRED AND FORTY-THREE ENGRAVINGS
          AND SEVEN COLORED PLATES.
         \  .....   __^ '


       PHILADELPHIA :
 J. B. LIPPINCOTT COMPANY.
London : 6 Henrietta Street, Covent Garden.
         1897. 
P\ v\ vn C/ /y-


    \<o^n
    Copyright, 1897,
          BY
J. B. Lippincott Company. 
PREFACE.
   In the preparation of this work we have  endeavored to present
clearly and with sufficient detail  the generally accepted teachings of
the day in regard to the pathology, symptomatology, diagnosis, and
treatment of syphilis and genito-urinary diseases.
   We have exercised the author's right of choice in  estimating  the
comparative value of various methods of treatment, and have given
chiefly those which our experience has led us to prefer, though alter-
native methods are usually mentioned.   As it was our wish to make
this book one of practical use to the physician, much space has been
devoted to symptomatology, diagnosis, and  treatment.  The  patho-
logical alterations characteristic of the diseases and injuries described
have  been briefly outlined, avoiding discussion of questions still  un-
settled.  Historical considerations  have been abbreviated as much as
possible, and references have been omitted, though proper credit has
been given for special methods or teachings.
   Emphasis has been laid upon genito-urinary antisepsis and  the
details of  operative and  manipulative technique, since thorough  un-
derstanding of these matters must form  the  foundation for all good
work in genito-urinary surgery.
   The modern methods of examination of the various portions of the
urinary and genital systems have been described with fulness, since
only upon familiarity with them  can exact diagnosis and scientific
therapeutics be based.
   We have included an exceptionally comprehensive study of the
changes in the urine  and  its constituents produced by disease, a sub-
ject so intimately connected with the specialty to which this work is
devoted as to  deserve much more attention  than it usually receives
in surgical text-books.
                                                          iii 
iv                          PKEFACE.
    While we  have freely discussed  established facts relating to the
recognition or treatment of disease or injury, and important theories
bearing on questions of surgical therapeutics, we have  tried to avoid
the confusion  which is  apt to result from the  effort to  be encyclo-
paedic.  Our views have been put in such form as to be of practical
use to the general practitioner and the medical  student, since we feel
that our experience as hospital  surgeons and  as teachers  during  a
number of years has familiarized us with their needs.
    We must acknowledge our indebtedness to the many writers of
text-books on this subject, and  especially to Guyon, Fournier, and
Finger.
    We must also express our thanks to Dr. G.  H. Fox for placing at
our disposal his admirable collection of photographs, to Mr. Joseph
McCreery for his aid  in  the correction of the proofs, to  Mr. Samuel
Macmeney for much kindness in  seeing the book through  the press,
and to Mr. G. E. H.  Weaver for preparation of the index.
                                             J. William  White.
                                             Edward Martin.
    Philadelphia, January, 1897. 
CONTENTS.
                           CHAPTER   I.
                  diseases  and  injuries of the  penis.
                                                                    PAGE
Anatomy of the Penis—Anomalies of the Penis—Anomalies of the Prepuce
    —Narrowing of the Preputial Orifice—Phimosis.—Injuries of the
    Penis—Contusion—Wounds of the Penis—Fracture of the Penis—Dis-
    location of the Penis.—Inflammatory Affections of the Penis—
    Acute Inflammation of the Penis—Chronic Inflammation of the Erectile
    Tissue—Inflammatory Lymphangitis—Balanitis and Balanoposthitis—
    Herpes Progenitalis.—Tumors of the  Penis—Cysts, Fibroma, Angi-
    oma, etc.—Lymphangioma or Elephantiasis—Verruca? or Papillomata—
    Horny Growths of the Penis—Malignant Disease..........1-45

                          CHAPTER   II.
                injuries and diseases of the urethra.
Anatomy of the  Urethra—Malformations of the Urethra—Hypospadia—
    Epispadia.—Injuries of the  Urethra—Bupture of the  Urethra.—
    Foreign Bodies in the Urethra.—Urethral Calculi.—Urethros-
    copy—Appearance of the Urethra................46-88

                          CHAPTER  III.
                              GONORRH(EA.
Typical Acute  Gonorrhoea of the Male Urethra—Subacute or Catarrhal Gon-
    orrhoea—Irritative or Abortive Gonorrhoea—Non-Specific  Urethritis—
    Acute Posterior Urethritis—Treatment of Acute Gonorrhoea in the Male
    —Systematic Treatment of Acute Gonorrhoea.—Chronic Urethritis—
    Chronic Anterior Urethritis—Chronic Posterior Urethritis.....89-143

                          CHAPTER   IV.
                         GONORRHOEA IN WOMEN.
Frequency of  the Disease—Seat of Infection—Contagion.—Urethritis—
    Acute  Urethritis—Chronic   Urethritis—Vulvitis.—Bartholinitis—
    Acute  Bartholinitis—Chronic Bartholinitis.—Metritis—Acute Metritis
    —Gonorrhoeal Salpingitis and Oophoritis—Perimetritis.—Vaginitis.—
    Gonorrhoea in  Children—Catarrhal Vulvo-Vaginitis—Gonorrhoeal
    Vulvo-Vaginitis—Gonorrhoea of the Hectum...........144-160
                                                                 v 
VI
CONTENTS.
                            CHAPTER  V.
                      COMPLICATIONS  OF GONORRHOEA.
                                                                      PAGE
 Balanitis and  Balanoposthitis—Phimosis—Paraphimosis—Lymphangitis
    Lymphadenitis or  Bubo—Follicular and Periurethral Abscess—Cow-
    peritis — Prostatitis —Vesiculitis — Epididymitis — Cystitis—Ureteritis,
    Pyelitis, and Nephritis.—Gonorrhoea of the Eye—Gonorrhoeal Con-
    junctivitis—Non-Specific  Gonorrhoeal  Conjunctivitis.—Gonorrhoeal
    Rheumatism—Arthritis—Gonorrhoeal Tenosynovitis......161-192

                          CHAPTER  VI.
                       STRICTURE OF THE URETHRA.
 Inflammatory Stricture—Spasmodic Stricture—Organic Stricture—Location
    of Stricture—Changes  in  the  Urethra.—Symptoms of Stricture—
    Subjective  Symptoms—Objective Symptoms.—Results of Stricture-
    Extravasation of Urine—Effects on  the Bladder—Ureters—Kidneys.—
    Treatment of Organic Stricture—Gradual Dilatation—Cleansing
    of Instruments—Cleansing of the Urethra—Passing  of the  Sound—
    Strictures of Small  Calibre.—Urethrotomy—Internal Urethrotomy—
    External Perineal  Urethrotomy—Miscellaneous Methods.—Summary
    of Treatment.—Stricture of the  Female Urethra—Spasmodic
    Stricture—Inflammatory Stricture—Organic Stricture.......193-251

                          CHAPTER  VII.
                          URETHRAL  FEVER, ETC.
Urethral Fever—Acute  Urinary Fever—Chronic Urinary Fever.—Fistula
    of the Urethra—Urethro-Bectal Fistula—Urethro-Perineo-Scrotal
    Fistula — Urethro-Penile Fistula.— Urethral  Pouches.— Urethral
    Vegetations.—Tuberculosis of  the Urethra.—Cancer of the
    Urethra.—Cysts  of  Cowper's Glands.—Cancer of  Cowper's
    Glands.—Care of Urethral Instruments..........252-272

                         CHAPTER  VIII.
                               CHANCROID.

Cause — Inoculability—Frequency—Localization— Pathology—Clinical As-
    pects.—Complications of Chancroid—Phimosis—Paraphimosis—
    Gangrene—Phagedaena — Lymphangitis — Bubo or  Lymphadenitis.—
    Treatment of Chancroid—Dry  Dressings—Wet Dressings—Antisep-
    tic Ointments—Cauterization—Operation—Treatment of the Complica-
    tions of Chancroid  .....................    273-297

                          CHAPTER  IX.
                                SYPHILIS.

Immunity against Syphilis—Syphilitic Beinfection—Contagion of Syphilis__
    Methods of Contagion—Types of Syphilis—Periods of Syphilis__Period
    of Primary Incubation.—Period of Primary Lesion—Induration.__. 
CONTENTS.
vii
    Genital Chancre—Varieties of the Genital Chancre —Complications of
    Chancre—Diagnosis—Differential Diagnosis—Concealed Genital Chan-
    cres—Urethral  Chancre.—Extragenital  Chancre—Chancres of the
    Head and Face—of the Lip—of the Tongue—of the Tonsils and Fauces
    —of the Breast—of the Anal Begion—of the Extremities—Vaccination
    Chancre.—Prognosis of Chancre—Primary Lymphatic Involvement
    —Syphilitic Lymphangitis—Syphilitic Lymphadenitis or Bubo—Period
    of Secondary Incubation....................298-331

                           CHAPTER  X.
 CONSTITUTIONAL SYPHILIS--THE SYPHILIDES--SYPHILIS OF THE ALIMENTARY
                                 CANAL.
Constitutional Syphilis—Alteration  in  the Blood—Period of  Secondary
    Lesions—Enlargement of Lymphatic Glands not anatomically connected
    with the  Chancre—Syphilitic Fever—Syphilitic Neuralgia—Syphilitic
    Eruptions of the Skin and the Mucous Membranes—Syphilitic  Involve-
    ment of the Viscera—Syphilitic  Disturbances of the Nervous System—
    Syphilitic Involvement of the Bones, Joints, and Tendinous  Sheaths.—
    Syphilitic  Skin  Eruptions—Erythematous   Syphilide—Papular
    Syphilide—Vesicular Syphilide—Pustular Syphilide—Pigmentary Syphi-
    lide—Tubercular  Syphilide—Non-Ulcerating  Tubercular Syphilide—
    Bullous Syphilide—Gummatous Syphilide.—Syphilitic Affections of
    the Appendages of the Skin—Syphilitic Alopecia and Onychia.—
    Syphilitic Lesions  of the Mucous  Membrane—Erythematous
    Syphilide—Papular Syphilide—Gummata—Syphilis of the Tongue—of
    the Palate—of  the Pharynx—of the (Esophagus, Stomach,  and Intes-
    tines—of the Bectum and Anus.................332-385

                          CHAPTER  XI.
SYPHILIS OF THE NERVOUS SYSTEM--OF THE EYE--OF THE RESPIRATORY TRACT.
Cerebral Syphilis.—Syphilis of the Spinal Cord.—Syphilis of the
    Nerves.—Syphilis of the Eye—Syphilis of the Lachrymal Apparatus
    —Syphilitic Affections of the Cornea—Syphilis of the Sclera—of the
    Iris—of the Ciliary Body—of the Choroid, Betina, and Optic  Nerve—
    Atrophy of the Optic  Nerve—Syphilitic Palsies of the External Ocular
    Muscles.—Syphilis of the  Ear.—Syphilis of  the Respiratory
    Tract—Syphilis of the Nose—of the  Nasal Cavities—of the Larynx—
    of the Lungs.........................386-419

                         CHAPTER   XII.
SYPHILIS  OF  THE BONES   AND  JOINTS—OF  THE MUSCLES--OF  THE CIRCULA-
    TORY SYSTEM—OF THE LYMPHATIC SYSTEM—OF  THE ABDOMINAL VISCERA
    —OF THE GENITO-URINARY  ORGANS.
Osteoperiostitis—Barefying Ostitis—Gummatous  Periostitis,  Ostitis, and
    Osteomyelitis—Osteosyphilosis  of  the Cranium—Vertebrae—Tibia—
    Phalanges.—Syphilis of the  Joints—Arthralgia—Synovitis—Gum- 
1                          CONTENTS.
                                                                PAGE
matous Arthritis—Bursitis.—Syphilis of the Muscles—Acute Irri-
tative Myositis—Chronic Interstitial  Myositis—Gummatous Myositis—
Syphilitic Tenosynovitis.—Syphilis  of the Circulatory System-
Heart—Arteries—Veins.—Syphilis of the Lymphatic  System.—
Syphilis of the Liver—Precocious Syphilis of the Liver—Tertiary
Syphilis of the Liver.—Syphilis of  the Spleen.—Syphilis of the
Pancreas.—Syphilis of  the  Uro-Genital  System—Kidneys-
Ureters  and  Bladder—Epididymis and Testicles—Syphilitic Epididy-
mitis—Syphilitic Orchitis—Syphilis of the  Vasa Deferentia, Seminal
Vesicles, Prostate, Urethra, and Erectile Bodies of the Penis.—Syphilis
of the Ovaries, Uterus, Vagina, and Vulva.—Syphilis of the
Mammary  Gland.....................420-450
                        CHAPTER  XIII.

              SYPHILITIC  HEREDITY--HEREDITARY  SYPHILIS.

Descent  from the  Father—Descent from  the Mother—Mixed Heredity—
    Direct Infection—Period of Syphilitic Heredity—Conceptional Syphilis
    —Syphilis and Marriage—Prognosis of Syphilitic Heredity.—Heredi-
    tary Syphilis.—Skin  and Mucous  Membrane Lesions  of
    Hereditary Syphilis—Erythematous (Boseola) Syphilides—Papular
    Syphilides and Mucous Patches—Vesicular Syphilide—Pustular Syphi-
    lide—Bullous  Syphilide—Tubercular  and  Gummatous  Syphilides—
    Lesions of the Mucous  Membrane.—Hereditary Syphilis affecting
    the  Eye, Ear, Teeth, Bones, and Joints—Syphilitic Dactylitis.—
    Hereditary  Syphilis affecting the  Lymphatic Glands,  the
    Nerve-Centres, and Nerves—Brain—Spinal Cord.—Hereditary
    Syphilis affecting the Viscera—Lungs—Liver—Spleen—Pancreas
    —Intestines—Kidneys.—Hereditary Syphilis affecting the Testi-
    cles.—Diagnosis of Inherited Syphilis  ........... 451-482
                        CHAPTER  XIV.

                      THE TREATMENT OF SYPHILIS.

Prophylactic  Treatment.—Abortive Treatment—Excision or De-
    struction of the  Chancre—Constitutional Abortive Treatment.—Con-
    stitutional Treatment of Syphilis—Modified Expectant Treatment
    — Interrupted  Treatment — Continuous  Treatment. — Systematic
    Treatment—Systematic Treatment by Iodides—Toxic Effects of Mer-
    cury—Hydrargyrism—Toxic Effects of the Iodides—lodism.—Methods
    of giving Mercury—Mouth Administration—Hypodermic Injections
    —Vaporization—Mercuric  Baths, Thermal Springs, and  Heat__Electric
    Baths—Intravenous Injection of Mercury—Elimination of Mercury__Use
    of Iodides in Syphilis—Serum  Treatment.—Local Treatment  of
    Syphilis.—Treatment of Hereditary Syphilis.......4j 
CONTENTS.
ix
                         CHAPTER   XV.
                INJURIES  AND  DISEASES  OF THE  BLADDER.
                                                                   PAGE
Anatomy.—Malformations and Malposition of the Bladder—Multi-
    ple  Bladder—Complete Absence of the  Bladder—Exstrophy—Patent
    Urachus—Hypertrophy  of the Bladder—Atrophy of  the  Bladder—
    Hernia of the Bladder.—General Symptomatology of  Diseases
    of the Urinary Tract—Pain—Frequency of Urination—Alterations
    in the Stream—Suppression of Urine—Betention of Urine.—Retention
    of Urine from  Prostatic Enlargement.—Retention  of  Urine
    from  Stricture.—Incontinence of  Urine—Incontinence without
    Lesions of the Urinary Tract—Incontinence with Lesions of the Urinary
    Tract.—Haematuria.—"Wounds, Contusion, and Rupture  of the
    Bladder...........................539-613

                         CHAPTER  XVI.
                      EXAMINATION OF  THE URINE.
Alterations in the Quantity of Urine—Alterations in the Specific Gravity—
    Alterations in  Color—Alterations in Beaction—Quantitative  Altera-
    tions of Normal Constituents—Chlorides—Sulphur—Phosphates—Car-
    bonates—Urea—Uric Acid—Oxalic  Acid.—Abnormal Substances
    in the  Urine—Serum-Albumen—Globulin—Albumoses—Haematuria
    —Haemoglobinuria — Carbohydrates — Choluria—Lipuria—Chyluria.—
    Sediments in the Urine—Blood—Pus—Urinary Casts—Spermatozoa.
    —Crystalline Sediment of Acid Urine.—Sediment of Alkaline
    Urine............................614-643

                        CHAPTER  XVII.
                CYSTITIS—VESICAL TUBERCULOSIS—FISTULA.
Cystitis—Superficial or Catarrhal Cystitis—Interstitial Cystitis—Membranous
    Cystitis—Gangrenous  Cystitis.—Perivesical  Inflammation — Peri-
    vesical Abscess.—Tuberculosis of the  Bladder.—Fistula  of the
    Bladder...........................644-671

                       CHAPTER  XVIII.
                       CALCULUS OF  THE  BLADDER.
Litholapaxy—Litholapaxy in Children.—Lithotomy—Perineal  Lithot-
    omy — Median  Lithotomy — Medio-Bilateral Lithotomy — Suprapubic
    Lithotomy.—Foreign Bodies in the Bladder.........672-715

                         CHAPTER  XIX.
                     CYSTOSCOPY--VESICAL TUMORS.
Cystoscopy—Cystoscopic Diagnosis.—Tumors of the Bladder—Papil-
    loma — Myxoma — Fibroma — Myoma — Sarcoma — Carcinoma—Cystic
    Tumors of the Bladder—Paravesical Tumors...........716-739 
x
CONTENTS.
                          CHAPTER  XX.
                DISEASES  AND INJURIES OF  THE URETERS.
                                                                     PAGE
Anatomy—Anomalies—Wounds and Bupture of the Ureters—Ureteritis—
    Stricture of the Ureter—Calculus of the Ureter—Fistula of the Ureter-
    Tuberculosis of the  Ureter—Tumors of the  Ureter—Prolapse of the
    Ureter............................740-763

                         CHAPTER  XXI.
                INJURIES  AND DISEASES  OF  THE KIDNEYS.
Surgical Anatomy—Anomalies of the Kidney—Floating Kidney—Movable
    Kidney.—Injuries  of  the Kidney—Contusion of  the  Kidney—
    Wounds of the Kidney—Nephrectomy..............764-791

                        CHAPTER   XXII.
                             KIDNEY  CALCULI.
Uric Acid Calculi—Phosphatic  Calculi—Oxalate Calculi—Cystin Calculi—
    Xanthin Calculi—Calcium Carbonate Calculi—Nephrolithotomy   .  .  792-804


                        CHAPTER  XXIII.
                 SUPPURATIVE DISEASES  OF THE  KIDNEY.
Pyelitis—Pyonephrosis—Suppurative Nephritis—Perinephritis.....805-827

                        CHAPTER   XXIV.
 HYDRONEPHROSIS—RENAL  TUBERCULOSIS—RENAL  FISTULA--PARASITES AND
                                TUMORS.
Congenital Hydronephrosis—Acquired Hydronephrosis.—Tuberculosis of
    the Kidney—Acute Benal Tuberculosis—Chronic Benal Tuberculosis.
    —Renal Fistulse.—Neoplasms of the Kidney—Epithelial  Tumors
    —Tumors of Connective-Tissue Origin.—Cysts of the Kidney—Sim-
    ple  Cysts—Agglomerated Cysts.—Parasites of the Kidneys—Echi-
    nococcus.—Suprarenal Capsules...............828-851

                        CHAPTER  XXV.
         INJURIES  AND DISEASES  OF THE  SCROTUM  AND  TESTICLES.
Anatomy.—Diseases of the Scrotum—Deformities—Injuries of the Scro-
    tum—Wounds of the Scrotum—CEderna of the  Scrotum—Emphysema__
    Cutaneous Affections of  the Scrotum—Gangrene of the Scrotum__Ele-
    phantiasis—Tumors of  the Scrotum.—Anomalies of the Testicle
    —Number—Size—Migration—Inversion  of  the Testicle__Luxation of
    the Testicle—Torsion of  the Testicle.—Contusions and "Wounds of
    the Testicle—Contusion—Epididymo-Orchitis from Strain__Wounds
    of the Testicle.—Inflammation of the Testicle—Urethral  Epididy-
    mitis—Epididymo-Orchitis  complicating Acute Infectious Diseases__ 
CONTENTS.
XI
    Abscess of the Testicle.—Fungus or Hernia  of the Testicle.—
    Tubercular Disease of the Testicle—Syphilis of the Testicle and
    Epididymis.—Tumors  of the Testicle—Carcinoma—Sarcoma—Cys-
    toma — Enchondroma — Lymphadenoma—Fibroma—Dermoid Cysts—
    Myxoma, Osteoma, and  Myoma.—Castration.—Hydrocele.—Acute
    Hydrocele.—Chronic Hydrocele—Hydrocele  of the Tunica  Vagi-
    nalis Testis—Congenital Hydrocele—Infantile Hydrocele—Inguinal Hy-
    drocele—Fatty Hydrocele—Encysted Hydrocele of the Epididymis and
    Testis.—Hydrocele of the Cord—Acute Hydrocele of the Cord—Dif-
    fuse Hydrocele of the Cord.—Hematocele—Hannatocele of the Tunica
    Vaginalis—Chronic  Hematocele  of  the  Tunica  Vaginalis—Encysted
    Hematocele of the  Testis—Intratesticular Haematocele—Hematocele
    of the Cord—Loose Bodies  in the Tunica Vaginalis.—Neuralgia of
    the Testicles........................852-937

                       CHAPTER  XXVI.
 INJURIES AND  DISEASES OF THE SPERMATIC  CORD  AND SEMINAL  VESICLES.
Contusions and Wounds of the Cord—Wounds of the  Cord—Inflammation
    of the Cord—Tumors of  the  Cord.—Seminal Vesicles—Anomalies
    of the Seminal Vesicles—Injuries of the  Seminal Vesicles—Vesiculitis
    or Spermatocystitis—Cystic Swelling of the Seminal Vesicles—Spermato-
    Cystic Concretions—Tuberculosis of the  Seminal  Vesicles—Malignant
    Growth...........................938-955

                       CHAPTER  XXVII.
                INJURIES  AND  DISEASES OF THE PROSTATE.
Anatomy of the Prostate.—Contusions and "Wounds of the Prostate
    —Contusion of the Prostate—Wounds of the Prostate.—Prostatitis—
    Chronic Prostatitis—Irritable Prostate.—Tuberculosis of the Pros-
    tate.—Enlargement of the Prostate.—Treatment of Enlarged
    Prostate—Hygienic Treatment — Medicinal Treatment — Mechanical
    Treatment — Operative  Treatment — Prostatotomy — Prostatectomy —
    Complications of Enlargement of  the  Prostate.—Atrophy of the
    Prostate.—Prostatic Calculi.—Malignant Tumors of the Pros-
    tate—Cysts of the Prostate.................956-1001

                       CHAPTER  XXVIII.
                    SEXUAL WEAKNESS  AND  STERILITY.
Mechanism of Erection—Organic Impotence—Psychical Impotence—Atonic
    Impotence — Genito-Urinary  Neuroses — Prostatorrhoea — Involuntary
    Seminal Emissions—Impotence in the  Female—Sterility .... 1002-1029

                       CHAPTER  XXIX.
                         PSYCHOPATHIA SEXUALIS.
Sexual Hyperaesthesia—Satyriasis and Nymphomania—Sexual Anaesthesia—
    Sexual Paresthesia.....................1030-1042 
 
LIST  OF* ILLUSTRATIONS.
                               PLATES.
FIGURE                                                                PAGE
  1. Double penis...........................    5
 12. Balanitis   ............................32
 13. Herpes of the glans........................32
 16. Epithelioma, ulcerating form....................42
 17. Epithelioma, vegetating form....................42
 58. Gonorrhoeal conjunctivitis.  Swelling of the lids and free discharge  .  .  186
 59. Gonorrhoeal conjunctivitis.  Infiltration of bulbar and palpebral  con-
       junctiva  ............................186
 91. Multiple chancroids of the coronary sulcus.............276
 92. Chancroid of labium major....................276
 93. Exulcerating or superficial chancroid................277
 94. Follicular chancroid  .......................277
 96. Phagedenic  chancroid.......................278
 9(L1.  Multiple chancroids.  (Fox.)   Colored...............278
 97. Chancroidal bubo.........................278
100. Chancre of the reflected layer...................307
101. Chancre of the meatus......................307
103. Chancre of the corona.   Colored..................309
106. Chancre of the tongue.   (Fox.)   ..................323
109. Erythematous syphilide.  (Fox.)..................343
110. Flat papular syphilide.......................344
111. Acuminated papular syphilide.   (Fox.)...............344
112. Acuminated papular syphilide.   (Fox.)...............345
113. Large flat papular syphilide. (Fox.)................345
114. Large flat papular syphilide. (Fox.)................345
115. Large flat papular syphilide....................345
116. Vegetations  and mucous patches about the vulva...........345
120. Large flat papular syphilide, showing scaling............346
122. Papulo-squamous syphilide.  (Fox.)................349
126. Papulo-squamous syphilide of the hand.  (Fox.)   Colored......350
127. Papulo-squamous syphilide of the palm.  (Fox.)   Colored......351
128. Papulo-squamous syphilide of the palm.  (Fox.)   Colored......351
129. Large pustular syphilide.  (Fox.)..................354
130. Pustulo-crustaceous syphilide.  (Fox.)   Colored...........355
133. Pustular syphilide (pustulo-crustaceous).  (Fox.)...........356
134. Pustular syphilide (pustulo-crustaceous).  (Fox.)...........356
135. Flat pustular and papulo-squamous syphilide............357
                                                                xiii 
xiv                    LIST OF ILLUSTRATIONS.
h'KH'RE                                                                     PAGE
l.'iS.l.  Tubercular syphilide.   (Fox.)  Colored..............-">-)^
141J.  Ulcerating tubercular syphilide.  (Fox.)  Colored..........361
1417>.  Squamous circinate syphilide.  (Fox.)  Colored..........361
142. Tubercular syphilide.   (Fox.)...................%&$
143. Tubercular syphilide.   (Fox.)...................363
144. Syphilitic rupia following the bullous syphilide...........363
166. Hypertrophy of the lateral lobes of the prostate.  (Watson.).....574
176. 1. Isolated  tubercle bacilli.  2.  Bacilli  grouped  in  fasciculi  (common
         grouping).  3. Fasciculation more marked.  4. Bacilli massed, show-
         ing curved and sigmoid grouping.  5. Bacilli irregularly massed.
         (Guyon.)...........................636
177. 1. Purulent urine containing a pure culture of colon bacillus (X 300).  2.
         The same (X 800).  3. Mixed infection, colon bacillus, and a small
         bacillus.  (Guyon.)......................636
178. 1. Mixed infection: acute  urethritis.   2. Mixed infection:  subacute
         urethritis.   3. Pseudo-gonococci  and  mixed infection:  subacute
         urethritis.   4. Subacute urethritis,  showing a common form  of
         saprophytic  micro-organism.  5. Subacute urethritis,  showing  a
         rare form of  saprophytic micro-organism.  (Guyon.).......636
179. 1. Irregular form of uric  acid.  2.  Calcium sulphate.   3. Bare forms of
         ammonio-magnesium  phosphate.   4.  Ammonio-magnesium  phos-
         phate (artificially precipitated).  5.  Cystin (artificially precipitated).
         6.  Urea nitrate (artificially precipitated).  (Guyon.)  .......64u
180. 1. Uric acid.  2. Sodium urate.  3. Calcium oxalate.  4. Acid calcium
         phosphate.    5. Ammonio-magnesium  phosphate.   6. Ammonium
         urate.   (Guyon.).......................641
193. Bladder distended........................706
U»4. Bladder distended and lifted upward by the rectal bag.  (Antal.)   .  .  .  706
195. Vesical calculus almost completely  filling an hypertrophied bladder  .  .  708
201. Smooth pedicled  epithelial growth.  Villous epithelioma.  Lobulated
       epithelioma.  (Albarran.)....................722
202. Myxosarcoma.   (Albarran.)....................723
203. Lobulated papilloma (epithelial cancer).  (Albarran.).........725
204. Carcinoma (epithelial cancer).   (Albarran.).............725
209. Kidneys occupying their normal position.  (Sappey.).........764
210. Longitudinal section of the kidney. (Sappey.)............764
211. Split kidney...........................765
212. Sinus of the kidney........................7(35
214. Bontgen ray shadowgraph showing calculus in the pelvis of the left kid-
       ney.   The renal artery and the colon are also shown........772
215. Various forms of  kidney-stone illustrating  the  irregularities  in  shape.
       (Torres.)............................793
244.4. Bilateral hypertrophy of the prostate.   (Watson.)..........971
245. Hypertrophy of the median lobe of the prostate.  (Watson)......971 
LIST OF ILLUSTRATIONS.                     xv
                               FIGURES.
FIGURE                                                                   PAGE
  2.  Application of forceps in circumcision...............  10
  3.  Appearance after first cut in circumcision..............  10
  4.  Trimming of  mucous membrane flaps in circumcision........10
  5,  Appearance after flaps have been trimmed in circumcision......  10
  6.  Insertion of first and second sutures in circumcision.........  11
  7.  Operation of  circumcision completed................  11
  8.  Paraphimosis...........................21
  9.  Beduction of  paraphimosis....................  22
 10.  Beduction of  paraphimosis....................  23
 11.  Osseous growth of the penis.   (Demarquay.)............30
 14.  Venereal warts..........................  39
 15.  Epithelioma.   (Demarquay.)....................42
 18.  Epithelioma with glandular involvement..............43
 19.  Cross-section  showing infiltration of an epithelioma.  (Demarquay.)  .  .  43
 20.  Forms of penile hypospadia.  (Kaufmann.).............52
 21.  Peno-scrotal hypospadia......................53
 22.  Penis straightened after transverse cut of lower surface........56
 23.  Transverse wound sutured longitudinally : glandular urethra formed .  .  56
 24.  Freshened  areas  and incisions made in forming glandular urethra.—
       Glandular urethra closed by sutures...............56
 25.  Formation of penile urethra....................57
 26.  Formation of penile urethra completed...............57
 27.  Glandular epispadia.  (Kaufmann.).................59
 28.  Usual form of epispadia......................60
 29.  Dolbeau's operation.—Formation  of abdominal,  urethral,  and scrotal
       flap ..............................61
 30.  Dolbeau's operation.—Flaps secured in place............62
 31.  Epispadia............................63
 32.  Formation of glandular urethra..................63
 33.  A. Outlining of flaps to form penile urethra.  B.  Cross-section of same  64
 34.  A. Flaps folded over and held in position by sutures.  B. Cross-section
       of same............................64
 35.  Transverse defect between penile and glandular  urethras; oblique in-
       cision through foreskin.  (Thiersch.)...............66
 36.  Foreskin brought up behind the glans ; line of sutures uniting freshened
       edges of transverse defect to foreskin.  (Thiersch.).........  66
 37.  Closing posterior defect.  (Thiersch.)................66
 38.  Suture of second flap.  (Thiersch.).................  66
 39.  Cured epispadia.   (Thiersch.)...................  67
 40.  Urethral forceps.........................78
 41.  Urethra]  calculi showing  segmentation...............79
 42.  Urethral calculi  showing mushroom shape.  Cross-section to exhibit
       lamination...........................80
 43.  Aero-urethroscope........................  82
 44.  Otis urethroscope.........................83 
xvj                    LIST  OF  ILLUSTRATIONS.
                                                                          PAGE
FIGURE
 45.  Gonococci.   (Guyon.).......................
 46.  Gonococci.   (Gunther.)......................   91
 47  Subacute gonorrhoea ;  pus ; epithelium ; mixed infection.   (Guyon.).  .   98
                                                                          111
 48.  Urethral syringe.........................X±A
                                                                          11 fi
 49.  Irrigating bag..........................X1D
 50.  Instillator............................134
 51.  Tommasoli's ointment-carrier....................13/
 52.  Prostatic dilator.........................139
 53.  Short straight bougie......................148
 54.  Gonorrhoeal phimosis.......................163
 55.  Bectal irrigator..........................173
 56.  Size  and relative position of the  testicle and epididymis in acute epi-
       didymitis...........................177
 57.  Epididymitis suspensory bandage..................180
 60.  Gonorrhoeal conjunctivitis passing into a panophthalmitis.......187
 61.  Linear strictures.........................197
 62.  Annular stricture.........................198
 63.  Tortuous stricture........................198
 64.  Traumatic stricture........................202
 65.  Cast  of the urethra........................209
 66.  Bougie a boule..........................210
 67.  Gauge for urethral instruments..................210
 68.  Filiform bougies.........................219
 69.  Tunnelled catheter........................220
 70.  Steel sound...........................220
 71.  Tip of catheter just entering the fixed curve of the urethra.  (Antal.)  .  222
 72.  Fixed urethral curve.......................223
 73.  Fixed curve of the urethra obliterated by the passage of a straight instru-
       ment.  (Antal.)  ........................223
 74.  Passing  the sound........................224
 75.  Passing  the sound........................225
 76.  Passing  the sound........................225
 77.  Passing  the sound........................226
 78.  Position of sound.........................226
 79.  Maisonneuve's urethrotome....................235
 80.  Teevan's urethrotome.......................235
 81.  Gross's urethrotome   .......................236
 82.  Otis's dilating urethrotome....................237
 83.  Gerster's urethrotome.......................237
 84.  Teale's probe-ended gorget....................939
 85.  Syme's grooved staff.......................239
 86.  Tunnelled catheter staff......................239
 87.  Wheelhouse's staff.....................        243
 88.  Closure  of  fistula......................        9(;2
 89.  Papilloma of the urethra...................      264
 90.  Sterilizing box for soft urethral instruments.............269
 95.  Indurated elevated chancroid................        o-g
 98.  Chancroidal phimosis....................        281
 99.  Chancroidal ulceration of an  incision of the  prepuce required  for the
       relief of phimosis....................        0qi 
                        LIST  OF ILLUSTRATIONS.                    xvii
FIGURE                                                                    PAGE
102.  Chancre of the coronary sulcus   ..................307
104.  Chancre of the lip........................321
105.  Chancre of the lip........................322
107.  Chancre of the tongue  ......................323
108.  Chancre of the hand.......................326
117.  Mucous patches of the lips   ....................345
118.  Mucous patches about the anus   ..................345
119.  Papular syphilide, showing papillary overgrowth...........346
121.  Syphilitic vegetations.......................347
123.  Papulo-squamous syphilide......-..............349
124.  Papulo-squamous syphilide.  (Fox.)................349
125.  Papulo-squamous syphilide of the hand.   (Fox.)...........350
131.  Pustular syphilide (pustulo-crustaceous).  (Fox.)   ..........355
132.  Pustular syphilide.   (Fox.)   ....................356
136.  Large, flat pustular syphilide (ecthyma).   (Fox.)...........357
137.  Serpiginous syphilide.  (Fox.)...................358
138.  Non-ulcerating tubercular syphilide.   (Fox.).............360
139.  Non-ulcerating tubercular syphilide.   (Fox.).............360
140.  Tubercular (squamous) syphilide.  (Fox.)..............361
145.  Gummatous syphilide.  (Fox.)...................364
146.  Single ulcerating gumma.....................365
147.  Ulcerating gummata becoming confluent.  (Fox.)..........365
148.  Multiple  gummata of the leg.  (Fox.)................366
149.  Sloughing gumma of the leg....................367
150.  Ulcerating gummata of the malleolar region.   (Fox.).........368
151.  Syphilitic alopecia following ulcerative lesions.  (Fox.)........370
152.  Gummatous ulceration destroying the nose.   (Fox.).........414
153.  Skull showing the results  of gummatous osteoperiostitis.......422
154.  Vault of the cranium exhibiting the results of gummatous osteoperiostitis  423
155.  Tubercular and gummatous ulceration of  hereditary syphilis.....461
156. Hereditary syphilis.   Cicatrices of fissured lips and gummata of the fore-
       head and orbit.  (De Schweinitz.)................481
157. Delations of the empty and of the full bladder to the peritoneum  .  .  .  540
158. Vesical triangle.  (Sappey.)....................542
159.  Day and night urinals.......................546
160.  Concentric hypertrophy of the bladder...............550
161. Areas of referred pain in  diseases of the  urinary tract, anterior surface.
       (Fenwick.)...........................556
162. Areas of referred pain in  diseases of the urinary tract, posterior surface.
       (Fenwick.)...........................556
163.  Tumor formed by the distended bladder...............565
164.  Hypertrophied bladder from urethral stricture............567
165.  Hypertrophy of the lateral and median lobes  of the prostate.   (Watson.)  574
167.  Soft rubber catheter........................577
168.  Olivary catheter.........................577
169.  Conical catheter.........................577
170.  Elbowed catheter.........................577
171.  Double-elbowed catheter.....................577
172.  Cylindrical catheter........................577
173.  Silver prostatic catheter......................578 
xvjij                   LIST OF  ILLUSTRATIONS.
                                                                          PAGE
FIGURE
174. Securing the catheter for continuous catheterization.........583
175. Securing the catheter for continuous catheterization.......-.  .  584
181. Stone-searcher..........................678
182. Thompson's stone-searcher....................6/8
183. Bigelow's lithotrite........................684
184. Weiss's lithotrite.........................684
185. Jaws of  Bigelow's lithotrite....................685
186. Bigelow's evacuator and tubes  ...................686
187. Uric acid calculus.   Exact size...................695
188. Uric acid calculus.   Exact size...................695
189. Lithotomy knife.........................698
190. Grooved lithotomy staff......................698
191. Stone forceps (curved)......................  698
192. Calculus scoop.........................  .  698
196. Cathcart's siphon drainage.....................710
197. Hook for the extraction of hair-pins from the female bladder.....715
198. Leiter cystoscope.........................  716
199. Cystoscope with the light and window on the outer aspect of the beak  .  717
200. Catheterizing cystoscope......................718
205. Thompson's forceps for removing vesical tumors...........731
206. Insertion of suture for ureteral anastomosis............745
207. Insertion of suture for ureteral anastomosis.............745
208. Ureteral anastomosis completed..................745
213. Benal pelvis dissected from the pyramids..............766
216. Left testis.  (Sappey.).......................853
217. Left testis.  (Sappey.).......................853
218. Lobules  of the  testis, the rete  vasculosum, the  efferent vessels, and  the
       epididymis.   (Sappey.).....................855
219. Efferent canal, etc.  (Sappey.)...................855
220. Dissection, showing seminal vessels and ampulle of the vasa.....856
221. Elephantiasis of the penis and scrotum, showing the result of operation  862
222. Tubercular  epididymitis.  (Monod and Terrillon.)..........893
223. Cancer of the right testicle.  (Monod and Terrillon.).........901
224. Lymphadenoma of the testicle (bilateral)..............905
225. Vertical  section of a hydrocele.  (Kocher.).............912
226. Vertical  section of a hydrocele, showing the testicle lying  below the cyst.
       (Kocher.)...........................914
227. Inguinal hernia with hydrocele.  (Kocher.).............915
228. Inguinal hernia invaginating the upper portion of the sac of a hydrocele.
       (Kocher.)...........................916
229. Tapping a hydrocele.......................916
230. Bilocular hydrocele.  (Beraud.)..................921
231. Congenital hydrocele with hernia   .................922
232. Intravaginal spermatocele.   (Hochenegg.)..............925
233. Encysted hydrocele (large cysts)..................926
234. Multilocular cyst of the epididymis.................926
235. Inguinal hernia, with hydrocele of the cord.  (Kocher.).......930
236. Lipoma of the cord.  (Pean.)...................939
237. Varicocele (Osborn) Monod and Terrillon..............94O
238. Dilatation of the veins in a marked case of varicocele.  (Kocher.) .      941 
LIST OF  ILLUSTRATIONS.
XIX
FIGURE                                                                    PAGE
239. Bight seminal vesicle, posterior surface, dissected out........945
240. Long section of dilated seminal vesicle.  (Sappey.).........945
241. Deferent canal and seminal vesicle.................946
242. Horizontal section of the bladder and seminal vesicles passing through
       the lower orifice of the ureters.   (Testut.)............946
243. Posterior urethra exposed by splitting its upper wall.........947
244. Separate tumors springing from  the  lateral  lobes  of  the prostate.
       (Watson.)...........................971
246. Hypertrophy  of the  median  and  one lateral  lobe  of  the prostate.
       (Watson.)..........................972
247. Bladder and prostate cut through longitudinally in the median line  .  .   973
248. Psychrophore..........................1016 
\ 
GENITO-URINARY  DISEASES
                           AND

                   SYPHILIS.
                      CHAPTER  I.

              DISEASES  AND INJURIES OF THE PENIS.

   Anatomy of the Penis.—The penis in size bears less constant
relation to general physical development than does any other organ
of the body.  Its  average length is about three inches when in the
flaccid condition and twice that when erect; its circumference when
it is flaccid averages about three inches.   It is made up in the main
of erectile tissue.  This is separated into three distinct compartments
by investments of tough fibrous  tissue.   The bulk of the penis  is
formed by the two corpora cavernosa lying side by side and  capped
by the glans, which is a continuation of the corpus spongiosum.  The
corpus spongiosum, much smaller in circumference than either of the
cavernous bodies, lies in the angle formed by their apposition, bearing
to them the relation that  a ramrod does to the barrels of a gun.
   The cavernous bodies arise from the tuberosity and ascending
ramus of the ischium on each  side, and pass  upward, forward, and
inward until they become closely apposed to each other beneath the
pubic symphysis.  They are then  continued forward, each in a fibro-
elastic sheath, which in  front  does  not form a complete partition
between the two.  They terminate in blunt extremities, which are
capped by the glans.
   The spongy body—composed of erectile tissue and also invested
by a fibro-elastic sheath—is made up of a central portion of com-
paratively small diameter, through which the urethra passes,  and of
two terminal  expansions, the  glans penis,  capping the  cavernous
bodies, and the bulb, lying in the angle formed by the two convergent
crura of the cavernous bodies, and attached  to the lower surface of
                                                    l 
2         GENITO-URINARY  DISEASES AND SYPHILIS.

the triangular ligament.  The flange-like expansion  at  the base of
the glans is  termed the corona, and the depression behind this  is
called the cervix, or coronary sulcus.
   In addition to the tough fibro-elastic sheath with which the spongy
and  cavernous bodies are  each supplied, there is a sheath, termed
Buck's  fascia, or the fascia of the penis, which binds  these  struc-
tures together.  This covers in the two rounded extremities of the
corpora  cavernosa and is  firmly attached to the base  of the glans
penis.   Passing  backward  as  a  complete investment of  the  body of
the penis, it is continuous  with the suspensory ligament above  and
with the deep layer of the superficial  fascia below.  Superficial to
this fascia lies an extremely loose layer of areolar tissue without fat,
containing a thin layer of muscular fibres.
   The thin movable skin covering  the  penis  is usually continued
forward  till  it partly  or  completely covers  the glans; it is  then
doubled back upon itself, is attached  to the cervix, and  is continued
forward over the glans penis till it joins the mucous membrane of the
urinary meatus.   This reduplication is termed the prepuce, or fore-
skin.   It passes  forward as a tough fibrous band, called  the frsenum,
from the lower central part of the coronary sulcus to just  beneath
the urinary meatus.  At the preputial orifice the subcutaneous layer
is especially well developed, often forming a tough fibrous ring.  The
inner surface of the prepuce and the  covering of the glans penis are
moist,  thin, and more like mucous membrane than like ordinary skin.
On the flange-like expansion of the glans, particularly on its  anterior
aspect, are placed the glands  of Tyson, which secrete a cheesy sub-
stance, termed smegma; this, when it undergoes decomposition, has
a characteristic offensive odor.
   The suspensory ligament of the penis is a strong, triangular, fibro-
elastic band attached to the front of the pubic symphysis and to the
two cavernous bodies at their  angle of junction.
   The muscles of the penis are the erector penis or ischio-cavernosus,
the accelerator urinae or bulbo-cavernosus, and the unstriped muscular
fibres  of the erectile tissues and of the urethra.
    The  erector  penis  muscles are  more  concerned in exercising
pressure upon veins, and thus increasing turgescence,  than in  me-
chanically altering the  position of the penis.  They arise  from the
ischiatic tuberosities and are inserted in the  lower side of the fibrous
sheath of the corpora cavernosa.
    The bulbo-cavernosi arise from the central perineal point, and,
passing upward and forward, encircle the bulb and posterior part of
the spongy body. The action of these muscles is to expel  by their 
DISEASES AND  INJURIES OF THE PENIS.
3
contraction  the  last drops of urine and to drive forward with force
the semen when it passes from the posterior urethra.
   The dorsal arteries of the penis,  two in number, run  forward
through the suspensory ligament on each side of the dorsal vein to
the glans and prepuce, also giving branches to the cavernous bodies.
The arteries of the corpora cavernosa give the main blood-supply to
the erectile  tissue of the  cavernous  bodies.  The artery of the bulb
gives  the  main blood-supply to the  corpus spongiosum.   All these
vessels  are  derived  from  the internal  pudic.   In addition, there is a
collateral  supply due  to  an  anastomosis of  the same vessels with
branches of the external pudic.
    The dorsal vein of the penis is the largest efferent vessel of this
organ;  it  passes backward in a groove  on the  dorsum of the penis
through the suspensory ligament and  into the prostatic plexus;  the
smaller veins nearly all pass backward, pouring their blood  into  the
same plexus.
    The nerves of the penis are derived from the internal pudic (the
dorsal nerve of  the penis) and from  the  hypogastric plexus (nervi
erigentes to the  erectile tissue).
    The lymphatics  pass  partly to the  inguinal region, particularly
those of the glans, the foreskin, the  surface of the penis, and the an-
terior part of the urethra, partly to the deep pelvic lymphatic system.
    The tensile strength of the penis, because of its tough fibrous in-
vestments, is sufficient  to  bear  the  entire  weight of the body.  The
fibrous  investment  of the blunt  extremities  of the two cavernous
bodies where  they are capped by the glans  delays, and sometimes
prevents,  the  backward  extension  of inflammatory  or infiltrating
processes, particularly cancerous infiltration, which primarily  involves
the glans.  This fibrous sheath, being a continuation of the deep layer
of the superficial fascia, also limits the forward  extension of urinary
and purulent infiltrations beneath this fascia, such infiltrations sparing
the glans.
    The free blood-supply to  the penis and  the rich innervation of the
organ insure rapid healing in case  of wounds, and justify conservative
treatment even though  it has been nearly  severed or extensively
crushed.
   The lymphatic vessels, passing as they do to the inguinal glands
and to  the  glands of the  pelvis, carry infection  in both  directions:
hence, for instance, in case of malignant disease with involvement of
the glands of  the groin,  removal of  the disease together with  the
enlarged inguinal glands gives no  assurance against  deep recurrence
of the growth. 
4          GENITO-URINARY  DISEASES  AND SYPHILIS.

   The lax vascular subcutaneous tissue readily becomes cedematous
either from local or from general causes, especially in the region of
the foreskin.
   The delicate  richly innervated skin is extremely sensitive to  irri-
tants.
   Anomalies  of the  Penis are  rarely  observed  unassociated
with other malformations.  A  large percentage of those thus afflicted
are mentally deficient.  The penis may be absent, concealed, minute,
gigantic, double,  twisted, or adherent.
   Absence  of the  Penis.—This anomaly  is practically unknown,
except in very young children afflicted  with other  and  more  pro-
nounced malformations,  such  as spina bifida, and hence  rarely sur-
viving any great length of time. Yet Demarquay quotes the case of a
patient who had  reached the  age of  twenty-seven when he sought
medical advice for the  relief of an acute orchitis.   The urethra opened
into  the anus, and there was  in the  perineum, just anterior to the
anus, a small wart-like projection of erectile tissue.  Venereal excite-
ment caused this tissue to become turgid, and, if sufficiently prolonged,
was followed by escape of semen through the urethra.
   Concealed  Penis.—Absence of the penis  may be seeming  only,
the organ being concealed beneath the surface.  In one such case an
incision freed  the organ and enabled  the infant, who was suffering
from retention of urine, to pass his water.
   Treatment of  the malformation is usually unnecessary, since con-
comitant deformities will  first require care.  When, however, there
is a chance for survival, opportunity should be taken to search  thor-
oughly for a concealed rudimentary penis.  This, if found, should be
dissected  free, and, by plastic operation, covered with integument
derived from the surrounding parts.
   Micropenis.—Arrested growth of an  otherwise perfectly  formed
penis is by no means uncommon, though  this rarely produces results
so marked that  the condition may be properly termed anomalous.
In general terms it may be stated  that a flaccid adult penis less than
two  inches in  circumference and  two and a half inches in length is
abnormal, though even in such a case  the  erectile tissue may be
dilatable to an unusual  degree, thus  making the organ  normal in
size when in a condition of physiological activity.  In some reported
cases the penis has varied in size from that of a quill  to that of the
last two joints of the  little finger.
   As  seen in adults, stunting of the penis  is perhaps more  com-
monly due to excessive masturbation  or to  other  causes  interfering
with development than to congenital defect. 
Fig. i.
Double penis.
 
 
DISEASES AND  INJURIES OF THE PENIS.
5
   Treatment.—A minute penis when observed at birth or shortly
after does  not require treatment, except for the  relief of preputial
adhesions or of tight phimosis, since the organ, as is  the case with
the testicles, may before puberty, or about this time, grow rapidly and
attain normal  dimensions.  A tight foreskin should be removed, and
any abnormal  condition interfering with local growth should be reme-
died.
   When the condition is observed soon after puberty or in the young
adult the prospect for ultimate growth is by no means hopeless.   In
these cases physiological activity of the part is at times followed by a
rapid growth till normal  size is reached.
   For the purpose of developing a stunted penis a suction apparatus
has been employed.   The penis is slipped into a large cylinder fitting
closely around the  root  of  the organ;  from this  cylinder the  air is
partly exhausted by means of a rubber bulb.  This causes congestion,
distention of the erectile tissue, and, it is asserted, permanent enlarge-
ment.   Such a treatment to be efficient would have to be long con-
tinued.
   Megalopenis.—As has already been observed, the size of the organ
bears no constant relation  to the size or strength of the individual.
In congenital  imbeciles it is often of unusual size,  and in dwarfs and
hunchbacks it is not uncommonly developed not only out of propor-
tion to the other parts of the organism, but  even beyond the average
for individuals of normal growth.  Hypertrophy  of the penis is  at
times an inconvenience, and may even be a source of danger, since
an excessive   development predisposes  to  abrasions  and fissures
through which inoculation with venereal diseases may occur.
   There is no surgical treatment for  this  affection, though by me-
chanical appliances  the interference with function may be partly or
completely obviated.
   Double Penis.—A few authentic cases illustrative of this anomaly
have been  reported.  The two organs are usually placed side by side,
and  there  are other evidences of  monstrosity by fusion.  In at least
two  reported cases each organ was functionally perfect. (Fig. 1.)
   Surgical treatment is not indicated.
   Torsion of the Penis, or a twisting of the penis on its long axis so
that the fraenum looks forward, is extremely rare, unless hypospadia
or other malformation  is present.  Urination and ejaculation of the
semen are not materially interfered with : hence treatment would be
indicated only from a cosmetic stand-point.
   Adherent Penis.—Rarely, as an isolated anomaly, the penis is found
adherent to the scrotum  through  nearly its whole extent.  This ma- 
6         GENITO-URINARY DISEASES AND SYPHILIS.

terially interferes with function, and, when the penis is of normal size
and not incurved, should be operated on as soon as it is discovered.
   The treatment consists in cutting through the skin  attachment of
the penis till the organ is entirely freed, providing for the  closure of
the raw surface by a plastic operation where necessary.
   Anomalies  of the Prepuce.—The foreskin may be absent, in-
completely developed, redundant, or adherent to the glans;  the pre-
putial orifice may be absent or extremely small; the fraenum may be
abnormally short.
   Absence  or incomplete  development  requires no  treatment, nor
does redundancy urgently demand surgical intervention, except where
it is complicated with phimosis and an irritated  or inflammatory con-
dition of the glans.
   Adhesions between the glans and the inner surface of the prepuce
are present in the  majority of infants.  At times such adhesions are
the result of a balanoposthitis;  they are usually congenital, and are
generally associated with phimosis.
   Adhesions may appear in the form of comparatively narrow bridles
or bands, or may involve broad areas.  Commonly the symphysis is
limited to the corona, and is so tight that in the operation for circum-
cision the line  of  adhesion  is frequently  taken for the normal line
along which the mucous membrane is reflected  behind the glans, and
thus the coronary sulcus is  not freed of the retained smegma usually
found here in such cases.   Exceptionally  the  whole  surface  of the
glans adheres to the foreskin, the lips of the meatus alone being free.
Adhesions between the foreskin  and  the glans sometimes  act as a
source of reflex irritation, causing nervous phenomena of a convulsive
or paralytic  type.   This  is, however, very exceptional, and probably
never occurs except when there are distinct local signs of irritation.
Children in whom the adhesions are tightest and most  extensive com-
monly exhibit a penis much below the average size.   In the adult such
adhesions, at least  as congenital  deformities, are rare, since the bond
of union is easily torn by slight mechanical interference.  Occasion-
ally the bands are  so tough that nothing short of an operation can
strip them.
   The treatment of adhesions between the glans and the foreskin is
in ordinary cases readily carried out.  Phimosis having been  relieved,
either by stretching the preputial orifice or by circumcision, the ad-
hesions between the two mucous surfaces of  the  foreskin  and the
glans can be stripped back by  firm sponging, or by the pressure of
the thumb-nail, or by blunt dissection, using the flat  end of a probe
for this purpose.  Sometimes rough handling is necessary before the 
DISEASES AND  INJURIES OF THE PENIS.
7
adhesions yield.  The stripping back should be  continued till the
coronary sulcus is freed through  its whole extent, usually exposing
a ring of smegma.   The  raw surfaces  resulting from this stripping
should be well coated with boric  ointment (acid, boric, si;  ung.
petrol, carbolat, 3i), when the prepuce  can be drawn forward again
if circumcision has not been performed.   Twice daily the  raw surfaces
should be exposed, washed with a mild antiseptic, and protected by
boric ointment.  In a week or ten  days  healing will be complete.
This  stripping operation  should be  conducted with  ordinary  anti-
septic precautions, since  death  from cellulitis has more  than  once
resulted when such  precautions were neglected.  Firm fibrous adhe-
sions require the use of the knife.
    Obliteration or occlusion of the preputial orifice may not be de-
tected directly after birth,  but  cannot  long escape attention,  since
failure to pass water and  the formation  of a tumor at the end of the
penis, due to distention of the preputial sac with urine, are certain to
be  noticed.   Demarquay, however, reports  a  case of four  months'
standing with a prepuce distended to the size of a bladder.
    The treatment is circumcision.
    Narrowing of  the Preputial Orifice—Phimosis.—The term
phimosis  implies that the preputial orifice is so narrowed  that the
foreskin  cannot be retracted behind the glans.  The orifice may be so
small that a probe will pass with  difficulty.  Phimosis may  be  tem-
porary or permanent.   In the former case it is  due to inflammatory
swelling  or infiltration; in the latter, to  congenital formation, or new
growth, or cicatricial contraction.
    Congenital Phimosis.—This condition is present in the great ma-
 jority of male infants at birth, and persists up to the fifth or seventh
year, at  which time  there usually  takes place distinct enlargement of
the preputial orifice, so that the foreskin  can be stripped back without
much difficulty.
    Phimosis when moderate in degree and not giving rise to  obstruc-
tion or inflammation occasions no symptoms.  Its complications are,
however, distressing, and  sometimes cause permanent  impairment of
health.
    The complications  of phimosis are :
    1. Those  due to local  irritation: i.e., balanitis, balanoposthitis,
adhesions, venereal warts, fissures.
    2. Those due to  obstruction: subpreputial calculi, retained secre-
tion, irritability of the bladder, hemorrhoids, hernia, and  dilatation of
the bladder, of the ureters,  and  of the kidney pelves.
    3. Those due to  reflex action:  retention or incontinence of urine, 
8         GENITO-URINARY  DISEASES AND SYPHILIS.

arrested development of the penis,  premature  sexual excitement,
seminal weakness, spastic palsies, simulated hip-joint disease, muscu-
lar incoordination, convulsions.
   Balanitis and balanoposthitis are caused by the decomposition of
the few drops of urine retained in the preputial sac.  This inflamma-
tion in its turn often gives rise to warts, fissures, or adhesions.
   As the  opening becomes narrower through continued irritation,
the salts of the urine are deposited and calculi may be formed.  If at
each act of micturition the prepuce " balloons," an unusual strain is
thrown on the bladder, which becomes irritable.
   The varied reflexes owe their existence  to  the exceedingly rich
nerve-supply of  the part.  When there are distinct evidences of local
irritation associated with symptoms of general nerve disturbance, the
possibility of a relation between the latter and the phimosis must be
carefully weighed.   This by no means implies that a phimosis which
excites  no  local symptoms can be regarded as surely the  exciting
cause of otherwise inexplicable nerve-storms.
   Acquired  Phimosis, when permanent, i.e., cicatricial,  differs from
the congenital form in that the redundant skin lying in front of the
preputial orifice  is usually wanting, and the latter is felt as a more or
less irregularly indurated band or circle, which instead of rolling back
on attempts  at  retraction  slowly  stretches, tightly  embracing  the
glans.
   When temporary,  acquired phimosis  is due to swelling, usually
inflammatory or congestive.
   Treatment.—Permanent phimosis, whether congenital or acquired,
should be treated by operation whenever it is responsible, for local or
reflex  symptoms.   As a prophylactic  against gonorrhoea, chancroid,
chancre, and cancer, the operation  is desirable, even when  the con-
dition excites no trouble.  The treatment  of temporary phimosis due
to inflammatory swelling will be described  when considering  the
various affections which may produce  this condition.
   The operation  of choice in phimosis is circumcision.  Incision of
the foreskin and stripping back will also relieve the condition.
   Stripping back is applicable only in the congenital form of phimosis.
It is possible  in  most  cases.   It is accomplished first  by making  the
body of the penis  as  prominent as possible.   Slight manipulation is
in children usually followed by erection.   Whether this occurs or not,
the skin is pulled back as far as possible towards the root of the penis,
this organ,  when it is  sufficiently developed, being made prominent
and held in place by the ring  and middle fingers of each hand, first
pressed in deeply towards the subpubic angle, then brought together 
DISEASES AND  INJURIES OF THE  PENIS.
9
so that the root of the penis is grasped firmly and so steadied between
their tips while subsequent manipulations  with  the foreskin are con-
ducted with  the  thumb and index finger of each hand.  These ma-
nipulations consist in stripping back and tearing adhesions with the
thumb-nails  or in forcible sponging on the part of an assistant or
in blunt  dissection with a probe or grooved director.  The stripping
must be continued till the ring of smegma is exposed and cleaned out.
The raw surfaces are then washed with weak bichloride solution (1 to
3000), dried,  well greased with boric  ointment, and the foreskin drawn
forward.  The foreskin must be retracted for washing and dressing
daily for ten to fourteen days.   Nor is it safe  to intrust  this treat-
ment to the mother, since, when  the preputial ring is tight, phimosis
may be converted into what is for her an irreducible paraphimosis.
    The operation of " stripping"  in  phimosis is  to be performed only
when circumcision is refused by parents.
    Circumcision.—This operation is  indicated   in every case  of phi-
mosis in children, not  only because it prevents the various compli-
cations  of a tight foreskin, which may interfere with  growth and
general nutrition, but  also because it does away with the  suggestion
to masturbation which the irritation of a tight foreskin often gives.
    In preparing for operation the parts  are thoroughly washed with
hot soapsuds, the preputial sac being cleaned by means of injections
of  1 to 40 carbolic in 1 to 4000  sublimate solution.  The ordinary
antiseptic precautions  are observed.  The penis is passed through a
small opening made in the centre of a sterilized towel, and the latter
is then spread out, thus preventing  the wound  surfaces from  coming
in contact with the  skin which has not been cleansed.  The instru-
ments required are a pair of fenestrated circumcision forceps, although
the fenestra is not necessary, a knife sharpened to a razor edge, a pair
of scissors which cut on the points, artery forceps, a pair of dissecting
forceps, and  small straight needles.
    The phimosis forceps  are applied loosely to the  foreskin  so that
the fenestra  lies just over the prominent  ridge of the corona and with
its  long axis parallel to this  ridge,—that  is, from above  downward
and from behind forward. Maintaining the forceps in their relative
position to the skin surface by light  pressure, the end of the prepuce
is drawn forward and the  forceps are gently closed, thus pressing the
glans penis behind them.  (Fig. 2.)   As soon as  the  operator  is sure
that the  glans is entirely behind the forceps they are closed  firmly,
and the prepuce is divided by carrying  the knife along the fenestra
with a sawing motion.  On releasing the forceps the skin  at once
retracts behind  the  corona, leaving the glans still covered with the 
10
GENITO-URINARY  DISEASES AND SYPHILIS.
mucous membrane; a band of integument often remains about the
preputial orifice.  (Fig. 3.)  One blade of a pair of scissors is  slipped
within the latter, care being taken that the  meatus  is not entered,
and the prepuce  is split along the dorsum to within  one-sixth of an
Fig. 2.
Fig. 3.
Application of forceps.
Appearance after first cut.
inch of its reflection from the coronary sulcus.   This part of the
operation is  sometimes  difficult,  on account of adhesions.   These
should be  thoroughly stripped, as already described.  The mucous
membrane having  been thus  split and stripped, each flap of it  is
                  Fig. 4.                                Fig. 5.
Trimming of mucous membrane flaps.
Appearance after flaps have
     been trimmed.
drawn away from the penis and trimmed off by means of the scis-
sors (Fig. 4), leaving a circular band of mucous membrane one-sixth
of an inch in width  passing  completely around behind the corona.
Bleeding points  are seized in  the artery forceps and  either twisted or
ligated with the  finest catgut.   By the oblique incision just described 
            DISEASES  AND INJURIES OF THE PENIS.          \\

the fraenal arteries frequently are not divided.  Where there is great
redundancy of tissue in this region, there should be no hesitation in
removing it.  When the fraenal arteries  are  cut, it  is safest to  tie
them.   If the operation has been properly planned, the apposition
between the edges of the divided skin and the remaining  strip  of
mucous membrane will be almost perfect, so that very few sutures  '
will be  required. (Fig. 5.)  The sutures employed should be of fine
silk, threaded on small  straight needles.   In infants, fine non-chromi-
cized  catgut is best, since this does not require removal.  The ordi-
nary  round-pointed sewing needle  will pass through the  delicate
tissues of very young children, and will not exhibit  the tendency to
cut out which is sometimes observed when edged surgical  needles
are used.
   The first suture  should be applied at the fraenum.   It includes a
Fig. 6.                                Fig. 7.
Insertion of first and second sutures.               Operation completed.
narrow strip of the skin at the position of the raphe, and should take
a fairly deep grip on the tissues of the fraenum.  As it is tightened,
care must be taken  that  the skin is not  inverted.  This cannot well
happen if the needle is inserted near its cut edge.  The next stitch
is inserted in the mid-dorsal region. (Fig. 6.)   A  stitch on either side
midway between the two already described is often sufficient, though
in adults it is safer to apply a complete row of sutures, since the irri-
tation incident to the operation often  occasions erection, which may
tear loose the feeble adhesions formed in the first few hours.  (Fig. 7.)
   The dressing may be  either dry or wet.   In the dry dressing the
line of incision is dusted with iodoform or acetanilid, then covered with
a thin film of bichloride cotton, and over this is painted fresh iodoform
collodion.  In  using  this dressing, which is applicable only  to such 
12        GENITO-URINARY  DISEASES AND SYPHILIS.
cases as are likely to heal by first intention,—i.e., those operated upon
under circumstances most favorable for the observance of rigid asepsis
and not complicated by previous inflammation,—the strip of dry sterile
cotton first applied to the wound must extend to but not across the
coronary sulcus.  This is then  secured in place by means of the  col-
lodion, which  is painted on in sufficient  quantity to  make with  the
cotton an occlusion dressing.  The penis is then wrapped in absorbent
cotton, and bandaged in the erect position  against the pubis and lower
belly surface  either  by the crossed of the  perineum or  the "jock-
strap," and the patient is allowed to be up and about.
   The wet dressing will  in the long  run give the  most  satisfactory
results.  A narrow strip of lint or gauze sixteen inches long, split at
one  end, is dipped into an antiseptic solution (phenol sodique  one
part, water  five parts,  or  boroglyceride,  twenty-five  per  cent.,  one
part, water three parts), and  secured in place  by tying the split ends.
This dressing is kept wet by the antiseptic solution, which is dropped
on at short intervals.   In  children  it is  maintained  in place by the
pressure  of the diaper.   The latter should  be perfectly clean, since
the wet strip is liable to drop off and thus allow of wound infection,
provided the penis comes  in contact with  soiled surfaces.  Cure is
usually accomplished in four to seven days.  Healing should be by
first  intention.  The stitches can  be removed on the fifth day,  and
after that the line of incision  may be dressed  with  a  narrow strip of
lint coated with a thick layer of boric  ointment and held  in place by
adhesive plaster, or the dressing may be of cotton and collodion.
   The complications of circumcision at  the  time of operation  are
hemorrhage and oedematous swelling of the  loose cellular tissue, par-
ticularly that near the fraenum.
   Hemorrhage is easily controlled by the  forceps.   They should pick
up the bleeding vessels with as little surrounding tissue as possible,
and  every bleeding point should be secured.  The  oedematous  in-
filtration readily  subsides in the  after-treatment  under  the use of
cold evaporating  lotions.  This rapid oedema  is troublesome  mainly
because it interferes with coaptation; sometimes as many as  twenty
or thirty sutures  are required  before the cut edges can be  brought
together accurately around the  entire line  of incision.   In such cases
it is  well to employ  the continuous  suture, interrupting it after four
or five stitches have been  taken.   Thus  the  neatest  apposition may
be secured in even the most troublesome cases.
   Consecutive hemorrhage from the fraenal arteries is  sometimes
severe.  When these arteries have not been tied, a moderately tight
bandage should be applied, and directions should be  given the nurse 
            DISEASES AND  INJURIES OF THE PENIS.          13

to watch for either rapid swelling  and discoloration of the penis or
external  bleeding.  When the  line of  suture  has been tight, the
blood may be extravasated into the cellular tissue, causing enormous
swelling, and, in case of concomitant infection, extensive sloughing.
   The treatment consists in opening the wound, securing the bleed-
ing vessels, and evacuating as much of the clot as possible.  Evapo-
rating and antiseptic  lotions, such as lead water and alcohol, subse-
quently may be applied.
   (Edematous swelling coming on after the operation is completed is
usually dependent upon bleeding, though it sometimes develops when
haemostasis  has been absolute.   It is commonly due  to  the use of
irritant antiseptics, though it  may occur without assignable cause.  It
subsides, in part at least, in from one to two days  under elevation,
the application of  evaporating lotions, and  the administration of a
brisk purgative.  It often persists for months in the form of a semi-
solid oedema about the fraenum.   In nearly all cases this  disfiguring
swelling ultimately disappears entirely.  This may be hastened  by
the application of stimulating and absorbent ointments,  such  as thyol
or ichthyol ten parts, and lanolin one hundred parts.
   Infection.—When through a lack of  care in antiseptic  precaution,
or because of operation on previously infected tissues, the wound be-
comes infected, swelling  is rapid and extensive, and all the symptoms
of local inflammation are marked.  Under these circumstances it is
best to provide for drainage by the  removal of stitches where the line
of suture has been tight.  The infected tissue should be washed with
hydrogen peroxide, followed  by  bichloride 1 to 2000, or carbolic 1 to
40, solutions, and should be wrapped in an antiseptic and cooling
wet  dressing, unless  the  inflammation is of such high grade  that the
vitality of the parts is threatened.   In this case large  hot antiseptic
fomentations are indicated,  together with treatment appropriate to
acute inflammation.  This complication of phimosis  is rarely  encoun-
tered,  except when  the  operation is performed  during  the course
of an acute inflammatory attack.   Under such  circumstances cir-
cumcision should not be undertaken unless  the indications for it are
imperative.
   Interference with Erection—-This results from the removal of too
much skin.   The operator may fail to notice the relations between the
skin surface and the deeper parts, but, seizing the prepuce and draw-
ing it forward as  far as possible, may apply his phimosis  forceps, make
his cut, and find that he has  denuded the penis almost as far back as
the scrotal junction.  In this case,  after healing marked distortion or
incurvation  of the penis may for a time occur on erection;  but, owing 
14         GENITO-URINARY DISEASES AND  SYPHILIS.

to the great extensibility of the skin, the ultimate prognosis is good;
at times the fraenum will require division.
   Recurrence of the Phimosis.—When too much of the mucous layer
of the foreskin has  been left, phimosis may recur in a more  severe
form than that for which the original  operation was  undertaken, the
cicatricial tissue along the line of suturing sometimes  contracting very
rapidly.  A strip of mucous membrane wider than a fourth of an
inch should never be left.   If narrower than a sixth of an inch, it is
somewhat difficult to insert the sutures satisfactorily.
   The operation of circumcision in children may be performed under
cocaine, a one per cent, solution of the drug  being employed.  By
means of a hypodermic syringe it is deposited along the  line of the
proposed incision, more being  driven  into the  region of the fraenum
than into any other part, since here  sensibility is greatest.   When
cocaine is used it is well to mark the position of the proposed cut
with an  aniline pencil, then entering the point  of a hypodermic
syringe in this line, in  the  mid-dorsal region, one  drop  is injected
between  the skin and  the mucous  surfaces.   The  needle is then
thrust  along the  proposed line of incision, either to  the  right or to
the  left,  for one-sixth of  an inch, and  another drop  injected.  Its
point  is thus advanced until the fraenum is reached, where several
drops  are injected.  The needle is then withdrawn  until  its point  is
just within the skin, and is carried  along the other side of the prepuce
in a similar manner.  Immediately after the injection an elastic band
is placed around the root of the penis, to prevent absorption of the
drug.   Even when  no cocaine  is  employed, the  marking of the pro-
posed line of incision by means of an aniline pencil is often of distinct
assistance.
   With children the use  of cocaine  is open  to the objection that
from fifteen to twenty drops of a one per cent, solution are required
to produce complete anaesthesia, and  that, in  addition to a possible
toxic  effect, this increases the  local oedema which, especially in chil-
dren,  so  often makes neat apposition of the cut edges difficult.  The
application of a rubber ligature immediately  following the  cocaine
injection, the limiting of the latter to the  proposed  line of incision,
the employment of not more than  twenty drops, and  the encouraging
of venous  oozing by partially slackening the ligature before it  is
entirely removed  after the  cutting is completed, effectually guard
against toxic symptoms save where there is idiosyncrasy.
   Schleich's  method of percutaneous filtration  has been  success-
fully used in the performance of  circumcision, and  is entirely free
from the dangers incident  to absorption.  Unless the  injections are 
DISEASES AND INJURIES OF THE  PENIS.
15
inserted  in both the outer and inner layers of the prepuce along the
proposed line of cutting, the pain of the operation will still be severe.
The solution to be employed is as follows :

                  R Cocainse hydrochloratis,
                    Morphinae hydrochloratis, aa gr. i;
                    Sodii chloridi, gr. ii;
                    Aquae destillatae, 3ji Tftxx.

    The syringe being filled with the solution, the needle is driven into
but not through the skin, and two  drops are injected, raising a white
bleb.   The  needle is then thrust in the line of  proposed incision be-
yond the border of the first bleb about a sixth of an inch, and two
drops are again injected ;  this is continued from the mid-dorsal region
till the fraenum is  reached,  the  injections being made into and  not
beneath  the  skin.   The other semi-circumference of skin is similarly
treated.  Then  the  foreskin is retracted  and its  inner  layer is in-
jected in the same  way, the  blebs  again being formed along the pro-
posed  line  of incision.  Finally, the  loose tissue lying between  the
skin-layers is infiltrated, when  the operation can be performed with-
out causing the slightest pain.  The objection to this method of anaes-
thesia lies in the fact that the necessary infiltration interferes with neat
coaptation, and where the foreskin  cannot be retracted it is difficult to
anaesthetize the inner layer.
    In very young children the operation of circumcision is much more
difficult than it is in adults.  The parts are small and the tissues soft
and non-resisting.  The previous adhesions are usually tight, so that
the glans is abraded from stripping.  The application of  dressings
which  may reasonably be expected to remain in place requires much
manual dexterity.
    A method of performing circumcision, popular because of its sim-
plicity, requires simply scissors, curved bistoury,  grooved  director,
artery  forceps, and needle  and thread.   The  grooved director is
passed through the preputial  orifice back to  the coronary sulcus.
It is moved from side to side to make  sure that it has not entered the
meatus, palpation with  the fingers showing that its extremity passes
over the surface of the  glans and does not cause this body to follow
its motions.  The curved bistoury is passed along the groove of  the
director, and  its  point  is  brought out  through the dorsum  of  the
prepuce.  By cutting forward and upward with the knife  the prepuce
and its mucous layer are  split.   By means of the scissors one of  the
tabs of skin and mucous  membrane is trimmed downward and for-
ward to  the meatus, leaving a width of not over one-sixth of an inch 
16        GENITO-URINARY DISEASES  AND SYPHILIS.
of mucous membrane.  The other tab is  trimmed off in the same
manner, and sutures are applied.
   This operation has the advantage of removing skin and mucous
membrane together and dispensing with the phimosis forceps.  It is
the method of choice in those cases of inflammatory swelling and
exudation in which the prepuce  cannot be drawn forward and the
fenestrated forceps cannot be applied.
   To recapitulate :  The operation of circumcision is indicated in all
cases of phimosis except those which are temporary and moderate in
degree.  In the absence of phimosis it is also indicated where there
is a tendency to the formation of venereal warts, to prolonged attacks
of balanoposthitis, to recurrent herpes  progenitalis, to fissurings and
erosions during intercourse, to hypersecretion on the part of Tyson's
glands, to  sexual erethism without evident cause, to apparently cause-
less functional disturbances of the bladder, such as nocturnal enuresis,
and to masturbation.
   If performed in a proper antiseptic way  the operation is without
danger, healing in non-inflammatory cases being by first intention.
   Various modifications of the foregoing methods have been advised
by different surgeons.  Palmer describes his operative technique as
follows:
   Immediately before operating, in cases of gleet wash out the urethra,
by means  of a catheter, with a hot 1 to 15,000 bichloride  solution ; in
cases of balanitis or excoriation, dress the parts twice  daily for several
days  before the operation with cotton wet  in saturated solution of
boric acid  ; in cases of chancroids, touch every visible sore with pure
carbolic acid  just before operating; and in all cases cleanse the parts
and  surroundings  very thoroughly with hot 1  to 2000  bichloride
solution, being  especially careful to purify the balano-preputial  fold.
Chloroform or ether need never be used ; four per cent, cocaine solu-
tion  injected into and  beneath the skin with a hypodermic  syringe
and incarcerated by a small Esmarch tube is sufficient.
   It is not necessary to cut both skin and  mucous membrane at the
same time.  In  some cases—for instance, in chronic balanitis—very
little mucous membrane is desirable. By trimming the mucous mem-
brane after removing the skin one is enabled to prevent bridling at
the fraenum during future erections.  The incision should be oblique,
beginning  close  to the  glans on the dorsum and  becoming more re-
mote from it, so as to leave a lengthy fraenum below.  It is of espe-
cial importance to recognize that  three coats must be cut if  a neat
operation  with speedy union is the aim.   After trimming the mucous
layer, and just before introducing  the stitches,  the connective tissue 
DISEASES AND  INJURIES OF  THE  PENIS.
17
in the bottom of the wound should be carefully clipped away around
the entire circumference of the floor.  If this is neglected, that tissue
will push outward between the stitches and, later, leave a ring of in-
duration that will be slow in disappearing.  After removal of  the con-
nective  tissue from four to six interrupted silk stitches are sufficient.
The fraenum should be preserved.
    After stitching, a piece of dry, aseptic  gauze, four inches long and
an inch and a half wide, covered  with iodoform and boric acid, is laid
under the fraenum, brought up around the  cut, right and left, to the
dorsum, and trimmed with scissors.  Over this a strip of absorbent
cotton,  three-quarters of  an inch wide, is placed.   Next a Maltese
cross of dry gauze,  with  a central  hole  for the meatus, is  applied,
and then a similar cross of rubber tissue, and the whole bandaged
snugly in place.  A waist-belt, a  jock-strap, and a bunch of cotton to
cover the glans, well dusted with boric acid, complete a dressing that
permits the patient to go to work at once  at  any ordinary vocation.
If the dressing is  retracted during  urination and the final drops are
wiped  off, the original  gauze  may be left on  five  days.  When the
stitches are removed the parts should be dusted with boric acid, and
a loose  pledget of  cotton wrapped around them.
    Occasionally, owing to oozing of  blood, it may be found necessary
to apply the dressing too tightly for permanency.  In such cases  an
extra one-inch roller may be put on over the permanent dressing,
to be  removed some  hours  later  without  disturbing the  dressing
proper.
    An ingenious operation has been proposed by Lewis.  He has de-
vised a special retractor, which is introduced into the meatus closed,
and is then opened, thus  allowing him to draw the prepuce well for-
ward.   His fenestrated clamp is convex forward;  this is so  applied,
after the foreskin is thoroughly stretched and forcibly pulled  forward,
that the glans is crowded back.  Six needles  armed with catgut are
passed through the fenestra, piercing the double thickness of the fore-
skin.   The redundant portion of this covering is trimmed off with scis-
sors in  front of the clamp, the latter is removed, and the sutures are
hooked up in the middle, divided, and tied.
    In the case of an adult exhibiting chancroid  complicated by phimo-
sis requiring  circumcision, ether should be given, the parts should
be repeatedly disinfected as before, but not by the  operator  or his
assistant, nor should any  of the basins  or solutions be used  which
are subsequently to be employed during the operation; the  foreskin
should  then be split to  an extent just sufficient to allow of thorough
cauterization with the Paquelin cautery of all the chancroids and  of
                                2 
18        GENITO-URINARY DISEASES AND SYPHILIS.

the wound made in splitting.  All the towels surrounding the penis,
and the solutions and basins used in former washings, are removed.
The seat of operation is surrounded with a fresh sterile or wet bichlo-
ride towel, the glans and foreskin are put through a vigorous course
of cleansing with fresh  solutions from  a clean  set of basins by the
surgeon and his assistants, and the circumcision is performed.  The
coaptation should be exact.   A  wet dressing is applied,  preferably
the gauze  bandage wrung out of dilute lead water and alcohol equal
parts, and the patient is kept in bed for five days, with the penis and
scrotum supported by a pillow of antiseptic cotton covered with gauze.
Often, in  spite of every precaution, the  entire circumcision wound
becomes chancroidal.  When redness,  swelling, and suppuration at
one or more points foretell this,  the stitches must be taken  out, and
the wound dressed several times  daily, as described under chancroid.
(See page 288.)
    In the case of infants and very young children ether should usually
be given, and especial care must be taken to avoid irritating the skin
of the scrotum, thighs, and buttocks by prolonged contact with the anti-
septics.  It  is in infants mainly that the fault of taking off too much
skin  has been committed.  This is avoided by marking the position
of the corona when the foreskin is not pulled forward.   It is also in
infants that the complication is most often observed incident to passing
one blade of the scissors into the urinary meatus instead of between
the glans and the inner preputial layer, and hence splitting the glans.
When such an accident occurs, the immediate closure of the wound
by deep sutures is followed by prompt healing with very slight subse-
quent deformity.  The most frequent  error is, however, neglect to
strip  adhesions,  which are nearly always present, until the coronary
sulcus is entirely free and its contained ring of smegma is  exposed.
This  failure in stripping leads to recurrence of the phimosis in a more
inveterate  form and  to  entire failure  to accomplish the object  for
which the operation was undertaken.   In infants and children con-
secutive  bleeding incident  to failure to secure the fraenal arteries has
been so obstinate and severe as  to threaten life: hence it is impor-
tant always to secure by ligature  the fraenal arteries, not trusting to
the suture as a means of controlling  these vessels.   The removal
of  stitches is always difficult in  infants, therefore  non-chromicized
catgut carried  in  the ordinary  round-pointed  seamstress's needles,
which do not cut out through the delicate inner layer of the prepuce,
is the best suture material.   The dressing  of infants  must be so
planned that it will remain in  place, will be comfortable,  is not
likely to become soaked in urine, and can be changed without giving 
DISEASES AND  INJURIES OF  THE  PENIS.
19
pain in case it becomes soiled.   Ordinarily  a  wet dressing made
of a narrow strip of lint (one-half inch wide, a foot long), soaked in
dilute antiseptic, wrapped neatly about the penis (see page 12),  and
kept in place by the  diaper, answers well.   This must be kept  wet
constantly by the nurse or mother, who is instructed to dip a small
sponge  in the  solution of choice, and, folding down the  diaper, to
squeeze out the sponge  so  that the lotion drops upon the bandage
enclosing the penis.  This must be done every  half-hour.   Moreover,
the diapers are kept scrupulously clean (boiled and sun-dried), so  that
in case  the deep dressing slips the wound will not become infected.
In four or five days, if silk stitches have been used, they can be taken
out, and the wet dressing can be replaced by boric ointment spread
on a narrow strip or applied to the circumcision wound  and kept in
place by a narrow bandage.
    Instead of the wet dressing an ointment may be  used, and this is
particularly serviceable when  extensive stripping has left the glans
raw and sensitive and readily adhering to any fabric, such as gauze,
which is brought  in immediate contact with it.  After the operation
is completed a T-bandage  is  applied, with the T  in front and an
opening properly placed in the vertical strip below the waistband to
admit the  penis.  A piece  of  lint backed by a piece of thin gutta-
percha is cut in the shape of a Maltese cross, with a perforation in the
centre for the meatus urinarius, and of such size that the limbs of the
cross, when the meatus is  placed at this opening, reach  to the peno-
scrotal junction.  The gutta-percha tissue and lint are basted together.
The lint side is then thickly spread with  recently sterilized  boric oint-
ment, and  closely applied to  the penis.  Finally, a gauze bandage
holds the dressing in  place and is secured  to the T  by safety-pins.
This dressing can be changed daily without giving pain.
    Shortness of the  Fraenum.—This  congenital  deformity in certain
cases interferes with complete erection of the  glans, turning the  ori-
fice of the meatus downward, and not only preventing ejaculation in
the proper direction, but also rendering sexual intercourse  painful, or
even impossible.
    The treatment is  simple and efficient.  The fraenum is put upon
the stretch, a narrow bistoury is thrust through  its  base, and by an
incision from within  outward  the bridle of skin is cut completely
through.   The prepuce is  kept retracted until the healing is com-
plete.
    Paraphimosis.—When the prepuce has been retracted behind the
glans and cannot  again be  brought forward, the condition is termed
paraphimosis.   The exciting cause is  usually a more or less forcible 
20        GENITO-URINARY  DISEASES  AND SYPHILIS.
retraction of a tight foreskin, though occasionally inflammatory swell-
ing will cause the foreskin to  roll back of itself.
   In gonorrhoea, chancroid, chancre, balanoposthitis, and all lesions
of the genitalia attended by swelling of the glans or the foreskin, this
complication  is particularly liable to  occur.  It is most frequently
observed in children as a result of manipulation of the parts.
   When a narrow preputial orifice is drawn behind  the corona the
constriction it exerts upon the parts causes rapid swelling. The glans
becomes markedly enlarged and glossy. It is often partially concealed
by a  thick collar  of shiny oedematous mucous  membrane, behind
which there is a deep excoriated sulcus, and back of this sulcus there
is usually a second  oedematous band  less marked than the one lying
immediately behind the coronary sulcus.   The penis seems to have a
distinct upward kink or bend just behind the glans.   This  appear-
ance is due to the deep notch caused by the margin of the retroverted
preputial orifice of the penis, and to the oedematous swelling which is
particularly marked about the position of  the fraenum.  In  some
cases, where the tense inelastic edge of the orifice exerts a more than
usual amount of constriction, circulation is markedly interfered with,
and ulceration  and even  sloughing involving both  the foreskin and
the head of the penis may take place.  This complication would un-
doubtedly be more  frequent were  it not for the rich blood-supply to
the glans and the anastomosis between its  vessels  and those of the
corpora cavernosa.  The ulceration usually involves the foreskin only.
   When the swelling consequent upon  paraphimosis is well devel-
oped  (Fig. 8) there is encountered first a furrow (a), the coronary
sulcus, which is normally found behind the  corona; in these cases it
appears deeper because it is intensified by the oedematous swelling.
Covering this furrow, and  even overlapping  the glans  somewhat, is a
shiny oedematous collar of mucous membrane (6).   This is that por-
tion of the prepuce which  is normally in  contact with the posterior
face and border of the corona.  Behind this swollen  fold is  found a
second deep, often ulcerated  furrow  (c);  this  is the  actual  seat  of
constriction, and  behind it is placed  yet another  ridge of  swollen
integument (d).
   Paraphimosis  is attended with  very severe  pain, which does  not
intermit until the constriction  has  been relieved, either by operation
or by the process of ulceration.   Where surgical interference  is de-
layed, or has not been successful in remedying the trouble, the subse-
quent  cicatricial contraction may occasion great deformity.
   Treatment—The treatment of  paraphimosis is, of course, reduc-
tion.   This should be effected at  once, except  in those  cases where 
DISEASES AND INJURIES OF THE PENIS.
21
paraphimosis is the result of a previously existing inflammation and
is not occasioning  sufficient interference with circulation  seriously to
complicate the original lesion.  For instance, patients with a  short
foreskin suffering from chancroid frequently have the  foreskin rolled
back, and, as a consequence of oedema following the  original lesion,
cannot bring it forward again.  In such cases the paraphimosis is a
result, not a cause, and  frequently occasions no circulatory disturb-
ance.  Treatment of  the  original  lesion,  together with  evaporating
lotions, rest, and elevation of the part, will  bring about a cure.   All
such cases  should, however, be carefully  watched,  and  should be
operated on at the first sign of strangulation.
    When paraphimosis is of sudden development and not dependent
upon oedema  consequent  upon a pre-existing lesion, it should be

                               Fig. 8.
reduced at once, whether symptoms of strangulation are present or
absent.   If the glans penis is purple, black, or mottled in color, cold,
and  non-sensitive,  the indications  for  interference are still more
urgent.   Here no time should  be lost in efforts at reduction by me-
chanical  means.  The constricting band should be divided,  the fore-
skin  drawn forward,  and the vitality of  the  parts restored  as far as
possible  by the long-continued application of hot compresses wrung
out in mild antiseptic  lotions and changed every few minutes. 
22        GENITO-URINARY  DISEASES AND SYPHILIS.

   Reduction is easily accomplished if the case is seen before oedema
has become very marked.   When there is no fear  for the vitality of
the part, an  ice-bag may be applied to the penis  for half an hour.
Ether should then  be administered, the thick oedematous collar, the
greatest obstacle to reduction, should be  punctured in  many places
by means of  an ordinary surgical needle, and the anterior and inner
surface  of this  collar and  the corona  glandis should be lubricated
with carbolized oil.  The surgeon then seizes the  penis  just behind
the seat of constriction between the lateral surfaces of the middle
and ring fingers of both hands, and while  the two thumbs and index
fingers  press upon the glans penis, not  pushing it backward,  but
squeezing it and drawing it  slightly forward, the fingers  endeavor to
draw  the prepuce  over the thus  narrowed  and  elongated glans.

                             Fig. 9.
Reduction of paraphimosis.
(Fig. 9.)   Backward pressure with the  thumbs  has  the  effect of
making the base of the glans broader, and thus effectually prevents
reduction.
   Reduction  may also be effected by grasping the penis  in  the left
hand, as in seizing a rope, the thumb and forefinger being  applied
behind the seat of  constriction.   The fingers  and the thumb of the
right hand are applied to the glans penis, which is compressed later-
ally and drawn slightly forward, while an effort is made to carry the
strictured part clear of the  corona  glandis by exerting traction with
the left hand.   (Fig. 10.)
   When these manipulations fail, a  rubber band may be wound
about the glans,  covering  it in completely from before  backward.
This so reduces the glans in size  that the end of a grooved  director 
DISEASES AND INJURIES  OF THE PENIS.
23
 or the  handle end of a scalpel  can usually be  passed  beneath the
 constricting  band.   When that is accomplished  the  rubber band  is
 removed, and by means of the instrument introduced  beneath the
 constriction  reduction is readily effected.
    When these measures prove unsuccessful, the constriction must be
 divided.  This can be done by passing a curved bistoury beneath the
 constriction  and cutting forward.  The collar of oedematous mucous
 membrane is pulled downward towards the glans as far as possible, a
 narrow bistoury is  carried from behind  forward, with its  blade flat,
 beneath the tense band formed by the stretched margin of the prepu-
 tial orifice, the  cutting edge is then  turned up,  and  the stricture is
 divided in one or more places.
 It must be borne in mind that                 FlG-10.
 the constriction usually  lies
 behind the oedematous collar
 of mucous membrane which
 covers  and conceals the coro-
 nary sulcus.
    Exceptionally, when  the
 prepuce is merely retracted
 instead of being rolled  back,
 and slips up  without turning
 over, the preputial ring grasps
 the penis immediately behind
 the corona.   This  may be
 compared  to pulling  up a
 tight coat-sleeve instead of
 turning it up.  If in such a
 case there  be sufficient con-
 striction to occasion strangu-
 lation,  the  thick collar of oedematous  mucous  membrane will  be
 wanting, and the constricting band  will lie in the coronary sulcus,
 where it can readily be divided  by inserting beneath it a grooved
 director, guided  by which an incision with a curved bistoury can be
 made.
    The incision must be sufficiently free to allow of easy reduction.
 Sometimes where enough time has  elapsed for the formation of in-
 flammatory adhesions two or three incisions are necessary.
    Reduction should be complete.   In cases of marked oedema after
prolonged manipulation, the congested fold of mucous membrane may
be  pulled completely over the glans, simulating  reduction when in
reality this has not been effected.  When the paraphimosis is properly
Reduction of paraphimosis 
24        GENITO-URINARY DISEASES AND SYPHILIS.
reduced the glans disappears entirely and can be exposed only by
forcibly drawing the foreskin backward.
   Under certain circumstances the surgeon may be  compelled to
resort to palliative measures.  The fears of a patient, in the case of a
child the anxiety of parents, or the comparative mildness of symptoms,
may justify  the application of  pressure.  This may be applied  by
means of adhesive straps or by a bandage.   Straps, if used, should be
narrow and so applied  that uniform pressure is exerted.  The resin
plaster should be employed.  The penis is completely covered in by
strips placed longitudinally, the first running from the middle of the
upper surface of the organ to the middle of the under surface, and the
others being applied so that each overlaps its predecessor.  Then cir-
cular straps are applied, running from the extremity of the penis back-
ward, the meatus  being left free.   In a day there is usually sufficient
diminution of swelling to permit reduction.
   After incision  and reduction the parts  should  be  wrapped in a
bandage kept continually wet with dilute lead water, or with phenol
sodique and  water equal parts, or with lead water and laudanum, till
the swelling subsides, when the wound may be dressed with powdered
iodoform or boric  acid ointment.
   Solid oedema  of  the  foreskin  sometimes persists for weeks  or
months.  In this case circumcision is advisable, though the persistent
use of pressure, supplemented by  applications of ichthyol  ointment
(ten per cent.), will ultimately cause the disappearance of the swelling.

                    INJURIES  OF THE  PENIS.
   Contusion.—This implies  an  injury by crushing  force  without
lesion of the skin.   The phenomena attendant upon such an injury do
not differ from  those following similar traumatisms in  other parts of
the body.  Owing to the looseness of the cellular tissue, ecchymosis
and oedema are often so pronounced as to simulate rapid gangrene.
   When  the vessels of the cavernous bodies are involved there is
free subcutaneous bleeding, giving rise to a circumscribed fluctuating
tumor, most prominent during erection.  This tumor is  somewhat
slow in forming,  and occasionally suppurates.  Under  conservative
treatment it  usually  disappears.  When  injury  has  not  only oc-
casioned extensive  extravasation  of blood, but has  lacerated  the
urethral canal, the inflammatory phenomena observed  after rupture
of the urethra quickly develop.   (See  page 71.)   Moreover, there is
immediately bleeding from the meatus, which should lead  to prompt
diagnosis and appropriate treatment.
   Treatment—The treatment of contusions of the penis is conducted 
DISEASES AND  INJURIES OF THE PENIS.
25
 on general  principles,—rest,  elevation,  pressure by  narrow  gauze
 bandages, the application of evaporating lotions, and, for the purpose
 of hastening absorption, general massage.
    Extensive swelling and discoloration  need not  occasion anxiety,
 unless there has  been rupture of the spongy or cavernous bodies or
 of the  urethra.   When gangrene is threatened on account  of  the
 severity of the lesion or because  of interference with circulation  oc-
 casioned by the  pressure  of effused blood, hot antiseptic fomenta-
 tions frequently repeated  are indicated.  These dressings are  made
 by wringing fifteen  or  twenty layers  of antiseptic gauze out of  a
 hot 1 to 10,000  bichloride solution.   They may be covered with
 waxed  paper  to  prevent  evaporation.  If the  symptoms are still
 progressive,  free incision  and  ligation  of bleeding  vessels,  followed
 by suture of the  wound,  are indicated.   Emphysema  is always  a
 serious symptom, and usually calls for free incision, as it probably
 results from  infection with saprophytic organisms in addition to those
 of suppuration.
    On the first sign of suppuration after contusion, incision should be
 made sufficiently free to secure thorough  drainage.
    Wounds of the Penis.—These are classified according to gen-
 eral surgical  principles as incised,  lacerated, punctured, and contused.
    Incised wounds, if superficial, are readily closed, and heal quickly.
 Deep wounds, that is, those involving the erectile tissue, bleed  freely,
 and, if transverse  and extensive, are  liable  to be followed by loss of
 erectile power in  the tissue lying  anterior to the wound.  When the
 penis is  completely divided, hemorrhage is  so rapid that, unless it is
 promptly arrested, a fatal issue is  probable.
    Treatment.—The treatment of  these wounds is conducted on gen-
 eral principles.  Violent hemorrhage is checked by ligatures : the sur-
 faces  are brought in apposition and held  there  by sutures passed
 through the fibrous sheath of the erectile tissue, but no deeper.   This
 simple fixation is usually sufficient to stop the venous oozing.  If not,
 a  stiff English catheter  is passed into the urethra,  and a pressure
 bandage is applied for some hours.  Inflammatory reaction always
 excites erection.   This interferes with primary healing, and should be
 prevented by full  doses of bromide (sii daily), by opium and  bella-
 donna suppositories,  or by hypodermics  of morphine.   Even  if the
 penis is almost completely  severed, hanging by a small strip of tissue,
 an effort should be made  to suture it in place.  When the penis  is
 completely cut off, the bleeding vessels are tied, the cavernous bodies
are covered in by suture of their fibrous envelopes, the  skin is drawn
forward  and sewed over the closed  ends of the corpora cavernosa, 
26        GENITO-URINARY DISEASES AND  SYPHILIS.

and the urethra is split and secured to the skin  to prevent subsequent
stricturing of its orifice.  (See page 44.)
   When the urethra is divided it  should be sutured, and a catheter
should be introduced into the bladder to relieve the primary retention
resulting from the wound and to prevent subsequent urinary infiltra-
tion.  This  catheter is kept in  for  from  five  to  seven days, until
healing is well advanced.  (See  page  74.)  If, as a result of cicatriza-
tion  following wounds, erection is  complete but there is deviation of
the penis from a straight line, cure by operation may be  successful.
When, however, there has  been obliteration  or obstruction  of the
spaces of the spongy and cavernous bodies, producing deviations and
incomplete erections, treatment  is unavailing.
   Punctured wounds of the penis, when inflammatory symptoms are
pronounced  and infection  is probable,  should be converted into
incised wounds, cleansed, and drained from the bottom.
   Contused and lacerated wounds of the  penis are particularly dan-
gerous only  when the urethra is involved or the injury is so great as
to devitalize  tissues.   When extensive they are liable to be followed
by imperfect erection or by distortion of the penis.  The treatment
consists in  subduing inflammatory phenomena.  Bleeding in these
cases is moderate ; when the urethra  is involved permanent catheter-
ization is practised.  Sometimes the catheter  cannot be introduced
till the urethra is opened behind the seat of inj.ury, and then the posi-
tion  of its proximal end in the  wound is  determined by passing an
instrument from behind forward.
   Gun-shot wounds of the penis  partake of the nature of contused
and  lacerated wounds, are  subject to the same complications,  and
require  similar treatment.   The shot or bullets, if  embedded  in the
erectile  tissue, should always be removed,  and every possible portion
of the penis  should be preserved.
   Fracture  of the Penis.—This injury, possible in a literal sense
only when  the penis has undergone calcification, occurs when  during
vigorous erection the organ is subjected to a sudden twist or bend.
The  cause of the injury is usually a false movement in coitus, though
a  wrench or a blow will also produce it,  as, for instance, when the
penis is caught in  closing a bureau drawer,  or is bruised by a falling
window-sash.   Demarquay states that it occurs mainly in those suf-
fering from  a partial calcification of the fibrous sheath of the penis.
The  foolish  custom of "breaking" a  chordee, at one time  quite fre-
quent among venereal  patients,  occasioned a number of cases  of this
injury, but fortunately  appears to be  dying out.
   Symptoms.— The symptoms of this injury are sudden severe, pain 
DISEASES AND  INJURIES OF  THE  PENIS.
27
and a sense of something having given way, consequent on a bending
or twisting strain of the erect penis.  The erection subsides at once,
and there is rapid and immediate swelling.  Deformity, unless masked
by the swelling, is pronounced.  The part of the penis anterior to the
break is preternaturally movable, and at the seat of injury there is an
angle producing a flail-like appearance.
    Prognosis.—The prognosis is only moderately good.  The subcu-
taneous effusion  of blood  may possibly cause so much  tension that
gangrene will  be threatened.   This,  however, is  rare, and under
proper antiseptic  treatment suppuration will not occur,  except when
the spongy body  and urethra have been involved in the injury and
there is extravasation of urine.
    The prognosis as to functional restoration must always be some-
what guarded. In some cases this apparently has  been perfect.   In
others there has  remained an  indurated mass at the seat of injury,
which has  seriously interfered with erections  and has resisted  all
treatment.
    Treatment—This  may be conservative  or radical.  Of the con-
servative treatment, rest in bed, elevation  of the part, and pressure
by means of a bandage crossing the perineum and carried around the
pelvis  and beneath the iliac crest, keeping the dorsal surface of  the
penis firmly apposed to the abdominal walls, are the  most important
factors, but the application of astringent, antiseptic, and evaporating
lotions, such as lead water and alcohol, should  not be omitted, and
will bring about gradual subsidence  of the swelling.   If  this  swelling
is so great that it threatens  to occlude the urethra by the pressure
exerted upon its  walls, a stiff woven catheter should be passed into
the bladder and retained there, a firm circular bandage being carried
about the penis.   Radical treatment implies incision, turning out of
clots, ligature of bleeding points, and suture of the tear in the fibrous
envelope.  In case the bleeding is continuous and gangrene threatens
from the tension of the retained blood, there is no choice as to treat-
ment:  incision must be practised, thus allowing ligature of bleeding
points.  Afterwards a permanent catheter  is  introduced,  and  the
whole  penis is covered in with a light  roller bandage.  In  twenty-
four hours  the catheter is removed, and should the bandage  first
applied  be  still too tight to allow of urination, this is replaced by one
sufficiently loose  to enable the patient to empty his bladder. Erec-
tions are prevented by keeping the bowels opened and by giving full
doses of potassium bromide (sii to 3iv daily).
   Dislocation of the Penis.—This accident  is produced by trau-
matism  exerted upon the  anterior portion of the flaccid organ. The 
 28         GENITO-URINARY DISEASES AND  SYPHILIS.

 penis is  pinched out of its sheath and  driven  into the scrotum, the
 loin, or the neighboring  regions, much  as a grape is squeezed out of
 its  skin.  The  mucous layer of the prepuce, which  should prevent
 this accident, gives way either at the preputial  orifice or, more  com-
 monly, along the line of the coronary sulcus.  The urethra is usually
 ruptured in the perineal region.
    Symptoms.—The symptoms of this accident are not so  marked as
 would be supposed. • The skin sheath of the penis is often  filled with
 clotted blood,  thus simulating the  presence of a shrunken organ.
 There is usually free  hemorrhage  from the preputial  orifice.  Later
 there is extravasation of urine,  with  its  concomitant  symptoms.
 Careful  investigation  will always  show the absence of the erectile
 tissues from their proper position and their presence elsewhere.
    Treatment.—The treatment consists  in immediate replacement of
 the organ.  This usually requires an incision, though in one reported
 case the  penis was hooked forward by an instrument introduced into
 the preputial orifice.   There should be no  hesitation in making the
 required incision so free that the proper manipulations for reduction
 can be easily carried out.  After this, if there has been extravasation
 of urine, an external perineal urethrotomy should be performed.

            INFLAMMATORY AFFECTIONS OF THE PENIS.
   The penis and its  envelopes are subject  to the inflammations  ob-
 served in other parts of the body.  Aside from the distinctly venereal
 diseases, eczema, parasitic diseases, herpes,  erysipelas,  lymphangitis,
 folliculitis, abscess, diffuse cellular  inflammation, and gangrene are to
be noted.  When superficial inflammation involves the glans, or the
glans and the prepuce, it is termed balanitis, or balanoposthitis.  These
 regions  are so  frequently affected that  the  inflammatory  conditions
involving them  will receive special  consideration.
   Eczema very commonly affects both the scrotum  and  the penis,
and is extremely rebellious to treatment.  The exciting cause is often
chafing  or rubbing  of the parts, though a  constitutional  dyscrasia,
such as gout or rheumatism, commonly predisposes  to the  disease.
It usually appears on the prepuce or about the base of the  penis.
   The  treatment is  the  same as for the disease  situated in other
parts of the body, except that, as the skin is extremely sensitive, irri-
tating applications must be avoided.
   Herpes of the entire  penis is rare; it usually attacks the foreskin
and glans.   (See page 35.)
   Acute  inflammation of the  penis may be localized  or diffuse.
It may involve the subcutaneous cellular tissue or the structure of the 
DISEASES AND  INJURIES OF  THE PENIS.
29
erectile tissue.   Localized  inflammation results in abscess.  This  is
treated in  accordance with general  principles, whether  it be super-
ficial  or placed in the substance of the organ,—i.e., it is opened and
drained.
    The diffuse inflammation may appear in the form of  erysipelas of
the subcutaneous tissues, or may attack the substance of the erectile
tissue, constituting the affection called penitis.   Elevation and the
application of evaporating  lotions are indicated,-followed by incision
and drainage should there be pus-formation.
    Gangrene occasionally results from deep-seated acute  inflamma-
tion, which may be due to local causes, such as phimosis or paraphi-
mosis, traumatism, or urinary  extravasation, or  may develop  as  a
result of thrombosis after acute fever, such as typhoid.
    Treatment.—The treatment of gangrene of the penis does not differ
materially  from  that  applicable to this condition when it is observed
in other parts of the body.  In case the gangrene is rapidly spreading,
threatening to destroy the entire penis in one  or two days, prompt
removal of the dead tissue by scissors and curette, supplemented by
thorough application of the actual cautery, is indicated.  Compresses
soaked in hot bichloride solution (1 to 10,000) and changed every half-
hour  are applied till healthy granulations form, when boric ointment,
or  a  dry dusting  powder, such as iodoform, or  acetanilid, may be
substituted.
  When gangrene is less fulminant in type, hot compresses, changed
every three minutes (bichloride solution  1 to  10,000, at a tempera-
ture of 110° F.), may be  applied for twenty-four hours, supplemented
by  thorough spraying of the involved parts with carbolic solution
(1 to  80) every two hours,  and by one thorough injection of the same
solution into the reddened and  infiltrated but  not yet sloughing
bordering tissues by means of a hypodermic syringe.  This injection
should infiltrate all the  still living tissues immediately  surrounding
the gangrenous  area, the  needle  being entered as frequently as  is
necessary to accomplish this object, and its contained fluid being in-
jected about as freely and much in the same way as in Schleich's an-
aesthesia method.   (See  page 14.)   When the gangrene is  distinctly
slow in type and resists ordinary treatment, a long-continued general
bath  or hip bath is indicated.  This should be kept comfortably hot
and should be mildly antiseptic (gss bichloride,  or gxii boric acid, to
the bath).  The  genitalia should be kept submerged day and night for
days,  and even, in exceptional cases, for weeks.
   The systemic treatment is extremely important in all cases of gan-
grene.  This must be tonic and stimulating.  Easily digestible food in 
30
GENITOURINARY DISEASES AND  SYPHILIS.
as
Fig. 11.
 ._ full quantity as can be given, tonics, particularly iron, strychnine,
and small doses of bichloride (grain one-sixtieth to one-fortieth thrice
daily), and  stimulants are indicated.  The bowels should  be moved
regularly.
   Chronic inflammation of the erectile tissue and its fibrous
envelope, particularly of the corpora cavernosa, results in slow, often
painless, areas of induration, which may be  fibrous,  calcareous, or
even  bony (Fig. 11), and which require  attention only because they
prevent complete  erection.   The cause  of  these  indurations is  un-
known.  They are  observed in middle-aged men, and  are often
                   associated with the  rheumatic and  gouty  diath-
                   eses.  They have been regarded as late lesions of
                   syphilis.   With this  disease they probably have
                   no relation, though it must be remembered that
                   gummata may appear in the corpora cavernosa.
                      Symptoms.—The  symptoms of this affection
                   are sufficiently characteristic.  Palpation demon-
                   strates   one or more  circumscribed,  hardened,
                   possibly tender areas, varying from  the size of a
                   split  pea to that of  the thumb-nail.  The erect
                   penis is bent at the seat of hardening, and often
                   erection is incomplete in  the portion  of the  in-
                   volved  cavernous body lying  to the distal side of
                   the lesion.
                      Treatment.—The  treatment of this affection is
                   without avail.  In the  early stages, when slight
                  ' constant pain and beginning hardness indicate the
                   nature  of the case, pressure  by means of a  thin
                   rubber bandage, inunctions of mercuric ointment,
                   and  the  internal administration  of  potassium
                   iodide and wine of colchicum root, continued for
                   many months, may prevent permanent crippling.
                   When the lesions are fully formed the same treat-
 ment may be tried, but with slight prospect  of  success.   Thyroid
 extract has been given, but unavailingly.  When a calcareous  or a
 bony plate materially interferes with functional activity and is placed
 superficially, there can be  no objection to removing it by a cutting
 operation, but the operator should hold out no definite hope of resto-
 ration of function.
    Inflammatory lymphangitis is secondary to peripheral inflam-
 mation, sometimes non-specific, but usually of venereal origin.  The
 indurated  band is often felt extending  up the dorsum of the penis
Osseous growth of the
 penis. (Demarquay.) 
DISEASES AND INJURIES OF THE PENIS.
31
to the first lymphatic glands.   It usually undergoes resolution, but
may suppurate.  Often small nodules form in the course of the lym-
phatics ; these commonly disappear spontaneously, but exceptionally
they become red and painful, and finally discharge pus.  They some-
times persist as fistulae, which  continue to open and reopen, and are
cured  only by extirpation.  When but a single trunk  is  involved,
the neighboring parts may or may not be swollen.
    Diagnosis.—The diagnosis  between lymphangitis and phlebitis is
based upon the much smaller size of the lymphatic vessels as com-
pared with the veins; upon the fact that the former vessels do not
pass upward in the middle line, but are directed into the groins; and
finally upon the ability to lift the indurated vessel up from the deeper
parts, this not being possible in the case of the vein, since it is placed
in a furrow between the  two cavernous bodies.  Phlebitis occasions
much more marked oedema.
    Treatment.—The treatment of inflammatory affections of the lym-
phatic vessels is by rest in bed and the  application  of evaporating
lotions, together with the administration of a saline.
    In a very rare  form of lymphangitis  the  lymphatic vessels  of the
prepuce are dilated without marked inflammatory phenomena.  The
symptoms of this affection usually appear after coitus or other cause
of acute congestion.  On retraction of the prepuce  the congested,
semi-transparent lymph-vessels  are  easily detected, passing upward
and backward from  the fraenum towards the dorsum of the  penis.
The swelling  subsides in a few days, but recurs after each attempt
at coitus, until  finally it becomes permanent.  When  the swollen
vessels are unduly prominent,  mechanical  disturbance is followed by
marked symptoms of local inflammation.
    The treatment  in the early stages consists in prolonged  hot local
baths and the use of astringents.  Fluid extract of hamamelis, one part
to four parts of water; ammoniated mercurial ointment, ten  grains
to the ounce of carbolated  cosmoline;  ointment of belladonna and
mercury, one part to  four parts of lanolin, well rubbed in;  or com-
presses kept wet in lead water and laudanum, will often effect a cure.
    When the  dilatation  becomes permanent surgical  interference is
necessary.  A seton passed through the enlarged vessel or excision
of a portion of its length will be followed by a temporary increase of
swelling, but ultimately by obliteration and cure.
    Phlebitis  occurs  secondarily to other  lesions of the  penis or
urethra.  A dense indurated cord is  felt along the course of the vein,
and there is great  swelling.  Suppuration  is rare, and treatment by
evaporating lotions and rest and catharsis is usually efficient. 
32        GENITO-URINARY  DISEASES AND SYPHILIS.
   Varicose veins  of the penis are frequently observed, either  as a
local  expression of general venous dilatation  or independently of
other lesions  of a similar kind and as a sequel of  inflammation.
Usually they occasion no inconvenience.   When they are so large as to
interfere with coitus, cure may be effected by ligation or by excision.
   The inflammatory affections which  most frequently involve the
glans and prepuce are balanitis, balanoposthitis, and  herpes progeni-
talis.
   Balanitis and Balanoposthitis.—Balanitis is an inflammation
of the surface of the glans penis.  Balanoposthitis is an inflammation
of both this surface and the mucous layer of the  foreskin.   Posthitis
is, of course, an inflammation  of the mucous layer of the foreskin
alone.   They may be  considered together.
   Causes.—The principal predisposing  cause of these  inflammations
is a redundant or phimotic foreskin.  This keeps the apposed mucous
surfaces macerated and irritated, favors retention and consequent de-
composition of smegma and urine, and offers conditions most  pro-
pitious to a successful inoculation when specific  virus is introduced
within the preputial sac.  The gouty or rheumatic diathesis  and dia-
betes also predispose to this form of inflammation.
   The exciting causes are either mechanical,  as from  friction or
abrasion, or chemical, as  from  contact with irritating discharges, like
those'from  chancre, chancroid, or gonorrhoea,  or from non-specific
lesions, as endometritis.
   Symptoms.—The symptoms  of  balanitis in its mildest  form, the
form from which most men who are not careful as to local cleansing
suffer at times,  are a sense of  heat and itching about the end of the
penis, some redness and swelling near the preputial  orifice,  a dis-
charge which crusts and is extremely offensive, and on  stripping back
the foreskin a hyperaemic infiltrated mucous membrane exhibiting on
its surface a thick, creamy  deposit, and at times patches of  super-
ficial  excoriation.  (Fig.  12.)  In  the  coronary sulcus is  found an
abnormal quantity of semi-liquid, offensive smegma.
   In severe cases the excoriations are extensive and well marked,
inflammatory phenomena  are  more pronounced, and the  whole
prepuce  becomes greatly  swollen,  and  in  consequence  phimotic
(inflammatory phimosis).   The discharge is  profuse.  This form  is
often secondary to gonorrhoea,  chancroids,  syphilitic  lesions, or  gen-
eral troubles, such as diabetes.  It is, however, not due to the direct
action of specific germs of  the  venereal disease, the  gonococcus, for
example, but to the irritation incident to the contact with decomposing
discharges and to infection with the ordinary staphylococci. 
Fig. 12.
Herpes of the glans. 
 
DISEASES AND  INJURIES OF  THE  PENIS.
33
    In certain cases the erosions and superficial ulcerations start from
the corona, exhibit  circinate borders, and progressively  involve the
entire mucous membrane of the glans and foreskin, lasting for several
weeks, and, so far as extension is concerned, resisting all treatment.
    As a  consequence  of balanoposthitis there  may  develop:  (1)
lymphadenitis ; (2) condylomata ; (3) hypertrophy ; (4) gangrene.
    Lymphadenitis, at least the suppurative  form of the  affection, is
rare.
    Condylomata frequently develop during or after balanoposthitis.
    Hypertrophy of the foreskin, in the sense of a greatly elongated,
thickened, rigid prepuce, interfering with physiological activity, may
result in consequence of organization of the inflammatory infiltration
consequent on repeated attacks of  acute or subacute  inflammation.
It is noticed in middle-aged men, especially diabetics, and is usually
accompanied by chronic inflammatory lesions  of the  glans  or pre-
puce.  It is sometimes followed by epithelioma.
    When the inflammation is hyperacute, inflammatory swelling may
be  followed  by gangrene.  This is  scarcely possible except in phi-
motic cases.  There is little danger to life  in  this process, which is
self-correcting.  There may be, however, ultimate cicatricial deformity.
    Diagnosis.—The  superficial, irregular or circinate erosions, together
with  the  surrounding surface hyperaemia and the characteristic dis-
charge, render diagnosis fairly easy when the foreskin can be retracted.
    Herpes will at first exhibit vesicles, and, when these vesicles have
ruptured, circinate lesions.  The distinction between these  and the
erosions of balanoposthitis is, however, not always possible, nor is it
important.
    Chancroidal balanoposthitis develops insidiously, is characterized
by  an inflammatory infiltration or thickening  or hardening of the
glans and foreskin rather than by an acute oedema, exhibits more dis-
tinctly circumscribed erosions,  which are shortly converted into true
ulcers, and is soon followed by characteristic inguinal adenopathy.
    Syphilitic balanoposthitis, occurring as a secondary lesion, would
be diagnosed by the history of the case, the appearance of character-
istic lesions on other surfaces  of the body, and  the development of
moist papules primarily, after which neglect of treatment might occa-
sion a general inflammation of  the preputial sac.
    Only in cases of  purulent discharge complicated by tight phimosis
would there be difficulty in deciding between balanoposthitis, chancre,
chancroid, and gonorrhoea.  Gonococci would prove that  gonorrhoea
was present, auto-inoculation of discharge would show the presence
of chancroid (although this is not to be recommended as routine prac-
                                3 
34        GENITO-URINARY  DISEASES AND SYPHILIS.

tice), and a distinctly indurated area felt beneath the prepuce would
suggest chancre.  If, however, the prepuce were reddened,  swollen,
and  painful,  whatever the  primary lesion, these symptoms would
almost certainly denote the development of balanoposthitis, and would
call for the treatment appropriate to this form of inflammation.
   Treatment.—The basis of all treatment is cleanliness.   If the pre-
puce can be retracted, the inflamed mucous surfaces are washed with
a mild antiseptic solution, dilute subacetate of lead lotion, or bichloride
solution 1 to 4000, dried by means of absorbent cotton, and the ero-
sions  brushed with a ten per cent, silver nitrate solution; the  parts
are then dusted with a powder made of equal parts  of bismuth sub-
nitrate and calomel, a very  thin layer of absorbent  cotton is placed
over the glans, and  the  foreskin is  drawn forward.   This dressing
should be changed several times daily.
   When the discharge  is profuse,  very finely powdered  alum  or
tannin may be used in place of the calomel and bismuth.  Lumpy or
gritty dusting powders do more harm than good.
   When the inflammation  is unusually acute in type and erosions
are extensive, a wet dressing is indicated.  Under such circumstances,
after washing  and drying, the dusting powder  and silver nitrate are
omitted, the thin layer of dry cotton  being  placed  directly on  the
glans  and then wet with the required solution, preferably dilute lead
water, or fluid extract of hydrastis  canadensis 1  part, rose water 9
parts.  In phimotic cases the preputial sac  should be  washed  out
every two  hours, first with warm water and  soap,  then with clear
water, and then  with  mild antiseptic solutions, such as sublimate
1 to 4000, or  carbolic  acid  1 to 500, or, better still, a solution con-
taining both these antiseptics in the  proportion  just given.  This
washing is best accomplished by means of a hard rubber  syringe pro-
vided with a  conical nozzle,  though when the preputial orifice is
sufficiently large a flat nozzle will occasion less irritation.   The whole
preputial sac should be ballooned out with the solution,  unless great
pain is caused by this distention.  Following the antiseptic injection
the hydrastis  solution  1  to  10 should be used.  When  suppuration
is very profuse, peroxide of hydrogen may precede  the antiseptic
injection.
   General swelling of the prepuce is combated by keeping the parts
wrapped in lint wet in dilute alcohol and lead water equal parts.
   When gangrene threatens, an attempt to abort may  be  made by
continued hot  local baths,—/.e.,  soaking the penis  in dilute antiseptic
solution as hot as can be  borne for two hours at a time, two or three
times a day.   If this does not promptly relieve tension, the prepuce 
DISEASES AND  INJURIES OF THE PENIS.
35
should be split along its dorsum, exposing the inflammatory lesions
and allowing them to be treated directly.
   Chancroidal balanoposthitis, or that complicating diabetes, is alone
liable to occasion such marked swelling as to require splitting of the
foreskin.  Under these circumstances, the immediate completion of
the operation by circumcision involves more risk than usual, but may
be attempted after the  patient has been fully warned as to the danger
of infection of the wound.  Munn  and  others have attained good
results by careful curetting and disinfection of the sores before opera-
tion.  In diabetic  cases, in this region  as elsewhere, rigid antisepsis
is of especial importance.
   Herpes Progenitalis.—This  affection is  characterized  by the
rather sudden appearance of vesicles clustering upon erythematous
bases situated on the  mucous or skin  surfaces  of  the penis, and
attended with itching and burning.   (Fig. 13.)  Commonly  they
appear in or about the coronary sulcus, involving both the glans and
the  foreskin.  When thus placed the covering of these vesicles is
quickly macerated, leaving rounded or irregular erosions which may
become  confluent but still  exhibit  a  polycyclic  outline.   A  mild
balanoposthitis usually complicates herpes, and the  affection some-
times causes suppurating  buboes.  Warts frequently develop.
   When these lesions are neglected the abrasions may be converted
into punched-out ulcers (ulcerating herpes).
   Sometimes the  lesions are accompanied by intense pain, much
like  that of herpes  zoster; the  affection is then  termed neuralgic
herpes.  The pain  may  precede  the development of the vesicles,
which may be so few and discrete as to  attract little attention.  Ex-
ceptionally there is marked sexual erethism,  causing prolonged erec-
tions and nocturnal pollutions.  The burning shooting pain is generally
confined to the penis ;  occasionally it is reflected to the perineum and
the groins, and even  down the thighs. This neuralgic herpes is some-
times accompanied by urethral discharge simulating  gonorrhoea, but
differing  from  it in the  absence of gonococci.  This discharge is not
favorably influenced  by local or general  treatment.  Herpes having
once appeared is prone to develop again ; at times the recurrence is
observed hard upon  the first attack, new crops  of vesicles forming as
fast as earlier lesions  are healed.  More frequently  there is a dis-
tinct interval between attacks.  When it has this tendency to relapse
it is called recurrent,  and is often neuralgic in type.  Herpes appearing
upon the skin  surface of the prepuce does not differ from the eruption
as observed  on other surfaces of the body. The eruption, wherever it
is situated, may be discrete, even to the extent of the formation of but 
36        GENITO-URINARY DISEASES AND SYPHILIS.

one or two vesicles, or  confluent, forming in this  case  usually small
patches, sometimes completely covering large surfaces and causing in-
tensely painful inflammatory erosions.  The pain is so severe that the
system suffers, and  the patients, generally women, are confined to
bed.
   Etiology.—-The causes of herpes are  practically the same as those
of balanoposthitis.   The eruption  is predisposed  to by rheumatism,
gout, and a neurotic tendency ; also locally by any causes tending to
excite inflammation, such as  phimosis and urethral or preputial  dis-
charges.  The mechanical  irritation of immoderate  coitus,  together
with the effect of prolonged contact with any irritating uterine or
vaginal discharge, may be an  exciting cause.
   The diagnosis of herpes is founded upon the rather sudden appear-
ance of vesicles in clusters, either without obvious cause or following
closely upon mechanical or chemical irritation.  When the lesions are
observed in their vesicular stage they cannot well be confounded with
any other affection.  Thus, when they appear on the skin of the penis
or scrotum there can be no doubt as to their nature.  When they are
placed on the mucous surfaces of the glans and foreskin, however,—
and this is their usual  situation,—they are rarely observed before
the coverings of the vesicles have been macerated  and the lesions are
erosive  or  ulcerative in type.   Even then they are usually super-
ficial, multiple, circular, or, when confluent, at least circinate in type,
non-indurated, except when  placed at or within the urethral orifice,
rapid in development, non-progressive, with moist, red surface, when
squeezed give a slight serous  discharge, and if kept clean rapidly heal,
though new lesions may occur on previously healthy surfaces.
   The differential diagnosis  must be made from chancre, chancroid,
balanoposthitis, and mucous  patches.   The points of difference be-
tween herpes, chancre, and  chancroid  are tabulated on page  314;
though it is of sufficient importance to  be  repeated here  that herpes
sometimes  (about once  in ten cases) causes  painless polyganglionic
bilateral inguinal  adenitis, exactly like that following chancre.
    The lesions of balanoposthitis are usually more diffuse and rather
irregular or serrated than polycyclic in outline.   Moreover, they are
not preceded  by vesicles.  The differential diagnosis cannot always
be made,  since  herpes is generally accompanied by  more or less
balanoposthitis.   Mucous patches are  accompanied  by other mani-
festations of syphilis, are slower in development than herpes, do not
begin as vesicles, and present a grayish  necrotic pseudo-membrane in
place of the red,  moist, shining surface of the herpetic lesion.
    Treatment.—Cleanliness is the key-note of successful treatment. 
DISEASES AND  INJURIES OF THE PENIS.
37
Antiseptic washings, careful drying, painting with silver nitrate, dusting
with zinc oxide or bismuth, the interposition of a thin layer of cotton
between the two  mucous surfaces, and, if necessary, the remainder
of the treatment  described as  appropriate  to balanoposthitis, ordi-
narily bring about cure in a  few days.  When the  inflammation is
more than usually acute, a wet dressing should be substituted for the
dusting powder.  In the ulcerating form the system is usually at fault;
here treatment appropriate to the general condition  present should
supplement local treatment, the gouty or tubercular diathesis receiving
proper medication and diet.
    Neuralgic herpes is often benefited by painting with  silver nitrate
solution ten grains to the ounce, or solution of chloral one drachm to
the ounce, or carbolic acid lotion 1 to  60; the erosions  should then
be dressed as already described.  This form of herpes is, however, not
readily influenced by treatment.   Local applications of cocaine will
sometimes relieve the pain.   This may be sprayed on, a four per cent.
solution being used, or the following ointment may be applied:

                     R Cocainse hydrochlor., gr. xii;
                        Menthol, gr. i;
                        Lanolin, giv.
                     M.  S.—Use locally.

When the pain is harassing and unrelieved by local treatment, the
galvanic  current  may be tried; this failing, the  suffering should be
relieved by an anodyne, since it will cease spontaneously in from  four
to twelve days.
    Recurrent herpes is most  frequently observed in connection with
a redundant or phimotic prepuce.   Here circumcision is often  the
only means which will bring permanent relief. When there seems to
be no local predisposing factor, the surfaces most often affected should
be  frequently bathed in aqueous solutions of hydrastis extract 1 to 5,
or hot saturated solution of alum, and after exposure  to any form
of irritation should be thoroughly cleansed with mild antiseptic lotions,
washed with the astringent, carefully dried, and dusted with stearate
of zinc or bismuth, or carbolized talc.  A general  tonic and support-
ing dietetic and medicinal treatment should be prescribed at the same
time, minute doses of arsenic and  bichloride of mercury (grain one-
sixtieth of  each t. i. d.) and the less irritating iron preparations being
particularly indicated.
                     TUMORS  OF  THE PENIS.
   Tumors of the penis may be cystic or solid, benign or malignant.
   Under the benign tumors are included cysts, sebaceous, blood, 
38        GENITO-URINARY DISEASES AND SYPHILIS.

and mucous, papilloma, horny growths, lymphangioma, fibroma, and
adenoma.  Except papilloma, these lesions are rare.
   The malignant tumors include carcinoma, sarcoma, and epithe-
lioma.  The latter is by far the commonest form of cancerous growth.
Carcinoma and sarcoma are sometimes observed in infants.
   Cysts, fibroma,  angioma, etc., are so rarely  observed, and
when seen coincide so completely with similar growths of other parts
of the body, that they require no detailed mention.  Sebaceous cysts
are occasionally  seen  in the prepuce.  Cysts  from  distention of
Tyson's glands may be  multiple,  and sometimes reach large  size.
Angiomata have caused troublesome bladder reflexes.
   The treatment is the same  as that appropriate to like  conditions
in other parts of the body,—i.e., removal when they are increasing in
size or cause pain or interfere with function.
   Lymphangioma,  or elephantiasis, rarely involves the  penis
alone; usually the scrotum is implicated.   An operation for the
removal  of  the thickened tissue  may be necessitated by  its inter-
ference with physiological activity.   (See page 862.)  The filaria may
or may not be found.   The diagnosis  is nearly always rendered easy
by the associated thickening  of the  skin of the scrotum and lower ex-
tremities.  When the foreskin is primarily attacked, at least in the early
stages, it may be difficult, indeed impossible, to decide whether the
overgrowth  is due to  infiltration consequent  upon a chronic balano-
posthitis, or to elephantiasis.  In the  latter case  the absence  of pre-
ceding balanoposthitis,  and  the steady progress of the infiltration
in spite of local  cleanliness, would in a short time lead to a correct
diagnosis.
   Verrucse or Papillomata.—Venereal warts  appear as small or
large,  discrete or confluent, moist  or dry  papillary overgrowths,
usually springing from the coronary sulcus, the  posterior  border of
the glans penis,  the inner surface and margin  of the prepuce, the
region of the fraenum, and the orifice of the urethra.   (Fig. 14.)
   Pathologically these outgrowths are found to be due to hypertro-
phy of the papillary and mucous  layers  of the  skin.  At  the  same
time there is a corresponding development of blood-vessels.  On the
mucous surfaces  they are moist, from maceration of the epithelial
covering; on the skin surfaces, as the penis, scrotum, or thigh, they
are generally dry.
   The cause of venereal warts  can usually be  traced to irritation
incident to prolonged contact with inflammatory discharges.   Thus,
in the uncleanly, in those suffering from gonorrhoea, herpes, chancroid,
or balanoposthitis, papillary  outgrowths are by no means uncommon. 
DISEASES AND INJURIES OF THE PENIS.
39
Fig. 14.
The most important  predisposing cause is a redundant or phimotic
foreskin.  In addition there  seems to be in certain persons a consti-
tutional predisposition towards papillary outgrowths.  Proof as to the
contagious  nature of  discharges from venereal warts  is still wanting,
though there  are many recorded cases of condylomata developing
apparently as the result of contagion.
    Symptoms.—Condylomata are found most  often in men between
the fifteenth and the twenty-fifth year, and in those who give a history
of inflammation about the genitalia, either from disease or from redun-
dant foreskin.  They appear as markedly
vascular outgrowths  from  either the
skin or the mucous membrane.   Some-
times  they  project like one or  more
threads,  or  may  form discrete,  small-
sized,  tuberous  excrescences,  or  by
confluence  may produce an outgrowth
resembling a raspberry or a cauliflower.
The confluent warts often assume the
shape  into which they are moulded by
the pressure of the surrounding parts;
thus, under the prepuce, pressed be-
neath the foreskin and the glans, they
may be  flat and  broad  like a  cock's
comb.
    Diagnosis.—Venereal warts may be
confounded with the mucous patch, or
condyloma lata, and with epithelioma.
    The  condyloma  lata,  or mucous
patch,  rarely  appears as  an isolated
lesion of syphilis; the  concomitant signs of the disease and a  history
of the  case usually indicate the nature of the affection, though  it must
not be forgotten that syphilis may excite true  papillary overgrowth
almost identical in appearance  with  the overgrowth of condyloma
acuminata.
    Epithelioma usually occurs after middle life.  It ulcerates, grows
rapidly, involves the surrounding tissues in a dense infiltrate, and is
accompanied by a characteristic induration of the inguinal glands.
   A wart found  upon the sexual organs of an old person,  even if
characteristic in appearance, should always excite suspicion, since this
benign neoplasm is comparatively rare after middle life, while malig-
nant growths are  by no means uncommon, and in their early period
closely resemble the venereal wart.
Venereal warts. 
40        GENITO-URINARY  DISEASES  AND SYPHILIS.

   At the time the differential  diagnosis is most important, i.e., in the
beginning, it is most difficult.   It should be remembered  that even at
this period of the disease the malignant growth infiltrates the tissues
from which it springs.
   Only by means of microscopic examination of sections from the
outgrowth can a positive  opinion be given, since clinical experience
shows that the benign neoplasm is at times transformed into a malig-
nant growth.
   Prognosis.—Venereal warts, if kept  clean, and  protected  from
mechanical irritation, spontaneously disappear, though predictions as
to when this result will occur can never be made  with safety.   If
utterly  neglected, they  ulcerate and  suppurate,  and may often be
complicated by inflammatory buboes or by sloughing and gangrene.
Exceptionally they form the starting point of cancer.
   Treatment.—Complete removal of the papilloma and cauterization
of the  base  from which it springs constitute the only reliable treat-
ment.   A ten per cent, solution of  cocaine applied  by  means of a
cotton  swab to the region of  operation for five  minutes before  the
warts are removed, then  again applied  to the  bleeding surface for
one minute before cauterization, will render the  operation practically
painless.
   The method  of operating on condylomata is as follows.  Where
the outgrowths are discrete and small, each is seized in a pair of rat-
tooth forceps,  drawn upward,  and removed, together with the tissues
of its base, by a snip of the scissors.   The little bleeding points left by
this cutting are touched with  pure carbolic acid, and the dressing is
completed by  dusting with iodoform or other powder, and, if neces-
sary, applying a clean  narrow gauze  pressure bandage.   When  the
neoplasm has a large base, the whole outgrowth may be shaved off
level with the surrounding surface by means of a sharp, flat knife.
The  wound left by this incision should be thoroughly curetted, and
then should be cauterized  with carbolic or nitric acid and  dressed
with iodoform or with a powder made of calomel  and zinc oxide,
equal parts of each.  Bleeding is free  for a few moments, but usually
stops on cauterization, or on the application  of a cotton  pledget
soaked in a five per cent, solution of antipyrin.  In excising unusually
large papillomata it is well to have an actual cautery ready in case
of continued hemorrhage.  Only spouting vessels should  be ligated.
   At the time this operation is performed an effort should be  made
to remove the exciting cause of the lesion.  Thus, phimotic  patients
should be circumcised,  urethral discharges should be  prevented from
coming in contact with the external parts, etc. 
DISEASES AND INJURIES OF THE PENIS.
41
   A still more radical method of procedure, and one always applica-
ble when the papilloma springs from the prepuce or skin surface, con-
sists in cutting away the entire base of the papilloma and approximating
the edges of the resulting wound by sutures.  This operation, if prop-
erly performed, gives absolute assurance  against  recurrence  of the
lesion in loco.  When operation is refused, warts may be removed by
nitric acid.   The  surrounding surfaces should be protected by the
application of a little cosmoline; the acid is well rubbed  into the
wart and a boric ointment  dressing is applied.  The  application is
repeated every second or  third  day until the papillary layer of the
skin is destroyed at the point of outgrowth.
    Chromic acid is an excellent application, but is open  to the  objec-
tion that occasionally it gives rise to general toxic  symptoms.   Fatal
cases have been reported.   It is  usually employed either pure or in
a ten per cent, solution, brushed  over the outgrowth once daily.
    Caustic potash is  an  excellent cauterant.  It may be used in the
following form:
                      B Plumbi oxidi, gr. ii;
                        Potass, hydrat., gr.  xx ;
                        Aquae, q. s. ad fjji.
    M. S.—Shake well, and apply by  means of a brush to the lesion, which has
previously been cleansed and dried.  One or two applications are sufficient.

    Certain non-cauterant  remedies are advised, and at times give
good results, possibly because of the spontaneous tendency towards
healing exhibited  by the condylomata.   Among these may be  men-
tioned the following:
                       R  Acidi salicylici, 2[i;
                          Acidi acetici, f^i.
                  M.  S.—Apply with a brush  once daily.

    Saturated solution of salicylic acid may be employed; this should
be applied repeatedly.   Astringents, such as dilute  lead water and
tincture of perchloride of  iron, are  frequently advised.   After  these
applications have  caused the papilloma to disappear, cauterization of
the base usually will be necessary to prevent recurrence.
   The effect of irritants not strong enough to act as  cauterants is
to stimulate the papillary outgrowths.
   Horny Growths of the Penis.—In  the few reported cases of
this  affection the  growth has  sprung from  the  surface of the  glans
penis of old men.   It is an extremely rare manifestation of perverted
epidermic hypertrophy.  It is easily recognized, and its main patho-
logical importance lies in the fact that it is at times the forerunner of
cancer.   The  appropriate  treatment is the thorough removal of the 
42        GENITO-URINARY DISEASES AND SYPHILIS.

horn, together with the base from which it grows.  When the patient
is  advanced in years and there is  no indication of epitheliomatous
degeneration, surgical operation is not indicated.
   Malignant Disease.—With the exception of epithelioma, malig-
nant disease of the penis is extremely rare.
   A few cases of medullary cancer have been described.  These de-
velop about the  period of puberty, and are apt to be consequent on
trauma.  They form rapidly growing, lobulated, painful tumors.  The
lobules may be so soft as to  suggest the formation of a  cyst.  There
are usually the phenomena of subacute inflammation, and the lym-
phatic glands of the groin are quickly involved.   Amputation carried
                                         wide  of the  disease  is
                  FlG- 15,                  the  only treatment, and
                                         even  if  this  procedure
                                         be  adopted early,  the
                                         ultimate  outlook  is  ex-
                                         tremely unfavorable.
                                           Epithelioma commonly
                                         appears  on  either  the
                                         glans  or the prepuce.   It
                                         may assume the  super-
                                         ficial  or the  infiltrating
                                         form.    (Fig.   15.)    It
                                         usually   develops  after
                                         middle  age,  and  some-
                                         times grows  from the seat
                                         of a former  chancre.
                                           Symptoms. — Epitheli-
                                         oma  generally  appears
                                         first  in   the   form  of
                                         a small venereal  wart,
                                         which  becomes  exco-
                                         riated,  ulcerated,   and
                                         shortly  indurated.   The
                                         disease,  beginning  as a
                                         small  ulcerative  vegeta-
tion, gradually extends  until a  large  portion  of the  prepuce  and
glans is involved.  (Fig.  16.)   The ulceration has a  hard base and is
irregularly  excavated.  Together with the deep ulcers there are often
cauliflower-like outgrowths.  (Fig. 17.)  The surrounding skin is infil-
trated, oedematous, nodular, elevated,  and purplish in  color.   The
glans is greatly swollen, irregular in outline, and lobulated.
Epithelioma. (Demarquay.) 
Fig. l(i.
Epithelioma, vegetating form. 
 
DISEASES AND INJURIES OF THE  PENIS.          43
   As the disease  extends backward  the  cavernous bodies  become
indurated and the overlying skin, at first slightly adherent, is involved

                               Fig. 18.
Epithelioma with glandular involvement.
Finally the lymphatic  glands of the groin become
ulcerated,  and  discharge fetid, blood-stained pus.
Fig. 19.
in the disease.
infiltrated  and
(Fig. 18.)
   Etiology.—The  pres-
ence of a  redundant  or
phimotic foreskin,  accu-
mulations  of   smegma,
subpreputial      calculi,
chronic  balanoposthitis,
specific  or  non-specific
ulcerations,  indeed, any
source of local irritation,
may act as  a predisposing
cause  for  the  develop-
ment of epithelioma.
   Diagnosis.—This    is
difficult only in the early
stages of the disease.
   When  without  ob-
vious  cause  a   warty
growth develops on the glans or the foreskin in a person past middle
life, this  lesion should be carefully watched.  Induration about the
base  (Fig.  19) or  ulceration of  the  excrescence  would  justify the
diagnosis of  epithelioma, and would indicate a prompt removal.
Cross-section showing infiltration of an epithelioma.
             (Demarquay.) 
44         GENITO-URINARY DISEASES AND SYPHILIS.

   Prognosis.—The prognosis of epithelioma is grave unless operation
is undertaken  in  its very earliest stages.   The course of the affection
varies greatly in different cases.  Some patients perish in two months,
others survive for many years.  When the inguinal glands are involved
there is but slight chance of ultimate recovery.
   Treatment.—The only treatment to be considered in these cases
is entire removal of the diseased part.   When the disease has not
developed further than slight ulceration of an indurated papule, total
excision of the involved area, with  subsequent cauterization of the
excision wound by means of caustic potash, may suffice.
   When epithelioma is fairly developed, amputation carried wide of
the disease is  the only resource.  Enlarged  lymphatic glands  should
be removed at the same time.
   Partial Amputation  of  the Penis.—A partial operation, and  one
to be adopted when  surgical intervention is simply palliative,  is per-
formed in the following manner.  If the point of amputation  is well
back, a stout acupressure needle is thrust through the corpora caver-
nosa from side to side, and behind this a medium-sized drainage-tube
is wound two or three  times around the penis and kept in place by
catch forceps or by knotting.  The latter prevents loss of blood ; the
former guards against retraction of the stump after amputation, which
might make securing of  the divided vessels extremely difficult.  By a
circular sweep of the knife  the skin of the penis is divided at the pro-
posed seat of  amputation.   Half an  inch in front of this the spongy
body of the urethra  is  cut  across and  dissected back to the level
of the  skin incision.   The corpora cavernosa are then cut through
on a level with  the first  incision, the rubber  ligature is removed,
the bleeding vessels are  secured by means of fine-pointed haemostatic
forceps  and by catgut  ligatures, and the acupressure  pin  is  taken
out.  Sutures  are then  passed drawing together the cut edges of the
fibrous  sheaths of the  cavernous bodies, thus completely covering
in the vascular erectile tissue, and both protecting it  from subsequent
infiltration  and  infection  by  the urine and immediately  checking
oozing.  The urethra is  split on its floor back to the  level of the sur-
face  of the divided cavernous bodies.  The borders of this incision,
together with the divided urethral end, are sutured to the skin.  The
latter is then  stitched so as to cover in the cavernous bodies.  A soft
rubber catheter is passed into the bladder, and is left in for from three
to five days. The line of suture is dusted with iodoform and is dressed
with iodoform gauze.  The dressing is  held in place  by a T-bandage,
provided with an aperture  for the catheter.  It  is well  to have some
form of cautery at. hand, in case bleeding should be persistent. 
           DISEASES  AND INJURIES OF THE PENIS.          45

   Amputation of the  Entire  Penis.—This operation is decidedly the
one of choice when the disease is so far advanced  that partial ex-
cision can no longer be considered, and when the healthy condition
of the inguinal lymphatics shows that there is still a possibility of
preventing  further extension by prompt  removal of  the  obviously
diseased parts.  Treves describes the operation as follows:
   The patient is placed in the lithotomy position, and the skin of the
scrotum is  incised along the whole length of the  raphe.   With the
finger and  the handle  of the scalpel the  halves of  the scrotum are
separated down to the  corpus  spongiosum.  A full-sized metal  cath-
eter is passed as far as the triangular ligament, and a knife is inserted
transversely between the corpora cavernosa and the corpus spongio-
sum.  The catheter  is withdrawn, the  urethra is cut across, and its
deep end is detached from  the penis back to the triangular ligament.
An incision is made around  the root of the penis continuous with
that in the  median line.  The suspensory ligament is divided and the
penis is separated, except at the attachment to the  crus.  The  knife
is then laid aside, and  with a stout periosteal elevator or rugine each
crus is detached from  the pubic arch.  The two arteries of the cor-
pora cavernosa and  the  two  dorsal arteries require ligature.   The
urethra and corpus  spongiosum are split up for about half an  inch,
and the edges of the cut are stitched to the back part of the incision
in the scrotum.   The  scrotal  incision  is closed  by sutures, and the
drainage-tube is so placed in the deep part of the wound that its end
can be brought out in  front and behind.   No catheter is retained in
the urethra. 
CHAPTER II.
              injuries and diseases of the  urethra.

   The Anatomy  of the Urethra.—The  urethra, serving the
double purpose of a  carrier for the urine  and for the semen, is a
tubular passage about eight  inches in length, of somewhat changing
calibre in various parts of its course.  Originating from the bladder,
it passes through the upper part of the central portion of the prostate
gland, pierces the anterior and posterior layers of the triangular liga-
ment about one inch below the lower border of the pubic symphysis,
and  then, surrounded by  the  corpus  spongiosum, passes  on to the
meatus.
   The prostatic portion of the urethra is about an inch and a quarter
long, and  is the widest and most dilatable part of the canal; the
membranous portion  is about three-quarters of an  inch long, and is
the narrowest, least dilatable part of the urethra, except the meatus.
The  spongy or penile portion of  the  canal is  about  six  inches in
length.
   The meatus is the narrowest part of the urethra.  Immediately
behind this opening the passage widens somewhat, forming the  fossa
navicularis.   Passing backward, the urethra  becomes slightly nar-
rower, and,  exhibiting a nearly  uniform  diameter,  traverses the
spongy body till it reaches the bulb, or posterior portion of this body,
where it  again dilates. This dilatation narrows abruptly at the an-
terior layer of the triangular ligament, the membranous urethra  being
of small  but uniform calibre.  After passing  through the posterior
layer of the triangular ligament the urethra again widens out, reaching
its greatest diameter  at the position of the caput gallinaginis.   Be-
fore  passing into the bladder there is a slight narrowing, noticeable
only when the latter viscus is empty.
   There  are, then, three regions of physiological dilatation.   These
are located in the prostate gland, at the bulb, and behind the meatus.
   The natural positions of physiological narrowing are at the meatus
and the membranous portion of the canal.
   The epithelial lining of the mucous membrane of  the urethra is
flat and laminated near the  meatus; in other  portions of  the tube it
is columnar.
     46 
          INJURIES AND DISEASES  OF THE URETHRA.        47

   The mucous membrane is continuous with the bladder internally
and with  the  integument of the glans penis externally.  It  is pro-
longed into the ducts of all the glands which open into the urethra.
   The submucous tissue is  made up of fibrous and elastic tissue,
together with  unstriped muscular  fibres.  These latter are arranged
in two layers,  one passing longitudinally, the other  circularly.  This
muscular layer is  most marked in the prostatic and membranous por-
tions of the urethra ;  passing forward, it becomes thinner, till in the
anterior part of the spongy urethra it  is replaced in a great measure
by fibrous tissue.
   On the mucous membrane of the urethra may be seen the open-
ings  of many  glands  and follicles.  These are situated in the  sub-
mucous tissue.  The glands, called the glands of Littre, vary greatly
in size, and are most abundant in the spongy portion of the canal and
about the meatus.  Their orifices are directed forward.   The largest
of the follicles, called  the lacuna magna, is situated in the upper wall
of the fossa navicularis, and  is one and one-half  inches from the
meatus.
   The spongy portion of the urethra, so named because it is sur-
rounded by the erectile tissue of the corpus spongiosum, extends from
the meatus to  the anterior layer of the triangular ligament.  It is fur-
ther  subdivided into a pendulous and a bulbous portion.   The pendu-
lous  portion extends from the meatus to the dilatation enclosed  by
the bulb (about four  and one-half inches in length).  The  bulbous
portion or dilatation  (about an inch  to  an inch and  a half long) is
abundantly  supplied with mucous glands and follicles ;  into it also
pass  the ducts of Cowper's glands. In direction the spongy urethra
first passes upward, then curves downward.
   The membranous portion of the urethra, beginning at the prostate
gland and  ending at the bulb, is separated from  the pubic symphysis
by muscular fibre and by the dorsal vessels and  nerves of the penis;
below  it lie Cowper's glands.  Its upper surface is concave, and is
about one-quarter of an inch longer  than the lower surface.  The
perineum  separates the lower surface of the membranous  urethra
from the rectum.   In  this portion of the urethra the erectile  tissue is
but slightly developed.  In place of this there is a complicated invest-
ment of muscular fibres.  First there  is a layer of unstriped fibres
passing circularly and longitudinally.   External to  this there is  an
investment of  voluntary muscular  fibres  completely surrounding the
urethra.  This muscular sheath is  named the compressor urethrae.
   The prostatic urethra is spindle-shaped,—that is, it is widest at its
middle. On the floor of the canal the mucous membrane  is projected 
48        GENITO-URINARY DISEASES AND SYPHILIS.

in the form of a longitudinal ridge, called the verumontanum, or caput
gallinaginis.   On  each side of this ridge lies a depression, called the
prostatic sinus, into  which open the  orifices of the prostatic  ducts.
Immediately in front of the verumontanum is  the sinus pocularis, a
blind pouch running upward  and backward beneath the middle por-
tion of the prostate gland.  At or just within the margin of the sinus
pocularis are the  slit-like openings of  the ejaculatory ducts.
    At the point where the prostatic  urethra enters the bladder it is
surrounded  by a muscle made up of unstriped fibres, called the in-
ternal vesical sphincter;  anterior to this a double layer of unstriped
muscular fibres and  the glandular structure of the prostate surround
the urethra.   At the apex of the prostate there is a sphincter made
up  of both voluntary and involuntary muscular fibres; this is called
the external vesical sphincter.
    The discharge of urine from the bladder is prevented by the tonic
contraction of the muscular  apparatus  of the membranous and the
prostatic urethra.  As the bladder becomes distended, the internal
vesical sphincter  yields, and the  urine enters the posterior part of the
prostatic urethra, causing a desire to urinate, which is  resisted by the
action of the voluntary fibres of the external  vesical sphincter  and
the compressor urethrae.  On passing a catheter when the bladder is
full, the urethra  seems  about an inch  shorter than  it does imme-
diately after micturition ; this is  owing to the participation  of the pos-
terior portion of  the prostatic urethra in the retentive  function of the
bladder.
    The compressor urethrae muscle is readily.excited to reflex spasm.
Ordinarily, on the passage of instruments, a moderate degree of resist-
ance can be detected, due to the contraction of  this muscle.  In irri-
table conditions  of the mucous membrane there may be excited a
spasm so violent  that it will be impossible to introduce a soft instru-
ment.  Such a spasm may also be excited by irritation  of the prostatic
urethra, either from distention of the bladder or from any other cause.
Thus, it is often found extremely difficult to evacuate the bladder when
the desire to  urinate  has been resisted  for many hours, and acute
inflammation of  the posterior urethra  not infrequently requires the
use of catheters  to  overcome the tight muscular contraction of the
compressor urethrae which prevents micturition.   Not only the intro-
duction of sounds, but even  the injection of bland liquids, will cause
contraction  of the  compressor  urethrae muscle,  and  hence prevent
such injection from reaching the membranous or the prostatic urethra.
Any inflammation in these portions of the urethra will also cause the
tonic contraction of the sphincter muscles to be accentuated.  Hence 
INJURIES AND  DISEASES OF THE  URETHRA.
49
inflammatory discharge from the membranous or the prostatic urethra
will  flow not forward, but into the bladder, and injections intended
to reach the deep urethra will, if driven in at the meatus, extend  no
farther  back than the anterior  layer of the triangular ligament.
   There seem, then, to be good grounds, both from a physiological
and  from a clinical stand-point, for dividing the urethra into an an-
terior erectile part and a posterior muscular part.
   Malformations of the Urethra.—The urethra may be absent,
obliterated, congenitally  strictured,  sacculated, or  deficient  as  to  its
floor or its roof.  Of these anomalies deficiency of the floor and of
the roof, entitled hypospadia and epispadia, are most common.
   Absence of  the urethra is a malformation usually  fatal to the
child before birth, since  the distended bladder by  pressing on the
umbilical arteries interferes with the foetal circulation.  Exceptionally
the  child  is born  alive with a  greatly dilated  bladder, in which case
the  urine may escape  through a patent urachus, or by way of the
rectum  or perineum, fistulae being formed; or operation by supra-
pubic or perineal puncture may give relief.
    Treatment.—The proper treatment for absent urethra  would  be
the  formation of a perineal fistula, the  position of the  base of the
bladder previously having been  determined by digital  examination
through the rectum.
   Atresia or obstruction of the urethra, usually at  one point, may
occur at any portion of  the canal,  but is commonly  observed  at  or
near the  meatus.   The  occlusion may be caused by a thin,  easily
pierced  membrane, the variety ordinarily seen near the meatus or in
some portion of the anterior urethra; or the  urethra itself may be
converted into  a fibrous  cord,  a form rarely observed, except  in  or
near the membranous portion of the canal.  In these cases fistulae
often form, giving  spontaneous relief.  Frequently, however, there is
retention  of urine, with  all its disastrous effects upon  the bladder
and  kidneys and upon the system at large.  As in the case of absent
urethra, the condition usually causes the death of the  foetus.
   The  diagnosis is founded upon the failure of the child to urinate,
the  presence of a  distended bladder, which  sometimes completely
fills the  belly, and  can be felt by abdominal palpation and  by digital
examination through the rectum, colicky pains, and the discovery of
obstruction, either by inspection, when the stoppage is located  at  or
near the meatus, thus allowing  the  urethra to become distended be-
hind the point  of  blocking, or by  instrumental examination, if the
visible portion of the urethra seems normal,
   Treatment.—The treatment, when the obstruction is at or near the
                               4 
50         GENITO-URINARY  DISEASES  AND SYPHILIS.

meatus, consists in opening the obstructed  portion of the urethra by
means of a trocar and canula, a tenotome, or a small sound.   When
it is placed deeper it would seem advisable to pass a sound down to
its anterior face and make an attempt by gentle pressure exerted in the
proper direction to pass through it.  Having succeeded in introducing
an instrument and evacuating the urine (not all at one sitting, in case
of great  bladder distention), the sound is passed through the seat of
obstruction at intervals of three days for several weeks.
   When instruments cannot be introduced, the  membranous and
prostatic portions of  the  urethra  should be opened  by  external
perineal urethrotomy, and the posterior limit of the obstruction de-
termined by  passing an instrument from behind forward; or if the
occlusion extends well back into  the membranous urethra the same
result may be accomplished more readily by performing suprapubic
cystotomy.  The position and the extent of the urethral obstruction
having been  exactly determined by one instrument passed from the
meatus backward, and by  another passed from  the membranous
urethra or the bladder forward, the urethra may be rendered per-
vious either by instruments cutting from within, a long knife passed
through  an endoscopic tube,  for instance, or by  an external ure-
throtomy, followed by plastic operation.  Unless the obstruction be
limited to a thin membrane, external operation will be required.  An
attempt may be made to repair the defect in the  urethral lining by
transplanting mucous membrane from the cheek.   This  is held in
place by a  few catgut sutures  and the permanent  catheter, the skin
opening being  closed by suture.  The catheter is  left  in place six
days.  Regular dilatation is necessary in the after-treatment.
   Congenital strictures, if the usual narrowing at  or just behind
the meatus be excepted, are extremely rare.  If present, they will be
denoted by slow dribbling urination, with increased frequency, dilata-
tion  of the bladder,  and colicky  pains.  Such strictures  should be
treated by gradual dilatation ; this failing, urethrotomy is indicated.
   Very exceptionally narrowing of  the meatus becomes so  extreme
that the  act  of micturition is  seriously  interfered with.   There is
usually an associated phimosis, which hides the real seat of  obstruc-
tion.   Meatotomy should  be  performed  immediately, the meatus
being kept patulous  by the regular passage  of bougies till healing
is complete.
   Valvular  folds have been found  post  mortem in the prostatic
urethra, with characteristic changes  of bladder, ureters, and  kidneys,
showing  that they had occasioned fatal obstruction.   Such folds are
also found about the junction of the  penile and the glandular urethra. 
INJURIES AND  DISEASES OF  THE  URETHRA.
51
   The diagnosis is difficult, and will  be founded on  slow, difficult,
frequent urination,  bladder distention, and colicky pains associated
with a urethra which readily admits a small sound.
   The urethroscopic tube (No.  12 to 14 F.) might render both  a
diagnosis and treatment by cutting practicable in the case of prostatic
valves.  The bulbous bougies should find anterior valves ; these are
readily divided by a tenotome.
   Urethral pouches or diverticula may sometimes reach large size.
They develop from  the floor of the urethra, and in the cases described
were found just behind the glans.  They were not associated with stric-
ture, but seemed to be dependent for their formation on absence of the
erectile tissue, leaving a thin urethral wall which  gradually dilated.
These congenital pouches are associated with incontinence of  urine.
They become distended with each act of micturition, and there is sub-
sequent dribbling from the slow leakage of the urine contained.
    Diagnosis.—A diagnosis is readily made from the  distention ob-
served during the  act of  urination and from the absence of inflam-
matory reaction.
    Treatment.—The treatment consists in removal of the redundant
walls of the pouch  and suture of mucous membrane and skin so that
the  calibre of the resulting urethra at the point of operation  shall be
about normal.
    As  an unusual anomaly  the  urethra,  on inspecting  the  glans,
seems to  be double or multiple.  Exploration of these openings will
show one or more blind pouches, the urethra opening by  a single
 orifice.  Or in case there is a second channel passing parallel with the
 urethra, this is probably a continuation of the ejaculatory ducts.
    Hypospadia.—This defect depends upon a congenital deficiency
 of the floor of the urethra, which channel, instead of being continued
to the glandular meatus, opens at some point on the lower surface of
the  penis.   The deformity is fairly common, being counted by  Bouis-
son once in three hundred males.  It is distinctly hereditary.  Duplay
describes two chief forms of hypospadia : (1) that in which the urethra
is absent in front of the  abnormal  opening, this being the common
form, and (2) that in which the urethra exists in front of the opening,
an extremely rare form.
    In regard to the position of the opening, hypospadia is classed as
(1) balanic, or glandular, the  urethra  terminating at the base of the
glans;  (2) penile, the urethra terminating at a  point between the
glans and  the peno-scrotal junction (Fig. 20); (3) perineal, including
under  this heading  the  perineo-scrotal forms,  where the  urethra
terminates in the scrotal cleft. 
52
GENITO-URINARY  DISEASES AND SYPHILIS.
   Cause.-The cause of hypospadia is obviously an arrest of devel-
opment.   The prostatic and membranous portions of the uretnra, tne
Fig. 20.
              Forms of penile hypospadia. S, scrotum. (Kaufmann.)

penile  portion, and the glandular portion are each developed  sepa-
rately.  The anterior  urethra represents, in the early part of its devel-
opment, simply  a  groove, which as the foetus grows older  is closed
9999993 
INJURIES AND DISEASES OF  THE  URETHRA.
53
from behind forward.  Failure to close any portion of this groove, or
failure of any of the three separately formed portions of the urethra
to unite, will occasion hypospadia.  Kaufmann attributes hypospadia
to obstruction of the urethra persisting after urine has been secreted
by the kidneys.   In  consequence of retention the urethra ruptures
behind the seat of obstruction.
   Balanic or glandular hypospadia is characterized by a rather broad
glans, curved somewhat downward, and covered on its dorsal surface
by a thickened hood, representing the malformed prepuce.  The frae-
num  is absent, and  the  urethra  terminates  usually  in  a  very  small
opening at the base of the glans,  being continued forward by a nar-
row groove, representing the upper wall of the navicular fossa.  (Fig.
20.)   A normally placed  meatus  is often found, but  this is simply a
                             Fig. 21.
Peno-scrotal hypospadia.
blind pouch.  The cavernous bodies are well formed.   Other de-
formities occasionally complicate balanic hypospadia;  thus, the penis
may be twisted, the cavernous bodies may be stunted or absent, the
testicles may be undescended, or the penis may be adherent.
   Penile Hypospadia.—The opening is usually found  either just be-
hind the glans, midway between the glans and the peno-scrotal junc-
tion, or at this junction.   (Fig. 21.)  The  penis in these cases is often
curved downward, the cavernous bodies are sometimes poorly de- 
54         GENITO-URINARY DISEASES AND  SYPHILIS.

veloped, and nearly always the prepuce is  redundant.  Associated
deformities  are  more  frequently encountered  in  this class  of cases
when hypospadic openings are placed at or near the  peno-scrotal
angle.   Anterior to the  abnormal opening  the urethra is generally
wanting entirely, or it  may appear in the form of a groove, or there
may be a  fibrous ridge  extending from  the glans  to the opening.
Rarely the meatus and some portion of the urethra back of this may
be  preserved, terminating in a blind pouch; or the urethra  may
continue anterior to the hypospadic  opening, ending  in a cul-de-sac
before it reaches the meatus;  or the urethra may be continuous to
the meatus, hypospadia  then simply representing congenital fistula.
The scrotum is not cleft in penile hypospadia.
    Perineal hypospadia  represents  the  most  inveterate form, and
that characteristic of the most marked interference with development.
The scrotum is divided by a deep cleft into two lateral  halves, in each
of which there may be placed a normal testicle, though usually these
organs are only partially developed, and frequently have  not descended.
In this case the scrotal flaps closely resemble the labia majora.  The
penis  is stunted, except in its glandular portion, and is curved down-
ward  and backward towards the scrotal cleft.  On raising it there is
seen a  funnel-shaped  depression,  in  the  deepest  part of which the
urethra opens by a vertical slit, provided at  either side with a muco-
cutaneous fold,  suggesting the  arrangement of the  labia  minora.
These folds pass forward along the under  surface of the penis and
the glans, constituting  either a groove  or a ridge, representing the
absent urethra.  The glans is broadened  and incurved, mainly owing
to imperfect development  of the lower  portion  of the cavernous
bodies;  here the fibrous envelope is extremely thick, and the septum
between the two  corpora cavernosa in some  cases participates in the
contraction.
    Glandular and penile hypospadia do not necessarily interfere with
either micturition or the procreative function.  By lifting the glans
the urine may be projected in an almost normal direction, and, unless
incurvation is  more than usually marked, sexual  congress is possi-
ble, but fecundation is  doubtful.  In the scrotal and perineal varie-
ties the functions of both micturition and copulation  are materially
interfered with.   The  backward curve of the urethra obstructs the
stream,  which is driven out with some force; the urine is usually
sprayed  in all  directions, requiring the patient to micturate in the
sitting position if he wishes to avoid soiling his clothing.  On erection
the incurvation of the organ becomes even more marked than before  ;
thus copulation is impossible. 
INJURIES AND  DISEASES OF  THE  URETHRA.
55
   Diagnosis.—The diagnosis is not difficult to make, a simple in-
spection, especially when  the patient urinates, sufficing, although in
one case we observed a practitioner had endeavored for three years
to catheterize a penile hypospadic through the cul-de-sac representing
the glandular urethra!
   Under some circumstances the determination of sex is extremely
difficult in cases of perineal hypospadia.   Careful examination through
the rectum combined with  abdominal  palpation will in some cases
show the  presence of either a prostate or a rudimentary uterus, thus
enabling the  surgeon to give judgment as to the  sex which  the case
most nearly resembles.
   Prognosis.—The prognosis of hypospadia, from  both  a functional
and  a cosmetic stand-point,  is fairly good when the testicles have
descended and are normal in size.
   Treatment.—The  treatment consists in correcting the incurvation
and  restoring the  urethra to  its natural position  and length.  This
end is accomplished by plastic operations.  These should be performed
in successive stages.  The first has for its object the straightening of
the penis; the second makes a new canal from the normal position
of the meatus and the neighborhood of the hypospadic opening; the
third joins this newly formed canal with the posterior portion of the
urethra.
   The  first  stage,  straightening  the  penis,  is  accomplished by a
transverse incision across the  under surface of the penis, dividing the
fibrous  ridge which so frequently passes from the hypospadic opening
to the glans,  and including in this division the thickened, contracted
sheath covering in the surface of the cavernous  bodies, and  also, if
necessary, a portion of  the septum between these two bodies.  The
incision can be carried as deep as is necessary for complete straighten-
ing of the curve.   This often implies section into the substance of the
cavernous bodies.   When the penis has been straightened the  wound
is united by means of sutures, so that its long axis is at right angles to
the line of the original incision.  (Figs. 22, 23.)   The wound is dressed
with  a  narrow strip of sterile gauze secured in place by a film of
cotton over which is painted collodion.  A few turns of a narrow
gauze bandage  are then applied, and the penis is held upward  against
the body  between two layers of  cotton, a crossed of the perineum
roller bandage  or a jock-strap securing  it in place.  Stitches  are
removed in five days.  The penis is subsequently held by dressings in
the same position till the next step in the operation is  undertaken.
   At the time the  penis is  straightened a portion  of  the  second
stage—i.e., the  formation of  the glandular urethra—is  accomplished. 
56
GENITO-URINARY DISEASES  AND SYPHILIS.
Where there is a deep  furrow representing the roof of the urethra,
freshening of its lower edges and apposition by suture may be suffi-
cient.  Usually a  deep vertical incision  or two lateral  incisions, one
on  the  upper  and outer  wall of each  side  of the groove, will be
required.  In the furrow  thus deepened is laid a section of catheter
Fig. 22.
Fig. 23.
Penis straightened after transverse cut
        of lower surface.
Transverse wound sutured longitudinally :
      glandular urethra formed.
corresponding in circumference to the normal calibre of the urethra,
and  the freshened edges of the furrow are neatly approximated by
suture,  two or three silk threads being used.  (Fig. 24.)   These are
removed  in  five days.   It is often difficult  to  keep the  section of
catheter in the penile  urethra  thus made.   This  trouble  may be

                               Fig. 24.
Freshened areas and incisions made in
    forming glandular urethra.
Glandular urethra closed by
       sutures.
overcome by taking a  piece  of small  catheter  sufficiently long  to
tie a knot in  each end.  Before proceeding to the  formation of the
penile  urethra  it  is well  to  wait for  some  months,  to determine
whether or  not  incurvation  of the  penis will  be  reproduced by
contraction.
   The second stage—i.e., the formation of a canal from  the glans to 
INJURIES AND DISEASES  OF THE URETHRA.
57
the hypospadic  opening—is performed by Duplay as follows.  The
penis is held up, and two parallel incisions are made in the lower sur-
face, each one-eighth  of  an  inch from  the  middle line  and extending
from the glans to within a short distance of the  hypospadic opening.
This leaves a median  strip  of skin a quarter of an inch wide, which
is  to  serve  as the  roof  and sides of  the  new urethra.   Short flaps
are raised from these incisions  towards the middle line, the skin
being dissected  free  on each side for about an eighth of an inch,
and long flaps are raised away from the middle line.   (Fig. 25.)   A

              Fig. 25.                             Fig. 26.
     Formation of penile urethra.—Flaps on the     Formation of penile urethra completed.
   left side of the penis dissected up, the short one
   towards the catheter, the long one away from it.

catheter of normal urethral calibre, from 12 F. to 16 F., depending
on the size of the penis, is passed through the artificially formed glan-
dular urethra and along the course of the proposed penile portion of
the tube.   The  two inner flaps are  lifted so that their skin surfaces
are in apposition with the sides of the catheter.   No  effort, however,
is  made to form them of sufficient  length completely to encircle the
instrument.  The long external  flaps are then brought over the
catheter,  and should be  loosened so  thoroughly that they cover it
completely without undue tension.
 
58        GENITO-URINARY  DISEASES AND SYPHILIS.

   The stitches, of very fine silver wire, do not include the  edges of
the short inner  flaps.  They are  placed a fifth of an inch apart, and
are passed through apertures  in  small pieces of  lead tubing or in
sections of  soft rubber catheter  (No. 12 F.), one on  each side of
the wound, and  of the same, length as the latter.  The edges of the
long flaps are accurately adjusted and held in place by shot slipped
over the ends of the sutures and  clamped against the lead  pipes or
pieces  of catheter, thus forming  a modified quill  suture.  (Fig. 26.)
Ordinary interrupted  sutures may be  applied wherever the apposi-
tion is  not perfect.   These are  always required to unite the anterior
portion of the skin flaps to the posterior lower portion of the glans,
which  must be  freshened before the  sutures are passed.   By this
operation  a canal is formed, partly  of the raw surface of the two
external long flaps and partly of the skin surface of the two short inner
flaps.  There  may be  some points where union is not perfect, but
these can be closed by subsequent operations.  A strip of iodoform
gauze is placed  oyer  the line  of  suture, and  is  secured in  place by
a film  of sterile cotton and iodoform collodion.   The catheter  over
which the new urethra is formed is withdrawn till its end lies beyond
the opening left for the escape of  urine.  A thread is passed through
it close to the  meatus, the catheter is cut off just beyond this point,
and  the piece left in the urethra is held in  place by fastening the
threads to  the sides of the penis  by  cotton film and collodion.  As a
final dressing  after  the application of iodoform  collodion, the penis
may be covered in  by a few turns of a very narrow gauze  bandage.
Care must be taken in applying this, since  pressure is thus brought to
bear directly along the line of  suture.  The sutures are taken out on
the fifth to  the  seventh  day, the sections of  the catheter being re-
moved at the  same time.  During micturition the area of operation
is  protected from contact with urine by pledgets of iodoform  gauze
well smeared  with iodoform ointment and kept pushed against the
posterior surface of the new urethra.  After healing, a period of eight
weeks  should be allowed to elapse before  attempting the next stage.
   The third stage of the operation consists in  completing the urethra
by bridging  the  remaining gap.   This  is accomplished by freshening
the borders of the hypospadic opening to the extent of a quarter-inch,
introducing a soft catheter from the meatus into the bladder, and ap-
proximating the freshened edges of the fistula by the lead pipe shotted
sutures used in the second operation.  The external dressing is made
of iodoform gauze kept in place by collodion.  The catheter is removed
in three days,  and the stitches  are taken out in five days.
   The first stage of this operation should be undertaken at about the 
          INJURIES AND DISEASES OF THE URETHRA.        59

fourth year, the  next stage six to ten months later.  The final stage
may be  reserved till puberty; though most surgeons prefer to  per-
form it as soon as it is  evident that the results of the earlier operative
interference are  satisfactory.
   The  operation may have to be  repeated in part many times before
the final result is satisfactory, since  only a portion of the  suture line
may hold.   Under such  circumstances  the edges of the resulting fis-
tulae must be freshened and  approximated.  Two or three years are
often required before  cure  is  ultimately accomplished.   This opera-
tion is difficult because of the  smallness of the penis in infancy and
early childhood.  It is sometimes  impossible to keep the parts clean.
Failure  is most often due to lack of care in  securing perfect apposi-
tion of raw surfaces, to suppuration, or to tension, either because flaps
have  not been  dissected up with sufficient freedom or because of
bleeding beneath the flaps.
    The functional result is satisfactory.   There is some dribbling after
urination, and the normal forcible stream cannot be driven out;  the
urethra has to be milked to get rid of the last few drops  of urine.  If
the penis has been thoroughly straightened, erections are vigorous and
ejaculation  occurs  so  nearly according to  the normal  fashion that
procreation is possible.
                              Fig. 27.
Glandular epispadia.  (Kaufmann.)
   Epispadia.—In this deformity a portion or all of the roof of the
urethra is absent, the canal being represented by a furrow traversing
the mid-dorsal aspect of the  penis.  It is  often complicated by ex- 
60        GENITO-URINARY DISEASES  AND SYPHILIS.

strophy of the bladder.  This  anomaly, rare  in  all its  forms, may
appear as the  glandular form,—i.e., the urethra is complete as far as
the glans, opening just behind this  expansion of the spongy  body
(Fig. 27); more often the abnormal  opening is just in front of  the
pubic symphysis (Fig. 28), or rather in the normal position of this
junction, since in many of these cases the pubic rami do not extend
to the middle line.
   In these cases the penis is short, broad, curved upward, at times
twisted; the prepuce is redundant below, and there is a projecting
                             Fig. 28.
Usual form of epispadia.
belly-fold above, against which the dorsum of the glans is apposed.
On drawing this down the  urethral furrow is seen lined with thin
mucous  membrane  and passing backward to  the  urethral  orifice
deeply sunken in the pubic region.  This orifice is usually large, often
admitting an examining finger without difficulty.   In case the poste-
rior urethra is involved, there is exstrophy of  the bladder, ordinarily
with absence of the pubic symphysis.
   Epispadia is  often  attended with  incontinence of  urine, though
when the posterior urethra is perfectly formed  and  there is no separa-
tion of the pubic bones micturition may be accomplished normally;
except in cases of marked curvation of the penis, erection and intro-
mission are possible. 
INJURIES  AND DISEASES  OF THE  URETHRA.
61
Fig. 29.
   Treatment—The treatment of epispadia is  either palliative—i.e.,
the adaptation of a properly fitting  portable urinal (see Exstrophy,
page 546)—or radical,—i.e., by operative measures.
   Operation.—The penis is straightened by one or more deep trans-
verse cuts across the dorsum, sutured so that the ends of the incision
are approximated, as in  hypospadia.  After a sufficient lapse of time
(see  above as to hypospadia) the edges of the urethral fissure are
freshened  and  approximated over  a  catheter, as described  under
hypospadia.   In this case, however, the catheter is passed into the
bladder through the epispadic opening, and is kept in place till the
apposed freshened surfaces have united.   The redundant prepuce is
button-holed  to  an extent sufficient to admit  the glans penis;  the
latter is then passed through this opening, the preputial layers are
split, and the resulting raw surface  is apposed  to  the dorsal coronal
surface of the glans penis and  the anterior border of the newly formed
penile urethra,  which are denuded  to  a sufficient extent to  receive
this  large  graft.   Thus  the  redundant
prepuce  is disposed of, and  the penile
urethra  and  the glandular  urethra are
covered with skin.
   Finally, the  borders of the  opening
remaining  between the  original  urethra
and  the part  newly formed are freshened
and  approximated by interrupted sutures.
   Dolbeau's operation, modelled on that
of Nelaton, may, with modifications and
additions  to  suit  individual   cases,  give
good results when  other methods are not
applicable.  He first forms from the belly
wall a quadrilateral flap three inches long
and  three-fourths of an  inch  broad, with
its attached base lying immediately above
the urethra.   Two smaller flaps are then
dissected up from either  side of the dorsal
furrow of the penis.  (Fig. 29.)  The free
edges of these  flaps are turned  inward
towards the median line.   When  the raw
surface  is thus prepared the  belly flap is turned down,  thus  serving
as a roof  for the  new canal, with  the cutaneous  side  down.  The
two  edges of the  belly flap  are  sewed to the edges  of the penis
flaps.   Two  parallel  curved incisions are then made  transversely
through  the  anterior surface  of  the scrotum,  thus outlining  a  flap
   Dolbeau's operation.—Formation
of abdominal, urethral, and scrotal
flap. 1, glans; 2, urethral furrow;
3, urethral orifice ; 4-4, 5-5, flaps from
abdominal wall and from dorsum of
penis; 6, scrotum; 7, upper scrotal
incision;  8,  lower scrotal incision.
(Thiersch.) 
62         GENITO-URINARY  DISEASES AND SYPHILIS.

continuous to the right and left with the skin of the scrotum.   (Fig.
29, 7 and  8).  This flap  is  tunnelled  under  by dissecting the skin
from  the  dartos, and  beneath the  skin  thus  raised  the penis  is
passed, so  that the glans  projects clear of the lower incision.  Thus
the raw surface  of the belly flap, which was previously turned cuta-
neous  side down, is  brought in contact with the raw surface of the
scrotal  skin,  which passes as a bridge  over the dorsum of  the penis.
Sutures  secure the  parts in place.   (Fig. 30.)   As  a result  of this
operation there is no glandular canal, and there is formed a penile
urethra much larger than is  necessary.  The patient, provided he has
previously suffered from  incontinence, is improved  only so far as he

                               Fig. 30.
   Dolbeau's operation.—Flaps secured in place. 1, glans; 2, fraenum; 3, foreskin; 4, scrotum;
5, bridge of skin raised from scrotum; 6, urethral orifice ; 7, raw surface left by downward reflection
of belly flap.  (Thiersch.)

is able  to wear a urinal or to use some  form of compression for the
purpose of retaining his water.
   The Thiersch method is still the favorite one, and gives excellent
results.  Thiersch states that by his method a new urethra is formed
which corresponds more closely with  the normal channel  in calibre,
function, and position.   (Fig.  31.)
   There are three distinct periods of  the operation.
   The first period is  devoted to the formation of a perineal fistula.
This is readily done  by  inserting into the  bladder the finger, or, in
case the  urethral orifice is  not  sufficiently  large,  by  passing in a 
INJURIES  AND DISEASES OF  THE URETHRA.
63
Fig. 31.
curved sound.   The end of the latter is introduced into the neck of
the bladder, and is pressed downward and forward into the perineum.
An incision is carried down to the point of the instrument, care being
taken not  to injure the rectum.  This can  be  guarded against  by
passing a finger of the  left hand  into  the anus while the perineal
cut is being made.   The bladder  having been  thus opened by me-
dian perineal cystotomy, a self-retaining  rubber catheter  is intro-
duced.  The best instrument for  this purpose  is that employed  by
Guyon.   If there has  been  excoriation  of skin from leaking and
decomposition  of urine, it is well  to
postpone the further steps of the oper-
ation until  thorough cleansing  of the
parts and the  application  of  astrin-
gent and mildly antiseptic dusting pow-
ders have subdued all irritation.  This
perineal  fistula, by diverting  the urine
from the seat  of  subsequent  opera-
tions, enables the surgeon to avoid the
dangers and delays incident  to suppu-
ration, which  almost inevitably  occurs
when the urine is allowed to escape  in
its natural course.
   The  second  step of the  operation
consists in the formation of a glandular
urethra.   To the right and left of the
glandular  furrow, parallel  with  the
latter, running  the whole length of the
glans, and  in  depth equalling  three-
fourths of its thickness,  there are  made incisions converging to such
an extent that were they continued to the lower surface of the glans
   Epispadia.—1, glans ; 2, penile fur-
row ; 3, urethral orifice; 4, scrotum; 5,
prepuce; 6, base of glans. (Thiersch.)
   Formation of glandular urethra.— A. 1-1, '2-2, freshened surface on each side of the penile
furrow. B. Cross-section of glans, showing depth and direction of incisions 1-1 and 2-2.  C. Glan-
dular urethra formed.  (Thiersch.)

they would meet.   (Fig. 32.)   By these cuts there are formed two
lateral flaps and a middle wedge-shaped piece  of  glandular  tissue,
the broad base of the latter looking upward  and being covered with 
GENITO-URINARY  DISEASES AND  SYPHILIS.
epidermis.   Along the outer border of each incision there is removed
a strip of the glandular covering, so that when these lateral flaps are
brought together fresh surfaces of sufficient breadth to assure firm
union will be apposed.   These lateral  flaps are  approximated over
the middle wedge and united  by two or three  harelip pin sutures.
The canal thus  formed  is more  deeply placed at its orifice than in
the  region  of the  corona, though  this  is  of minor  consequence.
Obliteration of this  canal is impossible, since the epithelial covering
of the middle wedge prevents it.
    The  next step of the operation consists in transforming  the penile
furrow into  a canal.  Close to the right  border of the furrow there is
made a  longitudinal incision dividing the skin and the  subcutaneous
tissues the entire length of the furrow.   (Fig. 33.)  From either end
Fig. 33.
Fig. 34.
   A. Outlining of flaps  to form  penile
urethra.—1, flap dissected  outward; 2, flap
dissected inward; 3, orifice of glandular
urethra.  (Thiersch.)
B. Cross-section of same, showing the direc-
   tion in which the flaps are dissected.
   A. Flaps folded over and held in position
by sutures.—1, long flap drawn to the left side
of the penis ; 2, stitches holding the short inner
flap in position; 3, meatus; 4, space between
glandular and penile urethras.  (Thiersch.)
B. Cross-section of same.
of this  incision a transverse cut is made running outward, thus out-
lining a long quadrilateral flap.   This is  dissected up with as  much
subcutaneous tissue as possible, especially near the base of the flap. 
INJURIES AND DISEASES OF THE URETHRA.
65
A  similar long incision is made to the left of the furrow, about two-
fifths of  an  inch  from its edge.  From  each end of  this incision a
transverse cut  is carried  inward as  far as the edge  of the furrow.
This flap is also  dissected up with as much  subcutaneous tissue as
possible.  It is then turned over exactly as one turns the leaf of a
book from  right  to left, so that its epithelial surface forms the roof
of the furrow, while its wound surface is turned outward.  If the flap
is  sufficiently wide to cover  in the  furrow entirely  without  undue
tension, three or  four threads with a needle on each end are passed
through  its  free border.  The first  flap is now drawn  directly over
this flap which has  been turned over,  thus approximating the two
fresh surfaces of the flaps and  covering the whole with skin.  (Fig. 34.)
Before suturing this flap in position the needles attached to the sutures
passing through the free border of the reflected flap are passed from
within outward through the base of the first flap, each stitch including
a very narrow  bridge of the skin.   These sutures are tied down, the
first flap while  they are inserted and  secured being  held with exactly
the same tension as is necessary  for its final suture.   Finally the
superficial  flap is secured by suture to the skin border from which
the reflected flap was turned  in.
    The canal thus formed is closed with skin both within and without,
and is of the right calibre.   There is  no danger of the flaps sloughing
provided they  have been left  sufficiently thick at their base and have
been dissected so freely that  there is no  tension.   Should there be
dangerous  tension, two long  incisions are made to the right and left
of the lower mid-line of the  penis.   These are carried down  to the
fibrous sheath, and are allowed to heal by granulation.
    The next step of the operation consists in the union of the glan-
dular and penile urethras.  This is  made at the expense of the fore-
skin.  The  transverse  defect existing between the  penile and the
glandular urethra is first  completely and widely  freshened.   The
foreskin is  stretched out and an oblique  incision  is made entirely
through it,  forming  an opening sufficiently large to allow the glans
to slip through.  (Fig. 35.)   The  lower half of the foreskin is thus
by its raw surface closely applied to the corona.  The foreskin  having
been brought up  in place, one of its layers is carefully sutured to the
upper border  (formed  by the new urethral roof) of  the defect, and
the other border is secured to  the freshened corona glandis.  (Fig. 36.)
It is necessary carefully to separate  the two  layers of  the  foreskin,
otherwise they will  unite to  each other instead of  to the  freshened
surfaces.  This portion of the  operation also  has  cosmetic virtues,
since it gives the  penis a more normal appearance.
                                5 
GENITO-URINARY DISEASES AND SYPHILIS.
   The  final step of the  operation consists in  closing  the posterior
defect.   This is accomplished by means of two  flaps  cut from the
surrounding belly walls.  The first flap is  formed from the left side.

               Fig. 35.                            Fig. 36.
   1. Transverse defect between penile and        1. Foreskin brought up behind the glans;
glandular urethras;  2, 3, oblique  incision      2, line of sutures uniting freshened edges of
through foreskin.  (Thiersch.)                 transverse defect to foreskin.  (Thiersch.)
It is in the shape of an equilateral triangle, with its base correspond-
ing to the left half of the skin surface lying immediately above and to
the left of the roof of the urethral orifice.   (Fig. 37.)  The corner of

             Fig. 37.                                Fig. 38.
1 and 2 ; suture of first flap.  (Thiersch.)
this  flap  is  folded downward and  inward so  that its  skin surface
covers  in the defect.   Its  lower  free  border  is  sutured to  the 
          INJURIES AND  DISEASES OF  THE URETHRA.        67

freshened upper border of the  new roof formed by transplantation
of the penile  skin.  The  second flap  approximates the  form of a
quadrilateral with its attached base in the region of the right inguinal
canal.  This flap is drawn downward and inward so that its freshened
surface covers in the fresh  surface of the triangular flap.  It is secured
                             Fig. 39.
Cured epispadia. (Thiersch.)
in this position by sutures, including both the lower flap and the bor-
ders of the skin incision required for the preparation of the triangular
flap.  (Fig. 38.)  The  raw surface left  after  this transplantation is
allowed to heal by granulation.
   Healing of the  perineal fistula completes the operation.  This is
readily accomplished by removing the tube.
   It cannot be expected that this  operation will be at once and com- 
68         GENITO-URINARY DISEASES AND  SYPHILIS.

pletely successful.  Fistulae often form ; portions of the flaps often fail
to unite.  The time of cure is, therefore, apt to be protracted.
   In Thiersch's own case (Fig. 39) it required about one and a half
years.   He holds that ordinarily it should be accomplished in  three
or four months.  He advises that the various steps of the operation
be performed in the order  given, allowing fourteen days for the for-
mation of the perineal fistula, fourteen days for forming the glandular
urethra, twenty-one days for closure of the perineal furrow, fourteen
days for transplantation of the foreskin, and, finally, for the closure of
the urethra and the  subsequent  operations which may be necessary,
forty-two  days.
                   INJURIES OF  THE  URETHRA.
   The urethra may be wounded or subcutaneously ruptured.
   Wounds of the urethra are  surgical or accidental.  Accidental
wounds are rare.
   Incised wounds of the urethra, if  longitudinal,  heal readily and
often without subsequent stricture, even though no sutures are ap-
plied.   When such injuries are inflicted from without, either inten-
tionally by the  surgeon, as in the case of external urethrotomy, or as
a  result of accident, provided the urethra  is healthy and the  urine
sterile, the wound may be sutured, the urethra being first closed by
fine buried catgut sutures, not including the epithelial coat, and the
skin, subcutaneous tissues, and spongy body being approximated by
a second  row of interrupted fine silkworm-gut sutures.  Continuous
catheterization  is kept up from two to five days.  When the urethra
is suppurating  the wound should be allowed to heal by granulation.
When the urethral  wound is not extensive it  is  not necessary to
employ stitches.
    When the urethra is incised  transversely there is  free bleeding,
and, if the canal is cut completely across, the proximal end retracts.
Healing by granulation  always implies  a  degree of coarctation de-
pending on the extent of the wound.  When the urethra is completely
divided, the proximal end may be found by posterior catheterization
through a suprapubic opening in  case it has retracted so that it is not
easily secured in the wound.  The divided urethral ends must then
be held in neat apposition by interrupted catgut sutures placed one-
eighth of an inch apart and not penetrating the epithelial layer.   When
the  continuity of the roof of the urethra is thus restored by three or
four sutures, a soft catheter is passed into the bladder, the urethral
suture is  completed, the external wound is closed, and the catheter is
tied in place ; as in all cases of continuous catheterization, the bladder
and urethra receive  frequent antiseptic irrigations. 
INJURIES AND  DISEASES OF THE URETHRA.
69
   Always after the healing of transverse wounds of the urethra in-
volving more than one-third of the circumference of the canal a sound
should be  passed at first once a week,  then at longer intervals, till
there is no marked  tendency  to stricture formation.
   Lacerated and  contused  wounds of the urethra  are  cleansed,
opened so that  drainage  both of  urine and of wound discharges is
freely provided  for, and allowed to heal by granulation, continuous
catheterization being maintained till the urethral  defect is entirely
closed  in.  Patients after these injuries must  be  instructed in  the
use of  the sound, since it will be necessary for  this instrument to be
passed at regular intervals for probably the  rest of their lives.
   Whenever,  because of the  limited  extent of a  lacerated  and
contused  wound, there is sufficient tissue  left, after trimming away
that which is devitalized, to  allow of urethral suture, this procedure
should always  be adopted, since  thus  subsequent stricture may be
lessened.
   Punctured wounds, when from without, are not attended by  ex-
travasation, and require simply the application of wet antiseptic and
evaporating lotions, as, for instance, lead water and alcohol, to limit
inflammatory reaction.  When the urine is sterile no  intra-urethral
treatment is required.  When it is infected, and particularly when  the
urethra is inflamed, as in acute or chronic gonorrhoea, irrigation with
silver solution 1 to  5000, or bichloride 1 to 20,000, is indicated.
   When the punctured  wound is from within, as in  the formation
of a false  passage,  free bleeding  and the detection  of the point of
the instrument  outside the  urethra  by external or rectal  palpation
show the  nature of the injury.   Usually such wounds heal sponta-
neously without becoming infected even though infection of the ure-
thra has existed previously.   Exceptionally they suppurate, forming
abscesses.
   The treatment of such  wounds  consists in  refraining from further
instrumentation,  making the urine slightly  antiseptic by  appropriate
medication, and using  mild antiseptic irrigation, 1 to 3000 bichloride
or 1 to 6000  permanganate, under low pressure (elevation of reser-
voir, three feet).  In case of  local and general symptoms pointing to
suppuration,  drainage must be provided for  by external incision.
   Rupture of the Urethra.—Subcutaneous rupture  of the urethra
is rarely seen in the penile  portion of the  canal.   It  is  usually the
result of the  breaking  of  chordee, fracture of the penis, or twisting,
wrenching, or pinching  force  applied to the  erect organ.   The penis
is so movable that it  usually  escapes the  crushing effect  of force
applied in the  form of blows and kicks.   Subcutaneous rupture is 
70         GENITO-URINARY  DISEASES AND SYPHILIS.

commonly observed in the perineal urethra.   Kaufmann, as the result
of a statistical study of over two hundred cases, gives as the form of
injury, falling astride eighty per cent., perineal blows twelve per cent.,
being run over by vehicles four per cent., being unseated upon the
pommel of the saddle four per cent.  The mechanism of the perineal
rupture depends  upon the shape of the vulnerating body and the
direction in which the force is applied.   Where there is a fall astride
upon a narrow body, as, for instance, the edge of  a half-inch plank,
this is forced upward  between the ischio-pubic rami, usually a little
to one side, tears the triangular ligament,  and crushes the urethra
against the ischio-pubic ramus of the opposite side.  When the vul-
nerating body is larger, as,  for instance, the square toe of a boot, the
urethra is driven directly upward against the lower or anterior sur-
face of the  pubis, the lower portion of the urethra rupturing first.
Kicks from behind when the pelvis is tilted forward rupture the bul-
bous  and membranous portions of  the urethra.  Together with the
urethral rupture there are always crushing and contusion of the bulb,
of the perineal tissues, and often of the attachment of  the cavernous
bodies.   In cases of fracture of the pelvis, or temporary or permanent
disjunction of the pelvic symphysis,  the membranous urethra may be
lacerated  by the jagged edges of the broken bone, or may be torn
partly or completely across  by the sharp drag upon  it exerted by the
triangular ligament.
   The rupture may be partial or complete.   In the mildest cases the
spongy tissue is the only part involved.   Its fibrous investment and the
mucous and submucous  layers of the urethra are uninjured.  There
results in consequence  a temporary narrowing or blocking of the
urethra, due to circumscribed  blood effusion into  the loose erectile
tissue of the spongy  body.  In more  severe cases both the spongy
body  and  the mucous  and submucous layers  of the urethra are
crushed and torn.  In the most severe cases not only is  the urethra
with the surrounding spongy body  injured, but likewise  the fibrous
investment of the latter, thus making a direct communication from the
floor of the  urethra to the  loose cellular tissue of  the scrotum  and
the perineum.
   The rupture  may involve  the entire  lumen of  the tube, or, as is
more frequently the case, may include only its lower and lateral wall.
In case of complete transverse laceration there is always  marked re-
traction, leaving a space from one-half  to three-fourths of an inch, at
first filled with blood-clot, later converted into an abscess.
   The seat of contusion and  laceration of the urethra is usually in
the bulbous part of the urethra, except when there is  fracture of 
INJURIES AND  DISEASES OF THE  URETHRA.
71
the pelvis or disjunction, temporary or permanent, of the pubic sym-
physis, in which cases the  membranous urethra is involved.
    Symptoms.—The symptoms of laceration of the urethra are urethral
hemorrhage, the immediate formation of a circumscribed tumor at the
seat of injury, retention of urine, and pain.
    The amount of bleeding from the urethra cannot be regarded as
an  index of the severity of the lesion.   It is rarely so violent or so
long continued  as to excite serious alarm, and when it escapes exter-
nally is less liable to form large perineal swellings.   Blood escaping
from  the meatus  after trauma  always indicates laceration  of the
mucous membrane, and even though but a small quantity is  lost, as
in the breaking of a  chordee or from  a false movement in  coitus,
there  is  liable  to result periurethral inflammation, with  the ultimate
formation of an unyielding stricture.
    The perineal swelling is  due in  the first place to extravasated
blood, at first circumscribed, later extending upward over the belly.
Skin discoloration appears after one or two days.   After extravasa-
tion of infected urine takes place  there will be the symptoms of deep
cellulitis.  Retention of urine is observed in a large majority of cases.
When there is total rupture this retention is due to separation of the
urethral  ends and the interposition between them of masses of coagu-
lated blood.  In cases of partial rupture, obstruction  of the tube from
blood-clot and urethral spasm incident to the injury may be operative
in causing retention.  If retention is not at first noticed, but develops
subsequently, it is due  to the pressure of effused blood and  to the
obstruction caused by inflammatory swelling.
    In rupture of the posterior urethra there may be neither bleeding
from  the meatus nor any sign of perineal  tumor.  When urinary
extravasation takes place  it occurs in the deep  tissues, and produces
no  symptoms  until cellulitis has been set up.   In cases of this char-
acter  there is retention of urine ; obstruction is not felt  on introduc-
tion of the  catheter until it has penetrated  to the depth of six inches
and is passing through the subpubic urethra.  Then  either its  further
progress is  arrested, or if  it passes into the bladder  and  remains un-
obstructed  by  blood-clot  there  flows urine mixed  with blood.   In
ruptures of the anterior urethra, when the bladder is once reached
by instrumentation, the urine is clear.
    The pain of ruptured  urethra is not intensely severe.  It  is ren-
dered worse on motion, but if the case runs a favorable course grad-
ually subsides.   The  pain elicited by palpation indicates the  seat of
rupture.  The prognosis of these cases is extremely  grave, since they
are usually complicated by fracture of the pelvis. 
72         GENITO-URINARY DISEASES AND  SYPHILIS.

   The consequences of rupture of the urethra are  urinary extrava-
sation, septic infection, and later traumatic stricture.  At each act of
micturition a part or the whole of the urine is liable  to be forced into
the periurethral cellular tissue, extending at once into the scrotum or
the perineum if the fibrous envelope of the bulb has  been torn.  This
urine, even if originally sterile, shortly becomes infected, sets up cellu-
litis, and occasions sloughing and gangrene, which, unless the case is
promptly attended to, result in death.  In consequence of the nature
of the injury—i.e., a crush—there is, when the canal is not torn  com-
pletely  across, more or less sloughing,  with  subsequent cicatricial
contraction, and often a most obstinate fistula.  When the ruptured
ends of the urethra have not been apposed, there is  formed between
them a granulating  sinus, whose walls  exhibit all the vices  of  cica-
tricial tissue.
   Diagnosis.—The  history  of the  injury, the  perineal  tumor  of
sudden formation, blood from  the meatus, either flowing  spontane-
ously or induced to appear by pressure on the perineal tumor, are
sufficient to justify an  absolute diagnosis of rupture of the anterior
urethra.  Bleeding is in itself diagnostic  when  it  follows trauma-
tism,  and  in the  absence  of  perineal tumor  and  marked  dysuria
denotes simply a slight tear of the mucous membrane without involve-
ment of the periurethral tissues.  A rapidly formed perineal tumor
associated  with  dysuria or retention usually  signifies an extensive
laceration.   The seat of rupture is indicated  by local tenderness and
often by the signs  of external violence.  The history of the injury is
also of importance in determining this point.   Thus, when there has
been a fall  astride of a comparatively wide surface, such as a joist or
the  pommel of a saddle,  the bulbous urethra  is  almost certainly
involved.   If the injury has resulted  from a fall on  the  edge of a
board, for instance, or from the toe of a boot, the kick being delivered
from behind while the patient is bending  forward, it is probable that
the membranous urethra is  ruptured.  In cases of pelvic fracture or
disjunction the diagnosis is sometimes extremely difficult.  There is
little deformity, and crepitus may not be elicited.   There may  be
bleeding from the meatus, but usually the spasm of the compressor
urethrae muscle causes the blood to flow back into the  bladder.  The
history of the injury,—commonly, in case of fracture, a crushing force
applied to the two sides of the pelvis,—the detection  of crepitus  by
rectal examination,  the almost invariable development  of  urinary
retention, and the  difficulty in catheterization or in the drawing off
from the bladder  of blood with the urine, would point to  rupture
of the membranous urethra. 
INJURIES AND  DISEASES OF  THE  URETHRA.
73
   Treatment.—In the least serious cases—i.e., those characterized by
moderate  hemorrhage  from the meatus, either with or without cir-
cumscribed non-progressive tumor-formation in the  perineal region,
and  not complicated by retention—the  use of pressure,  together
with the application of hot antiseptic compresses, the administration
of urinary antiseptics  by the mouth, rest in bed, free purgation, and
mild antiseptic irrigation  of the urethra, may bring about cure.   The
surgeon must, however,  bear in  mind  that the simplest  cases—i.e.,
those characterized by the loss of a few drops of blood, by transient
dysuria, and without appreciable  perineal swelling—may be followed
by perineal extravasation and infection with all its grave conse-
quences, and must be on the  alert for the first symptoms or signs
of this grave complication.  It  should also be remembered  that un-
necessary catheterization prevents the urethral wound from healing,
and  that the use of an unclean catheter in cases of urethral rupture
is as dangerous as the use of an unclean probe in the exploration of
a gun-shot wound involving other parts of the body.  As it  is im-
possible thoroughly to sterilize the urethral mucous membrane, the
introduction of a catheter necessarily increases the danger of local
infection:  hence in the simplest form of urethral rupture the catheter
should not be used unless dysuria or retention makes it necessary.
Under these circumstances a large, soft, absolutely sterile instrument
should be  employed; and its use should be preceded and  followed
by flushing of  the  urethra with silver nitrate solution 1 to 2000.  In
case symptoms of deep inflammation develop,—i.e.,  increased swell-
ing and tenderness, with constitutional  involvement,—recourse must
at once be had to more radical means.
   In the  severer cases of rupture, characterized by decided perineal
tumor, dysuria, etc., free hemorrhage is checked by the external ap-
plication of cold and pressure.  If the patient urinates spontaneously
after some hours, and if  local and general inflammatory phenomena
do not develop, the treatment may be conducted on the lines already
laid  down.  If,  however, there is retention or marked dysuria, an
attempt to pass a catheter must be made.   This should be preceded
by flushing of the urethra with boric acid solution by means of a small
soft  catheter passed in as far  as possible  and attached to a syringe
containing the antiseptic  solution.  An effort is first made to pass soft
catheters.   The Nelaton  catheter, or the English woven catheter with
a large curve, which keeps its  extremity apposed to the roof  of the
urethra, is the best instrument to  employ.   One of these instruments
may be passed down to the seat  of laceration, keeping its tip closely
applied  to the  roof of the canal, the portion  least likely to be torn, 
74        GENITO-URINARY DISEASES AND  SYPHILIS.

and after a  few moments' manipulation may  slip into  the  bladder,
drawing  off  clear urine.   When  this result is obtained,  the  catheter
should be left in place, the bladder and the urethra by the  side of the
catheter  being  irrigated  with boric  acid solution four per  cent., or
silver nitrate solution 1 to 2000, twice daily.  If the soft catheter can-
not be made to  enter the bladder  it is best to  practise  immediate
perineal  section.   The advantages of this  operation are that it  cer-
tainly prevents  extravasation of urine, and that it renders  less obdu-
rate to treatment the traumatic  stricture which  is  certain to result.
An added reason for its prompt performance lies in the fact  that
should the laceration involve the membranous urethra, by  the time
symptoms of urinary extravasation become pronounced cellulitis may
have reached a stage of development beyond the  reach of surgical in-
tervention, since inflammatory swelling of the parts surrounding the
deep urethra is  not immediately apparent, as is the case in the anterior
urethra.   The  earlier, therefore, that perineal section is  performed
the better is  the prognosis of the case.  Advisable whenever there is
retention or marked dysuria and the catheter cannot be passed readily,
this operation becomes absolutely imperative when oedematous swell-
ing of the perineum and scrotum and symptoms of constitutional de-
pression  make  it apparent that urinary extravasation and consequent
cellulitis  have occurred.
   The  operation is conducted in accordance with the principles laid
down on page 243.  A catheter or  staff  is passed to the seat of rup-
ture, and the perineum is opened upon this in the middle line.  This
can often be  done under cocaine anaesthesia.  The incision should be
free.  Usually on opening the deep layer of the superficial fascia there
is found  a cavity filled with  clots-, with, in recent cases, bleeding still
persisting.  Guided  by the catheter, the  urethra  is readily identified,
threads  are passed  through its two sides to act as retractors, and, in
case the  canal  is not completely torn  across, the catheter is readily
passed into the  bladder.   Bleeding points are then secured by ligature,
and the urethral rent is closed, if possible, by interrupted chromicized
gut suture, including in  its  grip as  much  periurethral tissue as  pos-
sible.   The cavity resulting from the bleeding is closed by buried cat-
gut sutures and the skin is secured by silkworm-gut.  The catheter
is left in  place from four to six days.
   If the urethra is completely  torn across, the retracted proximal
end is sometimes hard to find.  In case the proximal  urethral end
is not discovered after  a brief but careful search, Guyon advises
the passage of  a sound from the meatus till its extremity is arrested
by the posterior wall of the  cavity made by the blood extravasation. 
INJURIES AND  DISEASES OF THE URETHRA.
75
The  left index finger is  then  passed, palmar side up, to the point
pressed upon  by the  tip of the sound.  The latter is  slightly with-
drawn, and  in many  cases just above the  position occupied by the
end of the finger will be found the proximal end.  Through it, guided
by the finger, may be  passed an instrument from  the perineum into
the bladder.   Sudden  bimanual pressure on the bladder by the
fingers of one hand in the rectum and of the other over the hypo-
gastric region may  cause a few drops of urine to exude, and  thus
show the position of the torn mucous channel, which in recent cases
is found  to be a movable bleeding cord.  When cocaine anaesthesia
has been employed, the  patient may aid the surgeon by efforts at
micturition.   When the case has  advanced  to abscess-formation and
extensive sloughing, or when the  rupture has occurred as a compli-
cation of pelvic  fracture, it may be  impossible to find  the proximal
end  of the  urethra except  by means of retrograde catheterization
practised through a suprapubic opening made in the bladder.  The
proximal end of the  urethra having been  found,  a  soft rubber  or
woven catheter is passed from the meatus  into the bladder, and the
ragged or irregular wound edges are trimmed off, and approximated
over the catheter by means of chromicized catgut sutures, taking in
the periurethral tissues.   This  suture is made easy by thrusting the
proximal end of the urethra downward and forward well into the
wound by means of a finger inserted into the rectum.  Often union
does not take place ; but, even though it fails, less cicatricial tissue is
formed than when there has been no attempt  at suture.   When there
is no local infection the whole wound is closed by buried catgut sutures,
an antiseptic dressing being held in place either by a T-bandage or by
a crossed of the perineum.  Continuous catheterization is not em-
ployed for more than six or seven days.  During this time the bladder
and the space between the catheter and the urethral walls  should be
washed twice daily with  saturated boric acid solution or with silver
nitrate solution 1 to 10,000.  At  the  end of  a week, or earlier if it
gives  rise to great irritation, the catheter may be withdrawn and a
full-size sound passed.  This sounding is repeated every three, four,
or five days for some weeks, and is afterwards continued at longer
intervals for months or years.
   When operation is delayed, and  infiltration and septic inflamma-
tion have already occurred, approximation of  the torn urethral ends
should be  attempted by suture.   There   should, however,  be no
effort to close the infected  cavity, this being cleansed and packed
with sterile  or iodoform gauze and  allowed  to granulate from the
bottom. 
76         GENITO-URINARY DISEASES AND  SYPHILIS.

               FOREIGN BODIES IN THE URETHRA.
   Foreign bodies in the urethra are either introduced from without
or pass forward  from the bladder,  in  the  latter  case appearing as
urinary calculi or fragments of neoplasm.   The  bodies introduced
from without are usually segments of catheter, the instruments em-
ployed being  old and breaking during introduction  or withdrawal.
In the case of sexual perverts almost any object, if sufficiently small,
may be passed into the urethra.
   The behavior of a foreign body lying completely within the urethra
depends upon its shape and size.  When it is smooth and rounded, as,
for instance, in the case of a broken fragment of catheter, a small wax
candle, or a piece of lead-pencil, it nearly always exhibits a tendency
to pass back into  the bladder.  This occurs in  about  thirty per cent.
of all cases, and is  due to  the constant handling of the parts by the
patient, to the frequent erections reflexly excited by the presence of
the foreign body, followed  during subsidence by  contraction of the
urethra in the direction of its length, and to the action of the longitu-
dinal unstriped muscular fibres of the  urethra.  A smooth,  not too
large foreign body may pass back into the bladder in less than a day.
   Should the foreign body remain in the urethra, the navicular fossa,
the bulb, and the prostatic urethra are its seats of preference, these
portions of the canal representing the regions of greatest dilatation.
   Symptoms.—Localized pain, interference  with micturition, and in-
flammatory phenomena are the  characteristic symptoms of foreign
body in the urethra.
   The pain is usually severe, especially when the foreign body is
irregular in shape.  When  a catheter is  broken off in a urethra which
has long been tolerant of instrumentation, there may be no suffering,
especially if the broken end is lodged in the  membranous or prostatic
portion.  Foreign bodies located in the posterior urethra, particularly
if irregular in shape, with sharp corners or angles,  cause pain charac-
teristic of  posterior urethritis,—i.e., there is a deep ache felt in the
perineum, with itching, burning, or a sense of weight and dragging in
the rectum, and shooting or persistent pain in the hypogastric region,
about the sacro-iliac articulation, and radiating down  the inner sur-
faces of the thighs.
   Interference with micturition depends mainly upon the  size and
position of the foreign body and upon  the  amount of inflammatory
reaction its presence sets up.   Immediate  retention is rare.  There
are always increased frequency of urination and lessening in the force
and  volume of the stream.  Unless the body is removed or passes 
INJURIES AND DISEASES OF THE URETHRA.
77
back into the bladder, micturition becomes progressively more diffi-
cult and painful because of swelling due to inflammation.
   Inflammatory phenomena are quickly developed.   When the body
is lodged in the anterior urethra, there is shortly a blood-stained muco-
purulent discharge, with redness,  heat, and swelling  of the  penis.
This is commonly accompanied by fever.   When the body is lodged
in the posterior urethra, increased  tenderness on perineal and rectal
palpation, the appearance of constitutional symptoms,  and  often the
development of cystitis or epididymitis, show extension of inflamma-
tion.
   Diagnosis.—The history of the case is  usually sufficient to estab-
lish the diagnosis.  In the case of a sexual pervert, a reliable history
may be entirely wanting.   The symptoms in themselves are merely
suggestive, since pain, frequent and obstructed urination, and ure-
thritis may develop from a variety  of causes.
   Direct examination, even in the absence  of history,  nearly always
makes the nature of the case plain.  Palpation will  usually show the
size, shape, and seat of the body if it is located in the anterior urethra.
Bimanual palpation is  employed  when the foreign body  is farther
back, the finger of one hand being passed into the rectum, whilst
with the other counter-pressure is  exerted first in the perineum, then
in the suprapubic region.
   Providing the urethra is not strictured, the urethroscope can always
be depended upon to bring the foreign body into view.  This instru-
ment also enables the surgeon to determine  the amount of impaction,
and to choose and apply his extracting instruments so that  they shall
act to the greatest mechanical advantage.   In introducing the urethro-
scopic tubes, if the position of the foreign body has been previously
determined, pressure behind it should be made, lest by manipulation
it  should be forced back into the bladder.
   The introduction of a metal sound about No. 18  F. will, in the
absence of the urethroscope, show  the position of the foreign body by
the resistance which is  encountered when it is reached, and, in case
the body be hard,  by the click which is heard when it is touched.  In
this manipulation, pressure from behind should be employed to pre-
vent the body from being pushed into the  bladder.
   A foreign body introduced into  the urethra, if neither expelled nor
extracted, may pass back  into the  bladder or may remain,  becoming
incrusted with urinary salts and causing ulceration which is prone to
extend through the urethral wall, forming  a  suppurating cavity which
opening externally may  result  in  an obstinate urethral fistula.   It
is  in the  prostatic  urethra that foreign bodies are most apt  to remain 
78        GENITO-URINARY  DISEASES AND SYPHILIS.

indefinitely,  causing slow ulceration, and becoming  so embedded in
inflammatory material that their detection may be extremely difficult.
   A foreign body once lodged within the urethra if not expelled with
the first subsequent act of micturition is not likely to be expelled after-
wards.  Inflammatory swelling fixes it more firmly,  and from  reflex
irritation causing frequent urination the stream loses in volume and
force.  There are, however,  exceptions to this rule.
   Treatment—The simplest method of ridding the urethra  of the
foreign body, and one which may succeed providing the case be seen
immediately after its introduction, is to direct the  patient to urinate
forcibly.   When the stream is fairly started the lips of the  meatus
are pressed  together for four or five seconds and are then suddenly
released.  This failing,  recourse  should  be  had at  once to forceps.
(Fig. 40.)  The  introduction of these is preceded  by examination
through the urethroscope, thus enabling the  surgeon  to judge how

                              Fig. 40.
best to apply them, or in case the foreign body be a pin or a splinter
it may be removed directly through an endoscopic tube.  In grasping
the body with forceps it should be pressed forward from behind by
perineal  or  rectal  pressure, thus avoiding  the  danger of pushing it
back into the bladder.  If the  forceps fail to grasp the body, or if
because of its angular  shape withdrawal requires so much  traction
that extensive laceration of the  urethra is liable to result, further
attempts at extraction  should be abandoned, the patient  being  put
in the lithotomy position and  the body being removed through a
perineal  or  penile incision carried  down to it in the middle line.
The resulting wound is closed by a buried catgut suture including
the urethra and its fibrous investment, but not  the  epithelial layer
of  the  mucous  membrane, and skin  stitches of silkworm-gut  or
horse-hair.
    Special manipulations may be serviceable in certain cases.  Thus,
should the foreign body be a gum catheter, a lead-pencil, or other
non-metallic body, and should the forceps fail to grasp it, ordinary 
          INJURIES AND DISEASES OF THE URETHRA.        79

round-pointed  sewing needles  may be driven into it  through the
urethra, and  by means of these, the elasticity of the urethral walls
allowing some  play to the needles, the  foreign body gradually may
be brought to the meatus.
   The evacuating tubes employed for  lithotomy, or, better still, a
large, straight cylinder, open at the end  and attached to the Bigelow
evacuator, may prove efficient when forceps fail.   The tube is carried
down to the  foreign body, the  urethra is temporarily obliterated be-
hind the latter by firm pressure, its anterior part is then distended by
sudden pressure upon the aspirating bag, and this pressure is imme-
diately  relaxed.  The foreign  body may thus be  sucked  into the
evacuating tube.  A pin, nearly always introduced head first, may be
extracted by driving its point through the urethral walls,  thus render-
ing it easy to seize the head in the forceps within the  urethra.

                       URETHRAL  CALCULI.
   Exceptionally calculi are formed within the urethra, in which case
they are always phosphatic.  Usually they come from the kidney or
the bladder,  and, though apparently  phosphatic from  incrustation,
show a uric  acid nucleus.   They  are most  frequently  observed in
infancy and past middle age.  Their common seat is in the bulbo-
membranous and prostatic regions and  in the navicular fossa.  Cal-
culi rarely form spontaneously in the  urethra behind a stricture, the
stagnation  not being  sufficient to allow of this.  It is in  urethral
pouches or diverticula, or in the suppurating blind pouches resulting
from  glandular inflammation complicating  urethritis, that  calculous
formation most frequently takes place.

                              Fig. 41.
Urethral calculi showing segmentation.
   The direction of growth from  incrustation  of the  calculi  found
behind strictures or in physiologically dilated parts of the  urethra is
dependent  upon the pressure exerted by the urethral walls.   The
layers of lime salt are so  deposited as a result of this pressure that
the growth is backward.  As the calculi increase in  length they are 
80         GENITO-URINARY  DISEASES AND  SYPHILIS.

liable to  be segmented by fracture:  hence in many  cases several
calculi are found  placed in  line and  articulating with one  another.
(Fig. 41.)  Prostatic calculi growing backward encounter much  pe-
ripheral resistance in the region of the vesical neck.  Having passed
this, there is  nothing  to prevent  their extension in all  directions.
Hence these  calculi  often exhibit  the appearance of two nodules
connected by a narrow bar.   (Fig. 42.)

                              Fig. 42.
Urethral calculi showing mushroom shape.  Cross-sections to exhibit lamination.
   The growing calculus may cause great dilatation of the infantile
urethra.   In the adult there is more commonly ulceration, the calcu-
lus escaping into the periurethral tissues, and sometimes in this posi-
tion  attaining great size before it reaches the surfaces or causes inflam-
mation or urinary infiltration sufficiently serious to require operation.
Usually the ulcerating cavities in which these calculi lie open exter-
nally.  In about twenty per cent, of cases  urinary infiltration occurs.
A calculus which has thus left the  urethra, and which lies in a cavity
which communicates with the latter only by a narrow opening, cannot
be detected by the passage of urethral instruments.
   Symptoms.—Calculi which form in the urethra would give no other 
INJURIES AND DISEASES  OF THE URETHRA.
81
symptoms than those due to the inflammation and gradually increas-
ing obstruction,—i.e., urethral discharge and increased frequency of
urination followed by dysuria.   Impacted calculi from above occur in
the persons of those who have passed gravel or have had attacks of
nephritic colic.  In children these  symptoms  are generally  absent.
The lodgement of- the stone  occurs  during  urination.   There  is
sudden partial  or complete stoppage of the  stream, with the sensa-
tion of a solid body having lodged in the  urethra.  This is followed
by the symptoms of foreign body in the urethra.  (See page 76.)
    Diagnosis.—Given the sudden stoppage of the stream during uri-
nation and the  sensation of a  foreign  body  having slipped into the
urethra, with a precedent  lithaemic history, the diagnosis is  reason-
ably certain.  It is further confirmed by palpation of the urethra,
which may show a hard body, but  more  commonly  elicits only
localized tenderness,  and  by the use of the urethroscope,  which
in the  absence of stricture makes the diagnosis  absolutely  certain,
and also shows the seat of lodgement. In  the absence of the urethro-
scope the soft woven catheter or bougie should be employed ;  this in
striking the  stone produces a rough grating sensation.   When there
is stricture the small metal  sound is passed, the click then showing the
position and nature of the obstruction, or, this failing, rectal examina-
tion may enable the stone to be felt lying between the finger and
the sound.  Stones lying in diverticula or in periurethral abscesses
can usually be detected only by palpation.
    The consequences  of the impaction of stone  in  the urethra are
not often serious.  In cases of stricture with damaged kidneys, com-
plete  retention, if not promptly relieved, may have disastrous conse-
quences.  The  symptoms of impaction are, however, so marked that
treatment is promptly instituted: hence there is  little chance  for
grave systemic disturbances.  Stones which  have ulcerated through
the urethral walls always expose the patient to the danger of urinary
infiltration.
    Treatment.—The treatment is practically the same as that directed
in the case of foreign bodies.  Immediate  removal of the stone is the
prominent indication.   If it is situated at or near the navicular fossa,
meatotomy may be required.   The  straight, open-ended  evacuating
tube may render valuable  service.  Calculi in  the prostato-mem-
branous urethra which cannot  be grasped readily by the forceps, or
which, if grasped and drawn upon, show such  resistance that extensive
laceration of the urethra is certain to occur, should be pushed into the
bladder by a bougie, and then crushed and evacuated.  If this pushing
back into the bladder requires force, they should  be  cut down upon
                                6 
82        GENITO-URINARY DISEASES AND  SYPHILIS.

and removed, the urethra and wound being closed by buried sutures.
Calculi in any part of the urethra which are firmly embedded should
be treated in the same way.  When the calculus lies behind a stricture,
this should be divided by internal urethrotomy if it lies anterior to the
bulb, by external urethrotomy if it is bulbo-membranous, the stone
then'being removed either through the meatus by forceps or through
the perineal  wound.  Stones lying in extra-urethral abscesses should
be removed  by  incision, the opening into the urethra being freshened
and closed by catgut sutures and the abscess-cavity being drained by
packing.
                        URETHROSCOPY.
   Instruments constructed to allow of visual examination of the
urethra are  termed endoscopes,  and are of various patterns.   Of
these the best  are the  bivalve dilating speculum  (Tilden Brown's),
the Grunfeld endoscope modified by Klotz, Fenwick's aero-urethro-

                             Fig. 43.
scope (Fig. 43), and the ingenious electrical endoscope modified from
Leiter's instrument by W. K. Otis (Fig. 44).  The aero-urethroscope
is so  planned that after introduction of the tube the urethra can be
inflated with air, thus exposing a long, flat wall, in place of the small
circle of lax mucous membrane which  forms the field of vision in
other instruments.
   The light required in these examinations may be reflected from a
head-mirror, or, far better, may be furnished by a small electric lamp
secured to the endoscopic tube  after it is introduced, as in the Otis
instrument.   The electricity is furnished by chemical or storage bat-
tery ; either can be obtained at moderate cost.
   The endoscopic tubes vary in calibre  and length according to the 
INJURIES AND DISEASES  OF THE URETHRA.
83
sizes of the urethra and the depth to which an examination must be
carried.  It is evident that the  shorter the tube and the wider its
calibre the more distinct  will be the image presented.   The tubes
vary in size from  No. 22 to No. 32 French calibre, and  should be

                             Fig. 44.
i
Cma
                          Otis urethroscope.

longer as the calibre is wider; thus, No. 24 F. should be about three
inches in length;  No. 26, four inches;  No. 28, five  inches; No. 30,
five and a half inches ; No. 32, six inches.  The flattened disk at the
end of this tube enables  even the shorter instrument  to be  carried
almost, if not quite, to the membranous urethra, since  after the tube
is introduced to its full length the head of the penis is pushed back
by the disk on its end.
   In addition  to  the endoscope, applicators are required, for the
purpose of removing secretions which may obscure the  field of vision
and for carrying medication to diseased mucous surfaces.  These may
be made  of wire with cotton wrapped about their roughened ends, or
long, straight splinters of wood, or, better still, split straws barbed at
the end, may be employed.  Before beginning an examination a suffi-
cient number of applicators should be prepared.  Several dozen may
be required.
   Examination.—This may be conducted with the patient in a half-
sitting position in a chair or in a recumbent position upon a lounge or
a table.   For a thorough examination the patient should be drawn
down to the foot of the table till his buttocks rest upon its lower edge.
The thighs are separated and the feet are supported on foot-holders
properly placed, or the legs and thighs may be allowed to hang.  The
surgeon then selects an endoscopic tube as large as the urethra will
 
84        GENITO-URINARY  DISEASES AND SYPHILIS.

take, inserts the obturator, lubricates the instrument, and, drawing
the penis directly upward from the body, separates  the lips of the
meatus and  slowly introduces  the tube by pressure upon the handle
of the obturator until it will go no farther.   Unless there is stricture
or some  abnormal obstruction, this would indicate that the rounded
end  of the  obturator has  encountered the  resistance due to the
anterior  layer of the triangular ligament and  to the  tonic  spasm of
the compressor  urethrae muscle.   Usually  this is as deep as  it  is
necessary to pass the instrument.
   When inspection of the posterior urethra is indicated, the disk end
of the endoscopic tube is depressed between the thighs until the tube
lies nearly parallel with  the plane of the body.  At  the same time
gentle inward pressure upon  the handle  of the obturator is made.
By continued pressure the compressor urethrae may be made to yield,
and the instrument then passes into the prostatic urethra.  To carry
it completely into the  bladder it may be necessary still further to de-
press the distal extremity until it points obliquely downward towards
the table.  The  internal vesical sphincter sometimes offers consider-
able resistance.  The passage of the endoscope through the posterior
urethra is usually painful, excites more or less traumatic inflamma-
tion, and should  be practised in exceptional cases only.
   The tube having been introduced to the required depth  is held in
place by  the fingers of the left hand, while with the  right the obtu-
rator is withdrawn and the illuminating apparatus secured  in place.
The  field of vision  is  usually  obstructed by pus, mucus,  or blood.
Such fluids  must be  removed by means of the cotton applicators
before a clear view can be obtained.
   The inspection is conducted by slowly withdrawing the tube, using
the cotton applicators  to cleanse exposed surfaces from discharge.  In
case the  instrument has been  carried in as far as the  internal vesical
sphincter, the disk is  elevated as it is withdrawn, so that the endo-
scopic tube shall correspond in direction to that of the  urethra.  As
the penile portion of the urethra is inspected, the  disk is withdrawn
from the  glans,  and the  penis, sagging down, may prevent the tube
of the  endoscope from being  concentric with  the  urethral canal, or
the weight of the penis may cause it to drop entirely away from the
endoscope.  To  prevent this,  as  the instrument is  drawn out the
thumb  and finger of the left hand shift their grasp from the disk to
the tube, while  the penis is supported between the  ring  and little
fingers of the same hand.
   Urethral stricture or a small meatus may temporarily prevent the
introduction of  an endoscopic tube.  Instrumentation  or  cutting  is 
INJURIES AND  DISEASES OF  THE  URETHRA.
85
then indicated to bring the urethra to its normal calibre.   Bleeding
may seriously interfere with a satisfactory urethroscopic examination.
This if slight will stop spontaneously in a few minutes, and after the
blood has been removed by the cotton  applicators the parts can be
thoroughly inspected.  If bleeding is free, it is liable to continue until
the instrument is withdrawn, and may entirely prevent a view of the
section  of  the  urethra  from  which it comes.   Examination under
these circumstances  must be given  up temporarily, but may be
attempted  again on the following day,  the instrument then being
introduced with extreme  gentleness.  Profuse  bleeding  generally
comes from an  inflamed  posterior urethra, and is due to the bruising
occasioned by the passage of the instrument.
    Occasionally the passage of the  instrument  causes syncope or
urethral fever,  or  such  severe  pain  that its introduction can be
accomplished only under the use  of anaesthetics.   It is well to follow
the urethroscopic examination by an  antiseptic flushing of the ante-
rior urethra.
    Appearance of the Urethra.—In an examination of the urethra
the following points are to be carefully considered (Griinfeld):
    1. The cone-like figure which the urethral walls assume beyond
the end of the endoscope.  This is due to the natural elasticity of the
urethra and the contraction of its muscular fibres.
    2. The color, the thickness, and the vascularity of the walls of this
cone.
    3. The  central point or figure, that is, the appearance  presented
by  the  closed lumen of the  urethra  which forms the apex  of  the
cone.  The  form, the size  or length, and the position  of this figure
are important.
    Every portion of the urethral mucous membrane must be sub-
jected to careful examination.  In inspecting the cone and its apex,
the central point or figure, the endoscopic tube is kept parallel with
the urethral  axis at the  point of examination.  For more  direct in-
spection of the  urethral walls, however, it becomes necessary to give
the endoscope a different relative position.  When  the  endoscope is
turned  slightly away from  the  axis  of  the urethra,  thus  exposing
more directly the parietes and carrying  the  central  figure towards
the periphery of the picture presented, the position is said to be ec-
centric.  When the  endoscope makes such a distinct angle with the
urethral axis that the central figure disappears entirely, and in place
there is seen a flat surface of the urethral wall,  the position is said
to be parietal.    Thus the upper, the lower, and the lateral walls
of the urethra  are inspected  directly each  time a new urethral sur- 
86        GENITO-URINARY DISEASES  AND SYPHILIS.

face is exposed  by drawing  out the endoscope  for one-quarter to
one-half  inch.  In making a complete examination it is well by vary-
ing the pressure to alter the relations of  the cone and  central figure
to the urethroscopic tube, now slightly  withdrawing, now  slightly
pushing it in.
    Starting from the prostatic portion of the normal posterior urethra,
a cone of longitudinally folded  dark-red mucous  membrane is ob-
served.   As the instrument  is withdrawn the mucous  membrane is
seen to close behind it,  till rather suddenly there rises from directly
below, if the endoscope  is  held precisely in the middle line, or from
one side when the instrument is  lateralized, a  smooth, rounded, poly-
poid mass, the caput gallinaginis.  This  fills  the greater part of the
field of vision, is of a brighter red than the surrounding urethra, and
changes the central figure from a point to a semilunar curve with
the convexity upward.   If the distal end of the urethroscope is now
raised  somewhat so that this  projection  occupies  almost  the entire
field of vision, the opening of the sinus pocularis, sometimes sealed by
a drop of viscid  matter, can often be seen.   If the small tube is em-
ployed, and is not kept directly in the centre of the urethra, the caput
may entirely escape attention, lying  to one side  of the instrument.
As  the endoscope is still further withdrawn  the  ridge projecting in
advance of the sinus pocularis forms a distinct fold on the floor of the
urethra, over which is  stretched the mucous  membrane of the roof
and sides of this canal, forming a crescentic fold less distinctly marked
from behind forward.   The mucous membrane becomes finally less
red, and when the membranous part of the urethra is  reached a
punctate  central figure  is formed, with  the  radial folds  of mucous
membrane extending from the periphery  towards it.  The endoscope
being still further withdrawn, its end  escapes from the grasp of the
compressor urethrae muscle, and unless the instrument be held firmly
may be thrust strongly forward by the contraction of the ischio-caver-
nosus and bulbo-cavernosus muscles.  If, however, the extremity of
the endoscope is  retained in the region of  the bulb, its distal extremity
being at the same time carried upward so  that it stands at right angles
to the plane of the body, the action of these muscles can be distinctly
seen in the alteration which takes place  in the central figure.  This
in place of appearing as a cone is converted into  a vertical slit, with
mucous membrane  bulging forward on either side.  This change of
form is due to the lateral pressure produced by the bulbo-cavernosus
and ischio-cavernosus muscles.   The mucous membrane is here pale
red, but  from pressure  of the  instrument  may be made to appear
almost white.  As the urethroscope is slowly withdrawn,  and as its 
INJURIES AND  DISEASES OF  THE  URETHRA.
87
extremity passes into the pendulous urethra, the figure presented is
again conical, the central figure appearing as a transverse  slit, with
radial folds varying in depth in accordance with the size of the in-
strument  employed.   The color is a pale  red.  On pressure of the
instrument the openings  of the glands and  follicles  can readily be
seen as minute pin-point spots, perhaps a little  deeper in color than
the surrounding mucous  membrane.  As  the  urethroscope reaches
the navicular fossa the central figure again changes in shape, appear-
ing first triangular, then at the meatus as a vertical slit; the mucous
membrane becomes purplish in color.
    The endoscopic picture of the normal urethra shows  then the
deepest color in  the prostatic portion of the canal; passing forward,
it steadily becomes a paler red until the meatus is reached.  At the
posterior  part of the  prostatic urethra a crimson  cone with a  punc-
tate centre is shown ;  farther forward the somewhat paler caput gal-
linaginis  bulges up, filling the greater part  of the field of vision, and
over it is folded the urethral mucous membrane, forming a crescentic
central  figure.  Advancing still farther forward, the  mucous  mem-
brane becomes distinctly paler, and in the membranous urethra again
is seen a cone with a punctate centre ; if the tonicity of the compressor
urethrae muscle is preserved, this cone is extremely shallow.  In the
bulbous urethra the field of vision is occupied by two bulging folds of
mucous membrane, the central figure appearing as a transverse slit
(according to Finger it is vertical); passing still farther forward, the
cone again appears of varying depth and with a transverse slit as the
central figure.   The latter becomes triangular at the fossa navicularis
and vertical at the meatus.
    The Use of the Endoscope.—During the acute stage of urethritis the
use of the endoscope is undesirable ; when, however, the disease has
become chronic and when, in spite  of well-conducted and sufficiently
prolonged treatment, discharge or other symptoms persist, an  endo-
scopic examination is often useful.
    The  appearance presented  by the pathological  urethra is simply
more or less a modification of that already described as characteristic
of the normal canal.   The conical field, the color, and the central
figure are all altered.  Thus, when the  inflammation is subacute the
mucous membrane is greatly swollen, soft, and succulent, and the nor-
mal cone  is practically obliterated, the walls  of the urethra coming
directly together, sometimes even  projecting  into  the  lumen of the
endoscopic tube.  When the subepithelial infiltration has  undergone
organization  the  cone-like figure becomes greatly elongated, and the
central figure may be triangular, quadrilateral, or in other ways irreg- 
88         GENITO-URINARY DISEASES AND SYPHILIS.

ular in shape.  Infiltration of one portion of the urethral circumfer-
ence will, of course, destroy the symmetry of the cone.
    Color alterations are usually marked.  The tint becomes dark red or
even purplish, and may appear in patches or may invade the greater
part of the urethra.   In place of the normal lustrous urethral surface
the mucous membrane may appear either shining and oedematous or
dull.  Exceptionally the surface is granular, either over a considerable
area or in localized patches.
    The openings  of Morgagni's follicles are often large, patulous, and
purplish.  Sometimes there are distinct epithelial outgrowths.  Areas
of corneous epithelium indicative of subepithelial cicatrization appear
as white patches,  presenting much the appearance that would result
from  touching the  surface with silver  nitrate.  In  chronic inflam-
mation  of the posterior  urethra the mucous membrane is  purplish,
swollen, oedematous, hypersensitive, and bleeds readily.
    The endoscope will thus enable the surgeon to discover and locate
circumscribed areas of inflammation,  chronically inflamed lacunae
and follicles, subepithelial infiltration, vegetations or polypi, stric-
tures, and  urethral  calculi.  Through it strong  applications may be
made to diseased areas.   Suppurating follicles may be readily split
up  and  cauterized.   The nature and position of foreign bodies may
be  determined.  Polypi may be removed.  The anterior opening of
eccentric strictures may be discovered. 
CHAPTER  III.
                           GONORRHOEA.

    Gonorrhoea is a  contagious specific inflammation of the  mucous
 membranes of the genito-urinary tract.  It also affects the conjunc-
 tiva, the rectum, and  possibly the mucous membranes of the  nose
 and mouth.  It is alleged that it can attack all the mucous membranes,
 but evidence upon this point is far from conclusive.
    Etiology.—Gonorrhoea depends for its development upon the pres-
 ence of a specific microbe termed the gonococcus.  In thus  defining
 gonorrhoea, strictly only such cases as are dependent upon the gono-
 coccus would be included;  but it should be  clearly recognized that
 an acute or a subacute  inflammation of the urethra may be excited by
 a variety of microbes  other than the gonococcus.  True gonorrhoea
 cannot  always be differentiated from  non-specific urethritis by the
 facts of its long duration, its greater tendency to extension, and its ob-
 stinate persistence in spite of careful treatment.  While it is true that
 the specific urethritis  usually runs a somewhat typical  course,—one
 much longer and attended with more complications than that due  to
 traumatism, or irritation,  or infection with the ordinary microbes of
 suppuration,—this is by  no  means  invariably the case.  Even the
 form of urethritis excited  by an irritating injection may exceptionally
 last for weeks and months, and may be attended by every  complica-
 tion that can possibly develop during  the course of an acute gonor-
 rhoea.   In  such cases  there is, of course, a secondary infection from
 without, although gonococci are absent.
    That the gonococcus is the specific organism of gonorrhoea can be
 considered as absolutely  established.  Upon  this point evidence  is
 convincing, and  there  are few at the present  day who are prepared
 to deny the causative role which this micro-organism plays in the pro-
 duction of  the disease.   Gonococci are always present in gonorrhoea.
 Their numbers are proportionate to the severity of the attack.  As
 the symptoms subside the gonococci  become less numerous,  and
 finally disappear entirely when the disease is cured.   It is exceedingly
 difficult to grow gonococci upon culture media, and even when pure
 cultures are obtained their virulence seems  to  be lost rapidly.  The
final link in the  chain  of evidence—that is,  the production  of a true
                                                          89 
90        GENITO-URINARY  DISEASES  AND SYPHILIS.

gonorrhoea from a pure culture of gonococci—is, however, not absent,
the experiment having been repeatedly successful.
   A weak point in the evidence as to the specific nature of the gono-
coccus lies in the fact that micro-organisms are found in  the healthy
urethra which  exactly resemble in size, form, grouping,  and  color
reactions the gonococcus.  It  is stated that these various forms can
be readily distinguished by means of culture ; but this  requires so
much time and skill that it can be carried out only by the bacteriolo-
gist, and hence it is not practically useful.
   The gonococcus when cultivated under favorable circumstances
on a suitable medium shows a very small, scarcely perceptible gray-
ish surface, appearing shiny, moist, and slightly yellowish by  reflected
light.  The development of this culture is slow, and the growth never
extends widely, reaching its uttermost dimensions  in two  or three
days, after which time the germs lose  their virulence, and shortly
can no longer be transplanted with successful results.  This growth
is always  on the  surface.  Baumgarten states  that  in twenty-four
hours its extent is not more than one to one and a half millimetres.
It is inhibited by extremely weak antiseptic solutions.
   Gonococci grow best at a temperature of 34° to 37° C, and human
blood-serum is the culture medium of choice.  Even in this  medium,
however, pure cultures are obtained with difficulty, since, because of
the slow growth of the gonococcus, its culture is interfered with by
the rapid proliferation of other pyogenic organisms.
   Torro asserts that the difficulty in cultivating the gonococcus lies
in the fact that alkaline media  have  been employed.  In acid urine
the gonococcus develops rapidly; this suggested to him the  idea that
acidity is a  requisite in all media.  He employed ordinary nutrient
gelatin without neutralizing, and obtained growths of the germ.   He
also asserts  that he has reproduced the disease from pure cultures
obtained by  inoculating dogs.   The cultures kept in acid media retain
their virulence for many weeks, whilst those transplanted to alkaline
media quickly become inert.
   It must be remembered that, even under favorable circumstances
and  on the  most approved media, pure cultures of the  gonococcus
cannot always be obtained.  Pus swarming with apparently virulent
organisms may be placed on proper media without growth.
   The gonococcus is distinguished by its shape, grouping, position,
color reaction, and growth on artificial media.
    In shape the gonococci resemble the two seeds of a coffee-bean,—
that is, they are diplococci, flat or slightly concave  on one  side, and
rounded on  the other, with their flat (Figs. 45-46) surfaces  apposed. 
GONORRHOEA.
91
It must be remembered that only by careful staining and by the use of
high power can these micro-organisms be seen as diplococci.  The two
half-spheres are separated by such a very narrow interval that this is
not perceived by the use of the ordinary one-fourth or one-eighth lens.
Fig. 45.                           Fig. 46.
Gonococci. (Guyon.)                  Gonococci.  (Giinther.)
 In the process of multiplication each half  of the diplococcus divides
 at right angles to the fissure between the two.
    The gonococci are always grouped in irregularly shaped colonies ;
 chains are never found.  They quickly take the stain of the aniline
 dyes.  For rapid diagnosis a concentrated  alcoholic solution of fuch-
 sine, or of methyl or gentian violet, is most convenient.   Methylene
 blue colors more slowly.
    In examining for these micro-organisms a fraction of a drop of the
 gonorrhoeal  pus is received  on the surface of a clean cover-glass.
 This drop is evenly spread by pressing a second cover-glass upon the
 first.   This  thin film is allowed to dry in the  air.   When it is thor-
 oughly dry each cover-glass is swept slowly three times through the
 flame of an  alcohol lamp.   This fixes the albumen and prevents  it
 from being washed off  in the process of  staining.   The cover-glass
 being then held film side up (preferably in  a pair of spring forceps), a
 few drops of the fuchsine or methyl violet  solution are dropped upon
 it.  In one minute this dye is washed off with distilled water and the
 cover-glass is placed under the microscope for examination.  This to
 be satisfactory should be conducted with a Zeiss one-twelfth homo-
geneous immersion lens or with one  of similar magnifying  power. 
92        GENITO-URINARY DISEASES AND SYPHILIS.

   A peculiarity in the staining of the gonococci is that, though they
quickly take the aniline stains, they are more readily bleached  than
other micro-organisms.   Roux's method of differential diagnosis de-
pends  upon this  fact.  In carrying out Roux's method the cover-
glasses are prepared  as above described.  In place of the  fuchsine,
gentian violet is employed.
   The concentrated gentian violet solution is made by mixing to-
gether one part of gentian violet, fifteen parts of alcohol, three parts
of aniline water, and eighty parts of water.   This dye  should be fil-
tered each time it is used.  The  cover-glasses are treated with this
dye, diluted with about  ten times as much water,  for three minutes;
they are  then washed with distilled water.   The  excess of water is
blotted off, and the specimen is  at once examined to discover the
comparative number of gonococci.   The  cover-glass is then floated
in Gram's liquid  for  two minutes.  This  is made up of one  part
iodine, two parts potassium  iodide, and three hundred parts water.
After remaining in Gram's solution for two minutes  the excess of
iodine  is washed off in water, and the specimen is placed in absolute
alcohol until decolorization takes place.  This requires  not over two
minutes.   The alcohol is then washed off with distilled water and the
cover-glass is again  examined.   All the gonococci will have disap-
peared, while other micro-organisms that may have been present will
be distinctly visible. It must be remembered that even Roux's method
is not absolutely diagnostic.   Very exceptionally micro-organisms not
gonococci give up their stain almost as readily as do the gonococci.
   The position of the gonococci  is exceedingly characteristic.  They
are always found heaped in the protoplasm of the pus  and epithelial
cells.  At times the cells appear entirely filled with these organisms.
   The number of gonococci in acute typical gonorrhoea is very con-
siderable ; though  there may be an admixture of other micro-organ-
isms, these latter are distinctly in the minority.   At the very begin-
ning of an acute  attack, or in its terminal  stages,  there may be very
few  gonococci.   It is here only  that  Roux's test is valuable, since
the shape, grouping, and number in the midcourse of an acute attack
are absolutely characteristic.
   The important characteristics  of gonococci may be summarized as
follows:  they are  diplococci;  they appear in heaps,  which nearly
always occupy the protoplasm of cells; they are very numerous in
acute cases;  they are readily colored by aniline  dyes and decolorized
by Gram's solution and alcohol; they form characteristic pure cultures
on suitable media (acid).
   Till the specific micro-organism was discovered, all inflammations 
GONORRHEA.
93
of the urethra were classed as gonorrhoea.  Since the general accept-
ance of the gonococcus as the causative agent in the ordinary venereal
form of the disease, inflammations of the urethra may be classified
under the following headings :
   1. Typical or acute inflammatory gonorrhoea.
   2. Subacute or catarrhal gonorrhoea.
   3. Non-specific urethritis (irritative or abortive gonorrhoea).
   Certain other varieties based mainly upon urethroscopic examina-
tions are described.  Thus, there are a membranous urethritis,  char-
acterized by  extreme chronicity and by exfoliation of casts of the
urethra; a granular urethritis, in which there are punctate elevations
of the mucous membrane ;  a suppurative urethritis, attended with the
formation of abscesses  in the submucous  tissue; and  an ulcerated
urethritis, noticed in patients who suffer from herpes.   There is also
a form of dry gonorrhoea, or gonorrhoea sicca, unattended with dis-
charge, but accompanied by pain, ardor urinae, and the other symp-
toms of inflammation.
   Typical Acute Gonorrhoea of the Male Urethra.—This form
of urethral inflammation is due to infection of the  urethra with the
gonococcus.   Such  infection is nearly always due to  sexual inter-
course, the virulent pus  from the female entering the male urethra to
a greater or less depth.  This method of acquiring the disease  is
termed immediate contagion.
   The disease also may be conveyed by mediate contagion,—that is,
through the medium of clothing  or  other articles containing specific
micro-organisms.   Since to  excite inflammation the micro-organism
must gain access to the urethra, it can readily be seen  that mediate
contagion, excepting by  the  agency of bodies introduced within the
urethra, must be exceedingly rare.
   It certainly cannot be denied that an acute  inflammatory non-
specific  urethritis may be developed as a result of contact with foul
and  irritating  discharges, even though these contain no  gonococci.
Careful examination of a great number of cases has shown that this
occurs in a small percentage of patients : hence extreme care must be
exercised in stating to the patient without a microscopic examination
of his discharge the nature  of the disease from which he suffers.
   Incubation.—There is always an  interval  of time between expo-
sure to contagion  and the development of noticeable urethral symp-
toms.  During  this  time the germs are multiplying, and a focus of
inflammation is becoming established  sufficiently extensive and in-
tense to excite attention. This time  varies between a few hours and
two or three weeks, since it  depends upon the original strength of the 
94        GENITO-URINARY DISEASES AND  SYPHILIS.

microbic invasion, the seat of entrance, and the vital resistance of the
mucous membrane.   An extremely short incubation  period  or one
which is unusually long should always lead the surgeon to doubt the
gonorrhoeal  nature of the urethritis till this is determined by micro-
scopic examination.  Three to five days represent the ordinary incu-
bation period,—that is, the  time  elapsing between exposure to the
disease and the development of the first symptom.
    Prodromal Symptoms.—Often the first  symptom of a developing
urethritis is a constantly recurring tendency to fix the attention on the
penis.   Even though the parts seem perfectly normal, there is a strong
desire to subject them to frequent inspection.
    A sense  of heat  and itching in the glans,  slight fugitive tickling
sensations at the meatus, together with a feeling of weight and tension
in the penis and a tendency to develop erection on the slightest excite-
ment, are most frequently noticed.
    Inflammatory Symptoms.—In twenty-four hours  symptoms of in-
flammation become  more pronounced: there are now developed (1)
swelling of the meatus and (2) discharge, becoming more  and more
marked from day to day, and shortly supplemented by (3) ardor
urinae and (4) chordee;  later by (5) frequent  urination and  vesical
tenesmus.
    Inflammatory Swelling.—1. The lips of the meatus are swollen and
oedematous,  often everted, or even eroded.  At times  the swelling is
so great that the urine can be passed only in a slow stream.  Usually
the  stream is forked  and irregular.
    In severe cases the glans becomes gorged with blood, and the fore-
skin may be swollen, reddened, and oedematous.  Enlarged lymphatic
vessels may be felt passing as hard cords from the fraenum to the back
of the penis.
    The urethra  swells  and becomes tender on pressure.  It is at
times nodular, owing to involvement of the glands and follicles.
    2. The discharge, at first scanty and of milk-and-water color, turns
to a greenish yellow, and is frequently mixed with blood from the con-
gested mucous membrane.  It varies  in quantity in accordance with
the  extent and violence of the inflammation, increasing till the disease
has reached its acme.
    In the first stage of the  disease the discharge is thin, gray-white,
and made up of mucus and of pavement epithelial cells, with a very
small amount of pus.  Gonococci are usually free;  some groups are
found in the epithelial cells.  As the disease  increases in intensity
the  epithelial cells and the mucus give place to pus-cells and the gono-
cocci become very abundant; the  discharge is thick,  yellow, greenish, 
GONORRHOEA.
95
or distinctly blood-stained, and very profuse.   As the disease passes
into the stage of decline the pus-cells are less abundant, and the dis-
charge lessens, becomes milk-and-watery in color and contains much
mucus, and  shows on  examination many flat transitional epithelial
cells.   Finally, the pus  entirely  disappears, usually leaving for days
or weeks an oversecretion of mucus, which appears in the urine as
long, irregular, translucent shreds.
   3. Ardor urince, or  pain during urination, becomes well marked
within the  first  few days.   The suffering may be  so intense as to
constitute the most  distressing symptom  of the  disease.  The pain
is commonly referred to the meatus or to the navicular fossa.   It is
often felt, however, along the entire anterior urethra, and may even
be reflected to the anal region.  This  pain is caused by the  action
of acid urine on the  inflamed  mucous  membrane.  The mechanical
disturbance  dependent  upon the flow of the  stream is in part the
cause of the suffering;  but that it is so to a very minor extent is well
shown by the effect of  alkaline diuretics, which, while increasing the
quantity of urine passed, hence adding to the  amount of mechanical
interference, greatly relieve the ardor urinae.
   Not only is there burning on urination, but from slight mechanical
disturbance, or even without obvious cause,  sharp, cutting, stabbing
pains are felt along  the course of the pendulous urethra at various
times.   These may be  so constant and annoying as to prevent all
but absolutely necessary movements.
   4. Painful Erection.—Even in the period of incubation there  is
usually increased  sexual  excitement,  manifested by frequent  and
long-continued  erections and even by increased pleasure in copula-
tion.  As the inflammation  becomes more intense  and wide-spread
the erections become more persistent, and are accompanied by pain
which is often so severe that it constitutes one of the most harassing
symptoms of the  disorder.  This pain is due to the fact that the
congested infiltrated mucous membrane and submucous  connective
tissue is not able to stretch  as it normally does when the cavernous
bodies become engorged with blood.  The tension upon the now non-
elastic  urethra is still further increased by a clonic contraction of the
ischio-cavernous and bulbo-cavernous muscles, which swing the penis
upward against the abdominal walls.
   Painful  erection is present to a greater or less  extent in all  cases.
It occurs most frequently during the sleeping hours,  though it may
give trouble  at any time, day or night.  The pain  is  felt mainly along
the under surface or  on the sides of the penis, and by its persistence
either awakens the patient or keeps him awake. 
96        GENITO-URINARY DISEASES AND SYPHILIS.

   When inflammation is unusually severe, chordee  develops,—that
is, during erection the penis is curved or bent, usually  downward,
though lateral or upward  curving is  sometimes  observed.   In these
cases the pain is generally severer than when there  is no  such de-
formity.  The marked bending of the  organ is due to the fact that the
inflammation extends to the  submucous connective tissue, and thence
to the trabecular of the erectile tissue  of the spongy body.   The exu-
dation of lymph consequent upon this fills  up the intertrabecular
spaces, which  by engorgement furnish the  ordinary  mechanical ele-
ment of normal erection.   When the organ becomes erect the cor-
pora  cavernosa  are  fully engorged with venous blood.   The  infil-
trated portion of the  corpus spongiosum,  however, remains  rigid
and  undilatable, the blood being unable to find its way into the par-
tially obliterated spaces.  If the inflammation extends to the corpora
cavernosa, erections will  be equally painful; but in this case the
curve will be  upward.  If only one  cavernous body is involved, the
curve, of course, will be towards the affected side.
   The almost  unbearable  pain of chordee may lead the patient to
adopt extreme measures for its relief.  At times the arch  is broken
by a sudden blow of the fist, the penis being placed on some hard,
flat surface.   The result of this treatment is a rupture of the urethra,
either partial or complete,  with subsequent  formation  of a dense
stricture as the least serious consequence.
   At times patients have endeavored to obtain relief by intercourse.
The results are nearly as disastrous  as those consequent on forcible
breaking, at least one death  being  attributable to  this method  of
treatment.
    " Russian clap" is  the vulgar name applied to gonorrhoea of a
hyperacute type.  In these cases there are swelling of the glans and
foreskin, lymphangitis, free bloody discharge, great sexual excitement,
frequent seminal emissions,  and obstinate chordee.  Bleeding is due
to rupture of the intensely congested vessels of the urethral mucous
membrane,  and both  the pus and the semen are distinctly blood-
stained.
    5. Frequent  Urination with Vesical Tenesmus.—This is a symptom
which occurs very often after the inflammation has reached  its height,
although in itself it  is usually characteristic of posterior  urethritis,
and is discussed more  fully under this heading.  (See page  100.)
    General Symptoms.—Although the most severe gonorrhoea usually
remains  a local  disease, during the height of its course it is often at-
tended by some general symptoms.   Rigors, slight fever, loss of appe-
tite, and malaise are frequently observed.  At  times there  is con- 
GONORRHOEA.
97
siderable mental  disturbance, so  that the patient, particularly when
erections  are  troublesome, acquires a  characteristic haggard and
worn appearance.
   The fever  and  malaise  are due to  toxic absorption from sup-
purating areas; the mental depression seems to be inseparable from
urethral discharge, and is usually profound in direct proportion to the
length  of time the latter lasts.
   To  summarize : the symptoms of  acute anterior  urethritis are,
after an incubation period of from three to five days, puffiness and
inflammation of the meatus, a muco-purulent discharge, ardor urinae,
diminution in the size of the  stream of urine, and painful erections.
   Unless  checked by appropriate remedies, the symptoms  steadily
increase in severity for about two  weeks;  this constitutes the in-
creasing stage.  During this  time gonococci have invaded the entire
urethra and have penetrated to the deepest  epithelial layers.
   For about one  or two weeks the  symptoms remain  stationary
(stationary stage);  they  then gradually subside (subsiding  stage),
ardor urinae and painful erections entirely disappearing,  and the dis-
charge becomes thinner, clearer,  and more  scanty, till, in about two
weeks  more, it is entirely suppressed. The disease  runs its course in
from five  to eight weeks, and lingers longest in the bulbous portion
of the  anterior urethra.
   Acute  gonorrhoea may  be greatly prolonged  by relapses or by de-
pressed conditions of the  system  rendering  the  tissues  less able to
resist or eliminate the  disease.  Relapses may be occasioned by ex-
posure  to  cold, by overexertion, by excesses,  or by the congestion
incident to seminal  emissions, which are, in turn, excited by the acute
inflammatory process.
   Acute  anterior urethritis commonly involves the  posterior urethra,
though exceptionally this portion of the canal  appears to escape.
Not  infrequently the symptoms of  posterior  inflammation are  so
slightly marked as to excite no attention.
   Gonorrhoea may terminate in  resolution or in chronic urethritis,
or may be followed by stricture.
   Prognosis of Acute  Urethritis.—This specific inflammation runs its
course  in  from five to eight weeks.   If carefully treated, the dis-
charge  disappears, the urine remaining absolutely clear of shreds, and
the disease is cured.  At times,  even  though  treatment has been
judicious  and has  been rigidly carried out, the  acute inflammation
runs into  the  chronic form, manifested by a gleety discharge, lasting
longer  than eight weeks.   This is especially liable to occur in  the
strumous  and  cachectic, in those of gouty or rheumatic tendency, and
                                7 
98
GENITO-URINARY DISEASES AND SYPHILIS.
 in patients who are careless in respect to treatment and impatient
 under restraint.   The prognosis as to the time when cure  can be
 expected must always be guarded.
    Complications.—In the increasing  stage, balanitis, balanoposthitis,
 phimosis, and paraphimosis are the  common complications; in the
 stationary stage, folliculitis and periurethritis,  lymphangitis, lymph-
 adenitis, cavernitis, and cowperitis.
    Subacute and  chronic gonorrhoea are liable to be complicated by
 rheumatism, ophthalmia, endocarditis, myelitis, and  other manifesta-
 tions of septic absorption.
    Subacute or  Catarrhal Gonorrhoea.—This  occurs most fre-
 quently in persons who have suffered  from a previous  attack of
 gonorrhoea, and exemplifies the tendency manifested by the mucous
 structures to  become  readily  excited to  inflammation  from  slight
 causes after  having once  been affected.  This is particularly notice-
 able in the urethra, because this canal affords periodical passage for
 the urine, which,  from changes in its constitution,  may become a
 natural irritant.  During erection it is exposed to intense congestion.
                                       On account of its excessive
                                       blood-supply and of the ab-
                                       sence of firm extra-vascular
                                       support,  the blood-vessels
                                       remain in an atonic condiv-
                                       tion  and   become  greatly
                                       congested on slight provo-
                                       cation long after apparent
                                       complete recovery from  an
                                       attack  of  urethritis.   The
                                       close apposition of the mu-
                                       cous surfaces during the in-
                                       terval of   micturition  also
                                       favors  the  continuance  of
                                       granular or congested areas
                                       or other traces  of inflam-
                                       mation : hence but few who
                                       have had one attack of gon-
                                       orrhoea  escape subsequent
manifestations, infection too  feeble to overcome the resistance of a
healthy urethra finding under such circumstances favorable soil.
   In this form of gonorrhoea  the incubation period is exceedingly
variable, and there is often no inflammatory symptom beyond a pro-
fuse muco-purulent urethral discharge.  There may be a slight feeling

w$*'
>■<?
7
/0-__



   mm
m
Subacute gonorrhoea ; pus ; epithelium; mixed infection
               (Guyon.) 
GONORRHOEA.
99
of warmth during urination and some increased sexual excitability,
but ardor urinae  and painful erections are usually absent.  A pure
pus discharge is very rare, the latter being mainly mucous or serous.
Gonococci and  pus-cells are  not abundant, but are found, together
with epithelial cells, principally of the flat and transitional variety.
(Fig. 47.)   The inflammation seems to be purely  superficial in its
nature, and the disease is rarely attended by local complications.
   Under treatment the discharge rapidly diminishes in quantity until
only a drop of mucus is found  in the mornings; but this  symptom
is liable to persist for a long period, and is exceedingly difficult to
suppress.
   Irritative or  Abortive  Gonorrhoea—Non-Speciflc Ure-
thritis.—This form  of  urethritis arises from contact with foul  dis-
charges, from traumatism, or from irritating conditions of the urine,
and is not due to  the presence of the gonococcus.
   It may be excited by mechanical or chemical irritants, or by any
one of a number of micro-organisms.  The usual cause is coitus with
a woman suffering from leucorrhoea.  It is characterized by a varying
period of incubation, usually very short, at most one or two days, by
a reddened, swollen, itching meatus, by some pain on urination, and
by a milky secretion from  the urethra, appearing only when  this
canal is stripped forward.  These symptoms are, of course, identical
with those of the earliest stage of acute  gonorrhoea, and, except by
microscopical examination of the discharge, this form of disease can-
not be distinguished from true  gonorrhoea.   Its course, however, is
different.  Unless the inflammation is treated by irritants, the symp-
toms do not increase in severity. Neither ardor urinae nor chordee
develops.   The discharge continues  for five to ten days  and then
ceases spontaneously.  There are no sequelae and  no complications.
The  condition is a purely catarrhal one.  It is these  cases which have
obtained for certain remedies a  repute for aborting  acute gonorrhoea.
The  disease subsides, under  almost any treatment which is not too
violent, in a time which is very short as compared with the  duration
of ordinary gonorrhoea.   The attendant is  often, and not unnaturally,
led to believe that such subsidence is due rather to his treatment than
to the spontaneous cessation of the disorder.
   The account just given  represents the  usual  course of a non-
specific urethritis.  Exceptionally the inflammation is as violent  and
prolonged as if from gonococcus infection.  In strumous and cachectic
individuals the  discharge may  remain  slight, but persists for weeks
and  months,  in spite of treatment, and  commonly brings about a
marked condition of sexual neurasthenia. 
100        GENITO-URINARY DISEASES AND SYPHILIS.

   Acute Posterior Urethritis.—Although it is true that the com-
pressor urethrae muscle  constitutes a sphincter, which  by its tonic
contraction keeps the  membranous part of the  canal constantly
closed against injections forced through the  meatus, the gonococcus
as it passes backward in the deeper layers of the epithelium is  not
arrested by this muscle, but with  few exceptions invades the poste-
rior urethra, from which region it can readily extend to the prostatic
ducts, the seminal vesicles, the vas and epididymis, and, very excep-
tionally, to the bladder.
   Strong injections,  bodily activity, indulgence in coitus, excesses in
drinking, neglect of treatment, are considered the common causes of
the extension of gonorrhoea to the posterior urethra, and,  without
doubt, justly, since whatever increases the intensity of the  original
attack  adds to its powers of extension.   It is true, however,  that
even though every precaution be  taken  to  subdue the violence of
a  gonorrhoea, the posterior urethra commonly becomes  involved.
This often occurs by the end of  the first week of  acute urethritis,
though  active symptoms are  rarely observed before the end of  the
second week.   In the third week they are usually most pronounced.
They may not  develop  till a much later period,—in the course of
relapses, for instance.  When the gonococci have been carried back-
ward by bougies or  by  injections, well-marked  posterior urethritis
may develop in the first days of the attack.
   Symptoms.—Usually the inflammation remains superficial and mild
in type  and occasions no very distinct symptoms, except  perhaps un-
due frequency and slight urgency in urination and the appearance of
pus-shreds in the urine.
   When the posterior urethritis  develops suddenly as a result of
exposure or excesses, it runs an acute  course, and is ushered in by
very characteristic symptoms, which reach their height in one or two
days.
   The attack begins with  painful urgent and frequent micturition
and  the appearance of pus  in the  last portion of urine.  In severe
cases these symptoms are followed by perineal pain, persistent erec-
tions, nocturnal pollutions,  haematuria, albuminuria, and sometimes
retention of urine.
   Urgent and Frequent Urination.—Normally, when the bladder be-
comes moderately distended, the internal vesical sphincter dilates and
the urine comes in contact with the prostatic urethra.   This occasions
a desire to urinate so  slight that the act may be postponed with com-
fort for hours.  When, however, the prostatic urethra is inflamed and
hypersensitive, the first contact of urine on the yielding of the  internal 
GONORRHOEA.
101
sphincter excites  an uncontrollable  desire to evacuate the  bladder
contents.
   In the hyperacute form the patient is compelled to micturate every
few minutes, but passes, after great straining, attended by almost un-
bearable pain, only a few drops of urine, without  any relief being
afforded to the intense desire to urinate.  From swelling of the mu-
cous membrane and reflex tonic contraction of the vesical sphincters
there may be obstinate retention of urine.
   When inflammation is less acute the constant straining is replaced
by frequent urination and  a precipitancy in the act; that is, when the
desire to urinate is felt, it immediately becomes so urgent that the
water is retained only with great difficulty.   This  latter symptom is
highly characteristic, and is readily explained on physiological grounds.
   Hematuria.—In addition to the tenesmus there is frequently haema-
turia,—a few drops of pure blood running from the urethra at the end
of urination.   This is  squeezed from  the  swollen,  congested, often
eroded mucous membrane of  the prostatic urethra.  Hemorrhage may
be very free.   In this case the blood will flow back into the bladder,
and the patient will pass it mixed with  his urine and after the latter
has ceased flowing.
   Albuminuria.—During the period when vesical tenesmus  is most
marked there  is always a quantity of  albumen  in the  urine greater
than can be accounted for by the pus present.   This is probably due
to damming back of the urine in the ureters,  dependent upon closure
of the orifices  of these canals by contraction  of the detrusor muscles
of the bladder, this having been shown to take place when tenesmus
is severe.
   Perineal Pain.—This  when  due  to   tenesmus—i.e., muscular
spasm—may be  almost unbearable in its intensity.  Aside from the
suffering by muscular spasm there  are usually tickling, burning,  or
shooting pains in the deep urethra and about the rectum.  These are
aggravated by micturition  or defecation.
   Erections are frequent, but are painless unless there is at the same
time acute anterior urethritis.
   Nocturnal emissions occur  repeatedly, and  are almost symptomatic
of inflammation of the posterior  urethra.  They are due to hyper-
aesthesia of the caput  gallinaginis, and are  often painful, the distress
being referred  to the deep urethra.
   Discharge.—However profuse the discharge of posterior urethritis,
it never passes forward, this being prevented  by  the tonic  contraction
of the compressor urethrae muscle.
   When gonorrhoeal inflammation involves the posterior urethra 
102       GENITO-URINARY  DISEASES AND SYPHILIS.

without occasioning symptoms it can be detected only by an examina-
tion of the urine, which will be found to be far more cloudy than can
be accounted for by the very slight anterior discharge.  The existence
of inflammation of the posterior urethra may be still further confirmed
by causing  the patient to pass  his water in two portions.  The first
part will, of course, wash clean both the anterior and  the posterior
urethra.  Should the second part be clouded from pus or mucus, this
(in the absence of cystitis or pyelitis) is a positive sign of involvement
of the posterior urethra, since the pus produced in the pars posterior
must necessarily, if it be secreted in any large quantity, first fill the
prostatic urethra, and  then flow back into  the bladder and  become
mingled with  the  urine.  If there be  but a small amount of pus
secreted, it will remain in the prostatic portion of the urethra and will
be carried away with the first urine:  hence, if the patient micturates
frequently or the discharge is slight, the second urine  will probably
remain clear.
   In this case the  source of the pus may be determined by passing
a small soft catheter into the urethra until its point encounters the
resistance caused by the contraction of the compressor urethrae mus-
cle.  All the pus lying in the anterior urethra is now washed away
by forcibly  injecting a stream of water  through the  catheter and
allowing it to escape from the meatus; six or  eight ounces of boric
acid solution  should be used  for this  washing.   Immediately  after
this irrigation the patient is instructed to urinate in two portions.  If
the first portion of water passed contains pus, while the last part is
clear, it shows that there is inflammation of the posterior urethra,
causing a discharge not sufficiently profuse to fill the prostatic urethra
completely and flow backward into the bladder.  Even this test is
not absolutely accurate.  The flushing out of the  anterior urethra
with a one  per cent, solution of methyl blue, followed by urination
and  microscopic  examination  of  shreds, would show if  the  latter
remain unstained  that they  probably  come   from  the posterior
urethra.
   It is only in acute  freely discharging cases, then, that the second
urine is always cloudy.  In  slight  cases this cloudiness will be ob-
served only after retention, or may not be found  at all.
   Since there is  prolonged retention of urine  at night, it is best to
examine the urine passed on rising in the morning.   The second por-
tion of this will nearly always show the presence  of pus, even though
the urethritis be of light grade.
    General  Symptoms.—Acute  posterior urethritis occasions  more
marked general symptoms  than occur when inflammation is located 
GONORRHOEA.
103
in the anterior urethra.   The fever  is more  pronounced, there is
more mental  depression; the  patient complains of anorexia,  head-
ache, and constipation.
   Prognosis.—In the majority of cases posterior urethritis remains
superficial and subsides without  direct treatment.   More frequently
than  is generally realized it becomes chronic, causing  intermittent
gleet and sexual neuroses of all types.
   Complications.—Prostatitis, vesiculitis,  epididymitis, and urethro-
cystitis are  the  ordinary complications of posterior urethritis.  A
true  gonorrhoeal cystitis is extremely rare, and is always due to mixed
infection, since the gonococci are not prone to attack surfaces covered
with squamous epithelium.
   The Pathology  of Acute  Goxorrhceal Urethritis.—The  gono-
cocci, having been  deposited  on the surface of the  mucous  mem-
brane, multiply rapidly and penetrate the epithelium, shortly reaching
its deepest  layers, but stopping abruptly at the subepithelial connec-
tive tissue.
   In twenty-four  hours after this invasion of the deeper epithelial
layers there is an active migration of leucocytes, separating the epithe-
lial cells, and  often causing exfoliation, usually of those lying super-
ficially, at times of complete layers.  Regeneration follows very quickly,
particularly in young  men.  According to Bumm and  Baumgarten,
only mucous surfaces  provided with cylindrical epithelium  or epithe-
lium transformed into this variety are subject to infection.  Thus they
explain the  immunity of the buccal and  part  of the nasal mucous
membrane  and of the vagina  of  adults.   This is  also interesting in
reference to the method of spontaneous  cure of gonorrhoea,  since
where the  micro-organisms  most deeply  invade the  tissues there is
formed during the process of healing a many-layered, horny, flat epi-
thelium.  The anatomical alterations consist in reddening, swelling,
and free discharge, first of thin fluid, later of thick pus often mingled
with blood.  The mucous membrane shows erosions, and, very excep-
tionally, distinct ulcers.  The crypts, follicles, and gland-ducts become
swollen, often  blocked with  pus-plugs, and form sacs containing pus
and degenerated epithelium.
   Treatment of  Acute  Gonorrhoea  in  the  Male.—Prophy-
lactic Measures.—The use of a cover sufficiently strong to remain
unbroken during coitus,  followed by careful ablution and urination
immediately on completion of the act, is  the only reliable means of
preventing contagion.   In the majority of  instances the cover is dis-
pensed with, the washing and  urination being relied upon to dispose
effectually of any contagious matter.   In  this  case the flushing  out 
104       GENITO-URINARY  DISEASES AND SYPHILIS.

of the urethra may be made more thorough by  passing the water in
as full a stream  as possible and suddenly stopping its flow  by oc-
cluding  the  meatus.  This widely distends the anterior urethra and
causes the water to penetrate  to all portions of the fossa  navicularis
and even  to the  lacuna magna.   This result is not obtained by ordi-
nary urination.  When passed in the way  directed, the  mechanical
cleansing  effect is superior to that of an injection, and the urine is at
the same time far less irritating to the mucous membrane.
   Among those who are constantly in the  habit of exposing  them-
selves to  contagion the employment  of  antiseptic injections  imme-
diately after coitus is popular.   If such injections are employed, they
should be so weak that no irritation of the mucous membrane will
be involved.  Since it has been  shown that the contagious pus does
not penetrate deeper than the fossa navicularis, the injection  should
not extend beyond the first two inches of the urethra, and since to
be efficient  the injection  must destroy all gonococci,  it must be  so
applied  that it will thoroughly distend  the  fossa  navicularis.   Car-
bolic acid 1 to 200, silver nitrate 1 to 6000, bichloride of mercury
1 to 10,000,  probably  represent the best solutions to be employed as
prophylactic injections.
   The use  of these  injections  should  be preceded  by  urination.
Even when  they are most skilfully administered  they do  not  afford
certain  immunity against  the development of  gonorrhoea, and unless
they absolutely destroy all the specific germs which have entered the
urethra they distinctly predispose to it.
   The Abortive Treatment.—The treatment of gonorrhoea in its early
stages by strong irritating injections, particularly those of silver nitrate,
with the idea of substituting  an acute inflammation  for  the specific
process and thus aborting the latter, is now seldom employed.  In-
creased severity  and  longer  duration of inflammation   have been
noted in cases thus treated, and  tight strictures  are much more fre-
quently observed  than when  gonorrhoea is  treated by  less  heroic
measures.   It has lately been asserted, however, that employed in the
right way and at the right  time the abortive treatment of gonorrhoea
is justifiable, since  it  is followed at times by prompt cure, and if it
fails it does not seriously aggravate  the  original disease.   Two meth-
ods of  treatment  may be  adopted with the idea of aborting the
disease:
    1.  Injections of strong solutions of silver nitrate.
    2.  Copious flushings with weak antiseptic solutions.
    1.  Injections  of Strong Solutions of Silver Nitrate.—It has been
shown experimentally that silver nitrate acts as  a powerful germicide 
GONORRHOEA.
105
upon the gonococcus.  Both the gonococcus and the silver nitrate pro-
duce the same effect upon the urethral mucous membrane,—that is,
they cause a desquamation  of the epithelium and an active inflam-
mation  of the deeper  structures.   The  silver nitrate, however, acts
very rapidly,—within a few hours;  the  gonococcus requires several
days to produce its full irritant effects.   If,  then, before the gono-
coccus has time to penetrate more deeply than the superficial layers
of the epithelium an injection of silver is employed, it seems  fairly
reasonable to hope  that it may not merely destroy the  microbes, but
may also  cause  them  to be thrown out from the  urethra  by  occa-
sioning  almost immediately  an active inflammatory discharge, which,
since it  is solely  due to a chemical irritation, may be expected to sub-
side entirely within  a few days.   If, however, the gonococcus has had
time to penetrate deeply,  further irritation  cannot accomplish its
extrusion, but will simply diminish tissue  resistance and add to the
pabulum of the  invading microbe, thereby increasing its multiplying
powers.
    It is, therefore, clear that the abortive treatment should not be
attempted except in the very earliest period of a gonorrhoea,—that is,
when the tickling of the meatus and  the drop of clear or slightly
cloudy discharge, made up of mucus and epithelium, denote that the
inflammatory process has not extended deeply.   A red or injected
meatus  with swollen, everted lips, a turgid glans, marked ardor urinae,
and particularly free purulent secretion, constitute absolute contra-
indications to this treatment, even if the case is seen early in its
course.   The injection should be made of  twenty grains   of silver
nitrate to the ounce of distilled water.  This is not  strong enough to
produce an inflammation of sufficient depth and intensity to be fol-
lowed by subsequent cicatricial contraction. The patient first urinates,
and has ten drops of a four  per cent,  solution  of cocaine injected into
the urethra.  Then the nozzle of a blunt-pointed  syringe is inserted,
the urethra is compressed two inches behind  the meatus, so that the
injection cannot  penetrate behind the point of  pressure, and  the silver
solution is forced in, until  all the urethra anterior to the   point of
pressure is fully distended.   The  solution is  retained a  few seconds,
and is then allowed  to escape by relaxing  the pressure of the nozzle
against the meatus.   The anterior portion of  the  urethra is thus dis-
tended with the  silver solution three times  in succession.
    After this treatment urination is postponed as long as is possible
without overdistending the bladder.
    In a few hours there is a yellowish-white, often blood-stained dis-
charge.   This diminishes, becomes white, and in forty-eight hours is 
106
GENITO-URINARY DISEASES  AND SYPHILIS.
changed  to a purely serous discharge, which entirely disappears in a
few days if the disease has been aborted.  If the free discharge per-
sists for from twenty-four to  thirty-six hours, the  treatment may  be
repeated, provided inflammatory reaction is not excessive.
   Usually when patients appear  for treatment the gonococci have
penetrated to a depth beyond the reach of the silver solution.  Even
when the case seems  suited to this treatment prognosis as  to prompt
cure must be guarded.
   We believe that, owing to the  impossibility of differentiating  the
irritative  form of the disease from the true or infective form  by clinical
symptoms alone at this early stage, this form of abortive  treatment
should not be used unless in  the mucoid  discharge gonococci can  be
found.
   2.  Copious Flushings with Mild Antiseptic Solutions.—This  treat-
ment, appropriate  in all stages of gonorrhoea, is sometimes followed
by rapid  cure when practised in the early stages of gonorrhoea.   The
technique of this method is described later.  (See page 116.)
   Systematic Treatment of  Acute Gonorrhoea.—The first
point  to be considered in the methodic treatment of acute gonorrhoea
is to  remove  as far as  possible all  additional sources  of irritation.
Among these are:
   1.  The influence of bodily activity, which always occasions more
or less friction and local congestion.
   2.  The congestive effect of sexual excitement.
   3.  The irritating effect of acid urine.
   The best way to avoid the deleterious effect of bodily exercise is
to order rest in bed, thus reducing  in  activity all the processes of  the
body  and exercising a powerful influence in controlling  local con-
gestion.  This is well shown by the  ease with  which gonorrhoea is
cured in hospital  practice.   Although this  treatment rarely can  be
carried out, it is useful  to insist upon  the  nearest practicable  ap-
proach to it.  The patient should be instructed to avoid all  active
exercise,  to walk as  little  as  possible, to  sit  rather  than stand, and,
whenever possible, to lie down with his hips elevated.
   Since inflammation of the urethra is frequently attended by marked
sexual excitability, the patient  should be made to  understand very
clearly that the hyperaemia  engendered  by  even moderate  sexual
excitement distinctly aggravates the inflammation and postpones  his
cure:  hence  he must avoid company, reading, or thoughts which
might produce local congestion.
   Careful attention to diet is of cardinal importance in rendering the
urine  bland.   If the  patient  can be limited to skimmed milk during 
GONORRHOEA.
107
the increasing stage of the disease, the chances are largely in favor of
his escaping without ardor urinae or chordee.  Unfortunately, very few
patients can  adopt this diet, since  so marked a departure from the
ordinary regimen would be certain to excite attention.   In such cases,
or when from choice the patient refuses to be restricted to skimmed
milk, he should be instructed to take very little meat, to avoid greasy,
fried, or highly seasoned articles, and to abstain from the use of  pep-
per, vinegar,  salt, coffee or tea, salad dressing, asparagus, acid fruits,
tomatoes,  pastry of  all kinds, and all articles of food  difficult of
digestion.   Alcoholic drinks of all  kinds must be interdicted,  par-
ticularly champagne, beer, and gin.   If to  avert suspicion it  becomes
necessary for the patient to take some form of alcoholic liquor, claret
should be chosen as the least hurtful.
    Effervescing  mineral waters or  ordinary water  may be taken
freely, but not to the extent of interfering with digestion.  Harassing
painful  erections are controlled by  potassium bromide one to three
drachms,  camphor monobromate  ten to  twenty grains, or hypoder-
mics of morphine one-quarter to one-half grain, at bedtime ; intense
ardor urinae by four per cent, cocaine solution  to the  meatus, or
urinating with the penis hanging in hot water.
    The moderate  use of tobacco is  rather beneficial than otherwise,
though  it should, of  course,  never be ordered  by  the physician.
Where the habit is already formed, and is practised in moderation, it
should  not be stopped.  Excessive use of tobacco should always  be
avoided.
    During the  night the  patient should  sleep  on a  hard bed,  and
should  not be too warmly covered.   He should rise once during the
night to pass water, thus  not only washing out the urethra, but also
removing a cause of erection and consequent local congestion.   Before
retiring  he should be instructed to take a hot bath, lasting from ten to
twenty minutes;  this by equalizing  the circulation  powerfully modi-
fies  local  congestion.  It  is often an efficient means  of  lessening or
preventing painful erections.  The bowels should be moved regularly,
a simple saline, such as effervescing Vichy, taken early in the morning,
answering well.
    For the purpose of rendering the urine entirely bland, in addition
to the milk diet and the free  use of water, it is well to prescribe  an
alkaline hydragogue diuretic, combining with it an arterial  sedative
and an  anodyne, directed especially to subduing the activity of the
genital  function.  There are many  ways in which these ends  may
be attained, but the following prescriptions satisfactorily fill the indi-
cations : 
108        GENITO-URINARY  DISEASES AND  SYPHILIS.

                  & Tinct. aconiti rad., gtt. xvi;
                    Pot. brom., Bviii;
                    Pot. acetat., ^ss;
                    Infus. pareirae bravae,  q. s. f^viii.
                  M.  S.—fgss in water every two hours.

                  R Tinct. verat. vir., gtt. viii;
                    Pot. brom.,
                    Sod. bicarb., aa 9 viii;
                    Liquor pot. cit., f^viii.
                  M.  S.—f^ss in water every two hours.

   Two five-grain tablets  of  potassium citrate may be given three
times a day after meals.
   Dressing.—The selection of  a  dressing which  shall collect  and
absorb the discharge, and which shall yet be neither heating nor cum-
bersome, is a matter of cardinal  importance.   The use of the rubber
bags  or pouches  sold for  this purpose is to  be condemned, since
they virtually act as poultices; the securing of dressings by tapes or
bandages bound  about the penis  is also objectionable,  since  the
venous  circulation is  often interfered with and  thus the  disease is
aggravated.
   If the foreskin entirely covers the penis, the best dressing consists
in the application of a small pledget of antiseptic absorbent  cotton.
This is retained in place by drawing the prepuce  forward.  It should
not be allowed to  become glued tightly to the meatus, so that the free
escape of pus will be  interfered with.   If the foreskin  only partially
covers the glans,  a slit should be cut in the  centre of a piece of lint
or of old linen,  about  two  and a half or three inches square.   This
slit is made just large  enough to slip over the head of the  penis  and
back of the corona.  The borders should be turned forward, and the
foreskin  should be brought in the  same direction, thus holding the
lint or the  linen in place.   If the foreskin is  absent, the  foot of an
old stocking, or a  bag  of similar size made out of any thin material,
may be pinned to  the  shirt  in front; at the bottom of this is placed a
wad of absorbent  cotton, and the penis is allowed to hang in the bag;
or a similar bag is secured about the loins by tapes.   Any dressing
which on removal is followed by the immediate  escape of one or more
drops of discharge, thus showing that there  is  a  damming back, should
be discontinued.
   The patient must be cautioned in regard to the contagious nature
of the  discharge.   He should wash his hands  carefully  after  each
handling of the organ or  of the dressing, and should  be especially
warned of the danger of gonorrhoeal conjunctivitis.  He  should be in- 
GONORRHOEA.
109
structed, in  addition to other precautions, to keep his fingers away
from his eyes.
   The directions above detailed should be  given the  first time the
patient is seen.  The importance of rest having been  pointed out, the
diet having  been regulated, hot baths and a diuretic mixture having
been  ordered, and  the  proper method of dressing the organ having
been explained, together with the danger of infecting  the eye, the ad-
ditional treatment will  depend upon  the nature of the inflammation.
If the case is one belonging to the irritative or abortive class, usually
all the  symptoms will  have  subsided in a few days.  If the case is
subacute or catarrhal,  the discharge  will become more profuse, but
no marked subjective symptoms will develop.  If the  case is one of
acute gonorrhoea, the  phenomena  already described will appear in
clue order, and will be severe in inverse  proportion to  the fidelity
with which the regulations given have been carried out.
   The irritative or  abortive gonorrhoea rarely needs further treatment.
   The subacute or catarrhal inflammation may be subjected at once
to the injection and medication  appropriate to the subsiding stage of
the disease.
   The acute inflammatory gonorrhoea may be treated (1) by interna]
medication, supplemented  later by injections ;  (2) by  immediate anti-
septic injections,  either with or without internal medication; (3) by
copious antiseptic flushings.
   1. Internal Medication, supplemented by Injections  in the Subsiding
Stage.—The general directions in regard to  rest, diet, the regulation
of the bowels, the dilution of the urine, and the dressing of the penis
having been given, the  question of exerting a direct germicidal action
upon the gonococci and at the same time increasing  tissue resistance
arises.  In cases  hyperacute-from the first, or rendered markedly in-
flammatory  in type by excesses or irritating injections, or in those
which react unduly to ordinary applications, many  surgeons prefer
postponing local treatment till the subsiding stage is reached, holding
that thus the disease runs a milder and shorter course and that compli-
cations, particularly those  associated with severe posterior urethritis,
are much less common than when injections  are used earlier.
   If  such a treatment is adopted, the remedies  appropriate to the
almost inevitable ardor urinae and  chordee (page 107) are supple-
mented by drugs, which,  when  they  are eliminated by the kidneys,
exert an antiseptic influence on the gonococci, at the same time slightly
stimulating the urethral mucous membrane.   Exceptionally even the
mildest  of these remedies aggravates the urethritis, or  so disorders the
stomach that its continuance is not practicable.  Usually the drugs com- 
HO        GENITO-URINARY DISEASES AND SYPHILIS.

monly employed markedly modify the amount of purulent discharge
and the violence of the inflammatory symptoms.
   Of the remedies which,  administered by the mouth, render the
urine mildly germicidal, the  most potent is  salol.   This when given
alone will materially modify the course of an acute  gonorrhoea, but
when  combined with other antiblennorrhagics is  greatly increased
in effectiveness.  After salol the  drugs  which most powerfully limit
the local  inflammation are oil of sandal wood, copaiba, and cubebs.
Cubebs and copaiba are generally used in the subsiding stage of the
disease, since they are  supposed to be too stimulating  during the
acute stages; frequently, however, they  form a valuable auxiliary to
the antiseptic treatment from the very beginning.   A capsule put up
according to the  following  formula (White's) will  not only abbreviate
the course of  gonorrhoea, but will often  prevent the development of
complications:
                      B Salol, gr. v;
                        Oleoresin. cubeb., gr. v ;
                        Para balsam, copaibae, gr. x ;
                        Pepsin., gr. i.
Or, as a change  from this, capsules containing:
                      B Salol, gr. iii;
                        01. santal., gr. iii;
                        Oleoresin. copaibae, gr. iii;
                        01. cinnamomi, gt. i.

   These capsules should be given, the former four to six a  day, the
latter six to ten.  They will be best borne by the stomach if adminis-
tered an hour after eating.
   An emulsion  is sometimes better tolerated by the stomach  than
are capsules.  The Lafayette mixture may then be employed ; this is
made up as follows:
                      B Balsam, copaibae,
                        Spir. lavand. comp.,
                        Spir. aeth. nitrosi,  aa ^ss ;
                        Liq. potassae, f^ss ;
                        01. gaultheriae, fgii;
                        Mucil. acaciae, q. s. ad fjiv.
            M.  S.—Two drachms three times a day after meals.

   In rare instances the urethral discharge seems  to be aggravated
by these remedies.  This is particularly the case when the posterior
urethra is acutely involved.  When  this occurs the medication  must
be stopped, the urine  being rendered mildly antiseptic by a blander
remedy.   Boric acid  answers well in fifteen-grain  doses four times 
GONORRHOEA.
Ill
a day.  A useful combination, especially when there are symptoms
of vesical irritation, is as follows:
                    B  Acidi borici,
                       Sodii bromidi, aa 9riii;
                       Tinct. belladonnae, f&i;
                       Liq. potassii citratis, f^viii.
             M.  S.—Tablespoonful in water four times daily.
    The possible disagreeable symptoms excited by salol and the bal-
samic remedies may be:
    1. Stomach indigestion, characterized  by heaviness after eating,
pain in the stomach, and gaseous and liquid eructations, bringing into
the mouth a taste of the medication.
    2. Copaiba  urticaria, appearing  especially upon the hands, feet,
arms, knees, and abdomen.
    3. Severe backache, fever, albuminous, smoky, or  bloody  urine,
and sometimes  complete suppression of the secretion.
    Marked kidney disease  is a contra-indication to the use of  either
salol or the balsams.
    At the end of the second or third week  of the treatment just
described the inflammatory symptoms will begin to subside, and the
discharge will become somewhat thinner and less abundant.  Without
any change of treatment a  cure may be expected in the majority of
cases in ten or twelve weeks.   This  cure is hastened and  rendered
more certain by antiseptic and astringent injections.
    Injections.—In making these the patient  is directed to procure a
hard rubber  urethral syringe, large  enough to hold  at  least four
drachms,  and  with  a nozzle so  shaped  that, while it cannot  injure
the urethral mucous membrane, yet when pressed in firmly it will
occlude the meatus  entirely  and  thus  allow the injections  to  be
conducted in  a  cleanly manner.   Either the blunt  hard rubber
urethral  syringe of  the  American  Rubber Comb  Company, or the
Goodyear syringe Xo. 1 C,  should be selected.  (Fig. 48.)   Or  if the
patient  has trouble in  employing a piston  syringe,  a soft rubber
bulb provided  with  a conical point
may be ordered.  This  is easily kept            Fig. 48.       ^s=^

It is, however,  ordinarily more diffi-                         V*^
    7                  J                      Urethral syringe.
cult to use than  is the  hard rubber
syringe, provided the piston of the latter works properly.  All syringes
with slender or sharp points which can penetrate for some depth into
the urethra and still further inflame the mucous membrane must be
forbidden. 
112       GENITO-URINARY  DISEASES AND SYPHILIS.

   Having procured a proper syringe, the patient should be instructed
in its use till he is able in the presence of the surgeon to perform upon
himself a skilful and thorough injection.
   In making the  injection  the.patient may either sit or stand.   He
first  urinates, then the syringe having been filled is taken between the
thumb and middle finger of the right hand, the tip of the index finger
resting on the piston.   The conical extremity of the syringe is in-
serted within the meatus, which is held  open for that purpose by the
thumb and index finger of the left hand, and which is  then drawn
tightly around the syringe, the  pressure being made laterally,  thus
narrowing the aperture instead of broadening it, as would  happen
were it compressed vertically.  The syringe is depressed so that the
nozzle  points about towards the umbilicus,  and the piston  is  then
driven in.
   The liquid should flow into the  urethra without  any  leakage;
should dribbling occur, it shows that the finger and thumb of the left
hand are  not so placed that the margins of the meatus are made to
embrace the syringe closely.  On the completion of the injection the
syringe  should be  quickly withdrawn,  and  the  meatus should be
instantly closed by pressure of the thumb and finger.  The injection
is  thus retained  within the urethra for  three minutes.  The whole
anterior urethra should be distended.   This requires two  or three
drachms of solution, and when the injection is first driven in excites
a feeling of tension and muscular spasm in the perineum correspond-
ing to the position of the bulb.   This sensation indicates that a suffi-
cient quantity has been injected.
   The soft rubber bulb is used in the same manner as the  syringe,
except that the liquid is forced out by compressing its sides instead of
by driving home a piston.
   Any injection which gives rise to more pain than may be char-
acterized as temporary stinging or smarting is likely to do more harm
than good, and should be either withdrawn or diluted.  Departure
from this rule, save in very exceptional  circumstances, is likely to be
followed by disastrous results.   The aim of  the surgeon is to accom-
plish cure with the weakest efficient injection.
   These injections are made after each act of micturition.
   Injections are contra-indicated in acute gonorrhoea :
   1. When they cause persistent and severe pain and seem to aggra-
vate  the severity of  the inflammatory symptoms.
   2. During the course of an acute posterior urethritis.
   The injections  which  are least irritating  and most  successful in
shortening the course of acute gonorrhoea are the following: 
GONORRHOEA.
113
                   B Hydrarg. chlor. corros., gr. £;
                      Sod. chlor., 3i;
                      Aquae destil., f,?vi.
                   M.  S.—Locally after urination.

                   B Argent,  nit.,  gr. i;
                      Aquae destil., f^i.
M.  S.—Solution 1 to 500;  add twelve drops to a tablespoonful of distilled water
      and inject.  Gradually increase until thirty or forty drops are added.

                   B Pot. permanganatis, gr. ii;
                      Aquae destil., fjiv.
M.  S.—Dilute with  an equal quantity of boiled  and  filtered water and inject.
               Gradually increase the strength of the injection.

                   B Zinci permanganatis, gr. ss ;
                      Aquae destil., f^ii.
M.  S.—Dilute with  an equal quantity of boiled  and  filtered water and inject.
                      Gradually increase the strength.

    Such injections as  those just  given, containing  only one active
principle, are usually less efficacious  than  those in  which the anti-
septic  and  astringent  properties  of  two or more drugs are combined :
hence the following prescriptions are  much more  popular and  effi-
cacious when injected by means of the ordinary syringe:

                   B Hydrarg. chlor. corros., gr. %;
                      Acidi carbolici, gr. xii;
                      Zinci sulphocarbolatis, gr.  xii to .^i;
                      Boroglycerid. (25  per cent.), f^ii;
                      Aquae, q. s. ad f^vi.
M.  S.—Inject  after urination, diluting or making stronger according to indica-
                                 tions.

    This injection has  proved more  efficacious than any other of the
large number popular with  the  profession.  It  is appropriate to all
stages  of gonorrhoea, the  strength being regulated  to suit  individual
peculiarities,  and  combines  nearly  all  the  essentials  theoretically
required of an injection.
    When  an astringent  action  seems  to  be  strongly  indicated, as
shown  by continued profuse muco-purulent discharge,  uninfluenced
by antiseptics, the following will  be found useful:

                       B Ext.  hydrast.  fl. (colorless),
                         Bismuthi subcarb.,
                         Glycerini, aa £ii;
                         Aquae destil.,  f^iv.
                      M.  S.—Inject after urination.
                                   8 
114        GENITO-URINARY  DISEASES AND SYPHILIS.

   To this may be added zinc sulphocarbolate in the proportion of
ten grains to the ounce of water, the bismuth being  replaced by this
drug towards the end of the attack to enable the surgeon to determine
the nature and quantity of the  discharge.
   Another  astringent  injection  efficacious  in the  last weeks  of
gonorrhoea, and serviceable at  all stages, is the  well-known  injection
Brou.   This  is compounded as follows :

                    B  Zinci sulphatis, gr. xv ;
                       Plumbi acetatis, gr. xx ;
                       Tinct. opii,
                       Tinct. catechu, aa 3ii;
                       Aquae ad f§vi.
                M.  S.—Use as an injection after urination.

   Ultzmann's injection is particularly efficacious when in  the sub-
siding  stage  discharge  ceases  to diminish under  other applications.
The formula for this is:

                    B  Zinci sulphatis,
                       Pulv. alum., aa gr. iv ad gr. xii;
                       Acidi carbolici, gr. iv;
                       Aquae, f§vi.
M.  S.—Use by injection, changing the strength in accordance with the indications.

   Other astringent injections  which may be employed are:

                    B  Zinci acetatis,
                       Acidi tannici, aa gr. xx ;
                       Aquae rosae, §iv.

                    B  Zinci sulphatis, gr. iv ad gr. xii;
                       Liq. plumbi subacetat. dil., fjiv.

   When the discharge has entirely disappeared the urine should be
examined to see whether it contains clap-shreds.  If these are present,
there must for a time, be no abatement in  the  treatment.   If pus is
entirely absent, shreds  being made up of epithelium  and mucus, and
other symptoms have ceased, the patient should stop treatment gradu-
ally.  Injections should be cut down to two a day, to one  a day, to
one every other day, until, in ten days, they are entirely stopped.
   The administration of antiseptics and balsams by the  mouth is
gradually diminished  in the   same way,  the urine  being examined
every second or third  day for  the  purpose of demonstrating whether
cessation of treatment is attended with reappearance  of purulent dis-
charge.  After the cessation of  all treatment  a full week should elapse
before  the patient relaxes the strict regimen  under which he  has been 
GONORRHOEA.
115
living.   If at the end of this time  his  first and last urine is entirely
free from discharge, he can safely resume his ordinary habits of life,
at least so far as relighting his gonorrhoeal inflammation is concerned.
   Summary of  Treatment by Internal Medication, supplemented by In-
jections in the Subsiding Stage.—1.  The patient is directed to keep as
quiet as possible, to avoid all sources of sexual  excitement, to render
the urine bland by diet, to secure regular daily motions of the bowels,
to take a hot bath  before retiring, and  to sleep on a hard bed with
light covering.
   2. He is given  remedies calculated to make the  urine bland, to
subdue local inflammation,  and when excreted by the urine to exert
an antiseptic influence on the gonococci (as salol, oil of sandal wood,
copaiba,  sodium bicarbonate, sodium bromide, potassium  citrate  or
acetate,  hyoscyamus, belladonna, aconite,  cubebs, and  boric  acid).
These  drugs are pushed till they either produce disagreeable effects
or accomplish to a satisfactory extent  the object for which they are
given.
   3. The treatment appropriate for relief of ardor urinae and  chordee
is ordered.  In  the beginning  of the subsiding stage an injection is
given after each urination.  These  injections are at first  exceedingly
weak, are gradually increased in strength as toleration is established,
and are made more distinctly astringent in the  subsiding stages.
   During an acute posterior  urethritis injections  of  the  anterior
urethra are  omitted.
   4. Treatment should be continued till examination  of  the  urine
shows  absence of purulent shreds for at least seven days.   It should
then be stopped gradually.
   The treatment of discharge lasting longer than eight weeks will be
considered under the heading Chronic Gonorrhoea.
   Treatment by Immediate Injection.—This differs from the  treatment
just described only in the fact that injections are ordered as soon as
the patient comes under observation and  the  diagnosis is confirmed
by microscopic  examination.   The general  directions,  the  internal
medication, and the injections are the same as those already detailed.
   The  contra-indication to this  treatment is  found in excessively
acute cases distinctly aggravated by any form of local treatment.
   The injection which has given  most satisfactory results is that
made up of zinc sulphocarbolate, carbolic acid, corrosive sublimate,
and boroglyceride (see page 113), supplemented in its action by the
salol, copaiba, and cubeb capsules (page 110).   Care must be taken
that the  injection be not too strong when it  is first applied.  This
is  determined  by the amount of pain excited  and the inflammatory 
116       GENITO-URINARY DISEASES  AND SYPHILIS.

reaction which follows the use of the lotion.  The first injection of
any lotion should usually be weakened  by  the addition of  an equal
quantity of sterile water.   Towards the end of the subsiding  stage the
strength may be materially increased.  Exceptionally it may be sub-
stituted by a more purely astringent lotion.
   Copious Irrigation of the Urethra with Dilute Antiseptic Solutions.—
This  method of  treatment,  applicable at any stage of gonorrhoeal
urethritis, will often be attended with  more  rapid subsidence of in-
flammatory  symptoms than either of the  methods  already described.
The  apparatus required  is a quart irrigating bag or bottle,  a  rubber
tube leading from this eight  feet in length, and a nozzle attached to
the rubber tube and shaped  in the form  of  a flattened cone,  so that
it fits into the meatus and prevents the irrigation liquid from flowing
out beside it, thus keeping the urethra distended.   (Fig. 49.)
   In place of the urethral nozzle a small  soft rubber catheter (No. 10
F.) may be fitted  to the tube  leading from the reservoir.  This should
                    be lubricated with carbolized glycerin and  carried
      Fig. 49.        down to the compressor urethrae muscle when
                    it is desired  to irrigate the anterior urethra alone.
                       The  solutions employed in the irrigating ap-
                    paratus  are  bichloride of mercury 1 to 20,000,
                    with one drachm  of sodium chloride added for
                    each pint of  water,  thus making the lotion of
                    about the same specific  gravity as the blood, and
                    hence less  irritating; potassium  permanganate
                    1 to 6000 to 2000;  silver nitrate  1 to 10,000 to
                    2000.
    irrigating bag.          The potassium permanganate  solution is the
                    one which is most popular and least irritating, at
least in the  early stages of acute gonorrhoea.  This is  used  as hot as
can be borne with comfort.   The  reservoir  is filled  and elevated to
a  height of two  to  three feet if the anterior urethra  alone is to be
irrigated, to a height of four  to six feet if both the anterior and the
posterior urethra  are to be medicated.
   The patient urinates, cleanses  the glans, foreskin, and urethral
orifice by turning the stream from the nozzle upon the parts, then
inserts the nozzle, with the stream still flowing,  into the meatus, the
penis being  drawn slightly upward  and forward in about the position
it  would  occupy  if erect.  The  patient should sit on  the  edge of  a
chair with a basin so arranged that the solution which escapes is re-
ceived in it, or,  better  still,  should  practise  these  injections while
sitting on  the seat of a commode  or water-closet.   When the anterior
 
GONORRHOEA.
117
urethra is alone involved in the inflammation these irrigations should
be limited to this part of the canal.   The bag should be elevated two
feet above the level of the bladder.   The stream  should  be allowed
to flow until a sense of distention in  the bulb and involuntary mus-
cular contraction  in the perineum  show that the  anterior urethra is
full and the compressor urethrae is excited to reflex contraction.  The
stream is then cut off, and the lotion contained in the urethra allowed
to flow out.  By starting the stream  and applying the nozzle to  the
meatus  the  anterior  urethra is again distended, and is emptied  as
before.  This process is repeated until the bagful of solution has been
used.
   If the urethral inflammation is total, as shown  by examination of
the urine,—and this is nearly  always the case,—the bag is elevated
four to five feet, and  the urethral nozzle is held  in  place  with  the
water-pressure  maintained until the  compressor urethrae yields and
a strong desire to urinate shows that  the bladder is full.   The nozzle
is then withdrawn, and the patient empties  the bladder of the solu-
tion which has flowed into it.   This is repeated once or twice at each
seance.  For the first three or four days these irrigations are repeated
twice in the twenty-four hours,—that is, morning and evening; after
that once in twenty-four hours is sufficient, the  strength of the solu-
tion being gradually  increased in accordance with the tolerance  of
the urethra  and bladder.  The first injections  should be made of a
strength  of 1 to 6000 permanganate, unless inflammatory  action is
severe, which will be shown by persistent  pain and by  swelling of
the meatus.  The solution is strengthened in the course of from seven
to fourteen clays till a lotion of 1 to 2000 is employed; stronger than
this  should not be introduced  into the bladder.  Exceptionally 1 to
500 may be employed in the anterior  urethra.
   When sublimate is  employed the strength is gradually increased
from  1 to 12,000 to  1  to 3000.  Silver nitrate  is used in about the
same strength as potassium permanganate.
   Janet gives two tables of treatment: one for the abortive treatment
of anterior urethritis,  in which he begins with a strength of 1 to 4000
and  on the  eighth  day  finishes with a strength  of  1  to 500;  the
second, in which he begins with the same strength, on the fifth day
uses 1 to 1000 to the anterior urethra, 1 to 2000 to the posterior, and
on the eighth day uses 1 to 500 to the  anterior, 1  to 1000 to the poste-
rior.  He holds that 1 to 1000 is as strong a solution  as should ever
be used in the posterior urethra, since 1 to  500 employed  here will
produce painful tenesmus.  In the first few hours  following irrigation
there is  a whitish  secretion,  followed by  clear  serum,  sometimes 
118       GENITO-URINARY DISEASES AND SYPHILIS.

slightly  blood-stained; then  absence of secretion; finally,  reappear-
ance of  purulent discharge, together with the  gonococci.  The return
of purulent  secretion is an indication that the effect of the irrigation
has passed off: hence these washings should  succeed  one another so
rapidly  that this recurrent  purulent discharge will be entirely pre-
vented ; that is, the second  irrigation should be given during the dry
period occasioned by the first irrigation.
   As to the question of predicting a cure, this is  difficult.  Usually
ten or eleven washings will be sufficient to bring about abortion.  At
this time there is no discharge and there are few or no shreds.   Some-
times there is  a little mucous discharge, especially if a strong  solution
has been  employed.   In this case irrigations are stopped, and the
patient is  advised to  continue his  observance of the  hygienic direc-
tions, and told to  report immediately on the first sign of  white dis-
charge.   In the absence of this he appears  eight  days after the last
irrigation.
   If recurrence takes place, the  discharge usually appears from the
second to the  fifth day after the last washing.  Janet  states that this
happened in three out of fifteen cases; the first time because a focus of
infection near the fraenum was neglected, the other two times because
a posterior urethritis was not suspected and received no treatment.
   In case of recurrence the irrigations are again administered ; some-
times two or three are sufficient, sometimes it is necessary to  give the
complete series. When the patients are cured, eight days after irriga-
tion there will be found a non-inflammatory meatus, entire  absence
of discharge, and absence of shreds  in the urine.  For the next two
months, however,  such a patient will be peculiarly susceptible to
renewed infection.
   When, in spite of this treatment, there is slight mucous discharge,
Janet advises  irrigation  of  the anterior  urethra with  silver nitrate
(1 to 2000).   He holds that permanganate has a peculiar action  on
the urethra.   It occasions a slight oedema  of  the urethra;  while this
lasts not a single microbe can be found in the secretion.  The success
of the permanganate treatment seems to show that the microbes are
so influenced  by the alteration of their  culture ground,  dependent
upon the oedema, that they cease to grow: hence, if this condition of
the urethra is sufficiently maintained, the complete destruction of the
microbes is sure.  It therefore follows  that for successful treatment it
is necessary to keep the  mucous membrane  continuously in a certain
condition of reaction.  If the treatment is carried  too far, the growth
of the microbe is encouraged; if  it is not carried far enough, inhibi-
tion ceases.   This  special reaction is  fugacious in proportion  to the 
GONORRHOEA.
119
acuteness of the gonorrhoea:  hence the necessity for  frequent repe-
titions of the injections.  The special  skill  in  treating this  disease
depends upon recognizing the required condition of reaction, and in
so regulating  the  strength and the frequency of treatment that  this
condition is maintained for several days.
    It is a matter of cardinal importance in applying these irrigations,
and indeed in any treatment of gonorrhoea, to disinfect thoroughly
any urethral  crypts which may  be found about the meatus.   On
separating the lips of the meatus these are readily seen opening at the
superior commissure.  They are practically always present in cases of
hypospadia.  They should be either thoroughly irrigated or cauterized,
their deepest portions being reached by means of a fine stick of silver
nitrate, or, better, with a hot needle.   When they are narrow  and
especially deep, their  canals  should be divided freely, thus allowing
of thorough  cauterization.  From  the  position  of these crypts it is
evident that unless  they are  searched for and treated directly they
are liable to remain as sources of renewed infection, since the nozzle
of either the syringe or the injecting pipe is carried beyond them,  and
they receive none  of the antiseptic fluid.
    As a result of  these  irrigations the  discharge is greatly lessened
and the gonococci disappear.
    When examination of the urine shows absence of clap-shreds, or,
if these  are present,  shows that they are made  up   of mucus  and
epithelium, the irrigations can be gradually stopped, being  adminis-
tered every other day for six days, then every third day for  six more
days, then omitted entirely.
    When there  is continuance of  mucous discharge,  in the absence
of gonococci and  a notable quantity of pus, silver nitrate irrigations
are particularly serviceable.   If, after complete cessation of treatment,
there recurs a white  drop made  up of  mucus  and  pus,  irrigation
should  be resumed, and  usually stops the discharge   in a few days.
If, after six weeks' treatment,  discharge  persists, astringent  injections
should be applied to the anterior urethra by means of a  piston syringe,
the posterior urethra being treated either by lotions or by instillations,
according to the indications of the  case.
    The advantages of the irrigation treatment with dilute  antiseptic
lotions are, that the discharge lessens almost immediately, that  the
ardor urinae and chordee are rarely intense, and that  the  disease in
general runs a milder course and is less frequently  and  seriously
complicated than is the case with injection treatment.   Exceptionally
the urine will  be found free from clap-shreds in  from  twelve to four-
teen days, there remaining  for one or two weeks a slight urorrhcea, 
120       GENITO-URINARY DISEASES AND SYPHILIS.

which  subsides  spontaneously.  This is particularly liable  to be the
case when the attack  is seen  early in  its course and is not highly
inflammatory in its type.  It often  happens, however, that the dis-
charge, though  quickly reduced to a morning  drop of milky pus or
to the  morning  gluing together of the lips of the  meatus, undergoes
no subsequent diminution; clap-shreds  are found  in the urine in the
third and  fourth weeks, and strong astringents are necessary to com-
plete the  cure.  This is  especially liable to occur when the disease
has reached its  acute  stage before being subjected to irrigation, and
when the  urethra is already strictured by previous attacks of inflam-
mation.  In the former case judicious strengthenings of the  solutions
may accomplish cure;  in the latter the  use of bougies will be neces-
sary to effect cessation  of the discharge.
   The disadvantages  of copious  flushings  are, that each treatment
takes about ten minutes for its proper performance, that a somewhat
cumbersome apparatus is required, and one which  it is difficult for
the patient himself to  employ unobserved,  and that in some  cases
the irrigations are followed by persistent and  very  severe  pain.  It
is also  urged against them that it is at times  impossible to limit their
action  to  the anterior  urethra, it being  undoubtedly true that even
when a soft catheter is  used the steady, gentle pressure of the column
of fluid will in a few minutes overcome the resistance of  the com-
pressor urethrae and sphincter vesicae  muscles and thus allow  the
lotion to flow backward into the prostatic urethra and the bladder.
This is, however, not a serious objection, since the  prostatic urethra is
usually involved and requires  treatment.  As  is true  of every other
method of treatment, these  copious flushings  are not suited to all
cases.   They  give better results,  however,  than  any  of the single
methods already described, and, although troublesome and time-con-
suming in application, tend  to prevent complications and to shorten
the course of  the  disease.   During  irrigation treatment the general
hygienic directions and the medication by the mouth already advised
should  be employed.
   It must be  understood that irrigations are contra-indicated when
they occasion severe and prolonged pain and when they are followed
by marked inflammatory  reaction.
    Treatment of Acute  Posterior Urethritis.—It  may be assumed that
in about  ninety per cent,  of all cases  of gonorrhoea  the  posterior
urethra is involved in the  inflammation.   Often this is not deep-
seated, and occasions no special symptoms beyond tendency to pria-
pism,  which,  though usually  attributed to  irritation  of the penile
urethra, is in reality a reflex from the posterior  urethra. 
                          GONORRHOEA.                       121
                               •
   When tenesmus, frequent urination, and pains in the deep urethra
indicate that this portion of the  passage is involved  in a hyperacute
form of inflammation, all  exclusively local  treatment to  the anterior
urethra, such as injections, should immediately cease.  As much rest
as possible  should be enforced, the bowels  should be moved daily by
Hunyadi taken immediately on rising  or by saline laxatives well di-
luted, the urine should be rendered copious and bland, and copaiba,
cubebs, or other stimulants to the urethral mucous membrane, if they
have been previously administered, should  be discontinued.
   Unless  the  stomach is disturbed  by this drug, salol  should be
administered in five-grain doses four times  a day.   This at times
seems to increase the violence of a posterior urethritis.   In  such a
case boric acid  should be administered instead, ten grains four times a
day.  The  use  of these antiseptics is most  valuable in preventing the
extension of the inflammation along the vasa deferentia or into the
bladder.
   General hot baths are  particularly serviceable in acute posterior
urethritis, giving sometimes immediate relief  to the most  distressing
symptoms.   If the tenesmus becomes so marked as to occasion acute
distress, suppositories of opium and hyoscyamus should be adminis-
tered, one  grain of the aqueous  extract of opium to one-fourth  of a
grain of hyoscyamus extract.   These should be repeated hourly until
the patient is completely relieved; four to six doses usually prove
sufficient.  In place of the suppositories hypodermics of morphine and
atropine may be given;  the  needle of the  syringe  should  be entered
in the perineum.
   Copious flushings  of  mild  antiseptic  solution  are  particularly
serviceable in these cases.  The solutions should, however, be so mild
as not  to  add  to the  already existing  irritation.   Potassium  per-
manganate  is  the  solution of choice, beginning with a strength of
1 to  10,000.  To the permanganate solution is added common salt in
the proportion  of one drachm to the pint.   The reflex spasm of the
compressor urethrae  muscle  excited  by the posterior  urethritis is
sometimes  so great that it will not yield even though the reservoir be
elevated six or  seven feet above the level of the bladder;  or when it
yields the inflow of solution through the prostatic urethra may be in-
tensely  painful.  In these  cases  the anterior  urethra  should be  first
flushed out, then, by means  of the instillator introduced just within
the grasp of the compressor,  ten  drops of a four per cent, solution of
cocaine should be injected into the posterior urethra.  Exceptionally
even the weakest of these  lotions seems  to aggravate the violence of
the inflammation.  When this is the case they should of course be 
122       GENITO-URINARY DISEASES AND SYPHILIS.

discontinued, and in place of this treatment copious injections of hot
saline solution  should be made  into the  rectum, a forcible stream
being thrown upward and forward directly against the prostate.
   In the hyperacute forms of posterior urethritis, when the  pains
and  tenesmus are not controlled by free doses of morphine, the in-
stillation of five to ten drops of a three to four per cent, solution of
silver nitrate will often give almost immediate  relief.
   During the irrigation treatment the general hygienic directions and
medication by the mouth already advised should be employed.
   ResumZ of the Treatment of Acute Urethritis.—1. Irritative urethritis
(the  form not due  to gonococci) may be  treated by salol and boric
acid, administered by the mouth.  The urine  should be kept bland.
Recovery usually takes place in from  seven to ten days; it may be
hastened by unirritating, mild, antiseptic injections.
   2. Acute gonorrhoeal urethritis may be aborted sometimes if the
infected mucous membrane (fossa navicularis)  receives a thorough ap-
plication of a strong solution of silver nitrate before the gonococci
have penetrated too deeply (first twelve hours).
   3. The general treatment of urethritis is the same for all cases:
rest, light diet, regular evacuation of the  bowels, ingestion  of bland
liquids in quantities as great as is compatible with good digestion, ab-
stinence from alcohol, from rich or highly seasoned foods, and from
the excessive  use  of tobacco,  avoidance  of  sexual  excitement, hot
baths at nights, drugs by the mouth calculated to diminish the acidity
of the urine and to make it antiseptic, proper provision  for  receiving
the  discharge,  and  the  treatment  appropriate to ardor urinae and
chordee.
   4. The local treatment is successful in proportion to the thorough-
ness with which mild antiseptics are applied  to the entire  diseased
surface.  The earlier in the attack their use is begun the more rapid
and  complete will be the cure.
   Copious irrigations of hot, very dilute antiseptics are attended with
most marked immediate improvement, but are not always able to pre-
vent the case from running into  gleet.   These irrigations should be
applied to the entire urethra.
   Repeated flushings with piston or bulb syringe somewhat  larger
than the one usually employed, using the  same solutions as are em-
ployed in copious irrigations, come next in order of efficiency during
the increasing and stationary stage of gonorrhoea.
   Single injections  repeated through the day with the ordinary piston
syringe have a  less  marked effect on the symptoms than either of the
preceding methods during the increasing and stationary stages.  During 
GONORRHOEA.
123
the subsiding stage they offer the most convenient method of applying
stronger antiseptic and astringent solutions than are usually employed
by the other methods.
    5. In the choice of local medication, the increasing and  stationary
stages  require a mild antiseptic; astringent action is  useless.   Since
all antiseptics  are irritating, the  solution must be exceedingly  dilute;
it  should be of about the same  density as the  blood-serum, and
should be applied  to the whole  of the  diseased  surface,—i.e., the
entire urethra.  In  the subsiding stages stimulation by stronger anti-
septics is allowable, and astringents for  the  relaxed  mucous  mem-
brane are particularly indicated.
    During the acute stage of posterior urethritis treatment of the ante-
rior urethra alone should cease, local symptoms  being subdued by
copious flushings with very dilute antiseptic solutions, hot baths, and
the administration of anodynes and sedatives.  When the acute symp-
toms subside, the flushings may be with stronger antiseptic lotions, and
may be supplemented by instillations with strong silver solutions.
    6. Idiosyncrasies  must always  be  considered in  the  choice of
injections and in  their  strength.   Changes must be  made to meet
individual cases, and in some rare cases all injections will have to be
suspended, intra-urethral treatment not being tolerated.
    For irrigations  and flushings, sublimate 1 to  12,000, potassium
permanganate 1 to 6000  to 2000, and  silver nitrate  1 to 2000 to 500,
give best results.   For  injections  the formula  containing corrosive
sublimate, carbolic acid,  and boroglyceride (see  page 113), varied in
strength to suit each case, is particularly serviceable.
    When astringents  are required, the  hydrastis-bismuth  formula,
silver nitrate, the injection Brou, or Ultzmann's  injection, containing
zinc, alum, and carbolic acid, will be found most serviceable.
    7. Treatment must not be intermitted  till pus disappears from the
urine, and even then must not be stopped suddenly.

                      CHBONIC URETHRITIS.
    A purulent post-gonorrhoeal discharge  lasting more than ten weeks
is  indicative of chronic urethritis, or gleet.  The essential,  and often
the only, sign of chronic  urethritis is  pus.  This may be discharged
from the meatus, particularly in the  morning, or may be found only
after careful examination of the urine.
   Contagion.—The chronic  inflammation is, at  least in  the early
period of its course, dependent on the persistence of gonococci, which
linger for a long time  either in  the diseased  gland-ducts or follicles
or in the deeper epithelial layers of the mucous membrane.   These 
124       GENITO-URINARY DISEASES AND SYPHILIS.

micro-organisms become weaker and less numerous in proportion to
the length of time the  disease has  lasted, till finally they disappear
entirely.   Thus in a long-standing gonorrhoea, even though gonococci
are demonstrated, the contagious  properties of the pus will be, com-
pared to those of acute  gonorrhoeal discharge, exceedingly feeble.
   To demonstrate the presence of  the gonococci in chronic urethral
discharge  many  examinations  must be  made,  since these micro-
organisms are never numerous.  If a demonstration of their presence
or absence is  particularly important, as, for instance,  when a patient
suffering from discharge desires to  marry, this may  be determined
by adding to the chronic irritation an acute  inflammation.  This is
best accomplished by injection of silver nitrate  1 to 2000.   There
follow an  active  hyperaemia and free discharge, in which  the micro-
organisms, stimulated to rapid growth by the abundant supply of
pabulum incident to the acute inflammation  and thrown off in  the
course of epithelial proliferation, may be found.  In spite of the feebly
contagious properties of long-standing gleet, it is a safe rule to forbid
coitus till the discharge  contains no gonococci.
   These micro-organisms  exceptionally  persist for two or  three
years.
   Finger has shown that in the healing stage of urethritis the newly
formed epithelium  growing  from  the  deeper layers  towards  the
urethral lumen  carries  with it the  gonococci and finally eliminates
them all, provided there is  no intercurrent acute inflammation.  If,
however, intercurrent inflammation  occurs, the  deep  epithelial  layer
is broken  through by the exudate, and by ways thus  made the gono-
cocci again  force an entrance into the papillary layers and by their
irritating  action  occasion  renewed  suppuration.  From prolonged
residence  upon the  same culture material  these microbes gradually
lose  their virulence, and hence occasion  progressively lighter recur-
rences, or, if conveyed to others, implant a mild form of  the disease.
Ultimately, even without antiseptic treatment, they disappear entirely.
As a result of this lessened  virulence after  repeated recurrences and
renewed penetration of the now feeble gonococci into the papillary
layers, they  may excite  so little irritation  here that scarcely any sup-
puration results, and hence the micro-organisms, not being eliminated,
linger indefinitely.
   Pathology.—The lesions of chronic urethritis  appear  as  intense
congestions, excoriations, granulations, epithelial thickenings amount-
ing at times to excrescences and  papillomata, follicular and  lacunar
involvement, and infiltration of the submucous periurethral connective
tissue, resulting ultimately in stricture. 
GONORRHOEA.
125
   The inflammation may be sharply localized  or may be associated
with a catarrhal  condition of the mucous membrane involving con-
siderable surface.  It may be confined to either the anterior urethra
or the posterior urethra; commonly both these regions are involved.
   In the early stage of chronic urethritis there is an abundant round-
celled infiltration of the urethral epithelium and  subepithelial con-
nective  tissue;  the epithelium overlying the inflammatory  infiltrate
proliferates and  exfoliates, leaving catarrhal erosions.  The lacunae
and follicles take part in this general catarrhal process, and as a result
of epithelium proliferation may become blocked, folliculitis, or even
abscesses, resulting.  As organization and contraction of the infiltrate
begin and the previously dilated blood-vessels  are compressed, atro-
phy of the mucous membrane and its glands follows, the epithelium
undergoing transformation from the cylindrical to the squamous form,
varying in thickness in proportion to the  density of the underlying
scar-tissue.   In the  early period of its  development this epithelium
proliferates, and contributes to the formation of clap-shreds; later it
becomes more firmly attached and horny in nature.  When the  cylin-
drical epithelium is transformed to the squamous variety it is no longer
translucent, but  becomes thick  and  whitish.  According to Finger,
erosions are very rare;  ulcers he never observed.  He frequently saw
patches of infiltrated epithelium, thickened and pale in color, which
resembled scar-tissue.
   Morgagni's follicles, scarcely visible in the normal urethra, are, as
a  result of inflammation,  converted into  small projecting  nodules,
often with very distinct openings.
   Finger concludes his study of the pathology of chronic urethritis
as follows. Chronic gonorrhoea is essentially chronic inflammation of
the subepithelial  tissue, which passes through  two stages,—namely,
that  of infiltration and that of connective-tissue formation and con-
traction.  Together with this essential lesion there are  proliferation,
catarrhal  desquamation, and mucoid degeneration of  the epithelium
of the urethra and of  its  lacunae, also disease of Littre's glands and
infiltrations of the cavernous tissue.   Consecutive to these lesions the
cylindrical epithelium  is changed to the  squamous form, the lacunae
are obliterated or blocked, and Littre's glands are destroyed.
   The seat  of  predilection  for chronic  urethritis is the posterior
urethra; the  next favorite seat is  the bulb, the  whole  of which is
usually involved.
   Etiology.—Chronic urethral discharge—that is, the discharge which
results from failure to cure the acute  inflammation—may be due to:
   1.  General systemic depression leaving the mucous membrane in 
126       GENITO-URINARY DISEASES AND  SYPHILIS.

a leaky condition after all lesions are healed and the gonococcus has
completely disappeared.
   2. Undue severity of the acute attack, with complications such as
folliculitis or periurethral abscess.
   3. Too early cessation of treatment and resumption of the ordi-
nary mode of  life, resulting in frequent relapses, each more stubborn
than its predecessor.
   4. Frequently repeated fresh infections, each attack being milder
than its predecessor, but more prolonged.
   5. A cachectic condition so marked that little or no reactive power
remains to favor a cure.   This is noticed in Bright's disease, diabetes,
tuberculosis, gout, and rheumatism.
   6. Congenital narrowings or obstruction of the urethra, as in the case
of a small meatus or valve-like foldings of the urethral membrane.
   7. Stricture  resulting from  infiltration  and subsequent sclerosis
and  contraction of the periurethral connective tissue.   This is gen-
erally associated with a granular condition of the neighboring mucous
membrane.
   Moreover,  strumous  and  gouty individuals  may  suffer  from  a
chronic urethral discharge entirely independent of gonorrhoeal infec-
tion.
   The usual causes of chronic anterior urethritis  are stricture and
chronic posterior urethritis.
   The catarrhal discharge dependent upon a weak and leaky mucous
membrane  and associated with no more serious pathological lesion
than moderate congestion must be carefully distinguished from other
post-gonorrhceal gleets,  since here the discharge is bland and non-
contagious,  and local treatment, except by  the mildest astringents, is
distinctly contra-indicated.   This  condition is termed  urorrhoza,  or
urethral catarrh.  After an  acute attack of gonorrhoea has subsided
and the last  drop of muco-pus has  disappeared, a patient suffering
from this trouble will  harass himself and weary  his physician by
complaining of a feeling of wetness about the meatus.   Sometimes on
stripping the urethra a drop  of clear albuminoid fluid may be pressed
out.  Beyond this there are no symptoms other than those created
by a worried imagination.  The  microscope  will at once  show the
nature of the  discharge.  It will be made up of mucus and epithelium.
There will be no pus, no gonococci.
    Under general tonic  and hygienic treatment this  discharge will
usually subside spontaneously in a few weeks  unless the slight con-
gestion  is  fanned to  an  active  inflammation  by  irritating  local
treatment. 
GONORRHOEA.
127
   Acute gonorrhoea frequently runs into the chronic form of disease
because of a general belief in the doctrine that the presence or the
absence of the " morning drop" of muco-pus is the  determining sign
as to whether an acute gonorrhoea is or is not cured.   Dependence
on this untrustworthy sign leads to abandonment of treatment and
restraint long before gonococci and pus have entirely disappeared.
The strict regimen to which  the patient  has been subjected is often
followed by excessive indulgence  in  previously interdicted pleasures.
This results in renewed perceptible discharge. This  again disappears
on treatment, but is started by  exposure even more readily than
before.  Finally the discharge becomes chronic.
   Repeated examination of  the urine will alone determine the pres-
ence or absence of discharge, and not until such examinations have
shown pus to be absent for  one  or two weeks should  treatment  be
entirely stopped.
   Chronic Anterior Urethritis.—The  only symptom exciting at-
tention in chronic anterior urethritis is the discharge.  If this is slight
and the focus of  trouble is in the bulbous urethra,  even this symp-
tom may be wanting,  the patient simply complaining of a sense  of
moisture about the meatus, or of the gluing together  of its lips, in the
morning.  Usually a single whitish drop in the morning is all that is
seen, micturition  during the  day  washing away the muco-pus as fast
as it is secreted, so that the patient is not  required to wear cotton  or
other protection to prevent staining of the clothing.   Coitus, drinking,
or other excesses tend to exaggerate the discharge.  After such causes
for exacerbation  it  becomes  more  purulent in character and runs
freely for a few days, when it again assumes the thin, whitish appear-
ance characteristic of a predominance of  mucus.
  Clap-shreds are constantly found  in the urine;  these,  when long,
translucent,  and  branching,  are mainly made up  of mucus;  when
short,  thick,  and tack-  or  comma-shaped,  they  denote  that  the
urethral crypts and follicles are involved.
   Symptoms.—The characteristic symptom of chronic anterior ureth-
ritis is muco-purulent  discharge.   This varies  greatly in  quantity,
from a free  continuous running to a morning drop without further
signs during the day, to a slight gluing of the lips of the  meatus, or to
no discharge whatever except that found floating in the urine in the
form of clap-shreds.
   The discharge varies in quality from thick yellow or yellow-green
pus to thick muco-pus containing the micro-organisms of suppuration,
or to nearly pure mucus containing a very few pus-cells and not show-
ing the presence of gonococci.  It is commonly intermittent, becoming 
GENITO-URINARY DISEASES  AND SYPHILIS.
frankly purulent and flowing freely after excesses or lapses from the
irksome routine of methodic treatment, or without assignable cause,
but quickly lessening  in  quantity under astringent injections till in a
few days the discharge is about the same as before the exacerbation.
This intermittence  is misleading to the patient,  since, on the one
hand, it may convince him  that he is well or nearly so when the dis-
ease is still active, and, on  the  other hand, it often leads him to sus-
pect that  he has acquired a fresh  attack  when symptoms are due
simply to the stirring up  of an  inflammation so slight as not to have
excited attention.
   Discharge is usually the only symptom ; occasionally there are in-
termittent ardor urinae, neuralgic pains along the course of the urethra,
and dribbling after urination.
   Diagnosis.—This is founded on the discharge, and  on the  char-
acter of the urine passed in two portions, the first containing clap-
shreds, while the last is clear;  the first is also  clear after  flushing  of
the anterior urethra.  The clap-shreds should always  be examined
for gonococci.  This is  done by spreading them on  a cover-glass,
removing  the urine in which they float by means of blotting-paper,
and then fixing  and staining them  in  the  ordinary way.   (See page
91.)
   Examination may be conducted by means of palpation, and by the
use of the bulbous bougie or the urethroscope.
   By palpation along the course of the urethra areas of tenderness
and  points of thickening may be  felt.  Polyps, or the  circumscribed
induration of a chronic folliculitis, may be detected.
   Instruments should not  be used till the disease is distinctly local-
ized and chronic;  then the bulbous bougies should be passed.   The
patient is first  instructed to  urinate;  after he has done this a soft
catheter should be passed  to the bulbo-membranous juncture, and
by means of a stream of weak bichloride solution (1 to  20,000) driven
through it the anterior urethra should be washed free of discharge.
   A thoroughly cleansed  bulbous bougie as large  as the meatus
will  admit should then be  sterilized, well lubricated with  carbolized
glycerin, and gently introduced into  the  urethra.  Points of special
tenderness or of undue  resistance should be  noted.   If the exami-
nation of the urine shows  that the inflammation is confined to the
anterior urethra, the bougie should  not be passed beyond the bulbo-
membranous juncture.   The resistance of  the compressor  urethrae
muscle  and the distance from the meatus will show when it  has
reached this  point.  It should  then be withdrawn.  Pus and  blood
upon its shoulder will denote  either  erosions  or  an extremely con- 
GONORRHOEA.
129
gested condition of the mucous membrane.  The seat of the lesion is
often determined by the locality of the  most severe pain attendant
upon the introduction and withdrawal of the instrument, and in the
later stages by an increased resistance to the passage of the instrument
at that point.  (See diagnosis of  stricture, page 210.)
   The urethroscope may be employed for the purpose of more ex-
actly determining the locality and nature of the lesions and as a means
of making strong applications to strictly localized inflammation, though
it may  often be dispensed with, the  diagnosis being made and the
treatment carried out with sufficient accuracy by the means already
described.
   Sometimes,  though the rest of the urethra is healthy, an annoying
discharge is  kept  up by  chronic inflammation of  the periurethral
crypts opening  at the  borders of the meatus  near the posterior com-
missure.  In this case examination of the everted lips of the  meatus
will show the dilated  opening, from which pus can be squeezed.
   Prognosis.—In  general terms the curability of  gonorrhoea  is in
inverse  proportion  to its  duration.  In other words, the longer the
disease  lasts the deeper-seated it becomes and the more obstinate to
treatment.   Stricture  is the  usual  sequel of chronic urethritis, and
when once developed, even to the slightest degree, tends indefinitely to
prolong urethral catarrh.   The  length of time  during which the dis-
charge of chronic urethritis is contagious  cannot positively be stated.
When, after repeated  examinations of an artificially  exacerbated dis-
charge, no gonococci are found, it is fair to infer that none are present;
yet it must be admitted  that it is not safe to give an absolute  opinion
upon this point, since thus the physician takes upon himself  the re-
sponsibility of permitting  intercourse, which  has in some few cases
been followed by infection of the woman.
   Treatment of Chronic  Anterior  Urethritis.—The most important
points in the treatment of any chronic urethral discharge are (1) the
restoration of the urethra to its normal  calibre; (2) the cure of the
general  catarrh; (3) the healing of localized areas of inflammation.
   The treatment is initiated by  a careful examination of the urethra.
Usually the meatus  is  found narrowed,—i.e., it will not admit a sound
the size of the normal calibre of the urethra.   In this case meatotomy
should be performed  at once and a full-sized steel sound introduced
as far as the bulbo-membranous juncture.  Following the introduction
of the  sound the urethra is again flushed out with a mild antiseptic
solution, and the patient is requested to appear for another treatment
in two or three days, instructions having been given for the  proper
treatment of the meatotomy wound.  (See page 234.)   In the mean
                                9 
130        GENITO-URINARY DISEASES  AND SYPHILIS.

time he uses daily either irrigations or the more astringent injections,
and continues his general treatment.   Salol and balsams are given by
the mouth, the latter in full doses.
   This treatment by sounding and irrigation is repeated every two or
three days, in accordance with the severity of the reaction it excites,
and  is usually followed  by cure in from  two to  six  weeks.  The
pressure  of a full-sized  sound empties the follicles  of their contents,
sets  up a reactive  inflammation in the areas of infiltration, which is
followed  by  absorption of  the  inflammatory infiltrate,  and restores
the tonicity of the over-distended blood-vessels.  The first  essential
in the cure of the  discharge is the restoration of the  urethra to  its
normal calibre.
   When urethroscopic examination  shows localized areas of acute
hyperaemia, or erosions, or infiltration and  inflammation about the
urethral follicles, or granular patches, or papillomata, or polypi, these
lesions, though benefited  by the introduction of the sound, are most
quickly cured by  direct  application  of  strongly stimulating  lotions.
Such applications can  be made only by means of a urethroscope.
The lesion, having been exposed, is touched  with a  ten-grain solution
of silver nitrate, or copper sulphate, or pure iodine,  or a bichloride of
mercury  1 to 100 solution, or an alcoholic  solution of  carbolic acid
ten per cent., or Lugol's solution and carbolic  acid equal  parts  of
each.  Applicators are  conveniently made of split  straws, barbed at
the end  to prevent the cotton  wrapped about them from dropping
into the urethra.
   In the choice of these remedies, silver nitrate is most serviceable
in the treatment  of  comparatively superficial catarrhal conditions
not strictly localized, and particularly during the early stages of the
chronic disease.  In the beginning weak  solutions should be tried, not
stronger  than two  per  cent.  The strength should be gradually in-
creased as the patient is able to  bear it.
   Inflamed follicles  are  treated by the  application of silver nitrate,
or of iodine  and carbolic  acid mixture.   Granular surfaces do better
under this latter remedy than  under silver nitrate.  The choice of
the various remedies is, however, subject to no set rule.   They should
be changed or continued in accordance with  the results they give.
   Following the use of the endoscope, and sometimes  following in-
strumentation, there are profuse discharge,  sometimes bleeding, and
usually ardor urinae.   After  two  days,  especially  when astringent
injections, such as the alum, zinc, and carbolic acid mixture, are taken
by the patient, the discharge disappears.  These endoscopic applica-
tions  are  repeated  not  oftener  than once in three  or four days, and 
GONORRHOEA.
131
exceptionally cause prompt  subsidence of discharge.   Usually they
have to be continued for several weeks  before cure is effected.
   Polyps or papillary outgrowths  may be removed by curette, by
caustics, or,  best of all, when these growths are sessile, by the  gal-
vano-cautery applied through the endoscope.
   In  certain cases the use  of the  endoscope either does not  better
the patient's condition or distinctly aggravates the urethral discharge.
Then,  even  though its use is apparently indicated  by the  nature of
the lesions,  it should  be supplanted by other methods of treatment;
preferably irrigation and dilatation.
   Irrigations, particularly with solutions of full strength, are quite
as valuable  in chronic  as  in acute  urethritis.   The reason for their
failure, and  also for the failure  of treatment  by injections, is that
chronic urethritis  is  rarely confined  to the  anterior  urethra,  and
hence  treatment directed to this portion of the passage alone fails to
reach the seat of trouble.
    Chronic Posterior Urethritis.—Pathology.—The pathology of
chronic posterior urethritis is similar to that of long-standing inflam-
mation of the anterior urethra.   Finger states that from the first there
is a round-cell infiltration of the subepithelial connective tissue,  which
subsequently undergoes organization  and  contraction.   This  infil-
tration is  commonly superficial, though in cases of long standing it
extends more  deeply, involving the prostatic glands, the sinus  pocu-
laris, and the ejaculatory ducts, producing, in the stage of contraction,
destruction of the  lacunae and  superficial glands, and at times oblit-
eration of the opening of the prostatic sinus and of the ejaculatory
ducts.  As a result of this infiltration  of the subepithelial tissues, a
catarrhal, often a suppurative, process is set up both on the urethral
surface and  in the  prostatic glands and  their ducts.
   Symptoms.—The prostatic and membranous portions of the urethra
are usually involved in cases of acute urethritis.  This involvement is
often  so slight that it occasions  no symptoms, not even undue  fre-
quency of  urination,  and  is detected  only  by finding  pus and  the
comma-shreds in the urine which has been evacuated after the  ante-
rior urethra has been thoroughly flushed by irrigation.
   This chronic indolent catarrh is  rendered subacute or even acute
by very slight causes,  such as exposure to cold, moderate drinking, or
coitus.  The inflammation  then  extends  forward  to  the bulbous
urethra, and there is  a more or  less free discharge, often associated
with slight  urgency  and  undue  frequency in  micturition.   These
symptoms  subside quickly,  and  are  usually  attributed to  a mild
cystitis. 
132       GENITO-URINARY DISEASES AND SYPHILIS.

   The anterior discharge disappears, and the patient considers him-
self well till  some further imprudence  causes  these symptoms to
recur.
   When the inflammation  extends  deeper,  involving  the  mucous
membrane of the caput gallinaginis and the glandular and periglandular
structure  of  the  prostate, the  symptoms usually  become very pro-
nounced.  The nerve-supply of this region is exceedingly rich, and its
relation to the  genital system is so close that any decided change in
the structure  of the prostate is necessarily attended by  well-marked
local and general  symptoms.
   Tenesmus is perhaps the most frequent local symptom observed.
This may appear  simply in the form of increased frequency of mictu-
rition, or it may force the patient to make several efforts  at urination,
passing  a small quantity each  time before the  sensation is relieved.
The passage of hardened faeces, the pressure of  the examining finger
through the  rectum, or the excitement of coitus  may all  occasion an
intense desire to urinate.
   Pain may be a pronounced  feature in these  cases.  At times it is
constant, deep-seated, burning,  stinging, and peculiarly harassing.  It
sometimes radiates to the rectum and down the thighs,  and  is often
greatly exaggerated by sexual intercourse.
   Sexual weakness  is a not infrequent sequel  of chronic posterior
urethritis.  It may take the  form of pollutions, impotence, prostator-
rhoea, or rarely true spermatorrhoea.
   Sexual neurasthenia is an almost invariable accompaniment of
the deeper-seated chronic inflammation of the posterior urethra.
   Diagnosis.—This is founded on  (1)  the repeated  recurrence of
purulent discharge after  apparent cure  and  from seemingly insuf-
ficient causes ;  2, clap-shreds in the  second urine or the presence of
unstained shreds in  the urine passed after  irrigation  of  the  anterior
urethra  with staining solutions, such  as methyl blue; 3, attacks of
epididymitis,  so-called cystitis,  and prostatitis;  4,  frequency  and ur-
gency of urination, either constant or  paroxysmal; 5, symptoms of
sexual neurasthenia.
   Prognosis.—The  great majority  of cases  of posterior urethritis
recover  without direct treatment.   It is, however, a  rule with few
exceptions that a  gleet cannot be permanently cured as long  as there
persists a  chronic inflammation of the posterior urethra, and  where
chronic urethral discharge is  not due to the presence of well-developed
stricture  its  dependence  upon posterior urethritis must always  be
suspected.  In  some  cases without treatment the inflammation lasts
indefinitely, extending gradually deeper  till irreparable  damage has 
GONORRHOEA.
133
been done to the structure of the prostate or the ejaculatory ducts
have become permanently blocked.  Often  the chronic inflammation
seems to be the exciting cause for the  development of genito-urinary
tuberculosis.
   Treatment.—The general hygienic and dietetic rules laid down in
the systematic  treatment of acute urethritis should be  enforced,
though moderate indulgence in light wines during meals need not be
forbidden unless  liquors  of all kinds  are contra-indicated  for other
reasons.   A sound digestion and regular movements of  the  bowels
are particularly to be insisted on.
   Balsams and antiseptics should be administered by the mouth in
doses not sufficient to disturb the stomach.  Often oil of sandal wood
and extract of saw palmetto  are particularly serviceable.  The urine
should  be rendered  bland  and unirritating.   Copious hot rectal
douches will prove serviceable when bladder  irritability or sexual
neuroses are marked.  Massage of the prostate is  of  value in long-
standing cases.  For the  direct treatment there  may be used irriga-
tions, sounds, instillations, and ointments or suppositories.
   Irrigation of the prostatic  urethra is practised  by means of the
short urethral nozzle or of a soft rubber catheter, or, if the spasmodic
action of the sphincter is  too strong to allow the introduction of this
instrument, of  an ordinary  English catheter.   This  instrument is
passed  till its  end is within  the grip  of  the  compressor urethrae
muscle;  then  a hard rubber syringe  is  employed  to throw in  two
ounces of a dilute antiseptic solution, such as 1 to 10,000 bichloride,
or 1 to 5000 silver nitrate, or 1 to 5000  potassium permanganate, or
Dobell's  solution, or a lotion representing corrosive sublimate 1 to
10,000,  with carbolic  acid  1  to 200.   This flows  back  into  the
bladder.   The  catheter is  then withdrawn  until, the injection being
continued, the fluid flows  out from the meatus, when it is attached to
a  fountain syringe containing one or two pints of a hot  dilute anti-
septic solution, and the anterior urethra is  flushed thoroughly, the
whole contents of the bag being employed  at each treatment.  This
injection may be accomplished without the intervention of the piston
syringe, the catheter being attached directly to the irrigator introduced
into the bladder and very slowly withdrawn  after the stream is turned
on until the back-flow escapes from the meatus.  These treatments
are repeated every day for two weeks, or until clap-shreds disappear
from the  urine, then every second or third day, being thus stopped
gradually.  When  a  given solution  occasions distinct  vesical irrita-
bility and  increased  urethral discharge, it  should  be weakened or
changed.   If it is well borne, it is gradually increased  in strength up 
 134       GENITO-URINARY  DISEASES AND  SYPHILIS.

 to  1 to 2000 bichloride, 1 to  1500 silver nitrate, or  1  to  1000 per-
 manganate.  Every third day, immediately preceding irrigation, a full-
 sized sound is passed.
    If, after two or three weeks of these irrigations or injections, the
 posterior catarrh continues, and particularly if  there are some tenes-
 mus and  undue  frequency of  urination, the posterior irrigations are
 supplanted by instillations.
    Instillations are made by means of a long catheter-nozzled syringe
 called an  instillator.   (Fig.  50.)   This is a hard rubber  or silver
 catheter, cylindrical in shape, eight inches long,  provided with a short

    Ik                        Fig. 50.

                              Instillator.

 terminal curve, and having an extremely fine central channel.  To the
 straight end of this catheter is secured an ordinary hypodermic syringe.
 The cross-bar at the top not  only facilitates injection, but  indicates
 the position  of  the curved end  of the  instrument.  Five to  twenty
 drops of the solution desired are  sucked up into the syringe  through
 the fine central tube of this catheter;  the latter is lubricated with anti-
 septic glycerin, and is then inserted until its end lies just within  the
 grip of the compressor urethrae muscle.  The solution is then driven
 in by pressure upon the piston of the syringe, and  flows backward
 along the membranous and  the prostatic urethra into the bladder.
 If these  injections  are properly  made, not a drop escapes into  the
 anterior urethra.
    These  instillations require  that the  extremity of  the instrument
 shall be carried exactly to the proper point,—i.e., just within the mem-
 branous  urethra.  Usually it is easy to determine this point.  It  lies
 over five  inches and under seven  inches  from the meatus, and is
 reached only when the shaft  of  the instrument is  swept vertically
 upward from the belly wall and  is  carried  downward between  the
 legs till it  makes an  angle of about  seventy degrees with the plane
 of the horizon.   The compressor  urethrae, at  first  resisting  the
 passage of the instrument,  on steady pressure rather suddenly yields,
 letting the  extremity easily  slip  farther.   Moreover, the patient is
 aware of this sensation of  yielding, and can notify the surgeon when
 it is felt, though  by the  former it may be wrongly attributed to  the
instrument entering the bladder.  Often at the moment the end of
the instrument passes within the grip of the compressor it  causes  a
violent desire to urinate, though the sensation is more  commonly
 
GONORRHOEA.
135
associated with irritation of the prostatic urethra, and is immediately
excited often to a most distressing degree when, after properly passing
the instillator, the strong injection is driven in.
   Exceptionally it is extremely difficult to determine just when the
instillator catheter has been introduced to the proper depth.  Thus
the distance guide (five and a half to seven inches) may fail in cases in
which the introduction of the instrument causes a condition of partial
erection, or when the penis varies greatly from the normal extremes
of size.   The resistance of  the  accelerator urinae may  be mistaken
for that  of the  compressor urethrae;  this mistake  will be avoided
if it is  remembered that the  resistance of the accelerator urinae is
always encountered less than five inches from the meatus and usually
less than four inches.  The compressor urethrae may offer such slight
resistance that it is not perceptible to the hand passing the instrument,
or, if in a condition of reflex irritability and if associated  with a capa-
cious bulb, may resist so tightly as to prevent the engagement of the
point of the instrument, which, when the handle is swept between the
thighs, glides upward, yielding a false sense of progression and lead-
ing to  injection into the anterior  urethra.   These mistakes may be
avoided by measuring the distance  from the meatus to the compressor
by means of a full-sized bulbous  bougie and marking this distance
on the shaft of the instillator, or by passing a soft catheter when the
bladder is but slightly distended, until urine begins to flow, withdraw-
ing it, measuring the distance  from the distal portion of  the eye and
the position of the meatus when the first drops of urine escaped, sub-
tracting from this distance one and three-fourths inches, as  represent-
ing the  minimum  allowance for the prostatic and  the membranous
urethra, and measuring off the  remainder on the shaft of the instillator
as indicating the  depth to  which it should be  introduced.  When
partial  erections occur, these  measurements will not be serviceable.
In the absence of the sense of yielding usually experienced when the
end of the instrument is held  firmly against  the compressor urethrae
muscle,  the instrument should be passed until its point is fixed,—i.e.,
cannot be rotated from  side to side, when the convexity  of the curve
is prevented from rocking by external  pressure made by the fingers
on the perineum.
   The  solutions employed in the instillation treatment  are those of
silver nitrate, copper sulphate, Lugol's  solution of iodine, iodine and
carbolic acid, and bichloride of mercury.   The stronger  the solution
the fewer the number of drops to be employed.
   The  most valuable of all  solutions in  the treatment of chronic
gonorrhoeal urethritis is silver nitrate, beginning with ten drops of a 
136        GENITO-URINARY DISEASES AND SYPHILIS.

one per cent, solution, repeating the application every third day, and
running the strength up to five or even ten per cent.  These  instilla-
tions usually should be preceded by the passage of a full-sized sound
and by an irrigation.  Copper sulphate or iodine and  carbolic acid,
equal parts of one per cent, to ten per cent, solution, may be employed
when silver nitrate is either ineffective  or is followed by an undue
amount of bladder irritability.   In making these injections the  bladder
should contain a small quantity of urine, since thus any  portion of the
medicament which  passes  into its cavity will  be at once diluted and,
in the case of silver nitrate, neutralized.  If the bladder is largely dis-
tended with urine, the medicament  is diluted before it has thoroughly
acted upon the whole of the prostatic urethra.
   Instillations are  particularly indicated when  in  addition to the
discharge  from  the posterior urethra there  are  frequent  or urgent
urination,  pollutions, pain  during orgasms, constant or intermittent
pain in the deep urethra,  or any of the symptoms denoting deep-
seated involvement of the prostatic urethra.   Instillations are  contra-
indicated when the symptoms are acute in type;  when examination
of the urine shows that the discharge is profuse;  when examination
through the rectum   indicates  acute inflammation of the  seminal
vesicles; when even  the weaker instillation lotions are followed by
prolonged perineal pain, distressing tenesmus and frequency of urina-
tion, fever, pain in the testicles, or the discharge of  blood at  the end
of urination.  In tubercular cases the silver nitrate always markedly
aggravates the severity of the symptoms, this bad effect  continuing for
many days.
   The effect of  the  instillation seems to be the substitution of an
acute urethral inflammation  for one which has become chronic and
deep-seated, thus producing a condition  of hyperaemia  and of abun-
dant exudate, followed by  active processes of absorption of both the
new and  the old  inflammatory exudates  and a return  to  normal
conditions.
   The most efficient application is silver nitrate  used  in  one to five
per cent, solution;  exceptionally the strength can be  run  up to ten
per cent.   Copper sulphate  is particularly indicated when the  dis-
charge remains fairly free  in  spite  of the application of  silver solu-
tions.  Thallin, two to ten per cent., is commended  as  being  less
irritating than silver  nitrate,  and  hence  of service when  that drug
excites a too violent inflammatory reaction.
   A mixture of  iodine and  carbolic acid, equal parts  of  each, is of
service in inveterate chronic cases so sluggish  that the stronger silver
solution seems to have no effect. 
GONORRHOEA.
137
   Ointments, especially those made with lanolin as an excipient, are
particularly commended by Finger as
being more  penetrating  and  more            Fig. 51.
lasting in their effect than  lotions.
Ointments  may be  applied  to  the
whole  urethra  by  means  of  the
sounds proposed  by Unna.   These
are coated with the  following mix-
ture :
    R 01. theobrom., ^i;
      Cerae flav., gr. x ;
      Argenti nit., gr. v ;
      Bals. Peruvian., gr. x.
M.  S.—Melt over a water bath.
    The sounds are covered with this
 ointment while it is warm, and  are
 then hung in the air  to cool and to
 allow of solidification of  the  oint-
 ment.  When the sound thus coated
 is  introduced  into  the  urethra  the
 heat of the parts melts the ointment,
 and  thus the  entire  mucous mem-
 brane is medicated.  In chronic cases
 associated with catarrh of the whole
 urethra  this treatment  is  of  value,
 since  the effect  of  medication  is
 enhanced by  the pressure  of the
 sound.
    Ointments may be applied to the
 posterior  urethra  alone or to local-
 ized  inflammations  of the  anterior
 urethra by a piston catheter so de-
 signed that the lumen of the instru-
 ment can be partly  filled  with the
 melted  ointment,  when by  pushing
 the piston down  as much  as is de-
 sired can be  forced  out  from the
 open end.   By making the lumen of
 the catheter of a given  diameter and
 by  proper markings on  the staff of
the piston, the  exact  quantity of ointment deposited on any portion
Tommasoli's ointment-carrier. 
138        GENITO-URINARY DISEASES AND SYPHILIS.

of the  urethra  may be known.   The  instrument of Tommasoli is
among the best.   (Fig. 51.)
   The ointments of choice are:
                    B  Creolin, n\,v to n\,xv;
                       Lanolin, %i;
                       01. olivae, ^ss.

   Silver nitrate or copper sulphate, five to fifteen grains, may replace
the creolin in this formula.
Or
                    B  Potassii iodidi, 3ss;
                       Iodi pur., gr. v ;
                       Lanolin, %i;
                       01. olivae, ^ss,
or
                    B  Amnion, sulph. ichthyolat., gr. xlviii;
                       Lanolin, %i,
may be used.
   The application of these ointments should follow the passage of a
full-sized  sound.
   Suppositories may be made of either gelatin or cacao butter.  They
are introduced  by means  of an instrument very like  that employed
for the application of ointments, except that the piston forms a close-
fitting obturator for the introduction.   This catheter  is passed until
the end has  engaged in the grasp of the compressor urethrae muscle;
the obturator is then withdrawn, and a suppository introduced within
the lumen of the  catheter and pushed into the prostatic  urethra  by
means of the obturator.   The  medications of choice  are practically
those already given,  silver  nitrate being  particularly  serviceable;
astringents and  sedatives may also be administered in  this way.

                      B Ext. hydrast., gr. v ;
                        Iodoform., gr. ii,

                      B Zinci sulphatis, gr. i;
                        Acidi carbolici, gr. i;
                        Morphin. sulph., gr. J;
                        Ext. belladonnae, gr. ss ;
                        Cocain. hydrochlor., gr. ss to gr. i,

will be found among the most useful formulae.
   These suppositories are occasionally of  service when  the patient
is  compelled to conduct most of the  treatment himself, since he can
readily be instructed as to the proper application, and since  they are
less irritating than strong instillations,  and hence, in case  of  improper
administration, are less liable to do harm. 
GONORRHOEA.
139
   Pressure and  cold water also are potent  means of influencing
chronic  posterior urethritis,  particularly when this  has penetrated
deeply and is  rebellious  to  ordinary treatment.  The pressure of a
full-sized sound is serviceable  and usually sufficient, but in  the  in-
veterate cases this will not answer,  since the narrow membranous
urethra  does not  allow of the  entrance of a solid  metal instrument
sufficiently large to dilate the prostatic urethra widely.  Under these
circumstances the prostatic  dilator (Fig. 52) applied at intervals of
from  seven  to fourteen days will  be found useful.   This should be

 Ik                           Fig. 52.
                           Prostatic dilator.            (T   JS

preceded by irrigation and  followed  by instillation.  The dilatation
should be carried  to  not  less than 32 F. and not  more than  44 F.,
the sensation of the patient being a fair index as to the amount of
stretching which is allowable.   It should  be gradual, ten to fifteen
minutes being required for its completion, and intermittent, the dilator
being run up to 34, for instance, maintained there a minute, and then
loosened until the patient is  entirely comfortable.  After  a little delay
it  is gradually  screwed up  to  36,  and  again loosened, finally per-
haps 38  or 40 being  reached, but not if the pain  excited by slighter
dilatations is extremely severe.
   In the inveterate  cases  characterized by prostatorrhcea  and the
symptoms of sexual neurasthenia, the psychrophore may be service-
able.  This  consists of a full-sized catheter closed at the end and so
partitioned off that a stream of water is kept flowing constantly.
   Summary of the Treatment of Chronic Gonorrhoea.—As a basis of
treatment the  seats of inflammation  must  be accurately located by
palpation, sounds,  bulbous  bougies, and the urethroscope.  Exami-
nation of the discharge as it flows from the meatus, and  as it appears
in the urine, shows  approximately the inflamed area, indicates the
extent of follicular involvement, and  affords a means of determining
whether the discharge is still contagious.
   The inflammation is  more  deeply seated and  more  persistent in
the bulb, the prostatic urethra,  and the navicular fossa.  It may be
sharply  circumscribed, but  more commonly there is an  extensive
surrounding area  of  congestion and catarrhal discharge  involving
both the anterior and  the posterior  portion of the urethra.
   Where there is  free secretion containing much mucus and flat and 
140        GENITO-URINARY DISEASES  AND SYPHILIS.

transitional  epithelium, irrigation is particularly serviceable in cutting
down  discharge  and  curing  the general  superficial  inflammation.
The irrigation, always immediately preceded  by urination, should be
made under strong pressure (five feet), and should include the entire
urethra.   Permanganate 1 to 6000 to 1000,  silver nitrate  1 to 6000
to 500, hydrastis  an ounce to the  pint,  zinc  sulphate, carbolic acid,
powdered alum, of each twelve grains to  the pint, are the solutions of
choice, and should occasionally be preceded by the passage of a full-
sized sound, thus  emptying the inflamed follicles of their contents and
allowing the astringent and cleansing lotions to reach the deepest re-
cesses of the diseased mucous membrane.   The irrigation is repeated
daily, the sounding every third day.  The strength of the solution  is
gradually increased as tolerance is established.
   When by irrigation the inflammation has  become circumscribed,
or when there is  spontaneous subsidence of the general catarrh but
local lesions persist,  direct applications  of stronger  astringent  and
antiseptic remedies to  the seat of  disease  are indicated.  These are
made to the lesions of the anterior  urethra  through the urethroscope,
to the lesions of the posterior urethra by the instillator.
   The solutions of choice are silver nitrate one to ten per cent., solu-
tion of copper sulphate in similar strength, or of iodine and carbolic
acid each two to  ten per cent, in glycerin.   These applications, which
are  confined strictly to the diseased areas, are preceded by the  pas-
sage of a sound and by irrigation, the solution of choice being one of
bichloride of mercury  1 to 10,000 in carbolic acid  1 to 200.   The
irrigation is repeated daily, the sounding every third day.
   When irrigations cause severe and lasting pain or excite marked
inflammatory reaction in spite of having been carefully weakened,  or
cannot  be taken  by the patient, injections  with the ordinary piston
syringe may be  used.  These cannot effectively reach the posterior
urethra, and when this part of the urinary passage is involved must
be  supplemented by  instillations, bougies, or ointments.   The  steel
sounds should be used in conjunction with these injections  once in
three days.  The injections are given from  four to six times daily,
and are held in the urethra  for  three minutes each  time.  The pain
and  tenesmus following vesical  sounding,  irrigation, and  instillation
are best relieved  by opium and belladonna  suppositories.   The proof
of cure of chronic  gonorrhoea is absence of clap-shreds in the urine.
Translucent, stringy shreds made  up of mucus and  epithelium will
persist as long as treatment is kept  up.   The  presence of these alone
indicates cessation of local treatment.  The general hygienic measures
to be observed by a gleety patient are much the same as those described 
GONORRHOEA.
141
under acute gonorrhoea,  except that  exercise should  be encouraged,
and the taboo upon liquors need not be so absolute.
   The first essential to successful  treatment is  restoration of the
urethra to its normal calibre ; this frequently necessitates meatotomy.
   It is well to recognize the  fact that  certain exceptional cases of
chronic posterior urethritis cannot be cured by active treatment.  The
source of  discharge is in these  cases  beyond the reach  of antiseptics
or astringents, often in the ducts or dilatations of the prostatic glands
or the prostatic sinus, the ejaculatory ducts, the ampulla of the vas, or
the  seminal vesicles.  Applications to the  surface of  the  prostatic
urethra, if painful, set up an acute inflammation,  which by blocking
the ducts  and orifices of already inflamed glands  and  follicles  may
cause  abscess-formation.   Moreover, frequently  repeated  irritation
may produce a chronic inflammation of the greater part of the prostatic
mucous membrane, with infiltration and thickening of the subepithelial
connective  tissue, thus  greatly aggravating  a  condition  which the
applications are powerless to help.   If after two months' treatment of
a posterior chronic urethritis not associated with stricture there is no
very marked improvement, and particularly if coincidently with active
treatment the patient becomes worse, all applications and medication
directed to  the  urethra, except, perhaps,  massage of  the  prostate,
should cease, and the patient should be given the hygienic directions
best calculated to put him in good general condition.   The ultimate
prognosis  under such circumstances is usually good.   Often apparent
cure quickly follows cessation of treatment.
   Finger gives the table on  the following page as indicating the
points to be considered in making a diagnosis of acute inflammations
of the urethra.
   The differential diagnosis between chronic anterior urethritis and
chronic posterior  urethritis may be summarized as follows (Finger):
   Discharge from Meatus.—In comparatively recent cases of chronic
anterior urethritis there is either a constant or a morning muco-puru-
lent discharge.  In old cases there  is simply a constant or usually only
a morning gluing of the lips of the meatus, or there may be no per-
ceptible discharge.
   Chronic posterior urethritis  gives no discharge from the meatus.
   Test  of the Two Beakers.—Chronic anterior  urethritis causes the
first portion of urine to exhibit shreds and often slight cloudiness.
   Chronic  posterior  urethritis if comparatively recent makes both
urines slightly cloudy,—the  first containing the ordinary stringy clap-
shreds, the second often exhibiting Fiirbringer's hooks (short, dense,
comma-shreds, supposed to represent plugs from  follicles  or gland- 
Table of  Differential Diagnosis.
Secretion  at  the
  orifice  of  the
  urethra.

Test of the two
  beakers.
Test of the three
  beakers.
Test of two beak-
  ers after irriga-
  tion of pars an-
  terior.
Reaction of urine.

Microscope.
Addition of
  acetic acid  to
  the urine.

Other character-
  istic symptoms.
Acute Anterior
  Urethritis.
Abundant.
First portion
  cloudy.
Second  portion
  always clear.
First portion
  cloudy.
Second and
  third portions
  always clear.
Two    portions
 clear.
Acid.

Secretion    and
  sediment   of
  first  portion:
  pus-cells con-
  taining  gono-
  cocci.

Cloudiness  un-
  changed or in-
  creased.1
Acute Posterior Urethritis.
Less abundant  and often con-
  trasting with intensity of tur-
  bidity of the urine.

First portion very cloudy.
Second portion cloudy, or clear
  and    cloudy   alternately;
  opacity always less than first
  portion.

First portion very cloudy.
Second  and  third  portions
  cloudy, or clear  and  cloudy
  alternately;   cloudiness  al-
  ways less  than that of first
  part.

First portion cloudy.
Second portion  cloudy, or al-
  ternately  clear and  cloudy;
  cloudiness always  less than
  first.

Acid.

Secretion and sediment of both
  portions: pus-cells containing
  gonococci.
Cloudiness   unchanged   and
  slightly increased.1
Vesical "tenesmus continuous or
  imperative;  hematuria with
  last drops of urine.
Acute Posterior Urethro-
        cystitis.
Slight and often contrasting
  with intensity of turbidity
  of the urine.

First portion cloudy.
Second   portion   always
  cloudy,   difference    in
  opacity  of both parts not
  marked.

First portion cloudy.
Second   portion   always
  cloudy.
Third  portion very cloudy,
  usually  more than first
  part.

First portion cloudy.
Second portion more cloudy
  than first portion.
Acid.

Secretion: pus-cells contain-
  ing gonococci, also abun-
  dant bladder  epithelium
  in sediment of both por-
  tions.
Cloudiness  unchanged  or
  slightly increased.1
Vesical  tenesmus;  hsema-
  turia (from the pars pros-
  tatica).
Acute Non-Blennor-
  rhagic Cystitis.
None.
First portion cloudy.
Second  portion  always
  more   cloudy   than
  first.
First portion cloudy.
Second portion like first,
Third   portion    more
  cloudy than first and
  second.
First portion cloudy.
Second   portion  more
  cloudy than first  por-
  tion.
Acid or alkaline.

Sediment  of both  por-
  tions : pus-cells,  blad-
  der  epithelium,  no
   fonococci,  numerous
   acteria.
Cloudiness  unchanged
  or slightly increased.1
Coagula of pus in alka-
  line urine.
Phosphaturia.
None.
Both portions equally
  cloudy.
All  three   portions
  equally cloudy.
Both portions cloudy.
Feebly acid or alkaline.

Amorphous granules,
  groups of crystals of
  calcium  phosphate
  and  calcium  car-
  bonate.
Cloudiness clears.
Very changeable, usu-
  ally  appears   only
  once or twice a day.
Bacteriuria.
None.
Both   portions
  equally cloudy.
All three portions
  equally cloudy.
Both portions
  cloudy.
Strongly acid.

Numerous   bacte-
  ria, few cellular
  elements.
Cloudiness un-
  changed.
to
CO

>
CO

CO



0

CO
Kj

W
   1 It must not be forgotten that any one of the processes may be complicated with phosphaturia, in which case the addition of acetic acid produces partial clei
up of the urine. 
GONORRHOEA.
143
ducts).  Long-standing chronic urethritis does  not cause cloudiness
of the urine, but causes shreds to appear always in the first portion
passed, often in both portions.
    Test of the Two Beakers after  Irrigation of the Anterior Urethra.—
In chronic anterior urethritis both urines are clear.
    In chronic posterior urethritis  the appearance of the urine is the
same as though the anterior  urethra had  not been irrigated,—i.e., as
in the test of the two beakers.
    In chronic anterior urethritis  the urethrometers or acorn bougies
will show in old cases  certain points of lessened  dilatability.  There
will be no other symptoms, while in chronic posterior urethritis there
are often tenesmus, prostatorrhcea, frequent  micturition, spermator-
rhoea, sexual  irritation, increased  desire, frequent pollutions, pre-
cipitate,  often painful,  ejaculation, feeble erection, impotence, and
neurasthenia. 
CHAPTER  IV.
                      GONORRHOEA IN WOMEN.

   Frequency of the Disease.—Leaving  aside the  consideration  of
harlots, practically all  of  whom  suffer  from  some  of the acute or
chronic forms of the disease, gonorrhoea attacks a  large number of
reputable  women.  The gloomy  Noeggerath  states that  eighty per
cent, of women are affected with  latent gonorrhoea, while Sanger, of
nineteen hundred and thirty women  coming to his  clinic, found that
twelve per cent, had this disease.  Young married women become
infected because long-standing gleet is  not  generally regarded as a
possible bar to matrimony: hence  men with chronic urethral discharge
should  at  least  understand that the gonococcus  may  persist and
maintain its virulence for two or three years.  Gonorrhoea in woman
excites  symptoms  which even in their  acute stage  may  not be  at-
tributed by the  patient to  any cause  more serious than a cold, a
strain,  or some  irregularity in her periodical sickness,  and  hence
treatment is often neglected.
   Seat of Infection.—In women,  as in men, the urethra is most fre-
quently involved in the gonorrhoeal inflammation.   Next in order of
frequency comes the mucous  membrane of the cervix, then that of
the uterus,  and finally that of the  Fallopian tubes.
   Vaginitis, at least that directly  due to the gonococcus, is extremely
rare, except in children, and  possibly in young women recently de-
flowered.
   Vulvitis is not uncommon, and is often accompanied by inflamma-
tion of the glands of Bartholin.
   Contagion.—As  in  the  male, gonorrhoea  is acute  or chronic.
Though it is usually conveyed during sexual intercourse, the possi-
bilities of mediate contagion through bathing-water,  garments, towels,
etc., are much greater in women than in men.
   In girl babies the  disease is  nearly always acquired  by mediate
contagion.  The discharge is  derived sometimes from a gonorrhoeal
ophthalmia, generally  from the  genital tract  of the mother.   Only
very exceptionally  is  the  contagion immediate and from criminal
practices.
   Acute  gonorrhoea is usually acquired from the  discharge  of an
     144 
GONORRHOEA  IN WOMEN.
145
acute case, though there can be no doubt that chronic gonorrhoea in
the male may excite a florid attack in the  female.  Gleety discharges,
if contagious, commonly give rise to a subacute attack.
    Symptoms.—The symptoms of acute gonorrhoea  are at the begin-
ning usually those of acute vulvitis  and  urethritis; in children  and
young girls  there is  also an acute vaginitis; in women, as has been
said, this is extremely rare.
    The patient complains  of a sense of heat and burning about the
genitalia, of profuse purulent discharge, of ardor urinae, and of urgency
and frequency in micturition.
    If the uterine mucous membrane is also involved  there are usually
marked constitutional symptoms, i.e., fever  and depression, and, in
addition, severe pains in the uterine region, swelling of the womb, and
bloody  purulent discharge from  it.   Not infrequently  perimetritis
complicates  the uterine inflammation.
    The involvement of the mucous membrane of the ovarian tubes
may cause salpingitis and peritonitis.
    An examination shows the mucous membrane of the vulva  and
sometimes that of the vagina infiltrated, reddened, and eroded.   Pus
can be milked from the urethra.
    The subacute gonorrhoea  usually acquired  from chronic gonor-
rhoea of the  male rarely shows itself by pronounced typical symptoms.
There are intermittent attacks of slight ardor urinae, frequency of mic-
turition, disorders of menstruation, pelvic pains, and disturbances in
the uterine  function, manifested  by  dysmenorrhcea, by  sterility, by
abortion, and by attacks of perimetritis,  salpingitis,  ovaritis, or local
or general peritonitis.  The patients  gradually lose  their health, be-
come unfit for work of any kind, and are prone to develop into typical
neurasthenics.
    On examination there will  usually be  found a  catarrhal  condition
of Bartholin's glands and of the periurethral follicles.   Purulent secre-
tion escapes from the cervical canal, which is sometimes eroded.  The
uterus is found  enlarged, tender on pressure, and fixed in its abnormal
position from attacks of perimetritis.   The ovaries and tubes are often
enlarged, displaced, and fixed.
   Diagnosis.—In the ordinary acute case this  is not difficult, since
the symptoms themselves are almost characteristic, and the detection
of the gonococcus will at once settle the nature of  the attack.
   The subacute form is  sometimes  extremely difficult to  diagnose,
since  the gonococcus may not be  found.  According to Sanger, in
arriving at  such a diagnosis careful search should be made for acute
or chronic gonorrhoea in the husband, or a history  of gonorrhoea sub-
                               10 
146       GENITO-URINARY DISEASES  AND SYPHILIS.

sequently cured.  The presence of gonorrhoeal ophthalmia in children
is highly suggestive.
   Matters of diagnostic import are : a history of uterine catarrh with-
out obvious  cause; disease of Bartholin's glands, and especially red-
ness of  the skin surrounding their ducts; the  presence  of condylo-
mata ; the discharge of muco-purulent matter from the cervix without
erosions or pseudo-erosions of the os ; disease of the adnexa or of the
pelvic peritoneum.  Without doubt many of these affections are due
to other germs than the  gonococcus, such  complications representing
a form of mixed infection.
                          URETHRITIS.
   The urethra is nearly always involved  in  gonorrhoeal infection,
and the presence of inflammation in this canal is in itself presumptive
evidence of the nature of the urethritis.
   Acute Urethritis.—The acute stage of  the disease is brief, and
is accompanied by symptoms of  moderate severity as compared with
urethritis in the male.  It is less liable to become  chronic than is the
case in men, or if it lingers it causes symptoms  so slight that they are
readily overlooked: hence the frequency  of the involvement  of the
urethra in gonorrhoeal inflammation is often underestimated.
   Symptoms.—These are very  much like  those observed in men.
The incubation period varies from a few hours to five or six days, and
exceptionally is much longer.   Slight tickling or  burning sensations
on urination, moderate purulent discharge, demonstrated by milking
the  urethra  from above  downward, and a  swollen,  oedematous
urethral orifice are often the only symptoms which can be detected,
though in specially sensitive women there will be  at the beginning of
the attack rigors, slight fever, and general malaise.  In  from a few
days to two or three weeks even these symptoms disappear, and the
disease is regarded as cured.
   Finger believes, however, that it becomes chronic in women much
more frequently than is the case in men, being subject to exacerbations,
and  often months after the original attack exciting a urethro-cystitis,
the symptoms and course of which are much like those  of the same
condition in man, except that it is less severe and more amenable to
treatment.
   Chronic urethritis rarely excites sufficiently characteristic symp-
toms to suggest a probable diagnosis without a thorough examination.
This should be conducted at a time when  the patient has not urinated
for several hours.  Pressure on the urethra from behind forward may
show that this tube is  thickened and somewhat sensitive, and  will
usually  press out a thin, milky, muco-purulent  drop.   In case there 
GONORRHOEA  IN  WOMEN.
147
is not  sufficient discharge for this, the vulva and vagina are carefully
washed and  the patient  is  requested to  urinate in  two portions.
Clap-shreds and pus will be found in the first portion; if  pus is dis-
covered in the last  portion, this is usually indicative of the presence
of chronic cystitis.
   An endoscopic examination in cases of acute  urethritis in women
shows redness, swelling, and  general acute congestion  of the mucous
membrane.  In the chronic cases diffuse redness, areas of epithelial
thickening, and sometimes comparatively deep erosions are observed,
the  latter especially  about the openings of follicles.
   Folliculitis.—As in the male, the urethra contains many follicles,
and  these are  subject to gonorrhoeal  inflammation,  forming  small
tender tumors  which  commonly  evacuate   their contents into the
urethra.
   There  are two  follicles which are particularly liable to  become
infected.   These are situated  in the lower urethral wall and open just
within the external urethral orifice.  A fine probe can be inserted into
the  duct of each to a depth of from one-half to three-fourths of an  inch.
When  these follicles are acutely inflamed and their urethral openings
firmly blocked, the  softening and breaking down may  cause urethro-
vestibular or urethro-vaginal fistulae.
    In  addition to these  two deep follicles  there are  a number of
smaller ones  situated about  the meatus.  Many or all of these  may
become inflamed, rendering  the  urethral  opening unsymmetrical.
They often rupture  into the urethra, but again fill up and continue to
discharge intermittently.
   The frequency with which these  follicles are involved in gonor-
rhoeal inflammation makes diagnosis particularly important.  A  care-
ful  examination  usually shows at once the  true  nature of the  case,
since immediately after the urethra has been washed clean  by the act
of urination  pressure causes  exudation of pus.   Moreover, on direct
examination the inflamed openings of the follicles can generally  be
found.
   Diagnosis.—The  diagnosis of acute urethritis is dependent  upon
the  symptoms and on finding the gonococcus.
   If after holding the water for several hours no pus can  be milked
from the urethra, the vulva and vagina should be washed free of dis-
charge.  The patient should then  micturate immediately, and the
urine should be carefully examined for pus.
   Prognosis.—The prognosis of urethritis is in women much  more
favorable than in men.   The disease  lasts for but a short  time; the
chronic forms of it occasion no trouble and usually undergo spon- 
148
GENITO-URINARY DISEASES  AND SYPHILIS.
taneous cure without producing serious  or permanent alterations in
the urethral mucous membrane.
    Treatment—The treatment of acute urethritis in  women  is con-
ducted on the  same  principles as  govern  the  management  of  this
disease  in men.   The  diet is regulated, and the urine is rendered
unirritating by the  administration  of potassium  citrate or  sodium
bicarbonate and an abundance of water.
    Balsams may be given from the first, and  as soon as the acute
symptoms subside injections are employed.  These should be driven
in by the  ordinary clap syringe, but not more than a drachm  should
be  injected at  one time.  The solutions  employed  are those used
in the male urethra, but may be  slightly stronger.   As soon as  the
acute stage is past the lesions are located by the urethroscope, and are
treated directly by means of  iodine two  to ten per cent, solution in
glycerin, or silver  nitrate one to ten per cent., these drugs, of  course,
being applied only to the inflamed spots by means of cotton tampons.
    Chronic urethritis in women is usually dependent upon folliculitis,
either the  paraurethral glands  about the meatus or a group of follicles
near the neck of the bladder being involved.  Destruction of the  fol-
licles by a finely pointed stick of silver nitrate or the electric  needle
when they are  accessible, or, when the inflammation is placed near
the bladder, the use of the endoscope for the application of iodine or
silver nitrate, is indicated in these cases.
    Exceptionally true stricture forms, usually at or near the meatus.
The symptoms are  frequent  micturition, slight dribbling,  and gleet,
though the latter is  rarely noticed.   The  fact  that stricture may
result from gonorrhoeal  inflammation of the female urethra would
suggest a search for this condition in cases of functional urinary diffi-
culty in  women.  The diagnosis  is readily made  by means  of  the
bulbous bougie.  Narrowing at or very near the meatus may require
division, the knife cutting backward.   Gradual dilatation will prove
efficient for all other cases not traumatic.   Straight metal bougies are
employed  running up to 40 F.  (Fig. 53.)
   There is one form of chronic urethritis much resembling in symp-
toms the  posterior urethritis  observed in men.   The  patient com-
plains of  frequent urgent urination, tenesmus, and reflexes, such as 
GONORRHOEA  IN WOMEN.
149
vaginismus and backache, and a general condition of neurasthenia.
On urethroscopic examination the mucous membrane at the neck of
the bladder—i.e., within the grip of the vesical sphincter—is found
greatly thickened and congested or even fissured.
   The treatment consists in dilatation and  the application of strong
solutions of silver nitrate.
                            VULVITIS.
   Inflammation of the vulva is characterized by oedematous swelling,
redness, and erosions affecting the greater and the lesser lips, and by a
profuse purulent, irritating, extremely fetid discharge.  This discharge
coming in  contact with the neighboring skin produces a dermatitis,
which  may pass backward towards the anus or downward along the
inner surfaces of the thighs.  There are constant itching and burning
about the vulva, which become aggravated to severe pain by walking
or motion  of any kind involving the lower half of the body.  Trick-
ling of the  urine over the abraded surfaces occasions  much burning.
Involvement of the inguinal glands is by no means uncommon.
   Usually vulvitis has a tendency to spontaneous  recovery.  Occa-
sionally,  especially in children, it becomes chronic, persisting in the
vestibular glands, and not only in those  about the urethra, but also in
those placed at the inner surface of the lesser lips.  These chronically
inflamed glands cause practically no symptoms,  and  are detected only
by direct examination.  Hyperaemic or eroded spots may be found
overlying the swollen glands, which can sometimes be felt as  small
nodules; condylomata are frequently observed.
   Treatment.—Cleanliness  will  usually accomplish  cure, which is
hastened by the employment of antiseptic and  astringent  lotions and
by protecting inflamed surfaces from contact with the urine.  In the
acute stages the treatment  consists in  irrigation with very hot saline
solution containing 1 to 6000 bichloride of  mercury,  practised  twice
a day,  or more  frequently if the discharge is free.  Each  irrigation is
followed by the insertion  between the greater  and  the  lesser lip
on each  side of a thin sheet of cotton  dipped  in dilute  lead water.
This cotton should  be  changed  every two  or  three  hours.  As the
symptoms  subside the inflamed  parts should be painted once daily
with a  one per cent, solution of silver nitrate, and the irrigation should
be followed by the use of a cleansing  and astringent dusting powder
and dry cotton.
                        BARTHOLINITIS.
   Inflammation of Bartholin's glands is perhaps the most frequent
complication of vulvitis, though even this is  exceptional.  It may be
either  acute or chronic. Whether it  be due  to infection  of  these 
150       GENITO-URINARY  DISEASES AND SYPHILIS.

glands by gonococci or  by the ordinary pus microbes, the clinical
fact remains that it is so rarely associated with non-gonorrhoeal forms
of vulvitis that if it occurs it is almost pathognomonic of gonorrhoea.
   Acute Bartholinitis.—Acute inflammation of these  glands  de-
velops suddenly, either  during the  fulminant stage of acute clap or
long  afterwards, from  lighting up  of the chronic inflammation by
sexual excess or other cause.
   There appears in the  posterior third of the greater lip, usually on
one side alone, though  sometimes on each side, a tender, hard, very
clearly outlined tumor  about the size of a hazel-nut.  This is soon
followed by an oedematous  swelling of the greater lip, sometimes  ex-
tending to the  lesser lip, and  often as far forward as the prepuce of
the clitoris.  In place of a distinctly outlined  tumor there develops a
dense inflammatory infiltration, forming an extremely tender, painful
swelling, often as large  as a pigeon's egg, the  surface of which is red.
Shortly fluctuation is detected, suppuration being denoted at the same
time by the constitutional symptoms of pus-formation.
   The pus may break through  the  capsule of the gland, the over-
lying skin remaining intact.  In this case it is apt to burrow backward
along the perineum, forming extensive sinuses, and even opening into
the rectum.  Usually the skin also ulcerates and  the pus is evacuated
on the inner surface of the greater lip.   This pus is blood-stained and
foul-smelling.
   Chronic  Bartholinitis.—Chronic  inflammation of  Bartholin's
glands may appear as  an inflammation of the gland-ducts alone,  the
most frequent form, or may involve the gland substance.  In the latter
case hard nodules are  felt on palpation, and on  pressure a purulent
fluid containing gonococci can  be forced from the ducts.  WThen  the
ducts alone are infected  no induration will be felt on palpation, and
on inspection nothing is seen except an area of hyperaemic, or possibly
eroded, mucous membrane around the duct opening.   Pressure may
cause a small drop  of  purulent fluid  to exude.   Sometimes a large
quantity of this fluid  can be  squeezed  out, owing to retention from
blocking of the  duct.  Not infrequently this  duct is the only mucous
surface in which the gonococci still survive:  hence in an examination
to confirm the  presence  or  the absence of gonorrhoea the condition
of Bartholin's glands and their ducts must always be most carefully
investigated.
    Treatment.—The treatment of the  acute inflammation in the early
stages before there is pus-formation consists in putting the patient to
bed, keeping the bowels open, and applying  evaporating lotions, con-
stantly renewed.  Of these, lead water and dilute alcohol are perhaps 
GONORRHOEA IN WOMEN.
151
the best.  As soon as fluctuation is  detected, or when  the  constitu-
tional symptoms denote pus-formation, the pus should  be evacuated
by a free incision made on the inner  surface of the greater lip.   The
cavity should be curetted, washed with 1 to 1000 bichloride solution,
and packed with iodoform  gauze.   This packing must be  repeated
frequently, and the cavity must be made to heal from the bottom.
    Chronic inflammation  is extremely difficult to cure.  When the
gland is involved and appears as  a hard, slightly tender, circumscribed
tumor subject to occasional attacks of  subacute  inflammation, the
whole gland should be dissected  out.  If the ducts alone are  involved,
the catarrhal process may be cured by astringent and antiseptic injec-
tions carried in by means of a hypodermic needle blunted at the end.
Usually, however, it  will be necessary to split the duct thoroughly,
scrape it, and pack with iodoform gauze until healing takes place.

                            METRITIS.
    Acute metritis develops in the course of acute urethritis, vulvitis,
or vaginitis.   It is characterized by rigors  and fever, pain in the hypo-
gastric and sacral regions, generally aggravated by motion, and a dis-
charge from the cervix, at first muco-purulent, then frankly  purulent.
On examination the womb is found to be tender and enlarged, and the
cervix is swollen, oedematous, and often eroded.
    The inflammation may be limited to the  cervical mucous mem-
brane.  More commonly it  involves the entire endometrium, and it
may extend to the perimetrium, tubes, ovaries, and peritoneum.
    Diagnosis.—The diagnosis is  founded  on the coexistence  of ureth-
ritis, bartholinitis, etc., and on the discovery of the gonococcus.
    Prognosis.—The prognosis as to  complete cure must be guarded,
since the disease has a tendency after subsidence of  acute symptoms
to linger indefinitely.
    Chronic metritis, according to  Finger, is acquired  from the dis-
charges of a chronic gonorrhoea of the urethra or external genitalia of
the woman, the uterus having escaped during the acute stage of the
disease, or is implanted by a male suffering from gleet.   This form of
metritis is the one commonly  observed  in young married women
infected by their  husbands.
    Symptoms.—The inflammation is ushered in by a muco-purulent
discharge, which excites little attention, since it is attributed to  cold,
defloration, excess, or other apparently sufficient cause. The discharge
becomes profuse at times, and is especially free after the menstrual
period.  Gradually menstruation becomes painful and irregular and
the flow is scanty ; at the same time there is  a deterioration in general 
152
GENITO-URINARY DISEASES  AND SYPHILIS.
 health, with a sense of weight and dragging about the uterus, and the
 patient becomes neurotic and unfit for work.
     The course of the chronic inflammation is varied by intercurrent
 subacute attacks, somewhat simulating acute metritis.
     On examination a swollen, tender uterus is found, from which  is
 discharged muco-pus.  The gonococci can  rarely be  discovered in
 this discharge.
     Diagnosis.—The diagnosis of chronic gonorrhoeal metritis  is ex-
• tremely difficult.  A preceding history of acute gonorrhoea, a venereal
 record on the part of  the husband, or  infection  of  others  by the
 discharges, would  strongly suggest the causative agency of the gono-
 coccus in producing this inflammation.
     Prognosis.—This form of inflammation has little tendency towards
 spontaneous cure ; rather it extends slowly, particularly in the direction
 of the tubes  and ovaries, producing sterility and chronic invalidism,
 and in many cases ultimately destroying life.
     Gonorrhoeal salpingitis and oophoritis—an extension  of the
 gonorrhoeal inflammation to the tubes and  ovaries—is not charac-
 terized by any pathognomonic  symptoms.   Menstruation is usually
 irregular, profuse,  and very  painful,  intercurrent  attacks of  pelvic
 peritonitis occur, and there is often a rapid loss of  health.  All these
 symptoms are also  observed in endometritis.
     The tubes may be filled with pus, and this pus may  escape into
 the uterus or may make a way for itself into the bowel, the case thus
 recovering spontaneously,  or it may  ulcerate through the tube or
 escape by its fimbriated extremity and occasion a fulminant  form of
 peritonitis.
     With  involvement and  obliteration of the tubes the  ovaries are
 nearly always  diseased, first a  parovaritis developing, followed  by
 atrophy and cyst-formation of the ovary.
     Diagnosis.—The diagnosis of gonorrhoeal  salpingitis and ovaritis
 must be founded on bimanual examination, preferably with the patient
 well relaxed by ether.
     Perimetritis.—The acute form of perimetritis is more prone to
 develop  during pregnancy or  after  childbirth.  The  symptoms are
 those of acute pelvic peritonitis and septic absorption,—i.e., pain, ten-
 derness, vomiting,  and fever,—and may terminate fatally in a few
 days.  More commonly resolution takes  place, even though there is
 apparently a large exudate.  This Sanger considers typical of  gonor-
 rhoeal infection.
     The recurring form of perimetritis is due to pus-tubes; the symp-
 toms are those of acute  local peritonitis, and are most severe and last- 
GONORRHOEA  IN WOMEN.
153
ing during the first attack.   In the intervals the woman may enjoy
perfect health.
   The chronic form is characterized by persistent pain and tender-
ness.   Every strain or jar is unbearable, coitus  is not possible, and
there is usually a marked condition of neurasthenia.
   Treatment.—Gonorrhoeal  cervical endometritis should be treated
first by thoroughly cleansing the vagina with antiseptic douches, 1 to
2000 bichloride (hot).  The cervix is  then exposed  and its  endo-
metrium cleared of the viscid mucus which coats  its surface by means
of cotton tampons.  Finally, the whole diseased surface is  touched
with one of the following solutions,  named  in the order of their effi-
ciency : 1, silver nitrate ten per cent.; 2, tincture  of iodine ; 3, copper
sulphate ten per cent.
   Small cysts found in this form of inflammation should be punctured,
and when there is marked congestion local depletion is indicated, the
cervix being scarified by means of a long-handled knife.
   When the inflammation  resists these  milder  forms of treatment,
a  thorough curetting, followed  by the application of zinc  chloride,
twenty per cent, solution, and by packing with iodoform gauze, will
be indicated.
   Endometritis involving the body of  the womb should receive no
direct treatment during the acute stage.  Rest in  bed,  local depletion
from the cervix, free  action on the bowels by salines, and, when pain
is very intense, the administration of an anodyne, represent the safest
and most efficient treatment in this stage.  When the disease has
become chronic, the uterine  cavity should be washed with hot bichlo-
ride solution 1 to 10,000, passed in through a two-way uterine  irri-
gator.  Large quantities of this fluid should be employed, one or two
quarts at a time, and the treatment  should be repeated every second
day.   If the disease still lingers in spite of this treatment, the cervix
should be dilated, and the uterus thoroughly curetted, swabbed with a
ten per cent, solution of zinc chloride, and packed with iodoform gauze.
When the disease has extended to the parametrium, tubes, and ovaries,
abdominal section is indicated as  soon as a distinct tumor can be de-
tected.   When there is simply a sense of increased resistance,  showing
that there has been an inflammatory infiltration, free movements of the
bowels, prolonged hot baths, and hot vaginal  douches are indicated
until very definite localizing  symptoms point to the use of the knife.

                            VAGINITIS.
   Inflammation of the vagina, at one time regarded as  the most char-
acteristic manifestation of gonorrhoea in the female, is now recognized 
154
GENITO-URINARY DISEASES AND SYPHILIS.
 as  occurring much  less frequently than urethritis or endometritis.
 The many  layers of squamous epithelium are usually sufficient to
 prevent penetration  of the  gonococci.  When,  however, the vaginal
 mucous membrane is succulent and the spaces between the epithelial
 cells are widened, as in infants and children, or in  young virgins, the
 gonococci may penetrate  deeply and produce  a true vaginitis.  The
 vaginal inflammation sometimes noted in older women is often due
 to the  irritating effect of decomposing discharges which flow from the
 endometrium.
    Symptoms.—A  sense of weight and burning in  the vagina, aggra-
 vated by motion, a free purulent discharge, and slight fever and malaise
 are the only symptoms of which the patient complains.   An examina-
 tion shows the vaginal mucous membrane reddened, oedematous, and
 freely suppurating, and its walls somewhat stiffened by recent inflam-
 matory exudation.  The epithelium is eroded in places, and there are
 observed extensive granular patches, especially in  pregnant women.
 Often  there is so  much tenderness that  examination  either  by the
 finger or by the speculum  is impossible.
    Diagnosis.—This  is founded on ocular and  digital  examination
 showing an  acute inflammation of  the vagina, usually associated with
 urethritis and vulvitis, and  often with endometritis.   The gonococcus
 may be found.
    Prognosis.—In itself gonorrhoeal vaginitis is not a serious affection.
 It is usually cured in two or three weeks.  Exceptionally it becomes
 chronic, and in prostitutes causes a stiffened, dry, rough  condition of
 the mucous membrane, termed xerosis vaginae.
    Treatment.—This should be cleansing and antiseptic.  Twice a day
 the vagina is flushed out with two quarts of normal saline  solution
 (seven-tenths per  cent.) containing 1 to 2000 corrosive  sublimate.
 This douche is best given  from a fountain syringe raised six to eight
 feet.  During its administration the patient  should lie on her back,
 with the hips slightly elevated, or, better still, should assume the knee-
 elbow position.   When there is a bath-tub these flushings are easily
 managed.
   After each washing the vagina  is packed with a  cotton-wool tam-
 pon dipped  in hydrastis-glycerin mixture 1 to 10,  or with iodoform
gauze, thus  keeping  its walls from coming in contact  and acting as
 mutual poultices;  the packing also, by its astringent action,  rapidly
 reduces the  discharge.
   When the acute  symptoms have subsided, a speculum is intro-
duced,  and the inflamed and granular patches, or the entire vagina if
all its surface is involved, are painted with ten per cent, silver nitrate 
GONORRHOEA  IN WOMEN.
155
solution.   This is repeated  in  three days  if necessary.  Tincture
of iodine may be used in place  of the silver nitrate.   In cases seen
early, or where the inflammation is  not so acute that insertion of a
speculum is very painful, the  silver nitrate  painting is  indicated from
the first.
    In chronic cases, irrigation, followed by  paintings of the vagina
with strong solutions of silver or copper ten per cent., or iodine pure,
and then by tamponing with iodoform gauze, is repeated daily for from
five to seven days; then  dilute antiseptic washes are employed once
daily  for two weeks till  epithelial regeneration is completed.   Sup-
positories of tannin and boric acid (ten grains of each) inserted twice
daily will almost always  greatly  lessen the discharge, and will some-
times cure a chronic inflammation when  other means have failed.

                    GONORRHOEA IN CHILDREN.
    Male Children.—The course of gonorrhoea as observed in male
children is not markedly different,  in symptomatology, duration, or
treatment, from the  disease as it occurs  in adults.  It is  a  rare  dis-
ease,  at least in  boys under twelve  years  of age,  in this respect
affording a marked  contrast  to  gonorrhoeal vulvo-vaginitis  observed
in the opposite sex.  The cause  is usually an attempt  at intercourse,
often suggested  by  a  much older  female.   Very exceptionally the
contagion  may be mediate by means of  fabrics or by foreign bodies
previously infected being introduced within the urethra.  When the
disease develops in boys over  twelve  years of  age it is usually acquired
in the ordinary manner.
    Symptoms.—These are the same  as have  been already described.
They develop  more  quickly after exposure to contagion, and run a
somewhat more acute course than is  customary in the adult, the whole
penis usually being swollen, the discharge being profuse, and the  child
complaining bitterly of the pain incident to micturition and erection.
    Complications.—Of  these  the most  frequent is balanoposthitis,
incident, no doubt, to the phimosis usually  present in children and to
the vulnerability of the  mucous  coverings  of the glans and foreskin.
Indeed, other complications are rare,  though a number of well-authen-
ticated instances  of  epididymitis are reported.  Posterior  urethritis
and urethro-cystitis are by no means exceptional.  There is usually
pronounced fever.
    Diagnosis.—This is founded  on  the  presence of the gonococcus.
Since it has been shown that in the  normal urethra there are micro-
organisms identical in all respects with the gonococcus, identification
of these micro-organisms under  the  microscope is not a proof of the 
156        GENITO-URINARY DISEASES AND SYPHILIS.

specific nature of the affection in medico-legal cases, though for clin-
ical purposes it can be considered sufficient.   When, as often occurs,
there is a probability of cases coming to court, the specific  nature
of the affection should be  proved by cultivation of the gonococcus
on artificial blood serum.   The growth is said to be absolutely char-
acteristic and to  differentiate satisfactorily  this micro-organism from
all others.
   The  search for  the gonococcus  should  always be made, since
simple irritative  urethritis is by  no  means  uncommon in children,
and is in the beginning of its course  not to be distinguished clinically
from  true gonorrhoea.  This simple  urethritis is often excited by the
introduction of foreign bodies, by a simple balanoposthitis, and by the
irritation incident to the passage of highly condensed urine or to a
narrowed preputial orifice.   It is  usually mild and of short duration,
contrasting  with  the inflammation resulting from the presence of the
gonococcus.
   The prognosis is  favorable, the discharge usually ceasing in from
three to  six  weeks.  In weak, strumous, cachectic' children it is liable
to last much  longer and may run  into  gleet.   Stricture has been
observed as a sequel.
   Treatment.—This  consists in rest  in bed, the relief of phimosis by
operation, circumcision being performed if the parts are not too greatly
swollen, light  diet, hot  baths, the administration of laxatives  when
required, and medicines calculated to subdue the fever, render  the
urine bland and  slightly antiseptic, and control the  painful erections.
These indications should be  met by aconite in small  doses, boric acid,
and  potassium bromide.  An excellent formula for  a child of five
years is the following:

                  B  Potassii  bromidi, gii;
                    Acidi borici, gr. xlviii;
                    Tinct. aconiti, gtt.  vi;
                    Tinct. belladonna?, gtt. xxiv;
                    Spts. setheris nit., f^iii;
                    Mist, potassii citratis, q. s. ad f^vi.
            M.  S.—Dessertspoonful in water every two hours.

   The penis should be kept wrapped in cloths wet in lead water and
laudanum.
   On the subsidence of the acute inflammatory symptoms injections
may  be administered.  These should  contain the  remedies used in
similar  conditions of the adult, but should  be somewhat weaker,
varying from one-half to two-thirds strength, according to the age of 
GONORRHOEA IN WOMEN.
157
the child.   They should never be used strong enough to cause acute
or prolonged pain.   It is well to begin with the following injection:
                 R Ext. opii aq., gr. vi;
                    Acidi carbolici, gtt. xv ;
                    Liq. plumbi subacetat. dil., f^vi.
                 M.  S.—Use locally.
    Later  an antiseptic  and  astringent injection, as the following,
should be employed:
                 R Hydrarg. chlorid. corros., gr. ^;
                    Acidi borici, £i ;
                    Zinci sulpho-carbolat., gr. xii;
                    Liq. hydrogen, peroxid., f^ss ;
                    Aquae Tosve, f^vss.
                 M.  S.—Use locally.
    These injections should  be administered immediately after the
child urinates, from half a drachm  to a drachm being thrown in each
time.  As  soon as the fever subsides the internal administration of
salol is serviceable.  This  may  be given in doses  of  one to three
grains  six times a day, depending  upon  the  age of the patient, and
may be combined with  balsam of  copaiba or oil of sandal wood in
appropriate doses.  When the fever persists and assumes an irregular
intermittent type full doses of quinine night and morning will be found
serviceable.
    Female  Children.—In female children gonorrhoea takes the
form of urethro-vulvo-vaginitis.  It is different from the disease as it
appears in the  adult, since in the latter the vagina is only exception-
ally involved.  Vulvo-vaginitis  is  in the majority  of  cases  not of
gonorrhoeal origin.   There are two distinct  forms:  1,  catarrhal or
irritative;  2, gonorrhoeal.
    Catarrhal vulvo-vaginitis may be caused  by any irritant, such as
prolonged  contact of irritating urine or of  faeces, lack of cleanliness,
seat-worms,  decomposing discharges incident  to  exanthemata, etc.
The inflammation is usually confined  to the vulva, the vagina being
but slightly involved, and the urethra escaping entirely.
    The symptoms are those of ordinary inflammation, as heat, redness,
swelling, pain, or itching, increased  by contact with urine.   There are
often extensive excoriations, or even distinct ulcers.
    The diagnosis is founded on the  absence of gonococci and on the
presence of vast  numbers  and varieties of  other  micro-organisms,
the comparatively mild  course of  the affection, though it may be
extremely  chronic and rebellious  to  treatment, and the absence of
involvement of the  urethra and vagina.  The prognosis  is good. 
GENITO-URINARY DISEASES AND SYPHILIS.
   The treatment consists in removal of the cause and in strict local
cleanliness.  Since this affection is very commonly associated with
seat-worms, these should always be searched for.   Mild antiseptic
washes, as  boric  acid, followed  by dusting powders, such as finely
powdered bismuth or zinc oxide, and the application of a thin layer
of cotton between abraded  and inflamed surfaces,—i.e.,  between
the greater and the lesser  lip of each side,—usually result in cure.
When the disease becomes chronic, stronger astringent injections and
washes are required.
   Gonorrhoeal Vulvo-Vaginitis.—This is a much more severe affec-
tion.
   Cause.—In the new-born and in young infants gonorrhoeal vulvo-
vaginitis  is acquired from the mother, either from  direct contagion
during parturition, or  from mediate contagion later through the
agency of towels,  wash-rags, fingers, etc.   When it develops after the
nursing period  it  is usually due  to mediate contagion.  Thus, it has
been shown that  when one case is introduced into an institution the
disease  spreads rapidly, probably by the medium of the bath or
towels.   The genital mucous membrane of the child seems to be ex-
ceedingly sensitive to the gonococcus.  Exceptionally vulvo-vaginitis
is caused by criminal practices.   When these are suspected, and con-
sequently when there is a possibility of a medico-legal  contest, the
presence of the gonococcus should always be confirmed by culture on
artificial  media.
   Symptoms.—These are pronounced.   The discharge is free, puru-
lent, often  blood-stained.  It comes  from the urethra,  vagina, and
vulva.   There  are great swelling, intense hyperaemia of  the mucous
surfaces, which  bleed readily  when  touched, pronounced ardor
urinae, and marked and persistent fever.   There is often bitter com-
plaint of severe abdominal and  pelvic pain.  On rectal examination
the womb may be found tender and swollen.
   The diagnosis is founded on the presence of gonococci, the involve-
ment of  the urethra, and the severity of  the symptoms.
   The prognosis  is good.  Some cases of peritonitis and death have
been reported,  and it has been urged on  the basis of apparently clear
clinical records that this inflammation in  infancy may occasion imper-
fect development of the genitalia, sterility, and chronic invalidism in
later life.  Positive  proof as to this is, however, wanting.  The local
conditions are apt to be rebellious to treatment.
   Treatment—Special  care must be taken to guard against transfer-
ence of the inflammation to the eye.  This is peculiarly liable to
happen in  public institutions.   The child  should be put  to bed, and 
GONORRHOEA IN WOMEN.
159
given a milk diet, the bowels should be opened regularly, and a hot
bath administered  night and morning.   Three times daily a  small
soft rubber  catheter should be introduced into the vagina, and there
should be gently injected first four ounces of a one per cent, hot
solution of sodium  bicarbonate, then the same quantity of a weak hot
antiseptic, such as  bichloride of mercury 1  to 10,000, carbolic acid
1 to 100, boric  and salicylic acids ten  grains of the former and five
grains of the latter to  the ounce, or silver nitrate 1 to 5000.   After
this irrigation the vulva should be dried carefully with moist absorbent
cotton, and dusted with a powder made of boric acid, zinc oxide, and
talc equal parts, and between the labia should be inserted a thin layer
of absorbent cotton.
    If these injections cause pain they must be weakened until they are
borne well.   As the acute stage passes they are gradually strength-
ened, hydrastis being added.  For the accompanying urethritis small
doses of salol and  boric acid are indicated, or the prescriptions  given
on page 113 can be advantageously used.
    The general health should receive careful attention, and in stru-
mous or cachectic  patients treatment may have to be prolonged for
weeks or months before cure is effected.
    Gonorrhoea of the Rectum.—Gonorrhoeal. inflammation of the
rectal mucous membrane is observed more frequently in women than
in men, mainly because women are more exposed to infection from the
backward trickling of gonococcus-bearing secretions  from the  vulva
and vagina.   The disease can be excited by unnatural practices.
    Symptoms.—The symptoms  are those  of acute  inflammation.
There are free discharge of blood-stained pus, tenesmus, painful defe-
cation, and on direct examination  acute redness and  infiltration of the
mucous membrane, with excoriations  about the anal  orifice.   The
disease is prone to become chronic, leaving on subsidence  of the gen-
eral inflammation  one or more localized ulcers.   These,  if allowed
to extend, may ultimately cause dense cicatrices.
    The diagnosis is, of course, founded upon the presence of the gono-
coccus, together with a history of  infection.
    The treatment consists in  relieving the tenesmus  and burning pain
of the early stages, in frequent cleansing of the mucous membrane of
the affected  surfaces, and in  applying astringent and antiseptic medi-
cations.
   For  the  relief of pain and tenesmus, suppositories containing a
grain of the watery extract of opium, a quarter of a  grain  of cocaine,
and a quarter of a  grain of belladonna will be sufficient.
   The  rectum should be cleaned  at least twice a  day by means of 
160        GENITO-URINARY DISEASES AND SYPHILIS.

a hot douche of corrosive sublimate 1 to 20,000, or silver nitrate 1 to
2000, or, if these solutions occasion severe pain, by a saturated solu-
tion of boric acid.
   When the acute symptoms have subsided, stronger solutions of
silver nitrate are employed, 1 to 1000 and 1 to 500, in smaller quan-
tities.   When the general  catarrh is cured, leaving only ulcers  or
hyperaemic patches, these are touched directly with a strong solution
of silver nitrate (ten per cent.), or with one of the other agents already
mentioned in the treatment of chronic gonorrhoea.
   In some cases when discharge  persists, two per cent, solution of
alum  or of tannin injected into the rectum will prove serviceable. 
CHAPTER V.
                   complications of  gonorrhoea.

    In the large majority of patients suffering from urethritis, when
treatment has been judiciously instituted  from the beginning of the
attack there  are  no  complications ;  that is, the disease  is limited to
the urethra and remains superficial.   Exceptionally the inflammation
exhibits  a tendency to extend  wide  of the urethra or even to attack
other parts  of the body.   In  these cases  there is usually mixed
infection, the ordinary  pus microbes being  present and  producing
either local  inflammations or a mild or even severe form of septic
poisoning, though there is evidence  that the  gonococcus in itself or
the ptomaines  engendered by  it may produce many of the compli-
cations which are encountered in these inflammations.
    There seems  to be a personal susceptibility towards  the develop-
ment of such  complications, since  certain patients  never have the
good fortune  to run through a simple uncomplicated attack.
    As to the  cause of complications, in general terms it is true that all
factors which tend to exacerbate an attack of gonorrhoea predispose to
complications.
    The fact  that these complications are usually due to  mixed infec-
tion is one which should be borne in mind  as  indicating the necessity
for perfect cleanliness in all local manipulations.
    The complications most frequently encountered in the male are:
1. Balanitis   and  balanoposthitis.   2. Phimosis and paraphimosis.
3. Lymphangitis and lymphadenitis.   4.  Folliculitis and  periurethral
abscess.   5.  Cowperitis.   6. Prostatitis.  7. Vesiculitis.  8. Epididy-
mitis.
    The complications common  to both the male and the female are:
1. Cystitis.  2. Ureteritis and uretero-pyelitis.  3.  Gonorrhoeal conjunc-
tivitis.   4. Gonorrhoeal rheumatism,  including such manifestations as
arthritis, endocarditis, and meningitis.
    In men the most frequent complication is epididymitis.
    Balanitis and Balanoposthitis.—Though gonococci seem to
play no causative rdle in the production of  balanitis, or inflammation
of the surface of the glans penis, this is a  frequent complication of
gonorrhoea.   It is usually caused by neglect  of cleanliness, the  dis-
                                11                        161 
162
GENITO-URINARY DISEASES  AND SYPHILIS.
 charge  from the urethra being allowed to accumulate  beneath the
 foreskin or to  remain in contact with the head of the penis, and,
 from its irritating character, setting up an active inflammation.  Some
 patients seem to be peculiarly  liable to the development of this form
 of inflammatory reaction, particularly those who are subject to ery-
 thema intertrigo.
    In  dispensary and hospital practice balanitis is  seen much more
 frequently than among private patients.   Balanitis  may precede the
 urethritis, often developing within twenty-four hours after coitus.   It
 is in this case due to contact with irritating discharges.
    Bacteriological examination of the  discharge of balanitis shows a
 great variety of microbes, one of which, a spirillum, is said to be con-
 stantly  found associated with  a  circinate form  of the disease which
 runs a  regular  course and stops only after complete erosion of the
 glans penis and the inner surface of  the foreskin.
    The symptoms, diagnosis, and treatment of balanitis and balano-
 posthitis have  already been described, the gonorrhoeal form of the
 affection running a course which does not differ from that due to other
 causes.
    Phimosis.—When in consequence of oedematous swelling due to
 gonorrhoea the  foreskin  becomes so thick that it cannot  be retracted,
 the complication constitutes a form of inflammatory phimosis.  (Fig.
 54.) This is always a troublesome  condition, since it materially in-
 terferes with treatment  and  may render the diagnosis exceedingly
 difficult.  Swelling  may  become so  great  that a  certain amount of
 sloughing occurs.  This at times involves the whole thickness of the
 foreskin, producing a perforation, which, by allowing the glans penis
 to escape, relieves pressure and prevents the further extension of the
 necrotic process.  The inflammatory induration  usually entirely dis-
 appears.  It may remain, leaving a thickened prepuce, which is readily
 fissured and eroded.
   If the  patient first comes  under treatment with a vague  history
 and with an  oedematous swollen prepuce  from the orifice of which
 blood and pus flow, it is sometimes difficult to determine  correctly the
 source  and nature of the discharge.
   Whether or not all the discharge comes from the preputial sac or
 a part of it from the urethra can be ascertained in this way.  The
preputial sac is thoroughly washed out by means of a syringe to which
is attached a soft rubber catheter small enough  to pass within the
preputial  orifice, and  immediately after this washing the patient  is
directed to urinate.   If the urine contains much  pus, the latter must
 come from the urethra. 
COMPLICATIONS  OF  GONORRHOEA.
163
   Chancroidal balanitis can be suspected only from the development
of bubo, the rapid  and progressive swelling, and the  free  discharge,
and from auto-inoculation, other sores forming on the free border of
the preputial  opening, or on the  scrotum or other portions of  the
                                Fig. 54.
Gonorrhoeal phimosis.
body with which  the discharge  comes in contact.  The main  points
of difference  between gonorrhoeal and chancroidal phimosis may be
summed up as follows :
       Phimosis from Gonorrhoea.
No history of sore on glans or prepuce.
  Swelling in  foreskin at first  almost
  entirely oedematous.
Discharge usually purulent, and contains
  gonococci.
No definite area harder or more tender
  than the rest.
Chordee often present.
Ardor urinae extends along whole length
  of canal.
Vesical symptoms not infrequent.

Bubo rare.
  Phimosis with Preputial Chancroid.
History of sore.   Swelling often due to
  presence  of plastic lymph  around
  ulcer.
Discharge often sanguinolent; no gono-
  cocci.
Distinct  spot  usually discoverable by
  palpation.
Never any true chordee.
Ardor urinae only when the urine comes
  in contact with the inflamed or ulcer-
  ated foreskin.
No vesical  symptoms in  uncomplicated
  cases.
Bubo common. 
164       GENITO-URINARY DISEASES  AND SYPHILIS.

   Phimosis and balanitis  from chancre  may be  diagnosed  by the
typical induration  of the  primary sore  and by  the  characteristic
lymphatic involvement and subsequent  development  of  secondary
symptoms.
   Phimosis and balanitis due to secondary or tertiary  manifesta-
tions  of  syphilis may occur.  The diagnosis will in the first case
depend upon the existence of typical  eruptions in other parts of the
body.  The tertiary manifestations  may be suspected from the history
of the case.  The mode  of onset is usually characteristic of syphilis,
a lesion appearing in the form of an infiltration or a hard node and
preceding the development  of phimosis.
   The symptomatology and  treatment  of  inflammatory phimosis
have already been discussed.
   Paraphimosis.—This,  as is the case with phimosis, is  dependent
upon  inflammatory swelling of the  foreskin, which, after rolling back
or being  forced  back, can no longer be brought forward.   The ques-
tion of differential diagnosis is scarcely raised here, since the urethral
meatus  is freely exposed  and  the discharge can be seen escaping
through it.  The treatment has been described.  (See page 20.)
   Lymphangitis.—In  a small  percentage of gonorrhoeal  cases a
simple lymphangitis or inflammation of the lymphatic vessels occurs
as a result of local infection.
   This is often caused by neglect  of  cleanliness, the discharge being
retained within the fossa navicularis  either by a congenitally narrow
meatus or by a faulty method of dressing.
   Symptoms.—The inflammation usually affects the lymphatics of the
dorsum of the penis.  Beneath the  skin can be felt one or more cords,
often  starting about the region of the fraenum and passing upward and
backward behind the corona to the dorsum of the penis, along which
a distinct cord  can be felt extending as far back as the  symphysis
pubis.  This cord is tender, hard, not very sharply circumscribed,
and  over its course the skin  is reddened and  sometimes adherent.
This line of induration may attain  the size of a lead-pencil, and may
even  be much larger than this.   It is attended with a great  deal of
pain,  which is especially severe during  erection.  Exceptionally an
indurated knob forms sometimes just behind the corona in the loose
subcutaneous connective tissue, sometimes in the course of the dorsal
lymphatics;  this  slowly enlarges, giving comparatively  little pain,
softens, and on being opened discharges pus.
    Gonorrhoeal lymphangitis may be distinguished from  that which
characterizes hard chancre by the  fact that its outlines are  not sharply
circumscribed, the inflammation commonly extending to the surround- 
COMPLICATIONS OF  GONORRHOEA.
165
ing cellular tissue, and often binding artery and vein together so that
one cannot be distinguished from  the other, and by its being tender
and painful, and involving the skin.
   It would be extremely  difficult to distinguish lymphangitis from
dorsal phlebitis.  This latter complication of gonorrhoea, if it ever does
occur, is certainly exceedingly rare.  It would be necessarily attended
by much more swelling of the penis, and would not be accompanied
by that  enlargement of the lymphatic glands of the groin which is
rarely absent when lymphangitis of the penis is observed.
   Treatment—Free drainage of pus  from the anterior urethra, ap-
propriate  treatment directed towards lessening the  severity of the
urethritis,  and careful cleansing of the preputial sac are matters which
should receive close attention.   Following these, rest should be en-
joined,  the bowels should be  opened,  and  continuous  applications
should be  made of cloths kept wet with alcohol and lead water  equal
parts.  Hot baths, local or general, are also serviceable, and when the
erections become  troublesome potassium bromide should be given in
sufficient  doses to control  them.  This drug failing, hypodermics of
morphine  may be given at night to procure rest.  When pus forms it
should be evacuated by incision, the remaining cavity being curetted
and packed from the bottom.
   Lymphadenitis or Bubo.—Adenitis  of the glands of the groin,
or bubo, is a comparatively rare complication of gonorrhoea.  It occurs
chiefly during the second stage of the disease.
   It  is commonly  excited by  excesses,  exposure, or  violent and
long-continued exertion.   Persons who are much on their feet suffer
more frequently from this complication than those whose  occupation
allows of more rest.  The  gland usually affected is one of the super-
ficial set lying just below Poupart's ligament, embedded in the sub-
cutaneous  cellular tissue and placed above the fascia lata.
   Symptoms.—A small, painful  tumor makes its appearance in the
groin; it is tender on pressure, and the  pain  is aggravated by stand-
ing or walking.  It is at first freely movable beneath the skin, but
afterwards contracts adhesions to the latter  and to the surrounding
parts, and  becomes doughy in feel and reddened or purplish in hue.
The majority of  these  cases  after reaching this  condition will sub-
side under appropriate  treatment, disappearing  in  time.  In  some
instances,  however, particularly in patients of scrofulous tendencies
or in those whose vitality is lessened through bad habits or overwork,
suppuration ensues,  ushered in by the local and general phenomena
of abscess-formation.  The discharge from a suppurative gonorrhoeal
bubo does not contain gonococci. 
166       GENITO-URINARY DISEASES AND SYPHILIS.

   Treatment—Gonorrhoeal bubo can often be relieved without sup-
puration by prolonged hot baths, followed by rest in bed, the applica-
tion of the iodine, mercury, and belladonna ointment over the inflamed
region, and the use of a bag of hot shot containing two to four pounds
placed directly over the inflamed part.
   If suppuration  takes place, the treatment should be that  directed
in the case of  chancroidal bubo,—i.e., puncture under  antiseptic pre-
cautions and evacuation  of the contents of the  abscess, followed by
antiseptic flushings of the sac and the application of a sterile  dressing
held in place by a pressure bandage.  This puncture, evacuation, and
washing out may  be repeated twice.  If the cavity again  fill up, free
incision, curetting,  and packing with iodoform gauze are indicated.
   Complete removal of gonorrhoeal buboes before they have broken
down is justifiable,  provided they become progressively worse  in
spite of one or two days'  careful treatment.
   Follicular and  Periurethral  Abscess.—Gonorrhoeal  inflam-
mation not only spreads along the surface of the urethra, but, dipping
into the mucous follicles and  gland ducts, involves their entire mucous
surface.  Often if the finger is passed along the  under surface of the
urethra there  can be felt  distinct nodulations,  due to the follicular
swelling.  At the meatus, where the glands and follicles are especially
well developed, pus may be  seen  to  escape  from their  orifices on
pressure.
   If the  ducts become  closed from swelling or from  inflammatory
exudation, the catarrhal secretion of the follicles being no  longer able
to escape into  the urethra, small pockets of pus, or follicular abscesses,
appear.   These follicular abscesses  are most frequently located in the
first  inch  of the urethra, the follicles being  numerous  in this region.
They appear as small, round, tender nodules, which may open inter-
nally without involving the skin, the duct finally becoming patulous.
Frequently, however, the skin reddens and is no longer movable over
the nodule, and the  latter discharges its contents externally.   In this
case the urethral  opening  of the gland usually remains  closed, and
no fistula  results, even though the fraenum be completely undermined
by suppurating follicles on  each side.  The fraenum itself  is apt to be
markedly oedematous during the  period of pus-formation  in the fol-
licles lying near its point of attachment behind and below the meatus.
On stripping back the foreskin the projecting swelling is readily seen
entirely obliterating  the normal depression situated at  the side of the
fraenal attachment.   When external rupture and discharge of  pus take
place, there is often  left a troublesome sinus.
   Sometimes the lacuna  magna remains in an inflammatory condi- 
COMPLICATIONS OF  GONORRHOEA.
167
tion  long after the urethral  mucous membrane has  returned  to  a
healthy state.  The opening of this  follicle  is so large that it is not
readily obliterated, yet it  may be  narrowed to  such an extent that
healing injections do  not  penetrate to its deeper portions.  Such an
inflammation will occasion a long-continued  discharge.
   At  the fraenum the mucous  follicles are surrounded by fibrous
tissue: hence this limits abscess-formation.  Farther back along the
urethra this investment of  connective  tissue is less marked: hence
the inflammation may readily extend into  the  cavernous tissue, and
in case the inflammation goes  on to suppuration, periurethral abscess
will be formed.
   Periurethral abscess begins as a case of folliculitis or adenitis, but
the swelling rapidly increases, and is attended with pain, tenderness,
and  often some diminution  in the size of the stream  passed during
urination.  The swelling may suddenly subside  from opening of the
obstructed duct.   This probably will be denoted by diminution in the
size and tension of the tumor, by blood and pus in the urine, and by
a sense of relief from pain.   The subsidence may inaugurate a speedy
cure, or, if the urine enters the abscess-cavity, may be shortly followed
by urinary extravasation.   Commonly the skin becomes reddened and
inflamed, and the  pus is evacuated externally, after which  the abscess-
cavity heals.
   If the abscess opens externally and internally at the same time,  a
urinary fistula results, and one difficult to cure.
   Periurethral abscesses occur at any portion of the anterior urethra,
but are most  frequently observed in the region of the bulb.  They
may be attended with considerable  inflammatory induration of the
corpus spongiosum, which may  ultimately undergo complete resolu-
tion, or may remain permanently, constituting an  incurable chordee
and preventing intercourse.
   When urinary extravasation occurs it is attended by rapid increase
in pain and swelling, and infiltration of sometimes the greater portion
of the corpus spongiosum.  The local pain  is much increased during
each urination.  There is commonly an opening formed externally,
which allows of free purulent  discharge and results in urinary fistula.
Sometimes  an extensive sloughing  process  is inaugurated, attended
with well-marked general septic symptoms.   Even in the mildest  case
of urinary extravasation there may be sufficient destruction of the
erectile tissue of the spongy body to cause great deformity of the penis
when the organ is erect.
   Treatment.—Gentle pressure and massage are sometimes successful
in rendering patulous the obstructed duct  of an inflamed gland or 
168       GENITO-URINARY  DISEASES AND SYPHILIS.

follicle.   When the swelling becomes marked and painful, cloths wet
with alcohol  and dilute lead water should be kept about the penis.
When the skin becomes adherent and  softening occurs, the follicles
should be opened, curetted, and packed with iodoform gauze.   They
usually heal kindly from the bottom.  When they have ruptured spon-
taneously, causing a troublesome sinus, this should be converted into
an open wound, and be curetted and packed.   When there are both
an internal and an external opening, the formation of a permanent
fistula is guarded against  by permanent or intermittent catheteriza-
tion, no urine being allowed to escape through  the artificial opening.
Fistulae  at times  heal  spontaneously.  If not, a plastic operation  is
indicated.
   When the lacuna  magna becomes  involved in a chronic inflam-
mation,  which, though not  going  on to  abscess-formation, persists
and  keeps  up discharge, a fine grooved  director should be  passed  to
its deepest part, and it should be slit out into the urethra.
   Periurethral abscess when once formed demands immediate evac-
uation, and this indication is even more imperative when there  is
urinary  extravasation.  The formation of a fistula is guarded against
by permanent catheterization.
   Cowperitis.—Cowperitis, or inflammation of  Cowper's  gland,
usually develops  in the third or fourth week of an  acute urethritis.
It is  due to an extension of the disease from the bulbous urethra, into
which the ducts of these glands empty.  All the causes which tend  to
aggravate an attack of acute  urethritis, such as sexual  or  alcoholic
excesses or violent exercise, predispose to inflammation of Cowper's
gland.
   Symptoms.—The first symptom is a sticking pain in the perineum;
this is greatly increased by pressure, so that sitting or walking mark-
edly increases the suffering.  The swelling of the glands is resisted by
the two layers of the triangular ligament between which they are situ-
ated and by the deep perineal fascia: hence,  as the inflammation
progresses, there  is developed great tension.
   Both micturition and  defecation are painful, the  suffering being
particularly  severe at  the termination  of the  former act,  since the
transverse fibres  of the compressor urethrae muscle, as they contract
to expel the  last drops of urine, compress the inflamed and swollen
gland.   If the swelling is very marked  there will be some  difficulty
in micturition from mechanical pressure.
   Usually but one gland is involved.   It may then be felt as a small,
hard, very tender tumor situated just behind the bulb,—that is, about
the middle of the perineum.   This tumor may be recognized by deep 
COMPLICATIONS OF  GONORRHOEA.
169
palpation of the perineum, or by pressure made in an upward and for-
ward direction by a finger inserted just within the external sphincter.
The fact that this swelling is on one side of the median line constitutes
a distinct diagnostic point.  When both glands  are  involved the
swelling will, of course, be bilateral.
   Suppuration  sometimes occurs.  When this involves the  peri-
glandular tissues the skin will become reddened and oedematous, and
the rigors, fever, and throbbing pains of pus-formation will be present.
The swelling in  these  cases  is nearly always  sufficient to interfere
materially with micturition.  The abscess usually perforates exter-
nally, and on  the  discharge of a large  quantity of pus heals kindly,
although it may  subsequently be followed by troublesome cicatricial
contraction.  In rare instances the  abscess  may perforate into the
urethra, but even then  extravasation of  urine  is very exceptional.
The inflammation frequently becomes chronic, lingering particularly
in the gland  ducts, and  occasioning a discharge which is extremely
hard to cure.
   During the course of an acute cowperitis the discharge of the ante-
rior urethritis usually ceases or is greatly diminished in quantity.
   Diagnosis.—When the case is seen early the anatomical position
of the firm nodule or nodules renders diagnosis easy; but when sup-
puration occurs, together with wide-spread periadenitis, it is sometimes
hard to determine the true  nature of the inflammation.
   It  may be distinguished from a simple  abscess of the perineum by
the fact that the  latter from its position cannot cause compression of
the bulb, and therefore difficult micturition.
   From urinary infiltration following stricture it can be distinguished
only by the history of  the case.  Periurethral abscess of the bulb is
farther forward  than is the tumor in cowperitis, and is always in the
median line.
   Treatment.—Every effort should  be made to lessen the urethral
inflammation.    Strong antiseptic or astringent  injections or  intra-
urethral manipulation  must be discontinued at once.  Rest in bed,
prolonged hot baths, and the administration of a laxative or a saline
purge are always indicated.   A hot-water bag applied to the perineum
relieves pain and seems  to lessen  the tendency to abscess-formation.
When the suffering is  intense,  hypodermics of morphine  driven into
the perineum are indicated.
   When throbbing pain,  oedema, fluctuation, and rigors and  fever
show  that pus has formed, the abscess should be cut  into at  once,
and its cavity curetted and  packed with iodoform gauze.  Urinary
extravasation,  of course, demands immediate incision and  drainage. 
170
GENITO-URINARY DISEASES  AND SYPHILIS.
Fistulae may be guarded against by permanent catheterization after
the abscess has been opened and drained.   When, in spite of every
precaution,  fistulae form, and are not relieved by catheterization  and
free dilatation, excision of the fistulous tract, as well as of any rem-
nant of the gland, and suture of the freshened edges,  are required.
   Prostatitis.—After the gonorrhoeal inflammation has reached its
full development in the prostatic urethra—that is, during the third
week of the attack or subsequent to this time—it may extend into the
substance of the  prostate gland.  The involvement  of  the prostate
occurs in but a small percentage of cases,  and is  at times observed
when the posterior urethritis is so slight as to have given  rise to no
marked symptoms.   The follicles and glandular elements of this body
are chiefly involved, the muscular tissue,  forming the greater portion
of its mass, remaining unaffected, except in the most severe cases.
   Symptoms.—Prostatitis is characterized by a feeling of weight and
distention in the perineum and  rectum.  This is shortly followed by
pain at the neck of the bladder,  increased by urination and  by defeca-
tion, especially when the faeces  are hard.   Urination is frequent, not
only because of increased irritability of the posterior urethra, but also
because the bladder cannot completely empty itself, a certain amount
of urine being retained owing to the engorged gland.  Though the end
of the act is painful, it is not accompanied with such marked tenesmus
as is characteristic of acute inflammation of the posterior urethra or of
the neck of the bladder, nor is there much discharge of pus and blood
at the end of urination.
   On examination per rectum  the anterior wall of the bowel is found
to be pushed downward and backward, and is hot, firm, and tender
to the touch.   Through it the  tender and  enlarged  prostate can be
distinctly felt.
   It will be  seen that  the  subjective symptomatology of acute
prostatitis is so like that of acute posterior urethritis that diagnosis
between the two  is extremely difficult.  Digital examination through
the rectum will, however, determine the true nature  of  the affection
by demonstrating the  enlargement and tenderness of the  prostate if
it is inflamed.
   Prostatitis is generally accompanied by the characteristic constitu-
tional symptoms of acute inflammation.   It may terminate in resolu-
tion, in abscess, or in chronic inflammation.
   Acute inflammation of the prostate varies greatly in severity and
in the extent of the tissue involved.  It may take the form of simple
acute prostatitis, acute follicular prostatitis,  or parenchymatous pros-
tatitis. 
COMPLICATIONS OF  GONORRHOEA.
171
   Simple acute prostatitis represents the mildest form of acute pros-
tatitis.  It is  probably present to a  minor degree  in  every case of
acute posterior urethritis, and represents little more than inflammatory
hyperaemia.
   Symptoms.—The symptoms are not well marked.  There is, as in
all forms of involvement  of the prostate, a sense  of fulness  in  the
perineum and rectum, urine is passed frequently, and there is some
pain during defecation. Examination of the rectum  shows a moderate
enlargement and slight tenderness.
   This is the most frequent form of prostatitis.   It ordinarily  under-
goes spontaneous  resolution,  subsiding in a few days; it may run
on to either of the other forms of prostatitis, or may  form  the starting-
point of a chronic prostatitis.
   Acute follicular  prostatitis is usually due  to some  cause  ex-
citing renewed intensity of gonorrhoeal inflammation, such as excessive
drinking or coitus.
   Symptoms.—The symptoms are those already given as characteris-
tic of prostatic inflammation.   The patient complains of burning during
urination, and sharp, shooting, clearly localized pains during the passage
of the last drops.  These pains are located in the deep urethra.  On
rectal examination the prostate is found to be not materially enlarged,
but presents one or  two well-defined nodules, usually  in one lobe
only.  These are intensely indurated, contrasting markedly with the
soft  condition of the remainder of  the gland, and  are painful on
pressure.  The inflammation is confined to the follicles and the peri-
follicular tissues.
   Parenchymatous prostatitis, after it runs on to suppuration, is the
most serious form of the affection.   The whole structure  of the gland
is involved.  There is not only great inflammatory hyperaemia, but also
marked exudation.  The constitutional reaction is pronounced.
   Symptoms.—The local  symptoms are the  same  as those observed
in other  forms, but are much more  severe.   Rectal  tenesmus  may
accompany vesical  tenesmus.  As the disease  progresses, the pain
increases, becoming unbearably sharp, particularly when the patient is
erect or in a sitting posture.  It radiates along the divisions  and anas-
tomoses of the  hypogastric plexus,—i.e., to the rectum, sacro-iliac
juncture, hypogastric region,  and down  the  inner surfaces  of  the
thighs.   It  is made much worse by defecation or micturition.  The
tumefaction  may be so great as to cause retention of both  urine and
faeces.  Examination by the  rectum shows the prostate to be hot,
excessively tender, and very greatly swollen.
   The inflammation  runs its course in from  five to seven days.  As 
172       GENITO-URINARY DISEASES AND SYPHILIS.

a rule, it then undergoes spontaneous resolution.  Suppuration some-
times occurs.  In this case the pain becomes still more severe and is
throbbing in character.  Rigors, with high fever, are noticed.  Pus-
formation is very rapid.   Its presence is made absolutely certain by
the discovery of a fluctuating tumor on palpation through the rectum.
   The abscess usually ruptures  into the urethra.  This will be de-
noted by aggravation of the pain during the act of defecation or of
micturition,  followed by a free discharge  of blood and pus through the
urethra, and the immediate  amelioration of all the symptoms.  This
is the most  favorable and the most common termination of  abscess-
formation ;  it may be followed by  urinary extravasation, requiring
operation, but this is unusual.
   The pus may penetrate the capsule of the gland at any point.  If
it is  not evacuated into the urethra, it  is prone to rupture into the
rectum.  If it does not open into either the rectum or the urethra, it
generally burrows into the perineum or the ischio-rectal fossa.   It may
burrow in almost any direction, cases being  recorded in which it
opened through the sciatic foramen, at the edge of the false ribs, and
into the abdominal cavity.
   At times prostatic  abscesses  develop in so quiet  a  manner as to
escape observation.  There are no symptoms other than  those com-
monly noted in the congestive form of the disease ;  these are so slight
that the patient makes no complaint.   After some days the symp-
toms of septic absorption, characterized by rigors and  fever, set in;
and  examination by the  rectum  shows a large  fluctuating  swelling
or prostatic abscess.   Hence in  all  cases of urethritis attended  by
undue systemic disturbance, examination should be made to  discover
whether or  not this insidious form of prostatic trouble is developing.
   Prognosis.—As  has been  said,  parenchymatous  prostatitis  may
terminate in resolution, or  suppuration may  ensue.   It may run on
into  chronic prostatitis, or may leave some fibrous thickening, a hy-
perplasia  of the cellular  tissue, which  is often the groundwork  for
future trouble.
   As a result of prostatic abscess  urinary or faecal  fistula  may  be
formed;  though this sequel is rare.  When pus  infiltrates  the sur-
rounding cellular tissues the prognosis must  be exceedingly guarded.
In these  cases  death  may  occur from  blood-poisoning  or  from
peritonitis.
   Chronic  prostatitis is  usually  a  sequel of one of the acute gonor-
rhoeal forms of prostatic inflammation.  The gland may be increased
or diminished in size, according  to  the amount  of organization and
contraction  which the inflammatory infiltrate exhibits.   Its glands 
COMPLICATIONS OF  GONORRHOEA.            173
and follicles are in a condition of catarrhal inflammation, often forming
many foci of  suppuration, muco-pus appearing intermittently in the
urine.
   Symptoms.—The symptoms are  those  of  acute prostatitis, except
that they are much milder in type, though  they are persistent.  There
are perineal uneasiness, aggravated by standing or walking, crossing
the legs, or being jolted in cars;  some irregularity in  the shape and
density of the prostate, as shown by rectal  examination; and often
prostatorrhoea and sexual neurasthenia.   (See sections on diseases
of the prostate and on impotence.)
   Treatment.—Rest  in bed, the  elevation of the buttocks by a hair
pillow, a soluble condition  of the bowels, a bland condition of the
urine, best attained by a skimmed  milk diet and alkaline diuretics,
and cessation of all irritating or strongly astringent injections into the
anterior urethra, represent the general therapeutics of all forms  of
acute prostatitis.   This does not necessarily  contra-indicate the use
of mild antiseptic lotions, such, for instance, as bichloride 1 to 30,000,
or seven-tenths per cent, salt solution, or permanganate 1 to 12,000,
used as hot as can be borne.  The use of these lotions must be re-
garded as empirical, and if  they are followed by increase of inflam-
mation they should be stopped.
   Heat and  cold tend to exert a resolvent influence on most forms
of inflammation, and may be applied to the prostate through the rec-
tum by means of a rectal injector.   (Fig. 55.)   A quart of seven-tenths
per cent, salt solution is heated from 110° to 115° F., and the injection

                             Fig. 55.
Rectal irrigator.
pipe is introduced into  the anus, and its end tilted upward and for-
ward so that the stream when it is turned on shall flow directly  on
the prostatic tumor as it bulges into the rectum.  The exit-pipe allows
the fluid to flow away as fast as it enters the bowel.  This treatment
should be repeated two or three times a day, and often gives immediate
and great relief.
   When the inflammation ranges high and is accompanied by marked
fever, cold irrigations sometimes give more comfort.  These, of course,
are not to be used after  pus has begun  to form, but in the early stages
sometimes  promptly abort the inflammation.  The choice of heat or 
174
GENITO-URINARY DISEASES AND SYPHILIS.
cold will depend to a  certain extent  upon  the inclination of the
patient.
    General hot baths and hot sitz baths are also of service.  When
the  pain becomes very intense  and  the  straining during urination
constant and harassing, belladonna and opium suppositories or hypo-
dermics  of morphine driven  into the perineum are clearly indicated,
enough of the drug being given to relieve pain and tenesmus.   Indeed,
in the majority of cases of prostatitis the administration of opium by
the  rectum is more  useful,  not  only in relieving pain, but also in
lessening the severity and the duration of the inflammation, than any
other form of treatment.
    Retention of urine incident to swelling of the prostate is sometimes
relieved  by hot baths, supplemented by large, hot, frequently changed
poultices over the hypogastrium.  When these means fail, the bella-
donna and opium suppositories may be successful.  If the retention
persists,  a soft catheter should be introduced, and, since this manipu-
lation occasions great pain, should be allowed to remain in the bladder.
    When pus has formed in  recognizable quantity and fails to find its
way into the urethra, it  should  be evacuated by a median perineal
incision.   Even if the abscess ruptures spontaneously into the rectum,
unless drainage  is perfect and both local and general symptoms
promptly subside, it  is best  to make the median incision and thor-
oughly  drain through  this.   When  the abscess  ruptures  into the
urethra,  if possible a catheter should be introduced into the  bladder
and be kept there.  The treatment of chronic prostatitis is discussed
elsewhere.
    Vesiculitis.—Vesiculitis, or inflammation of  the seminal vesicles,
occurs as a complication of acute posterior urethritis in a much larger
percentage of cases than is generally imagined, the symptoms differ-
ing so slightly from those of inflammation of the prostate that the in-
volvement of the seminal vesicles is not suspected unless a rectal
examination is made.
    Acute vesiculitis  is due  to extension of  the  inflammation along
the ejaculatory ducts.  This, in turn, is usually dependent  upon an
exacerbation of a previously  mild urethritis.
    Symptoms.—Pain in the perineum is constant, with stabbing ex-
acerbations ;  it is made worse by urination or defecation, and  radiates
to the anus and to the thigh, testicle, sacro-iliac articulation, and hypo-
gastric region of  the affected side.   Pain experienced in the  hip and
passing down the outer surface of the thigh is particularly character-
istic of spermatocystitis.
    Urination is frequent, straining, painful, and often spasmodically 
COMPLICATIONS OF  GONORRHOEA.
175
interrupted.   Ejaculation is hurried  and .painful.  Nocturnal  pollu-
tions are frequent, and the sperm is red- or chocolate-colored from
admixture of blood.  Digital examination shows a swollen, often ten-
der,  nodulated, or  obscurely  fluctuating  seminal vesicle  extending
upward and backward from each prostatic lobe.
   Diagnosis.—The diagnosis is founded on the blood in the  semen
and on digital examination through the rectum.  Inflammation of the
ampulla of the vas gives precisely the same symptoms, but can some-
times be distinguished by the detection of an indurated  cord; when
there is infiltration of the surrounding cellular tissues it is not always
possible to state whether the cord or the testicles or both are inflamed.
   Prognosis.—The disease may terminate  in resolution or may go
on to chronic inflammation or to suppuration and abscess-formation.
Resolution is  the most frequent termination.  When  suppuration
occurs the pus may burrow into the rectum, forming a vesico-rectal
fistula, or may rupture into the peritoneal cavity, causing a fulminant
fatal peritonitis.
   Chronic  vesiculitis exhibits the same symptoms as the acute in-
flammation, but in  a  less severe form.  Associated with the pains,
which, though neither severe nor constant,  are harassing, and which
are often limited  to the side affected, there are usually some  sexual
weakness and a well-developed condition of neurasthenia.  On rectal
examination the seminal vesicle can be  felt larger than normal, some-
times nodular, as though it contained concretions, sometimes distended
and fluctuating.  On direct  pressure it  is usually possible to force the
contents of a chronically inflamed vesicle through the ejaculatory duct
and  into the prostatic urethra.  The material  thus  squeezed out is
made up  of pus, mucus, some dead spermatozoa, and frequently
blood, the latter giving the product a chocolate color. The method
of securing the contents of the seminal vesicles as expressed  by the
finger in the rectum is as follows.   The patient reports with a moder-
ately full bladder; the prostate  is milked, and he then passes a por-
tion of his urine, thus washing free of  discharge the entire urethra;
the finger is then introduced into the rectum and an effort made by
direct pressure to squeeze the contents of the inflamed vesicle into the
urethra; the patient then passes the rest of his urine in two portions,
the first of which will, of course, carry with it any liquid which  has
been pressed into  the prostatic urethra, whilst the second will contain
simply the urine as it was in the bladder.
   Treatment.—Acute  seminal vesiculitis should be treated  by rest in
bed, with the pelvis  elevated  on a pillow, thorough evacuation of the
lower bowel procured by the administration of salines, aided by the 
176
GENITO-URINARY DISEASES AND SYPHILIS.
use of copious hot rectal  enemata  (boric acid, four ounces;  water,
temperature  110° F., two  quarts), and the use of  hot sitz-baths  or
the hot general bath  repeated twice daily and lasting each  ten  to
fifteen minutes.   The diet should be light and of such nature that the
urine may be unirritating.   Salol should be given by the mouth, four
grains thrice daily, as  a urinary antiseptic not prone to increase the
violence of the concomitant  posterior urethritis.  All irritating treat-
ment of the urethra, such, for  instance, as instillations or  strong irri-
gations, should be temporarily discontinued.  Irrigations of  unirri-
tating solutions, such as hot potassium permanganate  1 to 6000, are
usually serviceable.  Not more than four ounces at a time should be
allowed to flow into the  bladder, and the treatment may be repeated
twice daily.  Should these irrigations increase pain and cause  lasting
tenesmus, local urethral treatment must be abandoned.  If general
and local symptoms of abscess-formation develop, and  particularly if
the symptoms of  local  or general peritonitis point  to infection extend-
ing in this direction, the  pus should be evacuated either through the
rectum or by the perineal route.  (See section on the seminal vesicles.)
    The treatment of chronic vesiculitis is discussed under this head-
ing.
    Epididymitis.—From an  anatomical consideration of the ejacu-
latory ducts, vas deferens, and epididymis, it is easy to understand how
by direct continuity inflammations of the  prostatic urethra may travel
to the epididymis.
    Epididymitis rarely develops before the third week  of gonorrhoea.
Most  of the cases begin in the fourth or fifth week of the disease.
It may occur within three  days of the onset of urethritis or not till a
gleet has run a course  of several years.
    It is due primarily to involvement of the posterior urethra  in the
gonorrhoeal process; secondarily, to  any cause which, by increasing
the violence of this inflammation, may favor its extension to the ejacu-
latory ducts and  the vas :  neglect of treatment, venereal excitement,
coitus, exposure to cold,  drinking, and violent exertion, all the causes
which aggravate  posterior urethritis, also render  more probable the
onset of  epididymitis.   Irritating anterior injections during the acute
stage of a  posterior urethritis  frequently cause epididymitis.  Of all
these causes those  commonly operative are neglect of  treatment and
coitus.
    The disease is usually unilateral, and seems to affect the  two sides
with about equal  frequency.
    Symptoms.—The first prodrome  which suggests the development
of gonorrhoeal epididymitis is  an  aching, sometimes a  neuralgic, pain 
COMPLICATIONS OF GONORRHOEA.
177
felt along the line of the groin, often running down to the testicle, and
made much worse by standing or walking.  If the cord be taken be-
tween the  thumb  and finger and rolled so that its  constituents are
separated, the vas deferens  may be found somewhat enlarged  and
tender on pressure.  Sometimes  there  is neither tenderness  nor en-
largement of the cord to be detected.  If the inflammation progresses,
the epididymis becomes involved in one or two days  at most.
    Frequently the disease develops without  any previous manifes-
tations of involvement of the cord.   Suddenly there will then be felt
in the testicle a fixed, dragging pain.   The epididymis increases rapidly
in size, the  scrotal covering of the affected testicle becomes oedematous
and purplish in color, and pain is at times almost unbearable and of a
peculiar sickening quality which renders it diagnostic.  The  anterior
discharge is  generally lessened;  sometimes it entirely ceases for the
time.
    On palpation the epididymis is found to be sensitive and so much
enlarged that it envelops, the testicle above, behind, and  below in a
swelling more voluminous than the gland itself.  (Fig. 56.)   In the
great majority of cases the
inflammation extends to the
tunica vaginalis and occasions
an effusion  of fluid, giving rise
to an acute  hydrocele; the
latter entirely masks the tes-
ticles, so that on palpation a
fluctuating  tumor is felt in
front, which is often  incor-
rectly diagnosed as a swollen
testicle, whilst behind is the
enlarged, exquisitely tender
epididymis.
    The patient,  unless the
testicle  is  supported,  walks
with  his body bent forward
and his  legs straddling,—a
gait almost  pathognomonic
of  the  ailment.   When  he
stands, free return of blood is prevented by the dragging of the tumor
upon the spermatic vessels ; this increases the tension and by additional
pressure upon the nerves greatly  aggravates the pain, which sometimes
spreads reflexly to the bladder, perineum, rectum,  back, abdomen,
thighs, and even to the thoracic region, and is almost unbearable.
                                12
Fig. 56.
   Showing the size and relative position of the testicle
and epididymis in acute epididymitis.  H, testis; N.h.,
epididymis; S, cord. A, the swelling is most marked
about the head of the epididymis; B, the swelling is
most marked about the tail.  (Kaufmann.) 
GENITO-URINARY DISEASES AND SYPHILIS.
   There are usually rigors, fever, and  great  mental anxiety and
depression.
   Sometimes  acute  epididymitis  in  its  onset is characterized by
symptoms so violent and apparently so disconnected from the testicle
as readily to occasion  a mistaken diagnosis.  In these cases there will
develop, often in connection with a posterior urethritis fanned to new
intensity, violent abdominal pains, accompanied by  tympany and
extreme sensitiveness  in the lower part of  the belly; fever runs high,
and  nausea, green vomiting, and collapse may follow.  These  symp-
toms subside almost as quickly as they develop, and are followed by
the ordinary symptoms of epididymitis. The disease usually reaches
its height in about five days.
   The  clinical  course of epididymitis varies  greatly in individual
cases.   Some patients experience only moderate dragging pain, which
does not incapacitate  them, and exhibit a somewhat sharply circum-
scribed tumor in the tail of the epididymis, with possibly slight hydro-
cele, and a little reddening and induration of the scrotal skin overlying
the seat of hardening.   In  the majority of cases  the pain, though
severe, is relieved by a properly fitting suspensory bandage, and the
patient is not forced  to take to his bed.  The swelling is, however,
usually very marked, being made up in  the main of inflammatory infil-
tration in the loose cellular tissue  surrounding the lower portion of
the cord and covering the epididymis, but not included in the  reflec-
tion  of the tunica vaginalis.  The redness and oedema of the posterior
aspect of the scrotum are  marked, and there is commonly a very
appreciable degree of  hydrocele present, which instead of being gen-
eral  may be  encysted  from inflammatory adhesions.  Exceptionally
the onset of the disease is sudden, the  pain violent, the constitutional
symptoms pronounced, the  patient unable to stir  from his bed.  In
these cases the local symptoms are usually exceedingly well marked,
tenderness, swelling, oedema, and either encysted or general hydrocele
are present,  and often accompanying the inflammation of the epi-
didymis there is a funiculitis characterized by a tender, thickened con-
dition of the vas, which can be felt  on  palpation, or by inflammatory
infiltration of all the structures of the cord, forming a doughy, sausage-
shaped tumor thicker than the thumb and extending up  into the
inguinal canal.  On rectal examination the thickened tender vas can
often be felt very distinctly.  When the funicular portion of the tunica
vaginalis has not been obliterated there may be formed a true hydro-
cele  of the cord.  Finally there are cases which, though not exhibit-
ing especially severe  local symptoms,  are  characterized by reflexes
which  so strongly suggest general peritonitis that they usually occa- 
COMPLICATIONS OF  GONORRHOEA.
179
sion grave anxiety until the local symptoms of  epididymitis become
well established.  Exceptionally, when the testicle and its epididymis
are not normally placed, an acute epididymitis  may lead to an error
in diagnosis.  Thus, when the testicle is retained within the inguinal
canal the early symptoms may readily  simulate those of a strangu-
lated hernia.  An examination of the scrotum, by showing the absence
of the testicle from its normal position,  would at once suggest the
diagnosis.
    The pathological changes  incident  to epididymitis  consist  of a
catarrhal inflammation of the vas and epididymis, associated in severe
cases with oedema and round-cell  infiltration  of its walls and the
surrounding loose connective tissue.  In the tail of the epididymis are
often found what appear to be foci of pus.  These are in reality con-
tained in the seminal  canal, and  are made  up of muco-pus and the
secretion of the testicle.
    Prognosis.—The prognosis of epididymitis is good, although cases
are reported in which life has been lost from extension of the inflam-
mation to the peritoneum.  These are  extremely rare.   The disease
usually  undergoes complete   resolution;  exceptionally  suppuration
occurs.   Commonly the inflammatory infiltrate, instead of being com-
pletely absorbed, organizes in  part, and forms a hard nodule in the
tail of the epididymis which obliterates the efferent duct of the testicle.
Exceptionally there is a permanent thickening of the entire epididymis.
The hydrocele not infrequently becomes chronic.   Suppuration is de-
noted by increased severity of the local inflammatory symptoms, by
rigors and sweats, and  finally by fluctuation.   On opening the abscess,
prolapse of the entire epididymis sometimes occurs ; when the suppu-
rative inflammation has involved the  testicle   proper,  this may be
entirely destroyed in a short time by rapid extension of the trouble;
or the suppurative process may become chronic and slowly extend,
finally resulting in destruction of the gland. Except in suppurative
cases the  testicle is rarely involved  in epididymitis, and hence is not
materially altered even though its efferent  duct is entirely blocked.
Very rarely after the  cure of a specially severe  epididymitis the tes-
ticle slowly atrophies.  In this event it is probable that the inflam-
mation  extends  to its structure, and  that as  the filtrate becomes
organized  and exercises pressure the glandular substance atrophies
until it is absorbed.  Even though  the  inflammation undergoes ap-
parent resolution it may cause  the development of latent tuberculosis.
   The  prognosis in regard to sterility  is, of course, good when but
one testicle is affected, though even then  it has been noted  that
spermatozoa disappear entirely from the semen during the height of 
180
GENITO-URINARY DISEASES  AND SYPHILIS.
an attack.   When the epididymitis is bilateral the prognosis must be
more guarded, though many of these cases recover with  functional
testicles.  In a certain proportion, however, especially in  those not
carefully treated, the  epididymis  of  both sides becomes obliterated
and the patients remain sterile.  When the sterility is of long standing
it is practically beyond therapeutic help.   Impotence is never a direct
consequence of epididymitis.
    Treatment.—Prophylaxis consists  in the continued administration
of antiseptics by the mouth, the proper use of carefully chosen anti-
septic  injections  or irrigations, and  the avoidance of intercourse,
violent muscular strain, or excesses  of any kind.  The wearing of a
suspensory bandage is also advisable. On the first prodromal symp-
toms—i.e., dragging pain  in  the  inguinal region, together with in-
creased tenderness and swelling along  the  cord,  best detected by
rectal  examination—the patient   should  be  put to bed, the bowels
should be freely opened, preferably by a saline, the testicles  should be
wrapped in  lead water and  laudanum, and  elevated  by a properly
applied handkerchief  bandage, and hot  compresses and a  hot-water
bag should be applied  to the inguinal  region.   These will usually limit
the inflammation to a  funiculitis, especially when the treatment appro-
priate to a posterior urethritis has been prescribed.  In the mild and
moderately severe  cases which do not apply for treatment until the
inflammation of the epididymis is pronounced, a  properly fitted sus-
pensory bandage will  usually relieve pain at  once and bring about
rapid resolution  without  requiring  the  patient to take to his bed.
The bandage  employed is a modification of the Langlebert-Horand,
                              and brings to the  relief of inflamma-
                              tion the most potent remedies at the
                              command of the  surgeon,—namely,
                              heat,  moisture, rest,  and  pressure.
                              (Fig. 57.)   The body of the suspensory
                              is  made up  of  mackintosh,  which is,
                              in  turn, lined with stout cloth.  The
                              bag of the bandage is shallow,  and
                              at  the sides are gores which are pro-
                              vided  with eyelets and laces.  When a
                             bandage of proper size is applied  and
                              strapped tightly it not only presses the
testicles upward against the soft parts lying anterior to and just below
the pubes, but by the lacings also exerts lateral  pressure, so that these
glands are evenly and  everywhere supported.   The method of apply-
ing this bandage is as  follows.  The  patient is placed in a recumbent
Fig. 57.
Epididymitis suspensory bandage. 
COMPLICATIONS OF  GONORRHOEA.
181
position, and the testicles and scrotum  are held up for four or five
minutes, thus  reducing congestion  as  much as possible by position.
The whole scrotum is then enveloped in a thick sheet of absorbent
cotton or wool.   Outside of this  the suspensory bandage  is applied.
It is strapped on tightly, and is  then  laced at the sides.   When the
appliance is properly  fitted, relief of pain is almost immediate and is
usually permanent, and resolution takes place promptly.
    In the severe  cases, those developing suddenly with great swelling
and agonizing pain, relief may sometimes be given by puncturing with
a narrow-bladed knife the  vaginal  tunic and  the infiltrated cellular
tissue at the back of the scrotum.   This operation must be conducted
under antiseptic  precautions.   It may be  rendered painless by the
preliminary injection  of a  few drops of cocaine, and should be per-
formed with a  straight, narrow-bladed knife, the latter being  driven
in at  the point where the  swelling, redness, oedema, and tenderness
are most pronounced, usually at  the  back of  the scrotum and  at
about the middle of the epididymis.  The knife should not be carried
to a depth  greater than half an  inch,  since it  is inadvisable to punc-
ture the tunica albuginea.  Following puncture there is usually the
escape  of  a few drops of serum,  which generally spurts  out as  if
under considerable pressure, with almost immediate lessening of pain.
The seat of puncture  should be covered with a small antiseptic dress-
ing, held in place with collodion,  after which  the pressure suspen-
sory bandage  above  described  may be  employed.   If this fails  to
give relief, the  scrotum should be elevated by means of a handker-
chief suspensory bandage folded in the  form  of a triangle, with its base
placed beneath and behind the testicles  and its two ends carried  up
over the front of the belly and  secured  to a band about the waist. By
carrying the third corner of this triangle upward and securing it to the
waistband the testicles are kept effectually elevated.  They should be
swathed in lint kept  constantly wet with lead water  and laudanum
equal parts, or with the following mixture :

                      R Tinct. aconiti,
                        Tinct. opii. aa f^i;
                        Liq. plumbi subacetatis,
                        Aquae, aa f§ii.
                      M. S.—For external use.

   If the pain is unrelieved  the hair should  be  shaved  over the groin
of the  affected  side,   and  six  ounces  of  blood should be  taken by
means of leeches applied along  the line of the cord, but above the
limits  of the scrotum.   Each morning  the patient should  take  half a 
Ig2       GENITO-URINARY  DISEASES  AND SYPHILIS.

bottle  of effervescing magnesium citrate.  The diet should  be re-
stricted, and the fever  should be combated by potassium bromide
five grains and tincture of aconite one drop,  given  every two hours.
In the suppurative cases incision should be made as soon as pus is
suspected, and  drainage  should  be provided  for  by packing  with
iodoform gauze.
   When the acute inflammatory symptoms have subsided,—i.e., when
the pain has lessened and is severe only upon motion, and the  epidid-
ymis  and  the surrounding cellular  tissue form a large solid mass-
pressure is always indicated.  This  is best applied by means of a sus-
pensory bandage, as already described, or in place of this strapping may
be employed.  Strapping of the testicle requires a preliminary shaving
of the scrotum.  There are cut twenty or thirty strips of resin adhesive
plaster, each half an inch in width and about one foot in length.  The
affected testicle is then drawn down firmly, and just above its upper
border is wrapped a strip of plaster, so that the testicle is retained in
the bottom of the scrotum by the encircling adhesive plaster.   Unless
this first strip is applied firmly, fixing the testicle in the pouch of the
scrotum, the proper application of the remaining strips will be impos-
sible.  The first strip having been put in place, others are successively
heated and  wrapped about the  testicle, first circularly from above
downward until the greatest bulge of the tumor  is passed and the
strips no longer lie smoothly, then vertically and  obliquely until the
skin overlying the testicle is entirely covered in.  A suspensory band-
age is then applied, and the patient may be allowed to leave his bed.
As the swelling subsides and the  strips loosen,  they should be re-
newed.  This usually requires a  new dressing  every second or third
day.   Before applying  the upper encircling strip  its  upper  border
should be notched  through its whole length  at intervals of a quarter
of an inch.   This allows it to accommodate itself to the soft skin
lying just above, which  is sometimes irritated or cut by an unbroken
edge.  After the removal of the strips, if these have been  employed,
or from the very beginning of the attack  when a sweating suspensory
bandage has been used, an ointment of belladonna and iodoform may
be applied to the affected side on a  piece of lint.
    This is made up as follows:

                    E  Iodoformi, ^i;
                      Unguenti belladonna;, .^vii.

    When all  inflammatory swelling  has  disappeared, but an indu-
rated nodule persists, the pressure suspensory bandage should still be
employed in conjunction with an ointment made of belladonna oint- 
COMPLICATIONS OF  GONORRHOEA.
183
ment  and mercuric ointment equal  parts, and internally five grains
of potassium iodide should be given three times a day.
   Cystitis.—Until  the nature of  posterior urethritis  was clearly
defined  it was common  to attribute the symptoms attendant  upon
this inflammation to involvement of the neck of the bladder.   The
possibility of extension of posterior urethritis to  the vesical  mucous
membrane cannot be denied, and any one of the many causes which
aggravate  the  original  disease may  occasion  such extension.   The
inflammation  does not spread  far  from  the internal  orifice of the
urethra, being  usually limited rather sharply to  the trigone.  In the
great majority of cases it is due to mixed infection, the gonococci them-
selves apparently not readily infecting the mucous  membrane of the
bladder.  Involvement  of the entire vesical mucosa  is extremely rare.
   Symptoms.—The subjective symptoms are so like those of posterior
urethritis that  on  these alone a differential diagnosis can scarcely be
made.   There  are urgency and frequency of urination, with straining
during and after the act, in place of the  normal relief usually experi-
enced at its completion; burning and shooting pains are felt along the
urethra.  These symptoms are more pronounced when the trigone is
involved, and  are influenced for the worse by the upright position.
The urine in acute cases is not markedly changed, except that it con-
tains somewhat more  albumen than could  be accounted for by the
amount of pus present, and this increased quantity of albumen bears
a relation to the tenesmus.
   The  urine is found to contain on microscopic examination  bladder
epithelium, mucus- and  pus-corpuscles, and in severe cases blood.
When the disease becomes  chronic  there are often very few subjec-
tive symptoms, pus and mucus in the urine alone  leading to a correct
diagnosis.  Constitutional symptoms are generally pronounced in the
acute stage.
   Diagnosis.—To distinguish cystitis, either limited to the trigone or,
as is very exceptional, involving the entire vesical mucosa from poste-
rior urethritis,  an  examination of the urine is necessary.  The patient
is  instructed  to  urinate in three  portions.  When the bladder  is
acutely involved, the first portion will be cloudy with pus and mucus
from the bladder plus that contained in  the urethra; the  second por-
tion will  be less cloudy, because it  contains only  the pus which  is
floating in the  urine contained in the bladder; the third  portion will
again  be more turbid, and may even be  more turbid  than the first
portion, because it contains the pus which has settled out  of the urine
to  the base of  the bladder.
   The very frequent and imperative urination of an acute attack may 
184       GENITO-URINARY DISEASES AND  SYPHILIS.

prevent a satisfactory trial of this method.  When such is the case a
soft catheter can be introduced fully within the bladder, the contents
of the latter withdrawn, and the bladder thoroughly washed with boric
solution until practically no pus is found in the washing.   The catheter
is then  clamped and the instrument is allowed to remain in place for
an hour, when the clamp is removed and the contents of the bladder
are drawn off.  If in this  urine pus is found it probably comes from
the bladder and not from the urethra.
   It is  usually necessary  in these examinations to determine the
presence of pus by  the microscope, since cloudiness alone is not a
reliable  diagnostic  symptom.  It may be  due to phosphates or to
bacteria.  To avoid  falling into error in regard to the nature of the
cloudiness, a specimen of turbid urine should be heated.   If cloudi-
ness increases, it is due either to the phosphates or to albumen.  On
adding a  few drops of acetic acid, cloudiness will disappear if it is
due to the earthy phosphates, but will not  be affected if it is due to
albumen.   When cloudiness is due to  bacteria it is neither increased
nor diminished  by heat and  acidulation.   (See  Table of Diagnosis,
page 142.)
   Prognosis.—Usually acute cystitis of gonorrhoeal origin, whether it
be local or general, undergoes resolution under appropriate treatment,
leaving  no further  effect than a tendency to recurrence of inflamma-
tion from apparently trivial  causes, and particularly  from each new
attack of gonorrhoea.   Exceptionally the disease becomes chronic, and,
though  the  subjective symptoms may disappear, the  urine continues
to be loaded with mucus and pus.  This condition is  difficult to cure,
pathological alterations taking place in the vesical mucosa, and, indeed,
in the whole thickness of the bladder-walls, which are liable perma-
nently to  cripple this viscus.
    Treatment.—The general treatment appropriate to acute posterior
urethritis and to prostatitis  requires no  material  alteration when it
becomes clear that the vesical mucosa is involved in the inflammation.
Rest in bed in a horizontal position with elevation of the pelvis, pur-
gation, counter-irritation, hot rectal douches, and a milk diet are indi-
cated.   The urine should be made bland.   Since it is usually strongly
acid from the concomitant fever, alkaline diuretics may be adminis-
tered.   Urinary antiseptics, particularly boric  acid, salol, and sodium
salicylate, should be  administered by the mouth, and on the sub-
sidence of acute symptoms these may be alternated with benzoic acid,
balsam  of copaiba,  oil of  sandal wood,  and  fluid extract of pichi.
Pain and tenesmus are, of course, to  be relieved  by opium  suppos-
itories or morphine injections.  When the disease becomes  chronic, 
COMPLICATIONS OF  GONORRHOEA.
185
general treatment must  be reinforced by local irrigations.  This is
fully discussed under cystitis.
   Ureteritis, Pyelitis, and Nephritis.—These complications are
rare, and  can scarcely occur unless  there is previous vesical disease
as the  result of urethral stricture, enlarged prostate, or other obstruc-
tive cause.  The use of medicaments which produce acute hyperaemia
or congestion of the kidneys and their excretory apparatus predisposes
to extension of inflammation in this  direction, as do all factors which
tend markedly to increase a posterior  urethritis and  cause it  to in-
volve the mucous membrane of the bladder, as, for instance, rough or
untimely instrumentation.   Usually  only one kidney is involved, and
this sometimes without alteration of  the ureter, although the latter is
commonly found  dilated and with thin walls,—in other words, ex-
hibiting the effect of backward pressure.   In the  early stage of the
affection the inflammation  involves  only the mucous membrane of
the renal  pelvis.   This  may be followed  by hydronephrosis from
blocking of the ureter and consequent  atrophy of  the kidney,  or
may extend into  the  kidney substance itself, producing  either par-
enchymatous or interstitial  nephritis.
   Symptoms.—The symptoms  of the extension of the inflammation
along the  ureters  and pelvis are not distinctly characteristic.  There
is a marked general deterioration of health;  there are  pains in the
lumbar region passing downward along the course of the  ureters, and
there will be found in the urine more albumen than can be accounted
for by  the pus,  epithelial  casts, kidney epithelium, and blood-corpus-
cles.  At times pus and albumen may quite disappear from the urine,
owing  to  temporary blockage  of the ureter of the affected kidney.
Coincident with this there may be chills, fever, and vomiting, together
with marked exacerbations  of pain in the kidney region,  and a  sense
of increased resistance upon deep pressure in the loin, or even distinct
tumor-formation.   Following this  there may  be a free flow of urine
containing large quantities of pus.  The disease often undergoes reso-
lution,  particularly when it is  comparatively  recent,  and when  the
cystitis  and posterior urethritis which- precede it have  been cured
and the urethra is no longer obstructed.  When it goes on to abscess-
formation the  prognosis without operative interference is practically
hopeless, the  patient perishing  either from a suppression of urine or
from septic absorption, or from both  of these causes.
   Diagnosis.—The diagnosis is founded on the urinary examination,
together with the general  symptoms of  kidney involvement.
   Treatment—The treatment is conducted mainly on general  prin-
ciples;  the bowels  are  kept  distinctly  loose, counter-irritation  is 
186
GENITO-URINARY DISEASES AND SYPHILIS.
applied over the kidney region by means of mild mustard plasters, or
by cupping, and the  diet is carefully regulated.  An absolute milk
diet is particularly indicated in these cases.   Threatening uraemia is
treated by hot foot-baths, by free purgation, by general diaphoresis, or
by saline transfusion, either intravenous or hypodermic.  The local
treatment of the coincident cystitis  should include  only the  mildest
applications, since the pyelitis is distinctly aggravated by any  exacer-
bation in bladder inflammation.   Salol may be administered in small
doses, five grains four times a day, but, as this sometimes has a
tendency to congest the kidneys, it must be given with extreme care.
Boric acid in similar dose is  indicated.  In case the symptoms steadily
grow worse, and particularly when chills and fever suggest the presence
of pus, opening and drainage of the renal pelvis,  together with daily
irrigations by antiseptic solutions, are advisable.

                    GONORRHOEA  OF THE EYE.
   Gonorrheal Conjunctivitis—Purulent  Ophthalmia;   Gonorrhoeal
Ophthalmia ; Acute Blennorrhoea in Adults.—This  is a violent  inflam-
mation of the  conjunctiva, characterized, in  its usual form, by great
swelling of the lids, serous infiltration of  the bulbar conjunctiva, and
the free secretion of contagious pus.
    Cause.—The source of contagion can usually be traced to an acute
gonorrhoea or  gleet, or to an eye similarly affected, soiled fingers or
linen being the usual  means of transmission.
   The gonococci of Neisser are present in great abundance during
the purulent stage, being found within the cells.  Later they penetrate
the  epithelium and  enter the  lymph-spaces  of  the subconjunctival
tissue.  The  secretion from  vaginal leucorrhcea, which is not un-
common in young girls, may produce a conjunctivitis of very analo-
gous type.
   Symptoms.—The symptoms appear from twelve to forty-eight hours
after  inoculation, and at first resemble those of an ordinary catarrhal
conjunctivitis.   They speedily give  place  to great  swelling of  the lids
(Fig. 58), intense congestion and  chemosis of the bulbar conjunctiva,
which forms a  ring of infiltration around the cornea, and thickening
of the palpebral conjunctiva, which becomes rough and dark red  in
color, and  is dotted over with  spots of ecchymosis.  (Fig. 59.)  The
slightly turbid  discharge  of the  early stage changes to a yellow  or
greenish-yellow pus, which is  secreted in  great  quantities.   The
vitality of the  cornea is soon threatened, and, unless the disease is
properly managed, ulcers form,  either small, oval lesions near the
margin of the  cornea, or larger ones at its centre.   These may ter- 
Fig. 58.
Gonorrhoeal conjunctivitis.  Swelling of the lids and free discharge.
Fig. 59
Gonorrhoeal conjunctivitis.  Infiltration of bulbar and palpebral conjunctiva 
 
COMPLICATIONS OF  GONORRHOEA.
187
minate in healing, or perforation may take place.  In the event of the
latter mishap, incarceration of the iris in the wound and the formation
of an adherent scar or leucoma result.   This scar may bulge forward
and form a partial  anterior staphyloma, or, if the prolapse has  been
an extensive  one, the whole  cornea is involved, and the protruding
cicatrix is known as a total  staphyloma.   In bad cases the inflam-
mation travels through all the tissues of the eyeball, which passes into
a state of general inflammation or panophthalmitis  (Fig. 60), ending
in atrophy and shrinking of the bulb.

                              Fig. 60.
Gonorrhoeal conjunctivitis passing into a panophthalmitis.
   Gonorrhoeal conjunctivitis  reaches  its height  in about ten days,
and then gradually subsides in from one to two months.   Sometimes
it passes into a chronic type of inflammation, with great redness of
the palpebral conjunctiva and hypertrophy of the papillae.  The right
eye is  usually first affected; the left one  may escape or be inocu-
lated ;  sometimes, however, both organs are simultaneously inflamed.
   Prognosis.—This is always grave, and, unless the disease is treated
from its  incipiency, corneal scars, or  the  more  serious  sequelae of
perforation which have just been described, are likely to  result.
   Treatment—During the earlier stages cold is the most useful agent.
This  may be applied by means of Letter's tubes, but it is more con-
venient to place upon a block of ice square compresses of patent lint, 
GENITO-URINARY DISEASES AND SYPHILIS.
which in turn are laid upon the swollen lids and as frequently changed
as may be needful to keep up a uniform cold impression.  The same
result is obtained by using small bladders containing crushed ice; but
they are  not so comfortable as the squares of chilled lint.
   The  discharge should be constantly  removed.   This may be done
by irrigating the conjunctival cul-de-sac at intervals of not more than
half  an hour with a saturated solution of boric acid  or a solution of
bichloride of mercury 1 to 8000.   It is a  mistake to use strong solu-
tions of  sublimate in  the  treatment of this  disease,  because they
increase  the liability of the cornea to ulceration, and, moreover, it is
not  possible to employ  them  in  such  strength that the  germicidal
properties of this drug will be efficient.
   As soon as the secretion  is free and creamy, which is early in
the disease, silver nitrate is the best of all remedies.  The lids should
be thoroughly everted without pressure  upon the globe, the inflamed
conjunctiva freed from all secretion, and a solution of this drug ten or
twenty grains to the ounce applied with a cotton mop or camefs-hair
brush to the exposed  surfaces.   The excess should immediately be
neutralized with a solution of  common salt a teaspoonful to a cup of
water, flooding the surface until every particle  of  the white film pro-
duced by the  silver has been washed away.   The lids are then re-
turned to their place.   This application may  be repeated once in
twenty-four hours.
   If a corneal ulcer forms and  is centrally situated, atropine drops
four  grains to the ounce should be instilled every three or four hours;
a marginal ulcer, with a tendency to perforate, may be  treated in like
manner with a solution of eserine one-sixth to one-half grain to the
ounce, or, as  this  drug, while it has  distinct value  in  preventing
sloughing of the cornea, tends to increase the hyperaemia of the iris
and  the  tendency to the production of iritis, it may be used every
four hours during the day and a drop or two of the atropine solution
at night.
   If the chemosis of  the conjunctiva is very great, scarification may
be tried, and  will  occasionally be beneficial.   Great swelling of the
lids, tending by their pressure to  endanger further the nutrition of the
cornea, may be relieved by canthotomy,—that  is, by cutting through
the external commissure of the affected eye.
   During the stage of corneal ulceration, should it occur, the cold
applications previously described  may be substituted by hot fomenta-
tions applied  by means of squares of antiseptic gauze wrung out  of
carbolized water of a temperature of 120° F. and frequently changed.
These applications are useless unless they are really hot. 
COMPLICATIONS OF  GONORRHOEA.
189
   Many other drugs in addition to those named have been used  for
irrigating the conjunctival cul-de-sac.  Of these, the most important
are mercuric cyanide 1 to 1500, formalin 1  to  2000, hydrogen per-
oxide, aluminium sulphate eight grains to  the ounce, carbolic acid
one-half to five per cent., and potassium permanganate.   Of the last-
named drug a tepid solution  1 to 5000  should be prepared, and  the
conjunctival cul-de-sac  freely flushed twice a day, at  least one litre
being employed at each irrigation.   The irrigations are best given
with the aid of a special laveur, although an ordinary irrigating appa-
ratus is useful.
   During the entire course of the treatment the lids should be kept
greased with pure vaseline, which should also be freely introduced
within the conjunctival cul-de-sac.
   Depletion is sometimes practised, but, unless the indications  for
canthotomy are present, its value is questionable.  The same may be
said  of the practice, once  common, of  beginning the  treatment  by
bringing the patients under the  influence of mercury.  Usually they
are debilitated, and supporting treatment—quinine, iron, strychnine,
and  milk punch—is essential.  If the pain is severe, there is no ob-
jection to the use of morphine or opium, the latter drug having a good
influence on the sloughing process in the cornea.
   Prophylaxis.—Patients suffering from gonorrhoea should be warned
of the  danger of infecting  their eyes and the eyes of  those around
them.   As  usually one  eye alone is affected, the other may be pro-
tected  by sealing it with an  antiseptic  bandage  the edges of which
are made secure by fastening along them strips of gauze painted with
flexible collodion, or by the application of Buller's shield, which con-
sists  of  a watch-glass of the ordinary form fitted in a square piece of
rubber adhesive plaster, which is carefully applied to the brow, temple,
lower margin of the  orbit, and  nose,  and secured with additional
strips to prevent the  discharge  from getting  under the edges.  The
watch-glass is directly in front of  the eye and permits its constant  in-
spection.  Great care must be exercised in applying this bandage, be-
cause if any of  the discharge  should be confined beneath it, or in any
way  should find entrance under the edges of the plaster, the chance
of infection would be greater  than without the bandage.
   Non-Specific Gonorrhoeal Conjunctivitis.—This disease is  occa-
sionally seen  during  gonorrhoea, and  does not depend upon  the
introduction into the eye of  infecting material  from the urethra.   It
is apt to occur in patients who suffer  from articular  complications.
It is  bilateral, mild in character, and resembles a moderate catarrhal
conjunctivitis.   Sometimes  iritis complicates it. 
190       GENITO-URINARY  DISEASES  AND SYPHILIS.

   The ordinary treatment of acute  conjunctivitis is indicated unless
there be iritis, and then the measures elsewhere described  are suit-
able.   It is the habit of some surgeons to apply the name  " gonor-
rhoeal  ophthalmia" to  this affection  and  reserve the term  "gonor-
rhoeal  conjunctivitis" for the disease which is caused by a specific
urethral discharge.
                   GONORRHOEAL RHEUMATISM.
   Gonorrhoeal  rheumatism commonly affects the joints.  It may,
however, involve the tendons, nerves, bursas, pericardium, endocar-
dium, and meninges of the cords.  It is due to systemic poisoning by
the specific micro-organisms or by the ordinary bacteria of suppura-
tion and the toxalbumens formed by  these germs.  When it is caused
by gonococci  carried from the urethra  into the  system and lodged at
remote points, the inflammation is fibrous and adhesive in type.
   Finger in a fatal case of gonorrhoeal rheumatism discovered gono-
cocci in the vegetations of the endocarditis.   There was also myo-
carditis, due to the presence of these germs.
   When there is free pus-formation the ordinary pyogenic microbes
are found.
   The disease  may begin before the third week of the urethritis,
though it commonly develops much later.
   In  the order of frequency the knee, ankle, wrist, and elbow are
the joints commonly involved.   Usually  more  than one joint is in-
flamed at. a time, though in about one-third of all cases the disease is
monarticular.
   It develops in about two per  cent, of all cases of urethritis, and is
far more frequently  observed  in men than in women.   It may com-
plicate  gonorrhoea of any mucous surface,—the  conjunctiva, for in-
stance.
   Symptoms.—There is absolutely no characteristic feature  of the
joint affection which will  enable the surgeon, from a local examina-
tion, to distinguish  gonorrhoeal  inflammation  from the  lesions of
ordinary rheumatism.  In making a diagnosis, however,  the following
points  should be borne in mind.   In  gonorrhoeal rheumatism there is
a preceding history  of urethritis, and the  severity of the rheumatic
attack  varies in proportion to the exacerbations and  remissions of
the urethral  inflammation.   The  disease  rarely pursues the acute
course  observed in ordinary rheumatism, but  rather has a tendency
to become chronic, and after it has once  occurred is prone to relapse
in case of new infection of the urethra.
   Arthritis is the commonest manifestation of gonorrhoeal  rheuma- 
COMPLICATIONS OF GONORRHOEA.
191
tism.   It may be ushered in by general rheumatic pains, but more
commonly  is characterized by rather sudden  swelling, pain, tender-
ness, and redness of the affected articulation.   There is synovial exu-
dation, with fixation of the joint in the position which most relaxes
its synovial investment.   There is moderate fever.
   These acute  symptoms usually last for several days.   The fever
then subsides, the patient suffering  only  from swelling, tenderness,
and pain on motion.   This condition may last for weeks or months,
being subject  to occasional exacerbations in  accordance  with the
condition of the  urethra.  Rarely suppuration takes place, character-
ized  by constitutional  and local  symptoms of pus-formation, often
resulting either in pyaemia  or, if the patient recovers from the acute
attack, in ankylosis of the joint.
   More commonly the chronic  inflammation produces a condition
of hydrarthrosis. This condition is attended with limitation of mo-
tion, but otherwise causes little pain and  but  slight  disability.  The
effusion usually undergoes absorption.  Occasionally it lasts  for weeks
or months,  causes stretching  of the ligaments, and finally preter-
natural mobility  and profound alteration in the joint.
   When several joints are affected the  distinction between gonor-
rhoeal  arthritis and that due to rheumatism is  exceedingly difficult to
make.   In  the former case, however, but few joints are  involved,
rarely more than two or three, and in these  the inflammation does
not appear  synchronously, but one  inflames  after the other.  The
fever is never very high, except in the rare cases when suppuration
occurs, nor is sweating so pronounced a symptom as in rheumatism.
   Occasionally  the gonorrhoeal rheumatism takes the form of peri-
arthritis. The symptoms are  much the  same as those of arthritis,
except that there is  no  exudation into the joint-cavity, and the red-
ness, oedema, pain, and  tenderness are somewhat more marked.  It
commonly terminates in resolution, but may cause ankylosis.
   Gonorrhoeal Tenosynovitis.—This affection develops usually after
the acute stage of gonorrhoea  has passed.  It  is often preceded by
wandering muscular and articular pains,  chill, and moderate fever.
The involved tendon exhibits over its course redness and oedematous
swelling; there is synovial effusion,  producing either crepitation or
distinct fluctuation.  Tenderness  is sometimes  extreme,  and  the
patient may suffer from continued pain, greatly increased by attempts
at motion.  The  more acute symptoms rapidly subside, but  pain and
fixation may last for several weeks.   The tendons most commonly
involved are the  extensors of the fingers, the  flexor  of the thumb,
and the extensors of the toes. 
192        GENITO-URINARY DISEASES  AND SYPHILIS.

   Complications of gonorrhoeal rheumatism are  rare;  as  localized
manifestations of the ptomaine- or germ-poisoning, pericarditis, endo-
carditis, pleuritis, and meningitis develop only  exceptionally, while
myalgia and  neuralgia are occasionally  so  pronounced  as to  call
urgently for treatment.
   The treatment of gonorrhoeal  rheumatism is extremely unsatis-
factory.   The  best  prophylactic  treatment is  the  employment of
urinary antiseptics,—salol,  boric  acid,  benzoic  acid,  and  quinine.
Salicylic acid and the salicylates should always be tried, since occa-
sionally the attack is ordinary rheumatism, and if the  latter be mild in
type and involve but few joints a differential diagnosis in the presence
of chronic gonorrhoea will be  scarcely possible.   Potassium  iodide is
sometimes serviceable.   Full doses of salol are nearly always bene-
ficial, and in the chronic and obstinate cases quinine pushed to its
physiological limit,  together with bichloride of mercury  one-sixtieth
of a grain thrice daily,  will sometimes act favorably.
   For the acute stage absolute  rest, with the joint in the most com-
fortable position, the application of cold, preferably in the form of an
ice-bag, and pressure as much as can  be endured with comfort, to-
gether with constitutional  treatment for fever, are the  best therapeutic
procedures.  When  the acute stage has passed, the affected joints
should be wrapped in  an ointment composed of  mercurial ointment,
belladonna  ointment,  compound  iodine  ointment,  and  cosmoline,
equal parts of each.  They should be bandaged firmly, and should
be vigorously massaged once daily, small doses of iodide, or of  qui-
nine and bichloride, being continued in the mean time. 
CHAPTER VI.
                    stricture  of the urethra.

    A stricture is a temporary or permanent narrowing of the urethral
 canal, caused by organic changes in the  tissues which make up its
 walls, or by muscular spasm.
    Strictures may be congenital or acquired.
    Congenital stricture is extremely  rare, except at the meatus or in
 its immediate vicinity.  Even these  narrowings are often the result
 of infantile balanoposthitis, and thus not really congenital.  A nar-
 rowing of the meatus, reducing it almost to pin-point  size, may exist
 from birth without giving  rise to appreciable difficulty, and, unless
 some urinary symptoms appear, requires no treatment.
    The normal  narrowing at  the meatus  is  of physiological impor-
 tance in  favoring the projection of a strong, smooth  stream of urine
 and the vigorous ejaculation of the sperm:  hence free  division of the
 meatus  should not be advised  on insufficient grounds.  Not  infre-
 quently the operation may leave the patient with an artificial balano-
 hypospadia and diminished projectile force.
    Congenital strictures should, however, be operated upon promptly
 when urinary symptoms arise which  reasonably can be  traced to
 them, or when  they interfere  with  the proper  treatment of more
 deeply seated morbid conditions of the urethra or of the bladder.
    Acquired  stricture is classified in accordance with its pathology
 under these general headings :
    1. Inflammatory.
    2. Spasmodic
    3. Organic ; (a) of large calibre ; (6)  of small calibre.
    1. Inflammatory stricture is due  to an acute catarrhal inflam-
 mation with  recent soft exudate, causing swelling  of the mucous
 membrane and encroachment on the urethral calibre.  It is of short
 duration, and  never causes retention, except when complicated by
 muscular spasm.  It is often the first step in the formation of organic
 stricture.
    Treatment.—The treatment is that appropriate to acute anterior
 urethritis.  The term inflammatory stricture is misleading, since some
authors thus designate true organic strictures,—i.e., those which ulti-
                               13                         193 
194
GENITO-URINARY DISEASES AND SYPHILIS.
mately result from chronic inflammation with  formation of fibrous
tissue.
    2. Spasmodic stricture is a temporary narrowing or obliteration
of the urethra, due  to  contraction of the involuntary or voluntary
muscles investing it.   This contraction is either reflex or psychical in
its origin, and the compressor urethras is usually the muscle at fault.
    Reflex muscular  spasm commonly depends on irritation trans-
mitted from some hyperaemic point of the urethra, as from the actively
inflamed mucous membrane of  the posterior urethra, or from a patch
of granular urethritis situated  in or near the bulb.   More rarely it
may arise from irritation at a greater distance, as from fissure of the
anus, hemorrhoids, worms, cancer of the rectum, etc.
    Among the causes of spasm  may be mentioned strongly acid or
irritating conditions of the urine, as in cantharidal poisoning or the
uric acid diathesis, and  urethral hyperesthesia from  sexual excess.
Organic stricture is the usual predisposing factor in the development
of the symptoms of spasmodic  stricture.
    The retention of urine incident to overdistention of the bladder, or
acute fevers, or surgical operations, especially those upon the anus and
the rectum, is probably as often the result of  vesical inhibition as of
urethral spasm, although it is usually attributed to the latter.
    Numerous cases  have been reported in which a more or less per-
sistent spasm has been  attributed to a small  meatus,  since this was
relieved by meatotomy;  but it must be remembered  that  spasmodic
stricture  is particularly  apt to  occur in  nervous, excitable, irritable
young men,  allied in type to  hysterical women, and that in  such
patients any marked mental impression may cause a disappearance of
existing symptoms.   A case has been reported in which all  the symp-
toms  of deep urethral obstruction existed for ten years, and were re-
lieved immediately and  permanently  by a single  catheterization, a
result which would doubtless have been attributed to a meatotomy
if that had been required as a preliminary operation.   If the meatus
is too small  to admit a good-sized sound, in  the presence of other-
wise  inexplicable  urinary symptoms  a  cutting operation is  clearly
indicated.
    Spasmodic stricture due to psychical cause is instanced by the in-
hibiting effect which  shame or even a sense  of hurry exerts over the
function of micturition.
    Diagnosis.—The diagnosis of spasmodic stricture is founded  upon
the  sudden onset of either dysuria or retention of urine without inflam-
matory symptoms  and without  preceding symptoms of urethral ob-
struction.  Sometimes the stream is irregularly interrupted, a condition 
STRICTURE OF  THE URETHRA.
195
designated as stuttering micturition.  The introduction of a full-sized
metal instrument may be resisted at  first, but on gentle continued
pressure the contracted muscles may be felt to yield and the instrument
readily slips into the bladder.
   Treatment—The treatment of spasmodic stricture varies in accord-
ance with  the cause.  When symptoms  recur, careful search always
should be made  for organic  stricture;  this, if cured, will be followed
by disappearance of the tendency to spasm.  Every pathological con-
dition about the  genitalia or rectum should be corrected, and in the
absence of contra-indications  full-sized sounds should  be passed at
regular intervals.
   When spasmodic  stricture is  complicated  by retention, the patient
should be put in a hot general bath (106° to 110° F.), and directed
to urinate while thus soaking.  A hot sitz-bath is equally efficacious,
but should be continued  not over fifteen minutes.   If  at the end of
this  time the bladder has not been emptied, the patient  should be
thoroughly dried,  put to bed,  and given  suppositories  containing
opium and belladonna, or hypodermic injections of morphine.  These
palliative measures should, however, never be persisted in when the
bladder is  greatly distended,—i.e., is readily perceptible on suprapubic
percussion.  The possible remote effects of overdistention of the blad-
der are far more to be dreaded than the slight discomfort attendant
on the passage of an instrument: hence if the distention is great and
the hot bath fails to give relief, catheterization should be practised at
once.  A soft rubber or an English gum catheter should  be used first;
if these fail, a metal instrument should  be introduced.   It must be
borne in mind that  under these circumstances  the bladder is pecu-
liarly liable to become infected; therefore the catheterization must be
practised with the observance of all the  antiseptic precautions cus-
tomary in major  operations.  The surgeon's hands must be thoroughly
cleansed, the instrument sterile, the glans and meatus  disinfected, and
the anterior urethra previously flushed out with an antiseptic solution.
   3. Organic Stricture.—This, in the vast  majority of cases, is due
to a  preceding urethritis or to traumatism, though a chancroid, chan-
cre, or ulcer due to lodgement of a foreign body may subsequently be
followed by cicatricial narrowing.  Gonorrhoeal urethritis is by far the
most common cause.
   Organic stricture may occur in persons  of any age, but is  most
frequent between the ages of twenty and forty-five.  Women are not
entirely exempt.  Gonorrhoeal stricture is said to occur less frequently
in negroes  than in white men, the proportion being about one stric-
ture  to twenty-three  cases of gonorrhoea in  the negro, while in the 
GENITO-URINARY DISEASES  AND SYPHILIS.
white man it is about one in eight.  The  longer  the  duration of the
attack of gonorrhoea  the more liable is the patient to have a stricture.
The intensity of the  attack is also of some importance in this regard.
The supposed development of stricture because of too rapid cure of
gonorrhoea is a  popular  myth.  The more speedy the cure the  less
likely are strictures to form, nor have strong irritating injections  any
effect on the production  of stricture unless they cause complications,
such as abscess, or prolong the inflammation.
    Inflammations of the urethra are peculiarly apt to become chronic,
for several  reasons.  The  canal  affords periodical  passage  to  the
urine,  which is liable to  become  an actual irritant by  reason of
changes in its composition ; erection, reflexly excited by inflammation,
intensely congests the urethral vessels, which, moreover, are especially
abundant, and are prone  to engorgement from the dependent position
of the penis and the  absence of extra-vascular support incident to the
loose character of the spongy  tissue.  All these factors favor the per-
sistence of congestion after a first attack of urethritis.  The approxi-
mation of the mucous  surfaces of the urethral walls, normal during
the intervals between micturition, is also unfavorable to  the disap-
pearance of the last  traces of  inflammation.  Finally the gonococcus
exhibits a  tendency to establish itself in the deeper  layers of the
mucous lining, and particularly  in the follicular and glandular ducts,
where it is inaccessible to direct treatment.
    Harrison holds that  in chronic granular urethritis  the  urethral
epithelium becomes so damaged at one or more spots as a consequence
of prolonged inflammation that it permits the escape  of minute quan-
tities of urine into the tissues composing and surrounding the urethra.
To prevent urine soaking farther into these tissues, inflammatory exu-
dation is  excited, and barriers  of lymph, which ultimately become
organized, are thrown out opposite the places where the leakages  take
place.   Thus splints of plastic tissue are formed corresponding to the
spot or spots where the epithelium has  been  most  damaged by the
persisting inflammation.
    Oberlander  demonstrates the  existence of two  chief forms of
chronic urethritis: (1) that in which the infiltration  of the mucous
membrane is diffuse and superficial and  the glandular  elements are
not involved, and (2) that in which the glands of Littre are markedly
affected.  Neelson has confirmed these views by a long series of au-
topsies, which  show that  the glandular affection is  extremely  per-
sistent, and easily recognizable even when cadaveric  maceration has
destroyed the evidences of change in the  mucosa and of the epithelial
proliferation. 
STRICTURE OF THE  URETHRA.
197
   The rapidity  of stricture  development is dependent  upon the
nature of the original  lesion.  In case of rupture of the urethra nar-
rowing of the lumen of  this canal begins from the time  the wound
cicatrizes ; that is, usually within a few months.  In the case of gonor-
rhoea, however,  the process is  much  more  slow.  The infiltration
caused by this disease, unless complicated by periurethral abscess, is
essentially chronic.  It is always a matter of months, and usually of
years, before this infiltration undergoes sufficient organization to en-
croach seriously  upon the calibre of  the urethra.  It may be said  in
general terms that  a stricture  rarely develops within one  year of the
beginning of an attack of gonorrhoea.   Guyon  holds that the greatest
number of strictures occur four to ten years from the beginning of the
original urethritis.
   Prolonged erection, excessive coitus, and masturbation have been
regarded  as  competent  causes of stricture, especially by  the ardent
believers in  strictures of large calibre, who find this lesion in nearly
every urethra, often without a history of gonorrhoea or of any of the
sources  of  irritation  previously
mentioned.    Theoretically  stric-
ture is possible from  such causes,
but practically it is of the greatest
rarity.
   Traumatic stricture follows such
wounds and contusions of the peri-
neum as  have  caused  partial or
complete laceration of the urethra.
Kicks in the perineum, falls astride
of a resistant body, and fractures
of the pelvis  often cause  such rup-
tures.  " Fracture of the penis,"—
that is, a sudden  twist or bend of
the erect penis, which causes sub-
cutaneous rupture  of  the erectile
tissue; " breaking a chordee,"—i.e.,
violently  straightening the  curve
incident to the inflammatory infil-
tration of the urethra  and peri-
urethral tissues ; injuries due to the
rough and clumsy use  of urethral instruments;  surgical treatment of
previously existing  strictures, such as incision, excision, cauterization,
and electrolysis,—all these causes may produce traumatic  strictures.
   Clinical  Forms of Stricture.—The strictured part of the urethra
   Linear strictures. A, glans; B, glandular
urethra;  C, spongy body; D, urethra dilated
behind the stricture; E, linear stricture; G,
linear stricture less developed; a, cavernous
body.  (Voillemier.) 
198        GENITOURINARY DISEASES AND  SYPHILIS.

varies greatly in extent, from a mere cord-like band, linear stricture
(Fig. 61), to one slightly broader, annular stricture (Fig. 62), and from
that to a contraction which may involve two or three inches of the
Fig. 62.                              Fig. 63'
Annular stricture.                            Tortuous stricture.
canal, changing it into a devious, irregular channel, tortuous stricture.
(Fig. 63.)
   Strictures may also be  classified as:  1.  Soft  or recent,  the sub-
epithelial exudate not yet having become extensively organized into
connective tissue.  Under this heading would be included strictures
of large  calibre and those cases of chronic urethritis which  resemble
stricture or constitute its first stage.  2.  Cicatricial, characterized  by 
STRICTURE OF  THE URETHRA.
199
an ill-defined mass of fibrous tissue  often cartilaginous in consist-
ency.  The traumatic strictures are made up entirely of fibrous tis-
sue; the gonorrhoeal strictures still  exhibit traces of the original
structure of the parts.
   There is also a peculiar form of contraction of the meatus, which
appears as a diffuse induration of the mucous membrane, scar-like in
appearance and cartilaginous in consistency; this extends outward on
the glans and for some  distance inward; it is apparently a form of
scleroderma.   Local treatment is of little use, but there is often some
spontaneous improvement after a considerable lapse of time.
   Strictures are further classified as,—
   1. Simple,—that is, exhibiting only the  symptoms and reactions
characteristic of the majority of strictures.
   2. Irritable.—Instrumentation  causes unusually severe pain, is
sometimes  followed by hemorrhage, and excites undue  local inflam-
mation or occasions urethral fever.
   3. Resilient, Contractile, or Recurring.—The stricture if  untreated
steadily becomes tighter.  Even if it can be dilated,  it again contracts
so rapidly that this method of treatment is without benefit.
   In accordance with  the  extent to which they narrow the urethra,
strictures are either of large calibre or of small calibre.
   The terms permeable and  impermeable indicate whether or not an
instrument can be passed through  the  narrowing.
   Every stricture following a urethritis must at some time have been
a stricture of large calibre, but just when such a stricture becomes a
pathological factor and is able to give rise to symptoms is an unsettled
point.   There is  no fixed calibre of the urethra, and the size of the
meatus is not a reliable  index as to the diameter of the  canal behind
it.  The circumference of the flaccid penis affords the best indication
as to the size of the urethra, the calibre of this canal increasing in pro-
portion  to the growth of the penis; but the ratio is only approximate
and is liable to variation.
   It must always be remembered that the urethra has certain points
of normal constriction,  notably at from one to three inches from the
meatus and in the vicinity of the pubic angle, and that it  is impossible
to distinguish  by means of instruments alone these natural irregu-
larities from constrictions of equal  calibre due to incipient stricture.
However, when narrowings in any point of the urethra are associated
with gleet, frequent urination, dribbling after micturition, and lumbar
and  hypogastric pain, it is safe to infer that there is some  degree of
urethral stricture.
   The  increased friction and resistance resulting from  even a slight 
200
GENITOURINARY DISEASES  AND SYPHILIS.
fibrous  periurethral deposit may disturb the equilibrium which has
been established and maintained between the usual efforts and power
of the bladder as an expulsive  organ and a certain average of resist-
ance which must be overcome before it can empty itself.  As a result
the bladder becomes irritable, and is often rendered still more so by
inflammation of the posterior urethra incident to backward  extension
of the catarrhal process usually active at the seat of narrowing.  Thus
is caused one of the most constant of the stricture symptoms,—i.e.,
frequent urination.
    The imperfect closure of the tube occasioned by the inflammatory
infiltrate, which prevents the urethral walls from being pressed tightly
to each  other by their investing  layer of involuntary muscle, causes
imperfect expulsion of the  last drops of urine, and  produces another
characteristic symptom,—dribbling at the end of micturition.
    The retention and decomposition of these last few drops, together
with the abnormal  friction between  the  stream of urine  and  the
urethral walls at the site of narrowing, cause a subacute inflamma-
tion of the mucous membrane, accompanied by a catarrhal  or muco-
purulent discharge, constituting the condition of gleet.
    Pain is developed in the lumbar and hypogastric region by reflex
irritation transmitted from  the area of inflammation and  from  the
irritated bladder.
    Where  the urethral calibre is markedly diminished, the relation
between causes and effects is, in the main, as just stated.  As to how
far the narrowing must go before  such symptoms are excited, no dog-
matic assertion can be made.  Otis has  promulgated a scale of rela-
tion between the calibre of the urethra and the circumference of  the
flaccid penis, any departure from which  he regards as an  evidence
of the existence  of  stricture.   This scale doubtless  represents accu-
rately the distensibility of the male urethra, but it does not represent
what can fairly be  called its normal calibre, and fails altogether to
recognize the  fact that there  are points  of physiological narrowing
along the pendulous urethra.
    The  variation in size and dilatability of the different parts of the
urethra  have long since been clearly demonstrated by Delpet, Guyon,
Sappey, and many others.
    Otis, however, in effect assumes that the urethra should be a tube
of uniform  calibre, at least anterior to the triangular ligament, and the
instrument which he has  devised,—the  urethrometer,—when used
under the guidance of his tables, will detect apparent strictures in the
majority of normal urethrae.  His teachings have, nevertheless, been
of great value, since they have demonstrated the distensibility of the 
STRICTURE OF THE  URETHRA.
201
normal urethra, have clearly shown the full pathological value of true
stricture, however  slight, and have rendered urethral surgery more
exact.
   For purposes of classification it may be admitted that, exclusive of
cases that are best described as examples of chronic urethritis, there are
others in which the superficial inflammation has  largely disappeared,
and  in which  the  periurethral  or submucous  deposit has  begun to
contract and to diminish the lumen of the  canal, the contraction still
allowing fairly good-sized instruments to pass with  ease.  Such nar-
rowings may be classed as strictures of large calibre.  Strictures  of
small calibre are those in which the encroachment  upon the canal is
more pronounced.
   A purely arbitrary standard has been established for convenience
in classifying organic strictures in accordance with the degree of nar-
rowing.  This is expressed in the following definitions:
   Strictures  of large calibre are  those  through which a  sound  or
bougie larger than No. 15 (F.) can be passed.
   Strictures  of small calibre are those  through which instruments
larger than No. 15 (F.) cannot be  passed.
   Location of Stricture.—In the large majority of cases gonorrhoeal
stricture is situated in the bulbo-membranous portion of the urethra.
The next most frequent seat is the first two and a  half inches of the
urethra,  and the least  frequent  seat  is the middle of the spongy
urethra.   Stricture of the  prostatic region  is practically  unknown.
The occurrence of stricture in  these regions is due to the  facts that
they are exceptionally vascular, and, with the exception of the mem-
branous urethra, are rich in glands and follicles,  and  that chronic
urethritis is apt to become localized at these points.  Gravitation in
both regions favors chronic congestion.
   The differences of opinion in regard to the localization of stricture
are due to the different stand-points from which the subject is regarded.
Those who demand evidence of some organic change before admitting
the existence of stricture, and who base their views on the exami-
nations of specimens  in museums, differ greatly  in their conclusions
from those who depend upon the findings of the urethrometer, and
who believe  in an almost unvarying relation between the  calibre  of
the urethra and the size of the penis.   In three hundred and twenty-
one specimens  examined  by Sir  Henry Thompson the stricture  in
two hundred and  sixteen, or  sixty-seven per cent., was  found  in
the bulbo-membranous  region; in fifty-four, or seventeen per cent.,
within two and a half inches of  the meatus ; and  in fifty-one, or only
sixteen per cent., in the  intermediate spongy portion. Otis describes 
202       GENITO-URINARY DISEASES AND SYPHILIS.

two hundred and fifty-eight strictures under his care as situated, one
hundred and fifteen, or forty-four and one-half  per cent., in the first
inch and a quarter of the urethra; one hundred and twenty-nine, or
fifty per cent., from  one and  a  quarter to five and a quarter inches
from the  meatus; and  only fourteen, or five and one-half per cent.,
from five and a half to seven and a quarter inches,—i.e., in the region
of the bulbo-membranous urethra.   It  can scarcely be doubted  that
many of these " strictures" were points of physiological narrowing.
    If narrowings  at the meatus  are excepted, gonorrhoeal strictures

                                Fig. 64.
   Traumatic stricture. A, bas-fond of bladder; B, ecchymosis of the mucous membrane of the
vesical neck :  C, prostatic urethra: D, verumontanum, much deformed ; E, lacunae; F, position of
greatest narrowing ; mucous membrane transformed to a thin layer of flat epithelial cells; F, small
diverticula in the fibrous tissue ; G, cicatricial tissue ; H, small round cavity ; K, spongy tissue com-
pletely destroyed; £7, mucous membrane in front of the stricture, thin and rugous ; L, spongy body;
M, anterior urethra. (Voillemier.)


are  usually single, though two, three, four, or even  more  may  be
present.
    Traumatic strictures are  nearly always single, and their situation
varies with the cause.  They occur in  the mid-spongy portion of the 
STRICTURE OF  THE  URETHRA.
203
urethra after rupture of a chordee;  at the  root of the penis when
caused by " false movements" in coition;  in  the perineo-bulbar por-
tions  of the  urethra when following contusions of the perineum ;
and in the membranous portion after  pelvic fractures.
   They are  most  frequently found  involving the bulbous  urethra.
(Fig. 64.)
   Strictures following  ulceration due to chancre, chancroid, or the
lodgement  of foreign bodies  are usually  found at  or near  the
meatus.
   Changes in the Urethra.—The urethra  behind a stricture under-
goes certain progressive changes.  It at first becomes  deeply con-
gested, thinned, and dilated.  As the  stricture grows smaller, altera-
tions in the mucous  membrane become more  and more marked.  The
increasing pressure causes a corresponding increase in the pouching
or dilatation; decomposition of the retained  urine sets up superficial
inflammation, and  erosion of the mucous surface occurs, with  de-
nuding  of the epithelial  layer; ulceration  follows, which, as it pro-
gresses, allows the escape of urine into the  spongy tissue.  Sooner or
later this causes  suppuration.  The pus, whether in minute  quantity
or as the contents  of a  recognizable  abscess, finds its way  towards
the skin,  and after its  discharge leaves urinary  fistula?.   These
fistulae,  when first formed, have soft, yielding walls, but these grad-
ually  become  dense  and  indurated,  undergoing the same patho-
logical changes as did the original  strictured  region.  Even after the
formation of a large fistula progressive contraction still takes place
at the  posterior surface  of the  urethral  stricture, since the fistu-
lous  opening cannot prevent the constant  contact of urine with this
portion  of the narrowing.   As a result,  the urethral outlet  is more
and more tightly sealed, and all the  urine is forced to  pass by the
new way.
   Gradually the walls of the  fistula  become indurated, its lumen  is
narrowed  by contraction, and  the  free passage of the urine  is again
obstructed.  Under such circumstances it is extremely rare to observe
any yielding in the stricture so that water can be voided per urethram.
Ordinarily other  abscesses  develop in the way already described, and
other fistula? are  formed.
   Wassermann  and Halle have shown that  the essential anatomico-
pathological characteristic  of the lesions of  gonorrhoeal stricture  is
their multiplicity, as opposed to the  precise limitation and  localiza-
tion of traumatic strictures.  In all cases of old gonorrhoeal strictures
the urethra exhibits pronounced lesions  throughout  a great part  of
its extent.  These  are most marked in the region of  the bulb.  The 
204
GENITO-URINARY  DISEASES AND SYPHILIS.
calibre of the urethra is lessened anterior to the stricture; behind it
there is dilatation.
   Because it is surrounded  by compressible, elastic spongy tissue,
the soft walls of the normal urethra lie directly in contact with each
other, a cross-section showing it as a  slit, transverse in the spongy
portion, vertical in the bulbar.  When the periurethral  tissues are
thickened and  rigid, the strictured  urethra becomes an open  canal
with a lumen which varies in  shape according to the position of the
periurethral  infiltration.   In  the posterior portion  of the bulb the
strictured urethra exhibits a  tendency to take the form  of  a  wide,
irregular, transverse opening, with its lateral angles extending almost
as far as the  fibrous envelope of the bulb.
   The epithelial  lining of the urethra is constantly altered.  Thick-
ening and  partial desquamation represent the  commonest  lesions.
These are found in all portions of the canal, even those least altered.
There is constantly observed a tendency towards the transformation of
the cylindrical epithelium to the stratified pavement form.   Commonly
there is a single basilar layer of cylindroid cells with the long axes
perpendicular to the derm.  The middle layer is made up of several
rows of polygonal, usually hexagonal, cells; finally, there  is a super-
ficial layer continuous with the middle  layer and made up of several
rows of flat cells with the long diameter parallel to the derm.  Some-
times the  flattened superficial  cell-layer rests  directly on the basilar
layer.  All forms  of  transition are  observed  in the epithelial  cells.
The  epithelium  may be thinned  and atrophic, or there may  be pro-
liferation,  forming vegetating masses which fill the urethral  calibre.
Finger states that there is a  distinct  relation between the type of
epithelial alteration and the pathological changes in the subjacent tis-
sues.  The distinctly dermoid and corneous epithelium (not observed
in the  membranous or  prostatic  urethra) is usually found in the re-
gions where periurethral sclerosis is  most pronounced.
   It is important to recognize the fact that these various lesions of
the mucous membrane are not limited, but are almost universal.
   The essential lesion of stricture is  in the spongy body.   As  an ulti-
mate result  of inflammatory infiltration, fibrous  tissue is gradually
substituted for the elastic, extensible vascular tissue of the spongy
urethra, forming a compact inextensible avascular mass  showing a
tendency towards retraction, atrophy, and obliteration.   Usually the
narrowing  is caused by a  fibrous ring, which  may be regularly dis-
posed or unequally deposited about the urethra.   There is no system
in its distribution.   Sometimes it is the  upper segment, sometimes the
lower or lateral segments, that are most profoundly involved.   At the 
STRICTURE OF THE URETHRA.
205
strictured point one-half or two-thirds of the diameter of the spongy
body is altered and obliterated.  This alteration often involves a con-
siderable extent of the canal beyond  the point retracted.
   These lesions of the spongy body, limited and irregular  in cases
of chronic urethritis,  are in fibrous stricture constant, deep,  and
extensive.
   The arteries of the spongy body in old cases constantly exhibit
an endarteritis  and a periarteritis, sometimes proceeding to complete
obliteration of the vessels.  Behind the stricture the superficial inflam-
matory lesions are almost  constant, and  it is here that embryonal
vegetations form by predilection.  The sclerosed tissue  surrounding
the urethra is not homogeneous, but contains all the elements of nor-
mal spongy tissue.  It is the result of a species of interstitial sclerosis,
which, though completely modifying  the appearance and the  proper-
ties of the normal tissue,  does not cause its total disappearance.
   In case of traumatic stricture the contrary is the case.  The spongy
body is entirely replaced in  loco by an ordinary fibrous cicatrix.
   The  glandular  and  lacunar lesions  of  stricture are constant.
Adenitis with proliferation  and epithelial transformation, glandular
dilatation, and simple periadenitis are nearly always found, especially
in the least altered portions of the strictured urethra.   At the seat of
stricture the glands have  often disappeared or are scarcely recogniza-
ble.   These glandular and  lacunar inflammations play an important
rdle in  the  production of the periurethral lesions,  causing fibrous
nodules to develop in the spongy body.  The irregularities, the folds,
and the nodular masses  observed in the walls of strictured  urethrae
often originate in the glands and their ducts.  Finally, the dilated and
suppurating glands may cause periurethral  abscesses, false routes, or
fistulous tracts.   When these fistula? originate in the bulbar urethra
it is from the region of one  of the lateral angles of the canal  that the
fistulous tract passes.   The sclerosed bulb is not traversed  directly
by this tract from above downward.   It winds laterally round  the half
circumference of the bulb and  opens through the skin.   Sometimes
the bulb is entirely dissected by two fistulous tracts placed symmet-
rically and laterally, uniting near a single suburethral pouch.   These
tracts are lined with  stratified pavement epithelium continuous with
the two surfaces:  hence  in  closing them it is necessary to extirpate
the whole tract.  In exploring these tracts it  must be borne in mind
that they take a circuitous  course, often  entering the urethra by its
lateral wall.
   The opening of the urethra  at the seat of stricture is commonly
near the roof of the  canal, since the bulk of the fibrous tissue is 
206
GENITO-URINARY DISEASES AND SYPHILIS.
usually placed in the urethral floor, thus encroaching upon the lumen
of the canal from below upward.   This opening may, however, be
eccentric in any other direction.
   The consistence of strictures varies with their age and with the
amount of fibrous and elastic  tissue they contain.  Their  dilatability
varies inversely with their consistence, as does their elasticity.
   Section of a stricture  of the annular or tortuous  variety  shows a
more or less imperfect ring of new inflammatory tissue, whose  limits
taper down gradually.  This tissue is hard, yellowish white near the
lumen and  darker peripherally, where reddish islets are seen, the
result of hemorrhagic infarcts,  which form foci for new inflammatory
changes.  Oberlander has shown that the inflammatory process prac-
tically begins in the glandular recesses.  These are most abundant
on the roof of the urethra, but the floor presents the greatest changes,
from  the  fact  that the  gonorrhoeal process is  always  more active
there.
   Complete obliteration of the urethra is extremely  rare, and it is
doubtful if it ever happens except in the traumatic forms of stricture
following  extensive  laceration or  complete  cross-crushing of the
canal. The  obliteration in  this case is usually  at least half an inch
wide, with fistula? placed behind it.

                    SYMPTOMS  OF STRICTURE.
   The phenomena produced by stricture vary with the degree and
the character of the narrowing.  They are most conveniently  clas-
sified under the following headings: 1,  subjective symptoms,  those
recognizable by the patient; 2, objective symptoms,  those  elicited by
exploration.
   Subjective Symptoms.—A. Urethral History.—Well-planned  ques-
tions  should elicit the fact that there  has been severe  or recurrent
urethritis  of long duration;  or traumatism to the urethra, perineum,
or pelvis ; or a urethral chancre or  chancroid.
   B. Alterations in Micturition.—1. Frequency.  This arises at first
from  the  change  in relation  between the  expulsive  efforts of the
bladder and the resistance  offered by the urethra; afterwards  from
extension  of inflammation backward  by continuity until the vesical
neck is involved ; from cystitis ; and finally from atony of the bladder
with the presence of residual urine.  In these cases  the frequency is
worse by  day, as in stone, not by night, as in prostatic disease.
   2. Changes  in the  character of the  stream, which may be double,
flat, gimlet-shaped, or spray-like, and in tight strictures becomes  much
reduced in size, are often of  slight significance, as the shape and size 
STRICTURE OF  THE  URETHRA.
207
of the stream depend more upon  the shape and size of the meatus
than upon any condition posterior to it.  When the meatus is of good
calibre urethral narrowing may remain unnoticed for some time, as a
compensatory hypertrophy of the muscular coat of the bladder occurs,
which overcomes the effects of the obstruction.
    3. Diminution in expulsive  power is  a late symptom, and  is de-
veloped only when vesical atony has succeeded to the hypertrophy.
    4. Dribbling after  urination depends  upon the retention of some
drops of urine behind the stricture.   These escape by gravity after
the act  of micturition is complete.   It is usually an early  symptom,
caused  by  irregular action of the  circular  muscular fibres  of  the
urethra.
    The dribbling from the overflow of a distended bladder (inconti-
nence of retention) is a very late  symptom,  and is associated  with a
high degree  of atony of the bladder.
    The incontinence  of  retention from  stricture  is at first always
worse in the daytime, when the patient is up and about, while the in-
continence of retention due to  hypertrophy of the prostate is worse
at night, when the  patient is lying down.
    The mechanism of incontinence from  stricture is as follows.   The
dilatation of the urethra behind the stricture having extended to the
neck of the bladder, the urinary reservoir becomes funnel-shaped, the
bladder representing the base and the stricture the neck.   The patient
being in the erect  position, the weight of  the column of urine comes
directly on  the  stricture, which permits it to filter through drop by
drop, but when he is reclining the bladder can fill up, and can usually
retain its contents unless the changes in it and  in the urethra are far
advanced.  In the prostatic patient it is possible that the congestion of
the lumbar cord produced by the recumbent position makes urination
more frequent at night and during the early morning hours.
    5. Ardor  urina? is very  variable, but is  not apt to be marked,
unless there is a considerable degree of prostato-cystitis present.
    6. Retention  of urine may occur  early and suddenly from an acute
increase of  the congestion of the mucous membrane in the strictured
region, or it  may be a late symptom dependent  upon the direct ob-
struction occasioned by the slowly contracting stricture.   In either
case it is apt to be precipitated by fatigue or cold, or by alcoholic or
sexual excess.
   7.  Vesical tenesmus is generally  constant  during the  entire act of
micturition;  that of prostatic hypertrophy is most violent at the be-
ginning and grows less as the water begins to flow ; that of cystitis is
most severe at the end of the act. 
208        GENITO-URINARY DISEASES AND  SYPHILIS.

   C.  Urethral Discharge.—Opinions vary as  to the  constancy of
gleet as a symptom, but it is probable that a large majority of stric-
tures  are accompanied by it.  Most of those patients who exhibit no
discharge show mucous and  epithelial shreds and pus-cells in the
urine.
   D.  Interference with Coition.—The physiological congestion of erec-
tion necessarily makes the  lumen of a tight  stricture still smaller,
thus causing  retention of semen  behind  the point  of narrowing.
This may be extremely painful because of the  consequent distention
of the  urethra, often inflamed and hypersensitive.   On subsidence of
erection  the stricture may become sufficiently patulous to allow the
semen to drop slowly from the meatus.
   If  ejaculation takes place  at all  it is apt to be premature.  The
erection  is often imperfect or subsides before  the completion of the
act.
   E.  Constitutional  Symptoms.—These are  late,  and depend upon
vesical and renal changes, with accompanying alterations in the urine.
They are, therefore, usually a  combination of ura?mic and septicemic
symptoms.  There is a red  glazed  tongue, with anorexia, dyspepsia,
constipation, etc. The dryness of the tongue extends to the walls of
the pharynx, making swallowing painful;  an irregular fever  super-
venes ;  the general  strength  fails, the face becomes  pinched and
yellow, the eyes sunken, and after  rapid  emaciation  and profound
prostration the patient dies comatose.
   Of the subjective  symptoms frequent urination, dribbling, and gleet
are the most characteristic of  stricture.
   Objective Symptoms.—Guyon divides the urethra into six regions:
   1.  The navicular  region, extending from the meatus to the corona.
   2.  The penile region, extending from the corona to the peno-scrotal
juncture.
   3.  The scrotal region, extending from the anterior to the posterior
scrotal wall.
   4.  The perineo-bulbar region, extending from the posterior scrotal
wall to the anterior layer of the  triangular  ligament.
   5.  The membranous region.
   6.  The prostatic region.
   It must be remembered that the superior urethral wall alone has
anything like a fixed  curve, while the inferior wall is only a broken
line.   The inferior wall is extensible, soft, and depressible,  and is
subject to variations in form and length: hence the important point
for the surgeon to remember  during urethral instrumentation is that
he should follow exactly the curve of the superior wall, or by manipu- 
STRICTURE OF THE URETHRA.
209
lations modify  the direction of the urethra.  The part most  suscep-
tible of modification or change in direction is that extending from the
suspensory ligament to the entrance into  the membranous division;
anatomical knowledge and the " touch" must be depended  upon  to
indicate the limit of  modification which the urethra will bear without
sustaining a lesion.   The urethra has no lateral flexions or bends, but
lies exactly in the median line.  Nothing, however, is easier  than  to
produce such deviation in the spongy urethra, especially in the bulbar
portion.
   The elasticity and extensibility of the urethra reside for the most
part in the spongy portion, as is clearly demonstrated by erection, and
this  elasticity belongs in  the greatest degree to the  inferior  wall,
which  permits  of easy distention or  elongation, while the superior
wall yields with much less readiness.   This difference increases  with
age,  and  is especially marked in the  senile urethra.  It  is therefore
evident that since the extensibility of the inferior wall  is brought into
play by even a moderate  force, the  surgeon  cannot count on its re-
sistance.   It  glides before  an instrument  and cannot  serve to guide
it.  It yields  readily to a mechanical pressure testing its extensibility;
it cannot be incised with any accuracy or precision; it  ruptures when
surprised by  distention.  It does not yield equally in all its parts, the
perineo-bulbar portion of the canal being the most distensible part of
the urethra.
   The superior wall is more regular and constant in form and direc-
tion, presents the smoother and firmer  surface, is less modified by
mechanical pressure, offers the greater resistance to rupture and pene-
tration, is less intimately connected with important structures, and is
the less vascular, of the two walls.

                              Fig. 65.
   Cast of the urethra,  a, navicular fossa; 6, membranous urethra;  c, expansion of the bulb.
                              (Letzel.)

   There are two relatively constricted points in the  urethra, the
internal and the external meatus,  and  three  dilatations, the  fossa
navicularis, the bulbar cul-de-sac, and the prostatic expansion, all of
                                14 
210
GENITO-URINARY DISEASES  AND SYPHILIS.
which present numerous individual varieties.  These  dilatations are
excavated at the expense of the inferior wall of the canal.  (Fig. 65.)
   Diagnosis.—The  best  instruments for  the  diagnosis of stricture
are the so-called bougies a boule.  They may be made of metal, with
slender stems, having small expanded ends, upon which the number
of the instrument is marked;  this represents in  millimetres the cir-
cumference  of the bulb at the shoulder.  Better instruments, how-
ever, are the black flexible bougies a boule.  (Fig. 66.)  The shoulder

                             Fig. 66.

                           Bougie k boule.

of the acorn bulb should join the  shaft at almost a right angle, and
not at an obtuse angle.
   The  size of the instrument selected for examination should be de-
termined approximately by noting the circumference of the flaccid
penis at the middle  of the spongy portion.  (Fig.  67.)  The following
is an average scale :

    Circumference of penis, 3 inches; calibre of urethra, 26-28 millimetres.
                    "  3} "       "       "    28-30
                    "  3£ "       "       "    30-32
                    "  3| "       "       "    32-34
                    "  4  "       "       "    34-36
   The meatus  should be cut if it is too small to permit the intro-
duction of a bulbous bougie of the required size.
Gauge for urethral instruments.
   The penis, with the  dorsum  facing the abdominal wall, is held
just behind the corona between the thumb and finger of the left hand,
the foreskin, if redundant, having been retracted.   The bougie, well
oiled, is then  passed  gently  into the bladder.   If it is arrested, the
point  on the shaft corresponding to the meatus  is marked with the
finger  and the instrument is withdrawn.  The distance  from the 
STRICTURE OF  THE URETHRA.
211
meatus to the bulb of the bougie is then measured, and the region of
the contraction is carefully noted.   If that instrument or a smaller size
passes through to the bladder, it is withdrawn after a moment's delay,
and if during its outward passage any contraction is found other than
that  at the posterior  layer of the triangular ligament, it is probably
due  to stricture, although spasm  may occasionally give rise to error
in diagnosis.
   Spasm cannot always be recognized with certainty.   It is generally
found at the membranous urethra, and occurs in many diseases of the
urinary tract, as in cystitis, in tuberculosis of the bladder or posterior
urethra, in phimosis or atresia of the meatus; it  also occurs in some
rectal and anal troubles, and in  spinal congestions and scleroses, as
well as in hysteria and neurasthenia.
   Gonorrhoeal strictures almost invariably give some point of rough-
ening or induration at their favorite seat,—i.e., just anterior to the
bulb.  In cases of spasm, when the bougie is pushed steadily onward
it will continue to  be held  till it passes through the membranous
urethra, while in  stricture it is released suddenly.  On withdrawing
the bougie there  should  be  no resistance  at this point from spasm,
while in  stricture there  is an  accentuated resistance and the same
sudden release on continuing to draw the instrument out.   Solid steel
sounds if  introduced gently  nearly always pass without difficulty the
narrowing due to spasm.  Pain is usually greater in spasm, but this
is not sufficiently constant to be of diagnostic value.  Uncomplicated
deep urethral  strictures  may be  exceedingly difficult  to  distinguish
from narrowing  due  to  spasm of the compressor urethrse  muscle,
symptomatic of anterior  stricture.
   As to the diagnosis of stricture of large calibre, even the bougie a
boule may be  misleading if used in  the  deep urethra,  on account of
the normal points of resistance to both its introduction and its with-
drawal which are there found, while the urethrometer is  similarly
misleading in the pendulous urethra, especially if its revelations are
interpreted according to the  unnecessarily large standard of Otis.  In
the latter region  the  normal variations account  satisfactorily for the
large proportion  of strictures found by a few writers  and would-be*
teachers on this subject  which may charitably be put  down to  self-
deception.   In the  deep urethra  it  has been necessary for them to
account for their frequent discovery of strictures, even  in cases with-
out the usual etiological  factor, by attributing them to  masturbation,
sexual excess, etc.  It has been demonstrated  that the " deep-seated
stricture usually of large calibre found at the subpubic  curvature and
its vicinity," and  described as " an essential lesion of masturbation" 
212
GENITO-URINARY DISEASES  AND SYPHILIS.
(Gross), is in reality the  point of normal  resistance to the withdrawal
of bulbous bougies offered by the posterior  layer of the triangular
ligament.
   The prostatic urethra  being at once more movable  and more
dilatable than the membranous portion, the bulb slips smoothly along
it until the point is reached at which the posterior layer of the tri-
angular ligament closely embraces the posterior  part  of the mem-
branous urethra and the outer surface  of the prostate.  Here, for
obvious reasons, it is arrested, and it is at this moment that the decep-
tive sensation which may be considered indicative  of the existence of
organic stricture is communicated to the hand.
   A series of  observations and dissections upon the  cadaver  have
proved the soundness of this view, which was originally purely theo-
retical, and,  moreover, eliminated the possibility of  the resistance
being due to a  spasm  of the compressor urethra?  muscle which sur-
rounds the canal at this point, arrest of the instrument occurring as
invariably after death as before.1
   Having in a number of cadavers carefully brought the bulb closely
up to  the point of resistance, it was  held in  position while the  deep
urethra was  exposed by dissection.  The shoulder of the bulb was
always found in the exact locality of  the deep layer of the fascia, the
edge of which  would  often be  felt tense and cord-like over the upper
wall of the urethra.  A division on either side  of its attachment to the
ramus of the ischium, or to the pubis beneath the crura penis, would
then cause an immediate disappearance of the  resistance, and the bulb
could be drawn outward smoothly and uninterruptedly.  If the handle
of the instrument was  depressed during its withdrawal,  the edge of
the prostate became a cause of obstruction ; and it may act thus to a
greater or less  extent in all cases.
   The  recognition of  strictures  of  small  calibre is a matter of no
difficulty.  In exploring them it is well to use a medium-sized bougie,
No. 16 or No. 18 French.   When this is passed to the anterior surface
of the stricture the region is noted, and its exact  calibre determined
by using successively smaller instruments.   Multiple  strictures may
be recognized and measured in the same manner.   The advantage of
using a rather large instrument at first is that it eliminates the element
of spasm in the membranous  urethra, which will often, after a little
gentle pressure, allow  the  blunt rounded  point  of a  medium-sized
bougie to pass, while  it would  contract firmly and persistently before
the point of a fine instrument.  By using progressively  smaller instru-
1 Philadelphia Medical Times, May 26, 1877. 
STRICTURE OF  THE  URETHRA.
213
ments also, the stricture can be measured more accurately both in
calibre and in situation.
   Sometimes, when no bougie a boule will pass, a steel sound several
sizes larger will do so with ease.   The  information it conveys is  not
so accurate as that obtained by exploration with  the  acorn bougie,
but is sufficiently so when the stricture is of small  calibre.
   In making a diagnosis between deep  stricture and hypertrophy of
the prostate the history and age of the patient are  important factors.
   In prostatic  hypertrophy the patient is apt to be over fifty  years
of age, and gives a history of partial retention with nocturnal incon-
tinence  of urine;  the urethra  is lengthened, so that  the shaft of a
catheter must be entered to an unusual depth and the handle must
be more than ordinarily depressed before the beak reaches the blad-
der ; the obstruction will be  found at a distance of more than six and
a half inches  from the meatus, and a finger in the rectum will  easily
make out the enlarged prostate.
   If the points of normal narrowing of the urethra, at the meatus, the
middle of the spongy portion, and the  membranous portion, are borne
in mind, together with the resistance offered by the posterior layer of
the triangular ligament  to the withdrawal of a bulbous bougie, it is
hardly possible to mistake these narrow areas for stricture.
   The  presence, location, and  calibre of a stricture having been de-
termined, its dilatability is ascertained by the use of  the conical steel
sound;  but it is  usually advisable to  make  this  investigation at a
second visit.

                    RESULTS  OF STRICTURE.
   Unrelieved obstruction of the urethral canal continued for a pro-
longed period produces, in addition to  the local  conditions  already
described, a series of changes in the  urinary  tract posterior to  the
lesion.  Under  long-continued  and increasing pressure the  urethra
gradually enlarges, and the mucous membrane becomes thinned and
pouched, projecting in  places between the bands of  muscular fibres,
forming diverticula analogous to those  seen in the bladder.  Some-
times, instead of permitting the  gradual  escape  of urine  through
minute  openings, with the formation of small  abscesses and  fistula?,
the urethra gives way more largely at a point behind the stricture,
and extravasation of urine follows.
   Extravasation of Urine.—This serious  complication of  stric-
ture is usually preceded  by the following symptoms.
   Symptoms.—After long continuance  of  the ordinary phenomena
due to  stricture a  tumor develops somewhat  suddenly along  the 
214        GENITO-URINARY DISEASES AND  SYPHILIS.

course of the urethra, accompanied by dysuria and frequent micturi-
tion or by complete retention.
   If the extravasation is gradual, this tumor will fluctuate, open ex-
ternally as an abscess, and form a urethral fistula.
   If the extravasation is sudden,—i.e., if the wall of limiting inflam-
matory tissue  thrown out at first is suddenly broken through by the
efforts at micturition,—the following symptoms will show the nature
of the accident.  While  straining to evacuate the bladder a sense of
something having given  way  is experienced, together with distinct
relief of bladder tension, although no urine escapes  externally.  A
smarting or burning pain is felt about the seat of  rupture.
   The local  symptoms  are those produced by  the  retention of an
irritant and often a poisonous fluid within the tissues.  The parts swell
and become oedematous, the color of the  skin changes to a dusky red,
purple, or dirty brown, emphysema occurs from the gases of decom-
position, and spots of gangrene appear.  When  the  urine is septic,
sloughing may set in by the end of the first day.
   The general symptoms are those of profound  septicemia, marked
by great prostration,  irregular temperature, a  dry, glazed tongue, a
running pulse, frequent shallow respirations, wandering delirium, and
finally, if the condition is  unrelieved, death in coma.   These develop
with greater intensity and rapidity if the bladder has been infected with
putrefactive microbes and the urine  is therefore  fetid and purulent
before extravasation takes place.
   The localizing symptoms—those which indicate the point at which
the urethra has given way—are based upon the  course taken by the
urine.
   A.  In case the pendulous urethra gives way, the result may be as
follows :
   1. When the urine is not septic and ammoniacal, and the extrava-
sation is not very rapid, it  may remain strictly limited, forming a blind
internal fistula.
   2. The urine extravasates  into the substance  of the corpus  spon-
giosum, passing forward in the course of the urethra, and  finally in-
volving the glans  penis in the sloughing process.   Brodie states that
the appearance of a black  spot on the glans penis after extravasation
is a fatal sign,  and Harrison concurs in this opinion.
   3. The corpus spongiosum may be  protected by  inflammatory
exudate,  ulceration extending to, but not through, its strong fibrous
envelope (Buck's fascia).   In this case the urine may burrow forward,
forming a long, indurated, fistulous tract, opening externally behind
the glans, or on the dorsal surface near the root of the penis. 
STRICTURE OF THE  URETHRA.
215
   4. Ulceration involves the common fascia of the penis at or near
the point of rupture.  In this case the loose cellular subcutaneous
tissue of  the  penis  becomes  enormously  oedematous, the swelling
extending backward to the scrotum.  This is the  common  course
when rapid extravasation takes place from the pendulous urethra.
   B. When extravasation occurs from  any portion of  the urethra
included between  the  attachment of the scrotum  and the anterior
layer of the  triangular  ligament, usually  the  bulbar portion, the
course of the  extravasated urine is governed by the attachments of
the deep  layer of  the  superficial fascia,—Colles's fascia.   The urine
will  first occupy the space enclosed by this fascia in front and below
and»by  the anterior layer of the triangular ligament behind, and, as
it cannot reach the ischio-rectal  space on account of the attachment
of the fascia to the base of the ligament, and cannot reach the thighs
on account of  the insertion of the fascia into the ischio-pubic  line, it
is directed into the scrotal tissues, and thence up between  the  pubic
spine and the  symphysis until it  reaches the abdominal wall.
   C. In case the membranous urethra gives way, the extravasated
urine is confined  to the region included between the layers  of the
triangular ligament, and  gains access to other parts only after sup-
puration and  sloughing have made for it an outlet.  The symptoms
following will  then depend upon the portion of the aponeurotic wall
which first gives way.  If the anterior layer  of the triangular liga-
ment yields, the extravasation will take the course described as char-
acteristic of extravasation from the bulbous  urethra; if the posterior
layer yields, the course of the urine  will correspond with that taken
when the prostatic urethra is ruptured.
   D. If the opening is situated behind the posterior layer of the tri-
angular ligament—in the prostatic  urethra—the urine  may either
follow the course of the rectum and  make its appearance in the anal
perineum, or, as it  is separated from the pelvis only by the thin pelvic
fascia, it may make its way through the latter near the pubo-prostatic
ligament, where the fascia is especially weak, and may spread rapidly
through  the  subperitoneal  connective  tissue,  sometimes forming
abscesses in the hypogastric region.
   The  usual  source of extravasation is from  the  bulbous and the
membranous urethra, the urine infiltrating the perineum and scrotum
and mounting upward to the belly-walls.  When extravasation occurs
from the membranous urethra  the  anterior layer of the triangular
ligament nearly always gives way.
   Prognosis.—The prognosis of extravasation  of  urine, except in
those few cases where  inflammatory  reaction protects the surround- 
216
GENITO-URINARY DISEASES  AND SYPHILIS.
ing tissues and where local  abscesses  and fistula?  are formed, is
always grave.   When the penile urethra is involved the skin usually
ulcerates, thus allowing escape of urine before  the extravasation has
become wide-spread.  Extravasation into the substance of the corpus
cavernosum is fortunately rare.
   In extravasation from the  bulbous or membranous  urethra there
is little  prospect of spontaneous relief being afforded by ulceration:
hence prompt interference is necessary to prevent wide-spread slough-
ing and death from septic poisoning.
   Extravasation from the prostatic urethra, and  extravasation from
the membranous urethra, with backward extension through the pos-
terior layer of the triangular ligament, are the most dangerous forms
of this complication of stricture, since the symptoms are not so char-
acteristic  that immediate diagnosis  can be made, and since it is diffi-
cult to drain the infected tissues thoroughly when the infiltration is
fairly started.
   Treatment.—The treatment of extravasation of  urine is sufficiently
simple in theory.   The two indications are prevention of further ex-
travasation, and thorough drainage.
   Further extravasation is prevented by external perineal urethrot-
omy or perineal section.  Usually an instrument  can be passed, the
breach in the urethral wall being upon the floor of this channel and
not very large.
   At the same time that the urethra is opened behind the stricture
the latter should be thoroughly divided.  The entire infiltrated area
is drained by long multiple incisions ; it is scarcely possible to overdo
this part  of the operation.  Two cuts are required for the scrotum,
two  or three  for  the  penis, and, if the case has lasted more than
twenty-four hours, three or four for the abdominal walls.  As much
of the extravasated urine as possible should be squeezed out through
these cuts by vigorous mechanical pressure, and the tissues should be
washed with bichloride 1 to 4000.  The cuts should be dressed with
iodoform, loosely packed with iodoform gauze, and covered with hot
antiseptic fomentations, changed every two hours (twenty layers of
gauze wrung out in bichloride  1 to 4000 and covered with oiled silk).
   When the prostatic urethra gives way, external perineal urethrot-
omy and drainage may not  suffice.   If the  infiltration  has been ex-
tensive, the parietal incision  for suprapubic cystotomy will also be
required, the prevesical space  being irrigated and drained.  By digital
examination through  the rectum, boggy or  indurated  areas can be
detected about the base of the bladder, and  must be opened  and
drained through the perineum. 
STRICTURE OF  THE  URETHRA.
217
    Bladder.—The bladder becomes affected as the stricture narrows.
 Occasionally, when the obstruction occurs suddenly, the walls are at
 once thinned and atrophied by overdistention.  As a rule, however, a
 compensatory hypertrophy takes place first, the muscles become thick
 and rigid, the capacity of the viscus diminishes, and  the  muscular
 fibres  stand  out  in  bars  or ridges, having  between them  lozenge-
 shaped spaces where the  walls are greatly thinned.  During the fre-
 quent and violent contractions of the  viscus the mucous membrane is
 driven outward  between  these muscular partitions, and the bladder
 finally becomes pouched at a number of places.
    Usually there  is  also  a severe  cystitis  developed by infection
 through  the  urethra  and  adding greatly to the  severity  of the
 symptoms.  Exceptionally the  sacculi rupture, causing collapse and
 death.
    Ureters.—The  ureters become dilated  partly  from  the  actual
 backward pressure of the  column of urine incident to distention of
 the bladder, and partly from the frequent compression of their vesi-
 cal ends during the  oft-repeated acts  of  urination.  Their oblique
 course through the  walls  of the bladder renders this compression
 very effective, and hydronephrosis is developed, causing mechanical
 obstruction to the secretion of urine.
    Kidneys.—Sooner or later microbic infection takes place, and the
 renal alterations due  to suppurative  inflammation follow.   A pyelo-
 nephritis first develops, and then foci of suppuration are formed at
 different points through the cortex and beneath the capsule, until
 finally  the kidney is converted into a large abscess-cavity,  or  into a
 series of pus-containing sacs, held together  by the capsule and in-
 flammatory lymph, and showing  no trace of  the  secreting  structure.
 This condition is called surgical kidney.
    Among the possible results of stricture may be mentioned vesical
 calculus, impotence, sterility, recto-vesical fistula,  and very  rarely
 spinal sclerosis or some of  the forms of  cerebral disease.
    Prognosis of Stricture.—The prognosis as to life depends, of course,
 on the stage which has been reached and upon the estimate which may
 be formed of  the secondary organic changes that  have already taken
 place.  Relief of the obstruction, drainage and antisepsis of the blad-
 der, milk diet, renal antisepsis, etc., often work astonishing changes in
 apparently desperate cases.
    Fenwick has forcibly called attention to the fact that in  the prac-
 tical treatment of stricture we too often concern ourselves merely
with the mechanical  removal of the obstruction, and do not pause to
ascertain to what extent the  secreting  structure  of the kidney has 
218
GENITO-URINARY DISEASES  AND SYPHILIS.
been weakened  or rendered susceptible to the invasion of inflam-
mation from continuous surfaces.
   Fenwick emphasizes the fact that in the obstruction offered to the
overflow of urine  by unrelieved stricture three muscular systems—
the vesical, the ureteric, and the  cardiac—become successively affected
with hypertrophy.  He adds:  This increase  of  expulsive power is
rarely of long duration, for that stage in which the  compensatory
hypertrophy is insufficient to cope with the resistance is soon reached,
and relaxation and atony supervene.  The cardiac condition is con-
tingent upon the renal changes, which, in their turn, depend upon the
failure of the barriers to backward  pressure which healthy or hyper-
trophied vesico-ureteric muscles present:  hence the importance of
estimating the condition of these dike-like muscles.  Their energy or
their incapacity may be appreciated by ascertaining the absence or
presence of residual  urine, and a systematic measurement  of the
latter at each step of the dilatation, besides affording an index to
the degree of atonicity of these  muscle  planes, will indicate roughly
the amount of backward pressure which has already  fallen upon
the kidney.
   With these ideas in mind, Fenwick made careful examination of
the amount and character of residual urine in seventy-five cases of
organic  stricture of the urethra, with the following interesting results:
    Residual urine was  found in all the cases examined  except five.
From this we may argue  that  residual  urine exists in varying pro-
portions in ninety-three per cent, of cases of stricture.
   Although the duration of the symptoms and the narrowness of the
stricture were powerful factors in the production of the atony on which
the residual urine depended, yet the age of the patient seemed to be
the most important predisposing cause.   The ultimate  recovery of
tone by the bladder-wall seems likewise to have been more influenced
by the age of the patient than by any other factor.   It might have been
supposed that in cases in which muscular power did not  return after
release of the bladder from backward pressure there would be found
a history of repeated retention, or at least of a single  great overdis-
tention, which had materially  weakened  the  bladder-wall; but this
was not the case.   Many of the patients whose atony  was the worst
had never had retention.  The  bladders of the older patients suffered
most, without regard to the past  histories.   This fact is  expressed
as follows:  given  three patients at the  ages of thirty-five,  forty-five,
and fifty-five, respectively, let  each become  the  subject of stricture
and be  examined  at the end  of six months.   It will  be found that
there will be a diminution of expulsive power for each  decennary and 
STRICTURE OF THE  URETHRA.
219
a correspondingly increased accumulation of residual urine.  There
are, of course, other factors for which allowance must be made,—e.g.,
the lowered vitality of the lumbar centre  from masturbation, exces-
sive venery, abuse of alcohol, and the loss of control consequent upon
cerebral or spinal lesions.
   The conclusions at which Fenwick arrives are as follows :
   In estimating the health of  the  kidneys from the  indications
afforded us by the examination of the residual urine, two items have
to be clearly borne in mind.  There is, first, the amount of pressure
which the kidneys have been working against.  This is to be meas-
ured  by  the quantity of  residual urine.  It may be safely  assumed
that five ounces of residual urine, which is probably near the average
of unreleased  narrow strictures, would indicate  sufficient  damage
to cause  anxiety  as to  the  effects of any intercurrent inflamma-
tion or disease,  while an amount over ten  ounces would  make us
cautious  in  operating for stricture  by internal urethrotomy, and in
giving anything but a grave prognosis of the ultimate effects of the
constriction.
   Secondly, the behavior of the muscles in their  progress towards
recovery will teach us much as regards the future course of  the case.
A disposition to relapse or sluggishness  in recuperation would cause
us to look forward with apprehension to that period of life when fatty
and  senile changes will step in to aggravate greatly the weakness of
an organ upon the condition of which comfort and health in old age
are mainly  dependent.   Lastly, we  are  amply justified, when the
initial amount of residual urine is under five ounces, and when re-
covery of the normal calibre is prompt, in giving a good prognosis,
provided the full calibre of the  urethra is maintained.

              TREATMENT OF ORGANIC STRICTURE.
   The various methods  employed in the treatment of stricture may
be divided into:  1, dilatation: a, gradual; 6,  continuous;  2, inter-
nal urethrotomy; 3,  external urethrot-
omy ;  4, combined  internal  and external________
urethrotomy ; 5, perineal section ; 6, mis-
cellaneous  methods, including divulsion,            _______^^^
rapid dilatation, electrolysis, excision, ureth-   ~N/
rectomy,  etc.                               .
   Gradual  Dilatation.—The  instru-        Filiform bougies.
ments for the gradual dilatation of stricture
consist of a  set of whalebone filiform bougies with  straight, angular,
and spiral ends (Fig. 68); a set of tunnelled catheters, ranging from 
220       GENITO-URINARY DISEASES AND SYPHILIS

No. 8 or 10 to No. 18 French (Fig. 69); a set of Thompson's conical
steel sounds, running from No. 12 to No. 36 French (Fig. 70); and

                              Fig. 69.
Tunnelled catheter. Enlargement of tip showing position of tunnel.
some flexible bougies of different sizes,—acorn, conical, and bulbous
or olive-tipped.  The flexible bougies should be so constructed that

                              Fig. 70.
                             Steel sound.

the portion just behind  the  tip is sufficiently yielding to allow the
latter to follow the sinuosities of a tortuous stricture.  Slight pressure
upon the end of such  a bougie should  cause flexion of the neck.
The English bougies are objectionable because they are not made
sufficiently flexible  near the  tip.   The  steel  instruments  should  be
absolutely  free from rust or any surface  roughness.  The  flexible
bougies should be smooth, strong, and without cracks.
    Cleansing  of Instruments.—The  principles of urethral antisepsis
must be rigorously  applied in the care of these instruments.  They
should be well scrubbed  with soap and  hot water  and thoroughly
dried immediately after being used.
    The steel instruments are sterilized by boiling for five  or ten min-
utes in water containing one per cent, sodium carbonate.  After this
they are dried and wrapped in clean towels.   When they are required
for use they are warmed  and finally sterilized by having their shafts
dipped in alcohol, which is then flamed off.   The soda prevents rust-
ing.  The  clean rubber and whalebone instruments can  be  washed
for half a minute in a 1  to  1000 sublimate solution.  They may be
wrapped, when not in use, in flannel which has had metallic mercury
rubbed in it, and should be stored in tight boxes ; or, better still, they
should be  sterilized by  formalin or trioxymethylene or paraform, as
in the case of catheters.   (See page 270.) 
STRICTURE OF  THE  URETHRA.
221
   The  lubricant employed  should be  aseptic or  antiseptic.  One
drachm of boric acid to the ounce of carbolated vaseline or albolene,
or of glycerin, answers well.   This may be placed in the steam ster-
ilizer before  being used.   Freshly prepared carbolized olive oil (one
part of the acid to forty parts of the oil) is  also useful, but it loses its
antiseptic properties in a short time.
   Cleansing of the Urethra.—In cases requiring the use of sounds the
meatus and  its immediate environment, together with  the urethra,
are often swarming with pyogenic organisms, which, gaining entrance
to the system through slight  cracks or through abrasions incident to
the passage  of the  instrument, may occasion violent  inflammation
with its sometimes serious local and general sequela^.  To lessen the
danger as far as possible, the glans and foreskin should be thoroughly
cleansed by  means of pledgets of cotton wet with  bichloride of mer-
cury 1 to 1000.  In women it is particularly important thoroughly to
cleanse the region about the urinary meatus before passing an instru-
ment into the bladder: hence catheterization by touch alone is to be
discouraged.
   The  urethra should be flushed of purulent contents by directing
the patient while  micturating forcibly to stop the stream abruptly by
sudden closure of the meatus with the finger.  When there is free
muco-purulent discharge,  the whole  urethra should receive an anti-
septic irrigation, either by means of injections thrown in by an ordinary
syringe,  by a small soft rubber catheter attached to a fountain syringe
passed beyond the stricture and very slowly withdrawn while the
antiseptic fluid is flowing,  or by the irrigating bag  and short urethral
nozzle.
   When the bladder has been infected, if the urethra is permeable,
it is best to precede the systematic treatment of stricture by irrigation
with some antiseptic  solution, as sublimate (from 1 in 20,000 to 1 in
10,000), potassium permanganate (1 in 5000 to 1 in 1000), boric acid
(fifteen grains to  the ounce of boiled water), hydrogen peroxide (ten
to fifty per cent,  solution), or silver  nitrate (from 1 in 5000 to 1 in
500).  At the same  time, when the stomach  permits, it is important
to administer antiseptic drugs, such as salol  and boric  acid, in from
five- to ten-grain  doses, from four to six times daily.
   These preliminaries having been attended to whenever possible,
and the stricture, if  its calibre will permit, having been  located and
measured by the bulbous bougie, a conical steel sound, two sizes larger
than the bulb which has passed the stricture, is warmed and sterilized
by flaming it with  alcohol, lubricated, and carefully introduced through
the stricture. 
222        GENITO-URINARY DISEASES AND SYPHILIS.

   The fixed curve of the urethra—i.e., the curve  assumed by the
majority of adult urethras in a condition  of  rest—is measured  from
just in front of the triangular ligament to the  neck of the bladder.
(Fig. 71.)   It is  theoretically considered as that part of a circle of three

                               Fig. 71.
   Tip of catheter just entering the fixed curve of the urethra. (Antal.)  -1, rectum ; B, bladder;
C, symphysis pubis; D, seminal vesicle; E, bulb; F, tip of instrument entering the fixed curve of
the urethra ; O, prostate.
and one-quarter inches' diameter which is subtended by a chord two
and three-quarters inches long.  (Fig. 72.)  Practically this curve varies
greatly from  this  standard.  Indeed, it is  not a  continuous  curve.
Depressing  the urethra by means of a finger placed on either side of
the root of  the penis somewhat straightens this curve.   It is always
lengthened  by hypertrophy of the prostate or a much distended blad-
der.  It may be temporarily obliterated by passing a straight instru-
ment into the bladder.  (Fig.  73.) 
STRICTURE  OF  THE URETHRA.
223
   Passing the  Sound.—For  the passage  of a properly made  steel
sound or silver catheter, the curve of which corresponds with  that
given above, the patient  should be placed in the  recumbent position,
Fig. 72.
Fixed urethral curve.
with the  head  and  shoulders  slightly elevated,  the knees a  little
separated, and the muscles  relaxed.   The surgeon,  if right-handed,
Fig. 73.
                     lA         E
Fixed curve of the urethra obliterated by the passage of a straight instrument. (Antal.)  A, rectum;
    B, bladder; C, symphysis pubis; D, scrotum; E, prostate; F, tip of catheter in bladder.

stands at the left side of the patient.   The sound  or catheter, having
been  previously sterilized, warmed,  and  lubricated, is taken in the
right  hand, and, the foreskin having been retracted, the  penis  is 
224
GENITO-URINARY DISEASES AND SYPHILIS.
held between the middle and ring fingers of the left hand.   The
organ is gently put on the stretch, care being taken to keep  the  dor-
sum towards the abdominal  wall, so as to avoid making twists in
the urethra, the  lips of the meatus are  separated by the thumb and
finger of the left hand, and the tip of the  instrument is passed into
the urethra.  At this  time the shaft of the sound or catheter should
be  parallel to the line of the groin.  (Fig. 74.)  This  is important

                              Fig. 74.
Passing the sound.  The shaft is parallel with Poupart's ligament; the tip has entered the urethra.
chiefly in persons with large, protuberant bellies,  in  whom,  if this
rule is not followed, the tip of the instrument will be made to catch
against the anterior layer of the triangular ligament, owing to the ele-
vation of the handle necessitated by the  prominent  abdomen.  In
any event the handle of the  instrument must be kept low until the
tip is about to enter the membranous urethra.   Having engaged the
point  of  the  sound, the penis is now drawn up with  the  left hand,
while the instrument is gradually pushed onward, until three or four
inches of the  shaft have disappeared, when the handle is swept inward
to the median line, the shaft  being kept parallel to the anterior plane
of the  body and nearly touching the abdomen.  (Fig. 75.)   The shaft
of the  instrument is now pushed downward towards the feet, and as
soon as this motion is arrested the fingers of the left hand are removed
from their hold on the  penis  and shifted to the perineum, where the
curve of  the  instrument is felt behind the scrotum.   (Fig.  76.)  The 
STRICTURE  OF  THE URETHRA.
225
handle is then, and not till then, raised from the abdominal wall and
swept gently over in the median line, while the left  hand  acts as a
Fig. 75.
Passing the sound.  The shaft is carried inward to the middle line of the body.


                        Fig. 76.
 Passing the sound. The shaft of the instrument swept upward ; the fingers of the left hand placed
                           against the perineum.


fulcrum over which the instrument glides.   After the shaft has passed

the perpendicular,  the  handle is taken in the left hand, and the index
                                  15 
226
GENITO-URINARY  DISEASES AND  SYPHILIS.
and middle fingers of the right hand are placed one on either side of
the root of the penis, making downward pressure, while the left hand
Fig. 77.
Passing the sound.  The handle taken in the left hand, the fingers of the right hand making down-
                      ward pressure at the root of the penis.

                                Fig. 78.
Position of sound, showing that its tip has entered the bladder.
depresses the handle between the legs,  carrying the point of the in-
strument through the membranous and the prostatic urethra into the 
STRICTURE OF  THE  URETHRA.
227
bladder.  (Fig. 77.)   The entrance  into this organ is  recognized by
the free motion of the tip of the sound when the handle is rotated,
and by the fact that the instrument remains exactly  in the median
line and points away from the pubes when the  hold  upon it is re-
laxed.  (Fig. 78.)  The whole manoeuvre must be effected with gentle-
ness ;  no force is necessary.
   If  there is a spasm of the circular muscular fibres  of the urethra
at any point, or of the compressor urethra? at the bulbo-membranous
juncture, gentle steady pressure for a minute or  two usually will be
followed by relaxation.
   If the handle is lifted too soon from its proximity to  the abdominal
wall, the tip of the instrument catches in the subpubic ligament above
the urethral orifice ;  if the handle is not raised soon enough, or if the
fingers on the perineum do not give the curve of the instrument the
gentle upward pressure that it needs, the tip buries itself in the loose
and movable floor  of the bulbous  urethra below the orifice  of the
membranous portion of the  canal.  (See Fig. 65.)  In  either case the
curve of the sound  protrudes  unnaturally in  the  perineum.  The
withdrawal of the instrument for an inch or two  and  its reintroduc-
tion, raising  or lowering the tip  as may be required,  will  suffice to
overcome  the obstacle.
    If the  instrument is used with ordinary care  and gentleness and
has been properly sterilized, and if  the  point is made to follow accu-
rately the  subpubic  curve of the urethra, the production of prostatitis,
epididymitis,  or urethral fever will follow  with  extreme rarity.  In
the majority of cases these complications  are due to the use of force
in the introduction  of the  bougie,  when the instrument practically
becomes a divulsor, or to a slovenly disregard of antisepsis, either the
instruments not  having been sterilized  or the urethra not having
received antiseptic irrigation before  manipulation.
    Sometimes a few drops of blood follow  the withdrawal of the in-
strument,  the next act of urination may be slightly painful,  and often
the gleety discharge  will increase for a day or two.
    The method of treating stricture by gradual  dilatation consists in
the passage of sounds of increasing gauge at intervals of from three to
five days, till the stricture readily admits an instrument corresponding
in size to the normal calibre of the  urethra.
   Each  sounding is followed  by a slight and transitory hyperaemia
of the region about  the stricture, and during this time, particularly in
recent cases, an appreciable softening and absorption of the stricture
tissue may occur.  This period lasts from three to four days, and not
until it subsides is the passage of an instrument to be  repeated. 
228
GENITO-URINARY DISEASES AND SYPHILIS.
   Ordinarily an advance of one or two numbers of the French scale
may be made each  time, but occasionally the same, instrument must
be introduced  at several sittings before it  can be exchanged for a
larger  one.   This is determined by the degree of resistance experi-
enced during its introduction, the pain which it excites at the time and
afterwards, and the presence or absence of bleeding.  Personal expe-
rience soon becomes the best guide as to the degree to which dilatation
may be carried  at any one  sitting, though the feelings of the patient
should  always be consulted.   When the full size  has  been reached
(vide table, page 210) the  symptoms will usually disappear, and after
this  it  is  only necessary  to carry  on the dilatation at increasingly
longer  intervals to maintain the calibre of the urethra.  If the patient
is of average intelligence, it  is easy to teach him to pass an instrument
on himself without the least discomfort or inconvenience.
   A certain proportion  of cases under this plan of treatment will
get entirely well, so that years afterwards no trace of stricture can be
discovered.   Others, if the intervals between the introduction of the
sound  are too long, will have a slight recontraction, evidenced possi-
bly by a recurrent gleet, and the treatment will have to be repeated.
   The introduction of a  sound into any stricture which it fills with-
out causing laceration is accompanied by certain phenomena.   There
is felt,  at the end of a minute or two, a difficulty in withdrawing the
instrument.   Soon the spasm disappears, and movement of the sound
becomes easy again.  Some hours later a muco-purulent discharge is
established in the canal,  and in a few days  the stricture allows the
passage of a larger sound.  The permanent enlargement obtained is
principally due to absorption incident to the inflammation excited in
the stricture by the presence  of  the foreign body, and not  to the
mechanical  dilatation and pressure of the sound.   Therefore, when
it is desired to make this  inflammation a little more severe, it is well
to leave the sound in situ  for five or ten  minutes.   The point may be
withdrawn a little during this time, to avoid irritation of the prostato-
vesical  region.  The effect  of sounds of gradually increasing size is
to stimulate the work of absorption and to  cause the contractile ele-
ments  to atrophy and the urethra to resume approximately its normal
character.
   These remarks  apply to all strictures, except those complicated
with abscesses, fistula?, urinary extravasation, etc.,  or those in which
there is marked resiliency, or where instrumentation is followed by
rigors and urethral fever.
   All surgeons are agreed that uncomplicated strictures of large calibre
should  be  treated by gradual dilatation when they are at or behind the 
STRICTURE OF  THE URETHRA.
229
bulbo-membranous juncture.  The treatment is, however, rejected by
some surgeons in favor of the cutting operation when such strictures
of the pendulous urethra are encountered.
   A review of a large number of reported cases of internal urethrot-
omy, and familiarity with a considerable number even less favorable
and  not  reported, lead us to believe that these figures rather under-
estimate  the mortality, and that the practitioner who decides to cut a
stricture  anterior to the bulbo-membranous juncture must do so with
the full knowledge that there  are at the  very least two chances in
the hundred of losing his patient.  There should certainly be definite
and  well-grounded reasons  for accepting  this risk, and the operation
which involves it should show  results unmistakably  superior to those
of gradual dilatation,—a procedure with practically no mortality.
   It is not in accord with other pathological observations to suppose
that the  mere division of a dense and old contractile band of fibrous
tissue will result in its absorption, and it is highly probable that  the
majority  of the true strictures of the spongy urethra which are cured
by internal urethrotomy are those in which the division of the stric-
ture is supplemented by the use for some time of full-sized bougies.
•The  relief of tension afforded by the section of the stricture gives  full
play to the  so-called  " inflammatory atrophic  dilatation," and in a
certain proportion of cases either  retrograde  metamorphosis and
absorption take place, or there  are at least a thinning and weakening
of the fibrous band, which  result in its practical disappearance as a
cause of  obstruction.
   It is also probable,  on both  clinical and pathological grounds, that
the great majority of  so-called strictures of  the pendulous urethra
which are cut by the extremists in urethrotomy are points of physio-
logical narrowing,  and that the so-called " cures" are merely illustra-
tions of the fact that by a linear incision into its long axis we can put
in the normal urethra a  longitudinal splice of fairly healthy tissue
which has little  tendency to contract afterwards, and can thus more
or less permanently enlarge the urethral calibre.
   It is difficult to see, however, why  such a splice should prevent
the steady contraction of a mass of old cicatricial  tissue, such as  occu-
pies the wall of the canal and the periurethral space  in strictures of
some standing.
   Strictures of Small Calibre.—The diagnosis of  stricture of small
calibre (less  than 15 French), situated at or deeper  than the bulbo-
membranous juncture, is made either with the bulbous bougie, if that
can be passed through, or by the introduction of a sound clown to the
anterior face of the contraction.  Such  strictures are usually accom- 
230
GENITO-URINARY DISEASES  AND SYPHILIS.
panied tiy gleet and marked vesical symptoms, increasing in severity
with the tightness of the contraction.
   The choice of treatment lies between dilatation and some form of
urethrotomy.  Divulsion is so clumsy, so uncertain, and so dangerous
as to have almost no advocates to-day.
   In beginning  the treatment of a stricture of small calibre it is best
to pass through it  a steel  sound, provided  its introduction requires
no force.  It is not  safe to use a sound  smaller than No. 8 or No. 10
of the  French scale, as even in  the most skilful and  experienced
hands there is an unavoidable danger of lacerating the inflamed and
degenerated mucous membrane  around the strictured region.   It is
in the  exploration of deep  stricture of small calibre that " false pas-
sages"  are  usually made, and almost  always with small metallic in-
struments,  either sounds or catheters.   The  mucous membrane in
front of a tight stricture is generally  inflamed and softened, and if
fistula? have formed behind the  stricture, diverting the course of the
urine, the anterior portion of the strictured region undergoes atrophy,
as it is no longer subject to constant irritation, and a thin-walled dila-
tation is frequently  found there, which  offers  but  little  resistance to
the point of an instrument.
   When a false passage is made, the sensation conveyed to the hand
differs  markedly from  that  attending  a successful  catheterization.
The point of the instrument is  not in  the median line, and is held
with unusual firmness.   There is free bleeding almost immediately;
the finger in the rectum will  detect the deflection of the instrument,
and the absence of the normal thickness of urethral and prostatic tissue
beneath its curve.   If there is no retention of urine, the immediate
treatment after making a false passage consists in rest in bed, urethral
and urinary antisepsis, continuous catheterization for some days, and
the avoidance of further instrumentation  for some weeks.  Should peri-
neal abscess or urinary infiltration follow, prompt incision is indicated.
   If a sound is passed  through  a stricture of small calibre,  it should
remain five or ten minutes, and then be withdrawn.  If it is the first
experience  with the patient, it is best to wait three or four days before
passing an instrument again, in the mean time administering five-grain
doses of salol or boric acid four to six times  daily, with a full dose of
quinine morning and evening.  At the next sitting it is well to recom-
mence with the same instrument, after which one, two, or three larger
sizes may be used in succession, provided their introduction is easy
and not  accompanied by pain or bleeding.   Hemorrhage and pain
are indications for lengthening the intervals between treatments and
for proceeding more slowly in the use of larger instruments. 
STRICTURE OF  THE URETHRA.
231
   Once fairly established,  however,  the  treatment by  dilatation is
carried on until the full normal calibre is reached : usually  this requires
from three to six weeks.
   If the stricture is not resilient or irritable, and is not  traumatic in
its origin, it will be found that all symptoms have disappeared, unless
perhaps the gleet  persists for a time.  This, too, will  often subside ;
but,  in view of the  extensive and  serious  urethral lesions  always
associated with long-standing stricture, it is apparent that gleet may
persist in spite of full dilatation, even  though it is reinforced by most
careful local and general treatment.
   When the stricture is a  recent  one, absorption  may take  place,
but in any event the occasional introduction of a steel sound by the
patient will always keep  the case under control.
   In cases of resilient, irritable, or traumatic stricture of the bulbo-
membranous region, external perineal urethrotomy is the operation
of choice.  Similar strictures of the penile urethra  should be treated
by internal urethrotomy.
   Strictures of Small Calibre permeable only to Filiform Bougies.—
In certain cases no steel sound or  ordinary soft instrument can be
made to pass  the stricture, but  a persevering trial with whalebone
filiform bougies will result  in the  passage of one  into the bladder.
This  trial should be made  persistently and patiently,  and in the ab-
sence of retention of urine may be frequently repeated.  After slightly
overdistending the urethra  anterior to the stricture by carbolized oil
injected by means of a piston syringe, a filiform is passed down to the
stricture, and  if, after  patient, gentle  effort, it refuses  to enter, it is
withdrawn, and is given an angle of forty-five degrees by bending  it
across the thumb-nail at about a quarter of an inch  from  the end.
(Fig. 68.)   As the orifice of a tight  stricture  is frequently not in the
middle of the  obstructed urethra, but at some point around its  cir-
cumference, this manoeuvre will often enable the surgeon to enter  it
when with a perfectly straight instrument he cannot do so.  If this
does  not succeed, several filiforms are passed by the side of the first
one,  to impinge on the irregular surface of the stricture at a number of
points; then by attempting to pass first one and then another of these
the filiform bearing the right relation to the orifice will usually be found
and can be introduced into the bladder.   If this fails and one filiform
can merely be engaged in the stricture, it is often best,  in the absence
of retention, to tie it in place and allow it to remain for twenty-four
hours.  In the great majority of cases at the end of this time it can
be passed through the stricture.  After the first instrument is intro-
duced, four courses are open to the surgeon. 
232
GENITO-URINARY DISEASES AND SYPHILIS.
    A.  Continuous Dilatation.—1. The filiform may remain in place,
with the certainty that in one or two days others may be slipped along-
side of it, and may be used as guides for the introduction first of a
tunnelled catheter and later of an ordinary soft or steel instrument.
    2.  An immediate attempt may be made to pass a tunnelled cathe-
ter into the  bladder, leaving it, if successful, to act for twenty-four
hours  by  continuous dilatation ; later gradual  dilatation  may  be
employed.
    B.  Urethrotomy.—3. A tunnelled and grooved staff may be passed
over the filiform, and external urethrotomy may be performed.
    4.  The filiform may be used as a guide for a Maisonneuve urethro-
tome,  and internal urethrotomy may be performed.
    If  the  stricture which is being  dealt with  is not of traumatic
origin, and is not specially resilient or irritable,  the  first  method will
lead to the adoption of gradual dilatation with the greatest degree of
comfort and absence of anxiety to both the patient and the surgeon.
Even if there has  been  moderate retention, it is  certain that  the
urine will pass with increasing freedom by the side of  the filiform,
and that the danger  of the case is  over  so far  as  retention is
concerned.
    If retention has been complete for many hours and it is necessary
to give immediate relief  to the overstretched bladder-walls, it is best
to adopt the second method,—that is, pass a catheter at once.  Failing
in this, the third method, or external perineal urethrotomy, should be
employed.  In all  deep strictures  when instrumentation  occasions
rigors  the external cutting operation is indicated.
    Internal urethrotomy is practised  in cases of tight,  bulbo-mem-
branous stricture complicated by retention only when the patient re-
fuses to have the external operation performed.  In the best hands
it is attended with a distinctly larger mortality than any  of the other
methods mentioned, and there  is no evidence that it is  followed  by
any larger percentage of permanent cures.
    While gradual dilatation is the preferable treatment  in the great
majority of cases, there are a number of strictures in which it is not
applicable, and which are best treated by other methods.

                         URETHROTOMY.
    A stricture may be  divided entirely from within the urethra, in
which  case the operation is termed  internal  urethrotomy ; it may be
divided by an incision carried through the overlying integument and
fascia,—external urethrotomy ; or both of these  methods may be em-
ployed,—combined internal and external urethrotomy. 
STRICTURE OF  THE  URETHRA.
233
    Internal Urethrotomy.—The  different methods employed  in
 the internal division of stricture depend upon the direction and loca-
 tion of the incision.  This may be made («) from before backward  or
 (6) from  behind forward; (c)  on the roof or (d) on  the  floor of the
 urethra.
    For operations on narrowings of the meatus or those placed within
 the navicular portion of the urethra an ordinary blunt-pointed  teno-
 tome with a convex cutting edge is all that is required.  But for opera-
 tions at a greater depth a number of instruments  have been devised,
 for each  of which some special merit is claimed.
    In cutting strictures at or anterior to the bulb the incision is  made
 in the roof of the urethra, except at the meatus, where the incision  is,
 as a  rule, made on the floor.   The division of stricture of the mem-
 branous  urethra is less liable to be attended with troublesome  hemor-
 rhage if  the  incision is  made on the  urethral floor.   Gonorrhoeal
 strictures are fortunately not frequent in this portion of the canal.
    If the hemorrhage is not controlled by the catheter alone, a firm
 bandage  should be applied to the penis, or, if the point of cutting is
 too deep to be reached  in this way, pressure  may be applied to the
 perineum by a compress placed over the seat of operation and the
 application of a crossed of the perineum.  For the temporary arrest
 of active hemorrhage perineal pressure  applied by a padded cane, the
 ferrule of which is braced against the foot-board of  the bed, will be
 found efficient, or digital compression may be made by an attendant.
    The  antiseptic  details required in internal urethrotomy are as fol-
 lows.  For from  five to seven days  before operation  salol and  boric
 acid should be given by the mouth,—five grains  of the former and
 ten grains of the latter four times  daily.  This is particularly indi-
 cated when cystitis is present and the urine is infected.  The urethra
 is rendered as surgically clean as  possible by previous  irrigation
 repeated night  and morning for several days before operation, with
 a final washing  just before  the introduction of the  urethrotome.
 The solutions used are normal saline, a 1 to 4000 lotion of corrosive
 sublimate, a 1 to 5000 solution of silver nitrate, or  a 1 to 200 carbolic
 solution.   If the stricture is permeable, a soft catheter of small calibre
 is passed behind it and  the whole  urethra  is flushed out with the
 cleansing lotion, from eight ounces to a pint being used  each  time.
 The  instrument employed is either  boiled in soda solution (one per
 cent.) or  taken to pieces and soaked  in carbolic lotion (five per cent.)
 for at least ten minutes before  it is used.
   After  the  stricture  is divided, a  full-sized soft catheter is  passed
into the bladder and retained  there  for twenty-four hours.  As it  is 
234
GENITO-URINARY  DISEASES AND SYPHILIS.
withdrawn, a 1 to 4000 bichloride lotion is allowed to flow through it,
thus flushing the urethra and  cleansing the seat of operation.  The
catheter  should be a new  one, and should be disinfected by boiling
immediately before operation.
   Indications for the Performance of Internal  Urethrotomy.—This
operation is indicated: 1. In all strictures at or near the meatus.
   2. In fibrous, resilient, or irritable  strictures of large calibre ante-
rior to the bulbo-membranous  juncture.
   3. In strictures of small calibre  situated in advance of the  bulbo-
membranous juncture, except when such  strictures are very recent,
soft, and dilatable.
   Or, still further to simplify the indications, it may be stated that
all  fibrous,  resilient, or irritable strictures anterior to the  bulbo-
membranous juncture should be treated by internal urethrotomy.
   Resiliency and resistance to dilatation are the chief indications for
preferring the cutting operation in the treatment of strictures of any
portion of the urethral tract: hence, even though the coarctations are
of large calibre, if they are distinctly resilient or  fibrous urethrotomy
is indicated.
   Strictures of small calibre situated in advance of the bulbo-mem-
branous  juncture, unless seen  very early  and found to be  soft and
dilatable, furnish the typical condition  for internal urethrotomy.  In
such cases the  operation is attended with the greatest prospect of a
permanent cure.  The exceptions  to  this  rule  will be given in the
section devoted  to combined internal and external urethrotomy.
   For strictures of the meatus and in the neighborhood of  the fossa
navicularis dilatation is peculiarly unsatisfactory, since the excessive
sensibility of this part and the intimate relation  between the spongy
tissue of the glans and the urethra make stretching painful and render
inflammatory reaction unduly severe.
   The incision is made on the  floor  of the urethra,  and  should be
sufficiently deep to remove all sense of resistance  upon the withdrawal
of a bulbous bougie two numbers  larger than  the normal urethral
calibre, since there is always slight contraction in healing.  A ten per
cent,  solution of cocaine, applied by  means of  a pledget of cotton
wrapped on  a  match-stick dipped  in  the  solution, passed  into  the
meatus and held in place for two minutes, will  render the operation
entirely painless.  The incision should be made exactly in  the middle
line, and bleeding  may  be checked by packing the  navicular fossa
with iodoform  gauze.  A  short  straight  conical bougie of  full size,
the so-called meatus sound (Fig. 53), should be  gently inserted once
daily during the healing process.  Applications of cocaine render this 
STRICTURE OF  THE  URETHRA.
235
procedure practically  painless, and  also  relieve the ardor urina?  of
which some patients complain.  Deeper-seated troubles, unless urgent
in their character, should be ignored until the healing is complete.
   Internal Urethrotomy from  before backward.—The best instru-
ment for performing  this operation  is Maisonneuve's urethrotome
(Fig. 79), or one of its modifications, as described by Teevan.  The

                             Fig. 79.
Maisonneuve's urethrotome.
Maisonneuve urethrotome is provided with screw-tipped filiform bou-
gies, which are first passed through the stricture into the bladder.
The tip is then screwed to the urethrotome,  and the latter is intro-
duced, accurately guided by the filiform.
   In Teevan's urethrotome (Fig. 80) the groove of the staff termi-
nates  two inches from  the end.  By means of a stylet a triangular

                             Fig. 80.
Teevan's urethrotome.
blade contained in a double sheath is made to slide along this groove
and to expose its cutting edge when the  stricture is reached.  A
screw on the end of the staff is provided for the attachment of the
filiform bougie.  By the withdrawal of the stylet the instrument is
converted into a catheter, thus allowing the surgeon to assure himself
that the instrument has certainly passed into the bladder by the proof
afforded by escape of urine.  Both these  instruments divide the stric-
ture on the urethral floor to a sufficient extent to allow of the passage 
236
GENITO-URINARY DISEASES AND SYPHILIS.
of a dilating urethrotome, by means of which an incision in the roof
of the urethra can be made, restoring it to its normal calibre.
   Cutting the stricture from before backward is thus performed.  A
fine, flexible, guiding bougie is passed into the bladder.  The screw
end of this is secured to the urethrotome, and the tip  of the latter is
passed through the stricture into the bladder and held  in position by
an assistant.  The operator with his left hand  draws the penis  for-
ward and with his right  hand pushes the sheathed knife down the
urethra until the obstruction is  reached.   The cutting edge  of the
knife is then exposed and  all the resisting  tissue  in  front  of it is
divided.   The knife is  then drawn into its sheath, and the latter is
pushed  along the urethra, gliding in readily if the division has been
complete.  If the  sheathed  knife meets with an obstruction when it
is pushed forward, the incision may have to be  repeated;  but this is
undesirable.  If the stricture is thoroughly divided, the instrument is
withdrawn immediately and a full-sized silver catheter is passed, the
bladder emptied, and the  catheter withdrawn.   If the  stricture is not
fully divided,—and this is usually the case when the Maisonneuve
or Teevan instrument is  used,—the foregoing operation  may be  re-
garded as a preliminary to division from behind forward by a dilating
urethrotome, and the introduction of the latter instrument (rendered
possible by the previous incision) should be the next  procedure,  the
incision in this  case being  made  on the roof of the urethra.  After
the  operation the patient is put to bed and placed on quinine and
urinary antiseptics,—i.e., salol  five grains, boric acid ten grains, each
three or four times a day.
    If no rigors have occurred within forty-eight hours after the oper-
ation, a sound  equal in size to the catheter is passed through  the
divided stricture.   The patient is then allowed to get up,  the sounds
being subsequently passed  every three or  four  days,  then every
week, etc.
    Internal Urethrotomy from behind  forward.—Among the many
instruments devised for this operation, Civiale's urethrotome, or some

                              Fig. 81.
Gross's urethrotome.
modification of it, such as that devised by Gross, is probably the best.
(Fig. 81.)   It consists of a slender straight shaft with a small bulbous
end.  The knife is concealed in the bulb, and by a simple contrivance
in the handle it  can be projected one, two, three, or four degrees, 
STRICTURE OF  THE URETHRA.
237
according  to  the  depth of the incision  required.   The method of
procedure is as follows.  The stricture having been dilated to No. 10
or No. 12 French, the bulbous end of Civiale's urethrotome is passed
fully half or three-quarters of an inch beyond the stricture, the knife
is  exposed on the roof of the  urethra, is held  firmly in place in its
relation to the instrument, and is withdrawn  until all  resistance  is
overcome.   The  blade is then sheathed and the instrument  with-
drawn.  A full-sized sound is then passed into the bladder.   If this
meets with any obstruction, the situation is noted, the urethrotome is
reintroduced, and the obstructing tissue is divided.
   The  urethrotome invented  by Otis (Fig. 82) is very useful  in the
treatment of strictures of large  calibre.  It  is  constructed  on the

                             Fig. 82.
                       Otis's dilating urethrotome.

principle of the parallel ruler, and when closed measures 18 (French).
The bars are separated by means of a screw apparatus at the handle,
the amount of  separation being registered on  a dial.  A sheathed
knife runs in a groove cut in the upper  bar of the instrument.  The
urethrotome is introduced beyond the stricture  and then dilated up
to or a millimetre or two above the normal calibre, in order to make
the fibrous bands completely salient; then the blade is drawn through
the entire area of narrowing.
                             Fig. 83.
Gerster's urethrotome.
   Gerster's urethrotome (Fig. 83) is constructed on the same gen-
eral  principles as  that of Otis, but  possesses  the advantage  of
being readily taken apart, so that it can be thoroughly cleansed after
use. 
238       GENITO-URINARY DISEASES AND  SYPHILIS.

   Gross's urethrotome serves as an exploring and a cutting instru-
ment at the same time.   When  the  shoulder  of the bulb is brought
up to the posterior face of the stricture the  concealed blade can be
protruded and the stricture divided as the instrument is withdrawn.
   The choice of the urethrotome is of small moment in the internal
cutting  of stricture.   The essential  feature of the operation is  that
a linear incision should be made in  the roof of the urethra (except
at or near the meatus or in the membranous urethra) through every
portion of stricture tissue, the cut extending from the normal parts
behind to the normal parts in front of the stricture.
   If the narrowing is of very small calibre, a preliminary urethrot-
omy from before backward may  be done with  Maisonneuve's instru-
ment, after  which a dilating urethrotome  completes the  operation
from behind forward.  Careful observance of the principles of urethral
and  urinary antisepsis as  already described (page 221) reduces to its
minimum the risk always  attendant on internal urethrotomy.
   In children internal urethrotomy has the  same applications as in
the adult, but the urethrotome must be modified in calibre and length
to suit the age of the individual patient.
   External  Perineal  Urethrotomy.—By this  operation  the
urethra is opened by an  incision carried inward from the skin  sur-
face  of the perineum.   In accordance with  the  calibre of  the stric-
ture, certain modifications will be necessary in the performance of
this  operation.
   Thus, if  the stricture is permeable, 1, external perineal urethrotomy
with a guide, or Syme's  operation, is indicated, a  grooved staff being
carried  through the narrowing and the incision being made on this.
   If the stricture is impermeable,  2, external perineal urethrotomy
without a guide, or "perineal section," is indicated, a staff being carried
down to  the anterior  face of  the stricture and the urethra being
opened at this point; subsequently, aided by sight, the  stricture is
divided from before backward.   In some  cases it is advisable not to
operate on  the  stricture,  but simply to relieve  retention ; then, 3,
Cock's operation of tapping the urethra at the  apex of the prostate is
performed.
   1. External Perineal Urethrotomy with a Guide, or Syme's Oper-
ation.—The instruments  required for  this operation  are  a grooved
staff, a scalpel, a probe,  a  broad grooved director, or a Teale's probe
gorget (Fig. 84), and a soft rubber or English  catheter of large calibre.
The  grooved staff (Fig. 85) has a narrowed terminal part which is
passed through  the  stricture.  Where this narrow portion joins the
shaft there is a shoulder, which rests against the anterior face of the 
STRICTURE OF THE URETHRA.
239
stricture  when the instrument  is in  position.   The patient  having
been etherized, the staff is introduced, and  the  patient is placed in
the lithotomy position.
Teale's probe-ended gorget.
   The use of the Syme  staff is possible only when  the stricture
will admit  at least a  No. 6 F. instrument; when  it is  so tight that
nothing larger than a filiform bougie can be passed, a grooved staff
similar to Syme's, but  with a  quarter  of an inch  of its extremity

                              Fig. 85.
Syme's grooved staff.
bridged over so as to convert the groove into a canal, a " tunnelled
catheter staff" (Fig.  86), is  used, and  is threaded over a  filiform
bougie.
                              Fig. 86.
          n   /F\/^i______CA.E.NTZ frSCm'a___________________
                         Tunnelled catheter staff.             ¥\

   In  passing  the filiform the urethra is  first  overdistended with
carbolized oil, then the  filiform  is  gently introduced.    If it  enters
a false passage it  is held in place, while another bougie is passed by
its side.  The second is allowed to remain where it is  arrested, and
other bougies are passed, some straight-tipped, others angled or cork-
screwed, till finally one goes  through the stricture into the bladder.
The  other guides, often five or six  in number, are then withdrawn.
The  tunnelled staff is threaded over the free end  of the  filiform, and
is gently pushed towards the  bladder, the  guide being held  by the
left hand.  It is best to release this guide, if the  strain and friction
become great, and allow it to be pushed onward  with  the staff.   Its
end will, of course, disappear  within the urethra,  but can usually be 
240
GENITO-URINARY  DISEASES AND SYPHILIS.
found again within an inch of the meatus by pressing the penis back-
ward after the metallic instrument is in the bladder; if it cannot be
found thus, it will certainly reappear when the staff is withdrawn.
   In whatever way the staff has been  passed, the assistant who holds
it is directed to make  its convexity bulge in the perineum.  The left
forefinger of the operator is inserted into the rectum, and  an incision
is made one inch in front of  the anus and exactly in the median line
of the perineum.  This incision is deepened till the knife-point enters
the groove of the narrow part of the staff, usually behind the stricture.
The  latter is then divided  by cutting  from behind  forward until the
projecting shoulder of  the  staff is  freed and passes  onward  towards
the bladder without difficulty.  A  director or Teale's probe gorget is
now introduced along the groove of the staff into the bladder, and the
staff is withdrawn.   Finally  a rubber  catheter,  No.  20 to No. 24 F.,
is passed from the meatus  into the bladder, guided by the  director or
gorget, and aided in its course by  manipulation through  the wound.
This catheter is  retained  for three  days,  and is then  withdrawn.
Should  urethral  or vesical  irritability  prevent the  retention of a
catheter, a tube may be passed into the bladder through the perineal
wound and retained in position by silk threads  secured to a J band-
age.   In from five to seven days a full-sized sound is passed through
the penile urethra into the bladder, and this is repeated every third
day for a  month, after which the intervals  between instrumentation
may be  made progressively longer.
   If the  filiform passes but  the tip of the tunnelled staff cannot be
forced through the stricture, the latter  is held in contact with the
anterior surface of  the narrowing by an assistant, and is  exposed by
a free incision in the median line of the perineum, splitting the urethra
in front of the stricture ; a loop of silk is then passed through each
edge of  the  divided  urethra  close to the face of the narrowing, thus
enabling the canal  to be held open.   The  staff is withdrawn a little
in order to bring the black filiform into view, and then the stricture
is divided from  before backward, together with half an inch of the
uncontracted canal  behind it, by means of a probe-tipped bistoury.
The  last step consists in passing the staff, guided by the filiform, into
the bladder.   The  subsequent treatment is the same as in  Syme's
operation.
   The  general indication for external urethrotomy is the existence in
the deep urethra—i.e.,  posterior to the bulbo-membranous juncture—
of a stricture not amenable to dilatation.  Under this head will come
a great variety of strictures, which may be classified as follows.
   1. Stricture which is resilient  or  so  densely fibrous  that it will 
STRICTURE OF  THE URETHRA.
241
not yield to either continuous or intermittent  dilatation.  Traumatic
stricture is  typical of this class of cases.   2. Stricture behind which
extravasation of urine has occurred.  3. Stricture  complicated  with
perineal abscess, the latter being laid open  at the same time that
the stricture is divided.   4.  Stricture complicated with fistula? which
do not close after full dilatation.   5.  Stricture complicated with a cys-
titis so intense that  continuous drainage of the bladder is indicated.
6. Stricture associated with enlargement of the prostate  and refusing
to yield to dilatation.  7. Stricture complicated with retention of urine
or with the " incontinence of retention."  The high  degree of atony
of the bladder which ordinarily exists in these cases renders perineal
drainage exceptionally desirable.  8.  Stricture in which urethral  fever
follows instrumentation, or in which renal congestion or nephritis is
known to exist.
    The Prognosis of Stricture after External Perineal Urethrotomy.—
The thorough  division of stricture by  external  urethrotomy occa-
sionally results  in cure without further treatment.   This, according
to Guyon, is because the elastic  fibres of the urethra run circularly;
when cut they retract, and restoration of the urethral lumen is accom-
plished by means of a wide scar, which  usually  does  not contract
sufficiently to produce stricture again.
    It is possible that  recent strictures unattended by submucous
fibroid  infiltration can be cured  either by gradual dilatation or by
section.  When there is distinct fibroid periurethral infiltration, with
decided alteration of the mucous membrane, section, followed  by a
prolonged  course of gradual  dilatation,  will  usually accomplish a
practical but not a truly radical cure.  In densely  fibrous inodular
stricture a  radical cure can be attempted  only by means of excision,
and even  then will  probably not be attained :  hence, though a stric-
ture be cut, either internally or externally, the  intermittent use of the
sound for a long period should be advised.
    Combined Internal and External Urethrotomy.—This operation is
described  by Reginald  Harrison, its  chief advocate, as  follows: The
stricture is divided by means of a urethrotome.  The patient is  then
placed in the lithotomy position, a grooved staff is introduced, and, with
a long, straight knife entered one inch in front of the anus, the mem-
branous urethra is punctured, the back of the knife being towards the
rectum.  The incision is  slightly enlarged forward, to permit the in-
troduction  of  the index finger.  If the staff is not fully exposed, a
somewhat  dull  though pointed knife is introduced along the finger,
and  the tissue  still remaining between  the tip of  the finger and the
groove is cleared away.   If a sharp  knife is used, there is danger of
                                16 
242
GENITO-URINARY  DISEASES AND  SYPHILIS.
making the incision unnecessarily large or of cutting the finger.  The
incision is planned first to fit the finger and afterwards the drainage-
tube.   When  the groove of the staff is felt, a probe-tipped gorget is
slid along it, the staff is removed, and a drainage-tube is passed along
the concavity of the gorget into  the bladder.   This tube drains the
bladder directly, giving the urethra physiological rest.   It is retained
seven to ten days ; after the second day it is taken out and cleansed
daily, and the bladder is  irrigated twice daily with a 1 to 10,000 or 1
to 5000 sublimate solution.
    This  operation possesses the advantage of preventing the freshly
cut stricture from being irritated by the urine.  Since contact with
urine is  an essential factor in the production  of  organic stricture,
such  a diversion of the  stream during  attempts at  radical cure is
worthy of consideration  whenever resilient, inodular,  or traumatic
anterior strictures are cut, or whenever the coarctation is complicated
by fistulae; physiological  rest is  thus  obtained for the whole region,
and the inflammatory products in the wall of the urethra are allowed
to undergo fatty degeneration and absorption.   In deep  strictures the
combined operation  is less likely to be useful, as external urethrotomy
meets the same indications, the incision being carried behind the stric-
tured region into healthy tissue  and the retained catheter serving to
divert the urine.
    Harrison,  however,  particularly  recommends  his  operation  in
cicatricial, contractile, and relapsing strictures  seated in  the  deeper
part of the urethra,  claiming for it the following advantages: 1.  It is
applicable  to  the worst  forms  of  urethral  strictures.  2. It  guards
against rigors, fever, and the complications which  tend to rise  from
these.  3. It tends  to  improve  permanently  the  condition  of the
stricture.
    Experience has shown that if the tissues can be freed  from every
source of irritation  and  can be given physiological  rest for a long
period, hardened lymph  will disappear and the  urethral walls again
will become soft and yielding.  Drainage by perineal opening is the
only way in which complete rest can be given to the strictured region.
    Perineal  Section.—This  operation  is  reserved  for strictures
through  which the smallest instrument cannot be  made to  pass.
Such strictures, whether gonorrhoeal or traumatic, are usually deeply
seated, and are approached through the perineum.  There are two
principal methods of operating.
    a.  Wheelhouse]s  Operation.—A  special hooked staff (Fig.  87) is
required, in addition to a probe-tipped gorget, scalpel, forceps, needles,
etc.  The patient is placed in the lithotomy position, and the staff is 
STRICTURE OF  THE  URETHRA.
243
introduced with the groove towards  the floor of the urethra,  its
hooked  extremity  being  brought gently into contact with the stric-
ture.  No force is permissible,  since  the urethra in these  cases  is
readily torn.  While an assistant holds the staff in position, an incision

                             Fig. 87.


                          Wheelhouse's staff.

is made in the perineum, and the urethra is exposed, and is opened in
the groove of the staff, not upon its point, thus making the incision at
least a quarter of an inch in front of the stricture, since the groove is
not continued to the hook-shaped extremity of the staff.  Through the
edges of the urethral incision are passed by means of curved needles
stout silk threads, one on each side, forming loops, by drawing  on
which the urethral walls are retracted.   The staff is gently withdrawn
until  the button point appears in the  wound.  It  is then  turned
around  so that the groove faces the roof, and the button is hooked in
the upper angle of the open  urethra.  The urethra is now stretched
open at three points just  in front of the stricture.  The button on the
staff, however, is often in the way, and, if so, this instrument should
be withdrawn.  With  the anterior surface of the stricture thus ex-
posed, the narrow opening  through  it is often seen, and a probe-
pointed  director is passed without difficulty.  Even if warty growths
or granulations conceal the position of the narrowed channel, careful
probing with  the director usually results in the  ready passage of the
latter into the bladder; this is shown by the freedom with which the
tip of the director can be moved about.  The groove of the director is
then turned downward, and along it the whole length of the stricture
is carefully and fully divided, this part of the operation being completed
by running a straight probe-pointed  bistoury  along the  groove  to
insure the cutting of every band.  Teale's gorget is now passed along
the groove of the director into the  bladder, and the director is with-
drawn.   The object of the gorget is to facilitate the introduction  of
catheters into  the  bladder, at times a most difficult procedure  after
perineal section. A silver catheter is passed from the meatus  into the
bladder, the gorget is withdrawn, and the catheter is fastened in the
urethra.  After three or four days the catheter is removed.  Sounds
are then passed daily or every second day or every third day, accord-
ing to circumstances, until the wound in the perineum is healed, and
after that from time to time to prevent recontraction.
   If  the probe-pointed  director does not find  the opening through 
244
GENITO-URINARY DISEASES  AND SYPHILIS.
the stricture, the operation must be continued by dissection until the
urethra is fairly opened.  If the bladder contains urine, pressure on
the hypogastrium, or bimanual pressure, one hand being placed on
the abdomen and a finger of the other in the rectum, will often cause
the expulsion of some urine, and thus show the opening through the
stricture.   The use of very hot water will sometimes be of service by
emphasizing the  difference  in  color between the surrounding parts
and the urethra, the latter being much paler.
    The operation requires a good light, and often much patience.
    b.  Cock's Operation.—This consists in  tapping the urethra at the
apex  of the prostate,—i.e., behind the  stricture,—no  guide having
been passed.
    The patient is placed in the lithotomy  position exactly on his
back, so that the surgeon may not be misled  as to the position of the
median line.
    The left forefinger of the operator is introduced into the rectum,
the bearings of the prostate are carefully noted, and the tip of the finger
is lodged  at the  apex of the gland.  A sharp-pointed, double-edged
knife is plunged boldly and steadily into the  median line of the peri-
neum, and carried on towards the tip of the left forefinger, which lies
in the  rectum.  By an upward and  downward movement the vertical
incision in the median line may be enlarged to any extent that is con-
sidered desirable.  The knife is never to be withdrawn in its progress
towards the apex of the prostate,  but its onward  course must be
steadily maintained until its point can be felt  in close proximity to the
tip of the  left forefinger.  When the operator has fully assured him-
self of the relative positions of his finger, of the apex of the prostate,
and of the point of the knife,  the  latter is advanced somewhat ob-
liquely, either to the  right or to the left side, and it can  hardly fail
to pierce the urethra.  If, in this step of the operation, the  anterior
extremity  of the prostate is incised, it is a matter of little consequence.
It is of the utmost importance  that the knife should not be removed
from  the  wound, and that  no deviation be  made from  its original
direction until the object is accomplished.  If the knife is prematurely
removed it will probably, when reinserted, make a fresh incision.
The knife  is now withdrawn, the  probe-pointed  director is carried
through the wound and  passed into the bladder, and, lastly, the finger
is withdrawn from the rectum.  A  drainage-tube is passed along the
director, the director  is removed, and the tube is tied in.  Through
the tube the bladder may be washed out.
   Indications for External Perineal  Urethrotomy without a Guide.—
Perineal section in  some form  is indicated in all cases of  impassable 
STRICTURE OF THE  URETHRA.
245
stricture.  If there are no other complications, Wheelhouse's method
is the best to employ.   But in cases in which a portion of the urethra
has been practically destroyed, in which urinary extravasation  has
occurred, and  the  perineum is riddled with sinuses, and in those of
great urgency from  retention,  when no  aspirating apparatus is at
hand, Cock's operation is indicated.  The operation is a difficult one,
is  sometimes disappointing in the best hands, and should be aban-
doned if the urethra is not opened at the first or the second trial.
   Retrograde Catheterization.—When all guides fail, and when after
perineal section the proximal end of the urethra cannot be found, as
in cases of  traumatic stricture with practical obliteration of the canal,
a suprapubic cystotomy and retrograde catheterization are indicated.
The  slight additional risk is far outweighed by the advantages to the
patient of having even an imperfect restoration of  the urethral canal.
   In performing  retrograde catheterization the suprapubic opening
into  the bladder is made sufficiently large to admit the  finger; guided
by the latter, which can  readily feel the vesical orifice of the urethra,
a steel  sound or a silver catheter is introduced from behind forward
till its tip becomes apparent through the perineal opening.  When
the belly is prominent it may be difficult to pass an ordinary sound,
by way  of the small vesical  opening, into and through the prostatic
and  membranous  portions of the urethra.   To obviate this difficulty
Guyon  has  suggested an instrument with  a longer or more com-
plete curve ; in the absence of this, an English gum catheter, provided
with a stylet and  with the required  curve given it and fixed for the
time by  immersing the  instrument in cold water, may be  employed.
As soon as the tip is freely exposed through the perineal Avound, a
soft catheter, the end of  which has been cut off, is slipped over it;  on
withdrawing the sound   this  catheter is carried from the  perineum
through the suprapubic  opening.  A sound  having been passed from
the meatus to the perineal wound, the other end of the soft  catheter
is forcibly pushed  over its tip and is drawn forward  till it projects from
the meatus.   The tube is left in place for from five to seven days.
   Drainage after External Urethrotomy and Perineal Section.—Many
authorities  advise  that in cases of section for stricture no catheter
should be employed, or that at the most a short  perineal  drainage-
tube  should be used.   Others direct that a catheter should be kept
in  for forty-eight  hours  and  then withdrawn.   Drainage  should  be
used, and  is best provided  for by  a large English  or soft  rubber
catheter (No. 20 to No. 24 F.), passed through the urethra till its eye is
jud within the bladder, and retained in position from three to five days.
If  the end of the catheter is  not allowed to project far into the blad- 
 246        GENITO-URINARY DISEASES AND SYPHILIS.

 der, and if it is kept clean and sweet by regular antiseptic  injections
 repeated twice daily, it is most efficient as  a  means  of preventing
 urethral fever.   After removal of the catheter  first introduced, regular
 dilatation at short intervals is indicated.
    The traumatic urethritis  which the retained catheter or the fre-
 quent use of the instrument is said to occasion will hardly ever occur
 when antiseptic irrigations are properly used, and when the urine is
 sterilized by the administration of drugs by the mouth.
    These irrigations must cleanse both the bladder and the urethra.
 In practising them the urethra is carefully washed out with the  solu-
 tion of choice, the nozzle being introduced into the meatus beside the
 soft  catheter.   This injection is repeated several times; when there
 has been a combined internal and external urethrotomy the cleans-
 ing lotion  passes  completely through  the  anterior urethra, escaping
 by the  perineal  opening.  After having thus washed the  anterior
 urethra, the bladder is  twice gently injected with four  ounces of the
 antiseptic solution, a clean sterile nozzle being used.  The tube  from
 an irrigating bag containing the antiseptic and  hanging two feet above
 the level of the bladder  is then attached to the  catheter, and the
 latter is slowly withdrawn till  the fluid  escapes  through the meatus
 or through the perineal wound.  The urethral mucous membrane is
 flushed with from  a pint to a quart of  the  antiseptic, after which the
 catheter is passed in till its  eye  lies just within the bladder, and is
 secured in  place till the next washing.
   Miscellaneous Methods.—Excision.—A number  of  successful
 cases of excision, usually for traumatic stricture, have been reported
 by Heusner, Koenig, Poncet,  and others.
   Poncet  states that the indications  for urethrectomy are found in
 the  existence of marked fibrous periurethral induration  encircling
 urethra in the perineum, and in a history of previous unsuccessful
 operations.
   Mayo Robson describes as follows his procedure in a case which
 he  says  six  months  afterwards easily  took  a  No.  13 (F.)  sound.
 The stricture on being fully exposed was found to consist of a fibrous
 cicatricial band about  one-fourth of an inch wide, involving mucous
 membrane, submucous  tissue, and the spongy structure of the bulb.
 The  whole of  the cicatrix was  excised, and the cut ends of the
 mucous membrane were  drawn  together over the gap thus formed
and  secured by a  continuous catgut suture.   A catheter being  then
passed into the bladder,  the longitudinal incision into the urethra
was united by catgut, thus closing the canal and leaving a continuous
and closed  urethra.  The  last sutures were an  after-thought, and per- 
STRICTURE  OF THE URETHRA.
247
haps unnecessary, for they gave way on the second day, and the urine
partly escaped for some little time by the perineal wound, which
healed by granulation, as in the ordinary boutonniere operation.
   Rollet, Southam, Sapregko, and others  report  excellent results
from excision of  densely fibrous  strictures, with subsequent suturing
of the  urethra over a catheter.   Rollet's case is  particularly encour-
aging.  His patient presented a brawny, greatly swollen perineum,
riddled with abscesses.   The  infiltrated perineal  mass was removed,
together with two inches of the urethra. A catheter was introduced
into  the bladder, the urethra was sutured,  and  the perineal tissues
were  closely  apposed about the catheter by rows  of buried catgut
sutures.  The catheter was kept in  place more than a  month.  Two
months later the patient's urethra  was  said to  be  still  functionally
satisfactory.
   Excision with Transplantation of Mucous Membrane.—Wolfler has
reported three cases in which  he employed Thiersch's method of
transplanting epiderm for the radical cure of impermeable stricture.
The  strictured portion of the urethra was  first excised, and after-
wards  the granulating  surface was entirely covered  with mucous
membrane dissected from a prolapsed  uterus.   This mucous mem-
brane was kept  in place by a packing of iodoform  gauze lubricated
on the inner side  with vaseline.  The first patient one year after,
and with  no  intermediate  treatment, urinated a thick  stream.  The
second did as well, but  the observation  had not lasted so long.  The
third died six months after the operation, from double nephritis, and
the autopsy showed a continuous mucous membrane.  The bounda-
ries between  the old and the new mucous  membrane could not be
clearly demonstrated.
   Electrolysis.—The  evidence adduced in favor of this method  is
insufficient to warrant its general adoption, and does not even justify
a belief in its usefulness in the average case.
   Divulsion.—This method  is  clumsy, uncertain,  and dangerous.
Under this general heading may be included forced catheterization,
immediate progressive dilatation, tunnelization, progressive divulsion,
and the modifications of  this latter  method.  All  involve rupture
of the mucous  or  submucous tissue  to an indeterminable extent
and to an uncertain point, and have all the disadvantages of internal
urethrotomy,  with  the superadded  risk of a lacerated  and contused
wound as compared with an incised  wound.
   Overdistention  of the  urethra has been especially advocated by
Tuttle, who devised a special instrument for  its performance.  While
it avoids many of the  dangers of divulsion, it would seem that  it 
248
GENITO-URINARY DISEASES  AND SYPHILIS.
must produce at least  minute tears of the mucous surfaces.  The
reported results  justify a careful testing of the method.
   Water and air have been employed, but rather as a means of
rendering tight strictures permeable to filiform  bougies  than with the
idea of producing any marked dilating  effect.  Hot water should  be
employed. A catheter provided with a terminal aperture is introduced
into the urethra and is kept well  down on the face of  the stricture.
Through this catheter, by means of a fountain  syringe, the  bag  of
which is  elevated  four  feet, the  water  is injected, the penis being
compressed on  the  catheter shaft to prevent the reflux of the water
and thus  loss of pressure.  The  seance lasts from three-quarters of
an  hour to an hour.  On removal of the water-pressure an attempt
is made to pass a filiform, and if this is  successful the case  is then
treated by one of the various methods already described.  The heat,
the pressure  of the water, and the gentle, continued pressure of the
catheter against the opening are said to cause the good  result.
    Massage has been employed by Antal with alleged  beneficial re-
sults in six cases.
    Cauterization is antiquated and barbarous.

                    SUMMARY OF TREATMENT.
    1. Gradual dilatation is indicated as the treatment of choice in all
recent, soft, or dilatable  strictures found  in any  part of the urethra,
without regard to the calibre of such strictures.
    2. Continuous dilatation is indicated  in uncomplicated  strictures
which are so tight that no instrument larger than a filiform can be made
to pass.   This continuous dilatation is practised till a small metal in-
strument  can be introduced,—No. 12 to No. 16 F.   Then the  normal
calibre of the urethra is restored by gradual dilatation or by cutting, in
accordance with the nature and the clinical behavior of  the stricture.
    3. Internal  urethrotomy is indicated  in all fibrous, irritable, and
resilient strictures anterior to the bulbo-membranous juncture.  Nar-
rowings at or near the meatus should be treated by the knife whenever
it is apparent that they are responsible for definite symptoms.  The
division is here made on the floor of the urethra.  All  other anterior
strictures are divided along the roof.
    4. External perineal  urethrotomy is indicated in all fibrous,  re-
silient, or irritable strictures situated behind the bulbo-membranous
juncture.
    5. Combined internal and external urethrotomy is indicated in the
treatment of anterior strictures which are  unusually dense or nodular
and which are complicated by fistula?. 
STRICTURE OF THE  URETHRA.
249
   6.  Perineal  section,  or  external perineal urethrotomy without a
guide, is indicated in the  treatment  of impassable  stricture of the
deep urethra.   When the  proximal urethral  end cannot be found,
suprapubic cystotomy and retrograde catheterization are justifiable.
   7.  Tapping the urethra at the  apex of the prostate, or Cock's
operation, is indicated when  an overfull bladder must be  relieved,
and when the surgeon is not prepared either to aspirate or  to divide
the stricture.
   8.  Excision is indicated in cases of impermeable stricture, nodular
or fibroid,  where  there has  been  complete destruction of mucous
membrane.  When so much  tissue is removed that it is impossible
to bring the divided urethral ends in apposition, transplantation of
mucous membrane is indicated.
   Formulating the  operative  indications  in accordance  with  the
clinical features of the stricture, the following  summary of treatment
is given.
   1.  Narrowings at or  near the meatus, if treated at all, are always
cut.
   2.  Strictures of large calibre (greater than 15 F.) are treated by
gradual dilatation.  Cutting is  almost never  required when such a
stricture is in the deep urethra ; it is sometimes  necessary when the
stricture is anterior to the bulbo-membranous  juncture.
   3.  Strictures of small calibre are treated by gradual  dilatation
if possible ;  when in the  deep  urethra they  often require  external
urethrotomy; when anterior to the  bulbo-membranous juncture they
usually require  internal  urethrotomy.
   4.  Impermeable strictures are treated by perineal section, followed
at times by excision and mucous membrane grafting.
   5.  Soft, recent, uncomplicated strictures are always dilated.
   6.  Fibrous,  nodular, irritable strictures complicated by urinary
fever,  fistula, etc., are always  cut.

             STRICTURE OF THE FEMALE URETHRA.
   Stricture of the female urethra is  comparatively rare.   In cause and
symptoms it corresponds with the like condition of the male urethra.
It may be congenital or  acquired, and the acquired stricture may be
spasmodic, inflammatory, or organic.  The congenital stricture is, as
in the case of the male,  usually placed at or near the urinary meatus.
   Spasmodic stricture, that due to muscular spasm, is more frequent
than in the male.   This is  doubtless owing to the greater reflex sus-
ceptibility of women.  Familiar  examples are afforded by retention
of urine due to  fright, exhaustion, exposure, urethritis, caruncles, etc. 
250
GENITO-URINARY DISEASES  AND SY^PHILIS.
    Inflammatory stricture—i.e., encroachment on the urethral calibre
by acute inflammatory swelling—probably never becomes sufficiently
marked to produce retention, this when it occurs being due to spasm
reflexly excited from the hypera?mic and hypera?sthetic areas.
    Organic stricture is due  to  trauma, commonly  inflicted during
childbirth, or  to inflammation, usually  gonorrhoeal in nature, but is
sometimes  occasioned  by a  urethral  calculus,  or by the virus of
chancre  or chancroid,  or  by irritating applications.   The  urethral
narrowing is due to the contraction of the fibrous tissue which has
been deposited in the walls of the canal as an inflammatory infiltrate
and which has subsequently become organized.  Hermann states that
in old women there is found stricture due to general fibroid thickening
of the urethra, occurring without  any history of gonorrhoea or other
discernible cause.  The seats of narrowing are oftenest at or near the
meatus and near the neck of the  bladder.  The stricture  is usually
single, and frequently occasions so little inconvenience that its presence
is not suspected by the  patient.
    Skene states that organic  stricture sometimes occurs at the junc-
ture of the urethra with the bladder, and  that even though it be of
large calibre it occasions symptoms out of all proportion to the amount
of narrowing  it produces; this  is probably because there is infiltra-
tion of the vesical sphincter and interference with its function.  Diffi-
cult urination and retention  are the most characteristic symptoms,
the stricture being of such  large calibre that it may escape detection
by the bulbous bougie.
    Symptoms.—The symptoms of stricture in women are frequent
urination, dribbling after the act, the passage of an irregular stream,
and often urethral discharge.
    At times the only symptom is an occasional attack of retention of
urine occasioned by slight causes, such as exposure  or fatigue, and
usually ascribed to muscular spasm.  Though the spasmodic element
is in these cases always  the exciting cause of the retention, the pre-
disposing cause will  occasionally be found to be a urethral stricture
of large calibre.
    Difficult urination and sometimes retention particularly character-
ize  stricture at the juncture of the urethra and the bladder.
    Diagnosis.—The diagnosis  is made by careful examination of the
floor of the urethra by means of  a finger introduced  into the vagina
and by the passage of bulbous bougies.   By the vaginal touch cica-
tricial induration of any part of the urethra, if marked, can be found.
This is the  most reliable method of detecting  the stricture of the
neck of the bladder, described by Skene, since  the narrowing may 
STRICTURE OF  THE  URETHRA.
251
be so slight that a comparatively large  instrument may pass through
readily.
   In passing the bulbous  bougie it must be borne in mind that the
urethra in women has two points of physiological narrowing,—i.e., the
meatus and the neck of the bladder; the canal between these points
admits of wide dilatation. If a very large bulbous bougie is introduced,
the resistance offered to the inward or outward passage of the instru-
ment by the seats of normal narrowing might readily be mistaken for
that due to organic stricture.
   Prognosis.—The prognosis of stricture of the urethra in women is
much less serious than is the  case with men.  The  narrowing rarely
reaches  such a  degree that the function of  micturition is greatly in-
terfered with, and hence the  train of vesical, renal, and general vas-
cular  changes which ultimately  result fatally is  rarely inaugurated.
In  exceptional  cases  when  the  urethral calibre  is  markedly  en-
croached on, if  the  condition is unrelieved, the prognosis is the same
as for men.
    Treatment—Congenital or inflammatory narrowings of the meatus
should be cut freely, the normal calibre being maintained by the use
of a meatus bougie.  The  directions given  for the performance of
meatotomy in the male obtain in these cases.   Soft, recent, dilatable
strictures are gradually cured by short straight steel sounds.  Dense,
traumatic,  nodular,  irritable, or resilient strictures  are  treated by
internal urethrotomy.   When the urethra is totally obliterated at one
point the propriety of excision and  of  mucous membrane transplan-
tation may be considered. 
CHAPTER  VII.
urethral   fever.—fistula.—pouches.—vegetations.—tuberculosis.—
   cancer.—cysts and cancer of cowper's glands.--care of urethral
   instruments.
   Urethral fever, called also urinary fever and catheter fever, is the
most serious sequel of mechanical interference with the urethra, and
is due to absorption of bacteria or their poisonous products through a
hypera?mic or abraded mucous surface.
   Since  the  passage of an instrument  into the  urethra has  been
shown to  produce a sudden, sometimes very pronounced fall of blood
pressure, it is  not  difficult to account for the syncope  so frequently
observed as a result of even the most gentle introduction of the sound.
As a direct or remote result of this primary reflex influence on the
circulation, when the kidneys  are already diseased, it is conceivable
that  their secretory function may be abolished, and  that death may
result from  the  ura?mia  incident to anuria.  Such cases—i.e., those
characterized by syncope, collapse, or anuria, presenting all the symp-
toms of shock  and  exceptionally terminating fatally in a very few
hours—are  not  properly classed under  urethral  fever,  and should
receive  the immediate stimulating treatment appropriate to syncope
or shock and afterwards that called for in ura?mia.
   There  is, however, evidence that the reflex  element, aside  from
primary syncope, plays a minor role in the development of the phe-
nomena just described.  Although certain forms of urinary fever are
apparently too rapid  in  their course to be ascribed  to septic infec-
tion, Albarran reports a case of internal  urethrotomy in which the
bacterium coli commune was found  in the blood of the patient, who
died twelve hours after operation.  This same micro-organism was dis-
covered in the urethral pus.  From this and from many similar cases
it would seem clear that even though the classical symptoms of septic
absorption are absent,—i.e.,  chill, fever, and sweat,—and though the
case  progresses to a fatal issue in a few hours, this rapid and irregular
course does not necessarily imply a reflex non-septic inhibition of the
renal function.   When the kidneys are  already crippled, it is possible
that  even  slight interference with the urethra may arrest their action,
and as a result death  may occur independently of sepsis.
   Etiology.—Retention of urine, with the consequent  effects on the
     252 
URETHRAL FEVER.
253
bladder walls and the kidneys,—i.e., chronic  cystitis,  pyelitis, and
nephritis,—acts as a strong predisposing factor in the development of
urinary fever.  As an exciting cause, contact of infected urine or of
purulent discharges with fissure or abrasion of the mucous membrane
of the  urethra is sufficient.   Urethral fever by no means follows as a
rule  in consequence of such contact. It is well known that forcible,
clumsy, unsuccessful catheterization,  attended by profuse bleeding and
rupture of the urethra, may be followed by no  constitutional symp-
toms, while the most skilful and gentle introduction of an instrument
may cause a malignant form of urinary fever.
   Lesions situated behind stricture and seats of obstruction, and
particularly lesions of the deep urethra, are more liable to be followed
by urinary fever than are wounds so placed  that the septic fluids are
not driven into them.
   It has been  noted  frequently that in cases where urinary fever
occurred each time a  stricture was  sounded,  instruments  could  be
passed with  impunity on complete cure of the narrowing.   In some
cases no fever develops till after  the urine has come in contact with
the raw surface : thus it is not uncommon to have a post-urethrotomy
urinary fever delayed till from the third to the fifth day, when the per-
manent catheter is removed, and the urine is allowed to flow over
the raw surfaces.  After perineal  urethrotomy and cystotomy, urinary
fever is extremely rare.
   The constitutional symptoms  incident to rapid extravasation  of
urine are those characteristic of diffuse cellulitis, and are not properly
classed with urinary fever.
   Symptoms.—The particular form in which urinary fever may mani-
fest itself is  quite independent of the severity of the  exciting  lesion,
since in at least one  reported  case, in  which  death  occurred a few
hours after the passage of a catheter, no  breach  was found in the con-
tinuity of the urethral mucous membrane.  The character of the fever
is probably dependent on the virulence of the germs and on the tissue
resistance of the individual.
   Guyon classifies urinary fever under the general headings of acute
and chronic.
   Acute urinary fever may take one  of the two following forms:
1, single paroxysm ; 2,  recurrent paroxysms.
   Acute Urinary Fever.—Single Paroxysm.—This is characterized
by chill, fever, and sweat.  The chill may come on a few minutes after
catheterization ;  usually it follows the first act of micturition subse-
quent to urethral interference.   The chill is pronounced,  the fever
high, 103° to 105° F., the sweat copious. 
254
GENITO-URINARY  DISEASES AND SYPHILIS.
   There is a single paroxysm, which subsides in  twenty-four hours:
at its height there may be  pain in the  head and back, delirium,
dyspnoea, nausea, and vomiting.  Usually the pulse is full and strong,
the mind is clear, and the patient feels comparatively well.
   This  form of urinary fever is the most common, and when  it is
frankly expressed is not greatly to be dreaded.  If the chill is severe,
the heart action modified  out  of proportion to the  amount of fever,
and  the  patient delirious and  markedly  dyspnoeic, the chances are
that there will be renewed paroxysms.
   Exceptionally the chill is  unduly severe and prolonged, lasting
possibly  for several  hours;  the  patient becomes collapsed, vomits,
purges, ceases to secrete  urine, and  dies in a few  hours, or in  one
or two days, of shock, of ura?mia, or of virulent septic poisoning.
   2. The  form with  recurrent paroxysms, termed by Thompson acute
recurring urinary fever, is  characterized  by irregular and  apparently
causeless elevations   in  temperature,  preceded by rigors or  chills,
which are not so well marked as in the first attack, and are followed
by sweats.   The temperature in  the interim does not reach normal,
the heart action continues unduly rapid.  These paroxysms may occur
several times a day, or the intervals may be of one to several days'
duration.   Oppression in breathing and congestion of the lungs are
often noticed.  In favorable cases these attacks cease in a few days or a
week, and the patient shortly regains strength, though not so rapidly as
after the single paroxysm.  When there is a focus of suppuration, as in
cases of prostatic abscess or limited urinary extravasation,  septicemia
or pyaemia  may develop, with characteristic symptoms, and, if the in-
fecting focus is not found and drained, usually with a fatal termination.
   Chronic Urinary  Fever.—This may  directly follow either of the
preceding forms, or may develop insidiously, at times without elevation
of temperature.  Long-standing retention, and the consequent changes
in the bladder and  kidneys, are the  common predisposing factors.
The exciting factor is  infection incident to catheterization.
   Symptoms.—The symptoms  of this form of urinary fever are septic
or ura?mic.  Hectic—i.e.,  irregular  paroxysms of chills, fever,  and
sweat, with progressive loss of strength—may be  combined with dry
brown tongue, vomiting,  diarrhoea, headache, and  stupor.  This con-
dition may last  for weeks without  instrumentation, but is prone to
terminate fatally on the slightest mechanical interference with the
bladder or  the urethra.
   Prognosis.—Urethral  fever,  when  it appears as a single paroxysm
none of the stages of which are markedly severe or prolonged, is not
especially serious.  A heavy, prolonged  chill, especially if it is asso- 
URETHRAL FEVER.
255
ciated with a rapid pulse-rate out of proportion to the temperature,
and with  suppression of urine, always suggests a malignant and  at
times a rapidly fatal form of infection.
   In recurrent paroxysms, if the kidneys are healthy and the patient
is young, the prognosis is fairly good.
   In chronic urinary fever the prognosis  must  be  guarded.  Old
prostatics  who have suffered long  before being relieved usually die
when this form of urinary  fever  develops; indeed, it is commonly a
sign of septic infection of the kidneys.   In younger men  with retention
from stricture the prognosis is somewhat more favorable.
   Treatment.—Rigid antisepsis,  both of  instruments and  of the
urethra  and the  bladder, is the most potent  means  of  preventing
urinary  fever.  Before  operating  on the urethra a  preliminary bacte-
riological  examination of the urine  is advisable.  If virulent colonies
of the colon group are found, it is well  to postpone operation till these
have disappeared  as a result of  internal  and local antiseptic  treat-
ment, or if surgical interference  is urgently demanded this should be
followed by perineal drainage.
   Acute  urinary fever, characterized by a single paroxysm or by re-
curring  paroxysms, provided the urine is abundant and normal and
the circulation is  not materially  disturbed, requires only rest in bed,
the administration of urinary antiseptics, a bland liquid diet, preferably
milk, and a mild saline, Hunyadi  or magnesium sulphate, in sufficient
doses to cause three loose passages a day.   When the constitutional
symptoms  are well marked, the  pulse becoming progressively more
rapid and  feeble, stimulants and  tonics are indicated, much the same
treatment being pursued as for septicemia.  Should the urine become
loaded with albumen or contain  blood, or should  the  kidneys  cease
to secrete, dry cups over the  loins, a half-dozen to each side, followed
by a digitalis poultice, full doses of tincture of digitalis, a teaspoonful
thrice1 daily (Otis), and on the supervention of uremic  symptoms the
hot vapor bath, repeated according to the indications, are the measures
which promise best results.
   When in spite of careful local  and general treatment symptoms
of septic absorption are steadily progressive, perineal drainage should
be established.   This  operation—indeed,  any interference with the
urethra—is, in the case of those who have long suffered from reten-
tion of urine to which has been  superadded urinary  fever, so often
followed by an aggravation of constitutional  symptoms  that there is a
natural  reluctance on  the  part of  surgeons to operate.   Under the
circumstances, however, such interference  practically  holds out the
only hope.  If the organism  has  already received  a fatal close of the 
256        GENITO-URINARY  DISEASES AND SYPHILIS.

germs or their products, or if the kidneys are hopelessly disorganized,
the operation can at the worst merely hasten the inevitably fatal ter-
mination.  If the infection  is  progressive because  of constant fresh
absorption from  the urethra, perineal drainage is as serviceable as is
opening an abscess in a case of ordinary suppuration.

                    FISTULA OF  THE URETHRA.
   Fistula of the urethra is an abnormal opening through which the
urine  escapes from this canal, either into the  rectum or externally.
Very exceptionally these fistule  are congenital, and  are due to the
establishment of  the function of the kidney before the urethral canal
is fully formed.    The bladder becomes overdistended, and the urethra,
not  being pervious, ruptures at a point  behind  the obstruction, thus
relieving tension  and allowing the urine to escape.
   The usual cause of urethral fistula is slow leakage of urine incident
to ulceration behind a stricture,  though suppurative  folliculitis  and
periurethral abscess occurring in the course of acute  or chronic gonor-
rhea, the lodgement of a stone or of a foreign  body, or rupture or
wound of the urethra may result in fistula formation.
   In accordance with  the position of the opening and course of the
tract the fistula  is named urethro-rectal, urethro-perineo-scrotal, or
urethro-penile.
   Urethro-rectal fistulas, in the non-congenital varieties,  formerly
were usually due to injury inflicted during the perineal operation for
stone, the rectum being accidentally wounded.
   The common  cause at the present time is the slow backward ex-
tension of prostatic abscess, the  ulceration  ultimately reaching  and
destroying the  rectal wall, and forming a small opening, except in
cases of acute  inflammation.   Tubercular or malignant infiltration,
whether primary in the urethra or in the rectum, often causes the
tissues lying between to break down.
   Finally, a foreign  body or calculus long  retained in the  prostatic
urethra may produce  urethro-rectal  fistula.   In  such cases  the
urethral opening is usually small, and  is generally in the  prostatic
portion of the  canal, at the side  of the verumontanum, the course
of the fistula being obliquely downward and backward:  hence there
is less chance  of feces passing into the urethra than of the urine
flowing into  the  rectum.  In  addition to  the rectal opening there is
often a tract opening into  the perineum.   Other tracts may form,
passing back to the perineum and to the ischio-rectal region, or through
the great sacro-sciatic foramen  opening near the  hip-joint, or upward
on the belly-wall.  The main tract, starting  from a  prostatic or peri- 
URETHRAL FISTULA.
257
prostatic  abscess-cavity, has  often  many diverticula,  forming blind
suppurating sinuses.
   The fistulous tract forms a dense, cord-like band, easily  felt  on
rectal examination, when there is not much infiltration of surrounding
tissues.   The opening into the rectum  is placed within the sphincter,
and may  be so small and so well covered by rectal folds that the find-
ing of it will  be difficult; in malignant and tubercular cases it  is
marked by a  button  of exuberant granulations.  Following large,
rapidly extending abscess of the prostate there is decided loss  of sub-
stance, the opening then being of considerable size.  The contact of
the urine often produces an inflammatory condition not  only of the
rectal mucous  membrane but also of the skin surrounding the anus.
   Symptoms.—Pathognomonic symptoms of urethro-rectal fistula are
the passage of urine by the rectum  and the escape of gas and excep-
tionally of feces through the urethra.
   The quantity of urine passing into the rectum varies in accordance
with the  size of the fistula.  When  the urethra is not obstructed, but
a few drops escape in this direction.   These usually appear externally
during or immediately after urination, though sometimes the urine is
retained  and is  discharged by the  motions of defecation, exactly as
would be a liquid stool.  Gas and feces may escape from the urethra
either during or after defecation.
   On rectal examination the nodular induration characteristic of a
fistula is  easily detected.  By means of a speculum the opening of this
tract can be found and a probe can be passed through it, encountering
the end of a sound passed through the urethra and into the bladder.
The urethral  orifice   can  sometimes  be detected  by urethroscopic
examination, and positive diagnosis  may be made by forcing a colored
liquid, such as one-tenth per cent, methyl-blue  solution, into  the
urethra, and noting whether or not  it can be seen in the  rectum.   Or
equally decisive is  the injection of  hydrogen peroxide into the rectal
opening of the fistula, the bubbles due to oxidation then appearing in
the urine.
   Diagnosis.—The  differential  diagnosis  of  urethro-rectal from
vesico-rectal fistula is made  by cystoscopic  examination and by in-
jection of colored fluids in moderate quantity directly into the blad-
der with  the patient in the dorsal decubitus.  If the fistulous opening
be in  the urethra, this solution will not appear in the rectum till the
patient urinates.  In urethro-rectal  fistula urine usually escapes only
during the act of micturition, and the inflammation of both the  rectum
and the bladder is much less marked than when the opening is directly
into the latter viscus.
                               17 
GENITO-URINARY  DISEASES AND SYPHILIS.
   A tubercular urethro-rectal fistula would be found associated with
an irregularly nodulated prostate, probably an infiltration and nodu-
lation of one or both  seminal vesicles, with  great  thickening of the
tissue lying between these two pouches, often induration and enlarge-
ment of the epididymis, and the presence of tubercular cystitis and
tubercle bacilli in the urine.   Urethro-rectal fistula occurs in malig-
nant  disease only when the infiltration is so well  marked as to be
practically unmistakable.
   Prognosis.—The prognosis of urethro-rectal  fistula in tubercular
and cancerous cases is  hopeless; even in simple ulceration, if there
has been much destruction of tissue, the chances of ultimate cure are
extremely  slight.   If the fistula is  small  it may heal spontaneously,
especially after the  relief of urethral  obstruction, which has tended
to keep it open.    The consequences of  an  uncured fistula of this
kind are usually grave, since both the rectum and the bladder become
chronically inflamed, and are  subject to the immediate and remote
complications incident to such inflammation.
   Treatment.—Spontaneous cure may take place after fistula-forma-
tion  resulting from suppuration of a prostatic gland.  This is rare.
One  case was cured by directing the patient  to urinate only when in
the position of ventral  decubitus.  The most important point in treat-
ment is to  remove obstruction  from the urethra.  Although stricture
is not a common cause of this form  of fistula, when once the abnormal
opening is formed a very slight urethral narrowing may be sufficient to
keep  it open indefinitely.
   If restoration of the urethral canal to its normal calibre  is not
followed by cure of the fistula, the tract of the latter should be  pro-
tected from the irritation incident  to the passage of urine and feces
by regular catheterization, or, better still, continuous catheterization
kept up for several  weeks, and  by the checking of diarrhoea and over-
stretching of the  rectal sphincter.   Perineal  and ischio-rectal tracts,
together with  their diverticula, should   be  opened, curetted,  and
forced to heal from the bottom by packing.
   Duplay advises the introduction into the rectum  of a silver canula
furnished  with an  apron for  the  purpose  of  closing the  fistulous
orifice in the intervals  of defecation.
   The fistula still  remaining open, repeated  cauterizations  of the
rectal orifice and of the whole tract by a stick of copper sulphate or
silver nitrate, or  by the galvano-cautery, may be tried, but will  suc-
ceed only in case the suppurating canal is very small.
   These  means  having failed, a staff is passed into the bladder, and
a probe is  introduced  into the rectum until it comes in contact  with 
URETHRAL FISTULA.
259
this staff.  External perineal urethrotomy is then performed, open-
ing the urethra at the point where the fistula  begins.  The perineal
incision  is continued in such  a way  that the  fistulous tract  passing
through the recto-vesical  septum  is  cut transversely.   The callous
walls of the fistula are then thoroughly curetted, a permanent drain-
age-tube  is  passed from  the perineum into  the  bladder, and the
portion of  the  incision bisecting  the fistulous tract is  well  packed
with iodoform  gauze.   As a  result  of this operation the urine  is
diverted from its course before it reaches the rectal opening, and the
latter frequently heals.  The  operation is  sometimes  successful  in
closing both the urethral and the rectal opening.   In case one closes
and the other remains, the operation appropriate to simple fistula will
probably be successful.
    A more radical method of procedure, and one giving a better pros-
pect of success, is  thus conducted.  A curved incision is made across
the perineum in front  of the anus, this orifice lying in the concavity of
the curve.   This incision, identical with that  employed for exposing the
seminal vesicles, is deepened till the rectal and  urethral orifices of the
fistula are exposed and  made accessible.  In this  dissection  a finger
introduced into the bowel and a  sound passed through the urethra
into the bladder will enable the surgeon to avoid wounding either the
rectum or the urethra.  The  two  orifices having  been exposed, and
the main tract and its diverticula having  been  opened, thoroughly
curetted, and cleaned, the edges of each fistulous opening are exten-
sively denuded and closed by catgut  suture  introduced as in the
closing of vesico-vaginal fistula.  When the tract is small and  fairly
direct and the  surrounding tissues are healthy, the  perineal wound
may be  closed by buried catgut sutures.   When there  have been
much infiltration and  suppuration, the wound should be packed and
allowed to heal from the bottom.
    In fistula dependent upon malignant disease  such operations are
not to be considered.
    Urethro-Perineo-Scrotal  Fistula.—This  fistula,  by  far the
commonest  of  all, is  usually due  to ulceration behind a stricture,
though traumatism, erosion by stone or foreign body, acute abscess,
ulceration extending from  caries or necrosis of the pelvis, or tuber-
cular or gummatous   infiltration, may occasionally cause it.   The
urethral orifice  is generally single, but externally there may be several
openings; this  being  due to the fact that the one first  formed  has a
tendency to contract slowly, thus obstructing the flow of urine, which
then burrows in various directions.  In cases of urinary extravasation
from traumatism several fistule may be formed at the same time. 
260
GENITO-URINARY DISEASES AND SYPHILIS.
   Occasionally the  cutaneous orifices of the fistula are placed well
back on the buttocks, down the thighs, in the region of the hip, or in the
belly-wall, though usually they are  found in the perineum and scro-
tum.  These fistule  form  dense fibrous tracts easily detected  on
palpation.  Some of these tracts end in blind  pouches, others open
externally.  They are lined by unhealthy granulations, sometimes,
though  rarely,  by epithelium.  Occasionally in their interior  calculi
are formed, or their walls are incrusted with urinary salts.  The
skin and subcutaneous tissue of the scrotum and  perineum are often
enormously thickened, producing a condition much like elephantiasis.
About the fistulous orifices large fibrous nodules of partially organized
inflammatory tissue may form.
   Diagnosis.—The  diagnosis is made easily.  Pus  and urine escape
from the surface openings of the fistula, the skin of the  perineum and
scrotum is inflamed and thickened, and  the  indurated  tracts charac-
teristic of fistula are detected  on palpation.
   Frequently  urine escapes from the opening in very small  quantity
and  acute inflammatory  phenomena are  entirely wanting.   Under
these circumstances blocking the urinary meatus during micturition
may cause a few drops of urine to escape  externally, or careful probing
through the fistula, a steel  instrument having been passed  into the
urethra, may determine whether or not the skin sinus communicates
with this mucous channel.
   Finally, the use of colored injections, or of hydrogen peroxide, or
of the urethroscope, may be necessary before diagnosis can be made.
   The differential diagnosis between urethro-perineal and  perineo-
anal fistula is founded on the  history of  the  case; in the former in-
stance there is usually a history of stricture, or at  least of dysuria,
followed by perineal abscess and escape  of urine.   Probing generally
determines definitely the  character of the fistula.  The course taken
by hydrogen peroxide or methyl-blue solution injected into the ex-
ternal opening under pressure will  also usually settle the matter
positively.   Exceptionally it  will show an  opening  into both the
urethra and  the  rectum.   Finally, in the case of anal and rectal
fistule  examination  conducted with  a good head light and a  spec-
ulum, the patient being in the knee-chest position, will  nearly always
show the  opening into the bowels.
   Through perineo-scrotal sinuses kept open by caries of the pelvic
bones there is no escape of urine.  Moreover, by careful probing the
roughened bone often can be felt.
   Sinuses dependent upon chronic  suppuration of Cowper's  glands
or of the  urethral glands can be diagnosed from fistule only by the 
URETHRAL FISTULA.
261
 absence  of  urine  leakage  and  the negative results of pressure  in-
 jections.
    Treatment.—The formation of these fistule may be prevented by
 prompt suture of the urethra in case the canal is ruptured or wounded
 either surgically or accidentally; by the  immediate evacuation and
 packing  of glandular and  periglandular urethral abscesses, followed
 by continuous  catheterization ;  and by the immediate dilatation of
 strictures as soon as they begin to give  obstructive symptoms.
    A perineo-scrotal fistula having formed, complete restoration of the
 urethra to its normal calibre is the first essential in successful treat-
 ment.  The  partial cure of stricture  is  in  these  cases  unavailing.
 Usually when the  calibre of the urethra is carried up to the point  in-
 dicated in the scale given on page 210,  the fistula, unless its walls are
 too densely indurated or have been covered with pavement epithelium,
 will heal spontaneously. At times  continuous catheterization, supple-
 mented by cleansing and stimulating the fistulous tracts, will accom-
 plish a cure.
    Since this variety of fistula, or at least its most intractable form, is
 rarely found except in conjunction with  stricture at  or about the
 bulbo-membranous juncture, it  is  advisable to restore the urethral
 calibre by external urethrotomy, employing continuous catheterization
 afterwards possibly for two or three weeks.   This not only cures the
 stricture, but entirely diverts the urine from the fistulous tracts, thus
 giving them an opportunity to heal.  If the  latter  are densely  indu-
 rated, or crusted with the salts of urine,  they should be laid open freely
 through  their entire course, curetted, and packed with iodoform gauze,
 and allowed to heal from  the  bottom.  Fibrous  nodules,  especially
 those placed about the urethra and in the skin openings of the tracts,
 should be excised.
    Urethro-penile fistula is usually encountered as a short, straight,
 single, non-indurated channel, lined with pavement epithelium,  pass-
 ing  by the  shortest route  from the urethra to  the surface, though
 exceptionally, when the urinary extravasation has taken place from
 the  mid-penile portion of the urethra, it may form a  subcutaneous
 tract, running parallel with the course of the urethra and opening just
' behind the glans.   Or the fistulous tract may pass backward and open
 near the root of the penis.
    Treatment.—The restoration of the  normal calibre -of the urethra
 anterior  to the  fistula is the first  essential of treatment, and will often
 be curative.
    If the fistula persists, regular evacuation of the  bladder by means
 of a catheter should  be continued  for  a week, the urethra receiving 
GENITO-URINARY  DISEASES AND  SYPHILIS.
Fig. 88.
an antiseptic flushing (boric acid four per cent., or silver nitrate 1 to
1000) after each  passage of the instrument.   If this  fails, and if the
fistula is direct and of  small size, cauterization of the  tract by the
galvano-cautery may cure.   This failing, the urethra should  be thor-
oughly freed  about the  margins of the opening, and  the borders  of
                    the latter having been freshened should be ap-
                    proximated by a row of catgut sutures (Fig. 88);
                    another row of silk sutures is employed to bring
                    together the  skin and underlying  fascia.  The
                    dilating  speculum or urethral  dilator greatly
                    facilitates this operation.  Undue tension on the
                    sutures and contamination by urine may be pre-
                    vented by regular catheterization, or still more
                    surely  by perineal  urethrotomy,  the  bladder
                    being drained through this opening till the fistula
                    is permanently closed.
                        If the fistula is so large that closure by this
                    operation  would entail too great  an encroach-
                    ment on the urethral calibre, a plastic operation
                    will be required.  A transplanted flap is usually
                    taken from the  scrotum; or one from  the pre-
                    puce or from the inguinal or abdominal  region
                    may  be employed.  When the flap is taken from
the  scrotum, a quadrilateral space about the fistulous opening is
freshened, a flap  of similar shape, with its  adherent base down, is
raised from  the  scrotum, and its anterior and  lateral borders are
sutured to the freshened surfaces.  In a week the pedicle is divided
and  secured  to the posterior border of the defect.  To secure success
in these  cases,  regular catheterization or perineal  urethrotomy is
necessary.
   Probably the  most  efficient way of closing these fistule is by the
operation of double lateral flaps described as appropriate to the treat-
ment of hypospadia.  (See page 57.)   The short flaps are turned  in,
bringing the  skin surfaces  towards the urethra; then the long flaps,
so freely dissected that they are  subject to  very little tension, are
brought together by sutures, their  raw surfaces being apposed to the'
raw surfaces of the inverted short flaps.
Closure of fistula.
URETHRAL  POUCHES.
   In addition to the congenital pouches already described, there are
observed sacculations at the expense of the urethral wall, due either
to gradual  yielding to vesical pressure or, more commonly, to ulcera- 
URETHRAL  VEGETATIONS.
263
tion  and abscess-formation, or to both these causes combined.  The
predisposing  factor is  inflammation incident to  stricture, especially
when there is a calculus lodged behind the stricture.
   Symptoms.—The symptoms are sufficiently characteristic.  There
is long-continued dribbling  of urine after apparent complete evacu-
ation of the bladder.   Examination  shows  either a sacculation or a
dilatation  in  the course of the  urethra, which is  distended during
the course of micturition, and which on being compressed becomes
flaccid, urine  at the same time dribbling from the meatus.  In some
cases, when the pouch contains a calculus, the latter changes position
during urination, acting as a valve.  Usually there  are no  inflam-
matory phenomena, and the tumor is compressible and painless, thus
differing from chronic urinary abscess.
    Treatment.—Treatment consists in extracting the calculus, if there
is one, either by intra-urethral manipulations or by external incision.
Strictures should be cured  by gradual dilatation, or by urethrotomy,
with perineal resection of the sac-walls if necessary.   Simple diver-
ticula behind  the stricture are usually cured by wide dilatation.  Ex-
ceptionally after cure  of  stricture the walls  of the pouch must  be
resected and  the opening into the urethra  freshened and closed  by
suture.

                    URETHRAL  VEGETATIONS.
   These  growths (which the use of the  urethroscope has shown  to
be not so rare  as was  formerly believed) appear as pedunculated  or
sessile, vascular, papillary outcroppings (Fig. 89), or as true polyps.
They grow from any portion of  the  canal, but are commonly found
in the navicular fossa and behind strictured  portions  of the urethra,
springing  from the floor.   They are usually small, but exceptionally
may attain a  size sufficient  to obstruct very considerably the stream
of urine.
   When  they develop near the meatus,  and this is their commonest
seat, they  are prone  to grow outward, projecting from the urethral
orifice as a soft,  easily bleeding, fungating mass.
   Symptoms.—These are usually slight, and are mostly mistaken for
those of gleet  dependent upon stricture.  There is a thin, muco-puru-
lent discharge, with slight burning during urination and,  if the polyp
attains large  size,  interference  with  the volume and force  of the
stream.   Often there is free bleeding on instrumentation, particularly
in cases characterized  by comparatively large areas of sessile, highly
vascular papillary hypertrophy.  The diagnosis is founded  on  an
intra-urethral examination.  The urethroscope shows these growths 
GENITO-URINARY  DISEASES AND  SYPHILIS.
usually as  slight villous  projections,  sometimes as  raspberry-like
masses, occasionally as gelatinous pyriform tumors.

                              Fig. 89.
    Treatment.—This consists in removal of the growth by means of a
wire snare, or curette, or galvano-cautery, introduced through the en-
doscopic tube.  If the polyp is snared or scraped away, the place from
which it was removed should be touched  with  glacial acetic acid  or
pure carbolic acid.   This  operation is not  difficult when the growths,
as is usually the case, are  situated near the meatus.  A dilating specu-
lum in these cases will prove more  serviceable than the closed tube.
When the growths are deep, great  difficulty may  be experienced  in
their removal.
                TUBERCULOSIS OF  THE URETHRA.
    Tubercular lesions of the  urethra  are extremely  rare.  When
observed they are usually part of a general uro-genital tuberculosis,
the prostate, seminal vesicles, testicles, bladder, and exceptionally the
ureters, exhibiting tubercular lesions.   Generally the lungs are also
invaded.
    Since the  infection  is usually descending and is carried by the
urine, its manifestations are found in the areas of physiological dilata-
tion, where the urine is most subject to delay,—i.e., in the prostatic,
bulbar, and navicular portions of the urethra.   The prostatic urethra
alone is affected in the great majority of cases.  Exceptionally lesions
are found along the entire urethra, even extending to the surface  of
the glans penis. 
CANCER OF  THE  URETHRA.
265
   These lesions may appear in the form of diffuse or clustered miliary
tubercles, indolent ulcers, or cheesy infiltrations presenting a diphthe-
roid  surface.   The ulcerating lesion may lead to stricture, as in one
case  reported by Ahrens.
   Urethral localization of tubercular lesions is favored by gonorrhoea
or by any form of inflammation which lessens tissue resistance and
breaks the surface of  healthy epithelium.  Primary  tuberculosis  in
this region, by direct infection  from without, or by localization of the
bacilli  present  in  the  blood,  is practically unknown.  The clinical
symptoms  of a general  infection,  however, may appear first in the
genito-urinary tract.
   Symptoms.—The  symptoms of urethral tuberculosis are a chronic
urethral discharge, and, when the disease affects the posterior urethra,
frequency of urination, tenesmus, pain, and  often blood at the end  of
urination.   Lesions of  the  anterior urethra usually excite  no symp-
toms other than a slight muco-purulent discharge.   Injection of silver
nitrate ordinarily occasions a violent reaction.
   Diagnosis.—The diagnosis of urethral tuberculosis is founded  on
the discovery of the tubercle bacillus, the association of the lesions
with evidence of tubercular infection in other parts of the body, par-
ticularly  in the genital  tract and  in  the lungs,  and  urethroscopic
examination.
   Treatment.—The treatment is dependent upon the extent and mul-
tiplicity of lesions  other than those found in the urethra.  When the
urethral infiltration is simply a part of a general infection, irrigation and
instillation of bichloride  solution 1 to 6000 once daily, and the use  of
iodoform bougies ten per cent, in cacao  butter or gelatin, or of iodo-
form insufflated through the tube of an endoscope, represent as active
local  treatment as is  serviceable.   A  single  or  limited infiltration
should, in the absence of lesions elsewhere, be thoroughly curetted
or removed by an external  urethrotomy, the  urethra  being resected
and subsequently sutured should complete removal require this.

                    CANCER OF THE URETHRA.
   This lesion, at least  in its  primitive form, has been  reported  so
rarely that there is scarcely sufficient knowledge upon the subject for
generalization.  It appears in the flat epithelial form in old men, and
particularly in  the persons of those who  have long suffered from
stricture and partial retention.  It has been found only in the bulbous
and the membranous urethra.
   Symptoms.—The  symptoms, during the early stage of infiltration,
are simply those of chronic  urethritis ; later there may be increasing 
GENITO-URINARY DISEASES AND SYPHILIS.
difficulty in urinating, obstruction to the passage of a catheter, and the
formation of rapidly growing infiltrations, which, in the absence of
previously existing  fistula, soften  in one or more  spots and rupture,
discharging pus, blood, and often very offensive urine.  After rupture
there is found a comparatively small  cavity with hard, irregular walls
tending to fungate in places.
    Diagnosis.—The diagnosis is based upon the dense infiltration, the
progressive  and rapid growth, and  the removal and microscopical
examination  of a portion of the tumor.  The tendency  to bleed and
fungate may  possibly prove of diagnostic value.
    Cancer of Cowper's gland, which on first examination may suggest
primary cancer of the urethra, may be distinguished from the latter
by the fact that it has at first a tendency to grow towards the skin and
rectum rather than  in the direction of the urethra, forming a palpable
perineal tumor, which, till it  has reached a large size, does not inter-
fere with the passage of a catheter or the free flow of the urine.
    In cancer of the urethra the  prognosis is absolutely bad, since
diagnosis is never made till the disease is well advanced.   The dura-
tion of  life from the time diagnosis is established is  rarely more than
six months.
    Treatment.—Immediate and complete removal of all the  diseased
parts  and of  the anatomically associated glands is indicated.  Where
this is not possible, irrigations, local washings, and morphine in suffi-
cient  doses to quiet the patient should be employed.

                   CYSTS OF COWPER'S GLANDS.
    Very few cases have been reported of cysts of the ducts of Cow-
per's  glands.  These usually form small  tumors, projecting into the
urethral lumen at the expense of its floor.   If large, they may be de-
tected by perineal or rectal palpation.  In one case the tumor opened
externally, discharging a  viscid fluid at irregular  intervals; this fluid
was apparently  secreted  much more rapidly during coitus than at
other times.
                  CANCER OF COWPER'S GLANDS.
    Very few cases of this affection have been reported.  The growth
usually appears in the form of a cylindroma, forming a hard, movable,
distinct encapsulated nodule.  As  it grows it becomes adherent to the
surrounding  parts.   The inguinal glands are involved.  The growth,
at first painless and attracting little attention, rapidly increases in size
and ultimately presses upon  the urethra.   Micturition becomes diffi-
cult, frequent, and sometimes painful.  Defecation is interfered with,
and sitting or walking increases suffering. 
THE CARE OF URETHRAL  INSTRUMENTS.
267
   Diagnosis.—The characteristic feature of this affection is the posi-
tion of the tumor.  It is placed upon the bulb, is at first covered with
healthy skin, and grows rapidly.  Combined rectal and perineal  ex-
amination shows it to  be  in the position which normally should be
occupied  by Cowper's glands.
   Treatment.—Complete early removal would give the only hope of
success, but will  usually be impossible, since by the time the patient
submits to operation infiltration will have progressed too far.
             THE  CARE  OF URETHRAL  INSTRUMENTS.
   The instruments  used in urethral surgery are of metal,  woven
thread coated with  gum, india-rubber,  or whalebone.  The metal
instruments include  the  knives, urethrotomes, urethroscopic tubes,
sounds, and catheters.
   The knives, and especially the  small  blades used in the urethro-
tomes, should have a smooth razor edge, and should be freshly pre-
pared for each operation.   They  are sterilized by boiling in  soda
solution (one to three per cent.)  not longer than five minutes, as
prolonged boiling invariably blunts a  keen edge.   If they have been
carefully cleansed by soap and  hot water and are free from rust, one
minute's boiling is sufficient to render them sterile.
   The urethrotomes are boiled for ten minutes  in soda solution,
but before being immersed  are  carefully tried to see that they work
smoothly and easily.  Immediately after being used they should be
taken apart completely, scrubbed in hot water and green soap, dried
out of boiling water,  and put together again.  It is well to place them
in an oven at about boiling  temperature for  five minutes to insure
thorough drying.  They should  then  be wrapped in dry sterile gauze
and stored in drawers, or, better still,  in a dry closed box.
   The urethroscopic tubes are either silver- or nickel-plated;  they
are sterilized by boiling in  soda solution or by flaming  with alcohol.
After use they are washed and swabbed out with hot soap and water,
washed in boiled water, and thoroughly dried.  Their  outer surface
must be  perfectly  smooth,  and  the obturator must fit the urethral
opening accurately.  The edges of the latter should be bevelled in
slightly.  It  is well to keep  each  separate tube wrapped in sterile
gauze, thus preventing denting or bruising of the plating.
   The sounds and metal catheters must present a perfectly smooth
polished surface.  The slightest irregularity which can be detected by
the sense  either of sight or of feeling is  sufficient ground for  having
the instrument  reburnished  or  replated.  These  instruments  should 
268        GENITO-URINARY DISEASES AND SYPHILIS.

be kept in boxes or racks so arranged that each  instrument is held
firmly in its place and is not liable to bruise or dent its fellows.  The
sounds may be sterilized either by boiling in soda solution or by being
dipped in alcohol to a  depth sufficient to wet all the instrument ex-
cept the  handle.  The  alcohol is then ignited, and  in burning causes
enough surface heat to render the sound  sterile.   Before this flaming,
instruments should be  polished for a moment by brisk friction with a
clean towel.   Metal catheters should be  sterilized by boiling in soda
solution.   Before subjecting them  to  this process it is well to  be
assured that their  canals  are  not blocked, and in the case of the
Gouley catheter that the obturator is movable, and that the " tunnel"
is sufficiently large  to accommodate  the filiform bougie over which it
is to be  passed.   After having  been used the  catheters should  be
cleansed immediately.
   None of the lubricants commonly employed injure  metal instru-
ments.  The lubricant  chosen should  be placed in a narrow speci-
men jar so deep that the entire shaft of the  instrument can be dipped.
By placing this jar in  the  steam sterilizer for ten  minutes every day
its contents can  be kept absolutely sterile.  Of the oily substances,
fluid albolene and castor oil are the best.   The objection to these and
similar lubricants is based upon the fact that they make the subse-
quent cleaning of the instruments difficult, and in the case of soft gum
and  rubber instruments produce a rapid deterioration in their strength
and  surface polish.   Guyon has suggested particularly for soft instru-
ments the following formule:
                       R  Pulv. sapon., ^iv ;
                          Acid, carbol., ^i;
                          Glycerini,
                          Aqua? destil., aa. §iv.
               M.  S.—Lubricant for urethral instruments.
                       R  Pulv. sapon., ^iv;
                          Resorcin, ^iii;
                          Glycerini,
                          Aqua? destil., aa %iv.
               M.  S.—Lubricant for urethral instruments.
   These formule of Guyon's form thick pastes,  which act admirably
as lubricants, but seem to be more irritating to the urethral  mucous
membrane than the oils.   They possess the advantages  of being de-
cidedly antiseptic, of having no deleterious influence on the soft in-
struments, and of washing  off at once as  soon  as the instrument  is
put in water.
   We have been well satisfied  with the following, which possesses 
THE CARE OF URETHRAL INSTRUMENTS.
269
all the  merits that Guyon claims for his preparations and  has proved
less irritating:
                       R Boroglyceride, §iii;
                         Aquae destil., f.^ix.
                 M.  S.—Use as a lubricant for sounds.

   None of  these preparations are as perfect lubricants as the oils.
   The soft urethral  instruments,  india-rubber and woven gum-
coated  bougies,  catheters, and whalebone  filiforms, are much more
difficult to sterilize and to keep serviceable  than are the metal instru-
ments.   The flexible india-rubber catheters  are, fortunately, rather
benefited than  otherwise by boiling in water: hence their thorough
sterilization is readily accomplished.   All fats act injuriously upon the
rubber, causing it to swell and soften  and to become so weak that it
is unsafe for use.  This action is  not noticeable for several weeks.
Ultimately these  india-rubber instruments  if  unused  become brittle.
They are so cheap that they can be replaced readily when they show
signs of deterioration.  The woven bougies and  catheters are coated
with a  varnish "which should exhibit an  absolutely smooth finish.
The best are those made so that  they  can withstand the temperature
of boiling water, though if frequently subjected to this process,  or if the
boiling is long continued, the varnish becomes irregular and blistered.
Fortunately, a  perfectly satisfactory  method  has  been  discovered
recently, and one which has no injurious effect on the instruments.
   Janet and Guyon, as the result of a very elaborate series of experi-
ments,  found that the vapor of formol, or of its derivative,  trioxy-
methylene, is the most efficient, most applicable,  and least  hurtful
of all antiseptics  which have been employed for the sterilization  of
urethral instruments.  The method of applying the disinfectant is as
follows.
                              Fig. 90.
Sterilizing-box for soft urethral instruments.
   A metal box is  made varying in  size in accordance with  the re-
quirements.   (Fig. 90.)   That designed for genito-urinary  clinics  or
for the specialist is eighteen  inches long, seven inches wide, and four
inches high,  hermetically closed  by  a metallic  cap with  a rubber 
270        GENITO-URINARY DISEASES AND  SYPHILIS.

washer, and provided with eight shelves made of perforated metal.
These shelves can be stored in the upper part  of the box when they
are not required.  In  the  bottom of the box there is a frame upon
which can be stretched a piece of cloth  twelve inches long and four
inches wide.  This cloth is placed above the  floor of the box, and
thus allows of rapid evaporation of the formol which is poured upon
it.  Upon this cloth can also be spread the trioxymethylene powder;
it  should be  sprinkled in a  shallow layer over the entire  surface.
This apparatus readily holds two hundred instruments, each of which
can be kept entirely separate from the others.
   A similar box is designed for patients  who are required to sterilize
their  own sounds and for  doctors who only occasionally use instru-
ments.   This is  seventeen  inches long, three inches high,  and  three
inches wide.  One end is closed by a soft  rubber cap.  It contains two
shelves,—the upper movable, the lower fixed,—and, below, a movable
frame  over which a cloth  can be stretched  or a  layer of  absorbent
cotton spread.   This  allows  of  the  sterilization of from  sixteen to
twenty instruments.   It is also large enough to  contain a cystoscope.
   The box designed for  patients who  are required to sterilize their
own catheters should be of such  size that a sufficient number can be
stored to last two days, a fresh instrument being used each time.
   Formol  or formalin and trioxymethylene  or paraform are par-
ticularly  adapted to the sterilization of bougies  and catheters of large
calibre, an  exposure  of twenty-four  hours being  sufficient.  There
may,  however, be failure when  small quantities of formol are em-
ployed, when the temperature of the  surrounding atmosphere is low,
or when  an attempt is made to sterilize small catheters with very fine
canals, or irrigating cystoscopes.   It is probable that all these instru-
ments could be  thoroughly sterilized by a more prolonged  exposure,
—forty-eight to  seventy-two hours.   It  is essential to  employ pure
formol or trioxymethylene spread over a considerable surface, to keep
the temperature  of the surrounding atmosphere above 56° F., and not
to attempt to secure sterilization in a shorter period than twenty-four
hours for large-calibred catheters, or  forty-eight hours for catheters
of fine calibre and for simple cystoscopes, which must have  been
washed previously.    Irrigating   cystoscopes and  ureteral catheters
cannot be sterilized certainly except after much longer exposure.
   As to the choice of the two agents, trioxymethylene is simpler in
its use, since its slow  evaporation keeps the  atmosphere dry, thus
avoiding  softening of the instruments.  Moreover, cystoscopes are less
likely to be altered by dry vapors of trioxymethylene, which gives off
its active principles slowly and constantly.  The powder, however, is 
THE CARE OF  URETHRAL  INSTRUMENTS.
271
less active and less readily volatile than formol, and hence should be
employed  only where  sterilization is  comparatively easy,—that is, in
the smaller apparatus suggested for the use of the general practitioner.
   After prolonged  exposure to formol vapor instruments remain as
smooth, supple, and shining as when they were first subjected to the
influence of the  antiseptic.  No action is perceptible upon the metallic
portions.   Ultimately flexible bougies  exposed to formol become some-
what softer than at first, probably because they are kept in a moist
atmosphere, since when trioxymethylene  is used this result is not
observed.   Moreover,  this can be remedied by putting the instruments
in a chamber which contains calcium chloride.  The softening is so
slight that it is of no serious  consequence.
   Instruments taken directly from  the  formol and  introduced into
the urethra occasion a slight  stinging  sensation.   This  is avoided by a
preliminary washing in boric acid solution.
   As to the preservation of soft instruments, in all cases they should
be carefully  washed with soap and  water within and without and
dried as nearly  as possible before sterilization, then subjected  to the
vapor of  formol for at least  twenty-four  hours.  When required for
use they are taken out and immediately submerged in  weak antiseptic
solutions,  biniodide of mercury 1 to 25,000  or boric acid four per
cent, answering well.
   If the  patient is required to pass an  instrument  on himself, say
four times daily,  he should have eight  catheters in the  small box
already described.  Four of these  catheters  are placed  upon the
upper shelf and four upon the  lower, and trioxymethylene is put in
place.  Each time the instrument is used the patient takes one cath-
eter from  the upper shelf. After having  drawn his water, he washes
the catheter and puts  it aside.   The  next day the four catheters that
have been used are soaped and washed,  dried  as thoroughly as  pos-
sible, and  put back upon the upper shelf, the patient then proceeding
to utilize those  upon the lower  shelf.  The cap should be removed
and replaced as rapidly as possible each time.
   For the general practitioner who  rarely employs sounds, it is best
to place the instruments that he is most likely to use in the sterilizing
box and leave them there indefinitely until they are required ; they can
be carried to the patient's house in a vessel filled  with  boric acid
solution and furnished with a screw cap.
   Whalebone  filiform bougies  may  be conveniently sterilized by the
formalin process.   In storing these  instruments it is  well to remem-
ber that they are  attacked  by a parasite, which so roughens and
weakens them that they become  unfit for use :  hence  they should be 
272       GENITO-URINARY DISEASES AND SYPHILIS.

slightly lubricated with albolene or cosmoline  and kept in a  tight
box.
   The rules  applicable to the care of soft instruments are  that they
should  be  kept straight and not coiled;  that  they should not be
allowed to lie  in contact with one another, this  being prevented by
wrapping each in sterile gauze ; that they should be thoroughly washed,
and, in the case of catheters, flushed out, immediately after being used,
and be dried by wiping, shaking, and finally by  exposure to dry heat
at about 150° F.  They should be thrown aside as soon as the surface
becomes rough, irregular, or blistered. 
CHAPTER  VIII.
                            CHANCROID.

   The chancroid is a contagious venereal ulcer.   It has no distinct
period of incubation, is inflammatory and destructive in type, and  is
frequently accompanied by suppurating buboes.   It is a local and not
a constitutional disease.  It has been  variously named soft chancre,
simple chancre, and non-infecting sore.
   Cause.—Chancroid is  due to the  local action of micro-organisms.
The  pus is  highly contagious, even when  diluted;  bactericides of
moderate strength destroy its virulence.
   It is generally accepted  that chancroid is a simple ulcer caused by
the inoculation of the well-known pyogenic microbes upon an abraded
surface.  It is  held that this ulcer runs  a somewhat peculiar course on
account of the  anatomical and physiological peculiarities of the tissues
upon which it  is usually situated.   This belief is founded on the facts
that  the ordinary pyogenic microbes are always present in chancroidal
discharge, and that these sores are  most frequently  encountered on
the persons of those who are most exposed to infection by pyogenic
microbes,—i.e., those who are uncleanly.   Moreover, inoculation with
the pus of acne  or of furuncle may  produce  sores presenting the
characteristics  of  chancroids.
   As opposed to these arguments and in favor of the dependence of
chancroid upon  a specific virus, the following points  are worthy of
consideration.   In addition to the  pyogenic  micro-organisms  found
in every open  wound, competent observers  have  described bacteria
always  associated with  chancroidal lesions  and appearing as pure
cultures when  repeated auto-inoculations are practised under anti-
septic  precautions.   Chancroid nearly always  arises  from contact
with  the discharge from  chancroid, and not  as a result of the irri-
tating action of retained or decomposing discharges from other sources.
The  chancroid nearly always runs a typical  course, even in healthy
persons, and involves the anatomically  associated lymphatic glands in
degenerative processes with  far greater frequency than is observed in
simple infections  with  pyogenic microbes.   Auto-inoculation  of the
discharge of the fresh chancroid is nearly always successful, and  can
be repeated almost indefinitely. The inoculation ulcers after a second
                               18                           273 
274        GENITO-URINARY  DISEASES AND  SYPHILIS.

generation show no pyogenic micro-organisms, but only those which
are held to be specific to the lesion.  Auto-inoculation with pus from
an ordinary ulcer usually fails, or, if successful, it produces a super-
ficial  lesion.  A rapidly extending chancroid if thoroughly cauterized
is at once converted into a simple ulcer, and, though pyogenic micro-
organisms  abound  in  the discharge  of  the  latter, the lesion runs a
benign and self-limited  course, essentially different from that charac-
teristic of chancroid.
   Ducrey, AVelander, and  Krefting  describe as the specific micro-
organism of  chancroid  a short, thick  bacillus, with rounded ends,
much like a dumb-bell, about one and a  half  micromillimetres in
length.   The micro-organism is found in the protoplasm and between
the cells, often  in  chains and  groups.   The staining solution is as
follows:
              Five per cent, boric solution, §ss;
              Saturated aqueous solution of methyl-blue, £v;
              Distilled water, ^vi.

   Cover-glass preparations made in the customary way are allowed
to float in this dye  for half an hour.  They are then washed in  dis-
tilled water, dried, and examined.  The  discharge from the chancroid
may contain  these  micro-organisms, but compared with  the number
of other  bacteria they are  extremely few.    In  the  first  inoculation
pustule these micro-organisms are more numerous, other bacteria be-
coming less in number.  In  the pustules of  the third generation these
bacteria  appear  as pure  cultures.   In no instance could an inocula-
tion  chancroid  be  produced without finding  in the discharge  the
bacillus just described.
   A review of  the  bacteriological evidence as to the microbic origin
of chancroid leaves the subject still in doubt, since  Jullien, Strauss,
and others were not able to confirm the presence of a specific micro-
organism, and  since the proof afforded by  the  inoculation of pure
cultures grown on artificial media is wanting.
   The  clinical history  of chancroid, however, marks it as a distinct
and separate lesion.
   Fournier  states that where  a chancroid  is found  there  has been
deposited chancroidal virus, and many other observers  believe  that
chancroid  is invariably due  to inoculation of pus  derived from a
similar ulcer.
   The  Inoculability of Chancroid.—The   chancroid is  capable of
almost indefinite reinoculation, the different parts of the body showing
varying susceptibility to the  action of the virus.  When  inoculations
are made  upon  the  thigh,  large,  sloughing ulcers  not  infrequently 
CHANCROID.
275
result.  The  lesions are more manageable when  the belly is inocu-
lated ; while  if the face, chest, or arms are selected they are still less
serious.  After a certain  time the skin of the region in which many
inoculations have been made acquires immunity against the develop-
ment of further sores.  This immunity is, however, only temporary.
Successive inoculations have  a tendency to become  milder, and recent
experiments  conducted  under antiseptic precautions appear to show
that the  original pus of each chancroid can be auto-inoculated only a
limited number of times.
    In the early stage of the  original sore, auto-inoculation almost in-
variably succeeds, producing a characteristic chancroidal  lesion.  As
the original sore grows older  the virulence of the pus diminishes, until
finally it disappears entirely, inoculation  then producing simply the
slight superficial lesion characteristic of the irritation of ordinary pus.
    According to Finger and others, acute diseases attended  with high
fever, such as pneumonia, pleurisy, and the exanthemata, during their
course render  the patient  immune  against the inoculation of chan-
croidal virus.   This, however, is disputed.
    Frequency of Chancroids.—Chancroids  are, in hospital practice at
least, more frequently encountered  than the chancre: hence given a
patient with suspicious sores  about the genitalia, the odds are in favor
of such sores being chancroidal.   Such a deduction cannot  be drawn
in private practice, however, since  in the well-to-do  the  chancre is
more frequently seen than is  the soft sore.
    Fournier states that the reason for this is that the hospital patients
are poor, ignorant, and uncleanly, and  hence  careless as  to the con-
dition  of  the partners  in  their indulgences.    The well-to-do are
protected from chancroid  by their  cleanliness  and general  healthy
condition, and by the fact that women suffering from a lesion as gross
and as superficial  in position as the non-infecting sore could prob-
ably not conceal the disease from them.  Moreover, such  lesions
in the better class of prostitutes would be immediately subjected  to
treatment.
    The Localization of the Chancroid.—The chancroid may be placed
upon any cutaneous or exposed mucous surface.   It is usually located
on or about the genitalia.   Reported cases show that it has attacked
the mucous  membrane of the mouth  and nose,  the conjunctiva, the
scalp, and the fingers ; but extragenital chancroid is far less frequent
than extragenital chancre.
   Genital chancroids in  the male are  usually found upon  the glans
and the prepuce.   The  favorite  position is at  or near the frenum,  in
the coronary sulcus  (Fig. 91), along the margin of the  prepuce,  on 
276        GENITO-URINARY DISEASES AND SYPHILIS.

the mucous surfaces of the glans and the foreskin, and at the urethral
orifice.
    In females these lesions are found along the margins of the greater
and smaller  labia,  about the  fourchette,  and in the region of the
urinary meatus.   (Fig. 92.)
    Anal chancroid is much more frequent in women than in men.
In them it is commonly  due to infection of cracks or fissures about
the rectal opening by the contagious discharge which flows backward
from the vulva.   The chancroid is usually multiple.
    The extragenital chancroids, if perigenital  lesions be excepted, are
rare.   The history of inoculation proves that such lesions are possible,
but as a matter of clinical experience they  are not often encountered.
This may be  because they are often not recognized.
    Pathology of Chancroid.—The  chancroidal ulcer  is made up of a
small round-celled  infiltrate, somewhat sharply limited in depth, but
extending considerably beyond the borders of the ulcer, and invading
papille which are still covered with apparently healthy  epithelium.
These papille undergo marked hypertrophy.
    The blood-vessels are dilated  and  increased in number, and ex-
hibit in the adventitia an inflammatory infiltration.   The lymphatic
vessels  are also  abnormally numerous, and  open directly into  the
ulcer.   If one of these vessels  is injected at a point remote from the
chancroid, this  injection will  flow from  the surface of the sore.
(Letzel.)
    The Clinical Aspects of Chancroid.—The inoculation chan-
croid presents the lesion  in its typical form.
    Inoculation is practised by moistening the point of a scalpel in
chancroidal discharge, then passing this point perpendicularly down
to the true skin, rotating  the knife  on its long axis, and rubbing in as
much of the discharge as remains on the sides of the blade. A watch-
crystal placed over the point of inoculation and held in place by straps
allows of  inspection of the sore in all the phases of its development.
    In from one to four clays an inflamed pustule develops, which, on
rupture, exposes a deep,  rounded, ragged, punched-out, often under-
mined ulcer, with a gray, sloughing surface.   This ulcer extends for a
period varying from one to three weeks, then remains stationary for
a few days, and  finally  undergoes resolution, ultimately healing and
leaving a cicatrix.
   Chancroid as acquired by coitus differs somewhat in its clinical
aspects from that caused by intentional inoculation.  The  pustular
stage  is rarely observed, the patient not detecting the lesion until an
ulcer has developed, since the chancroid is usually so placed that the 
Fig. 91.
Multiple chancroids of the coronary sulcus.
Fig. 92.
 
Fig. 93.
I^J^S** '
Exulrc ratinj,' or superficial chancroid.
Fig. 94.
Follicular chancroid. 
CHANCROID.
277
thin  skin covering the pustule is quickly macerated.  The acquired
chancroid frequently  seems to have a period of incubation varying
from three to seven  days;  exceptionally the apparent incubation is
much longer; generally this is because the sore is not noticed in  its
early stages.  Indeed, it is not uncommon in stripping back  the fore-
skin  to expose an ulcer which  is at least several days old and of the
existence of which the patient was entirely ignorant.  Ricord explains
these cases  by the theory that the virus is deposited on healthy sur-
faces, which subsequently becoming eroded offer an entrance-point to
the micro-organisms.
   The shape of the  chancroid will depend  upon  the shape of the
eroded surface through which inoculation takes  place, and also upon
the anatomical peculiarities of the part.   Thus, inoculation of a " hair-
cut" will be followed by a linear chancroid ; the inoculation of an ex-
tensive abrasion by a  sore corresponding in outlines with this abraded
surface.  The lesions of herpes will preserve their general  outline, but
will  take on chancroidal  ulceration.  An infected follicle will form
first a hard, rounded, elevated lesion resembling a furuncle.  This
rapidly breaks down  and discharges, exposing a characteristic chan-
croidal ulcer.  When  the chancroid involves the sides of the frenum
it forms a long, irregularly shaped lesion, which not infrequently causes
complete destruction of this bridle.   When it is placed in the coronary
sulcus it has a tendency to extend in the direction of this furrow.
When it attacks the anus it spreads in the direction of the skin-folds
of this region.
   For  convenience of description chancroids are  frequently named
in accordance with their clinical  features.   Thus, the   ecthymatous
chancroid is one characterized by the formation of thick  crusts;  the
exulcerating chancroid is one which remains superficial (Fig. 93);  the
follicular  chancroid  is one which  primarily  involves a  follicle, re-
sembling first a furuncle, later  producing a  deep, often indurated
lesion (Fig.  94); the  ulcus elevatum is one which is raised  from  the
surrounding tissues, owing to a more than usually abundant inflam-
matory infiltrate, which, moreover, may  so closely simulate the hard-
ness of a  syphilitic sore as  to make diagnosis a matter of great diffi-
culty.  (Fig. 95.)  If from lessened tissue-resistance to virulent infection
there is excited inflammation more acute than is commonly observed,
there results an inflamed chancroid.   If this  inflammation occasions
rapid extension of the lesions, together with sloughing of surrounding
tissues, the  chancroid is termed phagedenic.  (Fig.  96.)   Where this
tissue-destruction is both rapid and extensive,  the lesion is termed
gangrenous.   When the chancroid becomes chronic, spreading slowly 
278
GENITO URINARY  DISEASES AND  SYPHILIS.
and  reaching  enormous dimensions, often healing in one part while
it is extending in another, it is termed serpiginous.
   Symptoms.—(1) There is no period of incubation; (2) the  lesions
are multiple ;  (3) they begin as pustules or ulcers and are rapid in their
course; (4) they form ragged, punched-out, often undermined ulcers,
                                     irregular in shape, discharging
                Fig. 95.                freely,  inflammatory  in type,
                                     and covered with  a gray, pus-
                                     soaked slough, which may be
                                     concealed   by  a  thick,  moist
                                     scab (Fig. 96 A);  (5) they pro-
                                     duce similar lesions on surfaces
                                     with which they come in con-
                                     tact, and their discharge can be
                                     inoculated  on  any portion of
                                     the  surface of the body;  (6)
                                     they  are  not   indurated;  (7)
                                     scrapings  from their  surfaces
                                     show pus and shreds of necrotic
                                     tissue, but  no  epithelium;  (8)
                                     they  are   frequently  compli-
                                     cated by inflammatory bubo.
                                        A positive diagnosis  cannot
                                     be founded  on  any  one of
                                     these characteristic features of
                                     the  sore,  but  must  rather be
                                     based  upon associated symp-
                                     toms.  Thus, as a rule, there is
no period of incubation, yet there are many reported cases  in which
such a period apparently existed.   While the  lesions are often mul-
tiple, this  is by no  means an invariable rule.  The  characteristic
feature in  regard to the multiplicity of chancroids is that they gen-
erally  appear not simultaneously, but successively,—i.e., from auto-
inoculation ;  though  when several  abrasions  are inoculated  at  the
same time the multiple lesions will, of  course, develop  at the same
time.
    Though the  disease usually begins as a pustule or an ulcer, its first
manifestation may take the form  of a more or less indurated  papule,
in which acute inflammatory phenomena may progress with compara-
tive slowness.  The  follicular chancroid sometimes  develops  in this
way.   Exceptionally the  chancroid  appears  as  a purely superficial
lesion, the nature of the sore in this  case not being suspected until
Indurated elevated chancroid. 
Fig. 96.

Phagedenic chancroid.
Fig. 9
 
 
Fig. 96 A.
■■"■ *v^r*^"' -
.>*?■&

Multiple chancroids.  (Fox.) 
 
CHANCROID.
279
it either suddenly assumes typical chancroidal characteristics or by
auto-inoculation proves its true nature.
   Auto-inoculation, if practised after the virulent stage of the chan-
croid is passed, will not succeed, and the discharge of other sores ex-
ceptionally produces  by inoculation  lesions not unlike those caused
by chancroidal pus.
   Sometimes  chancroids are  indurated; this is  particularly true of
the follicular chancroid and of those sores which have been cauterized.
Finally, suppurating buboes, when the chancroids are seen early and
are carefully treated, are the exception rather than the rule.
   Hence in determining the nature of such a sore the general symp-
tom  group will be taken rather than any  one  peculiarity, and upon
this an opinion will be given, always modified by the knowledge that,
even though the lesion be distinctly chancroidal in type, it is possible
for it ultimately to develop into a typical chancre.
   What might be called the  natural  auto-inoculation—that is, the
production of  other  and  similar sores  upon  healthy surfaces with
which  the first lesion  comes  in  contact—is  one  of the strongest
reasons for pronouncing an ulcer chancroidal in nature, since this,
though possible, rarely takes place from  other forms of ulceration.
   Diagnosis.—Chancroid must  be  distinguished from chancre, from
herpes, from follicular abscess, from erosions of balanitis and balanopos-
thitis, from ulcerating papular syphilides,  from ulcerating gummata, and
from tuberculous ulcerations.
   The distinction between the soft sore  and the chancre is one which
the surgeon most frequently will be called upon to make, and is some-
times extremely difficult; it may, indeed, be quite impossible to formu-
late  it.   The typical  features of each sore, with a diagnostic table,
have been set  forth in another part of this work (see chapter on the
primary sore of syphilis), but it is not amiss to call attention here to
the fact that the chancroid may be indurated whilst the chancre may
not be.  In the chronic chancroid attacking the vulva of women, the
secondary  hardening may be so absolutely like that of the primary
lesion of syphilis as to deceive the most skilled.   Again,  chancroid
may cause chronic enlargement of several  of the inguinal  lymphatic
glands, thus departing from its type, while chancre may make a parallel
variation by causing suppurative lymphadenitis.
   In typical  cases a distinction may be readily  made, but in those
which are atypical  the surgeon should not commit himself to a positive
opinion, since  even so skilled a syphilographer as Fournier acknow-
ledges that he has  been deceived.
   The mixed  chancre—that is, the lesion  resulting from inoculation 
280
GENITO-URINARY DISEASES  AND SYPHILIS.
with chancroidal virua and  the virus of syphilis at the same point-
can be  properly diagnosed only after prolonged observation: hence,
even though the sore conform absolutely to the  chancroidal type, it is
not safe to assert on first  inspection that syphilitic infection has not
taken place.
   The lesions of herpes, follicular abscess, the erosions of balanitis and
balanoposthitis, or mechanical  abrasions may readily be  mistaken for
chancroids when they first appear.  In a few days, at most, the super-
ficial nature of the inflammation and the prompt yielding to cleansing
applications show that chancroidal infection is absent.
    Ulcerating papular syphilides when found upon the genitalia closely
resemble  chancroids, but are more slow in their course, are less in-
flammatory in type, and exhibit other lesions of the disease ; on exami-
nation of the patient a history of  preceding syphilitic infection usually
may be elicited.
    Ulcerating gummata of the genitalia produce lesions indistinguish-
able in  appearance from chancroids.  Here again, however, a history
of syphilis, the development of a tumor preceding ulceration, the slow
progress of the lesion, the absence of the symptoms of acute inflam-
mation, and the effect of constitutional treatment will lead to a correct
diagnosis.
    Tuberculous ulcers are extremely rare ; they cannot be distinguished
from  chancroidal lesions  by inspection  alone.   They have, however,
a history of very slow extension, are usually associated with tuber-
culous lesions in other parts of the body, sometimes exhibit about the
periphery  of the ulceration grayish, semi-transparent, miliary tuber-
cles, and on  microscopic  examination of the  scrapings of the  lesion
often show the tubercle bacillus.  Moreover, inoculation on guinea-
pigs will after a time disclose the  true nature of  the lesion.
    Sometimes a  differential diagnosis  can be  made only by auto-
inoculation,—a valuable means of determining the  presence or ab-
sence of the  chancroidal virus, but one which is not  infallible.   Its
valuo is perhaps best formulated  by stating that  the majority of chan-
croids will produce ulcers of a similar  type on inoculation, while the
majority of other ulcers, either syphilitic, tuberculous, or inflammatory,
will not produce such  lesions.

                   COMPLICATIONS OF CHANCROID.
    1. Phimosis and paraphimosis ; 2, Excessive inflammation, phage-
dena, and gangrene ;  3, Lymphangitis and lymphadenitis.
    Of all  these complications lymphadenitis, or bubo,  is by far the
most common. 
CHANCROID.
281
   Phimosis.—This  forms  a  serious  complication  of chancroid,
mainly because it  prevents the ulcer from  being efficiently treated
and causes retention of discharge, and consequently favors the occur-
rence of acute inflammation and the formation of inguinal buboes.
   Sometimes a chancroid develops upon the glans penis or the inner
preputial surface in cases congenitally phimotic.   More frequently phi-
mosis is  occasioned by the swelling  incident to the lesion,—a long,
easily retracted foreskin becoming from oedema and  infiltration so
thickened and the preputial  orifice  so narrow  that  retraction  is

                              Fig. 98.
         Chancroidal phimosis. Secondary chancroids about the preputial orifice.

impossible.  If the chancroid is placed upon the  outer surface  of
the prepuce this complication is of slight moment,  usually  yielding
quickly  to  treatment.  When, however, the sore is concealed and
rendered inaccessible by the swelling, a vicious circle is established,
which may be productive of the most serious consequences.  The irri-
tation incident to retained  and decomposing discharges  increases the
inflammatory swelling, renders the phimosis  still more complete, and
by interfering with circulation weakens tissue-resistance, so that  the
lesion rapidly extends, a ring of inoculation chancroids often develop-
ing about the preputial orifice.   (Fig. 98.)  In severe cases extensive 
GENITO-URINARY DISEASES AND SYPHILIS.
sloughing and gangrene  occur.  The foreskin becomes dark, almost
black,  cold, non-resisting,  and finally melts down  at one or more
points  into a putrid, pultaceous mass.  This gangrenous process may
attack  also the glans penis, and partly or totally destroy it.
    Diagnosis.—The diagnosis of subpreputial  chancroid  is founded
upon the severity of the inflammatory symptoms, upon their persist-
ence, or even  their aggravation, in spite of careful treatment, and
upon the result of auto-inoculation.  At times palpation will elicit
local tenderness, and the inflammatory induration of the lesion  may
be recognized by touch through the foreskin.
    Herpes and balanoposthitis rarely occasion  as active local symp-
toms as does chancroid.   The discharge is  moderate; the edema is
not excessive ; cleansing  treatment quickly cures.
    Concealed chancre occasions  moderate  swelling, can be  felt as
an indurated plaque or nodule, and is accompanied  by the inguinal
adenitis and other symptoms of chancre.
    Gonorrheal phimosis, usually associated with balanoposthitis, will
show in the  discharge the gonococci, and  will be accompanied by
ardor urine, felt along the urethra, by chordee, and by the other symp-
toms of gonorrhea.   It must not be forgotten  that  both gonorrhea
and chancroid may  be present.
    Paraphimosis.—Patients with  congenitally  short prepuces, or
those whose foreskins are habitually retracted, frequently suffer from
paraphimosis incident to the swelling occasioned by chancroid; or this
condition may result from retraction of the foreskin after the swelling
is well advanced, as it is then often impossible to draw it forward.
This complication is much less troublesome than phimosis, since the
lesion  is exposed and can be properly treated.   It  occasions, how-
ever, more rapid and dangerous congestion than  phimosis, and usually
demands immediate relief.
    Gangrene—Phagedsena.—Chancroids may be unusually inflam-
matory in type from the first, or after a comparatively mild  course
may suddenly become acutely inflamed.
   The causes of this are usually  a general cachectic condition, local
irritation, either mechanical, as from coitus, or chemical, as from filth,
decomposing discharges, and irritating applications, and disturbances of
circulation, as from phimosis and paraphimosis.
   In these cases swelling  and redness extend far beyond the lesion
and the whole involved part becomes edematous.  The patient com-
plains of pain, there is often a mild  inflammatory fever, and the ulcer
rapidly spreads.
   If the causes producing inflammation remain still operative and 
CHANCROID.
283
prompt treatment is not applied, the  lesion becomes gangrenous;  in
this case swelling is more pronounced, and large areas become dusky
red, dirty brown, and finally quite black and  putrid.  In a very few
hours extensive tissue-destruction may result.   The entire penis may
be destroyed, the testicles may  be laid bare, and  the  process  may
extend far up  the belly-walls.   The constitutional symptoms are
pronounced.
   At times the destructive process is much slower in its course, ulti-
mately producing lesions  quite as extensive, but rather  by molecular
death.  The ulcer steadily extends,  in spite  of treatment,  until  it
attains enormous dimensions, exposing the blood-vessels of the groins,
destroying the entire scrotum, eating far back along the perineum, and
leaving but the stump of the penis.   This process  is termed phage-
denic, and is never observed except in those whose systems are pro-
foundly depressed.  Thus it is  encountered in diabetics, or in those
suffering from scurvy or scrofula, from visceral diseases, such as chronic
hepatitis and nephritis, or from tertiary syphilis.
   The phagedenic ulcer sometimes  lasts for months or years, mani-
festing a  tendency to heal in one part whilst  it steadily extends  in
another, the lines of  extension often  having a circinate  or serpentine
outline.  This form of ulceration is termed serpiginous.
   Lymphangitis,  or inflammation of the  lymphatic  vessels, is a
rare complication of  chancroid ;  even though suppurating buboes de-
velop, the lymphatic  vessels which carry the irritating substance from
the ulcers to the glands are generally spared.  When  they are in-
volved there is formed, usually on the dorsum of the penis, a tender,
indurated  cord, over which the skin  is reddened.   The perivascular
tissues become infiltrated and edematous, and there may be consider-
able swelling of the  subcutaneous tissues.   Resolution  usually takes
place under appropriate treatment.  Exceptionally suppuration occurs.
At one or more  points the swelling  is more marked, the skin is ad-
herent and bluish red, fluctuation  is detected, and an abscess forms.
This opening usually heals kindly ; but sometimes it is converted into
a chancroid.
   Bubo, or lymphadenitis, as has been stated, is the commonest
complication of chancroid.  The number of cases suffering from this
complication varies, according to different reports, from  five per cent.
to thirty per cent, of the total number suffering from chancroid.   In
hospital practice about one out of five ambulant chancroid cases de-
velop bubo; in  office practice and  among the well-to-do this compli-
cation is comparatively rare.  This is because intelligent  people detect
the sore early and have it treated.  The glands involved  are generally 
284
GENITO-URINARY DISEASES AND SYPHILIS.
those to which the lymph-vessels supplying the seat of ulceration pass
most directly,—i.e., the group of glands lying  below Poupart's liga-
ment,  above the saphenous opening.  The glands  lying  near  the
middle line of the body to the right and left of the symphysis pubis
generally  escape.  Adenitis from  lesions of the foot or leg  attacks
primarily  the glands  lying just  below the saphenous opening in  the
course of  the long saphenous vein.
   It is usual, in cases of sores  on the  genitalia, for bubo to form on
the side of the body corresponding with that of the lesion.   This rule
is at times reversed, sores on the right side of the penis, for instance
causing suppurating bubo  in the  left groin.   Lesions of the frenum
frequently cause double buboes,—that  is, involvement of lymphatics
in both groins,—and, indeed, sores of this region and upon the pre-
puce and glans  are followed by a larger percentage of  buboes than
when the  chancroids are located on any other part of the genitalia.
   In patients of a tubercular tendency frequently the entire lymphatic
chain of glands slowly enlarges, forming a lobulated tumor, sometimes
the  size of  a child's  head.  Softening and  disintegration take place
slowly, and if the case is untreated fistule will form, which may  last
for months or years.
   The bubo is generally single and unilateral; it  may be multiple
and  bilateral.
    Cause.—Aside from the fact that retained discharges distinctly pre-
dispose to bubo, the character of the sore seems to  have little influ-
ence in the development of this complication.  Thus a sloughing or
gangrenous  chancroid will  run its course without any effect  upon the
lymphatic glands, while a  superficial lesion the  size of a split pea may
be accompanied by a  double suppurating lymphadenitis.
   This complication  usually develops  from  the second  to the fourth
week of the chancroid.   It may, however, appear almost as soon as
the  lesion, or may develop weeks after the chancroid has been com-
pletely cicatrized.
   The direct cause of bubo is not clearly formulated.   The destructive
adenitis is not due to the  action of micro-organisms upon the gland.
Cultures and auto-inoculations made with the discharge of buboes give
negative results,  and microscopic examination of such discharge fails
to show bacteria.  The degeneration of the glands is probably owing
to the presence of a  chemical  irritant  absorbed from the ulcerating
surface.
   Symptoms.—The  bubo usually begins  with a sense of pain on
motion referred  to the inguinal  region.  On examination there is
found  a hard, tender lump over  which the skin is  freely  movable. 
CHANCROID.
285
This lump steadily increases in size, becomes constantly painful, and
is so tender that the patient is confined to his chair or  bed.   The
overlying skin becomes reddened, adherent, and  edematous.   The
patient complains of rigors, fever, and thirst, and finally on examina-
tion fluctuation is detected.
   The pain may be constant and almost unbearable;  sometimes
without obvious cause it is suddenly relieved.  This is due to rupture
of the  gland capsule and  escape of its contents into the surrounding
tissue,  and is followed  by rapid increase  of swelling and  breaking
down of the periglandular tissues.
   On evacuation of the suppurating bubo, thick, blood-stained pus is
discharged, leaving a cavity with gray and necrotic walls.  On digital
examination of this cavity it is  often possible to detect several swollen
glands which have been involved in the inflammatory process  but
have not yet been completely destroyed.   These are felt projecting
into the space from which the pus has been evacuated.
    If the abscess is untreated, the  pus often burrows  in various
directions, forming long sinuses before spontaneous  evacuation takes
place.   These  seriously complicate  the  subsequent course of  the
affection.
    Usually,  after evacuation of the pus and proper surgical treatment
of the resulting cavity, healing takes  place promptly.   In such cases
the lesion is said to be a simple bubo.  Exceptionally soon  after open-
ing the bubo its whole surface becomes  converted into a huge ulcer
corresponding in type with chancroid. This is termed the  chancroidal
bubo.  (Fig. 97.)  Appropriate treatment, however,  shortly  converts
this into a simple ulcer, which ultimately heals kindly,  though, as in
the case of the chancroid itself, inflammation, gangrene, or  phagedena
may complicate the healing.   It is probable that the bubo  is never
primarily chancroidal, but becomes so by inoculation  either during
or after operation.
    In  women buboes rarely  complicate chancroids.   When they
occur they are generally found in the inguinal  region, the lymphatic
vessels  about the vulva  and the  rectum  communicating  with  the
glands of the groin.
    Prognosis.—The  chancroid as it  occurs in  healthy people, and
especially in those who are cleanly in their habits and who will scru-
pulously follow a mild antiseptic treatment, runs  its course in from
three to six weeks without complication.   Even  if no treatment what-
ever is  applied,  the  majority of chancroids will  heal  spontaneously
in six weeks.  During the whole course of the  lesion, and even after
cicatrization has taken place, buboes  may form, and prognosis as to 
286
GENITO-URINARY  DISEASES AND  SYPHILIS.
the avoidance of this  complication  should  be extremely  guarded.
Except  in the  most superficial  forms,  the lesion is followed by
scarring.
                   TREATMENT  OF CHANCROID.
   Since  it is pretty generally conceded that  chancroid is due to
inoculation with the  discharge of a  similar  lesion, and  since such
inoculation takes place almost invariably by sexual congress, the pro-
phylaxis of chancroid is comparatively simple.   Where, however, this
means—i.e., avoidance of exposure—is not adopted, careful and thor-
ough washing with weak antiseptics, particular attention being devoted
to the folds of skin in the region of the frenum, and the treatment of
abrasions  by means of  strong solutions  of mercury  bichloride  or of
carbolic acid, 1 to 200 of the former,  1 to 10 of the latter, will nearly
always prevent the appearance of  chancroid.   These solutions should
be applied directly to the abrasions by means of a small cotton swab,
and should not be employed as lotions for the entire penis.
   Whatever form of treatment is adopted, the end to be attained is
the conversion of the unhealthy spreading ulcer into a healing, granu-
lating surface.   Since the  virulent properties of the  chancroid are
dependent upon the  presence of  micro-organisms, it necessarily fol-
lows that  efficient treatment must have for its end either an inhibitory
or a destructive action  upon these micro-organisms, or must so in-
crease the local resistance that the lesion cannot spread.   Antiseptics
in some form are indicated.   These should be either so mild that
they produce little or no irritation, or so powerful that they cause total
destruction of the entire diseased area,—i.e., they should be distinctly
cauterant.
   Under the application of mild  antiseptics the chancroid is usually
cured in from two to six weeks.   Under the application of cauterants
a cure sometimes results in from seven to fourteen  days.
   Satisfactory results may be obtained by the observance of surgical
cleanliness, not  only of the surface of the sore, but also of  the sur-
rounding  skin  or mucous  membrane.  After thorough washing with
soap and  hot water, a  spray  of hydrogen peroxide, full strength, is
directed on the chancroid  and the skin  near it; this  is followed by
washing or spraying with carbolic  1 to 60 or  bichloride 1 to 3000.
   After  the chancroid and the surrounding  surfaces  have  been
cleansed,  the surgeon may conduct the  treatment with either non-
irritating antiseptic applications or with cauterants.
   Non-irritating antiseptic applications may be made in the form of
powders,  of ointments, or of lotions. 
CHANCROID.
287
   Dry Dressings.—The powders commonly employed  are  iodoform,
aristol, iodol, boric acid, calomel, acetanilid, zinc stearate, zinc oxide,
and bismuth subnitrate.  None of these are strongly antiseptic.  The
most efficient is iodoform;  this has  practically no antiseptic value,
but in the  presence of pus  undergoes decomposition,  the  products
of which render ptomaines inert and have a distinct inhibitory effect
upon  further germ-growth.   The  objections to the use of  the  drug
are its penetrating  odor  and occasionally the production of  violent
inflammation.   The  odor may be in  part  disguised by mixing with
the powder, in  the proportion of a drop to a drachm, oil of lavender
or attar of  roses, or finely pulverized  coffee in the proportion of one
part to five may be added to the iodoform.  None of these expedients
will be found perfectly satisfactory.
   In applying  this  powder it is important to bring it directly in con-
tact with the ulcerating surface ; when  it is placed upon the surround-
ing skin or  upon crusts covering lesions it  is absolutely useless, except
to intensify the  odor.   It can be dusted upon  the cleansed lesion by
means of a small pledget of cotton which is first rubbed in the pow-
der, or by an insufflator, or in the form of a spray of iodoform in ether.
It should be used only after the  lesion has been thoroughly cleansed
by hydrogen peroxide and dilute antiseptics.
   Iodol and aristol have  similar properties,  but are more prone to
form crusts, thus favoring retention of  discharge.  In clinical practice
they have been  found distinctly less efficient than iodoform.
   Zinc, calomel, and bismuth are mainly efficient as drying agents,
though they undoubtedly have feeble astringent and  antiseptic prop-
erties.
   In the application of dusting-powders they should never be allowed
to form with the secretions scabs or crusts, thus preventing the  escape
of discharges, and they should be brought immediately in contact with
granulating surfaces.   Boric  acid and salicylic  acid  are  sometimes
useful as dusting powders, and are less prone thus to form crusts than
the insoluble preparations.   Salicylic  acid is  often so  irritating that
its application is not advisable, especially as its antiseptic powers are
limited.
   If  dry dressings  are  used, the lesion  is treated from  one to six
times  a  day in accordance with the amount of discharge.   It is first
cleansed, then dried by means of absorbent cotton, then dusted  with
the remedy of choice ;  finally a thin sheet of absorbent  cotton is laid
over it, and is retained in position by straps or bandages, or by pulling
the foreskin forward.
   Dry  dressing is  indicated in  chancroids of  moderate  severity 
288        GENITO-URINARY DISEASES AND  SYPHILIS.

which are not inflammatory in type and which do  not  discharge
profusely.
    Wet Dressings.—In  place  of the  dusting powders, after thorough
cleansing of the lesions  and surrounding parts there may be placed on
the ulcerating surface pledgets of cotton wet in one of a variety of mild
antiseptic lotions.   Of these the most efficient are carbolic acid 1 to 60,
bichloride  1  to 3000, zinc sulphate 1 to 60, copper sulphate 1 to 60,
phenol sodique 1 to 6, dilute lead water.  These  wet cotton pledgets
should be changed frequently, especially when the discharge is abun-
dant.  This is readily managed, since the patient can carry with him a
small bottle of the antiseptic  solution and some  cotton.   He should
change the cotton  pledget each time he  urinates.   The dressing is
kept in place by the  foreskin in many cases, or by straps, bandages,
jock-straps, or swimming-tights.
   The wet  dressing is especially indicated in patients whose incli-
nation or surroundings prevent them from carrying out  the careful
cleansings  required in  dry dressings, and in patients  whose lesions
discharge freely and are inflammatory in type.
   Antiseptic Ointments.—Ointments employed in the  treatment of
chancroid have for their active principle a drug such as iodoform, boric
acid, salicylic acid, carbolic acid, or one of a large  variety of similar
antiseptics.   The formule commonly used are as  follows:

                     R  Iodoform, £i;
                       Vaseline, ^vii.

Boric acid and  salicylic  acid are employed in the same strength.

                     R  Ung. hydrargyri nitrat., gii;
                       Vaseline, ^vi.

                     R  Cupri sulphat., 9i;
                       Vaseline, %i.

   Ointments are  least harmful when  there  is  a tendency to form
crusts, and when the lesions are cicatrizing.  They are not to be com-
mended in the  treatment of chancroid.
   Cauterization.—Immediate and complete destruction of  a chan-
croidal ulcer is the safest routine treatment, since thus its virulent
qualities are immediately destroyed and there results a healthy granu-
lating surface which quickly cicatrizes, and which, if kept clean, is at-
tacked only in very exceptional circumstances by the complications
characteristic of chancroid.  The  main  objection urged against  this
method of treatment is that it is unnecessarily severe, since the major- 
CHANCROID.
289
ity of chancroids will heal kindly under simple  antiseptic dressings.
This argument obtains particularly among  the  well-to-do, who,  by
careful observance  of  treatment, usually  recover promptly.  In dis-
pensary patients, however, and in those who are  careless, or who,
from their  surroundings, cannot treat chancroids in accordance with
the principles of surgical cleanliness, cauterization is particularly to be
commended.
    For cauterizing chancroids, nitric acid, sulphuric acid, caustic pot-
ash, bromine,  iodine, zinc chloride, copper  sulphate, arsenous acid,
and the actual cautery  have all been successfully employed.
    The best instrument for destroying  chancroids  is the  actual cau-
tery ; this  may  be used  in  the form  of a  heated iron, Paquelin's
cautery, or the galvano-cautery.
    In performing the  operation the  chancroid and the  surrounding
healthy area are first thoroughly cleansed, and are then anesthetized
by  means  of  a  spray  of  ten per  cent, solution of cocaine directed
against  the ulcerating  surface  and by hypodermic injection of ten
drops of a one per  cent, solution of cocaine driven into  the cellular
tissue surrounding the  base of the  lesion.   The cautery at a white heat
is then applied,  so that not only the chancroid is destroyed, but also
the surrounding  tissue  to the extent of one-eighth of an inch from the
borders of the sore.  The cautery  must be carried to every recess  of
the ulcer.  If sinuses  are present, these must be  slit up and their
unhealthy  walls  cauterized.   If the minutest  portion of  the sore is
left untouched by the cautery, the probability is that the entire lesion
produced  by  the operation will again  become infected.   After cau-
terizing, the chancroid and  the surrounding parts should again  be
thoroughly disinfected.  The dry eschar resulting from the burning is
dusted with iodoform and protected by the application of a little ab-
sorbent cotton.   In from  three to five  days this eschar comes away,
exposing a healthy ulcer, which quickly cicatrizes.
    Inflammatory swelling resulting frpm this application is combated
by the application of strips of lint wrung  out of dilute lead water, or
dilute lead water and  alcohol equal parts, and  kept constantly wet
with this solution.
    In case  the actual cautery cannot be employed, nitric  acid is gen-
erally used.  This is applied by means either of a  glass  rod or of a
pledget of cotton wrapped on a wooden applicator.  It is thoroughly
rubbed into the  chancroid and carried a little wide of the ulcerating
surface.   The  dressing in  this case is the same as that applied after
the  use of the  actual cautery.
   Caustic  potash, iodine, and other  cauterants are employed in  the
                               19 
290
GENITO-URINARY  DISEASES AND SYPHILIS.
same way.   At one time a paste made by mixing sulphuric acid and
charcoal was a favorite remedy, but it is now abandoned.  The objec-
tion to this paste lies in the fact that by the drying out of the acid an
artificial scab is formed, beneath which the discharges are retained,
thus encouraging the spread of the chancroid in case the application
has not thoroughly destroyed its virulent properties.
   Silver nitrate should never be applied to chancroids when they
are in their  active stage.  The action of this drug is so purely super-
ficial that it  cannot reach and destroy the active  virus.  It is, however,
sufficiently irritating to encourage local congestion, and hence to lessen
tissue resistance.
   In  the  healing stage of the lesion, when  the  granulations are
healthy, applications of a four  per  cent, solution of silver materially
hasten the cicatricial process.
   Cauterization is indicated when chancroids are seen in their early
stages, when they are rapidly extending, and When they are gangrenous,
phagedenic, or serpiginous.
   Cauterization is contra-indicated when the inflammatory swelling
incident to its use would probably occasion phimosis and paraphimo-
sis, when the chancroid is  markedly inflamed but not yet  sloughing
extensively, and when the lesion has passed through its virulent stage
and is healing.
   Operation.—Two operations have been suggested and carried out
in the hope  of accomplishing the immediate cure of chancroid.
   The first requires a thorough curetting of the lesion, careful anti-
septic washing, and dusting with iodoform powder.
   The second  requires excision of the lesion and immediate  suture
of the resulting  wound.
   If reports of  cases can be accepted  as conclusive evidence in favor
of any treatment, these operations should  be universally adopted.
Our experience, however, has  not corroborated  the favorable opinion
of these methods advanced by others.   The wound left by  operation
is extremely liable to become infected  with  the  chancroidal  virus and
to be converted  into a lesion larger and more  difficult to manage than
that for which the operation was undertaken.
   If excision is attempted with the  idea  of aborting  chancroid, it
should  be thus  conducted.  First the sore and the  surrounding sur-
faces  should be thoroughly disinfected, as for a formal operation on
healthy tissues.   The chancroid  should next be cauterized with the
hot iron.   Disinfection  is   then  repeated by the  surgeon, and the
excision and  suture are completed in  accordance with  the  principles
of antiseptic surgery. 
CHANCROID.
291
   Treatment of the  Complications of Chancroid.—Phimosis.
—When the subpreputial  chancroid is  complicated by phimosis, ef-
ficient treatment is rendered difficult by the fact that the sore  is not
readily accessible and by the retention of discharge;  consequently
such lesions are prone  to become inflammatory  in type, to  excite
edema and congestion,  to develop phagedenic  or gangrenous  symp-
toms, and to be complicated by  buboes.   When  the  symptoms of
inflammation are moderately severe, satisfactory results may be ob-
tained by  the frequent employment of  mild antiseptic subpreputial

                             Fig. 99.
Chancroidal ulceration of an incision of the prepuce required for the relief of phimosis.
washes and the  external application  of  evaporating  lotions.  Thus
the whole preputial sac may be syringed out every two hours with
hydrogen peroxide, followed by  mild bichloride solution 1 to  6000, or
other unirritating antiseptic.   The penis  should be kept elevated, so
that venous congestion may be  diminished, and should be wrapped
in lint kept wet with alcohol and lead water equal parts of each ; or,
when the  circumstances of the patient  are  such  as to permit this
treatment, subpreputial washes,  followed by prolonged soaking of the
penis  in water as hot  as can  be borne, are at times most efficacious 
292        GENITO-URINARY DISEASES AND SYPHILIS.

in reducing inflammation.   The soaking should last for an hour, and
should be repeated three or four times daily.
   If, despite this  treatment, swelling  rapidly increases, and it is evi-
dent that the chancroid is steadily extending, there should be no hesi-
tation in splitting the prepuce along the dorsum, exposing the chancroid,
cleansing it carefully, and thoroughly cauterizing it.   The cautery iron
should also be carried along the preputial incision, since otherwise this
fresh wound would probably become  infected and form a chancroid
as virulent in  type as that for  the relief of which the operation was
required.   (Fig.  99.)  The objection  to performing  circumcision at
this  time  lies  in the fact that  the  operation wound is usually con-
verted into a chancroid.  Moreover, when there is great edema, there
is difficulty in  accurately gauging  the flaps.   These objections are not
of sufficient weight to  cause circumcision to be rejected invariably;
indeed, in  a fair proportion of cases, when  every antiseptic precau-
tion  has been taken, union may be almost as prompt as when non-
chancroidal lesions are subject to operation.   There  can, however, be
no certainty that the circumcision wound will remain healthy.
   Paraphimosis.—When  paraphimosis complicates  chancroid,  an
effort at reduction should be made immediately, unless  the swelling
is so great that there  is obviously no chance of succeeding.  If, as
a  result  of the paraphimosis, there   are  not great  congestion  and
edema, and the chancroid is not obviously extending, it may be  suf-
ficient to treat this condition in accordance with ordinary principles,
—elevating the  penis and keeping it  swathed in cloths wrapped in
evaporating lotions.  If, however, the  edema is rapidly growing more
marked and the ulcer is extending, a cutting operation should be prac-
tised, the  paraphimosis being reduced.  Before  doing this  it is well
to cauterize the chancroid thoroughly, and after the reduction to sear
the operation  wound.   If there is danger of converting  the case by
reduction  to  one  of inflammatory phimosis, the foreskin should be
split along its dorsum, as advised  for phimosis, and the line of  in-
cision cauterized.  When the congestion incident to phimosis or para-
phimosis reaches  such a point that gangrene is threatened,  operative
interference is imperative.  It is possible to treat these cases under
cocaine anesthesia, but, since both the use of the knife and the ap-
plication  of the  cautery should be deliberate and thorough,  and since
the results of  hurried or partial treatment are often disastrous, ether
should be administered.
   Gangrene and  Phagedena.—When gangrene develops, the first in-
dications are to relieve constriction or pressure. When it complicates
a phimosis or  a paraphimosis, these conditions should receive prompt 
CHANCROID.
293
surgical treatment.  The patient must be kept in bed, with the involved
parts elevated and wrapped in hot antiseptic fomentations frequently
changed.  These may be made by wringing out pads formed of twenty
or thirty layers of gauze wet in bichloride solution 1 to 2000  as hot
as can be borne, enveloping the gangrenous regions in these pads, and
covering this dressing with oiled  silk to prevent evaporation.   These
compresses  should be  changed  every fifteen  minutes.  Prolonged
soaking of the parts in  hot water or a hot mild antiseptic solution is
a powerful means of arresting gangrene.
    If, in spite of treatment  by heat, the gangrene  is rapidly extend-
ing, the parts already devitalized should  be clipped away, and the
ulcerated and raw surfaces should receive a thorough application of
the actual cautery, or of nitric acid, the field of  operation being sub-
sequently dressed with compresses kept wet with lead water  and
alcohol.
    In all these cases of  gangrene the constitutional treatment should
receive  careful attention and should be supporting and stimulating.
Iron, quinine, and nux  vomica are the tonics  of  choice.  Potassio-
ferric tartrate has been particularly recommended.  Cod-liver oil will
be found beneficial in perhaps the majority of cases.
    The chronic phagedenic chancroid and the serpiginous sore are so
invariably associated with constitutional dyscrasia that local treatment
alone is  powerless to effect  a cure.  Often the underlying lesion  is
syphilitic in  nature  and appropriate specific treatment will  be fol-
lowed by cure.  Frequently it is tubercular or is dependent upon vis-
ceral lesions.  In any case general treatment is of cardinal importance.
This should  be  tonic and  supporting in type.   Stimulants, cod-liver
oil, the hypophosphites,  and arsenic render valuable service.  Locally
the lesion should be treated in accordance with the condition of the
granulating surface:  thus, applications of  silver"nitrate ten per cent.,
or copper sulphate of equal strength, followed by dusting with iodo-
form, will sometimes be  followed  by good results.   Usually these and
other mild methods of treatment are perfectly futile.  In such cases cau-
terization of the entire lesion, followed by packing with iodoform gauze
and the application of an antiseptic dressing, may accomplish  a cure.
In some  instances a continuous  warm  bath, lasting for  days or even
weeks, has caused  lesions to heal which  had  resisted every other
form of treatment.  This bath  may be made mildly antiseptic by the
addition of boric acid or sublimate; though the results seem to be
equally favorable when water  alone is employed.   Occasionally such
cases recover when complete change of air and surroundings is made,
supplemented by ordinary  clean dressings. 
 294       GENITO-URINARY  DISEASES AND SYPHILIS.

    Lymphangitis.—This comparatively rare complication of chancroid
 is treated in accordance with general surgical principles;  that is, the
 chancroid should be cleansed and drained, the penis should be elevated
 and swathed in cloths wet with evaporating lotions, and the patient
 should be kept quiet on a light  diet, and should have his bowels thor-
 oughly opened.   Usually resolution takes place.   Fluctuation denotes
 that pus has formed.  This should be evacuated by a small puncture
 made with all antiseptic precautions, and the  cavity washed out with
 peroxide, followed by bichloride  1  to  2000,  and sealed up with an
 iodoform gauze collodion dressing.   In case  of reaccumulation the
 evacuation and washing are repeated.   If inflammatory phenomena
 become  pronounced, the  abscess-cavity should be freely opened and
 packed with  iodoform gauze.  These abscesses  become  chancroidal
 only because of inoculation from without.
    Lymphadenitis or Bubo.—This complication of chancroid will usu-
 ally be avoided when  the lesion is kept thoroughly clean from the
 first and when  the  patient is content to remain quiet.  Even when
 the glands have begun to swell, as evidenced  by pain and tenderness
 in the  groin and the detection of a distinct lump, further enlargement
 can  often be prevented by rest in bed, the administration of a saline
 purge, and the application  over the affected region of heat and press-
 ure. This is best applied by means of lint wet with dilute lead water.
 Over this is laid the ordinary rubber  hot-water bag, fastened in  place
 by one or two  turns of a spica, the patient lying on his back in bed,
 scrupulous attention being paid at the same time to the cleansing of
 the chancroid.
   When this treatment by rest in bed and application of heat is not
 practicable, there may be placed over the sore  the following ointment:

                    R  Ung. hydrargyri,
                      Ung. iodi  comp.,
                      Ung. belladonna?,
                      Ung. petrolei carbolat., aa gii.

   Over  this is placed a compress, and firm pressure is made on the
gland by means  of a spica bandage.
   After twenty-four hours of this treatment, if there is no improve-
ment, and particularly if the pain, swelling, and inflammatory phenom-
ena are more marked, time and suffering will be saved the patient by
administering ether and then proceeding at once to excise the affected
gland or  glands, since it is almost certain in these cases that suppura-
tion will  take place.  This excision is conducted  in  accordance with
the principles of modern surgery.  All enlarged glands are shelled out, 
CHANCROID.
295
and the wound is thoroughly cleaned, and is closed without drainage.
When patients object to this radical treatment,—and this will be in the
majority of cases,—an effort should be made to cause resolution by
the injection of antiseptic solutions into the substance of the inflamed
gland.  The drug most  employed is benzoate of mercury in one  per
cent, solution.   From ten to fifteen drops of this  are driven directly
into the inflammatory focus.   Antiseptic compresses and a pressure
bandage are then applied over the affected region.  This is followed
by increase of swelling for twenty-four hours, but  after this resolution
usually takes place.   In  place of the benzoate of mercury a three per
cent, solution of carbolic acid may be employed in equal quantity, ten
to twenty minims being  injected at one time.
   If suppuration occurs in spite of this treatment, or, when a case
first  comes  under observation, if there is fluctuation, the abscess-sac
should be punctured under antiseptic precautions, its contents squeezed
out, and bichloride solution 1 to 2000 injected.  This should then be
pressed out, and over the seat of abscess-formation should be placed
a large absorbent antiseptic  dressing.   If, following this operation,
there is reaccumulation  of fluid in the abscess-cavity, it should again
be evacuated by puncture.  If more than two punctures are  required,
the cavities should be  freely incised,  gently curetted, packed  with
sterile  iodoform gauze, and dressed antiseptically.
   If when the case  comes under observation there is a large abscess
with the  overlying skin livid and devitalized, or already ulcerated
through, the cavity  should be  opened by a free  incision parallel to
Poupart's ligament.   Careful search should be made for glands begin-
ning to soften but not yet completely broken down, which should be
removed  either by means of  blunt dissection with the finger, or by
careful cutting with  the knife.   The whole wound cavity should be
thoroughly curetted, and should be packed with sterile iodoform gauze.
Any sinuses which may form must be followed to their end,  being
freely slit open to the surface.  This operation sometimes results in
an enormous wound, but no  hesitation  should be felt in making it,
since otherwise  ultimate cure  is uncertain.
   When  that form of inflammation is encountered which  is some-
times seen in tubercular cases,—that is, when  gland after, gland en-
larges and slowly breaks down, its capsule becoming firmly  adherent
to the  surrounding parts and the whole forming a  large lobulated
tumor,—removal by careful dissection is the only  means  of treatment
which will be followed by cure.   In these cases the glands sometimes
contract adhesions to the femoral vein, and a number of  deaths have
been recorded from the wounding of this vessel in the course of an 
296
GENITO-URINARY  DISEASES AND SYPHILIS.
operation.   Following the dissection the wound is packed with iodo-
form gauze.
   When the bubo has ruptured before it has come under observa-
tion, and when it is infected with the ordinary pyogenic microbes, in
addition  to free incision  and curetting  it is well  to paint the whole
raw surface with a solution of zinc chloride, sixty grains to the ounce,
subsequently packing with iodoform and dressing the wound as before
described.
   When a bubo becomes chancroidal in type,  the  resultant sore
should be treated in accordance with the principles governing the treat-
ment of chancroid.  Thorough cauterization will usually be followed
by prompt cure.   If cauterants cannot  be employed, applications of
the ordinary  antiseptics are  often  efficacious.   These  chancroidal
buboes are of course  subject to the same inflammatory complications
as are  chancroids of the penis.
   The after-treatment of buboes which  have been operated  on is
comparatively simple.  Rest in  bed is advisable for  at least from
five to seven days, since thus the parts will be kept quiet.   A spica
of the  groin holds the dressing  in place.   This is to be changed in
accordance with the strictest antiseptic principles, since it is possible
at any  time to have the ulcerating surface inoculated with the chan-
croidal virus.  In some instances healing goes on  more rapidly when
the patient  is allowed to be up  and  about than when he is kept in
bed.  If,  however, walking  or  sitting  in the erect  posture retards
healing, the patient  should  be kept in  bed  until convalescence is
established.
   The treatment of chancroidal buboes  may be  summarized as fol-
lows.  1. Buboes are to be avoided by thorough cleansing of the chan-
croids  and  by rest upon the part of the  patient.  2.  They  may be
aborted in  their earliest stages by active purgation, by rest in bed, and
by the application of  heat  and  pressure.  If in  twenty-four hours
abortive  treatment is not followed by improvement, no further effort
should be made in this direction.  3.  If the bubo is steadily progress-
ing in spite of appropriate treatment, excision before softening has oc-
curred offers the quickest method of cure.   4. When this is not prac-
ticable, injections of  antiseptics  into the  substance of the diseased
glands, followed by pressure and rest, will often bring  about reso-
lution.    5.  When softening has occurred, but the  skin is  not yet
involved, evacuation of the  contents of the abscess through  a  small
puncture, followed by antiseptic  irrigation and the application of a
pressure bandage, will favor resolution.    6. If after this treatment
once repeated the abscess-cavity again fills, or if  the abscess is large 
CHANCROID.                        297
and the skin is already partly devitalized, the abscess should be opened
by free incision  parallel with Poupart's ligament, all enlarged  glands
should be shelled out or excised, all sinuses should be followed to their
extreme limit and opened  freely, and the  ulcerating wound  should
be packed with iodoform gauze.   7.  This same treatment should  be
applied  to  buboes which have  already  opened  spontaneously, and
should be supplemented by  the application of  zinc chloride, sixty
grains to the ounce, to the curetted surfaces.  8. The tubercular type
of bubo requires excision of all the enlarged glands.  9. All operations
on chancroidal  buboes should be conducted with scrupulous regard
to the principles of antisepsis. 
CHAPTER  IX.
                             SYPHILIS.

   Syphilis is a contagious, inoculable disease, transmissible by hered-
ity.  The first lesion of the acquired form of syphilis is a chancre;
this is followed by general lymphatic enlargement, by eruptions of the
skin, usually superficial and symmetrical and associated with similar
lesions of the mucous membranes ;  later by chronic inflammation and
infiltration of the cellulo-vascular tissues, the bones, and the perios-
teum, and  finally by the formation  of small tumors called gummata,
which  may appear in any portion of  the body, but which commonly
develop in the connective tissue.
   Etiology.—Syphilis is almost certainly due to  the presence in the
system  of  a specific microbe.   A number of  bacteriologists  have
announced the discovery of this microbe, but convincing proof of the
direct relation between the micro-organisms described and the specific
lesions with which they have been found associated  is still wanting.
The clinical evidence as to the microbic nature of the disease is, how-
ever, fairly conclusive.  The languor, pain, and  fever preceding the
eruption are  readily explained  on  the  theory  of  intoxication by
ptomaines  engendered by the germs which are  not yet sufficiently
generalized to produce more pronounced symptoms.  The eruptions
on the skin and mucous membranes are due to local deposits of the
virus ;  this is shown by the  fact that the discharges from such lesions
are contagious.  The profound alteration  in nutrition so often asso-
ciated  with the secondary  eruption  is due to auto-intoxication by
tissue-products passing into  the circulation.
   Following the  secondary  stage of the disease there may be no
further  symptoms of syphilis, or, after a period of latency, gummata
may develop.   During this period of latency or apparent cure, syphilis
may be  transmitted to offspring, showing that the  active virus  is still in
the system.  This virus or its ptomaines, however, absolutely protect
against  fresh inoculation.  A person who has had syphilis is immune
against  a fresh attack, positively during the primary and secondary
stages of the disease, probably for many years or for the entire period
of life.   It is true that cases of reinfection  are reported, but  they are
     298 
SYPHILIS.
299
rare; the majority found in medical  literature are cases of so-called
relapsing chancre, in reality a tertiary lesion of syphilis.
   Immunity against Syphilis.—It is found impossible to inocu-
late the syphilitic virus:
   1. Upon a person who  has already suffered from the acquired
form of the disease.
   2. Upon a person who has inherited syphilis from one  or both
parents.  (Profeta's immunity.)
   3. Upon a mother who has borne  a syphilitic  child without show-
ing in her own person any of the lesions of acquired syphilis.  (Colles's
immunity.)
   The immunity against fresh infection  conferred by acquired syphi-
lis is present in the earliest stages of the  disease, usually from  the first
appearance of the chancre; in some  cases even  before this.  It per-
sists long after syphilitic manifestations  have disappeared, and it can
be transmitted to offspring independently of  the active virus.
   These facts show conclusively that  the  immunity in syphilis, as
in other infectious  diseases, must be due to the tissue-products of  its
organized virus passing into the circulation.
   Profeta's  immunity—namely, that observed  in  the offspring  of
syphilitic parents—is noted  at times in children who exhibit no signs
of hereditary syphilis.  Here inhibiting tissue-products without the
active virus are  present in  the circulation.  This is also the case  in
Colles's immunity, in accordance with which  the mother of a child
syphilitic by its father cannot be inoculated with syphilis.  The ex-
planation of this fact depends either on the absorption into the mother's
blood through the placental circulation of only the tissue-products  of
the specific micro-organisms, the so-called antitoxins, or upon  the fact
that the mother is really suffering from latent  symptoms, both the
active virus and the tissue-products having been absorbed, but having
been so modified by pregnancy that none of the ordinary manifestations
of the  disease are observed.
   Syphilitic Reinfection.—Although, as  already stated, syphilitic
reinfection  is exceedingly  rare, it unquestionably occurs in some few
cases.   In the great majority of those reported  the symptoms could
be more satisfactorily explained by regarding them as the result of a
recrudescence of the original attack.   Fournier states that reinfection
is certain only when  the  following conditions can be noted  in their
proper chronological order:
   An  indurated chancre with indolent inguinal pleiades; some weeks
later, a typical roseola or  other  syphilitic eruption, cephalalgia, alo-
pecia,  or mucous patches;  a complete  absence  of  tertiary accidents 
300
GENITOURINARY DISEASES AND SYPHILIS.
for  some  years;  finally a new indurated  chancre after a  suspicious
coitus, with characteristic adenopathies, followed, after some  weeks,
by  incontestable  secondary symptoms, such as  headache, alopecia,
mucous patches,  typical eruptions of macular  or papular syphilo-
dermata, or of other syphilides.
    The difficulty in these cases  lies in the fact  that it is at times
impossible to distinguish the primary chancre  from  the  indurated
pseudo-chancre.  The pseudo-chancres may be divided into:
    1. Those which develop, as the result of  the spontaneous awaken-
ing of the syphilitic  virus, at a  point where the virus has already
manifested its action.
    In this case it  is sometimes possible, where one has observed this
lesion at its debut, to distinguish it from syphilitic chancre ; for, accord-
ing to the  investigation of Fournier, Vidal, and  others, it begins by a
hardness profound from the first, then becomes excoriated  and forms
a sore, while the induration of the true chancre is consecutive to the
ulceration, or, at most, contemporaneous with it.
    2. Those which occur as the result of an extrasyphilitic irritation,
—the inoculation  of the chancroidal virus, for example,  or an outbreak
of simple  herpes,  or  the lesion of some form of traumatism.  Here
the sore has preceded the induration.
    Objectively, these  lesions  may be absolutely identical with in-
durated chancre.    Their ulceration  is sometimes deeper,  but more
excavated and attended  with more  secretion; these  characteristics
may, however, be absent.
    There  is no authentic example of a case of reinfection in a syphi-
litic who is suffering  from secondary  manifestations of  the  disease.
Reinoculation practised upon persons presenting the tertiary forms of
the eruption has been uniformly unsuccessful.
    The Contagion of Syphilis.—The blood of a  syphilitic during
the secondary period and the secretion from a chancre  or from any of
the secondary lesions  are contagious.  The blood may carry contagion
after all the inflammatory phenomena of syphilis have  disappeared.
    Even during the most active stage of the  disease the normal secre-
tions, the saliva, the sweat, the milk, and the semen, will not  convey
the disease, provided  they  have  not mixed with them a discharge
from  some of the  inflammatory  lesions.  It is  possible that in the
passage of the serum of the blood through  the glandular membranes
and cells the contagious particles  are strained out.
    Although the semen cannot convey contagion, it must contain the
virus  in some form, since it is able to  infect the embryo, and, by this
means, the organism of the mother. 
SYPHILIS.
301
   After the primary and secondary stages of the disease, both  the
blood and the discharge from the lesions are innocuous, so far  as
the conveyance of syphilis is concerned.   This condition is generally
reached at the end  of two years.   After three  years contagion is
almost unknown, and, according to Hutchinson, there is no recorded
instance of its  having taken place after five years.  Nevertheless, in-
flammatory lesions the result of syphilitic poison may appear for many
years after the  virus has lost its power of contagion.
   Whether contagion be derived from the  discharge of a chancre,
from that of a mucous patch, or  from  the blood of a syphilitic, the
primary lesion  at the seat of inoculation is invariably a chancre.
   Except in  the  hereditary and conceptional  forms, a chancre is
always the starting-point of syphilis.
   Methods of Contagion.—Syphilis has been aptly compared by
Hutchinson to  the contagious eruptive  fevers, such as small-pox and
scarlet fever.   Like  these fevers, it is communicated from a diseased
person to a healthy one, and the  smallest portion of virus can affect
the whole body.  It has its stages  of incubation, eruption,  and decline,
and also its sequele, the latter not always appearing, and usually being
non-contagious;  it  can be  transmitted to offspring, but  its  sequele
cannot be  so transmitted.
   It differs from the other exanthemata in the slowness of its course,
in the comparative mildness of its constitutional symptoms, and par-
ticularly in the fact that it is contagious  but not  infectious, requiring
contact before  it  can be transmitted.
   The contagion may be either immediate or mediate.
   Immediate contagion—that is, contagion direct from  one individual
to another'—usually takes place  during sexual  approach, though it
may occur from  unnatural  practices, from kissing, from  wounds in-
flicted by the teeth of  syphilitics, or, in the case of medical men, from
operating on syphilitic patients, when the hands  of the operator are
wounded or abraded.
   In one case observed in the Out-Patient Department  of the Uni-
versity Hospital,  a chancre developed at the seat of puncture made in
the skin of the lower eyelid  for the purpose  of sucking out a blood-
clot caused by a blow.  The man who  made suction was  suffering
from mucous patches of the mouth.
   Mediate Contagion.—In this  form of contagion the disease is con-
veyed not by direct surface  contact, but by means of spoons, glasses,
pipes, clothing, etc., upon which the  specific  virus is  deposited by a
person suffering from some of the lesions  of syphilis, and from which
it is inoculated in some surface break of a person not immune to the 
302
GENITO-URINARY DISEASES AND SYPHILIS.
disease.  The list of  articles which have thus conveyed syphilis is
comprehensive.  Among the frequent carriers of contagion are pipes,
cigars,  razors, surgical  and dental  instruments,  handkerchiefs  and
articles of clothing, and human vaccination lymph.
   In one case of Hunterian chancre of the arm  the  contagion was
conveyed  by means  of a towel.   The patient was the keeper of a
house  of  assignation.   She attended  to  her own housework,  and
with sleeves rolled up was in the habit of collecting the soiled towels,
throwing them over her bared left arm.  At the seat of a slight scratch
on the flexor surface a typical primary lesion developed.
   Types of Syphilis.—Syphilis may begin  and end with chancre
and  inguinal adenitis,  no other symptoms developing.  Under these
circumstances doubt may reasonably be entertained as to the nature
of the original sore.   It  has, however, been proved beyond contra-
diction that after such a sore and the entire absence  of secondaries
unmistakable tertiary  lesions may appear years  later, and it seems
reasonable to conclude that infection may  exceptionally  be so mild
that it is sufficiently overcome by systemic  resistance  in  its primary
stage to prevent the secondary efflorescence.
   The disease  may  have for  its manifestations a chancre, general
adenitis,  and  one light  outbreak  of macular or papular  eruption
involving the skin and the mucous surfaces of the mouth and throat,
thereafter showing no signs.
   More commonly  following the chancre  there is  a single exan-
thematous outbreak, disappearing  promptly under treatment, but re-
curring occasionally,  particularly in the mouth and  throat.  These
recurrences yield promptly to more vigorous antisyphilitic treatment,
and  are not followed  by tertiaries.  The types of disease thus de-
scribed are termed  benign, but any of them may be followed by
tertiary manifestations of the most dangerous and incurable form.
   Exceptionally the disease is distinctly atypical in its development,
deep ulcerating and infiltrating lesions appearing in the early second-
ary period.   In these  cases syphilis may assume a malignant type.
   This form of the   disease  is  characterized by its acute course.
Even the  chancre exhibits a destructive tendency, resembling in its
development phagedenic chancroid.  Syphilitic  fever, concomitant
rheumatism, and anemia are well marked.  The first eruption quickly
becomes pustular, and ulcers form which are deep enough to leave
pigmented scars  on the skin, and in the mouth and nose to involve
the superficial bones  and cartilages, causing necrosis and deformity.
Deep ulcers and ulcerating gummata appearing in  the secondary
period are especially  characteristic of this form of syphilis.  Recur- 
SYPHILIS.
303
rences following hard upon one another are also typical of malignant
syphilis, while early involvement of the bones, the nervous system,
and the viscera  is not uncommon.    In  the latter  case  syphilitic
marasmus and death often result.
   The  malignant form of the disease seems to depend not so much
upon the virulence of the infection  as upon the lessened tissue resist-
ance.  Thus, syphilis is prone  to  exhibit its malignant form in the
weak, the anemic, chronic drunkards, the scrofulous, the tuberculous,
the malarial, and in pregnant or nursing women.
   Periods of Syphilis.—In accordance with  its clinical course the
phenomena of acquired syphilis are  classed  under certain  periods.
These are as follows:
   1.  The Period of Primary Incubation.—The  time intervening be-
tween exposure to contagion and the appearance of the chancre.  This
is, on an average, three weeks.
   2.  The Period of Primary Symptoms.—The chancre develops and
the anatomically  related glands become enlarged.  This period, on an
average, is from three to ten days.
   3.  The Period of Secondary Incubation.—The  time elapsing be-
tween the appearance of the chancre and the development of secondary
symptoms.  This is, on an average, about  six weeks, and includes, of
course, the period of primary symptoms.
   4.  The Period of Secondary Symptoms.—Syphilitic fever, anemia,
neuralgic pains, and  the syphilides of the skin and  mucous mem-
branes develop during  this period.   This is, on an average,  from
twelve to eighteen months.
   5.  Intermediate Period.—During this time the patient may be en-
tirely free  from any signs of syphilis, or he may suffer from  slighter,
more  irregular, less symmetrical, and less generalized symptoms than
those of the secondary stage.   Children begotten by a patient in the
first half of this stage of the disease often show the signs of hereditary
syphilis.  This period lasts from two to four years.  It may terminate
in complete recovery or may be followed by :
   6.  The Period of Tertiary Symptoms.—This is characterized either
by the formation of  gummata  or  by  diffuse infiltration of various
organs.  Chronic periostitis and ostitis, skin diseases of the tuberculo-
ulcerous type, disease of the  nervous  system, etc., are encountered
during this  stage.  In  the majority of properly  treated  cases the
lesions of this period  never  appear;  though they may develop at
any time subsequent  to the chancre, they commonly are seen in the
third and fourth years following the primary lesion.
   It must be understood that this division of syphilis into periods is 
GENITO-URINARY DISEASES AND SYPHILIS.
to an extent artificial, there being  rarely any sharp limitations; one
period runs insensibly into another.   Indeed, it is possible that lesions
of primary, secondary, and tertiary syphilis  may all be present at the
same time.
   The Period of  Primary Incubation.—In a  person exposed
to contagion the lesion  of  syphilis does not develop  immediately.
Although there is  little reason to suppose that  the virus of syphilis
remains localized during the entire period elapsing between inoculation
and the appearance of the chancre, it is probable that it remains  at
or near the seat of inoculation a certain length of time, and hence if
immediately removed by caustic applications or by surgical  operation,
local and  general symptoms of syphilis will not follow.  There are
cases on  record, however, which  seem  to disprove  this.   Abrasions
through which the virus might have been  absorbed have been cut
out a few  hours after suspicious connection,  and yet characteristic
induration  and secondary symptoms of syphilis have developed at the
regular time.   It is, of course, possible  that excision in these cases
was  not  sufficiently thorough.  Such instances  show that  even after
very early removal the prognosis concerning subsequent disease must
be exceedingly guarded.
   It is possible that syphilis  may be acquired from contact with the
virus through unbroken  surfaces, especially where the epidermis  is
extremely thin; but  the presence of  fissures or of abrasions greatly
facilitates the contraction of the disease.
   As has been said, from whatever source  the  contagion is derived,
a chancre at the point of inoculation is the invariable result.
   The period of primary incubation varies from ten days to three
months.   The average period  is three weeks.  As a rule, it is  safe to
assume that any sore which appears more than ten days after the last
exposure to contagion is a chancre.  During  the  period of primary
incubation there are neither general nor local symptoms.

                THE  PERIOD  OF PRIMARY  LESION.
   After  the  period of  primary  incubation the primary  lesion  of
syphilis, a  chancre, develops.   This begins as  a  spot of erythema,
which in  a few hours becomes  a superficial papule;  it  gradually
extends in circumference and depth, loses its epithelial or epidermic
covering, and  in the course of a few days is surrounded by an area
of induration.   This represents the  development of a typical chancre.
Frequently, however, the chancre when first seen appears as a fissure
or an abrasion, or, if located on the mucous membrane, as a super-
ficial ulceration covered by a grayish or yellowish false membrane. 
SYPHILIS.
305
   Often there is no break in the continuity of the epidermis overlying
a chancre, but merely a gradual thinning of this layer of the skin from
the margins towards the centre.
   When actual ulceration exists it forms a simple cup-shaped depres-
sion, with  sloping margins and smooth surface, in the centre of which
is a false membrane ; beneath this there is a granulating surface, which
bleeds readily on mechanical interference.
   As  synonymes for  chancre  the  following terms  are  employed:
Hunterian chancre; infecting chancre;  hard chancre;  indurated neo-
plasm ;  primary sore.
   The  chancre  is usually single.  When  the virus has been inocu-
lated at  the same time in several places a number of sores may appear,
but they all develop at the same time, and are never due to inocula-
tion  of  surrounding  or apposing  surfaces with the  discharge of a
first sore.
   Induration.—In from  five to ten  days the most  characteristic
feature of chancre, the induration, becomes perceptible ; it commonly
reaches  its maximum in about  two weeks from the appearance  of
the chancre.  In some cases the induration is  entirely absent.  It is
present  and distinct in the great majority of cases, but may appear in
different forms.   This hardening about the primary lesion of syphilis
is due to a cellular infiltration of the connective tissue and of the coats
of the venules and arterioles, affecting chiefly the tunica adventitia of
the latter.  It is the thickening of the blood-vessel walls which, in
conjunction with  the cellular infiltration,  gives to  the chancre  the
specific induration.
   The  blood-vessels of the skin form two horizontal net-works,—one
beneath the papille, the other in  the deepest  portion  of the derm.
When only the  superficial  net-work of vessels is sclerosed there is
simply a surface induration ; when both net-works, together with  the
vtermediate branches, are affected, there is a distinct nodule, varying
in thickness according to the extent of skin surface involved.   Nearly
always the vascular sclerosis is continued far beyond the area of indu-
ration, but usually in such a comparatively slight degree that the line
of demarcation  between the borders of the chancre and  the sur-
rounding tissue is  distinctly marked.
   In accordance with its depth the induration is classified as follows:
   1. Laminated  Induration.—The  hardening  around  the  lesion,
though distinctly outlined from the surrounding tissues, forms a layer
so thin that it  gives to the examining fingers a sensation as if a disk of
writing-paper  had been inserted in the superficial layers of the skin.
  2. Parchment Induration.—This is somewhat  thicker than the 1am-
                               20 
306        GENITO-URINARY DISEASES AND  SYPHILIS.

inated induration, giving on palpation such a sensation  as would be
conveyed were the lesion placed upon a disk of parchment.
   3. Nodular Induration.—This, in the absence of acute inflamma-
tion, is  the most  characteristic form  of induration.  It  is hard  and
thick, feeling like a nodule of wood or of cartilage.  In well-developed
cases of this nature not only the vessels of the skin but also those of
the subdermic connective tissue  are  involved.   The hardening is in
some cases so great as to suggest the presence of malignant growth.
   4. Annular Induration.—As is implied by the name,  this form of
induration  affects  only the margins of the chancre, a hard ring being
formed  about the centre, which retains almost normal elasticity.
   The induration of the  chancre is best detected by gently pinching
together the soft parts wide of the lesion till  the  hardened edges  are
felt by the  thumb and finger placed on opposite sides of the sore;  the
whole plaque  is  then  lifted upward  from  the subcutaneous tissues,
when, by further gentle pressure and  palpation, the depth and extent
of the induration can be readily determined.
   As would be  supposed from a knowledge  of the cause of indu-
ration, the  extent of the latter varies  in accordance with the seat of
the primary lesion.   When  occurring  upon the glans  penis, upon
the mucous membrane of the prepuce, or  in  the  fossa glandis,  the
chancre  is  usually very distinctly indurated.   Upon the skin of  the
penis and  the general  integument induration is  not so marked.  In
women the induration of the primary lesion is far less distinct than
is  the case with men;  when  the  chancre is  situated upon the labia
majora  the characteristic  hardening is more pronounced than when
it involves  the labia minora or the fourchette.
   The  chancre, if ulcerated, commonly heals in four to six weeks,
the induration lasting not much  longer than  this,  though, if it  has
been  distinctly nodular in character,  it may persist for  months and
even  years, or, after having entirely disappeared, may again become
marked, constituting a form of the so-called pseudo-chancre.
   Location  of the Chancre.—The chancre may be located on any
part of the body.  Genital chancres are those placed on  or about the
genitalia.   The great  majority of chancres, especially in men,  are
genital or perigenital.
   Extragenital chancres are those situated on other surfaces of  the
body.   The disease when acquired in ways other than by normal or
perverted sexual congress is termed syphilis insontium.   The extra-
genital chancre may be found  on any  portion of the surface of  the
body  exposed  to contact  with syphilitic virus.  The usual seats of
such  chancres  are the lips, the mucous surfaces of the mouth and 
Fig. 100.
Chancre of the reflected layer.
Fig. 101.
 
 
SYPHILIS.
307
pharynx, the region of the anus, and  the  region of the nipple.   In
the mouth  the chancre is commonly  found on the tongue,  excep-
tionally  on  the  tonsils or the  half-arches.  Among  surgeons and
accoucheurs extragenital chancre is usually found  on the fingers or
hand.  With very few exceptions, extragenital chancres are acquired
in innocent ways;  even the anal chancres often  noted in women are
commonly due to infection by discharges flowing backward from the
vagina.  Extragenital chancres rarely present the typical  features of
the sore as observed about  the genitalia.   At times the lesions are
so slight as to  excite scarcely any attention; more commonly inflam-
matory  symptoms become so pronounced that  characteristic indu-
ration, if present, is entirely masked,
and, except  in the clinical  history of           Fig. 102.
the case, there is nothing to  suggest
that the sore is syphilitic in nature.
    Chancres of  the face are  often
much larger than the average genital
chancre, and  sometimes form huge
ulcers.  This is also true of chancres
of the lips.

      THE  GENITAL CHANCRE.
    The common position of the gen-
ital chancre in men is on the mucous
membrane of the prepuce in or just
behind the coronary sulcus (Figs. 100,
102), on the surface of the glans penis,
particularly in  the region of the fre-
num, and about the margin  of the
preputial opening.   Three-fourths of
all chancres are in these  localities.
The primary sore  is found at times
at the meatus urinarius, on the skin
of the  penis,  on  the  groin  or the
scrotum, and in the urethra.
    The characteristic  induration is
most marked in those Chancres found      Chancre of the coronary sulcus.
at the seats of preference,—i.e., on
the mucous  membrane of the prepuce  just behind the sulcus.   Upon
the surface of  the  glans, in the region of the frenum, and  about the
urinary meatus the induration is often slight, and the sore  frequently
assumes a distinctly inflammatory type.   (Fig. 101.)
 
GENITO-URINARY  DISEASES AND SYPHILIS.
   On the free edge of the prepuce the induration may be absent or
may form a ring of great hardness.
   In women chancres are commonly placed  on the labia majora or
labia minora.   They are not infrequently found in the regions of the
fourchette and the clitoris, and have occasionally been observed about
the os uteri.  They are hardly  ever seen upon the surface of  the
vagina, although this  canal is  probably more  exposed to  contagion
than any other surface.  This immunity is due to the structure of the
vaginal mucous membrane, which, being guarded with thick layers of
flat epithelial cells, and having no glandular orifices, forms an efficient
barrier against microbic infection.
   As has been said, the induration of chancre is  far less marked in
women than in men; the typical sharply circumscribed cartilaginous
hardening is rarely observed; it is replaced by a  more diffuse and
less  sharply marked infiltration, often very little greater than would
attend a non-specific lesion of the same size.
   Varieties  of the Genital Chancre.—Although the primary
lesion  may appear  in  a great variety of forms, the  majority of  cases
present certain characteristic  features, enabling  them to  be con-
sidered under a few headings.
   In  the  order of their relative frequency chancres may be classed
as:
   1. Chancrous erosions.
   2. Chancrous ulcerations.
   3. Indurated papules.
   Exceptionally there are observed certain erratic forms of chancre
which  would  not strictly fall  under any of these headings.  Among
these are encountered:
   1. The multiple herpetifbrm  chancre, closely resembling herpes,
but  not presenting the multiple circinate  margin of the  latter,  not
giving the characteristic exudation of herpes on pressure, and having
a different clinical history.
   2. The " silvery spot," a lesion such as would be produced by the
application of a finely pointed silver nitrate  stick, generally situated
on the surface of the glans penis, and often giving place finally to the
chancrous  erosion.
   3. The mixed chancre, a lesion which  results from the action of
both the chancroidal and the syphilitic virus.  The  chancroid runs its
typical course and  may be healed before the  syphilitic induration is
noted.   More frequently there  is a persistent chancroidal ulceration,
around which the hardening of the true chancre appears at its regular
time. 
Fig. 10:;.
Chancre of the corona.  (Fox.)
 
 
SYPHILIS.
309
   1.  The  Chancrous  Erosion.—About two-thirds of  all  genital
chancres appear in the form of chancrous  erosions.  The lesion at
first looks like  a small abrasion,  such as might result from a very
slight  scratch with the  finger-nail.  As the chancre develops it be-
comes oval or round in shape, is surrounded  by a dusky-red areola,
presents  a polished raw surface, the  central  portion of which is
covered by a gray false membrane, and discharges a small quantity
of blood-stained  serum.   The  lesion is an  exfoliation of  the  epi-
derm, exposing but  not  destroying  the  true skin.  The  induration
develops in  about a week from the beginning of the erosion, and is
usually parchment-like, though it may be nodular.
   2.  The Chancrous Ulceration.—This form of chancre  exhibits a
deeper  ulceration than the  chancrous  erosion.   The latter causes
epithelial desquamation;  the former involves the true skin, or, in its
more  exaggerated form,  the subcutaneous tissues.  The  chancrous
ulceration may  be superficial or deep.
   The superficial form of  chancrous ulceration, called by Fournier
the exulcerative chancre,  attacks the  true skin, but does not entirely
destroy it.  An ulcer is formed of moderate depth,  with sloping edges
and a scanty sero-sanguineous discharge.  The granulating surface
is frequently covered by a gray adherent false membrane.   The indu-
ration is more  marked than in the  chancrous erosion, being rather
of the nodular than of  the parchment variety.  (Fig. 103.)
   The deep form  of  chancrous  ulceration, called by Fournier the
ulcerative chancre, is comparatively  rare.  There  is formed a deep
ulcer  with sloping edges, moderate sero-sanguineous discharge, and
typical extensive cartilaginous induration into which the ulcer seems
to have eaten.
   3.  The Indurated Papule.—This primary lesion of syphilis differs
from the chancrous erosion in the fact that the skin is not broken. A
hard,  raised,  dusky-red tubercle is formed, sharply defined from the
surrounding tissues.  The surface is dry, but  is frequently crusted
with layers of exfoliated  epithelium.  The papule may be large and
prominent, or so small as to  escape the notice of the patient.
   Complications of Chancre.—The types of genital chancre just
described may be so modified that they present an appearance en-
tirely different from that  commonly supposed to be characteristic of
the primary lesion of syphilis.
   The  modification may be brought about by:  1, simple inflam-
mation ;  2, chancroidal inflammation ; 3, papillary growth; 4, con-
version into a mucous patch  ; 5, phagedena and gangrene.
   Simple inflammation may attack a chancre as a result of inocula- 
310        GENITOURINARY DISEASES AND  SYPHILIS.

tion with the ordinary micro-organisms of suppuration.   This will be
more  likely to take place if the chancre is exposed to irritating appli-
cations, to friction, or to any mechanical  injury which will render the
soil favorable to the multiplication of pyogenic microbes.   The chancre
will be modified by the  local signs of acute inflammation,—namely,
heat, pain,  redness, swelling, and free  discharge.  As a further com-
plication, suppurating buboes may form in the groins.
    Chancroidal  Inflammation.—The virus  of chancroid  and that  of
syphilis may be inoculated at the same time.  In this case the chancroid
will appear first, and may even have run  its course and be completely
cicatrized before the characteristic induration of the chancre is noted.
More commonly the chancroid persists, the spreading, inflamed, slough-
ing, punched-out, freely discharging  ulcer becoming gradually envel-
oped in a hardened infiltrate as the period  for the  full local develop-
ment of the syphilitic lesion  is reached.   In place of being acquired
at the  same time, the  chancroidal virus may be  inoculated on a
well-developed chancre; the result of  this will be the formation of a
chancroid,  the induration  being the only remaining local symptom
to suggest  chancre.   If  the chancroid spread rapidly it may cause
sloughing of the indurated area, in that case leaving no  local sign
which  would suggest syphilis; or the  syphilitic virus may be inocu-
lated on the chancroid, the latter then running its course unaltered
except for the formation of an induration.
   A sore resulting from the inoculation of both syphilis and chan-
croid at the same spot is called a mixed  chancre.  It is liable to any
of the  complications  which follow the inoculation  of  either of the
poisons separately.
   Papillary Outgrowth and Conversion of the Chancre into a Mucous
Patch or Condyloma.—Associated with the chancre there is often an
abundant outgrowth of warts, such as are common in balanoposthitis
or other inflammatory conditions of the glans and the prepuce.  These
warts seem to be due simply to irritation, and are not specific in their
nature.   The chancre itself at times loses its induration as secondary
symptoms develop, becomes covered with  gray false  membrane, and
presents all the  characteristics of a  mucous patch ; or the  papillary
layer of the skin may proliferate, forming  a condyloma, a broad, flat
elevation, the surface of which  is  covered with  a gray,  adherent
pellicle.
   Phagedoena and  Gangrene.—Phagedena may be regarded as the
result of inflammation more rapid and intense than that which char-
acterizes the inflamed chancre.  The  engorgement becomes so great
that there is loss of vitality, and sloughs are formed, or gangrene may 
SYPHILIS.
311
attack the tissues.   More  rarely it progresses slowly, the  ulcerating
process being then termed serpiginous.
   Phagedena is more liable to occur in persons of depressed consti-
tution, yet it  is noted at times in the robust.  There is undoubtedly
a systemic predisposition, which is in many cases  successfully com-
bated by specific treatment; the exciting cause is, however, purely
local; this is shown by the fact that in the same  person one sore
may become phagedenic  while  another pursues  an  uncomplicated
course.
   Phagedena may attack the  chancre at any stage of  its develop-
ment, or may complicate any of  the  secondary or tertiary ulcerations
of the disease.  If rapid, it destroys the induration more quickly than
it can form, and thus removes the most  characteristic feature of the
chancre.
   Diagnosis of Chancre.—Under ordinary circumstances the diag-
nosis of chancre is  comparatively easy, yet it must be remembered
that there is no infallible sign, and that the primary lesion of syphilis
may present only the features of a simple ulcer.   It is safe to refuse
to give a positive opinion from the examination of the sore alone.
   An opinion as to the nature of a genital  sore will be formed after
due  consideration of the following points:
    1. Confrontation,  or examination  of the person from whom the
lesion was presumably acquired.  Even  though he or she is  found
to be suffering from  symptoms of primary or secondary syphilis, it is
not proper to conclude  that the lesions acquired are  necessarily
specific.  They may be of mechanical, herpetic, or  chancroidal origin.
This method of diagnosis is rarely practicable in this country.
   2. The History of Incubation.—A lesion developing in less  than
five  days  from exposure  is certainly not  specific.  One developing
in from ten days to five weeks is probably specific, unless some other
cause, such as mechanical or chemical irritation,  or fresh exposure,
can be assigned for it.
   3. The Development of the Lesion.—When this begins as a macule,
or slight painless excoriation, or scratch, which persists  in  spite  of
careful local treatment, which slowly spreads without marked inflam-
matory  symptoms, which becomes distinctly hard peripherally and at
the base as though there  were a dense cellular infiltrate, and which
gives a thin, scanty discharge, showing a tendency to crust or to form
a pseudo-membranous deposit covering the excoriated  surface, the
diagnosis of chancre can be made with considerable confidence.
   4. Induration.—When the lesion, be it papule, erosion, or  ulcer,
develops the laminated, parchment, or nodular induration, a sharply 
312       GENITO-URINARY DISEASES AND SYPHILIS.

circumscribed hardening, spreading wide of  the  central lesion  and
absolutely unlike the  general  thickening about an  area of simple
inflammation, it is almost certainly a chancre.
   5. Lymphatic  Involvement.—If the lymphatic glands  of the groin
steadily increase in size and hardness, without accompanying pain or
other symptom of acute inflammation, forming a chain of little tumors,
including several or all of the inguinal glands of both sides, the  evi-
dence  as  to  the specific nature of a genital lesion is  still further
strengthened.
   The chief considerations on which a diagnosis is founded are, the
period of incubation, the presence or absence of induration, and the
condition of the anatomically related lymphatic glands.   Even should
all these point to syphilis, an absolute  opinion should not be given
until it is justified by the  appearance of some of the constitutional
phenomena which in from six to eight weeks follow chancre.
   Difficulties of diagnosis are greatest during the first week or ten
days, and  steadily diminish with the age  of the lesion, which, if
syphilitic, is almost certain to show the characteristics of the  chancre.
Confrontation is  seldom  practicable.  The  history of incubation is
often vague and uncertain, and the development of the lesion  is rarely
studied attentively by the patient.
   Induration is present in the great majority of chancres, and when
typically developed is  almost enough to justify a positive diagnosis.
Induration, however, may fail  as  a diagnostic sign,  since—1, it may
be absent or  but slightly developed ;  2, it may be masked ; 3, it may
be present in non-specific ulcers;  4, it may be present  in relapsing
chancres.
   1. Lesions  absolutely without  induration, and  yet  followed by
secondary syphilis, have  been reported by  competent  observers.
More frequently the induration is so slight as to be readily confounded
with ordinary inflammatory infiltration.  Thus the initial lesion some-
times appears as an infecting balanoposthitis, differing from  ordinary
balanoposthitis only in thickening and hardening of the prepuce, but
slightly greater than that observed  as a result of simple untreated
inflammation;  or syphilis may be  inaugurated by the multiple her-
petiform chancre, which may become indurated to only a moderate
degree.  On  the glans penis the induration  is often developed  not
much more markedly than is common in the case of  chancroids.
   In the genital chancres of women the induration is, as a rule, poorly
developed;  it  is rare to find  in women  the typical  cartilaginous
hardening.
   2. Induration may be masked by cellular infiltration dependent 
SYPHILIS.
313
upon  acute  inflammation attacking a  chancre,  or may be  entirely
destroyed by a rapid phagedenic process.
   3.  Certain non-specific sores may present  induration so like that
of the chancre that differential diagnosis  founded on this sign alone
cannot be made.  A simple sore which has been treated by caustics
will frequently take on induration:  hence it  should be a rule in ex-
amining such cases to ask the patients how they have been treated,
and  thus avoid attaching  too much  importance  to  an apparently
characteristic induration.  A forming furuncle, the inflamed orifice of
a suppurating vulvo-vaginal gland, a tubercular ulcer, may all present
a  circumferential induration  which will make  immediate  diagnosis
impossible.
   4.  Finally,  the  so-called  relapsing  chancre,  generally a tertiary
lesion, may,  with the exception  of the  inguinal  adenopathy, exactly
simulate the primary sore of syphilis.
   The involvement of the anatomically connected lymphatic glands
is  absent as  a very rare  exception, and when typical is highly char-
acteristic.  It must be borne in mind, however, that:
   1.  Many  non-syphilitic patients  exhibit hard, movable lymphatic
tumors in both groins: hence it is important to  examine a suspected
case frequently, to determine whether or not the enlargement is pro-
gressive.
   2.  Simple sores sometimes cause enlargement of several glands,
with very slight inflammatory phenomena.   Occasionally, from mixed
infection, syphilitic buboes exhibit marked inflammatory reaction.
   3.  In  very rare  cases chancre may be followed  by secondary
syphilis without  involvement of the  anatomically related lymphatic
glands.
   The Differential Diagnosis of Genital Chancre.—Since ulcer-
ative  lesions of the genitalia may be due  to a variety of causes, and
since,  even though different  in their nature, they may present some
features in common, the question of differential diagnosis becomes one
of great importance.
   To distinguish between a " mixed chancre" and  a chancroid or simple
venereal ulcer is often impossible.  Even  should a chancroid be ab-
solutely typical in  all its clinical features, it is  not safe to  make a
positive statement that syphilis will not develop.  If, in spite of the
favorable course of a simple  ulcer, after two or three weeks  charac-
teristic induration develops, and in another seven days the  inguinal
glands on both sides painlessly enlarge  one after another, the proba-
bility of syphilis and chancroid having been  inoculated at  the same
point  is great.   Per contra,  if a non-inflammatory indurated  sore 
314         GENITO-URINARY DISEASES AND SYPHILIS.

appears at an interval of more than ten days after exposure, and in
consequence of further  exposure rapidly assumes an  inflammatory
type, sloughs, and  extends beyond the area of induration, destroying
the  latter,  and  presenting on examination  only  the features of  the
simple  venereal sore, the  probability is that the lesion  is a mixed
chancre,  the  chancroidal  virus  having been inoculated  upon  the
primary lesion.   This  probability is made  still  stronger if  painless
multiple  enlarged  lymphatic  glands  are found in the groins.   Even
should  a  suppurating bubo form, this should  not  influence the  diag-
nosis in  regard to syphilis,  since  each  disease  will run its course
independent of  the other.
   The differential diagnosis between chancre, chancroid,  and herpes
will  depend upon a consideration of the characteristics  of  each as
given in the following table :
       Chancre.
Origin.—Due to inocula-
  tion with the blood or
  lesion-discharges of  a
  syphilitic.
Incubation.—From   ten
  days to  eight weeks.
  Average  about  three
  weeks.
Situation.—Generally  on
  the genitalia.  Often on
  lips, nipples, and hands.
Number.—Single; at times
  simultaneously  multi-
  ple.
Beginning.—Begins as an
  erosion, papule, tuber-
  cle, or  ulcer.  May re-
  main  without  ulcera-
  tion through its entire
  course.
       Chancroid.
Due  to inoculation with
  the discharge of a chan-
  croidal  sore.  Possibly
  caused  by  pus  from
  other sources.
No  definite period.   It
  may not be noticed for
  two or three days.

Generally  on the  glans
  penis  and  the prepuce.
  Rarely on other geni-
  tal  surfaces.   Hardly
  ever on other parts of
  the body.
Frequently multiple, often
  on apposing surfaces by
  auto-inoculation.
Begins as a pustule or an
  ulcer.   Always   ulcer-
  ates.
        Herpes.
Due to,—
(1) Mechanical irritation,
  as in sexual intercourse.
(2) Chemical   irritation,
  such as is produced by
  acrid discharges or by
  uncleanliness,
(3) To  neuroses ;  often
  following  fever,  and
  particularly  occurring
  in syphilitics.
None.
Generally on  the glans
  penis  and  the inner
  layer of the prepuce.
Multiple. Ultimately often
  confluent.

Begins as a group of vesi-
  cles, which  may coa-
  lesce or may ulcerate
  singly. 
SYPHILIS.
315
        Chancre.
Shape.—Round,  oval,  or
  symmetrically  irregu-
  lar.
Depth.—Usually superfi-
  cial, cup-shaped or sau-
  cer-shaped, or may be
  elevated.
Surface.—Smooth,   shin-
  ing, dusky red, glazed;
  diphtheritic membrane,
  or  scab  or  epithelial
  crusts.
Secretion.—Scanty, serous,
  hardly  ever  auto-in-
  oculable,   except  in
  cases  of mixed  infec-
  tion,  when   a  chan-
  croidal sore may be pro-
  duced.  On  squeezing
  cannot press out  a dis-
  charge.
Induration.—Almost  al-
  ways   present;   firm,
  cartilaginous, or parch-
  ment-like ; sharply cir-
  cumscribed ;   movable
  upon  subjacent  parts.
  Prolonged pressure by
  the examining fingers
  does not produce any
  change in it; usually
  persistent;   disappears
  under   specific  treat-
  ment.
Sensibility.—Very rarely
  painful.
Course.—Progressively to-
  wards  cure,  the   sore
  often healing spontane-
  ously.   Relapses   and
  phagedaena uncommon.
        Chancroid.
Round, oval,  or  unsym-
  metrically    irregular,
  with  border described
  by  segments  of large
  circles.
Hollow,   excavated,   or
  " punched out."
Rough, uneven, " worm-
  eaten," warty, grayish,
  pultaceous slough.
Abundant, purulent, read-
  ily auto-inoculable.
Only  exceptionally  pres-
  ent.  Due to caustics or
  other  irritants,  or to
  simple  inflammation;
  boggy, inelastic, shades
  off   into  surrounding
  parts, to which it is ad-
  herent ; disappears soon
  after cicatrization. Pro-
  longed  pressure causes
  changes in shape,such
  as are noted in oedema.

Often painful.

Irregular; may cicatrize
  rapidly or may extend.
  Relapses  and  phage-
  daena not uncommon.
         Herpes.
Irregular, circinate  bor-
  ders,  representing seg-
  ments of small circles;
  sometimes serrated.

Superficial.
Bright   red   superficial
  granulations,    some-
  times covered by diph-
  theritic membrane.

Moderate secretion, auto-
  inoculable  with   diffi-
  culty.   On squeezing a
  small serous drop ex-
  udes.   When  this  is
  wiped  away,  another
  drop can be pressed out.
  This  can be  repeated
  several times.
Same as local ulcer.
Often painful.

Easily and quickly cured.
  Sometimes spreads  by
  the appearance of suc-
  cessive  crops of vesi-
  cles.  Lesions preserve
  the  polycyclic   form.
  Likely  to  recur, espe-
  cially in syphilitics and
  in  uncleanly patients
  with long foreskins. 
316        GENITO-URINARY DISEASES AND  SYPHILIS.
        Chancre.
Histology.—A  new  cell
  growth.  Very little de-
  struction   of  tissue.
  Scrapings often show
  more or less epithelium.
Bubo. — Constant,  pain-
  less, multiple, generally
  bilateral.
Prognosis.—Good locally;
  ulceration is at the ex-
  pense of the infiltrate:
  hence there is little ul-
  timate scarring; consti-
  tutional syphilis follows
  in the great majority  of
  cases.   In a few it may
  not appear, or may be
  prevented from appear-
  ing by treatment.
Treatment.—Excision
  when seen  early ; other
  purely local treatment
  is ineffective.
       Chancroid.
An ulceration, with more
  or less loss of substance.
  Scrapings show granu-
  lation-tissue.

Appears only in one-third
  of the cases; painful,
  inflammatory,  single,
  or a single one on each
  side.
More serious locally,  for
  there is tissue destruc-
  tion.   May  refuse  to
  heal  or  may  become
  phagedenic.  Never fol-
  lowed    by   syphilis
  (unless mixed).
Local treatment is  cura-
  tive.
         Herpes.
Originally  an  elevation
  of  the  epidermis  in
  spots  by an effusion of
  serum.

Rare.  When it does oc-
  cur, painful, inflamma-
  tory, single, or a single
  one on each side.
Always   good.   Recur-
  rences are frequent, es-
  pecially in syphilitics.
  (The  herpetic chancre
  closely simulates her-
  pes.)
Local treatment is cura-
  tive. Tendency to spon-
  taneous cure.
    When phimosis is  present, so that a lesion of the glans or of the
under  surface  of the  foreskin cannot be  exposed, it  is  exceedingly
difficult to  determine whether such a lesion is chancrous or is due
to  inflammatory processes  of a  different  nature.   In  such cases a
diagnosis must be made after a consideration of the following points
of difference:
         Subpreputial Chancre.
Incubation.—Never less than ten  days.
  Usually three weeks ; may be more.

Number.—The lesion is usually single.
  (This may be learned from the history
  of the case before phimosis developed,
  or from palpation.)
Inflammation.—Acute symptoms absent
  or but slightly marked.

Swelling.—Hard, characteristic circum-
  scribed  induration.  Can  often  be
  isolated from surrounding tissues and
  raised  and felt between the thumb
  and finger.
 Non-Syphilitic Subpreputial Ulceration.
Incubation.—Really  none.  Inflamma-
  tory symptoms  become pronounced
  in less than ten days.
Number.—The lesions are usually mul-
  tiple.
Inflammation.—Acute  symptoms  very
  pronounced.  (Heat, swelling, pain,
  redness.)
Swelling.—Diffuse, oedematous, general
  inflammatory infiltration.  Cannot be
  isolated or felt as a circumscribed in-
  duration. 
SYPHILIS.
317
       Subpreputial Chancre.           Non-Syphilitic Subpreputial Ulceration.
Discharge.—Moderate, thin, at times  Discharge.—Often produces auto-inocu-
  blood-stained.  Not readily auto-in-    lation by accidental contact.
  oculable.
Preputial Orifice.—Not markedly ulcer-  Preputial  Orifice.—Almost  invariably
  ated.                               ulcerated.
Buboes.—Non-inflammatory, bilateral,  Buboes.—Single, inflammatory, suppu-
  inguinal buboes always develop.         rating buboes often develop.

    Concealed Genital Chancres.—Typical chancre may develop about
the genitalia, yet  from  the fact that it is so placed as to be concealed
from view it may not be observed; thus chancres of the cervix uteri
and chancres of  the urethra  are not usually recognized as such  till
constitutional symptoms develop.
    Chancre of the cervix uteri is probably more common than is
generally believed.  It is often not discovered because the lesion thus
placed produces  no pain and but very slight discharge : hence there
are no  symptoms which would  lead a patient to present herself  for
examination.
    The chancre is nearly always situated at the margin of the os, and
presents the same variations in size  and surface as  are  noted  in
primary sores of the external genitalia.   It may appear as an erosion,
as a deep ulceration with a smooth pseudo-membranous surface, or as
a papillary outgrowth.  It may be no larger than a split pea, or may
present a raw surface the size of the thumb-nail.  Induration, though
present,  cannot be felt, owing to the position of the lesion.  Chancre
of the  cervix must be  distinguished from ulcerating folliculitis, from
mechanical erosions and ulcerations, from herpes, and  at times  from
malignant growths.
    Ulcerating  folliculitis is commonly   associated  with  a chronic
catarrhal condition, and produces  small, often  multiple lesions, ex-
tending very little beyond the  limits  of the follicle.  These lesions
promptly heal  under appropriate treatment.
    Mechanical  erosions and ulcerations may closely simulate the spe-
cific lesion, but are less sharply circumscribed and do not  show the
characteristic regular development of the specific sore.
    Herpetic lesions can be distinguished from chancre of the cervix
by the fact  that  the former are usually multiple, often  coalesce, pre-
senting  a circinate margin  formed of the  segments  of many circles,
and heal rapidly.
    Cancer occurs at an age when chancre is not common ; its course
is often painful  and always progressive.   It causes deep  ulceration and
steadily infiltrates surrounding  tissues.   If  at first glance  a chancre 
318
GENITO-URINARY DISEASES  AND SYPHILIS.
resembles cancer, the further progress of the case will shortly decide
the diagnosis.
   Urethral chancre is often overlooked, not because of absence of
characteristic features, but rather because the lesion in this locality is
so rare that methodical search is not made for it.  As would naturally
be expected, the chancre is  generally at or  near the  meatus.   It is
rarely placed farther back than the fossa navicularis.
   When the sore involves the meatus it looks  more like a chancroid
than like a chancre.   (Fig. 101.)  From frequently repeated irritation
incident  to the  flow  of urine,  the lesions  become distinctly inflam-
matory in type; they are  ulcerative  and destructive, showing jagged,
punched-out borders, and but  moderate induration, best detected by
taking the end of the glans between the  thumb and the forefinger and
squeezing it in  an antero-posterior direction.  Permanent cicatricial
deformity is often left after  they have  healed.   Chancre is perhaps
more prone to develop at the meatus than is  chancroid : hence a sore
in this region should be suspected, even though it exhibits none of
the clinical features of the syphilitic lesion.
    Chancres of the urethra have been noted exceptionally as far back
as an inch and a half from the meatus.  They are generally  found
within the first  half-inch of this canal.   The first symptom noted is
commonly a purulent discharge, which may be accompanied by ob-
struction to the flow of water, occasioning  forking and  twisting  of
the stream, and some dribbling of urine after  the act of micturition
is completed.   On palpation induration generally can be  detected;
this  is more marked, more  diffuse, and more chronic in its  course
than the inflammatory nodules  characteristic of gonorrheal folliculitis.
    Inflammatory infiltration of the prepuce in the region of the frenum
is so frequently noted in urethral chancre that it has been thought to
have diagnostic value.
    The discharge is scanty, muco-purulent, and accompanied by little
or no pain.   Urethroscopic  examination shows a lesion covered with
a grayish false membrane and seated on an infiltrated base.
    The symptoms of urethral chancre may be limited to a slight pain-
less  muco-purulent discharge,  spontaneously disappearing in one or
two weeks ; when such symptoms are detected, especially if they have
followed exposure by an interval greater than ten days, the possibility
that they have been  caused by a urethral chancre should  be carefully
considered.
    Urethral chancre must  be distinguished from gonorrhea,  from
simple urethritis, from  chancroid, and  from mucous patches of the
urethra. 
SYPHILIS.
319
   From gonorrhea the urethral chancre  can be  differentiated by a
consideration of the contrasted characteristics of each :
          Urethral Chancre.
Incubation.—Ten days to three weeks.
Seat.—At or near the  meatus.

Urethroscopic Appearance.—An erosion
  or ulceration,—a circumscribed  area
  of congested mucous membrane.  A
  healthy urethra behind the lesion.

Symptoms.—Slight ardor urinae, felt only
  at or near the meatus.  Painful erec-
  tions mostly absent.  No pain.  Gen-
  erally  marked oedema about the frae-
  num.
Discharge. — Scanty,   mucous,  blood-
  stained.   Contains  no gonococci.

Induration.—Distinct, somewhat diffuse,
  often involves one lip of the meatus.
Sequelce.—Painless,  non-inflammatory
  enlargement of inguinal lymphatics,
  followed  in six  or  eight weeks  by
  secondary  symptoms.  Spontaneous
  subsidence of local symptoms.
Sensibility.—The application of a syringe
  or any mechanical interference occa-
  sions pain at or near the meatus.
             Gonorrhcea.
Incubation.—On» to seven days.
Seat.—The entire anterior urethra.  Usu-
  ally invades the posterior urethra.
Urethroscopic Appearance.—Marked vas-
  cular  engorgement   of  the  entire
  urethral  mucous  membrane,  often
  with many areas  of epithelial  exfo-
  liation.
Symptoms.—Ardor urinae  marked, and
  felt along the course  of the urethra.
  Painful  erections  mostly  present.
  Often pain.   Sometimes marked pre-
  putial oedema.
Discharge. — Profuse,   muco-purulent.
  Usually  not blood-stained.  Contains
  gonococci.
Induration.—Absent.  At times a  hard,
  round follicle felt beneath the urethra,
  which either suppurates, discharging
  externally,  or evacuates  its contents
  into the urethra and quickly subsides.
Sequelce.—Lymphatics do  not enlarge,
  or exceptionally one or two  become
  acutely inflamed, and  sometimes sup-
  purate.

Sensibility.—The use of a long-nozzled
  syringe  or  any  mechanical interfer-
  ence occasions pain along the course
  of the urethra.
    The  diagnosis between  urethral chancre and chancroid must be
made upon the grounds which enable the  surgeon to distinguish be-
tween these  two lesions when situated  upon  the surfaces  of the
genitalia.  The  absence of a  period  of incubation,  the acute  local
inflammatory  symptoms, the free  discharge,  and,  above all, the
punched-out,  ragged,   non-indurated,  spreading  ulcer,  are  fairly
characteristic  of chancroid, but,  as  has  been  stated, the meatus
chancre  is often distinctly chancroidal in type.
    The  diagnosis  of  urethral  chancre  from   mucous  patches  of
the urethra  is usually made  easy by the presence  of other mani-
festations  of  secondary  syphilis  and  the  absence of  an  indurated
ulceration or  abrasion.  The  lesions are not different  from  those 
320       GENITO-URINARY DISEASES AND  SYPHILIS.

observed  on other mucous  membranes.  The discharge is highly
contagious.
                    EXTRAGENITAL CHANCRE.
   Errors or difficulties in diagnosis may arise from the fact that a
chancre is extragenital.
   As a rule, chancroid is found only about the genital organs: hence
in other regions  the question of distinguishing between this sore and
chancre rarely comes up.  The extragenital lesion is usually single.
   Its favorite seats have been given.
   Herpetiform  erosions of the lips, papules on the tip of the tongue,
scabby ulcerations of the skin, scratches which absolutely refuse to
heal, chronic inflammations at the tips of the fingers, resembling felons,
but without the accompanying acute  inflammatory symptoms,—all
such lesions should be regarded with  suspicion if  indolent in course,
obstinate to treatment, and accompanied by slight  discharge which
has a tendency to form crusts or a pseudo-membranous deposit on the
eroded surface.  If, moreover, such lesions are placed upon an elastic,
sharply circumscribed, indurated base, and are followed by hard, pain-
less enlargement of the nearest associated group of lymphatic glands,
the diagnosis receives strong corroboration.
   Chancres of the Head and Face.—Razor-cuts on the chin, cheek,
or lips which, after having healed, reopen and become covered with
crusts, pseudo-furuncles or acneiform pustules, and cracks around the
mouth or nose which persist, are painless, are surrounded by an area
of inflammatory edematous swelling, and give a thin, blood-stained
discharge which exhibits a tendency to form  crusts, should suggest
the possibility of  chancre, and should lead to frequently  repeated
examination of the parotid and submaxillary lymphatic glands.   The
primary  sore of syphilis  when it occurs on  the scalp  or on the
bearded  cheeks  or chin  closely resembles  ecthyma.  On removing
the surrounding and  covering  hair, a glazed, flat,  slightly elevated
superficial ulceration is detected.  When a patient presents  himself
with such lesion it is often impossible from the local signs to deter-
mine  whether  or  not the  sore is  specific.   The  syphilitic lesion
begins as a papule or an  erosion, which slowly extends, is  attended
with distinct induration, is never actively inflammatory in type, causes
painless enlargement and hardening of the nearest lymphatic glands,
and is followed by secondary  symptoms.   The ecthymatous lesion
begins as a  flat  pustule,  surrounded by an acute inflammatory but
non-indurated base, is  generally multiple, and runs its course in two
or three weeks.
   The eyelids and the ocular conjunctiva may be the seat of primary 
SYPHILIS.
321
sore.  The  lesion begins as a papule, which gradually becomes in-
durated and eroded or ulcerated, presenting the characteristic sloping
edges and hard base of chancre.  This lesion has often been mistaken
for a stye;  its development and the absence of acute inflammatory
symptoms would make  a correct  diagnosis possible in a very few
days.  Lymphatic  enlargement is first noted in the glands in front
of the ear and at the angle of the jaw.
   At times chancre of  the  head  and face attains enormous  size,
differing entirely in appearance  from the primary lesion of syphilis
as ordinarily observed;  induration  may be  absent, and  occasionally
acute inflammatory  symptoms are  pronounced.   In such  cases  a
positive diagnosis can be made only by recognizing the characteristic
lymphatic enlargement and the development of secondary lesions.
   Chancre of  the Lip.—As is  the case  in chancre of other extra-
genital regions,  chancre of the lip  in its  beginning closely simulates
ordinary non-specific sores.   It often begins as a  chap or fissure,
                             Fig.  104.
Chancre of the lip.
frequently found in the median line as an aphthous lesion, an herpetic
ulceration, or an ulceration such as would be produced by the burn
of a cigar or of a cigarette.  In the early stage there is nothing char-
acteristic about these  lesions, but in a few days the extension of the
erosion  or ulcer and  the  formation of a characteristic and  usually
very pronounced and extensive induration indicate the nature of the
                               21 
322        GENITO-URINARY DISEASES AND  SYPHILIS.

affection.   (Fig. 104.)  The diagnosis is  made  still more positive in
the course of one or two weeks by  enlargement of the submental
lymphatic glands.
   The whole  lip is generally  congested and swollen, sometimes
reaching an enormous size.  (Fig. 105.)  At times the induration of lip

                               Fig. 105.
Chancre of the lip.
chancre is so great and the ulcerating process so marked that on first
inspection it seems to be malignant.  The fact that chancres have been
excised because they were mistaken for epitheliomata, thus  entailing
on a patient unnecessary mutilation, justifies a tabulation of the points
of difference between the two affections, by a consideration of which
the nature of  each may be correctly determined.

          Labial Chancre.                      Labial Epithelioma.
History.—Sometimes a  history of ex-  History.—Sometimes a history of cancer
  posure to syphilitic inoculation.          in the  family.
Age.—Occurs at any age.               Age.—Occurs nearly always after middle
                                     life.
Sex.—Affects males and females indiffer-  Sex.—Hardly ever affects females.
  ently. 
Fig. 106.
                 Chancre of the tongue.
(From the collection of photograpbs of Dr.  George Henry Fox.)
 
 
SYPHILIS.
323
      Labial Chancre.
Seat.—Involves either lip.
Local Symptoms.—A  painless  elevated
  sore, regular in outline, with a smooth
  surface and a sharply circumscribed,
  dense induration.  A scanty, odor-
  less discharge.
Course.—The sore  develops- in a few
  weeks at most,  often in  from seven
  to ten days.  It is followed in one or
  two weeks by submaxillary glandular
  enlargements, and in from six to eight
  weeks by secondary symptoms.
Therapeutic  Test.—Mercury causes  the
  prompt disappearance of the  chancre.
Microscopic Examination.—The chancre
  shows a small, round-celled infiltrate,
  particularly along the course of the
  blood-vessels.
         Labial Epithelioma.
Seat.—Almost always involves lower lip.
Local Symptoms.—An irregular, ragged,
  often painful sore, bleeding easily, and
  irregularly indurated.  An  offensive
  discharge.

Course.—The sore develops very slowly,
  —a matter of months.  The  glands
  are involved only after several months.
Therapeutic Test.—Mercury has no bene-
  ficial effect upon the epithelioma.
Microscopic Examination.—The epitheli-
  oma shows the pearly bodies.
    Chancre of the Tongue.—The primary lesion of syphilis is  less
common on the tongue than on the lips.   It usually involves the an-
terior half of the organ, and
is found on the dorsal  sur-                 Fig. 107.
face,  the sides,  or the tip.
    It commonly assumes the
erosive form, presenting an
appearance almost identical
with  that  of similar genital
lesions.  There is  simply a
painless, oval,  or  rounded
superficial    lesion,    with
smooth  surface,  frequently
covered by a grayish pseudo-
membrane  seated   upon  a
parchment-like  induration.
(Figs. 106, 107.)  It is often
as large as  a ten-cent piece.
The  supra-hyoidean   and
sometimes  the  submental
glands first exhibit  the spe-
cific enlargement.   Fournier  states  that when the tip of the tongue
is  involved, glandular enlargement is at times noted just behind the
symphysis of the lower  jaw.
   The  ulcerative  form of  lingual chancre exhibits  a  deep lesion,
Chancre of the tongue 
324        GENITO-URINARY DISEASES  AND SYPHILIS

often upward of an inch in diameter, with sloping edges, and dense,
well-marked induration.
   However easy the diagnosis may be when  the  chancre is well
developed, in the first stages lingual chancres simulate non-specific
lesions  so  closely that mistakes very readily occur.  An early  diag-
nosis is extremely important  in  such  cases, since failure  to rec-
ognize the syphilitic nature  of  the  disease may result in its trans-
mission to healthy persons.  If an ulceration apparently produced
by carious teeth, or a  papule arising without given cause,  fails  to
heal in five or six  days, but,  on the contrary, enlarges, becomes
elevated, is eroded, is covered  with pseudo-membrane,  and is not
made  better  by applications of  silver  nitrate,  the  lesion  may be
looked  on  with great  suspicion,  which  will  deepen  into  almost
certainty with the appearance of induration and glandular  enlarge-
ment.
   Chancre  of  the Tonsils and  Fauces.—Chancre is rare in these
regions, and when observed is so masked by concomitant  inflam-
matory symptoms that diagnosis is usually impossible. The lesion as
described presents the appearance of a mucous patch, which is single,
and, if it can be palpated  by one finger in the pharynx and the other
external to its walls, is found to be indurated.  There is a history of
prolonged sore throat, and in one or two weeks the glands at the angle
of the jaw enlarge.
   Primary syphilis of the tonsil is  observed in  women much more
frequently than in men.
   Chancre  of  the  Breast.—The lesion  is usually caused by a
syphilitic infant  nursed by a healthy woman: hence it is in women
that  it is  nearly always observed, though a few cases have been re-
ported in men, with a different etiology.
   The sore may appear  either about or upon the  nipple, or upon
the skin covering the  mammary gland.   In  the latter case it  usually
exhibits the  characteristic features of chancre as found on the geni-
talia, being commonly of the erosive or the ulcerative type and rarely
offering diagnostic difficulties.
   When the lesion is situated on  the  nipple or at its base, the diag-
nosis may be a matter of very great difficulty.  As is the case  with
chancre about the  nose  and mouth, the  sore very closely simulates
non-specific affections, such as simple fissure, mechanical erosion or
ulcer, or even beginning eczema.   If, however, a lesion so apparently
simple,  instead  of healing under  treatment, slowly extends, if it is
accompanied by  little or  no pain, if it gives a scanty, blood-stained
discharge which has a tendency to  crust, and, most important of all, 
SYPHILIS.
325
if it exhibits  distinct induration and painless, non-inflammatory lym-
phatic enlargement in the axilla, the diagnosis of chancre can be made
with some certainty.
   Suspicious  lesions in a nursing woman should  at  once suggest
an examination of the  child she  suckles.  Secondary lesions in the
mouth of the latter would constitute  almost positive evidence as to
the syphilitic nature of  the breast lesions in the woman, provided she
is not the mother of the diseased  child (Colles's immunity).
   Chancres of  the Anal Region.—Chancres of the anus are much
more  common in women than in men.  This is due not necessarily
to unnatural practices, but rather to the fact that in the dorsal decu-
bitus the vaginal discharges flow  downward over the perineum  and
the anus and thus inoculate the  cracks or abrasions which may exist
in those regions.
   The  sore is usually placed at the anal margin, in one of the muco-
cutaneous folds or puckerings incident to the normal contraction of
the external sphincter.   The ulceration often follows the line of these
folds,  thus producing an elongated or linear  lesion ; this becomes in-
durated, gives a scanty  discharge, is not painful, is refractory to local
treatment, and is generally followed by characteristic enlargement of
the inguinal glands.
   In place of the indurated linear ulcer, an  anal chancre may appear
as an excoriated papule,  or, more rarely, as a typical cup-shaped,
densely  indurated, ulcerating chancre.
   From the appearance of the anal  lesion it is sometimes very diffi-
cult to  determine  whether it  is a fissure, or a  simple  ulcer, or the
primary sore of syphilis.  The slow, progressive development of the
chancre, and the absence of pain and of spasm of the sphincter, will
indicate the specific nature of the affection, even before induration and
lymphatic involvement make the diagnosis almost positive.  Chancres
of the rectum are exceedingly  rare.
   Chancres of  the Extremities.—Chancre is occasionally observed
on the thighs, the anterior surface in men and the  posterior surface
in women being the regions of preference, on the antero-lateral sur-
faces of  the  forearm in both sexes, and particularly on  the fingers at
the margins of the  nails.  Occasionally it develops  over  a knuckle,
having been inoculated  through a wound caused by a blow on the
teeth of a syphilitic.  (Fig. 108.)  Except on the fingers, the chancre
develops in  a characteristic manner and offers no special diagnostic
difficulties.
   Digital chancres commonly appear at the edges or the base of the
nail, starting as erosions, papules, or pustules, becoming indurated, 
326        GENITO-URINARY DISEASES AND SYPHILIS.

elevated, and ulcerated, being accompanied by much swelling of the
surrounding finger pulp, and presenting the appearance of an ulcer-
ating felon.

                             Fig. 108.
Chancre of the hand.
   The chancre, however, develops slowly, gives  almost no pain,
discharges  but little, is not favorably influenced by local  treatment,
and is shortly followed by epitrochlear and axillary glandular enlarge-
ment.   When  the  lesion  involves the  ring or the little  finger, the
gland at the elbow, if present, is enlarged; the lymphatics from the
thumb and from the index and middle  fingers  pass  directly to the
axillary gland.
   Sometimes the chancre may develop so insidiously and may form
so insignificant a lesion, simply  a  small indurated papule, that even
the patient's attention is  not directed to it, and he has no suspicion
of having acquired syphilis till the secondary lesions appear.
   The early diagnosis of digital chancre is often a matter of very
great importance, since a mistake may readily lead to neglect of pre-
cautions which would prevent the disease from  being  conveyed to
healthy persons.   This is particularly important with  doctors  and
nurses, who  form the class in which digital chancres are  observed.
Any painless lesion about the fingers giving a scanty discharge, steadily
enlarging in spite of treatment,  and becoming distinctly hard, should 
SYPHILIS.
327
excite suspicion, and should lead to the same precautions that would
be observed were chancre known to be present.
   Vaccination Chancre.—When  bovine virus is  used, vaccination
syphilis from the lymph is an impossibility.   When, however, human
lymph is employed, this  accident has occurred many times.  If the
vaccination takes, the pustule may run the typical course, and may be
healed before evidences of the  chancre appear.  More commonly the
healing of the ulcer resulting  from the  vaccinal  suppuration is de-
layed; it presents a smooth surface,  gives a very scanty discharge,
is  unattended by pain, and characteristic induration develops.  The
associated lymphatic glands are enlarged, and secondary symptoms
follow.
   If the vaccination does not take, there may be no sign of trouble
for fifteen to thirty days.  Then an indurated papule is formed, which
slowly ulcerates and offers all the peculiarities of erosive or ulcerative
chancre.   Sometimes the vaccination ulcer becomes acutely inflamed,
even  phagedenic, the  inflammatory  symptoms  thus masking the
syphilitic nature  of the  lesion: simple vaccinal phagedenism  may,
however, present some of the features of an inflamed chancre.  The
prompt yielding  of the former to local treatment should  establish a
correct diagnosis in a few days.
   The Prognosis of Chancre.—Usually in three or four weeks,
sometimes in as many months, the chancres  become cicatrized, the
induration disappears, and there is  left a brownish scar, which may
persist for years.   This scar may retain its pigmentation as long as it
remains perceptible ; more commonly it becomes white.
   Healing of the chancre will take place spontaneously, but will  be
greatly accelerated when mercury is administered.   Even in extensive
ulcerating chancres, such as are observed  on the cheeks or the lips, for
instance, there is almost no ultimate deformity, since the destruction
of tissue is mainly at the expense of the syphilitic infiltrate.  If the
chancre is attacked by phagedaena,—which is rare,—and if the slough-
ing process destroys the induration and passes wide of its limits,  there
may be resultant cicatricial  deformity, but this will be due not to the
specific poison, but to the destructive influence of other microbes.
   Chancre of the conjunctiva may give rise to grave ophthalmia.
   Chancre of the tongue or of the  fauces may, through interference
with mastication or deglutition, cause great  debility, and chancre of
the urethra is frequently followed by stricture.
   The prognosis of syphilitic  chancre considered as a local disease
is,  then, almost uniformly favorable.  As  to any relation existing be-
tween  the source of contagion, the chancre, and the constitutional 
328       GENITO-URINARY  DISEASES AND SYPHILIS.

disease of which it is the precursor, the following clinical facts seem
well established:
   1. It is impossible to predict the form of chancre from the charac-
ter of the source of infection.  It is well known that the most widely
differing  forms of initial  lesion  may  be acquired  from the  same
individual.
   2. The severity of the constitutional disease bears no relation to
the form  of the initial lesion.  A  dry papule may be followed by
severe secondary symptoms, while an ulcerating chancre may precede
a very slight form of constitutional involvement.
   3. A short primary incubation followed by unusually well-marked
induration and by a short period of secondary incubation shows either
impaired resistance of tissues or more than ordinary virulence of the
specific poison; accordingly such symptoms denote  that  the subse-
quent course of the case will probably be severe.
   4. The amount of glandular implication is as  uncertain a  prog-
nostic guide, in regard to the severity of the constitutional disease,
as is the type of chancre.
   The  treatment of chancre  is  fully  described under the  abortive
treatment of syphilis.  (See page 529.)
   Primary Lymphatic Involvement.—Coincident with the de-
velopment of the chancre there is  a marked alteration in the asso-
ciated lymphatic vessels  {lymphangitis) and glands {lymphadenitis or
bubo).
   Syphilitic  Lymphangitis.—In  about twenty per  cent, of genital
chancres there develops usually within  the first week, and before the
lymphatic glands are involved,  a painless, often  beaded hardening
of the lymphatic  vessels of the  dorsum of the penis.  They form a
cord about the size of a match-stick, and may be felt starting from
the region of the chancre and running up as far as the inguinal glands,
though the hardening does not often extend more than two or three
inches along the back  of the penis.  Unless there  is mixed infection,
the skin over these lymphatic vessels does not become discolored or
adherent; except the induration, there are no signs of inflammation.
There may be  several  of these indurated lymphatic vessels, forming
small distinct cords.
   The specific lymphangitis  usually subsides  with the induration of
the chancre,—that is, within from three to five weeks;  though, like
the latter, it may last for several months.
   The lymphangitis accompanying extragenital chancres and genital
chancres of  women can rarely be detected, owing to the less accessi-
ble position of the involved lymphatic vessels. 
SYPHILIS.
329
   Syphilitic Lymphadenitis or Bubo.—The syphilitic bubo is, after the
chancrous induration, the most characteristic and  constant feature of
primary syphilis.  As commonly used, the term syphilitic bubo is ap-
plied only to those glands with which the lymphatic vessels from the
chancre communicate directly.  In about a week from the appearance
of the chancre these glands undergo a painless enlargement.  Since
chancres are usually placed upon the genitalia, the inguinal glands are
the ones commonly affected.  In accordance with  the seat of chancre,
the bubo will be placed as follows :
   Genital and  perigenital chancres (including those of the perineum
and anus) involve the inguinal  glands;  chancres of the lip and  chin
involve the  submaxillary glands ; chancres of the tongue involve the
suprahyoid  or submaxillary glands ; chancres  of the eyelid  involve
the preauricular glands ;  chancres of the fingers  involve the  epi-
trochlear or axillary  glands;  chancres  of  the  breast involve the
axillary glands.
   In genital chancre the gland first affected  is  usually the nearest
one of the chain on the affected side, though when the lesion is situ-
ated upon the  side of the fraenum a gland of the opposite side may
first enlarge.  Subsequently, one after the other, several of the glands
or the entire chain become  hypertrophied.  This  commonly takes
place  in both groins, though exceptionally it is limited to one side.
On examination the glands are felt,  each distinct,  hard, almond-
shaped, painless, and freely movable.
   There are often one large gland and a group of from three to five
smaller ones, each  about  the  same size.  Sometimes but a single
gland is enlarged;  this  is  particularly  the  case with extragenital
chancres, such  as those of the  lip.  The enlargement is never very
great, the ganglia  rarely exceeding the size of a marble.  The group
of typically indurated  glands  of  the  groin has been termed the
"pleiade ganglionnaire."
   Suppuration occurs in these glands only as  a  result of mixed in-
fection,  the pyogenic microbes gaining access  through the  surface
break caused by the chancre.
   In very exceptional cases chancre is not accompanied by syphilitic
bubo.
   Diagnosis.—Since lymphatic vessels and glands may be enlarged
as a consequence  of  simple inflammation,  and  since the syphilitic
bubo is one of the most important  means of diagnosing chancre, it is
necessary to bear in mind the points of difference between syphilitic
and simple  inflammatory  involvement  of the  lymphatics.  These
points of difference are as follows: 
330
GENITO-URINARY . DISEASES AND SYPHILIS.
       Syphilitic Lymphangitis.
Cause.—Always a chancre.

Symptoms.—A hard, painless cord, un-
  accompanied by heat, redness, or ten-
  derness.  Erection painless.  Little or
  no oedema.

Termination.—Undergoes resolution and
  is uninfluenced by local treatment.

          Syphilitic Bubo.
Cause.—Always chancre.


Number.—Several  glands,  usually  in
  both groins.
Time of Appearance.—Shortly after chan-
  cre ;  about one week.
Symptoms.—Small,  indolent,  painless,
  movable,  non-inflammatory tumors,
  non-adherent to the  skin,  and of car-
  tilaginous hardness.

Termination.—Resolution.
Treatment.—Local  remedies  without
  effect.  General mercurial treatment
  hastens resolution.

    The diagnosis of syphilitic buboes from the lymphatic enlargement
so frequently noted in strumous patients must depend entirely on the
history of the case and the development of the tumors.  The strumous
adenomata neither  increase nor decrease in size unless they become
inflamed, in which  case they break down and  suppurate.  A tuber-
cular  family history, together with  other signs  of struma about the
patient, can often be elicited; there  is no progressive glandular in-
volvement first of the lymphatics anatomically connected with the seat
of the sore, then of all the  lymphatics  accessible to the examining
fingers;  and finally resolution does not partly or wholly take place in
the majority of cases in from two to six weeks, nor is this resolution
in the slightest degree quickened by the administration of mercury.
    Treatment.—Syphilitic infiltration  of  the lymphatic vessels and
glands usually requires no  treatment, subsiding spontaneously soon
after the  disappearance of the induration of the chancre, though the
enlargement  of  the  lymphatic  glands  may  persist  for five or six
months, or, exceptionally, for many  years.  The administration  of
     Inflammatory Lymphangitis.
Cause.—Chancroids, herpes,  or other
  non-specific lesion.
Symptoms.—A cord not so hard nor so
  sharply circumscribed ; often painful,
  especially  on  erection;  tender  and
  accompanied by heat, redness,  and
  oedema of the overlying skin.
Termination.—Undergoes suppuration or
  resolution.  Local treatment effective.

        Inflammatory Bubo.
Cause.—Chancroid,  herpes,  balanopos-
  thitis, gonorrhoea, or any non-specific
  lesion.
Number.—One gland implicated. Rarely
  bilateral.
Time  of Appearance.—At  any  time
  during the  existence of a lesion.
Symptoms.—A large,  tender,  painful,
  acutely inflamed tumor,  adherent to
  the  skin, and causing  redness  and
  heat  of the latter.  The hardness is
  that of inflammation.
Termination.—Frequently suppuration.
Treatment.—Local  treatment curative;
  general mercurial treatment useless. 
SYPHILIS.
331
mercury, when the diagnosis has  become  so  certain that  its use is
justifiable, causes a rapid disappearance of the specific infiltrate.  In
cases complicated by acute inflammation and  suppuration  the treat-
ment is the same as that appropriate to chancroidal lymphangitis and
bubo.
   The Period of Secondary Incubation.—The period between
the appearance of chancre and the development of secondary lesions
varies from two weeks  to three, or even  six,  months.  The average
time, however, is forty-two days.   The primary lesion often remains
during the whole of  this period.
   The  disease, so far  as constitutional  symptoms are concerned, is
apparently quiescent.  In reality the virus is becoming disseminated
through the entire system,  first manifesting its effect upon the ac-
cessible lymphatic glands not  anatomically connected with the pri-
mary sore.   Enlargement of these glands usually constitutes the first
secondary symptom, and is, except changes in the blood, the earliest
positive sign of constitutional syphilis. 
CHAPTER  X.
CONSTITUTIONAL syphilis.--THE syphilides.—syphilis of the alimentary
                              CANAL.

    Constitutional syphilis includes  the period of secondary symp-
toms, the intermediate period, and the period of tertiary symptoms.
    The period of secondary symptoms is characterized by—
    1. Alterations of the blood.
    2. General lymphatic enlargement.
    3. Moderate fever, the temperature reaching 100° to 101° F. in the
evening;  often associated  with malaise and anorexia.
    4. Muscular and articular pains, located about the chest, back, and
upper  extremities, usually moderate  in severity, but sometimes very
severe.
    5. Alopecia, involving  the hairy  surfaces of the entire body, and
causing ragged and irregular bald spots very unlike those incident to
the ordinary atrophy of hair-follicles.
    6. Eruptions of the skin and the  mucous membranes.
    Frequently associated  with  these  manifestations are symptoms
dependent upon involvement of the eyes,  the nervous system, the
bones and periosteum,  the testicle, and the liver and other glands.
    The term secondary syphilis has been applied to those  lesions
which appear during the first two or three years of the constitutional
disease, and which are for the most  part superficial; yet it must be
remembered that  secondary  symptoms  may never appear, the first
manifestation of  constitutional  involvement occurring  after one  or
two years in the deeper ulcerative form of surface lesions, or in the
more serious visceral  complications which  characterize  tertiary  or
late syphilis.  When such deep ulcerative lesions are noted during
the period when   secondary  symptoms  should appear,—that is, in
the first few months of the attack,—the disease is known as malig-
nant syphilis.  Conversely, during the period when tertiary eruptions
and visceral complications ordinarily appear, and when such  lesions
are actually present, lesions  particularly characteristic of secondary
syphilis may develop,  such,  for instance, as papules of the skin  or
mucous patches of the mouth, or at the height  of a characteristic
secondary eruption a tubercular or  gummatous tertiary lesion  may
     332 
CONSTITUTIONAL SYPHILIS.
333
develop.  Irregular syphilis is a term  applied to cases thus differing
in course from those ordinarily observed.
   It will be remembered that the diagnosis of syphilis can be made
with absolute  surety only when one  or  more  of the constitutional
symptoms develop.  One of the first of these symptoms, and the one
upon which diagnosis is usually founded, is enlargement of  lymphatic
glands at a distance from the chancre.  Unless treatment be started
at once, there will usually develop in a few days following this enlarge-
ment  the secondary  symptoms already mentioned,—namely, fever,
osteocopic pains, skin eruptions, mucous patches, sore throat, falling
of the hair in patches, and at times iritis, orchitis, or jaundice.
   Alteration in the Blood.—If systematic observations  of the
blood be made, there  will be  found a  marked diminution  in the
haemoglobin  percentage,  with some slight  increase in the number
of white corpuscles.   The red  blood-corpuscles are diminished  in
number.  These blood  changes  are the  first sign of constitutional
syphilis, preceding lymphatic enlargement by two or three weeks;
they become  more marked  with the  advent of fever and on the
appearance of  eruption.
   Enlargement of Lymphatic Glands not anatomically con-
nected with the Chancre.—The indolent enlargement which prob-
ably involves to some extent all the lymphatic glands of the economy,
and which becomes apparent to the touch in certain accessible regions
about the sixth week from the appearance of the chancre, must not
be confounded with the syphilitic buboes which develop in  the group
of glands anatomically  nearest to the chancre in about a week from
the appearance of this lesion.  This late glandular enlargement when
characteristically developed is pathognomonic of syphilis.  Though it
is probable that all the lymphatic  glands are involved, those  in the
post-cervical regions and the one lying in front of the internal condyle
of the humerus, the epitrochlear gland, are most prone to exhibit the
indolent  cartilaginous,  painless,  non-inflammatory  enlargement so
characteristic  of developing  secondary syphilis.  The submaxillary,
the anterior  cervical  group, the  axillary, in fact, all  the  superficial
glands, may show the specific induration, but  rarely in  so character-
istic a manner as those in  the  two  regions named.  The tumors
formed vary in size from that of a pea to that of a chestnut.
   The post-cervical chain passing downward from the occipital bone
along the outer edge  of the trapezius muscle is, in cleanly  people  at
least, rarely enlarged  from causes other than syphilis; thus painless,
hard, indolent  infiltration of these  glands would be far stronger evi-
dence of  specific disease than a similar condition noted in the sub- 
334        GENITO-URINARY DISEASES AND SYPHILIS.

maxillary and anterior cervical group, which, owing to the presence
of catarrhal  and inflammatory affections of  the throat from which
they receive  lymph, are found enlarged in perhaps the majority of
people.  For a similar reason characteristically enlarged epitrochlear
glands—that is, those above and in front of the internal condyle—
constitute presumptive evidence of syphilis.
   In syphilitic  lymphatic glands the follicles of the delicate reticu-
lated tissues  are hypertrophied, and  give  rise  to small lobulated
projections  upon the  surface when the capsule  is removed.   The
lymph-spaces exhibit a cellular  infiltration,  and the  fibrous tissues
separating the alveoli are thickened.  Frequently these glands remain
more or less  hypertrophied not only during  the period  of secondary
lesions, but also long after the syphilides have disappeared.
   Although there  is no clearly  established relation  between  the
extent of  glandular lesion and  the severity of other secondary symp-
toms of syphilis, early and well-marked glandular involvement fre-
quently has been noted in attacks of more than usual severity.
   Syphilitic Fever.—About the time of glandular enlargement, and
coincident with the earliest eruption, or preceding it, fever develops,
associated with  pallor, weakness, general malaise, headache, coated
tongue, anorexia, and muscular or arthritic pains.   The temperature
rarely rises above 102° F., and the pulse is not markedly affected.  In
many patients the fever is either absent or so slightly marked that it
is not  noticed.  It  rarely becomes so severe as to oblige the patient
to keep to his bed.   Exceptionally it assumes a malarial type, being
characterized by irregular paroxysms of  chills, fever, and  sweat, but
differs from malaria in the irregularity of the paroxysms and in  the
fact that quinine is utterly without  effect in controlling it, while  mer-
cury is curative.
   When the fever is continued and moderate in severity, and  asso-
ciated  with depression of spirits, pallor, headache, and general  de-
bility,  it may strongly  suggest typhoid.   If  continued  and of high
grade,  running to 104° or 105° F. and associated with evident osteo-
copic pains, it may lead to a suspicion of developing eruptive fever.
If associated with an outbreak of pustular syphiloderm, such as  ex-
ceptionally appears as an early skin lesion, the diagnosis from small-
pox may be exceedingly difficult.
   The involvement of the joints in early syphilis  may, if associated
with syphilitic fever, make the diagnosis  of the latter from rheumatic
fever a matter of impossibility till other symptoms of syphilis develop.
   Diagnosis.—In making a diagnosis of syphilitic fever, the history
of a preceding chancre and the presence of general lymphatic enlarge- 
CONSTITUTIONAL SYPHILIS.
335
ments are, of course, matters of prime importance.  In addition to the
history, it is to be noted that syphilitic fever is frequently associated
with a clean tongue, good  digestion, normal  condition of the bowels,
and an absence of the special diagnostic features which characterize
each of the fevers with which it may be confounded, as, for instance,
the plasmodia and enlarged spleen of malaria, the tympany and spots
of typhoid, the crisis of variola, the drenching sweats and acid  urine
of rheumatism.
   It commonly subsides  shortly after the appearance of  the  erup-
tion.  When  it is continuous in  type, is  pronounced, and lasts for
some time, the probability is that the attack of syphilis will be un-
usually severe and prolonged.  In exceptional cases it does not appear
till after the eruption has developed.  It is mostly in women that the
severe forms  of continuous syphilitic fever are observed.
   Syphilitic Neuralgia.—Coincidently with the syphilitic fever and
constituting one of its symptoms, but also developing in the absence
of evident  fever, or sometimes preceding it, there may be dull pain,
which is commonly  neuralgic and shifting  in character, and is felt
mostly about the back  of the neck, the back, and the shoulders,
though it may be localized  in  any portion of the fibro-osseous sys-
tem.  This pain is most apt to  be noticed at night;  when continuous
and severe there are usually nocturnal exacerbations.  It occasionally
attacks one or more joints, and may be accompanied by effusion and
fixation; or it  may assume a distinctly  neuralgic type, simulating
pleurodynia or other form of localized pain.  Headaches,  with noc-
turnal exacerbations, and  sometimes associated with vertigo and
nausea, point to meningeal congestion.
    Frequently the pains are osteocopic (bone-breaking) in  character,
and are accompanied by marked  tenderness over certain bones, par-
ticularly the  middle third of the ribs and  the  lower third of the
sternum.   This is so often noted that some  diagnostic value is given
to the  presence  of  pain  on  moderate  pressure over these bones.
These osteocopic pains are explained (Jullien)  on the ground that
the medulla of the bone takes part in the general lymphatic enlarge-
ment, thus occasioning pressure  upon the nerves.   Painful nodular
swellings over the frontal  and parietal bones, or  over the long bones,
are also noted at times.
   In doubtful cases rheumatoid,  neuralgic, and osteocopic  pains,
either singly or associated, are of great value in deciding for  or against
the presence of syphilis.   In some instances lymphatic enlargement
and  syphilitic pains may be the only symptoms  which develop, fever
being absent. 
336       GENITO-URINARY  DISEASES AND SYPHILIS.

   Among the symptoms which exceptionally precede alopecia and
the secondary eruption, jaundice, albuminuria, ravenous appetite or
bulimia, alteration in the sensibility of the skin, exaggerated reflexes,
and enlargement of the spleen have been observed.
   Syphilitic  Eruptions of the  Skin and the Mucous Mem-
branes.—The  syphilides, or eruptions of the skin, commonly appear
a few days after the general glandular enlargement, though they are
occasionally the first manifestations of constitutional  disease.   They
are usually found  about the  forty-second  day after the  chancre.
Exceptionally they have been seen within two weeks.  On the other
hand, they may not develop  for four  or  five months,  or in  some
few cases secondary syphilis  may never appear, tertiary lesions first
proving conclusively that a  genital  sore was a  chancre.  This is
especially liable to be the case if mercury has been given before the
appearance of secondary symptoms.
   Cutaneous  and  mucous syphilides  are more superficial in the
early  stages of the constitutional disease;  as it grows  older  these
lesions become deeper.
   Thus the syphilides of the first period of secondary syphilis are
due to a  local  hyperaemia and slight cell-infiltrate, affecting only the
epidermic and  papillary layers of the skin and producing erythema-
tous,  macular, and  papular  lesions.  These heal without leaving
scars.  The older syphilides belonging to the late secondary and the
tertiary period not only affect the  epiderm and the papillary layer,
but involve also the true derm and even the subdermic tissues, appear-
ing as pustules and tubercles, which are often destructive and are fol-
lowed  by cicatrices.  These lesions are due to a cell-infiltrate much
like that  of granulation-tissue, except that it is not nearly so vascular.
   The syphilides may,  so far as the lesions are concerned,  mimic
with absolute  fidelity  many of the well-known skin diseases;  there
are, however, certain characteristics of the eruption, taken as a whole,
which will generally make a correct diagnosis possible.
   The  general  features of secondary  syphilitic eruptions are as
follows:
   1. The lesions develop slowly, are painless, and do not  itch.
   2. They are rounded in form and grouping, and tend to scale.
   3. They are of a copper or raw-ham color.
   4. They are symmetrical.
   5. They are polymorphous.
   6. They are superficial.
   7. They yield to mercurial treatment.
   The later eruptions of the secondary period—that is, those  occur- 
CONSTITUTIONAL SYPHILIS.
337
 ring after the first year—and those of the intermediary and  tertiary
 periods exhibit the following characteristics :
    1. They are rounded in form and circinate in grouping.  This is
 particularly well marked.
    2. The lesions do not appear as a general eruption, but are grouped
 upon certain regions of the body.
    3. They are deep, often involving the whole thickness of the skin
 and the subcutaneous tissue.
    4. If dry, they are covered with a thin layer of gray,  slightly
 adherent scales.
    5. If ulcerating, they form punched-out, chronic ulcers, often cov-
 ered with raised, thick, greenish-black, adherent crusts.
    6. They are accompanied by very slight subjective symptoms.
    When a general eruption first  appearing on the chest and abdo-
 men presents these features after full development, it can certainly be
 judged syphilitic in its nature.  Frequently, however, the syphilide
 will depart in one or more points from the type  to which it should
 theoretically correspond.
    The absence of subjective symptoms—that is, freedom from pain and
 from itching—is a rule which has but few exceptions, if  eruptions on
 the  scalp and the hairy parts of  the body are excluded.  In  these
 regions itching is very common.  On the body and extremities the
 eruption is often  not  noted  by the  patient till the physician calls
 attention to  it; or the patient becomes aware of it only because he
 has noticed it while dressing or bathing.
    Exceptionally the itching is severe and harassing; this may arise
 from the specific  eruption, but commonly it is found to be dependent
 upon an intercurrent  condition, such as urticaria  or prurigo or the
 presence of pediculi.
    The rounded form and  grouping of the syphilides are usually fairly
 well marked, though individual  lesions  widely depart from this  type.
 The circinate grouping is  much more  pronounced in the late sec-
 ondary and in the tertiary lesions; indeed, it is a striking feature of
 the eruption.   In the early secondary lesions, particularly in roseola,
 this  grouping is rarely so  conspicuous  as to be noticeable till it is
 carefully searched for.
   The raw-ham or copper  color  of the eruption is not pronounced at
 first.  The early erythema is usually a dusky red, though it may pre-
 sent the  rosy-red hue of  simple erythema.  As the lesions develop,
 a certain  amount of  skin pigmentation  takes  place,  the erythe-
matous  patches no  longer disappearing entirely  on pressure, but
leaving a dark stain.  The macules and papules become  still more
                               22 
338        GENITO-URINARY DISEASES  AND SYPHILIS.

dusky, like  raw ham, or even present a distinct  coppery hue.  This
is fairly constant, but is not characteristic till  the lesion has persisted
at least some days.  A similar coloration, together with absence of
itching, is sometimes observed  in the skin  eruptions of gouty and
rheumatic subjects.  This pigmentation may last for years;  usually
it disappears in a few  months.   The epidermic  layer  of the skin
suffers by reason of the interference with its  nutrition caused by the
cell-exudation  in the  papillary layer beneath it.   Most  syphilides,
therefore, tend to become squamous.
   The symmetrical development  of the  secondary syphilides is  an
almost  constant feature  of the  eruption. The two corresponding
sides of the body  are usually invaded equally  and by a somewhat
similar form of the  eruption.  This tendency to symmetrical develop-
ment is not observable in tertiary eruptions.
   The polymorphism of secondary syphilides is at times the feature
of most importance in establishing a correct diagnosis.   This term
implies  that the lesion is many-formed ; that  is, while in one  part of
the body  it is macular, in another it is papular, in  still another pus-
tular, etc.  The skin diseases which syphilis  simulates usually con-
form to one type;  that is, if certain lesions are observed in one part
of the body, similar lesions, and  no others, will be observed in other
parts.   This is not the case with syphilis,  except at the beginning.
   Usually the eruption develops  gradually, first in the  form of  an
erythema  so slight as not to be noticed  till  the patient's skin is ex-
posed to the air, when the eruption appears on the anterior and  lat-
eral aspects of the chest and belly as an exaggeration of that mottling
which constantly occurs when a portion of the surface generally cov-
ered is suddenly chilled.   This erythema  becomes  quite distinct in a
few days.   It persists and gradually shows the  pigmentary changes;
but in the mean time papules are developing in certain regions, or
perhaps pustules or vesicles.  The multiform eruption is due to  the
fact that the lesions  persist, one variety  not completing its  course
before another is developed.
   The general eruption  receives its  name  from  the predominant
lesion.
   The superficial  character of the early syphilides is  due  to  the
tendency of bacterial growth to  occur  in regions  where the  blood-
current is  slowed.   The  most marked effects of the disease  in this
early secondary stage are, therefore, shown in the  papillary layer of
the skin, the epidermis becoming secondarily involved.
   The Influence of Mercurial Treatment.—Although individual lesions
may  persist for months in spite of most careful medication, the usual 
CONSTITUTIONAL SYPHILIS.
339
effect of efficient mercurial  treatment upon general secondary syphi-
litic eruptions is prompt and pronounced.   Within a week the erup-
tion is undergoing rapid resolution.   This gives a means of diagnosis
which in doubtful cases is exceedingly valuable.
   Eruptions of the Mucous Membranes.—Involvement of the mucous
membrane of the mouth  is  one  of the most constant symptoms of
constitutional syphilis.  It  often occurs even  before the skin erup-
tions.
   It may appear in the  form of an acute  erythema (acute syphilitic
angina), involving the palate, half-arches, tonsils, and pharynx, accom-
panied by a marked oedema, closely resembling the non-specific sore
throat, and generally ascribed to catching  cold; more  commonly it
appears in the form of mucous patches.  Indeed, these are the most
constant lesions of secondary syphilis.  They are commonly found on
the tongue, the buccal mucous membrane, the half-arches, the tonsils,
and the palate.  Exceptionally they extend from the posterior half-
arch to the pharyngeal mucous  membrane.   They appear as gray-
white, irregularly shaped markings, not elevated above the surround-
ing healthy surface.  The appearance presented by an individual lesion
is very like that produced by brushing the mucous membrane with a
stick of silver nitrate, except that the margins of the mucous patch
are more sharply defined.
   Together with the mucous patches  there are  often erosions  and
fissures of the tongue.  The latter when deep and placed at the sides
of the  organ are painful, though the mouth  eruption of secondary
syphilis conforms to the general character of the disease in presenting
few subjective symptoms.   Contact with irritating or very hot foods
may, however, cause pain.
   Both the mucous patch  and acute erythema also  develop in the
urethra of the male, giving rise to  a  discharge which may  simu-
late a mild attack of gonorrhoea.  In the female there may be acute
erythema of the  vagina; more commonly, indeed, in the  majority of
cases, mucous patches develop about the vaginal outlet.
   Syphilitic Alopecia.—The impaired nutrition of the hair-follicles
incident to constitutional syphilis causes the hair to lose its lustre and
to come out  in  irregular patches.  Usually the scalp and the eye-
brows  are  alone affected.   Sometimes all  the hairy regions are in-
volved, and there results complete denudation of the entire body.
   The rapid onset of the  baldness, the  irregularity of distribution,
and the fact that  under constitutional treatment it is completely
curable are characteristic features of  the condition.
   At times alopecia attacks the eyebrows alone, causing an irregular 
340       GENITO-URINARY  DISEASES AND SYPHILIS.

bald patch.  This is so peculiar to syphilis that it is considered diag-
nostic.  (Fournier.)
   The alopecia which comes on later in the disease as a consequence
of ulcerative lesions  is  due to atrophy of the hair-follicles, and is
incurable.
   Syphilitic onychia is dependent  upon impaired nutrition of the
nail matrix, and is commonly associated with the papular or pus-
tular  eruptions.   The nails may  become  brittle  and  lustreless,  or
may be hypertrophied and deformed, or may exfoliate.   These pro-
cesses are associated at  times with deep ulceration around the  nails
(perionychia).
   Syphilitic  Involvement  of the Viscera.—At about the time
the early constitutional symptoms,  such as general lymphatic enlarge-
ment, fever, and syphilodermata, develop, there may be manifestations
of the disturbing effect  of the virus upon  the viscera,  though  such
signs, at least  in their more serious forms, do not usually occur till
late in the disease.  The visceral symptoms which develop in  early
secondary syphilis are nearly always dependent upon an acute hyper-
aemia which, though caused by the syphilitic poison, differs in no way
from similar conditions brought about by other causes, except in the
fact that it yields promptly to specific treatment.   Thus there may be
temporary albuminuria from hyperaemia or inflammation of the kidney,
violent cephalalgia from  meningitis, pleural effusion from pleuritis.
   In  the early stage of secondary syphilis the liver may be hyper-
trophied.  This may be  accompanied either by pain or by jaundice,
or by both  of  these  symptoms.   Jaundice does not appear as an
isolated  symptom   of syphilis.  Syphilides of the skin  or of the
mucous membrane  are found associated with it.
   It is more convenient to consider under tertiary syphilis the effects
of the disease on the muscles, the bones, the nervous and vascular
systems, and the viscera,  since the  secondary manifestations of the
disease in these portions  of the body are  transitory and  compara-
tively rare, and present only the ordinary  symptoms of a more or
less acute inflammation.
   It is noteworthy that the symptoms in connection with the viscera
become less acute in type  as the attack of syphilis becomes older, and
that when they develop they resemble  the  chronic rather than the
acute form of inflammation,  until finally in the  tertiary period the
formation of gummata takes place.
   Syphilitic  Disturbances of  the Nervous  System.—The
commonest symptom of involvement of the nervous system in con-
stitutional syphilis  is  the  syphilitic neuralgia  to which  reference has 
CONSTITUTIONAL SYPHILIS.
341
already been made.  This and the other symptoms may be dependent
upon the general cachexia, or more rarely may be due to pressure, as
from enlarged  lymphatics or swelling of the  medulla or the perios-
teum of bones.   The first and second branches of the trifacial nerve
are especially subject to this  form of syphilitic neuralgia.
   Cephalalgia is common in the  early secondary period.   It is  usu-
ally of moderate severity, is  not a surface pain, but is located in the
frontal  or  the  occipital region of the  brain, and  is harassing rather
than disabling;  there  are  nocturnal  exacerbations.   Very excep-
tionally it becomes exceedingly severe.
   Analgesia when present  is  found over the metacarpal region of
each hand.  It is an early, usually symmetrical lesion, and is not ac-
companied by  anaesthesia, tactile sensation being retained.  It  may
exceptionally take the form of thermo-analgesia or  muscular analgesia.
   Paralysis, particularly of  the  muscles of the eye  and the face, is
occasionally  observed in early syphilis.  It may involve single muscles
or muscle  groups, or may cause hemiplegia or paraplegia.
   The nerve manifestations of secondary syphilis are usually short-
lived and yield quickly to constitutional treatment.
   Syphilitic involvement of the bones, joints, and tendinous
sheaths is not rare in the secondary stage of the disease.  The bones
lying nearest the surface exhibit painful nodular swellings with the
characteristic symptoms of acute periostitis.  One  or many joints may
be the seat of more or less  acute inflammation.   Certain  of the ten-
dinous  sheaths may develop the  crackling and  tenderness of teno-
synovitis.
   Iritis  is  the commonest  eye manifestation of  secondary syphilis;
it  may  assume the plastic or the serous form.   In either case  the
symptoms are  like those  of the  inflammatory form  of the disease,
except that they  are less acute.
   Epididymitis  occasionally  develops as a lesion of early constitu-
tional disease ;  it is unilateral,  painless,  and quickly subsides  on
treatment.   Orchitis is rarely observed till the tertiary stage.
   As a result of secondary  syphilis, menstrual disturbances are very
common:  these  may take any  of the forms noted in  debility from
other causes.  Both  amenorrhcea and metrorrhagia  have been  ob-
served.  In the pregnant uterus abortion generally occurs.

                  SYPHILITIC  SKIN ERUPTIONS.
   It should be  remembered that recent syphilides (secondary) are
superficial, while later eruptions (tertiary) are deep, but that typical
tertiary eruptions may exceptionally appear  in the  secondary stage 
342
GENITO-URINARY DISEASES  AND SYPHILIS.
of the disease, or the secondary  eruptions  may  appear late.  The
skin lesions of syphilis may be classed as follows:
    1.  Erythematous syphilides, called also erythema, macules, roseola.
    2.  Papular syphilides.  In accordance with their size, shape, and
surface, the papular syphilides are  :
        A. Conical or acuminated  papular syphilides.
               a. Large.
               b. Small.
        B. Flat or lenticular papular syphilides.
               a. Large.
               b. Small.
        C. Moist  papules (mucous  patches).
        D. Papulo-squamous syphilides.
    3. Vesicular syphilides.
    4. Pustular syphilides.
           a.  Small, acuminated pustular syphilides (miliary).
           6.  Large, acuminated pustular syphilides (acneiform).
           c.  Small, flat pustular syphilides (impetiginous).
           d.  Large, flat pustular  syphilides (ecthymatous).
    5. Pigmentary syphilides.
    6. Bullous syphilides.
    7. Tubercular syphilides.
    8. Gummatous syphilides.
    A pathological study of the secondary skin eruptions shows that
they are made up of a small round-celled infiltration of the cutis and
adnexa, together  with  the lower  layers of  the rete Malpighii.  The
blood-vessels are dilated, the endothelium is thickened, and there is a
small-celled infiltrate of the  adventitia.   These changes involve the
vessels of the papillae, the Malpighian net-work, the hair-follicles, the
sebaceous  glands, and the sweat-glands.   Whether the eruption  be
macular, papular, or pustular, the  pathology is the same.
    The pathology of  the tertiary lesions differs  from that of the
secondary only in that the small-celled infiltrate is much more exten-
sive, invading the entire thickness of the  skin and the subcutaneous
tissues.  As a result, this mass of embryonal tissue, always poorly
vascularized, degenerates centrally, and either ulcerates, discharging
externally, or is  partly  absorbed  and partly converted into fibrous
tissue.
    Grouping the  skin lesions in accordance with the time of develop-
ment, the eruptions  of the secondary period are:
    The erythematous syphilides (roseola);  the papular and papulo-
squamous  syphilides (mucous  patch,  lichen, condyloma,  psoriasis, 
Fig. 109.
                Erythematous syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
 
 
CONSTITUTIONAL SYPHILIS.
343
etc.);  the general pustular syphilides (acne, impetigo); the pigmentary
syphilides;  the bullous syphilides; the vesicular syphilides ; the tuber-
cular syphilides.
   During  the  same time there may develop on the mucous mem-
branes :
   1.  An acute erythema ;
   2.  Mucous and scaly patches ; or,
   3.  Superficial ulcerations.
   With the exception of the pigmentary syphilide and the squamous
form of the papular syphilide, these are general  eruptions and appear
during secondary syphilis in about the  order given, the tubercular
lesion  being well on the  border-line between the secondary and the
tertiary period.
   The syphilides  of the  tertiary stage are pustular  and  bullous
syphilides,  which appear discretely or in groups, and which ulcerate
deeply (ecthyma, rupia), and gummata.
   The mucous membrane manifestations of this stage  are mucous
and scaly patches and gummata.
   Erythematous Syphilide.—This is the earliest and the  most
constant of all the skin lesions of syphilis. It appears about the same
time that the general  lymphatic enlargements become apparent.  In
the uncleanly and careless it may run its course without attracting the
attention of the patient.  The eruption  exhibits less of  the rounded
shape or grouping than any  of the other  syphilides.
   It  first  appears  as an irregular rose-red mottling of  the surface,
such as is constantly seen when covered surfaces are exposed to the
cold.   The lesion  may  not develop beyond this point,  terminating
promptly under treatment,  or  at  times  even without it, in a  slight
branny epithelial shedding.   More commonly syphilitic  roseola de-
velops,—that is, patches  of varying size  are formed, the  smallest not
larger than a pin-head, the largest the  size of  a quarter- or a half-
dollar.  (Fig. 109.)   These patches are irregular in shape, frequently
rounded or oval, but not necessarily so, and  shortly become  raw-
ham or even coppery in color.  At first pressure of the finger and
emptying of the superficial vessels leave the  skin white for a moment,
but later there is distinct pigmentation, the copper color remaining.
   The eruption commonly appears on the sides and front of the
belly and chest.  It is also  frequently observed on the back  and  on
the flexor  surfaces of the extremities.  It is sometimes  seen at the
hair-line of the forehead and upon the  palmar and plantar surfaces.
It may, of course, develop on any surface of the body, but the regions
just given  are, in their order, those of preference. 
344       GENITO-URINARY DISEASES AND SYPHILIS.

   The full erythematous eruption develops in about a week.  Under
treatment it rapidly disappears, even the pigment being absorbed and
leaving no trace.   If not treated, it lasts for weeks or months, and is
accompanied by papular and pustular lesions, giving  the eruption one
of its characteristic features,—polymorphism.
   Diagnosis.—The  diagnosis of  the erythematous syphilide is much
simplified by the presence of concomitant signs of  the disease.  At
this  stage the remains of a chancre are usually present, the enlarged
glands can be felt, and a history of rheumatoid pains,  of sore throat, of
headache, and of a slight feverish attack will be given.
   Simple  erythema and  the copaiba  rash may both simulate syphi-
litic  roseola.   Simple erythema,  however, is not associated with a
history  of chancre or with the signs of early  secondary syphilis, is
more commonly accompanied by  distinct fever and digestive disorder,
itches,  and develops  and  subsides  in a short  time, showing no
tendency to persist and to become pigmented.
   The copaiba rash often exhibits large itching confluent patches,
which run  their course in a few  days, which appear with special in-
tensity in certain regions, such as  the extensor surfaces of the joints,
and which subside promptly on stopping the drug.  There is a history
of ingestion of copaiba, or, if this is denied, an  examination  of the
urine will demonstrate the copaiba odor.
   Under mercurial treatment recurrences of erythematous syphilides
are rare.  When they do  appear it is in the  form of a few large,
slightly  pigmented, discrete  patches.  Mercury given  in full doses
causes rapid disappearance of the eruption.
   Papular Syphilide.—The lesions of the papular syphiloderms
appear as hard, small or large, acuminated or flat, smooth or scaling,
rounded elevations,  exhibiting a characteristic  raw-ham or copper
color.   These lesions are due to circumscribed  hyperaemia, together
with cellular infiltration of the papillary layer of  the skin.  They are
frequently converted into vesicles or pustules.
   The Small Papular Syphilide.—This eruption is usually an early
manifestation of constitutional syphilis, exceptionally even preceding
the roseola ;  frequently it  does not develop till  considerably after the
fourth month.  The  papules may be conical, rounded, flat (lenticular),
or umbilicated, and often exhibit a  fine scaling.  They vary in size
from that of a pin-head to that of a split pea.  At first rose-red,  they
become raw-ham or  coppery in  color. The lesions are  apt to ex-
hibit a circinate  grouping, appearing as segments of circles, as com-
plete  circles, or in figures  of eight.   The  eruption is usually  well
marked and involves a large surface.   (Fig. 110.) 
Fig. 110.
'
f
*> >■

*
~^<mr
>
Sk
Flat papular syphilide.
55 
Fig. 111.
             Acuminated papular syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
 
Fig. 112.
             Acuminata
(From the collect
hilide.
ge Henry Fox.) 
 
Fig. 113.
Fig. 114.
               Larjre flat papular syphilide.
(From the collection of photographs of Dr. George Henry Fox.) 
Fig. 115.
Large flat papular syphilide.





        Fig. 11*;.
Vegetations and mucous patches about the vulva. 
CONSTITUTIONAL SYPHILIS.
345
     The acuminated (miliary) form is first noticed on the face.  It sub-
  sequently appears on the trunk and the extremities.
     The  flat,  lenticular, lichen-like  form  appears  first  about  the
  shoulders, but the face, body, and  extremities are soon involved, the
  lesions   being  particularly
  abundant about the flexures                 Fig. 117.
  of  the joints.  The palmar
  and  plantar  surfaces  also
  suffer.   The  eruption  is
  somewhat  chronic   in  its
  course,  and is more  resist-
  ant to treatment  than  the
  erythema.  It yields in three
  or four weeks, but is sub-
  ject to relapses.
     The Large Papular Syph-
  ilide.—As  in  the  smaller
  lesions,  these  papules may
  be conical or flat.
    The  large conical pap-
  ules are usually discrete, few
  in number, are found asso-
  ciated with the  small pap-
  ules, and are most abundant on the  back, the buttocks, the back of
 the neck, the face, and the extensor surface of the thighs.  (Figs  111
  112.)
    The large, flat papules vary
 in size from that of a  shirt-
 button to  that  of a penny.
 (Figs.  113, 114,  115.)   They
 are sharply circumscribed, ele-
 vated,  and commonly exhibit a
 branny scaling.   The  eruption
 may be widely distributed or
 may be grouped  in certain re-
 gions.   Thus,  the  lesions are
 frequently found  on the back,
 the nape of the neck, the  fore-
 head, the flexor surfaces of the
 extremities, and  the scrotum,
and  about the mucous outlets.
become fissured, and may give rise to severe pain.  This is especially
Mucous patches of the lips.
Mucous patches about the anus.
(Fig. 120.)   Sometimes the lesions 
346        GENITO-UKINAKY DISEASES AND  SYPHILIS.

apt to occur on  the  hands and feet and about the  mouth and the
anus.
   Mucous Patch.—When the papular syphilide develops on surfaces
of the body which are kept constantly moist by secretions, or which
are subject to  moisture  and friction, as on mucous  surfaces at the
angles of the mouth  (Fig.  117),  beneath the  dependent  mammary
gland, about  the  anus (Fig. 118) and the vulva (Fig.  116), within the
foreskin, on the scrotum, or between the toes,  instead of the branny
scaling which characterizes  the  dry lesion there is often an abraded
surface, which secretes freely and is partly or completely covered by a
gray, adherent, offensive  pseudo-membrane.  The irritating secretions
of these mucous patches frequently give rise to warty growths in the

                             Fig. 119.
Papular syphilide, showing papillary overgrowth.
immediate  environment.   Sometimes  the  moist papule exhibits, in
addition  to hyperaemia, cell infiltration and abrasion, or superficial
ulceration,  a distinct papillary  overgrowth, forming small or large
papillomata.  (Fig.  119.)  These are properly termed condylomata, 
Fig. 120.
I
Large flat papular syphilide, showing scaling. 
 
CONSTITUTIONAL  SYPHILIS.
347
and should be distinguished from the mucous patch in which hyper-
trophy of the  papillae either is not present or is not marked.  /Com-
monly these condylomata appear as raised flat, raw surfaces, the cel-
lular infiltration being so abundant  that the papillary nature of the
growth is  but imperfectly  marked.  Occasionally large  cauliflower-
like warty growths  are formed, particularly in the regions of the face,
scalp, shoulders, and genitals (Duhring).   These are termed vegetating

                             Fig. 121.
Syphilitic vegetations.
papules, and are often accompanied by abrasions and crusting of the
surrounding skin.  (Fig. 121.)
   When subject to friction and not treated, the mucous patches may
form ulcers.  On the delicate skin of babies mucous patches fre-
quently  develop, and are in them one of the commonest lesions of
syphilis.  In the adult they appear early, but are prone to relapses,
and may occur in the mouth even during the tertiary stage of syphilis.
The secretions of the mucous patch are highly contagious.
   Diagnosis  of the Papular  Syphilide*.—The  concomitant signs  of
syphilis,  such as the remains of a chancre, enlarged lymphatic glands,
sore throat, alopecia, scabs  in the hair, etc.,  are usually present, and, 
348        GENITO-UKINAKY DISEASES AND  SYPHILIS.

in conjunction with  the copper color of  the eruption, its polymor-
phism, the absence of itching, and its grouping about the back, the
neck, the forehead, the sides, and  the  buttocks, render the diagnosis
of this syphilide easy.
   When the large, flat, papular syphilides develop, either in the
dry form or as mucous  patches, the diagnosis can be made with cer-
tainty, since these  lesions are absolutely characteristic of syphilis and
are simulated by no skin disease.
   Acne papillosum and lichen are, both closely simulated by some
forms of the papular syphilides.
   Acne papulosum is associated with  none of  the concomitant  signs
of syphilis, is found  commonly about the  forehead, cheeks,  chin,
shoulders,  and  back,  leaves  no pigmentation  at  the seat of cured
lesions, and is often accompanied by pustules;  or there may be  scars
resulting from the  healing of the latter.   When papular acne develops
only on the  forehead, the  diagnosis must be formed mainly on the
absence of other signs of syphilis.
   Lichen may be acuminated or flat, and may  be widely distributed.
The lesions of this disease are dusky in color and occasion pigmenta-
tion  of the  skin.  The  individual  papules are, however, angular in
outline rather than rounded, and in place of  a  circular  grouping are
often arranged  in rows or lines.   They usually itch, and  are not
associated with any of the signs of syphilis.  The  eruption, however
diffuse it may be, is papular throughout.
   Keratosis pilaris, the conical elevations seated about the apertures
of the hair-follicles and  mostly found on the extensor surfaces of the
thighs and arms  and on the forearms, is sometimes mistaken for the
small miliary syphilide.   The absence of circular grouping, the dis-
tribution of the  lesion, the uniform appearance presented by it, and
the fact that each papule is invariably placed at the aperture of a  hair-
follicle, will, in the absence of other signs of syphilis, render diagnosis
easy.
   Prognosis.—Papular syphilides  yield to treatment, leaving a brown-
ish pigmentation, which  ultimately  disappears.   The effect of mercury
is not so immediate as in the case  of roseola.  Still, in a few weeks a
general papular eruption usually fades completely under constitutional
treatment.   The recurrent forms are somewhat more obstinate.  These
are prone to appear in circinate groups.
   Trecdment.—Mercury should always be given, in some cases  pref-
erably by fumigation or  inunction.
   Papulo-Squamous Syphilides.—There is more or less desquamation
with all the papular  syphilides, but in some  cases this may be so 
Fig. 122.
              Papulo-squamous syphilide.
(From the collection of photographs of Dr. George Henry Fox.) 
 
CONSTITUTIONAL SYPHILIS.
349
marked as to give the disease a distinctly squamous type.  The lesions
in this form of syphiloderm are generally flat, and are  covered with
                              Fig. 123.
fine  gray scales,  which  are  not very tightly adherent.   As  these
scales are brushed away,  the coppery glistening surface of the papule
                              Fig. 124.
           Papulo-squamous syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
is exposed,  surrounded with  a fairly well-marked  collar of ragged
epithelium. 
350       GENITO-URINARY  DISEASES AND SYPHILIS.

   These lesions when  they appear early may be multiple and gen-
eral, the  patches varying in  size as do those  of  papular syphilis.
(Figs. 122, 123.)
   In recurrent, late eruptions the lesions may be few and grouped.
(Fig. 124.) They may  remain weeks or months without increasing
in size, and commonly exhibit a  distinct circinate arrangement of the
individual papules of a group.
   The  well-marked papulo-squamous syphilides usually  appear
after the sixth month, and may develop in any subsequent period of
the disease.   The distribution of this lesion is similar to that of the
papular syphilide.
   On the palms and soles these papulo-squamous eruptions are most
frequent and most resistant.  (Figs. 125, 126,127, 128.)   In the early
period of the disease  they are symmetrical; later this feature is not
noted.  Instead of the familiar macule with glistening coppery centre
and  gray epithelial scales about the edges there may be a marked
overgrowth of the corneous layer  of the skin, forming  hard conical
projections in size from that of a pin-head to that of a pea.   These
can be dug out from the skin, leaving deep pits or depressions. They
are most frequently noted on the soles, and are liable to  occasion
pain on walking.  The papulo-squamous syphilides of the palms and
soles are often complicated by painful and obstinate fissures.
   These lesions  may appear in the third month,  or much later.
They are prone to relapse,  beginning about the centre of the palm
and extending peripherally, forming lesions of circinate or serpiginous
shape.
   Papulo-squamous  eruption of the palms or soles alone, accom- 
Fig. 12(1.
/-*■-  '•■
Papulo-squamous syphilide of the hand.  (Fox.) 
 
 
 
CONSTITUTIONAL SYPHILIS.
351
panied by but slight subjective symptoms, is almost pathognomonic
of syphilis.   Exceptionally  the  palmar syphilide appears as a  dif-
fuse exfoliation of fine epithelial scales, giving the surface a silvery
aspect.
   Diagnosis.—Papulo-squamous syphilides must be  distinguished
from psoriasis and from palmar eczema.
   Psoriasis is entirely superficial, exhibiting but slight  thickening, is
not polymorphous, frequently appears before the twentieth year, its
individual lesions are not markedly raised  above the level of the sur-
rounding surface, it is covered with a thick, imbricated skin, made up
of white  scales, is generally symmetrical (the late syphilitic  papulo-
squamous eruption  does not usually exhibit this feature), is rarely
confined  to the palms and the soles, being commonly associated with
similar lesions grouped about the extensor surfaces of the knees  and
the elbows, is always dry, is extremely chronic, is subject to relapses
and obstinate  to treatment, is not influenced by mercury, and  pri-
marily is not associated with other signs or symptoms of syphilis.
   Eczema of the palms is attended with discharge, crusting, and itch-
ing ; it begins about the wrist first, and not in the centre of the palm,
and is not as sharply outlined as the specific lesion.  When  palmar
or plantar syphilides become fissured or eroded  they cannot be  dis-
tinguished from eczema.   Their reaction  to specific treatment is so
slow that the therapeutic test is of little service.
   The circinate form of papulo-squamous  syphiloderm may closely
resemble the lesion  of tinea circinata; the latter is, however, pro-
gressive, and microscopic examination shows the parasite.
    Prognosis.—The lesions  are  obstinate, but ultimately heal; they
may leave permanent scarring.   Their pigmentation disappears.
    Treatment.—Mercury and potassium iodide.
    Vesicular Syphilide.—This  eruption is exceedingly  rare.   It
may closely simulate, so far as the skin lesions are concerned, almost
any of the non-specific vesicular diseases.    Thus there  are the ecze-
matous form,  the varicelloid form, and the herpetic form.
   The  vesicles may be small or large, may be  generalized, or may
come  out in groups in certain regions of the body.  They are prone
to appear about the  hair-follicles.  They  are observed on the face,
the trunk, and the extremities.  If there are  seats of preference, these
are perhaps the face, genitalia, forearms, and legs.
   The  eczematous  form appears as  a general  eruption  of small
vesicles, either discrete or in patches, and generally sparing the face.
When the vesicles are discrete, each is surrounded by a  characteristic
raw-ham-colored areola.  If the fluid of the vesicles remains clear, it 
352        GENITO-URINARY DISEASES AND SYPHILIS.

may break through its thin epidermic wall and escape, or may be re-
absorbed, leaving  only a slight epidermic exfoliation and  temporary
pigmentation; frequently, however, pustulation takes place, and  thin
yellow crusts are  formed (impetigo).  This  last form is prone to
appear on  the face and about the genitalia, and is usually associated
with papular and pustular lesions on other parts of the body.
   The diagnosis  from  vesicular eczema will be made by the char-
acteristic areola, the  absence of itching and  of  acute  inflammatory
signs, the influence of mercury, and the presence of associated signs
of syphilis.
   The varicelloid form appears as  large,  not very numerous, dis-
crete, split-pea-sized  vesicles, either  globular or umbilicated, which
persist for some time, and then rupture, leaving  an area of slight
crusting  and pigmentation.   Or they may pustulate (presenting the
appearance of varioloid)  and crust.   The base of each vesicle is  sur-
rounded by a characteristic copper-colored areola, and other syphi-
lides  are usually present.  Were the patient  suffering from  a well-
marked fever, the syphilitic eruption might readily be taken for either
varicella or varioloid, according to its type.  A  history of the case,
and  the  concomitant signs of constitutional syphilis, should  quickly
establish the proper diagnosis.
   The herpetic form of the vesicular  syphilide  exhibits  clusters of
vesicles of various sizes, either irregularly grouped or having a distinct
circinate arrangement.
   The lesions of the circinate form are small, are not persistent, dry
up without rupture, and leave an area of superficial exfoliation  and
raw-ham-colored staining.
   The diagnosis  from  ordinary herpes is generally  made without
trouble.   Yet  at  times  the syphilitic  nature of  the  eruption  can
be determined only by  the  associated signs  of syphilis.   Although
syphilitic vesicles  as such  do  not persist for any great length of
time, the  copper-colored  macules or pustules left  after  the  ab-
sorption  or rupture  of the vesicles are liable to  remain for many
months.
    Treatment—The treatment of vesicular  syphilides consists in the
administration of mercury, supplemented by mercurial baths  to  pre-
vent the  vesicles from becoming converted into pustules.
   Pustular Syphilide.—The syphilitic pustule  may be small or
large, and either of these varieties may be acuminated or flat.
   The lesions are commonly  placed  on indurated copper-colored
bases; they may be surrounded by an extensive dusky areola.
   In the early eruptions, and when the lesion first appears, the pus 
CONSTITUTIONAL SYPHILIS.
353
is contained between  the  raised epiderm and the true skin;  later,
deeper ulcers may be formed.
   These syphilides very closely simulate any of the  pustular non-
specific skin eruptions.  They are prone to  crust, the crusts  vary-
ing  from  a dark-yellow to  a dark-green or brown-black color, and
exhibiting, when raised from  the  surface of the  lesion, a distinct
punched-out ulcer covered with viscid pus.
   When  the pustular  lesions heal, they leave marked pigmenta-
tions, and,  unless  the ulceration  is purely  superficial,  permanent
cicatrices.
   Pustules commonly appear late  in  the disease ; their early  de-
velopment is usually associated with  a severe form of syphilis.
   The pustular syphilides may develop on any skin surface ;  if  the
lesions are few in number, they are perhaps more frequently  noted
on the face, the scalp,  and the  legs.
   Any of the  syphilides  may be  found  associated  with  pustular
lesions, and even when the predominant eruption is papular the pus-
tule may be found at the same time in all its forms and at all stages
of evolution.  An  early pustular eruption is especially liable  to  be
preceded by syphilitic fever of an intermittent type, with its associated
symptoms of malaise,  pallor, inability to concentrate the thoughts,
headache, insomnia, articular pains, and sternal tenderness.
   The pustular syphilides are somewhat obstinate to treatment, are
prone to recur, and are more  frequently followed by  tertiary mani-
festations than when the eruption appears in a macular or a papular
form.  (Bassereau.)   When  pustulation has  been unusually  well
marked  during  the secondary stages of the  disease the tubercular
and  gummatous lesions of  the tertiary stage of  the disease  exhibit a
marked tendency to suppurate.
   Small Acuminated Pustular Syphilide.—This eruption is  the most
superficial, and  usually in its  time of appearance the  earliest,  erup-
tion  of this group.  It is made up of minute miliary  pustules, each
situated about a hair-follicle or the opening of a sebaceous gland.   It
is followed by the formation of small yellowish crusts, leaving a pig-
mented spot surrounded by a fringe of exfoliating epithelium.  On its
first appearance the eruption usually covers a large surface, may be
discrete  or confluent,  and exhibits circinate grouping.  Relapses  of
this syphilide are  not  apt to appear as a  general eruption, but rather
the lesions will be grouped in certain localities.
   When the lesions  become confluent, superficial scabs are formed
very like those observed in impetigo.  The eruption about the lips is
sometimes accompanied by a  warty growth.   This eruption corre-
                               23 
354        GENITO-URINARY DISEASES  AND SYPHILIS.

sponds closely to the small vesicular syphilide, the only difference
being that the raised epidermis has beneath it pus instead of serum.
   This pustular syphilide does  not last  long.  Slight crusting takes
place, and a pigmented spot is left which is slow to disappear.  Some-
times,  and this is particularly true  of the relapses, ulceration takes
place and a permanent cicatrix is left.
   Diagnosis.—The diagnosis is founded  upon the pigmentation,  and
is usually rendered easy by the fact that this eruption  very  rarely
appears alone, being commonly associated with papules and roseola.
   Large Acuminated Pustular Syphilide (Fig. 129).—This eruption
may develop suddenly, or may  form slowly with fever.  When  the
pustules are moderate in size, they  so closely resemble ordinary acne
that the term  syphilitic acne is very generally employed to designate
them.   The individual lesion begins as a macule, which quickly be-
comes  converted into a  papule, then  a  pustule, commonly placed
about a hair-follicle, upon a papular, infiltrated, copper-colored base.
The  pustule remains  for  one or two weeks before rupturing.  Then
crusts  are formed,  which in dropping  off expose  either a superficial
ulcer or, more commonly, a coppery papule.  This and the pigmenta-
tion  very slowly disappear; usually there is scarring.
   Syphilitic acne may appear as a general eruption ; more commonly
it invades the scalp, face, and trunk; it is  often found on the extremi-
ties.
   When the  eruption develops  suddenly,  is generalized, and is
accompanied by  fever, it  very closely resembles variola.  This form
is exceedingly rare.
   Diagnosis.—The diagnosis of the large acuminated  pustular syph-
ilide will be founded mainly on the  presence of other signs of syphilis,
particularly the other syphilides.   Ordinary acne commonly appears
on the face,  chest,  and back, about the  age  of puberty, being rare
in late  life, and  on the  removal of the crusts  does not exhibit  the
coppery, lenticular  papule of syphilis.  An acne-like  eruption con-
fined to the trunk and the legs strongly  suggests syphilis.  Again, the
specific eruption is  commonly associated with  other syphilides.
   Variola is a uniform eruption, the lesions all corresponding  to the
pustular type.   It  is  acute,  runs its course  in a few days, and is
attended with very pronounced constitutional symptoms.  There is
little danger of mistaking this eruption for a pustular syphiloderm.
An error the reverse of  this has been made  many times,  syphilitic
patients having been sent  to small-pox hospitals.
   Small, Flat  Pustular  Syphilide.—The lesions  of this  form of
syphilide  closely  resemble those of impetigo.   They are  more com- 
Fig. 129.
                Large pustular syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
 
 
 
 
CONSTITUTIONAL SYPHILIS.
355
 mon than the acuminated syphilides.  Small, flat, split-pea-sized pus-
 tules  form  on  somewhat  elevated  copper-colored  bases.   These
 pustules shortly rupture, and are followed by rather thick, adherent,
 yellowish or greenish crusts.   These  lesions may be discrete, may
 exhibit  a circinate grouping, or
 maybe  confluent, formingirregu-               Fig. 131.
 larly shaped crusts (pustulo-crus-
 taceous).   (Fig.  130.)   In the
 latter periods of the disease this
 eruption commonly  appears in
 the form of  irregular  patches,
 often presenting a narrow crusted
 circinate border, which, spreading
 peripherally, encloses an area of
 pigmented,  scarred,  or normal
 skin.  (Fig.  131.)
    Beneath the crusts  of syphi-
 litic impetigo are found ulcers.
 These may be superficial or  deep,
 the latter variety appearing late
 in the disease.  These ulcers on
 healing   leave depressed,   pig-
 mented   cicatrices,  which  are
 prone to scale for months.    The
 pigmentation  finally  fades, the
 scar remaining white.
    When syphilitic impetigo ap-
 pears  as an early  general  erup-
 tion, it may last but a few weeks.
 The late confluent circinate and
 serpiginous forms are extremely
 chronic.
    The  favorite seat is the  face,
 especially in the hairy portions,
 as the beard and the eyebrows, and about the nostrils and lips.   (Figs.
 133, 134.)  They also develop frequently on the  scalp (Fig.  132), the
 chest, and the  outer surfaces of the arms and legs.   (Fig. 135.)
   Diagnosis.—The diagnosis of small,  flat pustular  syphiloderm  is
 sometimes not possible from the inspection of the  lesions alone, the
 latter corresponding  very closely  to  those of pustular eczema and
impetigo.
   The crusts of pustular eczema on being raised show an excoriation,
  Pustular syphilide (pustulo-crustaceous).
(From the collection of photographs of Dr. George
           Henry Fox.) 
356        GENITO-URINARY  DISEASES AND SYPHILIS.

and  the disease  is distinctly more inflammatory in type  than the
syphiloderm.   The pustule of impetigo is discrete, not placed on an
infiltrated base, and exhibits no copper-colored areola.

                              Fig. 132.
             Pustular syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
    It is  mainly by the presence  or the absence of associated signs
of syphilis that a diagnosis is to be made.
    Large,  Flat Pustular Syphilide.—The lesions  of this  syphilide
closely resemble ecthyma: hence the eruption is  commonly called
syphilitic ecthyma.   It appears in  the  form of large,  flat  pustules,
varying from a quarter of an inch to an inch and a half in diameter.
(Fig. 136.)  The lesion  commonly begins as  a raised, dusky red,
slightly inflamed, and indurated area, which quickly  suppurates, the
pus raising the  epiderm  but  slightly, and  forming  a large, flat, not
very tense pustule, which shortly  crusts.
   The lesion may remain superficial, limited, and only moderately
crusted, exposing, on exfoliation  or removal of the scab, an erosion
or a shallow ulceration, or it may extend both in depth and in circum-
ference.
   The superficial form occurs towards the end of the  first year of
constitutional  syphilis ; it is amenable  to treatment, and particularly
affects the shoulders, back, and extremities. 
Fig. 133
Fig. 134.
          Pustular syphilide (pustulo-crustacei hi.-
(From the collection of photographs of Dr. George Henry Fox.) 
Fig. 135.
I    •     •
Flat pustular and papulo-squamous syphilide.
 
CONSTITUTIONAL SYPHILIS.
357
Fig. 136
    In the deep form of syphilitic  ecthyma  the  ulceration is progres-
 sive in all directions.  The crust  increases in  thickness and  extent,
 the material for  it being furnished in the  continued suppuration of
 the extending ulcer; it projects  from the  surface in the  form of a
 greenish or  brown-black  cone, often exhibiting
 distinct stratification.   This thick, conical, adhe-
 rent crust commonly overlaps the  raw  surface
 beneath; sometimes its base is sunk in the ulcer
 and is completely surrounded by unhealthy granu-  ■
 lations.
    Lesions made up of these dark, raised, conical,  j
 laminated  crusts, seated upon deep  ulcers, and  |
 surrounded  by reddened,  indurated  areas, are
 called  rupial.  When the ulceration extends lat-
 erally and  does not grow  materially  deeper, the
 crust may be depressed in the centre and elevated
 about the margins.
    When the thick crusts  of deep ecthyma are
 removed, punched-out  ulcers  covered with thick
 greenish or yellow pus  are  found.  These  ulcers
 are rounded  or circular, and usually discrete and
 few in number.  When the pustules  are  closely
 grouped  they commonly become  confluent, the
 outline of the resultant lesion being circinate.
    The chronic  crusted lesions of the pustular
 syphilides are termed pustulo-crustaceous.   When
 they are confluent, spreading widely  in circinate
 forms,  and  are destructive, they are termed  ser-
 piginous.  (Fig. 137.)
    Diagnosis.—The  diagnosis  of syphilitic  ec-
 thyma  from simple ecthyma will be based largely
 upon the evolution of the lesions, which in non-
 specific disease  develop  rapidly  and run  their
 course  in a few weeks, are attended with heat, pain, and other symp-
 toms of acute inflammation, form  brownish, not very thick, laminated
 crusts,  and exhibit on removal of the latter  superficial ulceration in
 place of the  punched-out unhealthy ulcer  of syphilis.   In ecthyma
 the eruption is uniform, and there are no coexistent signs of syphilis.
   Deep ecthyma leaves permanent cicatrices.  Rupial and the other
 forms of deep syphilitic ecthyma appear as late  lesions of syphilis.
   All the late pustular eruptions, particularly those which are deep,
yield to  specific  treatment  slowly.   They usually develop in the
Large, flat pustular syphi-
 lide (ecthyma).
 (From the collection of
photographs of Dr. George
Henry Fox.) 
358        GENITO-URINARY DISEASES  AND SYPHILIS.

cachectic and poorly nourished, and  indicate tonic  supporting treat-
ment in addition to specific medication and local applications.

                             Fig. 137.
            Serpiginous syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
   Pigmentary Syphilide.—The  pigmentary  syphilides  are quite
distinct from the stains secondary to the papular or pustular eruption
of syphilis.   They are dependent upon a primary excess of pigment,
which may  subsequently give place to leucoderma, or loss of color.
The lesion appears in three forms (Taylor):
   1. As rounded, oval,  or irregular plaques, with sharply defined or
jagged borders, varying from light brown to deep brown.
   2. As diffuse pigmentation, which becomes the seat of leucoderma-
tous  changes, appearing first as small spots, which gradually increase
in size.  (Retiform pigmentation.)
   3. As abnormal distribution of pigment, some parts of the skin ap-
pearing lighter, others  darker,  than normal.  (Marbled pigmentation.) 
Tubercular syphilide.  (Fox.) 
 
CONSTITUTIONAL SYPHILIS.
359
    The pigmentation is unaffected by pressure, the patches are not
 above the surface of the surrounding skin, and there is no exfoliation.
 It is usually a secondary manifestation of the disease, developing about
 the sixth month, though it is at times observed as late as the  second
 or the third year.   It is more common in females before middle age.
 Its seats of preference  are the  sides of the neck,  though it may be
 found elsewhere, as the chest, the forehead, and the flexor surfaces
 of the limbs.   It lasts for several months, then gradually fades, the
 skin resuming its natural color.  Treatment seems to have no effect
 upon it.
    Tubercular  Syphilide.—Tubercular syphilides appear as pin-
 head- or almond-sized, rounded or flat, hard, copper-colored infiltra-
 tions, which invade  the entire  thickness of the  skin, differing in this
 respect  from  the papular eruption, and resembling, except in the
 absence of inflammatory symptoms, a forming furuncle.
    The eruption may be generalized, or may occur  in patches on cer-
 tain parts of the body; it may be discrete or confluent; it may  be
 circinate, serpiginous, or irregularly grouped.  It may ulcerate, or the
 infiltrate may become  absorbed.  In  either case  there is usually
 permanent scarring.
    A discrete general eruption is rare; it occurs  in the late secondary
 or in the tertiary period of the disease, rarely before the end of the
 first year, though exceptionally it may develop within six months  of
 the chancre.
    The eruption  commonly appears grouped on one or more regions
 of the body, the indurated lesions having a tendency to coalesce and
 form  circular, scaling, or, if ulceration  takes place, eroding patches.
 Lesions of  this kind may develop twenty, thirty, or forty years after
 the appearance of a chancre.  (Bassereau.)
   Though the  tubercular syphilide may attack any portion of the
 skin surface, its seats of preference are the face, particularly about the
 lips and nose, the  forehead, the ears, the back, and the legs.  The
 course of this eruption is extremely chronic ; it is prone  to relapse.
   The Non-Ulcerating Tubercular Syphilide.—The hard, dusky
 red, chronic, scaling, tubercular eruption, when general and discrete,
 cannot well be confounded with any other lesion, except the papular
 syphilide; an  error  of no  great moment, but one  which is avoided
 by noting that the tubercle involves the  entire thickness of the skin
 and  appears at  a later stage of the disease than  does  the papule.
 When grouped, the  individual lesions of each group are usually much
 smaller  than the lesions of the  discrete general eruption; they tend
to coalesce, forming  circular  or irregular  patches (Figs. 138, 138 A), 
360        G-ENITO-URINARY  DISEASES AND  SYPHILIS.
which  increase  in  size peripherally, while absorption  and more or
less atrophy of  the skin take place in  the centre.  This results  in a
raised  circular margin made up  of  tubercles  so  merged  that they
can rarely be  distinguished as separate  tumors,  within which lies
the depressed, pigmented, atrophic skin.   (Fig. 139.)  These circles
       Non-ulcerating tubercular syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
vary in diameter from a fraction of an  inch to  four or five inches.
The surface of the non-ulcerating tubercle may be dry and glistening.
More  commonly there  is a  covering of branny scales  (tuberculo-
squamous  syphilide).   (Fig.  140.)   These lesions  develop without
subjective  sensations, except when situated  upon the face.  After an
alcoholic debauch there may be marked  local inflammatory phenom-
ena in lesions thus situated.
   The tubercles are resistant to treatment, often lasting for months.
They  may  form permanent scars, incident to  a process of interstitial 
 
 
CONSTITUTIONAL SYPHILIS.
absorption.  These scars are at first brown or copper-colored;  ulti-
mately they become white.
                             Fig. 140.
        Tubercular (squamous) syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
   Ulcerating tubercular syphilides are much more serious than the
dry tubercular  eruption, both in their immediate effects and from a
prognostic  stand-point.   The dry lesion after persisting for months
may break down ;  more commonly the tubercle from the first shows
a tendency to crust.  This  form of eruption  is rarely general, com-
monly affects certain regions of the body, exhibits a round grouping,
and may invade a large  surface.
   The  ulceration may be  superficial, attended by a slight  scabbing
and followed by very little  scarring; or it may be deep, invading the
entire thickness of the skin  (Fig. 141), may be covered by thick scabs
(Fig. 142), and may be followed by dense cicatrices, which cause both
disfigurement and disability.
   The  ulceration extends slowly, healing with the formation of scar-
tissue in one place while breaking down is taking place in another.
This process may continue for months or years, the  diseased area
forming circles, broad bands, or irregular figures (Fig. 143), and in-
volving  a large surface.   Thus the entire  face may be disfigured by 
362         GENITO-URINARY DISEASES AND SYPHILIS.
the  lesion.   This form is called  serpiginous.   It is,  of course,  not
exempt from the microbic invasion to which all open surfaces  are
exposed, and as a  result of infection may  become  phagedenic,  the
ulceration  extending with extreme rapidity and destroying a  large
amount of tissue in a few hours.
    The face and back are the favorite seats of serpiginous syphilides.
    As in other forms of syphilitic skin eruptions, in place of ulceration
and destruction there may be hypertrophy, the  skin papillae growing
from the ulcerated surface of a tubercle to form a pus-secreting cauli-
flower growth.
    Frequently the  cicatrices  of  ulcerating tubercular syphilides  are
pathognomonic of the specific lesions ;  in  the midst of the large scars
can  be  seen the small, depressed, round  cicatrices of the  individual
tubercle.
    Diagnosis.—The diagnosis of the  tubercular syphilide must be
made from lupus  vulgaris.   Lepra and  carcinoma are  also closely
simulated by this syphilide.
    The main diagnostic points between ulcerating tubercular syphilide
and lupus vulgaris are  as  follows :
        Tubercular Syphilide.
Tubercular  syphilide  generally  occurs
  in adults who give a history of syph-
  ilis or exhibit signs of other syphilitic
  lesions.
Begins as a copper-colored or brownish
  tubercle, which becomes a character-
  istic ulcer in one or two months.
The tubercles are of a brownish-red or
  coppery color, and are comparatively
  large.
The skin is distinctly infiltrated through
  its entire thickness.
Ulcers, if distinct, are small, circular,
  punched out.  If confluent, they in-
  volve a  large area.  The  secretion
  may be copious and offensive.

The crusts are bulky and greenish or
  brownish black.
The scabs  are irregular in shape  and
  attachment.

The scars are soft, white, and circular.
  Local treatment is ineffective.   Inter-
  nal specific treatment effects a cure.
          Lupus Vulgaris.
Lupus vulgaris generally occurs, or at
  least first appears, before  the twen-
  tieth year of life, without  history or
  signs of syphilis.
Begins as a tubercle, which does not
  ulcerate to the same extent for many
  months or even years.
The tubercles are often  translucent, of
  lighter color, and are small.

The infiltration of the  skin  is not so
  marked.
Ulcers  are  rarely distinct.  They are
  superficial, are not punched out, ex-
  hibit no regular form, and seldom in-
  volve  large  areas.  The secretion is
  slight and not offensive.
The crusts are thin and dark red.

The scabs are arranged more regularly,
  attached in the centre, and loosened
  at the edges.
The scars are distorted,  irregular, and
  puckered.  Active surgical  interven-
  tion  is effective.  Internal specific
  treatment is without effect. 
Fig. 142.
Fig. 143.
                  Tubercular syphilide.
(From the collection of photographs of Dr. George Henry Fox.) 
Fig. 144.
Syphilitic rupia following thc^rmiious syphilide
 
CONSTITUTIONAL SYPHILIS.
363
    Aside from  the history of the case, the most  important points to
 be considered in  differentiating  between  lupus and syphilis are the
 early age at  which lupus begins, its very  slow course, its superficial
 ulcerations, and its cicatrices, which  exhibit  neither the character-
 istic coppery stains nor the many small, depressed, circular scars of
 ulcerating tubercular syphilides.
    Cancer is sometimes closely simulated by the tubercular syphilide.
 The slow growth, the steady progress without attempt at cicatriza-
 tion, the  scanty discharge,  the  lancinating pains, the  lymphatic in-
 volvement, the absence of signs or history of syphilis, and the resist-
 ance  to  specific treatment, are symptoms which  will generally lead
 to a correct diagnosis.
    The  Bullous  Syphilide.—This eruption  usually  appears  as
 rounded or oval, discrete blebs surrounded by a slight areola, varying
 in size from that of a split pea to that of a penny.  The clear serum
 contained within the bleb shortly becomes turbid and blood-stained
 or  even  distinctly purulent.   On rupture of the  blebs, the  contents
 form  dark-yellowish  or greenish-black scabs.   These,  growing from
 the bottom, by the drying of the freshly secreted pus of the  slowly
 enlarging ulcer, finally result in  raised,  conical,  imbricated  crusts,
 often half an inch  to an inch in height, and sometimes twice as much
 in diameter.  (Fig. 144.)  These crusts  are adherent, and usually over-
 lap and conceal the underlying ulcer, though sometimes they may be
 set in the latter as a watch-crystal is set in its rim.  Unless mechani-
 cally disturbed, they generally remain  till the ulcer is healed.  If they
 are removed, a deep, punched-out, unhealthy, granulating surface is
 exposed, covered with black, sanious pus.
    The bullous syphiloderm is commonly found in broken-down sub-
 jects, and is significant of an inveterate form of syphilitic poisoning.
 The crusted ulcers following bullae or pustules form the typical rupial
 lesion.  The  crusts  of rupia are large, and  are thicker and darker
 than those of any of the syphilides.  The ulceration involves the
 entire thickness of the skin, and often  extends over a large surface.
   The scars left  by  rupia  are  similar to those of deep  ecthyma.
 The eruption is encountered in the tertiary stage of  the disease, and
 is one of the  most  characteristic lesions of  syphilis.
   The Gummatous  Syphilide.—Though gummata of  the skin
 exceptionally appear in the first six months of syphilis, in  such cases
 indicating a grave form of the disease,  they commonly develop three
 or four years  after  the chancre.
   Gumma differs  from the lesions already described in the fact that
it is a  true tumor or granuloma, which, having once developed, in 
364
GENITO-URINARY DISEASES  AND SYPHILIS.
whatever way it terminates permanently affects the  seat of inva-
sion.
   The favorite localities of the gummatous syphilides are the face,
particularly the  forehead, arms, forearms, the anterior surface of the
tibia, particularly the upper third, the skin overlying the sternum and
clavicle, the scrotum, the penis, the external genitalia of women.

                             Fig. 145.
            Gummatous syphilide.
(From the collection of photographs of Dr. George Henry Fox.)
   Gummata of the skin commonly appear as rounded, painless, sub-
cutaneous nodules, freely movable, and varying in size from that of
a pea to that of a cherry.  These slowly grow, reddening, infiltrating,
and softening the superficial layers of the skin and breaking down to
form  deep,  undermined, sloughing ulcers.   (Figs. 145, 146, 147.)
Sometimes the gumma begins as a circumscribed infiltration of the
skin instead of a distinct subcutaneous tumor.
   The gumma goes through the stages of: 1. Formation, usually
of long duration and unattended by pain.   2. Softening, fluctuation
being felt when the tumor has reached its full size (from that of an
almond to  that of  a  hen's egg).  3. Ulceration;   the skin becomes
discolored and perforated, and a small  quantity of puriform, gummy
liquid is  discharged.  4. Reparation;  after  extrusion of the slough
granulations form, growing centrally from the periphery of the ulcer.
   When the gumma  opens there is at once an escape of mucilagi-
nous  liquid.    The partially  disorganized infiltrate adheres by its
deeper portions to the  subcutaneous cellular tissue,  and  is subse-
quently thrown off in the form of sloughs. By the process of ulcera-
tion a number of contiguous gummata may coalesce, forming  one
huge cavity, with irregular sloughing walls. 
                   CONSTITUTIONAL SYPHILIS                oo~
                                                                obo
   Though  the  stage  of formation is slow and painless, the patient
often  noticing the  tumor only by accident,  softening and ulceration
may progress with great  rapidity.  Thus,  Bassereau  states  that a
Fig. 146.
Fig. 147
Single ulcerating gumma.
Ulcerating gummata becoming confluent.
  (From the collection of photographs of
      Dr. George Henry Fox.)
small,  indolent, subcutaneous  nodule of  the  nose  or ear has  in  a
single  night undergone  extensive destructive  ulceration,  producing
permanent disfigurement.
   The gumma may be single or multiple.  In  the latter case there
are rarely more than half a dozen.  (Fig. 148.)   Exceptionally several 
366        GENITO-URINARY DISEASES AND SYPHILIS.

dozen may develop, either simultaneously or following one another,
usually  showing  a circular  or  circinate  grouping and  exhibiting a
tendency to coalesce, forming a  diffuse infiltration, which on  ulcera-
tion may discharge by several openings through the blue undermined
skin.
   The middle of the forehead  is a favorite seat  of gummata.  One
or several nodules may develop.   They commonly involve the under-

                             Fig. 148.
lying  bone, producing caries, which  may extend through its  entire
thickness, exposing the dura.   Exceptionally there  develops a deep
and diffuse infiltration of the face, causing great thickening of the skin
and presenting the appearance of leontiasis.  Acute  inflammation of
this infiltrate is  especially liable to occur in drunkards, and  leads to
extensive destruction of  tissue  and  consequent deformity,  and ex-
ceptionally  to violent hemorrhage from erosion of blood-vessels. 
CONSTITUTIONAL SYPHILIS.
367
Fig. 149.
These gummatous infiltrations are sometimes transformed to tuber-
culous or cancerous lesions.
    Gummata of the extremities  may  be single or multiple.  As  they
appear on the leg they are commonly multiple, and have for their seats
of predilection  the  anterior and lateral surfaces of the  upper third
and the  malleolar regions.   When
placed here they break down readily
and are subject to infectious inflam-
mations.   (Fig.  149.)  They are  ex-
tremely obstinate to treatment, and
ultimately assume the  chronic  in-
durated appearance of ulcers  due to
other causes, particularly when they
are near the malleoli.   (Fig.  150.)
Gummatous syphilides  when they
develop over the clavicle and ster-
num  are   often  associated  with
underlying  periostitis  and  ostitis.
Because  of  this, when  they have
ulcerated they are difficult to cure.
    The prepuce may be affected by
either diffuse gummatous infiltration
or  individual  nodules.    In  either
case  the  diagnosis from  primary
lesion can  be made from the fact
that infiltration preceded ulceration.
Single ulcerating gummatous lesions
of the glans penis may exactly simu-
late chancre.  The  inguinal glands
do not, however, share  the charac-
teristic enlargement  of  the  primary  lesion,  and  the development
of the lesion and the history of the  case usually point  to the  true
diagnosis.
   The gummatous ulcer may  become serpiginous or phagedenic.
The  necrosis involves  not only  the  imperfectly organized,  round-
celled infiltrate of gumma, but also the anatomically associated  tissues,
often  exposing and eroding bone, destroying tendons and muscles,
opening mucous channels, and resulting in disfiguring and disabling
cicatrices.  In the scrofulous,  gummatous ulcers are particularly per-
sistent.  Exceptionally  these   ulcers  exhibit papillary  outcroppings
presenting an appearance much  like that of epithelioma.   From the
scars of these ulcers epitheliomata sometimes develop.
Sloughing gumma of the leg. 
368        GENITO-URINARY DISEASES  AND SYPHILIS.

   Diagnosis.—A history of syphilis, or concomitant signs of the dis-
ease, and the typical development of a painless infiltration at the seats
of predilection, should  establish the diagnosis of  gumma.  As this
lesion is a late tertiary symptom, it may stand alone as an expression
of the constitutional disease, since too often a clear history is wanting
both of preceding syphilis and  of the mode of onset of the gumma.
     Ulcerating gummata of the malleolar region.
(From the collection of photographs of Dr. George Henry Fox.)
When the tumor is seen during the stage of infiltration it may simulate
benign tumor or sarcoma so closely that diagnosis can be made only
by the therapeutic test or by keeping the growth under  observation
a sufficient  length of  time  to  note  its mode of development.  The
alleged cure of sarcoma by mercury  clearly shows  the  difficulty in
making a correct diagnosis from one examination.
   When the gumma has ulcerated and exhibits papillary outgrowths
it may resemble epithelioma almost exactly.  The mode of onset is,
however, different, epithelioma beginning as a wart or an ulcer, and
not as an infiltration.  Microscopical examination of  a portion of  the 
CONSTITUTIONAL SYPHILIS.
369
removed growth and the effect of specific treatment should definitely
and promptly settle  the diagnosis.
   The cicatrices of healed gummata are depressed and adherent to
deeper structures.

   SYPHILITIC AFFECTIONS OF THE APPENDAGES OF THE SKIN.
   Syphilitic Alopecia and  Onychia.—Syphilitic  alopecia  ap-
pears with the early  secondary symptoms,—i.e., about the third month
from the development of the  chancre ; it may develop much later.
There may be total  or partial loss  of the hair.  Total loss  is rare.
Partial loss may develop  in the form of a general shedding, the hair
coming out readily and the resultant appearance of the scalp simu-
lating that of advancing baldness from  other causes.   More charac-
teristic is the shedding of hair in irregular, usually rounded, scaling
patches, giving the scalp a typical moth-eaten appearance.  Both the
general  and the  circumscribed alopecia are often  associated  with
papular and papulo-pustular lesions of the scalp.  As has been stated,
the prognosis of these forms of alopecia is favorable, the hairs grow-
ing again on the  absorption  of the infiltrate which  interferes with
their nutrition.
   Circumscribed alopecia due to ulcerating and tubercular syphilides
is permanent, since the  lesions entirely destroy the  hair-follicles.
(Fig. 151.)
   The  diagnosis of specific  alopecia is founded on  the  rapidity of
the process, the history of syphilis  and associated symptoms of the
disease, and the patchy, moth-eaten appearance of the scalp, the bare
spots showing prominent follicles and a scaling  surface.  When the
alopecia is partial,  shedding  of the hair is  most noticed over the
posterior portions of the  scalp, thus differing  from ordinary baldness.
   In addition to.  vigorous  constitutional  treatment,  shampooing,
massage, and active  counter-irritation are indicated.
   Onychia  is due to the influence  of  the syphilitic poison on  the
matrix of the nail and on the periungual and subungual  epidermic
tissue.  The term paronychia signifies  that the  tissues surrounding
the nails are  involved  primarily.   The  nails become dry,  brittle,
lustreless, and break  on  the least pressure (friable onychia).  They
may be fissured and loosened from their matrices, to be finally shed
completely, giving place to a new naih   Sometimes the  nail becomes
greatly discolored, thickened, and distorted (onychia hypertrophica).
   These forms of onychia are  usually observed in the early secondary
period of syphilis. They are painless, non-inflammatory, and produce
no permanent deformity,  the new nail-tissue being healthy in  appear-
                               24 
370        GENITO-URINARY DISEASES AND  SYPHILIS.

ance  when active constitutional treatment has  succeeded  in  over-
coming the specific virus.  The nails of the fingers are more frequently
attacked than those of the toes.
   The treatment is constitutional.   Local treatment, except cleanli-
ness and protection, is without effect.
   Paronychia, or inflammation in the tissues around the  nails, may
be dry or moist
   The dry paronychia, or non-ulcerative form of the affection, is

                               Fig. 151.
    Syphilitic alopecia following ulcerative lesions.
(From the collection of photographs of Dr. George Henry Fox.)
commonly associated with the papular syphilides.  It  begins either
as a papule which  involves  the cutaneous folds, occasioning horny
thickening and exfoliation of the  epidermis,  or as an infiltration
surrounding the nail, much  as  would an  ordinary " run-around,"
except that it  is chronic  in  its course, painless, and exhibits a deep
coppery color.   In either  case the nail is often brittle, cracked, and
deformed.
   Moist paronychia, or the  ulcerating form of the affection,  is often 
CONSTITUTIONAL SYPHILIS.
371
associated with the vesicular or  pustular  syphilides.   It  begins  as
in the dry form, but goes on  to  ulceration, the  infiltrate  becoming
fissured  and  suppurating.   As a result there  is  found about the
periphery of the nail, and frequently undermining it, an unhealthy
ulcer, the granulations of which may become exuberant.  There may
be swelling of the extremity  of the digit as  marked as that observed
in felon.
   Diagnosis.—The diagnosis of syphilitic  paronychia is founded  on
the painless, chronic  course of the affection, the  absence of acute
inflammatory symptoms, and the presence of other signs of syphilis.
   The  nail is frequently shed, and, if the ulceration has been suffi-
ciently deep to destroy the matrix, will not be reproduced.  It usually
grows again, but is shrivelled and deformed.   The infiltrate may
remain for many months.
   Treatment.—The treatment of ulcerating  paronychia is primarily
that  suited to the  management  of secondary syphilis.   The local
treatment must be  conducted on general  surgical principles.  Pro-
longed  immersion  in  weak, hot bichloride  solution  (1  to  2000),
followed by  the  application  of  moist compresses wrung out  of the
same solution and  kept from drying by the application  of  waxed
paper or oiled silk, will aid in rendering the ulcerating  surface clean
and will promote healing.
   When the  granulations  are indolent and exuberant,  forming a
mushroom-like growth, they may  be  thoroughly  curetted, or their
surface may be sprinkled with dry powdered lead nitrate, an ordinary
gauze dressing being applied over this.   When ulceration has  under-
mined the nail,  the latter should  be trimmed  away sufficiently  to
allow thorough local treatment to be applied to  the  entire diseased
surface.   Iodoform  and aristol are  both useful applications, but only
when they are brought in direct contact with the ulcer.  When cica-
trization has taken  place, careful strapping with thin strips of resin
adhesive plaster, repeated daily,  will encourage the formation of a
symmetrical  nail.

         SYPHILITIC LESIONS OF  THE  MUCOUS MEMBRANE.
   The  mucous membrane  manifestations of syphilis correspond  in
pathology and general features with those appearing on the skin, the
difference depending  upon increased vascularity, diminished resist-
ance to extension and ulceration  on the  part  of the  surrounding
macerated mucous  membrane, and a greater or less degree of irrita-
tion  incident  to  secretions which are constantly brought in contact
with the lesions. 
372       GENITO-URINARY  DISEASES AND SYPHILIS.

   Erythematous  Syphilide.—This attacks the throat, the vagina,
the urethra, the glans penis, and the inner surface of the foreskin.  It
may  develop  on any mucous surface of the respiratory, digestive, or
genito-urinary tract.  As in the case of the corresponding skin erup-
tion,  the lesions first appear as discrete spots ; these become confluent
in a  few hours,  exhibiting then  a somewhat sharply circumscribed
circinate margin.
   The mucous membrane of  the throat is  most frequently attacked,
the patient suffering from syphilitic angina, which  may assume the
acute or the chronic  form.  The hyperaemia and oedema involve the
pharynx, tonsils, half-arches, and  soft palate, but  rarely extend to
the hard palate, though the latter may exhibit discrete macules.
   So quickly does the  macular eruption of the mucous membrane
become confluent that,  when first observed, the lesions depending
upon their location closely simulate simple sore throat, balanoposthitis,
vaginitis, or urethritis.   It is most important to recognize the syphi-
litic nature of such lesions, since they may appear before other more
characteristic secondary symptoms, or as the only manifestation of
the disease, and since their discharges are contagious.
   Diagnosis.—The  diagnosis  will usually be founded on associated
signs or symptoms of syphilis, and on the absence of a cause for
simple inflammation. There is  nothing typical  or characteristic in
the local appearance.
   Papular  Syphilide.—The papular  eruption upon the mucous
membranes may appear as a denudation or erosion, as a circum-
scribed  diphtheroid  patch, as a vegetating  papule, as  a superficial
ulceration, or as a scaly patch.  These lesions are more prone to re-
cur than the  homologous lesions of the skin, and are more  obstinate
to treatment.
   They are  exactly simulated by the papular  syphilide,  as it de-
velops about the  mucous  orifices, on  the scrotum,  beneath the
breasts, or  in any  region where heat,  moisture, and friction modify
the eruption.
   All forms of papular eruption are  classed under the  general
heading  of mucous  patches,  though this  term  is  often limited to
lesions covered by a gray-white pseudo-membrane or to  the  later
scaly eruption of the mucous membrane.
   The papular erosion appears in the form of oval or rounded, small
or large, infiltrated patches, exhibiting a raw-ham color, denuded of
epithelial covering, and  showing a  smooth, glistening surface.  It is
usually  placed on the dorsum of the tongue, and  associated with it
are found fissures of the borders of the  organ, and mucous patches. 
CONSTITUTIONAL SYPHILIS.
373
It is particularly  common in inveterate smokers and hard drinkers;
and, indeed, this is true of all the mouth lesions of syphilis.
   The diphtheroid papule, the commonest form of the mucous patch,
appears as a small or large, discrete or confluent papule covered with
a tightly adherent, gray-white pseudo-membrane, which on being re-
moved leaves a bleeding surface.   The diphtheroid membrane is but
little elevated above the level of the surrounding healthy surface.   It
is somewhat sharply defined from  the latter by a narrow hyperaemic
zone often  exhibiting  the  dusky-red coloration  of syphilitic  lesions.
There may be central  absorption of the infiltrate and  healing in this
portion of the lesion while there  is extension at the periphery, thus
producing ring-like and serpiginous figures.
   This form of mucous  patch is generally found  on the mucous
membrane  of the  cheeks  and lips and  at the angles of the  mouth,
where  it becomes  fissured, on the sides, under surface, and fraenum
of the  tongue, on the  gums, and on the soft  palate,  half-arches, and
tonsils.
   The lesions may be attended with Assuring, with superficial ulcera-
tion, and, when situated on the  tonsils, with deep  and destructive
ulceration.   Under these circumstances they may become extremely
sensitive, interfering with  eating or drinking, or even  speaking, and
occasioning an annoying flow of saliva.
   When the  mucous patch is undergoing  involution, either under
the influence of constitutional or local  treatment or spontaneously,
and  loses its diphtheroid  covering, it presents the  appearance of a
papular erosion, then heals over, exhibiting a temporary pigmentation.
   When these diphtheroid  papules become  distinctly inflammatory
in type they may react  upon the anatomically related lymphatic glands,
producing enlargement, and in some cases, from  mixed  infection,
suppuration.
   The vegetating papule exhibits  the  tendency towards local hyper-
trophy which is sometimes a marked feature  of syphilitic lesions.
   The infiltration common to all  the lesions of syphilis is in the case
of this manifestation of the disease particularly well marked; in addi-
tion, the papillae of the mucous membrane are greatly hypertrophied ;
there results a raised  lesion, which is in reality an infiltrated papil-
loma, varying in size from that of a split pea to that of a half-walnut.
   The surface of this lesion may he covered with a gray-white false
membrane,  or may present an eroded appearance.  The lesions have
a marked tendency towards  peripheral extension, and  when  several
are placed near together these are  likely to become confluent.
   The vegetating papule is comparatively rare  upon mucous  mem- 
 374        GENITO-URINARY DISEASES AND SYPHILIS.

 branes.  It is commonly encountered about the vulva in women  and
 in the anal region in men.   From infiltration the surface upon which
 these lesions are placed loses its elasticity, so that rhagades or fissures
 are likely to occur.
    Superficial  ulcerations  are frequently associated with the vege-
 tating  papules; these represent infiltration  in which there has been
 destruction of  tissue, a distinct,  punched-out, freely secreting ulcer
 occupying the  site of a lesion which in its  early stages presented the
 appearance of a vegetating papule.  This ulcerating lesion is more  fre-
 quently encountered upon the skin than upon the mucous membranes.
    Papulo-Squamous Syphilide.—The scaly patches (mucous psoriasis,
 opaline plaques) rarely appear in the course of constitutional syphilis.
 They are rounded  or irregularly shaped, flat, smooth, bluish-white
 patches, such  as  would  result from  lightly brushing a surface with
 strong silver nitrate solution.  The white coloration is due to changes
 in the  epithelium, consequent on chronic irritation and inflammatory
' infiltration.  The normal columnar cells  are  replaced by squamous
 epithelium arranged in many layers, producing a species  of cornifi-
 cation  identical with that described when considering the pathological
 changes incident to chronic urethritis ; as the thickening is greatest at
 the centre and becomes less marked towards the periphery, so the
 color shades into that of the  surrounding mucous membrane.  The
 thickened  epithelium  is itself adherent to the  underlying surface,
 but its  removal does not occasion bleeding.  Frequently the  central
 thickened epithelium exfoliates, while the lesion  extends peripherally,
 leaving either  a  surface of hypertrophied and  infiltrated papilla?, a
 distinct erosion, or even healthy mucous membrane  surrounded by a
 white ring of epithelium.  From confluence of such patches curious
 markings are sometimes observed on the tongue.
    This lesion is most  frequently observed  on the buccal mucous
 membrane, along the  alignment of  the  upper and the  lower teeth
 when the jaw  is  closed, the patches usually being more or less con-
 fluent.  It also develops on the  inner surface  of  the lips, and on the
 dorsum, sides, and under surface of the tongue.
    As  with other lesions of syphilis, there is  little pain excited  by
 white scaly patches, except where they are associated  with fissures
 and ulcerations.
    Unlike the other forms of papular eruption, the scaly patch usually
 denotes a late stage of the disease.  It may develop at any time in the
 late secondary  and  tertiary periods, and is usually exceedingly obsti-
 nate to treatment.
    Gummata may develop in  tertiary syphilis, both in the mucous 
CONSTITUTIONAL SYPHILIS.
375*
membrane and  in the submucous connective tissue.   They may take
the form of diffuse infiltrations or of circumscribed tumors.
   The mucous gummata appear as small tumors, wdiich rarely reach
the size of a pea before breaking  down, forming punched-out, un-
healthy ulcers, about the circumference of which is often to be  noted
a raw-ham-colored infiltrate.
   These lesions peculiarly affect the hard  and the soft palate, and
often  exhibit a  serpiginous grouping and  a slow extension in one
direction  while  cicatrization  is taking place in the ulcer which first
developed.
   The  submucous   gummata form larger  tumors before breaking
down. They exhibit, however, a marked tendency to soften towards
the surface, producing  deep, punched-out  ulcers  with infiltrated
borders.
   The ulcerating gummata  are responsible for the  stenosing  cica-
trices which may develop in nearly any portion  of  the  alimentary
canal, though they are  most  frequently recognized in the  oesophagus
and the rectum.
   Diagnosis of Mucous Syphilides.—To distinguish the erosive and
diphtheroid  forms of the  mucous  patch from the ulcers of  simple
aphthae is,  from the appearance of the lesions  alone, impossible.
Aphthae, however, are generally more  tender, more liable to be dis-
crete, develop in a day or two, run a rapid course, and, either with
or without treatment, are well in a few days.
   The difficulty in diagnosis is made much greater by the fact that
it is especially in syphilitics that aphthous spots are liable to develop.
Fournier describes a recurrent herpes which attacks the oral mucous
membrane of syphilitics, producing small erosions which exactly re-
semble mucous  patches.   This eruption develops  some years after a
methodical course of treatment has apparently eradicated the syphi-
litic taint.   Specific treatment is absolutely without  effect, the erosions
disappearing spontaneously in a few days and recurring at irregular
intervals.
   In making a differential diagnosis between the  erosive and diph-
theroid forms of mucous  patches, aphthae, and  herpetic lesions, the
history of  the case,  the  presence of other  signs of syphilis, and the
effect of constitutional treatment would all lead to a correct decision.
   The  scaly patches (mucous psoriasis, opaline  plaques) must  be
distinguished from  non-specific  leucoplakia (hyperkeratosis).   The
latter sometimes develops acutely, particularly in women and chil-
dren.  The lesions change  in form and distribution  with such rapidity
that there is little danger of considering the disease specific. 
376        GENITO-URINARY DISEASES AND SYPHILIS.

   The chronic form of leucoplakia may be so  closely simulated by
the syphilitic lesion that a differential diagnosis will be a  matter of
great difficulty.
   The idiopathic  leucoplakia—i.e., that of non-syphilitic drinkers
and smokers—is even slower in development than the specific lesion;
the white  color and the heaping up  of  epithelial cells  are  more
marked and irregular; there is not the same tendency towards central
exfoliation, as the  lesion extends  peripherally,—hence the resultant
ring-like configuration is less common.   In leucoplakia  the lesions are
more often found on the tongue and the lower lip, subjective sensa-
tions are said to be more marked, and specific treatment is absolutely
without avail in effecting a cure.
   The points  of difference by which ulcerating gummatous lesions
of the  mucous membrane  can be distinguished  from the tubercular
and malignant  infiltrations will be considered when  discussing the
subject of gummata in special regions.
   Treatment.—The treatment of mucous syphilides is constitutional
and local, topical applications being much  more distinctly indicated
than is the case with skin lesions,  except when the  latter assume the
form of mucous patches.
   Syphilis of the Tongue.—Chancre is rare upon the tongue, but
when present is usually at or near the tip of this organ. (Du Castel.)
It is of the erosive  type, and presents no peculiarities of development.
   Roseola is rare and  ephemeral.  It  appears in the  form of  slight
desquamative stains.
   Mucous patches are of the erosive, diphtheroid, and vegetating
type; the last variety is rare.  When mucous patches  are numerous
and confluent there is general swelling of the tongue, the latter show-
ing on  its borders  the imprint of the teeth.  Mucous patches placed
along the sides of the tongue—a favorite seat—often exhibit more or
less Assuring, in which case they may be accompanied by much pain.
   The ulcerations of secondary syphilis are usually small and super-
ficial, and are attended with few subjective symptoms  ; even should
they become deep, inflammatory symptoms are not marked.
   Smooth patches (Fournier) are not very perceptible  till the tongue
is dried by a towel or some absorbing  fabric.  They then appear as
smooth,  shining surfaces from which  the epithelium has  entirely
disappeared.   There is  no sign of erosion.  The lesions are  circular
in form, and are grouped in circles or segments of circles.
   This form of desquamating glossitis is found in both  the secondary
and the tertiary period of syphilis.  It at times  precedes the forma-
tion of syphilitic leucoplakia. 
CONSTITUTIONAL SYPHILIS.
377
   Scaly patches (syphilitic leucoplakia) are hardly ever seen except
on the tongues of habitual smokers and drinkers.  They exhibit the
gray-white, circular, circinate, or annular stains  already described,
and  occasion no symptoms  unless  extensive, when  they  may  be
associated with  some stiffness of the tongue interfering with articu-
lation ; there  may also be tingling  and a feeling of numbness.  The
importance of these lesions lies in the fact that they are prone to
become  cancerous.
   The  strictly  tertiary lesions of  the  tongue  may appear either in
the form of a diffuse gummatous infiltration  (sclerous glossitis) or
as circumscribed  gummata.  These gummatous lesions  develop  on
the tongue more frequently than in any other  portion of the mouth.
They are much more commonly observed in  men than in  women,
probably because of the  chronic irritation produced by the use  of
tobacco  and alcohol.
   Diffuse gummatous infiltration, or syphilitic sclerous glossitis, is
really a form of chronic myositis.  It may  be either  superficial or
deep, and may involve part of the tongue or the whole organ.
   The affection begins as a slowly progressive, hard swelling, usually
involving but  one side of the tongue, and producing marked asymme-
try.   When both sides are enlarged there may be £o much  swelling
that the patient will not be able to close his mouth.  This condition
develops with comparatively slight  symptoms.   There is no pain, the
patient complaining only of a feeling of weight and  stiffness, making
articulation somewhat  labored.  After weeks, or perhaps  months,
the swelling gradually subsides coincidently with the  occurrence of
atrophic changes, which produce even greater stiffening and indura-
tion than were present in the early stages of  the affection.
   Examination  of the surface of  the  tongue  then showrs irregular
lobulations, with marked alteration of the mucous membrane. There
are often  smooth,  red  patches, due  to exfoliation of epithelium, or
areas of greatly thickened epithelium, which  may present the typical
white appearance of syphilitic leucoplakia.
   From mechanical irritation by the teeth, cracks,  erosions, and
ulcers are often  formed.
   Circumscribed gumma, or gummatous glossitis, may be superficial or
deep,—that is, it may involve the mucous  or the submucous tissues,
or may start in the substance of the muscles.
   The superficial gummata appear as small, round, hard nodules of
the mucous membrane or submucous connective tissue.  They vary
in size from that of a grape-seed to that of a cherry.   They  occasion
little or no pain, and if not treated by internal medication usually 
378        GENITO-URINARY DISEASES AND SYPHILIS.

soften and  ulcerate,  forming punched-out, indurated,  undermined,
unhealthy ulcers.
   When these gummatous ulcers are multiple and confluent, and
particularly when they are phagedenic in type, they may destroy the
greater part of the tongue,  and may threaten  life from backward
extension of the inflammation and sudden oedema of the glottis.
   The deep or muscular gummata begin as hard, painless tumors,
firmly adherent to the surrounding  tissues.  They are nearly always
placed on  the  dorsum  of the tongue.   They occasion  little  or no
pain,  causing inconvenience  only  from  the  limitation of motion.
They grow  slowly, usually not  softening  and ulcerating for two or
three months.   They vary in size from that of a cherry to that of a
lemon.   When  they  finally  ulcerate,  deep,  punched-out, indolent,
indurated ulcers are found.
   The ulcerating gummata of the tongue, even though deep and
confluent, excite little pain except on  motion,  and,  indeed, all the
symptoms of acute inflammation are absent.  On the healing of the
ulceration there results  a scar, which  may be both disabling and
deforming.
   Diagnosis.—The diagnosis of syphilitic affections of the tongue is
made upon the general principles discussed when treating of syphilis
of the mucous membranes.
   It is particularly on the tongue that the lesions of recurrent herpes
are manifested, and it is here that they are most  frequently taken for
mucous patches or other lesions of  active syphilis.
   Among other affections simulating syphilis of the tongue, such as
ichthyosis and  superficial glossitis,  is a disease  of infancy variously
characterized  as erratic  rash,  circinated herpes, or  geographical
annulus migrans.  The tongue becomes covered with concentric rings
formed by small, red patches.  The senses of taste  and touch are
normal;  sometimes, however, they may be slightly hyperacute.  This
disease may easily be mistaken for  mucous patches or for congenital
syphilis.
   Ulcerating gummata  of the  tongue  may  readily be  confounded
with tubercular or cancerous lesions.
   Tubercular lesions are usually single, and are  seated at or near the
tip or on the dorsal surface of the  organ.  They begin as cracks or
fissures, attended by swelling, and slowly form shallow, jagged, pain-
ful ulcerations, with  non-indurated borders,  which  are  often  sur-
rounded by  minute, pale-yellow points with opaque centres.   These
are tubercular granulations undergoing caseous degeneration.  They
are frequently thrown off by ulceration, and are  never seen in syph- 
CONSTITUTIONAL SYPHILIS.
379
ilis.  Tubercular glossitis rarely appears as an isolated symptom of
the diathesis, the larynx, lungs, or other  organs  generally showing
involvement.   The  tubercle bacillus may be  found  on  microscopic
examination, or may be cultivated by inoculation of guinea-pigs.   The
lesion is slow in its  course, and is not favorably influenced by specific
treatment.
   The gumma begins as a single submucous or muscular mass, open-
ing after a time by  a narrow^ passage, ulcerating and  discharging like
a furuncle, having a sloughing indurated base.
   Carcinoma is generally found at the borders of the  tongue, as a
consequence of long-standing irritation.   It begins as  an erosion  or
ulcer, which subsequently becomes  indurated, may  show about its
borders epithelial pegs, is shortly followed by glandular involvement,
is steadily progressive  and somewhat rapid in its  course, and is fre-
quently very painful.  The  diagnosis may be  obscured, indeed  ren-
dered impossible, by the fact that carcinoma and gumma may develop
side by side.
   The points of difference between carcinoma and ulcerating gumma
are embodied in  the following table (Fournier).
           Epithelioma.
Period of Occurrence.—Chiefly after the
  fiftieth year.
History.—Often cancerous, and preceded
  by lingual psoriasis.
Location.—Often  on  the lateral  and
  under  surface  of the  tongue;  uni-
  lateral.
Number.—Single.
Beginning.—An  irregular,  indurated,
  superficial ulceration, which extends
  rapidly.   Marked induration follows
  ulceration.
Appearance.—Elevated, irregular, evert-
  ed borders; ulcerating surfaces bleed-
  ing rapidly on mechanical interfer-
  ence.  No  cavity resembling abscess.
Discharge.—Profuse,  offensive,   irri-
  tating.
Symptoms.—Lancinating pain often dart-
  ing towards the ear ;  great functional
  disturbance (deglutition, mastication,
  speech, etc.).  General cachexia.
Lymphatic  Involvement.—Submaxillary
  lymphatic  glands progressively en-
  larged and densely indurated.
              Gumma.
Period of Occurrence.—Earlier in life.

History.—Not cancerous.  Not preceded
  by lingual psoriasis.
Location.—Always on  the  dorsal sur-
  face ; may be bilateral.

Number.—May be multiple.
Beginning.—A  thick,  rounded  indura-
  tion, opening  like  a furuncle, and
  leaving a deep hollow ulcer.  Marked
  induration precedes ulceration.
Appearance.—Punched-out,  sharply de-
  fined  edges; sloughing  surface,  not
  easily  excited to bleeding.  Excava-
  tion like an abscess-cavity.
Discharge.—Moderate,  not  very  offen-
  sive.
Symptoms.—Nearly painless ; only slight
  functional disturbance.  No cachexia.
Lymphatic Involvement.—None, or slight
  swelling and tenderness. 
GENITO-URINARY  DISEASES AND  SYPHILIS.
            Epithelioma.                          Gumma.
 Therapeutic   Test.—Specific  treatment   Therapeutic  Test.—Specific  treatment
  useless or harmful.                   curative.
 Microscopic Examination.—Pearly bodies.   Microscopic  Examination.—Embryonal
                                    cells in various stages of granular
                                    degeneration.

    Syphilis of the Palate.—The soft palate, uvula, and half-arches
 usually show the diffuse  or macular erythema of the early secondary
 specific anginas; mucous patches are also frequently found attacking
•these structures.
    Gummata of the hard  palate usually begin in the periosteum, and
 are  found in or near the middle  line  forming elevated,  sometimes
 painful, usually multiple, elastic swellings, which shortly soften and
 ulcerate, exposing  the bone, resulting  in necrosis of the latter and
 in direct communication between  the  cavities of the  nose and the
 mouth.
    When  these gummata  begin on the  oral  surface  of  the palate
 they usually can be detected in time to prevent perforation.
    When, as is  more commonly the case, they develop on the nasal
 side of the palate, there is  often no suspicion of  trouble till a dusky,
 oedematous, circumscribed swelling appears  on  the roof of the mouth,
 which in a very few days shows an opening into the  cavity of the
 nose.   This opening  represents the small end  of a funnel-shaped
 ulcer, which on  examination from  the  nasal side of the  palate may
 be found to be of considerable size.
    The  gummata may be  multiple, and by confluence may produce
 large openings in both the hard and the soft palate.  They sometimes
 develop very rapidly, destroying the uvula and the greater part of the
 soft palate in a few days.  When these ulcerating gummata heal there
 may result great cicatricial deformity, and perforations which can be
 closed only by plastic operation.
    Gummata of the  soft palate develop  slowly,  without pain or dis-
 comfort on the part of the patient.   There  may be a general nodular
 infiltration, or but a single gumma  at one  point.  Ordinarily there is a
 diffuse  infiltrate, which  can  be distinctly felt  on  palpation.   If this
 primarily involves the pharyngeal  wall  of the palate, the only appre-
 ciable symptoms will be stiffness and immobility, which are diagnostic
 signs of considerable value.  These signs can be elicited by exposing
 the  pharynx while  the  throat is being  examined  and instructing the
 patient to  utter some sounds  requiring the assistance of the soft palate
 for their production.  When  immobility is thus detected and is found
 to be  associated with nodular  induration,  the diagnosis of gumma 
CONSTITUTIONAL SYPHILIS.
381
can be made at once.  If the anterior wall is involved, the dark  red,
oedematous, sometimes nodular mucous membrane will  suggest the
nature of the affection.  This diffuse infiltration is prone to ulcerate,
destroying a part or the whole  of the palate and uvula.  The inflam-
matory process is not limited to the soft palate, often extending to the
anterior  and posterior half-arches.  The cicatricial processes follow-
ing ulceration may produce great deformity.   The soft palate may be
partly or totally wanting, or may be adherent to the posterior pharyn-
geal wall, partly or completely  separating the naso-pharynx from the
pharynx; though not adherent, it may be stretched tightly across the
naso-pharynx, having entirely lost its suppleness and mobility.
   Circumscribed gummata of the soft palate may be single or mul-
tiple ; they are commonly placed on the oral surface.  They usually
ulcerate  if untreated, often  causing perforation.  Mauriac has called
attention to the fact that gummatous ulceration involving the velum,
the tonsil, the half-arches, and the lateral wall of the pharynx, and
opening  up the Eustachian tube, often begins in the recess formed by
the juncture of the anterior and posterior half-arches and the upper
surface of the tonsil.  This ulceration may be extensive and rapid,
spreading  wide  of the tonsil and  palato-pharyngeal  fold and even
eroding the carotid artery.
   Syphihs of the Pharynx.—Gummata of the pharynx may be
submucous or subperiosteal.   They usually appear as one or more
hard, painless swellings of the posterior wall.  Softening and ulcer-
ation follow, resulting in deep, punched-out, indurated  ulcers.   When
gummatous ulceration involves both the soft palate and the pharynx,
adhesions  may take place in the  process  of  healing,  which entirely
shut off  the nasal cavity from the mouth; or by involvement of the
half-arches and tonsils the pharyngeal communications between the
mouth and the larynx may be greatly narrowed.
   The late ulcerating lesions of the soft palate and the pharynx are
often accompanied  during their  evolution by pain,  disability,  and
interference with hearing, and may be followed by intractable catarrh
of the naso-pharynx incident to the deformity following cicatrization.
   As a result of this cicatricial contraction the voice may be mark-
edly  altered; deglutition may be difficult;  or the  isthmus of the
fauces may be so narrowed that there will be marked obstruction to
the entrance of air.   Such cicatrices are  almost  pathognomonic of
syphilitic ulceration.
   Gummata of the  pharynx  are  generally associated with tertiary
infiltrations of the nasal or the oral mucous membrane.   The throat
often presents an irregularly ulcerated appearance, and exceptionally 
GENITO-URINARY DISEASES AND SYPHILIS.
extremely chronic,  distinct, punched-out, typical gummatous ulcers
develop, which, if untreated, may extend to the underlying bone.
   The Tonsils.—Gummata are very rarely observed  upon the lips
or cheeks, and are comparatively rare upon the tonsils.
   The ulcerating lesion commonly  observed  on the tonsil and often
considered gummatous  is in reality a vegetating papule, which ulcer-
ates, spreads somewhat rapidly, and may assume  a diphtheroid or
even a phagedenic  type.   The ulceration  is much  more superficial
than is that of gumma.
   Gummatous tonsillitis is characterized by painless,  hard  enlarge-
ment, with little functional  disturbance, except perhaps  some inter-
ference with hearing.   The mucous membrane,  at first stretched
tightly over the swelling, becomes somewhat  less tense  as softening
takes place, and finally ruptures.  Then result one or more punched-
out ulcers with indurated borders and gray sloughing surfaces.  These
may become confluent, involving the anterior half-arches, and may
produce marked deformity when healing takes  place. Cicatricial con-
tractions resulting from  these gummata may cause permanent closure
of the Eustachian tube and interference with hearing.
   Subperiosteal gummata, resulting in caries and necrosis, are most
frequently observed  on the hard palate, the  alveolar  border of the
upper jaw at the insertion of the incisor teeth, and the  posterior wall
of the pharynx.
   The (Esophagus,  Stomach, and Intestines.—It is apparent
from a few reported cases and from  many autopsies that gummatous
ulceration may occur in any portion of the alimentary canal.  It seems
probable,  also, that the mucous  membrane of this tract is  subject
to specific general or local inflammation during the secondary period
of the disease.  Thus the symptoms of catarrhal gastritis or gastro-
enteritis  which are so frequently associated with  syphilitic  fever or
are observed before or during the outbreak of  the first erythema may
be due to the direct effect of syphilis upon the stomach  and  bowels.
The chronic gastritis often associated with specific lesions of the liver
or spleen may also represent a specific infiltration, since it is favorably
influenced by specific treatment.
    The CEsophagus.—The superficial lesions of early syphilis have not
been recognized in the oesophagus.  Deep ulceration extending from
the pharynx is  followed by stricture.   Infiltrating gummata devel-
oping in the submucous connective tissue commonly ulcerate, event-
ually forming incurable strictures.   The diagnosis  during either the
ulcerating  or the cicatrizing stage of the lesion is dependent abso-
lutely on the finding of associated signs of syphilis in the absence of 
CONSTITUTIONAL SYPHILIS.
383
other etiological factors, and on the effect of vigorous constitutional
treatment.   This, if pushed  in the ulcerating or  early contracting
stage, should produce rapid improvement in the symptoms of oeso-
phageal narrowing.
   The Stomach.—In addition to the symptoms of acute and chronic
catarrh,  those  of gastric  ulcer  are sometimes noted.  This, even
though occurring in a syphilitic, may be non-specific  in nature, or it
may be due to  the breaking down of a gumma.  In the latter case it
is likely to be located near the lesser curvature in the pyloric region.
The symptoms of gastric ulcer of syphilitic origin do  not differ from
those of the non-specific ulcer.   The diagnosis must  be founded  on
a therapeutic test, though at least tw'o reported  cases  seem to show
that when the lesion is due to syphilis the pain is greatest at night.
    The  Intestines.—Except the beneficial results  of  specific  treat-
ment, there  is  no feature of acute  or chronic syphilitic enteritis to
distinguish it from non-specific catarrh.
    Ulceration  of the  small  intestine may be due to the breaking
down either of a gumma or of the  lymph-glands of the intestinal
wall.  According to Rieder's researches, ulceration of the bowel is
most  frequent in the  upper portion of the  small intestine.   The
ulcers are multiple and grouped, exhibit the characteristic infiltration
of  gummatous  ulcers, and  are late  tertiary manifestations.   They
involve all the coats  of the bowel.  They may result in cicatricial
stenosis.
    These lesions  offer  no clinical  features peculiar  to themselves.
Their nature can be  suspected  only from associated symptoms  of
syphilis.
    The Rectum and Anus.—About the anal aperture, especially in
women, mucous patches frequently form.   These, from maceration
and from the irritation incident to  defecation, are prone to ulcerate,
forming rhagades and fissures, which, by extending  in depth, may in-
volve  the tissues  of the ischio-rectal space,  forming  deep ulcers  or
resulting in fistulae.  It is important to bear in mind that such lesions
may occur in the secondary stage of syphilis.
    Gummata may develop on or beneath the mucous  membrane  of
the anus  and rectum, or in the surrounding tissue of the ischio-rectal
fossa.   Not infrequently they assume the form of a diffuse infiltration,
producing rigidity of the walls of the bowel,  the mucous  membrane
remaining quite healthy.  This may be followed, if untreated, by ulcer-
ation or interstitial absorption, in either case  resulting in stricture.
    Gummatous ulceration of the mucous membrane usually begins
just about the internal sphincter,  appearing first  as one or  many 
384
GENITO-URINARY DISEASES  AND SYPHILIS.
small nodules, which soften and break down, exhibiting dark gelat-
inous cores.   They finally destroy the overlying mucous membrane,
forming ulcers, which become confluent, extend in area and depth,
and  are  generally accompanied by  inflammatory infiltration of the
muscular coat of the gut, including the  sphincter, thus producing a
narrowing and rigidity distinctly perceptible to the examining finger.
   The ulceration frequently extends upward, other gummata form-
ing and ulcerating.  From the surface and border of these ulcers there
may be  an exuberant  growth  of  granulations,  producing  fungous
masses, which may simulate those of malignant disease.
   Healing is  accompanied by the formation of  scar-tissue, which in
its subsequent contraction often produces tight strictures.
   The perirectal gummata form tumors  which may reach consid-
erable size before involving and breaking through  the mucous mem-
brane.  As a result of the entrance of the bowel contents into  the
cavities of these gummata, ischio-rectal abscesses are formed, ter-
minating  in fistulae.  These fistulae  may be vesico-vaginal, are often
multiple, and  in some cases riddle the entire perineum, even opening
on the surface of the thighs.
   The strictures resulting from cicatrization of recto-anal ulceration
are much more frequent in women than in men.  They are generally
found involving the lowest portion of the rectum, and are often asso-
ciated with vegetating ulcers.
   Symptoms.—The acute or chronic proctitis  often  accompanying
ulceration and gummata of the  rectum occasions a muco-purulent
discharge, a feeling  of fulness in the rectum, and usually moderate
tenesmus.  When  the  ulcers become  fissured and  deep,  burning
pain, tenesmus, and blood-stained purulent discharge  are prominent
symptoms.  The passage of faeces occasions some  suffering, and is
usually followed by bleeding.  When stricture-formation is fairly well
advanced there  will be  constipation alternating with  diarrhoea and
the passage of ribbon-shaped or broken stools.
   The prognosis must be guarded.   Even  if active specific treatment
cures the palpable lesions, there sometimes follows  faecal  inconti-
nence, from atrophy of the sphincter consequent on interstitial myo-
sitis.   Ulcers about the rectum are always  extremely slow to heal.
   Diagnosis.—The lesions of syphilis must be  distinguished from
those of  tuberculosis or cancer.
   The  tubercular ulcer is found  in  persons exhibiting other  un-
doubted  lesions  of tuberculosis.
   Cancer almost exactly simulates infiltrating and ulcerating gum-
mata.  It is more prone early to contract tight adhesions to neigh- 
CONSTITUTIONAL SYPHILIS.
385
boring parts, and is usually placed higher up the bowel than gumma.
Excision and examination of a portion of the growth would establish
its pathology.
   Treatment.—In  addition to general  specific medication, the ulcer-
ating surfaces must be treated carefully.  When ulcerations are slight
and superficial, regulation of the  bowels  and cleansing  injections
repeated  night and  morning may  be sufficient.   Deep  ulcers may
require stretching  of the sphincter  followed by many weeks of rest
in bed, with daily  topical applications suited  to the condition of the
granulating surface.  Strictures can  be benefited only by dilatation or
operation.
25 
CHAPTER  XI.
SYPHILIS OF THE  NERVOUS SYSTEM.--OF  THE EYE.--OF THE  EAR.—OF THE
                        RESPIRATORY  TRACT.

   Cerebral  Syphilis.—There is  no nervous symptom caused by
syphilis which may not be exactly paralleled by a symptom found in
a cerebropathy  from another cause;  in other wrords,  there are no
symptoms pathognomonic of the disease.   Caries of the bones of the
skull, indirectly implicating the brain, produces the same symptoms
whether the caries be tubercular, traumatic, or syphilitic, and pachy-
meningitis, endarteritis, and cerebral growths cause similar symptoms
regardless of their etiology.
   Etiology.—A nervous  temperament seems to predispose to the
development of  brain-lesions, though  from this it  must not be under-
stood that brain-workers are more  prone to suffer from this form of
the disease than are others.  The conditions which certainly predis-
pose to the development  of brain-symptoms during the course of
syphilis are  absence of a sufficiently long and thorough course of
specific treatment during  the secondary and the early tertiary period
of the disease,  alcoholism, or  hereditary neurosis.  The rheumatic
diathesis, traumatism, prolonged worry or anxiety, and exposure to
heat are also held to favor the same result.
   In the large majority of cases in which syphilis attacks the nervous
system, it does  so in the absence of any obviously sufficient cause,
and  " simply," as  Mauriac says, " because, forsooth, it  pleases it to
do so.11
   Mauriac and  Broadbent among others have observed that in cases
of cerebral syphilis  the  primary lesion and  the early manifestations
are more than  likely to  have  been quite insignificant; no positive
conclusion, however, can be based upon this observation, because no
one w7ould maintain the truth of its converse,—viz., that because the
secondary lesions or manifestations were severe, no invasion of the
nervous system  would follows   The  probable reason  why syphilis
attacks the nervous system after a light secondary  stage is that, on ac-
count of its mildness, a sufficiently vigorous and prolonged mercurial
treatment was not enforced.  Violent  nervous disturbances occurring
at the time of the secondary eruption and disappearing with it do not
necessarily indicate a future determination of the  disease to the brain
     386 
SYPHILIS OF THE NERVOUS SYSTEM.
387
or the spinal cord ;  but if these disturbances increase after the disap-
pearance of the cutaneous eruption, or if after disappearing they re-
appear, the prognosis as regards cerebropathies must be guarded.
   Time of Appearance.—Cerebral syphilomata  are the  most  pre-
cocious of  all the tertiary  manifestations; the nervous  centres  may
be attacked  at any period of the disease after the  beginning of the
secondary  stage.  The average time, however, for their appearance is
in the third  and  fourth  years after infection, but they may manifest
themselves even  as late as eighteen years after the infecting chancre.
Later than this they are of greater rarity.
   Pathology.—Brain-lesions  of  syphilis may  appear  as areas of
sclerosis or of softening and atrophy, or gummata may  develop.  In
either case the pathology is the same.  There are cellular prolifera-
tion  and formation of vascularized granulation-tissue, usually diffuse
in the case  of the central nervous system  and its  meninges, and
ultimately  resulting in atrophy and sclerosis.   Exceptionally cellular
proliferation is circumscribed and extensive,  forming gumma.  As-
sociated with these changes,  or  developing independently of them,
syphilitic arteritis is a prime factor in  the causation of brain- and
cord-lesions.
   Gummata are formed with far less frequency in the cerebral tissue
proper than in the bones of the  skull, or in  the  meninges or the
subarachnoid space.   When they  form, however, they assume  the
same general appearance  as  elsewhere.  They are seldom  smaller
than a pea or larger  than  an egg, are very consistent, with a caseous
dry core, and are surrounded by highly vascular cerebral  tissue  con-
taining numerous embryonal connective-tissue cells.
   Gummata are commonly found in groups of three or  four;  they
may be single or multiple.   Although they may be found throughout
the brain,  they usually grow from  the dura mater or the subarach-
noid space at the base of the cerebral hemispheres near the pituitary
body, or on the convexity about the frontal convolutions.
   It is at  times  extremely difficult to distinguish a large tubercle of
the brain  from gumma.   The symptoms will be the same.   An au-
topsy shows the  tubercle as a somewhat regular and sharply defined
tumor, with no extensions  into the surrounding tissue, frequently ex-
hibiting miliary tubercles  about the periphery, and at times having
undergone almost  complete caseous degeneration.  These are char-
acteristics  never  observed in gummata.  The vessels in  the tuber-
cular mass are obliterated ;  in large gummata  the vessels, even to the
centre, are  pervious.   Tubercle is  found far more frequently in  the
young, and is usually associated with miliary deposits elsewhere in 
388        GENITO-URINARY DISEASES AND SYPHILIS.

the body.   Nowhere  else,  however,  have these two lesions such
similarity as in the brain.
   Gumma-formation in the brain is not a rapid process; it increases
slowly up to a certain point, and then  remains a long time  station-
ary unless  by  its size the gumma occludes blood-vessels and there-
upon  sets  up  a passive  hyperaemia or ischaemia with consequent
softening, which is  the  natural tendency of all  such neoplasms.
Under antisyphilitic  treatment,  however, gummata may be appar-
ently  absorbed, or  at least checked, and  then,  not  infrequently, a
post-mortem discloses on  the surface of the brain characteristic cica-
trices or depressions, which are the remains of the pre-existing gum-
mata, of which the patient had been apparently cured for many years.
   Intracranial syphilitic  processes  never  involve  the entire tissue
wherein they  are situated, but  are  apt to  develop from several foci
situated on any of the intracranial tissues.   They seldom attain a large
size, and even the  pseudo-membranous patches  of the dura mater,
which are more diffuse or extensive than gummata, never cover com-
pletely the  surfaces of the membrane over  the hemispheres, wherein
they differ from the ordinary congestive and inflammatory processes.
   Syphilitic  processes in general are  far more frequently found on
the surface of the brain and on the meninges than  deep in the cerebral
substance.  Their most frequent seat is on the frontal portions and on
the base of the brain in the sphenoidal region.
   In addition to the gummatous and sclerotic lesions, which are the
direct product of syphilis, there are  lesions  dependent on  inflam-
matory or ischaemic processes,—the sequelae of syphilitic endarteritis.
This  endarteritis brings  about  a narrowing  of  the  calibre of the
vessels, producing a  lessened  blood-supply and  consequent inter-
ference with function.  As this narrowing increases, thrombosis may
occur, with complete obliteration, in  consequence of which, if the
vessel affected is a terminal artery, the portion of the brain supplied
by this vessel  degenerates.  When the  basilar arteries are involved,
the free collateral circulation prevents any symptom, even though the
process has advanced to the formation of thrombosis.  From this
clot, however, an embolus may be  loosened, which will produce the
same  symptoms as a cerebral embolism occurring  in the course of any
other disease.
   The degeneration of the arteries, whether caused by syphilis direct
or by the proximity of syphilitic lesions, is perhaps the most important
factor in the cerebropathies of syphilis, particularly in regard to soft-
ening and hemorrhages.  When syphilis attacks the bones of the skull
there  may be cerebral symptoms, caused either by an actual infection 
SYPHILIS OF  THE  NERVOUS SYSTEM.
389
of the brain or by a mechanical  compression arising from a gum-
matous formation or by the presence of pus between the  bones of
the skull and the dura mater.  It  is rare that the brain-substance at
the point of osseous lesion is not affected.
   Of the envelopes of the brain the dura mater is the most frequent
seat of syphilitic lesions, not only because they are prone primarily to
develop  here,  but also because the osseous lesions implicate  this
membrane.
   In the patches of chronic syphilitic pachymeningitis there is little
to characterize as specific;  in all  respects  they resemble patches of
pachymeningitis produced by any other cause.   W7hen situated on
the  upper surface of the  membrane these sclerotic patches can in-
volve large areas without giving  rise to appreciable symptoms, but
when situated in the membrane surrounding the canals of exit of the
nerves they become highly dangerous.
   Gummata of the dura mater may occur on either surface  of that
membrane, and are round in shape, of firm consistence,  sometimes a
little soft,  almost  never liquid.  One or more may be present, from
the  size of a millet-seed to that of an egg; they are grayish in color,
with a firm centre.  The adjoining nerves are atrophied, and the arte-
ries  may be not only obstructed by compression  but invaded by the
gummatous material, or even obliterated. Obliteration of the carotid,
middle meningeal, and basilar arteries  has been noted.  In a case
of gumma of the  tentorium cerebelli all  the sinuses bordering on the
torcular Herophili wrere obliterated (Dowes).
   Syphilomata of the arachnoid  are rare, and appear as opalescent
spots more or less thickened.  They are  either  diffuse or grouped
in compact masses in the centres of which  are  gray degenerations.
True gummata are very rarely found.
   The  pia mater is the  cranial tissue wherein the  development of
syphilitic meningitis is by  far the most frequent.
   From this membrane the greater part  of the  sclerotic  and gum-
matous changes start, subsequently  invading the other portions of
the encephalon.  The lesions are more often of a  fibro-cellular char-
acter than gummatous,  and  assume the  form of plates. or bands,
following the course of vessels, most  frequently along the edge of the
fissure of Sylvius.  They consist merely of opalescent patches, with
a slight  thickening of the  membranes.   Their tendency  to  extend
along the  vessels or nerves  often  produces symptoms of circum-
scribed ischaemia  and cerebral malnutrition, as  well as  neuralgias
and  paralyses of certain nerves.  The motor nerves of  the eye  and
the fifth  pair are most liable to be  thus affected. 
390       GENITO-URINARY  DISEASES AND SYPHILIS.

   The post-mortem appearance of these lesions shows a close union
of the membranes of the brain, with perhaps a slight adhesion to the
cerebral cortex.  True  gummata in the pia mater are not quite so
common as in the dura; they may attain large size.  They are most
frequently found in the frontal  regions and at the base of the brain
near the sella turcica.  Small gummatous nodules also form along the
arteries, and impinge not only on the brain but on the arteries them-
selves, at first obstructing their lumina and afterwards obliterating
them, thus producing ischaemia of the brain.
   The nerves of the membrane may likewise suffer and become
atrophied by compression.
   The  arteries of the brain  are always more or less implicated,
either primarily or consecutively.
   Wlien they are themselves the seats of syphilitic degeneration they
influence the nervous system directly by means of aneurismal dilata-
tion or by hemorrhages which press upon the brain-substance.   Indi-
rectly, syphilis of the arteries can  affect the brain by narrowing the
lumen of the  vessels and by destroying their elasticity, thus cutting
off the  blood-supply; all  the symptoms of  cerebral ischaemia there-
upon follow.   A thorough post-mortem microscopical examination is
sometimes required to reveal the numerous miliary aneurisms along
the smaller arteries and capillaries or the obliteration of these ves-
sels.  Syphilis, then, may attack the brain in the form of:
   1. Diffuse gummatous infiltration of the meninges, with extension
to the brain-substance.
   2. Gummata, or circumscribed tumors.
   3. Endarteritis, with its concomitant brain-lesions.
   . Symptomatology.—An examination of the symptoms of syphilis of
the cerebrum and of its  envelopes  must include all  known  symp-
toms.   But, while there  exists no  one pathognomonic sign  to serve
as a guide, there  are,  nevertheless, groups  of symptoms, subjective
or objective, which are fairly distinctive.
   In general, syphilitic neuroses are characterized by multiplicity and
incoordination of symptoms of either gradual or rapid development.
   Except headache, disturbances of sensation, wdiether neuralgias or
anaesthesias, are not commonly due to syphilis when they predom-
inate over the other symptoms.  On the other hand, disturbances of
motility are frequent.   Cerebral syphilis will inevitably, sooner or
later, if left to itself, develop a paralysis or paresis.  The neurosis
may be at first revealed by epileptiform convulsions, but eventually
paresis  sets in, together with  other symptoms of cerebral softening,
rapid loss of memory, and weakened cerebration. 
SYPHILIS OF THE NERVOUS  SYSTEM.
391
   As  a prodromal  symptom  headache is chiefly  characteristic.
This varies greatly in intensity.   It is worse at  night, and is usually
constant, is deep-seated and extremely harassing, and is accompanied
by a certain failure  in mental  power, a  lack of ability to concentrate
the attention, and a  condition of nervousness characterized by marked
excitement from trifling  causes.  There are often vertigo, insomnia,
and profound mental depression.
   When the syphilitic process is circumscribed, as in the case of a
gumma or of an aneurism due to syphilitic  arteritis, the pain is re-
stricted to a limited  area, and is described as like that of a nail being
driven into the head.  When patches of sclerosis are extensive, the
cephalalgia may cover all one side of the head.
    Fournier has described this symptom and its indications as fol-
lows : Pain in the head is one  of  the most frequent manifestations of
secondary syphilis.   The prodromal headache  of tertiary encepha-
lopathies is  universally recognized.   It  is unfortunate that the  term
specific cephalalgia  conveys the  impression  of  a single pathological
process, when, as a  matter of clinical fact, the  lesions  are  often
widely diverse in their nature.  The single  symptom common  to all
is pain in the head.
    Aside from syphilitic  affections of the brain and its meninges, the
true specific encephalalgias, the pain may be  due to the specific poison
affecting one or more of  the cranial nerves, constituting what may be
called neuralgic headache.  Or it  may be due to lesions of the cranial
bones, such-as periostosis or gummatous osteoma, causing bone pain.
Or it may develop as bone neuralgia without demonstrable lesion, in
which  case it is  often impossible to locate  it.  In  many respects  it
does not differ from headaches  due to causes  other.than syphilis.
Finally, there  is  a  headache  which,  though dependent on syphilis,
is not syphilitic in  nature;  in other  words, it is a  parasyphilitic
neurosis.
   Syphilitic neuralgias  are not  headaches in the true sense of the
word; the pain is located in the trunk  or branches  of distribution of
a given nerve, and is aggravated by pressure along the course of this
nerve, particularly at its  point of emergence from  the bone.   This
pain most frequently attacks the fifth pair, and has for its type supra-
orbital neuralgia.  It is  observed during the early stage of the sec-
ondary period,—that is, in the  first six or eight months of the disease.
It is impossible to state whether or not  it is dependent upon organic
lesion.  When it occurs during the  tertiary period it is nearly always
due to a distinct  infiltration ;  sometimes it is caused by the pressure
of a gumma or bony outgrowth.   These specific neuralgias exhibit 
392       GENITO-URINARY DISEASES AND SYPHILIS

almost the same symptoms that distinguish neuritis from other causes.
They have, however, a tendency to become worse at night, and yield
promptly  to specific treatment.  Indeed, the therapeutic test is the
only means of making a positive diagnosis.
   Headache from Bone-Lesions.—Pain due to bone-involvement may
occur in the early stages, during the height of the disease, or at a late
tertiary period.  It is most  frequent in the tertiary period,  and is
then  readily recognized, since the lesions are  gross, producing con-
siderable deformity.
   Secondary lesions  are slight,  circumscribed,  and readily  over-
looked, especially when they develop in the hairy scalp.   They occur
during this early period as periostitis, periostosis, or ostealgia char-
acterized by circumscribed areas of hyperaesthesia without appreciable
infiltration.  These lesions are very common, especially in women.
   The periostites produce slight circumscribed swelling of the bone,
particularly in the parietal, temporal, and frontal regions.  The in-
volved areas are small,—about the size of a  ten-cent piece, some-
times as large  as a fifty-cent piece,—very slightly raised, sometimes
obscurely fluctuating.   They are  painful  and extremely sensitive.
This excessive sensibility is a characteristic sign.
   Periostoses  give the same symptoms, and are even more painful.
They are, however, more  dense and resistant and last longer.  There
is true bony proliferation.
   The ostealgias  are characterized solely  by pain and  tenderness.
There is neither swelling nor appreciable alteration of any kind.  The
pathological basis of this symptom is absolutely unknown. The pain
is sometimes agonizing,  and often radiates over a large surface.  The
diagnosis is founded upon careful and thorough palpation of the entire
cranium.
   Headaches due to syphilitic affections of the brain  or its enve-
lopes are more diffuse and more deeply placed than those dependent
upon bony lesions or  upon neuralgias.  It is impossible from the
symptoms to decide whether they are  caused by lesions of the  me-
ninges, of the cerebrum, or of the blood-vessels, or whether all these
structures are involved.
   Clinically, three varieties are recognized:  1, secondary  enceph-
alalgia; 2, headache symptomatic  of cephalic lesions ; 3, parasyphilitic
headache, due to hysteria or neurasthenia.
   Secondary syphilitic headache,  which develops  during the early
periods of this  stage of the  disease, is very  common, especially in
women; indeed, in  them when  untreated it  is usually severe  and
prolonged. The pain is felt within the head.  It is general, but especially 
SYPHILIS OF THE NERVOUS SYSTEM.
393
severe in the regions of the forehead, the temples, and the occiput.  The
pain maybe described as a feeling of weight in the head, or a beating,
or a sense of pressure;  sometimes  it is lancinating or tearing, as if
the  cranium were about to burst.   The pain varies greatly in inten-
sity ; it may be slight, bearable, not interfering with the pursuits of
life; or as severe  as an  ordinary migraine, preventing work, particu-
larly that requiring much thought, and  disturbing sleep ; or agonizing
and absolutely unbearable.
   Associated with the headache there are usually diminution of ap-
petite, disordered  digestion, general malaise, nervous  erethism, great
excitability, and sometimes disturbance of vision, with vertigo.  The
patient becomes morose, melancholic, stupid, and forgetful.
   These headaches  may assume the  intermittent type  or the con-
tinuous type with  exacerbations.  The intermittent type is most fre-
quent, especially in the  slight  forms and  those of medium severity.
The pain usually comes  on at about five or six o'clock in the evening
and disappears during the night, often recurring at the same hour and
in the same form day after day and following the same course.
   The continuous type with exacerbations is less  frequent.  In these
cases  the headache never  disappears  entirely;  but  here again the
exacerbation is observed in the evening or during the night.
    In some cases  these  secondary headaches disappear in a few days
or one or two weeks.  Usually they persist for several weeks, or even
for  several months.
   Diagnosis.—The diagnosis  is founded  on  the  nocturnal exacer-
bations and the prompt, characteristic, and extraordinarily curative
effect of specific treatment.  Night exacerbations  of  cephalalgia are
not confined to syphilis.   From the symptoms alone these headaches
cannot be distinguished  from those of anaemia, of hysteria, or of rheu-
matism.   Fortunately, syphilitic headache is  commonly associated
with other  incontestable signs of the disease or with a history which
is suggestive.   Usually there are syphilides or  alopecia and articular
pains.  In the rare cases where both history and concomitant symp-
toms of syphilis are wanting, an elimination of other causes of ceph-
alalgia would suggest syphilis  and consequently  specific treatment.
Thus, neuralgic cephalalgia would be distinguished by pain or referred
to certain points along the course  of nerves;  migraine, by compara-
tively  long  periods of remission;  rheumatic  cephalalgia, by  super-
ficial, muscular pain, increased  on contraction of muscles, and relieved
by heat;  anaemic  cephalalgia, by the facts  that it  lessens during the
evening, that  it is made  better  by eating, and  that it is accompanied
by other symptoms  of  lessened haemoglobin; neurasthenic  cepha- 
394
GENITO-URINARY DISEASES  AND SYPHILIS.
lalgia, by its less severe pain, its partly diurnal character, and its long
continuance.
    Treatment.—The  specific treatment  of  secondary cephalalgia is
attended by prompt results.  Mercury protiodide and  full  doses  of
potassium iodide should be given.
    Prodromal Cephalalgia of Tertiary Lesions.—The most important
variety of specific migraine is that preceding the grosser symptoms  of
cerebral  syphilis.  In  certainly two-thirds of all  cases of hemiplegia,
amnesia, aphasia,  epilepsy,  coma, pseudo-paralysis, etc., dependent
upon syphilis, there is this prodromal headache.  A large percentage
of these  cases  could  have been saved from these grave  accidents by
vigorous treatment instituted during the prodromal period.
    This  headache differs from  other  cephalalgias, as,  for instance,
those due to neuralgia or to epicranial rheumatism, in the fact that it
is felt to be deep within the  head.  The character of the pain varies:
1,  there  may be simply a sense of weight and  hebetude; 2, there
may be a constrictive pain, as though the head  were  screwed in a
vice; 3,  the  sensation may resemble  that produced by blows  of a
hammer, the suffering being intense  and  the  pain deeply placed.
These three types  may be associated or may succeed one another.
    The pain may be sharply circumscribed to an  area not larger than
a half-dollar.  In this case it frequently indicates  the formation of a
gumma.  Sometimes  it is diffuse, occupying a general region, as the
frontal, temporal, parietal, or occipital, or is  spread over two or more
of these  regions.  Exceptionally it seems to involve the whole head.
The fronto-parietal region is the one to which this  pain is most fre-
quently referred.  This form of cephalalgia has  three characteristics
which  should at least strongly suggest  its  nature: 1, there is an
habitual  intensity, sometimes extraordinary severity, of pain ; 2, it is
persistent, tenacious,  long-lasting; 3,  there  are  nocturnal  exacerba-
tions.
    Even in mild cases the pain is less  bearable than the ordinary
headache ; it harasses the sufferers, making them despondent, morose,
excitable, and sleepless,  and interferes with general nutrition;  or it
may be so severe as completely to prostrate them.  Exceptionally the
pain amounts to a veritable anguish, comparable in intensity to that
of hepatic or nephritic colic.
    As  a rule, syphilitic cephalalgia precedes the  grave  developments
of brain-syphilis by an interval of from three to six weeks ; it is, how-
ever, not uncommon for  this pain to last from three to six months;
exceptionally the pain may  exhibit remissions and exacerbations for
two or three years. Under the influence of  intermittent mild specific 
SYPHILIS OF THE NERVOUS SYSTEM.           395
treatment  the headache  may be temporarily  cured,  to  recur  time
after time, till symptoms such  as hemiplegia or  epilepsy show that
irreparable damage has been done.
   Nocturnal exacerbations of pain, though the  rule, are by no means
invariable.  In the secondary period  this characteristic is most pro-
nounced ; in  the tertiary period it may be wanting entirely; indeed,
there may even be nocturnal remissions.
   The prodromal headache of  tertiary syphilis is a sign of inestima-
ble value, enabling treatment to be adopted in  time to prevent grave
lesions.
   Treatment.—The treatment should be instituted early,  and should
be sufficiently thorough to cure the headache and to eradicate as far
as possible  the underlying constitutional taint.  Mercury  and potas-
sium  iodide  should be given in the most active manner possible.
Every ten days a hypodermic injection of sublimate or calomel should
be employed, and repeated as often as may be  required.  Internally,
potassium iodide  should  be administered and  rapidly pushed to the
extreme point of  toleration:  to a woman,  one  to one and a half
drachms a day;  to a man, nearly twice this dose.  This treatment
should be long continued, with appropriate short intervals  of rest,
until there  is  good reason to believe that there is no likelihood of
recurrence.
   Parasyphilitic Cephalalgia.—Among the parasyphilitic headaches
may be mentioned the neuralgic migraine and the crises of pain often
observed in tabes.  The  most  important cause of these  headaches,
and by far the most common, is neurasthenia.  This  is an ordinary
sequel of syphilis, and among  its multitudinous symptoms  none is
more troublesome or more frequent than headache.
   This parasyphilitic  neurasthenic   headache is  characterized by
moderate intensity; it  is not really  a pain, but rather a sensation
of weight or  constriction, of dulled or imperfect  cerebral action.  It
usually lasts several years.  It  is present in the  morning on rising;
is  sometimes better after meals, but shortly returns with its original
intensity, or even with a slight excess of this ; it is better at night, so
that sleep is not disturbed.   It is not benefited  by specific treatment;
it is usually located in the occipital region; and it is often associated
with other  signs of neurasthenia.  These  are  characteristics which
sufficiently distinguish this cephalalgia from pain preceding the recog-
nized cephalopathies ; indeed, a headache which has lasted for several
years almost  certainly does not belong to the latter class, since apo-
plexy or some one of the serious symptoms denoting irreparable brain-
lesion  is certain to develop long before the expiration of this period. 
396       GENITO-URINARY  DISEASES AND SYPHILIS.

Yet it may well happen that a differential diagnosis cannot be made.
In this case the mixed speciAc treatment should be given one thorough
trial.  Should it fail, there should be no further effort in the direction
of attempting cure by this treatment.
   When the diagnosis of parasyphilitic neurasthenia is firmly estab-
lished, minute attention to general  hygiene, thorough hydrotherapy,
especially with douches of brief duration, and congenial surroundings,
represent the best methods of accomplishing a cure.  The only drug
which is of the least service, aside from tonics and nutritives, is potas-
sium bromide ;  this sometimes relieves the headache.
   But  we cannot affirm that all grave  syphilitic cerebropathies are
preceded by these headaches.  Mauriac quotes a case in which a man
aged twenty-two was suddenly seized with severe convulsions of the
left arm, which were undoubtedly  due to syphilis, but which were
preceded by no prodromal headache  or other nervous  symptoms.
Fournier also has noted  a  similar case  wherein  the  patient had
suffered no headache during the ailment, and yet the post-mortem
disclosed extensive syphilitic disease of the brain.
   Following these prodromal symptoms there are certain  symptoms,
which Finger classifies as follows :
   1. Psychical disturbances, with  epilepsy  accompanied  by  paresis
not involving the  cerebral nerves, terminating in coma.  In these
cases gummata and wide-spread endarteritis of the convexity of the
brain are found.
   Following the  prodromes or without symptoms there is a sudden,
often violent, epileptic attack,  sometimes not accompanied by com-
plete loss of consciousness.  This is followed by cerebral irritability
and  fatigue, mental  failure, progressing to  dementia,  localized mus-
cular weakness, paresis  or paralysis which  may be of irregular dis-
tribution, and slowT, halting speech.
   2. Apoplectic attacks followed by hemiplegia associated with som-
nolence, with symptoms of irritation of  one  side and paralysis of the
cerebral nerves.
   In these cases  there are gummatous inAltration of the base and
arteritis involving the vessels of  the large central ganglia.  Following
prodromal  symptoms there is  suddenly developed palsy of one or
more cranial nerves, the  oculo-motor and abducens being most  fre-
quently  involved.   This will be  shown  by ptosis, strabismus, loss of
accommodation, etc.  These palsies are persistent, and  may be pre-
ceded or accompanied by twitchings or contractions  of the muscles
supplied by  the  affected nerves.   Following  these symptoms, or
sometimes  preceding them, there is an apoplectic attack, often not 
SYPHILIS OF THE NERVOUS  SYSTEM.
397
attended by loss of consciousness, but with  hemiplegia and disturb-
ance of speech.   Even wiien  this stage  is reached almost complete
restoration of mental power is possible.   If the disease is progressive,
other apoplectic attacks supervene, the  mind becomes dull and list-
less, there are involuntary micturition and defecation, and finally coma
and death supervene.
    3. Psychoses, appearing generally in the form of paralytic demen-
tia  or progressive  paralysis.
    These psychoses are usually accompanied by paresis or paralysis,
especially of the cranial nerves, and  by epileptiform attacks.
    The syphilitic cerebropathies are most commonly characterized
by  a slow but steady  advance;  thus,  a slight  neuralgia  expands
into epileptiform  convulsions, and  finally  ends with  paresis or pa-
ralysis.
    Diagnosis.—In general it may be affirmed that all non-traumatic
or  non-toxic cerebropathies found  in  persons of previously good
health between the ages of twenty and forty are probably of syphilitic
origin.  If there is a history of preceding chancre the diagnosis is still
further  assured.   Epilepsy, if idiopathic or inherited, always  makes
its  appearance in childhood;  wiien it occurs late in life and is non-
traumatic it is exceptional, and  is  then  probably due to  syphilis.
Paresis, not of toxic or traumatic origin, occurring between the ages
of twenty and forty, is due to syphilis in eighty per cent, of cases.  In
nervous  disorders wherein two  diatheses are  possible causes,  for
instance, the gouty and the syphilitic, the diagnosis is to a certain
extent dependent  upon the therapeutic test.
    A gouty diathesis is apt to produce nervous symptoms only late in
life, but in all other respects gouty and syphilitic cerebropathies may
be almost identical.  In both  gout  and  syphilis arterio-sclerosis is a
common feature, and the same symptoms would follow from whatever
cause the lesion was produced.
    Even the therapeutic test is not wholly trustworthy in deciding as
to the specific nature of palsies.   Paralysis of the facial nerve, though
strongly suggesting syphilis, is  not pathognomonic, since facial paraly-
sis may be produced by cold, and may be  only a transitory affection,
which disappears under full doses of potassium iodide simply because
it has run its course.   It  is ahvays  possible  that the paralysis may
have been an independent acute attack, and might have disappeared
of itself without treatment.
   Attention has  been called  to the fact that the  symptoms of cere-
bral syphilis are often attributed to slight disorders, and hence treat-
ment is not instituted at the time that it is most valuable. 
398        GENITOURINARY DISEASES AND SYPHILIS.

   In forming  a diagnosis a minute study of the previous history
is imperative, as well as careful observation of the entire symptom-
complex.   The diagnosis will then be founded on a syphilitic history,
a prodromal headache worse at night, impaired mental activity, local-
ized  paresis,  epileptiform or apoplectiform attacks,  not necessarily
attended with loss  of consciousness,  hemiplegia and  paralysis par-
ticularly involving the cranial nerves, marked psychoses, and coma.
These symptoms are somewhat irregular, but progressive.  They are
checked by specific treatment.
   Prognosis.—The  prognosis is always grave unless  energetic anti-
syphilitic treatment can  be instituted before the syphilitic lesions have
produced actual loss of substance in the nerve-tissue.  But  in no
other manifestation  of  syphilis is there so prompt and decisive an
arrest of the process as in affections of the nervous system subjected
to mercury and potassium iodide.
   Tissues cannot be replaced, and consequently, unless the disease
is attacked at its earliest onset, there are always  reminders in the
shape of impaired functions or enfeebled cerebration.
   Syphilis in any form whatever may be  so  capricious and lawless
and  may lie dormant for so many years that the prognosis must be
always guarded.
   Treatment.—The treatment for cerebral syphilis is the same as that
for all tertiary lesions,—namely, a mixed treatment of potassium iodide
and  mercury.   The potassium iodide should be started in full doses
of thirty to forty grains daily and pushed rapidly to the point of  toler-
ance.  Everything depends  upon  obtaining a prompt action, and to
begin with small doses of Ave or six grains is a dangerous waste of
time.  The prodromal period is the time to avert irremediable de-
generations and to ward off the violent nerve-storms which are sure
to follow if the treatment be neglected.  Hygienic measures are not
to be ignored, the  nervous system must be kept at rest, there must
be no household or business worries, and there  must be, if possible,
moderate and regular exercise.  Attention to the digestive tract is of
the utmost importance.
   In convulsive types the  bromides  are Useful; antipyrin, chloral,
and chloralamide are at times of greatest service When the pains are
intense.  Electricity should be employed to exercise and stimulate
the paralyzed muscles.  When rapid action of the specific is impera-
tive,  hypodermic injections of mercury are  indicated.   Potassium
iodide is most conveniently given in the saturated solution of which
one  minim contains one grain.   The  mercury may be  given  hypo-
dermically or by inunction. 
SYPHILIS OF THE NERVOUS SYSTEM.
399
                 SYPHILIS OF THE SPINAL CORD.
   Syphilis of the spinal cord cannot be said to have in its symptoms
the irregularity and incongruity which are the characteristic features
of cerebral syphilis.   Myelopathies due to  syphilis correspond  in
every respect to those due to other causes.   Syphilis, however, is an
etiological factor of the greatest frequency in all myelopathies, whether
distinguished by softening or by  sclerosis,  either diffuse or circum-
scribed : so that it is almost justifiable to assert that any myelopathy
of which the cause is not manifest is syphilitic.
   The  syphilitic lesions which may  affect the cord and its mem-
branes are identical with those which affect the brain,—namely, dif-
fuse  gummatous inAltration  followed by sclerosis,  circumscribed
gummata, and endarteritis.   Myelopathies  occur with the greatest
frequency during the  third  or  fourth year  after infection;  cases,
however, have been observed occurring as late as twenty-five  years
after the contraction of syphilis.
   Etiology.—There is no satisfactory explanation as to why syphilis
should attack the cord in some cases  and not in others.  In addition
to the general  causes  mentioned when treating of  cerebral syphilis,
venereal excess  and, according to Mauriac, the  influence of a damp
cold climate should  be included.
   Morel-Lavallee thinks that there is  special virulence in the original
infecting germ  of certain cases of syphilis  which has a  predilection
for the nervous system.  He cites from personal observation the cases
of Ave  men who contracted syphilis  from  the same source, and all
of whom died, at varying periods  after infection, from syphilitic dis-
ease of the nervous system,  while,  strangely enough,  the woman
who infected  them  married and gave birth to a healthy child.   This
special virulence  he  calls the " verole nerveuse."
   As a rule, syphilis  does not attack primarily the essential tissues
of an organ,—as, for  instance,  the  nerve-cells themselves: hence
gummata of the cord are excessively  rare;  they do occur, however,
in the  centre  of the  cord, and somewhat more frequently on its
surface,  adhering closely to the meninges, from which possibly they
originate.   They present the same appearance as gummata of the
cerebrum.
   The most common forms of syphilitic myelopathies  are sclerosis
and softening, which are usually associated and which may be wide-
spread or circumscribed.   Softening often, not always, follows in the
path of  the sclerosis; it is only exceptionally a rapid  process, and
where symptoms of spinal disorder have existed for a length of  time 
400        GENITO-URINARY DISEASES AND SYPHILIS.

is commonly found in disseminated patches.   When the myelopathy
has advanced rapidly and deep bed-sores form in  the  sacral region,
the softening is generally extensive, without patches of sclerosis.
   Fibrous  degeneration or  sclerosis of the cord is more  frequent
than softening, but for the most part  the two processes are so inti-
mately associated that they may be considered  as but two phases of
the same process.
   Lesions of the cord consequent upon syphilis of its bony envelope
are far less frequent than are the corresponding cerebral  lesions;
possibly because of the greater space between the vertebrae and the
nervous  tissue, and also  because the  vertebrae  have a periosteal
envelope independent of the  dura mater.
   The meninges of the cord are especially liable to be attacked.  The
membranes are so intimately associated that it is  almost impossible
to distinguish in which  of the  three the lesion originated, since it
always rapidly spreads  from  one to the other, thus making at the in-
vaded  point one  thick  membrane, possibly studded here and there
with gummatous deposits.
   Symptomatology.—The symptoms of  myelo-syphilis present  the
same general characteristics as cerebral syphiloses,—namely, dissem-
ination of manifestations, a marked tendency to temporary ameliora-
tion, and recurrences, together with «arly implication of the bladder
and rectum.
   The development of symptoms due to compression of the cord by
a syphilitic osteophyte  is usually comparatively slow, but otherwise
the same as from compression  due to any other  cause.  When, on
the other hand, syphilitic disease of the bone  has gone to  such an
extent as to produce  a sudden dislocation  of the vertebrae, then
symptoms  arise as suddenly, and vesical and rectal  troubles are
among the  first.
   The paralytic  and trophic symptoms vary according to the situa-
tion of the  compression or degeneration.  The cervical region is most
frequently attacked, and if the compression is only slight the upper
extremities alone will be affected.  A point of tenderness can almost
ahvays be  elicited on the spinal column opposite  the  lesion of the
cord, and in a case of suspected cervical lesion an examination of the
throat should always be made; there is a possibility that deep ulcera-
tions may indicate disease of  the vertebrae in this region.
   Syphilitic meningitis is rarely of an acute type ; it more commonly
assumes the form of  sclerotic patches or bands pressing on the cord,
and is manifested in much the same manner as compression due to
other causes.   The dorsal and lumbar pains are of excruciating in- 
SYPHILIS OF THE NERVOUS SYSTEM.
401
tensity, made worse by motion.   Finally, paralysis of the extremities
and sphincters supervenes, and indicates  that  softening or annular
constriction of the cord has commenced.
   Acute or subacute myelo-syphiloses are  not as common as the
chronic, and are often found  in  secondary  syphilis.  When they
occur at a period long after  the chancre, with  no other  manifesta-
tion  of the  disease, the diagnosis is  extremely  difficult.   Vesical
troubles and weakness of the lower limbs are usually the first symp-
toms, which rapidly advance to paralysis and retention of urine and
faeces, followed  shortly by incontinence and the formation of deep
bed-sores on the sacrum and the  heels.  Fever,  if any develops, is
slight.
   Treatment is of little avail, and death ensues in a few days or
weeks. This acute myelo-syphilosis is the most dangerous  of the
syphilitic affections of the cord.
   Chronic myelo-syphiloses are distinguished not so much by their
duration as  by the gradual development of symptoms.  They are
much more common than the  acute forms, and less likely to have a
rapid termination.
   The first  symptoms are usually overlooked, and consist of neural-
gic pains, with weakness in the limbs.   Slight difficulties of micturi-
tion and gradual enfeeblement of sexual power follow in order.   The
weakness gradually develops  to paresis or paralysis, and the  sexual
power is entirely lost.  The patient next suffers all the excruciating
pains and  girdle symptoms of myelitis.  It  is very rare for disturb-
ances of sensation to keep pace with  the paralysis.   A part of the
body entirely paralyzed may still retain its normal sensibility, or else
the sensation may be merely blunted and the patient be unable accu-
rately to localize the sensation.   The reflexes are at first exaggerated,
but soon become much diminished  or abolished.   Bed-sores are very
slow to make their appearance.   The symptoms are usually confined
to the lowTer extremities, and  it  is rare for the process  to have a
tendency to ascend the  cord.
   Under  the  influence of specific treatment  the disease may be
occasionally checked or even apparently cured; but it must be re-
membered that  temporary ameliorations  are  characteristic  of all
syphilitic neuroses.
   Tabes Dorsalis.—In all other myelo-syphiloses certain pathological
elements can be found—namely,  traces of gummatous material—
which  determine the syphilitic origin  of the  lesion,  but in tabes
dorsalis or locomotor ataxia of syphilitics search  for a pronounced
syphilitic element is vain.  It  is only from the evidence supplied by
                               26 
402        GENITO-URINARY DISEASES  AND SYPHILIS.

numerous  statistics  showing the association  of tabes dorsalis with
syphilis that we can infer a connection between the two.
   The# tabes which attacks syphilitics  is identical with that which
attacks those  who have not the slightest syphilitic taint.  Fournier
found in two hundred and forty-nine cases of tabes two hundred and
thirty-one  in  which there was  undoubted  syphilis,—that is, ninety-
three per cent.   Many  others have compiled statistics coinciding for
the most part with this  percentage.
   As syphilitic  tabes is similar in symptoms to ordinary tabes, so is
it similar in its usual incurability; when it is once firmly established,
potassium iodide and mercury often have no effect; on the contrary,
they may be rather deleterious.
   The diagnosis of tabes is not very difficult  when  the disease is
fully developed, but to  be able  to recognize it  in- an  incipient stage
and find a  clue to its etiology is, though most difficult,  of the utmost
importance.   In this early stage, cures under antisyphilitic treatment
are possible ;  this strengthens the  theory of its syphilitic connection
or origin.
   The premonitory symptoms  of ataxia may be nothing more than
pains in the lower extremities, which are for a considerable time  re-
garded simply as rheumatic ; they have not the  characteristics of the
osteocopic  pains.  Urinary troubles without apparent  cause  are also
signs of great value, and it is quite common to see associated, in addi-
tion to all the  symptoms of ordinary tabes, a few other manifestations
of an irregular, perhaps cerebral, type.
         »
                    SYPHILIS OF  THE  NERVES.
   At any  period of the disease syphilis is liable to attack the nerves
or the ganglia.
   Syphilitic degeneration of the parenchyma of the  nerve itself is
rare; the process usually takes place in the net-work of connective
tissue  between  the  fibres and  in  the  sheaths of the nerves.  But
wherever the  lesion is  situated  in  the nerve, the symptoms are vir-
tually the same, and manifest themselves, as in other organic neuroses,
by disturbances of sensation, motion, and nutrition.
   The sciatic nerve is perhaps  the most frequently affected,  al-
though any one  of  the nerves  is liable to attack.  The pains pro-
duced  by these  lesions  are not to be confounded with the rheuma-
toid neuralgias which occur early in the secondary stage, and which
are in reality  only slight functional disorders and not the result of
true neuritis;  nor with  the pain caused by small periosteal tumors,
such, for instance, as those formed upon the sternum and the ribs. 
SYPHILIS OF THE NERVOUS SYSTEM.
403
   The suffering caused by syphilitic  neuritis is  intense, and  fre-
quently accompanied by contractions  of the  muscles,  paresis,  and
paralysis.  The early sciaticas—those occurring at the  beginning of
the secondary stage—are  readily cured by specific  treatment,  and
rarely last more than a week or two; coming on later in the disease
and accompanied by evidences of degeneration, they are much more
serious, and are then probably due to sclerosis or gumma formation
in the connective tissue and substance of the nerve.
   In like manner neuralgias of the occipital and cervical  nerves are
of slight  import in the  early secondary stage, but when occurring in
the tertiary period  they are to  be regarded as grave  symptoms of
disease of the cervical vertebrae.
   Syphilis not uncommonly attacks the cranial nerves and the nerves
of special sense.  The  lesions may be of the  nerves themselves, or
of their sheaths, or of their canals  of exit from the skull; or the
symptoms may be due to the presence of neighboring gummata.
   In any event there  will probably be paralyses or  possibly con-
tractions  of the muscles which the involved  nerves supply.  Although
the symptoms are the  same as from neuritis dependent upon other
causes, a history of syphilis affords sufficient justification for assuming
that the lesions are  specific and for treating them  as such.   If they
occur at  a  period remote from  other syphilitic  manifestations they
must  be  diagnosed  by the method of exclusion or  by applying the
therapeutic test.
   The  earlier the  symptoms of  nerve-involvement appear in the
disease the more favorable is the prognosis.
   The optic nerve,  according to Charcot, may be the seat of fibrous
metamorphosis incident  to parenchymatous neuritis.  The lesion of
the optic nerve is  usually a phenomenon  of late appearance,  and
depends more or less upon cerebro-syphiloses.
   The sense of smell is affected when pachymeningitis of the anterior
cerebral  fossa causes pressure upon the olfactory lobes: it may  also
be impaired by extensive  destruction of the bones and the mucous
membrane of the nose.
   In like manner the auditory nerve is affected  either  by central
lesion or  by destruction of its bony envelope.
   Of all the cranial nerves the motor oculi, or third pair, is  the one
most frequently affected.   Paralysis of this  nerve often  makes its ap-
pearance early in the  secondary stage, but  is  then only a transitory
affection.  When  the  lesion  is deep-seated the symptoms  will be
ptosis, dilatation of the  pupil, external strabismus, and paralysis of
accommodation. 
404        GENITO-URINARY DISEASES AND  SYPHILIS.

   Possibly mydriasis may be the only symptom ; this has been found
to be the case when the lesion is situated near the lenticular ganglion
and cuts off only the short ciliary branches of the nerve.
   The fourth pair is rarely affected.
   Lesions  of  the fifth  pair are  common,  and are  manifested by
neuralgias or hyperaesthesias of any or all of its branches.
   Affections  of  the sixth pair are rare;  they are  accompanied by
diplopia, convergent strabismus, and orbital neuralgia.
   The seventh pair of  nerves exhibits a peculiarity in that it is so
often affected early in the disease, at times within a fewr weeks of the
appearance of chancre.
   The symptoms vary  according  to the situation of the  lesion:  if
it is situated on  the main trunk of the nerve  within the Fallopian
canal, or beyond it, paralysis of the face is the only symptom; if it
is situated within the skull, the usual symptoms of intracranial lesion
—headache, vertigo, aphasia, convulsions, etc.—are also present.
   The other cranial nerves are rarely affected.

                      SYPHILIS  OF THE EYE.
   Chancre may develop on the  eyelid or on the conjunctiva.  Be-
ginning as a pimple, the lesion gradually develops into a characteristic,
saucer-shaped ulceration, with rounded edges and indurated base.
   Secondary syphilis  may appear upon the  eyelids, as well as gum-
mata of the skin and so-called tertiary ulcers.
   Syphilitic tarsitis is an inflammation of the tarsus, which produces
great thickening of the lids, and in some instances is due to a diffuse
gummatous infiltration.  More rarely it is acute, and then must not be
mistaken for an ordinary strumous inflammation of the ciliary border,
from wiiich it is to be distinguished by the  thickening and induration
of the tarsus.
   Syphilitic conjunctivitis has been described in a few instances, the
appearances being somewhat analogous to  those of granular lids, the
disease yielding, however, only to antisyphilitic remedies.
   Syphilitic periostitis may attack the orbital margins either in a
gummatous or in a sclerosing form.  When the orbital walls are in-
volved behind the capsule of Tenon, the type is almost always gum-
matous.  The symptoms are then pain, worse at night, restriction in
the mobility of the globe,  squint, and diplopia.  As complications
there may be optic neuritis and inflammation of the  cornea.
   Caries of the  margin  of the  orbit  is not uncommon in syphilis,
usually as the result of pre-existing periostitis.
   Syphilis of  the  Lachrymal Apparatus.—Occasionally the 
SYPHILIS OF THE EYE.
405
lachrymal  gland becomes enlarged and  indurated as the result  of
syphilis, and hypertrophy of this  body, appearing as an  indurated
lobulated tumor, having its situation in the upper and outer  part  of
the orbit,  should always be  given careful antisyphilitic  treatment
before surgical measures are adopted.
   Occasionally aiachrymal  abscess  forms in children above the in-
ternal palpebral ligament and external to the  sac itself:  hence the
name prelachrymal abscess;  it is usually due to inherited syphilis.
   The lachrymal sac and nasal duct may become obstructed through
periostitis  and caries of the lachrymal bone or  the pressure of gum-
matous deposits.  The lachrymal apparatus in its entirety is singularly
free from manifestations of syphilis.
   Syphilitic Affections of the Cornea.—Interstitial Keratitis
(syphilitic, inherited,  specific, parenchymatous, or diffuse keratitis).—
This is a chronic inflammation of  the whole thickness of the cornea,
the membrane  gradually passing  into a  condition of universal thick
haziness, associated with vascularization, but almost  always  without
ulceration.
   Causes.—Inherited syphilis is the cause in between sixty and seventy
per cent, of the cases.  Very rarely perfectly typical examples appear
with acquired syphilis.  It is described under hereditary  syphilis.
   Punctate keratitis, characterized by the deposition of opaque dots
arranged in a triangular manner upon the posterior elastic  lamina of
the cornea, is  usually an indication of affections of the  iris, choroid,
and vitreous, but may also appear both  with and without iritis, and
as a syphilitic  inflammation.   It  occurs  in the  late or gummatous
period of  syphilis, but is seen also in children before puberty as one
of the forms of inherited syphilis.   The treatment is the  same as that
described  under interstitial keratitis.
   Syphihs of the Sclera.—A certain number of cases  of scleritis
and episcleritis—that is, inflammation of the sclera itself or its over-
lying tissue—have been ascribed  to acquired syphilis and  yielded to
the ordinary remedies.  So,  also,  in the late stages of syphilis, a true
gummatous scleritis  may develop, characterized by the formation of
yellowish-brown and semi-translucent nodules on this membrane.
   Syphilis  of the Iris.—1.  Syphilitic  Plastic Iritis.—This may
occur in  the early stages of general  syphilis, usually between the
second and the ninth month after  the initial lesion, and is  character-
ized by the ordinary  symptoms  of iritis,—namely, fine pericorneal
injection,  contracted,  sluggish, or immobile  pupil,  discolored  iris,
abnormal  reaction to a mydriatic, slight  tenderness on pressure, the
formation  of  attachments between  the  margin  of the  iris  and the 
406        GENITO-URINARY DISEASES AND SYPHILIS.

capsule of the lens (posterior synechias), and severe pain in the brow
and head, worse at night.
   The symptoms do not differ from  those  of a  simple  iritis from
other cause, and  are of themselves not characteristic of the disease,
yet the lesions are due to the syphilitic taint and yield to the ordinary
constitutional remedies and local measures.
   2. Syphilitic parenchymatous iritis, or true syphilitic iritis, belongs
to the  parenchymatous variety of the affection, being an accompani-
ment of secondary syphilis, and is characterized by a deposit  of  yel-
lowish-red nodules  on the  ciliary or  the pupillary  border  of the
inflamed iris, comparable to the papules and condylomata of the stage
at which it occurs, and hence called iritis papulosa or condylomatous
iritis.  These small nodules vary in number from one to four, and are
gradually absorbed  under  treatment, leaving  faint scars in the  iris-
tissue to mark their former situation.   Sometimes instead of distinct
nodules there are local  swellings  in the  iris-tissue, the  membrane
being  attached at these  situations by broad and moderately  soft
synechiae to the capsule of the lens.
   3. Gummatous iritis—gumma of  the  iris—occurs in the  late or
tertiary stages of syphilis, and is characterized by the  development
of large yellowish nodules, usually on  the ciliary  border  of the  iris,
and strongly analogous to gummata elsewhere in the body.
   Occasionally at this late stage an  iritis  unassociated  with nodules
appears, somewhat resembling the plastic type of the disease, and
probably the relapse of  a plastic iritis which occurred in an early
stage, owing to a failure in the absorption of the  original synechiae.
   4.  Serous  iritis (more properly, serous cyclitis), characterized by
a serous or sero-plastic exudate, deepening of the  anterior chamber,
slight dilatation of the pupil, haziness of the cornea, and opaque  dots
on its posterior elastic membrane arranged in a triangular manner, is
an unusual variety of  iritis as the  result of acquired  syphilis  in the
secondary  stage,  although common from many other causes.
   Prognosis.—The  prognosis of the various  types of  syphilitic  iritis
is good, provided the cases  are seen early, before firm adhesions
form and much exudation pours out into the pupillary space,  causing
either  its occlusion or its exclusion. When thoroughly cured, relapses
are infrequent.   Commonly both eyes are attacked, one a little  later
than its fellow;  occasionally the  onset is simultaneous.
    Treatment.—This should consist in the free use  of atropine drops,
four grains to the ounce, hot compresses and leeching  the temple to
relieve pain and enhance the action of the atropine, and the persistent
use of such antisyphilitic  remedies as  are indicated by the stage at 
SYPHILIS OF THE EYE.
407
which the iritis appears.  In stubborn cases, and especially in gumma-
tous iritis, subconjunctival injections of bichloride of mercury may be
used with  benefit.   Success depends upon beginning the treatment
early enough to tear loose the synechiae by  the use of atropine,
which, except in the cases  of serous iritis where there is a tendency
to rise of intra-ocular tension, must be  vigorously  used until  all
signs of  irritation have passed away and  a perfectly round  pupil is
obtained.
   Inherited syphilis may  also produce iritis, the disease, character-
ized  by  much exudation and rapid occlusion  of the pupil, usually
appearing  between  the ages  of  two and fifteen months,  and being
very much more frequent in  girls  than in boys.   It is probable that
all iritis  occurring in young children is due to syphilis.
   Subacute, chronic, and  so-called  quiet  iritis may also  be caused
by syphilis, the latter,  as its  name implies, being unassociated with
much pain or ciliary congestion, the progressive dimness of vision
usually leading to its discovery.
   Syphilis of  the Ciliary Body.—Independently of the fact that
this  structure  is commonly involved in all the  severe types  of  in-
flammation of the iris, forming  the  so-called irido-cyclitis, and that
serous iritis is really a manifestation of inflammation of the  ciliary
body, syphilis  strictly confined  to this structure is uncommon.  In a
few instances,  howrever, gummata thus located have been described.
   The  treatment of cyclitis of syphilitic origin, or, more properly,
irido-cyclitis, does not differ from that of iritis.
   Syphilis  of the  Choroid,  Retina,  and Optic Nerve.—The
most important lesions of these structures, discoverable only with the
ophthalmoscope, are the  following:
   Deep choroiditis, characterized in its diffuse exudative variety by
yellowish-white plaques,  going on later to absorption, heaping of  pig-
ment, and atrophy of the retina (choroido-retinitis), and in its dissem-
inated variety by the formation of  numerous round and oval spots in
the fundus oculi, which  have a characteristic punched-out look  and
the margins of which are bordered with black  pigment.   In the later
stages opacities in the vitreous  humor are common, and atrophy of
the optic nerve  may take  place.  Vision is  often seriously  affected,
especially if  the region of the macula is involved.
   The  various types of  choroiditis which  are due to acquired syphi-
lis appear from  six  months to two years  after the initial  lesion;
sometimes ten years elapse before  their appearance.
   Choroiditis of similar type may be due to  inherited syphilis, and
develops between  the sixth month and the third year of life.  The 
408
GENITO-URINARY  DISEASES AND SYPHILIS.
treatment consists in the exhibition of the usual antisyphilitic reme-
dies.   The  subconjunctival  injections of  sublimate are said to be
especially efficacious.
   There are a number of other types of choroiditis which probably
depend upon syphilis, but that named is the most important.
   Syphilitic retinitis  occurs in various  types.   The  first  variety,
ordinarily called choroido-retinitis, is really a disease of the  choroid.
The most important symptoms are  opacity of the vitreous (syphilitic
hyalitis), usually in the  form of  dust-like  particles;  loss  of trans-
parency of the  retina  around the head of  the  optic nerve,  which is
unduly hyperaemic; and numerous yellow or white spots of exuda-
tion  bounded by  pigment lying beneath the vessels of the retina.
Vision is much  affected, especially in dim lights, the field of  vision is
contracted, and  the patient complains of shimmerings, spots, circles,
dancing lights, and distortion of  objects.
   Sometimes the  disease is more truly located in the retina, which
becomes affected with a gray opacity, the optic  nerve entrance being
yellowish red in color, while floating opacities arise in the vitreous;
occasionally there are hemorrhages.
   Of an unusual type and  one belonging  to the late manifestations
is a central retinitis, located largely in the macular regions, and char-
acterized by the appearance  of numerous  yellow or yellowish-white
spots and pigment-dots.
   Retinitis may occur both  in congenital and in  acquired  syphilis.
In the acquired  form it appears  usually from one to twro years after
infection, but sometimes as early as the sixth month.   Generally both
eyes are involved.
   In the hereditary  disease it  arises, like  choroiditis, between the
sixth  month and the third year of life.
   The treatment  consists in the exhibition of the  ordinary anti-
syphilitic  remedies, which should  be vigorously pushed in  order to
prevent secondary changes in the optic nerve and  consequent blind-
ness.   The eye should be protected with dark glasses, and the accom-
modation paralyzed with a weak solution of atropine.
   Syphilitic optic neuritis, characterized by swelling of the nerve-
head, distention of the veins, which become darker in color and tor-
tuous, and hemorrhages  upon the swollen papilla or in its immediate
neighborhood, may  be caused by the formation  of an intracranial
product, for example, a gumma, or may develop as an essential  sign
of syphilis.
   Rapid mercurialization should be practised, to  be  followed later
by the iodides, and if the exudation is quickly absorbed the prognosis 
                     SYPHILIS  OF THE EYE.                  409

 as  to vision  may be good; otherwise the tissues are  strangled,  and
 there results
    Atrophy of the Optic Nerve.—In addition to this consecutive
 atrophy of the optic nerve the result of a syphilitic neuritis, a primary
 atrophy occurs,  as well as the various types of degeneration of  the
 nerve-head, which are due to  general  causes resulting  from syphilis,
 for example,  locomotor ataxia.
    The usual symptoms of optic nerve atrophy are progressive  loss
 of  vision, ever-increasing restriction of the field of vision, and  the
 ophthalmoscopic appearances of atrophy,—namely, pallor of  the
 disk, absence of capillaries, and shrinking of the size of the vessels.
    Syphilitic  Palsies of the  External Ocular  Muscles.—The
 most frequent  cause of paralysis of the external  ocular muscles is
 syphilis,  fully one-half  of the cases  having this  origin.   The  usual
 lesion is an inflammation or  gummatous change affecting  the  nerve
 at the base of the brain, or in the orbit, or there may be diseases of
 the nuclei of the nerve or of the  brain in their immediate vicinity, or,
 finally, the lesions may exist  in  the third ventricle, in the aqueduct
 of Sylvius, or in the fourth ventricle.  Syphilitic paralysis is usually
 but not always  one of the late manifestations of syphilis.  The oculo-
 motor nerve is the one most frequently affected.
    In rare instances there is paralysis of the ocular muscles as  the
 result of inherited syphilis.
    The usual symptoms of palsy  of the ocular muscles are present,—
 namely,  double  vision,  strabismus,  limitation of movement in  the
 direction of the  affected muscles, vertigo, and an altered position of
 the carriage of the head, which is apt to  be turned in the direction in
 which the patient is least troubled by the double images.
    Ophthalmoplegia is a term  used to characterize a loss of power in
 one  or more of  the  eye-muscles, which gradually increases and  in-
 volves other muscles until all  of  them may be paralyzed.  This may
 be caused by hereditary and also by constitutional syphilis.
   In addition  to  the paralysis of the external muscles of the eye
 there are various conditions of the pupil  and ciliary body  which  arise
 under the influence of syphilis ; thus, if the oculo-motor is paralyzed
 and those branches  which supply the iris and the ciliary body are
 affected, there will be dilatation of the pupil and loss of accommoda-
 tion.  Occasionally there is a  wide dilatation  of one pupil without
 affection of the ciliary body, and inequality  of the pupils may arise in
 the course of  a focal syphilitic  brain-lesion.   The treatment of these
 ocular palsies, both external and internal, demands the use of mercury
and ascending doses of potassium iodide. 
410
GENITO-URINARY DISEASES AND SYPHILIS.
                     SYPHILIS  OF THE EAR.
   The auricle  and meatus may exhibit  any of the characteristic
lesions of constitutional syphilis.
   In the secondary stage of the  disease dry or moist papules are
observed.  These when they involve the meatus are prone to ulcerate
or to form papular  overgrowths, accompanied by marked purulent
secretion.  As a result of free suppuration and blocking of the canal,
perforation of the  drum  and suppurative disease of the middle ear
may result.   Condylomata are the most frequent specific  lesions of
the meatus.
   Gummata of the  external auditory meatus appear in the form of
moderate-sized chronic abscesses. These are, however, extremely rare.
   The middle ear if involved shows the changes incident to catarrhal
inflammation. This is usually secondary to suppurating lesions of the
throat.
   The pharyngeal opening of the Eustachian tube is frequently the
seat of chancre,—the infection being carried by the Eustachian cath-
eter,—of mucous patches, and of gummata.  Cicatricial contraction
following these  lesions  may completely block the Eustachian tube.
Syphilitic otitis media may assume the suppurative or the sclerosing
form.  Meningitis, sinus thrombosis, facial palsy, and  the other com-
plications of non-specific  middle-ear disease  may  develop.  Local
treatment is of cardinal  importance.
   The labyrinth  is exceptionally attacked  in  the early secondary
stage of the disease; usually this is a late tertiary manifestation, and
it  is much more frequent in congenital than  in acquired  syphilis.
Tinnitus, vertigo, and sudden onset of deafness  are the chief symp-
toms.
   Diagnosis.—This is founded on the history of syphilis and the
absence of other discoverable cause for  disturbance of hearing.   The
rapid onset of deafness is also characteristic.  The prognosis always
should  be guarded.   The most severe  cases  sometimes  recover
promptly as the result of specific  treatment; the mildest  cases  may
remain uninfluenced by  mercury and  the iodides.
    Treatment.—This when the meatus  is involved should comprise
thorough  cleansing,  the  use of  astringents,  and the application of
cauterants to ulcerating  spots.   Extensive overgrowths and polypi
should be detached by snaring or curetting.
   When the labyrinth is involved the  specific treatment should be
pushed  to its extreme limit.  The prognosis is unfavorable in these
cases. 
SYPHILIS OF THE RESPIRATORY TRACT.
411
             SYPHILIS  OF THE RESPIRATORY TRACT.
   Syphilis of the Nose.—Primary lesions of the  nose are ex-
tremely rare.  A few cases are recorded  due to the use of infected
instruments,  and in  some  instances  the disease has arisen  from
unnatural practices.
   Secondary manifestations, in the  form  of moist  papules,  fre-
quently appear about the nostrils.
   Gummata involving  the external nose exhibit a  predilection for
the wings, the point, the cartilaginous septum, and the  neighborhood
of the  tear-ducts.  These gummata,  beginning  first in  the subcu-
taneous tissues,  extend  in depth, involving  the  bones or  cartilages
beneath.  When there is also gummatous infiltration of the walls of
the nasal cavity marked deformity results.
   Syphilis of  the Nasal Cavities.
      1. Syphilitic rhinitis.
          Acute.
          Chronic;  hypertrophic.
                   atrophic.
      2. Gummata.
          Nodular.
          Infiltrating.
   Acute Syphilitic Rhinitis.—Acute  rhinitis, one of the most  fre-
quent secondaries of hereditary syphilis, is comparatively rare in the
acquired form of  the disease.  It begins much as does  a simple
catarrhal rhinitis, and at first  cannot be distinguished from this affec-
tion ;  later it develops one of the chief characteristics of syphilis,—
polymorphism.   If the nasal  cavities are examined, the inflammation
will be found to vary in intensity even in different parts of  the same
nostril.   Ecchymoses, abrasions, superficial ulcerations, and  at times
mucous patches  may be seen, particularly on the  septum  and the
lower turbinals.   The posterior  nares are at first but  slightly in-
volved ; later they show the characteristic  thickening, hyperaemia, and
dusky redness of acute inflammation; by this time deeper lesions
will have developed anteriorly.
   Acute specific rhinitis differs from  the catarrhal inflammation by
persisting in spite of  careful  treatment and by giving blood-stained
discharge or hemorrhage not at the  beginning  of the attack, but later
when  erosions and ulcers have developed.   Usually the accessory
nasal cavities are but slightly involved.   Hypertrophic and ultimately
atrophic rhinitis may be  the direct sequelae of the acute inflammation.
   Hypertrophic rhinitis presents a spongy, swollen, polypoid mucous 
412        GENITO-URINARY DISEASES  AND SYPHILIS.

membrane, so  thickened  that practically no  breathing-space is  left.
Ulceration  is often present, particularly on  the  nasal  septum, the
lesion here being sharply defined and exhibiting an unhealthy, readily-
bleeding surface.
   The secretion is abundant, often blood-stained, and stinking.  The
mucous membrane of the maxillary, frontal, and  sphenoidal  sinuses
may become involved, causing, from retained secretions,  severe head-
ache or neuralgic pain, and  finally abscess.  Since the mucous mem-
brane is closely applied to the nasal  bones and cartilages, particularly
that overlying  the lower turbinals, perichondritis, periostitis, ostitis,
caries, and necrosis generally complicate  chronic  specific  rhinitis.
Bone- or cartilage-involvement commonly gives rise to no subjective
symptoms  beyond deformity and blood-stained  discharge, complete
perforation of the septum often taking place without the patient being
aware of it.  The nostrils may be so effectually closed  that mouth-
breathing,  with its evil consequences,  results.  The sense of smell
may be lost, and the tear-ducts may be chronically inflamed or may
be obliterated.
   Atrophic  rhinitis  follows the hypertrophic inflammation,  or may
be caused by the wasting which follows gummatous infiltration.  The
turbinals are often involved in the atrophic process, and  may be cov-
ered by thick offensive crusts concealing ulcerations.  The abnormal
roominess  of the nasal  cavities, the  thin, bloodless, scar-like mucous
membrane, and  the  fetor  are  characteristic  of atrophic  rhinitis,
whether it  be specific or not.
   Diagnosis.—The diagnosis of chronic syphilitic rhinitis must be
based on a specific history or associated signs of the disease,  since it
does not differ from the catarrh  observed in non-syphilitics, particu-
larly in those of a strumous diathesis.
   Gummata.—These lesions when they are developed  in the nasal
cavity are  usually late  tertiaries.   If not treated promptly and ener-
getically they produce conspicuous and irremediable deformity of the
external nose.   They appear as  distinct nodules  or as  diffuse infil-
trations.
   The gummatous nodule  attacks  by preference the  cartilaginous
septum and the floor of the nasal canals.  Occasionally it is found on
or near the alar cartilages.   It is usually single, grows slowly, rarely
reaching the size  of a small cherry, and is often associated with syph-
ilitic rhinitis or gummatous infiltration.  Though painless in its course,
if untreated it commonly  erodes the underlying cartilage or bone.
The resulting deformity is much less than that incident to the break-
ing down  of gummatous infiltration.  Gummata growing from the 
SYPHILIS OF  THE  RESPIRATORY  TRACT.
413
mucous  membrane covering the alar cartilages  perforate the latter
and open into the nasal cavity.  When they originate in the  cartilage
itself the perforation may be external.  In the latter case ulceration
may extend to the lower border of the cartilage, and be followed by
a peculiar pinching deformity, which may be symmetrical.
   Gummata on the floor of the nose are  rarely detected until they
have broken down and formed ulcers, or until they have opened into
the mouth.   The upper portion of the nasal cavity is rarely attacked
by the nodular gumma.
    Gummatous  infiltration involves both the mucous membrane and
the underlying  periosteum and perichondrium, and extends rapidly
both in depth and  in  surface.   Because  of  rapid interference with
blood-supply, it is prone to  slough, the destructive process extending
wide of the original infiltrate.  Bones and cartilages rapidly  necrose;
there may be complete destruction of all the cartilages and the bones
immediately surrounding the nasal space.   Necrosis of the cribriform
plate of the ethmoid and the vomer, by taking away the support  of
the nasal bones, allowrs  them to sink, even though they are not
involved, producing the  so-called  saddle-back nose.  This is  more
commonly due to associated necrosis of these bones, which may  cause
complete destruction of  the  nose.  (Fig.  152.)   From  extension  of
the inflammation the ethmoid, the sphenoid, the palatal bone, and
the superior maxillaries, particularly the palatal, nasal,  and alveolar
processes, may become extensively diseased.
    Diagnosis.—Gummata and gummatous infiltrations, involving the
mucous membrane of the nose, are characterized by ordinary catarrhal
symptoms, but  differ from catarrh  in the fact that the symptoms are
constantly referred to  the  same  diseased area.   When ulceration
becomes deep, involving bones, and before this  in hypertrophic and
atrophic rhinitis, the discharge  is extremely offensive.   On exami-
nation the destructive process is often  found  to  be  wide-spread.
Rounded ulcers, often  covered with thick crusts, mark the position
where, on probing, dead bone is detected.   As a result of gummatous
involvement of the cribriform plate, lethal inflammation may extend
to the meninges of the brain.
    In the early stages, where there is  simply beginning infiltration,
the symptoms and  lesions are so like those of  chronic catarrh that
differential diagnosis may be impossible.  The history of the case, the
presence of possibly specific  lesions  resisting the ordinary  catarrhal
treatment, and finally the therapeutic test, should decide this question
before destruction of bone has taken place.
    When perforation of the septum  is found the disease is almost 
414
GENITO-URINARY DISEASES  AND SYPHILIS.
certainly syphilitic, though tuberculous lesions may produce the same
result.
   Syphilitic involvement of the olfactory nerves, commonly due to
pachymeningitis of the base, may cause anosmia,  or loss of smell.
Fig. 152.

                   Gummatous ulceration destroying the nose.
              (From the collection of photographs of Dr. George Henry Fox.)

    Treatment  consists in the  internal administration of specifics and
in local cleanliness, accomplished by antiseptic and stimulating sprays
and vapors.  Exceptionally the bone-lesions are premature.—i.e., they
complicate secondary syphilis ; mercury should  then be combined with
the iodides.  When these lesions are distinctly gummatous in type,— 
SYPHILIS OF THE RESPIRATORY TRACT.
415
and under such circumstances they are nearly always late tertiaries,—
the iodides form  the  basis of treatment, supplemented by mercury,
administered preferably by inunctions.  When dead bone is found it
should be  removed.  This  is accomplished under ether by means of
the finger of the  surgeon aided by a .curette.  Bleeding is often pro-
fuse, but is readily controlled by packing.   Following this the whole
nasal cavity must  be cleaned  every two hours with  sprays, the
first containing hydrogen peroxide  twenty-five per cent., the second
dilute solutions of thymol, or Dobelfs  solution, or other disinfectants
and  antiseptics.   Insufflations of iodoform and iodol may be service-
able after the cleansing spray.  When a  small  portion  of bone  is
necrotic it is safe to wait until this is loosened before attempting to
remove  it, at the same time pushing the constitutional treatment.
   For the deformity of the nose which sometimes results from cica-
tricial contraction following extensive  necroses, plastic operations of
various  kinds  are indicated.  Perhaps the most  satisfactory from a
cosmetic stand-point is  the insertion  of an artificial bridge of  gold,
silver, or celluloid.  Over this the loosened skin is drawn  by the per-
cutaneous suture.   When there is not enough healthy tissue for this
procedure, the fitting on of an artificial nose is advisable.
   Syphilis  of  the  Larynx.—Secondary lesions of  the larynx
appear either  as  a  general  erythema, not distinguishable from that
incident to cold or irritation, or as mucous patches, which  are mostly
found on  the aryepiglottic  folds, the vocal bands,  the arytenoid car-
tilages, and the borders of the  epiglottis.   These  papules  are some-
times converted into superficial erosions, but usually yield quickly to
constitutional treatment, leaving no trace, save at  times alteration of
the voice,  due  to  slight  thickening of the  mucous membrane.   Very
exceptionally these erosions  become true ulcers, closely  simulating
those incident to gumma,  except that they are not so deep nor so
destructive.
   Tertiary lesions  may be expressed in the form of a diffuse gum-
matous infiltration or circumscribed gumma.
   Diffuse gummatous infiltration usually attacks the epiglottis, the
vocal cords, and the posterior wrall of the larynx.  The mucous mem-
brane is reddened and thickened, and there is ill-defined, wide-spread
infiltration of the  surrounding tissues.  If ulceration takes place it is
generally superficial, though a large surface may be involved.
   Symptoms.—The symptoms are due to disturbance of function in-
cident to infiltration.  There is  little or no pain.  Until  the voice be-
comes husky the  patient's  attention is not markedly attracted to the
throat.  Very slowly progressing ulceration and subsequent cicatricial 
416       GENITO-URINARY DISEASES AND  SYPHILIS.

contraction produce marked alterations in the voice and may obstruct
breathing.  Exceptionally there is immediate total  aphonia, followed
later by partial stenosis, with the constitutional symptoms dependent
upon dyspnoea.
   Diagnosis.—This is  founded upon the discovery of a thickened,
often superficially ulcerated area, without  associated diseases of the
lungs, and with a preceding history of syphilis  and  often other mani-
festations of the disease.
   Tubercular laryngitis, the only affection with which it is liable to
be  confounded, is hardly  ever  encountered  in  conjunction  with
healthy lungs.
   Circumscribed  gummata involve by  preference the epiglottis, the
aryepiglottic folds, the true and false vocal cords, and the  posterior
wTall of the larynx.  At first they appear as rounded elevations, the
mucous  covering of which is thickened;  later softening takes place
and  deep destructive  ulcerations  are formed, ultimately resulting in
cicatricial contraction, which seriously interferes with the function
of the larynx.   During the ulcerating stage acute oedema sometimes
develops and threatens death from suffocation.
   Symptoms.—The symptoms are much the same as those of diffuse
gummatous  infiltration, except that the discharge is more profuse,
pain and tenderness are  more frequently  noted, and the functional
disturbances are more marked.
   Diagnosis.—This is founded on laryngeal inflammation associated
with nodules and ulcers and the existence of a history and other signs
of syphilis.
   In distinguishing these lesions from those of tuberculosis it must be
remembered that the mucous membrane surrounding syphilitic ulcers
is  practically normal in color or  congested, not pale.   The develop-
ment of the gummatous infiltration is much more rapid, and the ther-
apeutic test will usually lead to a correct diagnosis.
   The  syphilitic  ulcers  develop  quickly, sometimes in a few days,
and  are surrounded  by  reddened,  oedematous mucous membrane.
The ulcers are  usually single, and involve by preference the upper
surface of the  epiglottis.  Tubercular lesions require months  for
development.
   The distinction between gummatous and carcinomatous infiltra-
tion is  dependent on somewiiat the same difference in symptoms,
though occasionally microscopic examination of an excised piece will
be necessary before the true nature of the case can be determined.
The  differential diagnosis between  syphilitic,  tubercular, and can-
cerous laryngitis may be tabulated as follows : 
SYPHILIS OF  THE RESPIRATORY  TRACT.
417
      Syphilis.
Development  of  ulcer
  acute, occupying  only
  a few days.
Considerable irregular in-
  flammatory or oedema-
  tous swelling.

Epiglottis affected, if  at
  all, on upper surface.
Ulcer  solitary ;  rarely
  more than two.
Proceeds  from centre  to
  periphery,  or   from
  above downward.
Deep, round, or oval.
Diameter of one-third to
  one inch.

No cachexia.
Treatment usually highly
  beneficial.
       Tubercle.
Development slow;  fol-
  lows  throat symptoms
  after several months.
Uniform,  pale  swelling,
  looking like an infiltra-
  tion.

Lower surface.

Ulcers numerous.

The reverse is true.
Generally round.
Diameter much smaller
  (one-sixth   to   one-
  twelfth inch).
Phthisical appearance.
Treatment has but very
  moderate effect.
        Cancer.
Intermediate in time ; ap-
  pearance of ulcers in a
  few weeks.
Nodular excrescences and
  acute inflammation of
  neighboring   mucous
  membrane.
No uniformity.

Ulcer solitary.

Irregular in its course.
Irregular in shape.
Diameter much smaller.
Cachexia.
Treatment has no effect.
   Prognosis.—The prognosis of gummatous laryngitis  is extremely
good if the diagnosis is made before ulceration has  had time to effect
much destruction of tissue.   Resolution  under  specific  treatment is
usually prompt.  When ulceration is extensive, medicine cannot pre-
vent cicatricial contraction  and  interference with  function.   Under
these circumstances, when dyspnoea sets in, dilatation of the strictured
portion, often supplemented by internal laryngotomy and the wearing
of an intubation tube, or tracheotomy, will be necessary.   In addition
to constitutional treatment, during the gummatous  stage of laryngitis
the lesion  should be  touched  daily with  iodine,  1 part, potassium
iodide, 10 parts, glycerin, 100 parts ; it having been previously sprayed
and cleaned by antiseptic solution of sublimate 1 to 2000.  Following
this the lesion should be dusted with iodol.
   Syphilis of the Lungs.—The trachea and bronchi exhibit the
lesions of secondary syphilis in the form of mucous  patches, which
in the  few observed cases were situated on the  posterior walls of
these tubes and wrere credited with causing an  obstinate bronchitis,
yielding only to specific treatment.
   Gummatous  ulceration of  the trachea  and bronchi  may be  exten-
sive  and superficial, or  localized  and deep.  It is  commonly placed
about the tracheal bifurcation, and may cause necrosis  of one or more
rings, these in some few cases having been coughed up.   As a result
of this gummatous  ulceration the surrounding  organs are involved,
                                 27 
418       GENITO-URINARY DISEASES AND  SYPHILIS.

and in some cases the  oesophagus, the aorta, and thp posterior medi-
astinum have been opened.
   If the respiratory tubes  recover from the inflammatory process,
subsequent cicatricial contraction may seriously embarrass respiration.
   Symptoms.—When the trachea is involved there may be an obsti-
nate cough, with expectoration of blood-stained sputa, and some pain
and  tenderness behind the sternum.   Large tracheal rales may be
heard on auscultation.   WThen the bronchi are  invaded the prognosis
is less favorable than when the trachea alone is attacked.
   Syphilis may attack the  lungs in the  form  of acute  catarrhal or
croupous pneumonia, somewhat atypical in development, symptoma-
tology, and course, and yielding to constitutional treatment.  This is
exceptional.
   Lung-symptoms depending on syphilis usually develop in the late
tertiary period.  Two forms of lesions are observed:
   1. Diffuse sclerosis, characterized by bronchial catarrh, and alter-
nate areas of dulness and resonance.
   2. Circumscribed syphilitic  gumma, single  or multiple, usually
found  in the middle third of the lungs,  but occurring also  at the
apices.   The   patient  may  exhibit  all  the symptoms  of typical
phthisis.
   A form of chronic pneumonia characterized by diffuse interstitial
infiltration is sometimes characteristic  of hereditary syphilis.  This
may involve the entire  lung or only a portion of it, and is a frequent
cause of  death.   The alveolar septa are so thickened by the specific
infiltrate  that the air-spaces are greatly encroached upon, the lungs
cannot expand, and the pulmonary circulation is interfered with.
   Gummatous  pulmonitis,  the  so-called  syphilitic phthisis,  under
which head are included the  diffuse and  circumscribed  infiltrations,
develops as an ordinary case of consumption, except  that  the  con-
stitutional symptoms are at first less marked and the  course  is less
rapid.  The disease begins with a cough, slight dyspnoea, and mod-
erate expectoration, usually without fever.   Percussion  dulness and
bronchial breathing are found over the  diseased area.  As the gum-
matous infiltrate  increases, the expectoration becomes more profuse
and  cavities  form.   Hectic  is developed, and  all  the characteristic
symptoms of advanced phthisis  appear.
   The mid-portions of the lungs are, according to the majority of
reports, most frequently affected.
   Diagnosis.—The diagnosis  is  founded upon a syphilitic history and
the presence of other manifestations of  the disease, such as  laryngeal
lesions, perforation of the palate, and skin cicatrices.   Letzel  states 
SYPHILIS OF  THE  RESPIRATORY TRACT.
419
that a sharply circumscribed area of dulness at the lung hilus is sug-
gestive, as is also an alteration of the proper relation which should
exist between the severity  of the symptoms and the length of the
disease.   Tubercle  bacilli are not  found in the  expectoration, and
constitutional treatment produces rapid improvement.
   Primary involvement of  the pleura, with characteristic symptoms
of pleurisy, is almost unknown.   There may, however, be a pleuritis
with effusion secondary to specific pulmonary involvement.
   Treatment—This is practically the same as that applicable to cases
of pulmonary tuberculosis, with the  addition of potassium iodide
pushed to the limit  of  toleration,  supplemented by inunctions of
mercury. 
CHAPTER  XII.
SYPHILIS OF  THE BONES  AND JOINTS.--OF THE  MUSCLES.--OF THE CIRCU-
   LATORY SYSTEM.--OF THE LYMPHATIC SYSTEM.—OF THE ABDOMINAL VIS-
   CERA.--OF THE GENITO-URINARY ORGANS.

   Lesions of the bones are among the most frequent manifestations
of constitutional syphilis ; indeed, as a seat of predilection, the osseous
system takes second rank, being surpassed only by the skin and mucous
membrane.
   Symptoms of bone-involvement may appear very early, at times
even  before  the skin  eruptions.  Usually the lesions are distinctly
tertiary in type and in their time of appearance.
   The scrofulous  temperament, cachexias which  are liable to be at-
tended with alteration of the bones, as gout or rheumatism, and par-
ticularly traumatism, often slight and unnoticed  in itself, are causes
which predispose to the development of specific bone-lesions.   Super-
ficially placed bones, such as the frontal bone, clavicle, sternum, radius,
ulna,  and tibia, are affected most frequently mainly because they are
so often exposed to slight injury.
   The lesions produced by syphilis vary from a simple periostitis to
the formation of typical  gummata.  These lesions may undergo resolu-
tion, or may be followed by exostosis, eburnation, caries, and necrosis.
They  may be classed under the following heads:
   1.  Simple osteoperiostitis.
   2.  Rarefying ostitis.
   3.  Gummatous osteoperiostitis.
   Osteoperiostitis, also called  precocious periostitis, may develop
at the time of skin  eruption, or even before  this, within  three weeks
of the appearance of  a chancre; more commonly it occurs either
in the first three  months of the disease or in the tertiary period.
Pathologically it does  not differ  from osteoperiostitis due  to non-
specific causes.  The periosteum  becomes hyperaemic, and  there is
cellular infiltration  of  its  deeper  layers and the  contiguous portion
of the bone.  The bones of the cranium, the tibia, the ribs, the ster-
num,  and the clavicle are most frequently affected.
   Symptoms.—These are  subacute in type.   On examination there is
detected a tender,  slightly elastic swelling,  evidently growing from
the bone; the  skin may be  slightly puffed  and reddened,  and the
     420 
SYPHILIS OF  THE  BONES AND JOINTS.
421
pain is often intense, especially at night.  Usually the symptoms yield
promptly to treatment, the swelling disappearing  without  leaving a
trace of its seat.   Sometimes, however, in place of resolution, osteo-
genesis takes place, and bony nodules called osteophytes permanently
mark the seat of  trouble; or from a deposit of bone on the walls of
the Haversian canals the osseous tissue  may become  unduly dense,
resulting in eburnation.
   Rarefying Ostitis.—When the inflammation is more intense
the cellular infiltrate not  only invades the  lower layer of  the perios-
teum and the bone surface, but penetrates  along  the course of the
Haversian canals, eroding their bony walls, and substituting for the
solid osseous substance soft embryonal tissue.   If the process is acute
the normal tissue may entirely disappear  at  the seat of  infiltration,
and suppuration  may take place, resulting in the formation of a bone
abscess and in caries or necrosis.
   Usually the embryonal tissue gradually encroaches upon the  bone-
tissue, till  the latter much resembles  sponge  in shape and structure,
or the infiltrate may become organized, obliterating the lumen of the
Haversian canals, and  filling the medullary canal with a hard, heavy,
compact, osseous tissue, producing eburnation.   Caries and necrosis
may also occur at the seat of eburnation as a result of ischaemia inci-
dent to obliteration of  the Haversian canals.
   Gummatous Periostitis, Ostitis, and Osteomyelitis.—While
the simple and rarefying  forms of osteoperiostitis offer no clinical or
pathological features which will distinguish them from similar lesions
due to causes other than syphilis, the formation of  gummata in bone
points definitely  to syphilis.  The lesions  appear as tumors varying
in size and exhibiting  a tendency towards  centric caseous degenera-
tion.  These tumors are formed by  rarefying ostitis in which  the
superabundant subperiosteal or medullary embryonal tissue under-
goes the  changes  and arrangement  characteristic of the gumma.
These gummata may develop in the deeper layer of the periosteum,
in the bone-substance, or in the medullary cavity.  They  are usually
multiple, and may invade any portion of the skeleton.
   The  gummatous involvement of the bone may be circumscribed
or diffuse.
   Circumscribed gummatous  osteomyelitis  appears  in  long  bones in
the form of nodules developing  in  the medullary  canal.   Centrally
they  are found to be  softened or undergoing caseous degeneration,
while peripherally they are surrounded by a sclerosed area.  In the
spongy tissue the gummata are imperfectly encapsulated by the same
fibrous formation. 
422
GENITO-URINARY DISEASES AND SYPHILIS.
   Diffuse Gummatous Osteomyelitis.—The  lesions of this form of
bone  syphilis more frequently involve the  soft parts  in  gummatous
                                         changes, resulting  in the
                 Fig. 153.                  formation of fistulae leading
                                         to the bone.  The perios-
                                         teum is always infiltrated;
                                         the bone is greatly deformed
                                         and  appears worm-eaten.
                                         Its   surface  is  irregular,
                                         studded with  osteophytes,
                                         perforated  with  small or
                                         large openings, and exceed-
                                         ingly unequal.   (Figs. 153,
                                         154.)  Some of these  per-
                                         forations are small, others
                                         as large as two-fifths of an
                                         inch in diameter.  On sec-
                                         tion  of the bone  hyper-
                                         ostosis and eburnation will
                                         be found in some regions,
                                         and  marked rarefaction in
                                         others, the  whole  bone
                                         being   considerably  in-
                                         creased in  volume.   The
                                         new ossification is exceed-
                                         ingly irregular in position
                                         and  consistence.  The bone
                                         is often so brittle that the
                                         least effort is  enough to
                                         break it.   Indeed, the ir-
regular eburnation and rarefaction are  considered by Oilier as char-
acteristic of  the osseous lesions of syphilis.
    All  these lesions  are  marked by absence  of suppuration and by
the rarity of extensive necrosis.   As a result  of intense rarefying
periostitis, particularly where  this is  diffuse, there is always destruc-
tion of bone-tissue.  When the flat bones are attacked, lesions may be
circular or semicircular in arrangement.  This circinate arrangement
is rarely observed in the  long bones.  Nearly  always associated with
the destruction of  tissue there is noticed  peripherally  a formative
ostitis.   This follows  the  course of  destructive  action,  resulting  in
overgrowth and eburnation.
    Necrosis usually results in consequence of the too energetic osteo-
Skull showing the results of gummatous osteoperiostitis. 
SYPHILIS OF THE BONES AND JOINTS.
423
genetic action.  Most of the  sequestra  are  found to be eburnated.
Sometimes  the  bone  seems almost normal  in structure, often being
cut off from  its nutrition  by a peripheral  gummatous  infiltration,
which obliterates its vessels and deprives it of  nutrition.

                             Fig. 154.
        Vault of the cranium exhibiting the results of gummatous osteoperiostitis.

   Tegumentary lesions  may cause bone  necrosis by  extension  of
infiltration to the periosteum ; thus the nasal bones and  cartilages are
most frequently destroyed.
   The more chronic forms resulting in osteosclerosis and osteoporo-
sis are attended with few subjective symptoms, perhaps nothing more
than boring nocturnal  pains, which are usually considered as  rheu-
matic.
   Symptoms.—The symptoms of gummatous bone-involvement are,
when the lesion is circumscribed and begins in the periosteum, fairly
characteristic.  There is formed a painless tumor of slow growth and
unaccompanied by subjective symptoms, which softens  centrally and
exhibits  a peripheral ring of  dense induration.   Several bones  are
often invaded at the same time, or  the lesion is  multiple, and there is
commonly a syphilitic history to be elicited.  The diagnosis between
syphilitic and tubercular ostitis will be founded on the points of differ-
ence formulated in  the following table : 
424
GENITO-URINARY DISEASES AND  SYPHILIS.
         Syphilitic Ostitis.                      Tubercular Ostitis.
Syphilitic ostitis  occurs  in  varying  Ostitis of tuberculosis occurs in persons
  physical conditions.                   who  have  other symptoms , of  this
                                     disease.
Begins most  frequently in the perios-  Begins in the medulla.
  teum.
Tends to the formation of  new bone or  Tends to disintegration of the parts.
  necrosis.
Is  often unaccompanied by  suppura-  Generally terminates  in the formation
  tion.                                of pus.
Does not involve neighboring articula-  Apt to do so.
  tions.
Frequent in bones of the cranium.       Scarcely ever found in this situation.
Histologically, consists of a  relatively  Made up of a varying number of tubercle
  large mass of granulation-tissue.         granulations and surrounded by iso-
                                     lated granules.
In the majority of cases can be cured, or  Nothing short of operative interference
  at least arrested, if taken in time, by    materially affects the course of  this
  judicious specific treatment.            disease.

    Osteosyphilosis of the  Cranium.—Precocious  osteoperiostitis
and ostitis,  together with tertiary exostoses,  are  frequently observed
in the bones of the  cranium.  The exostoses may develop upon both
the external and  the internal table.   In the latter case they are danger-
ous to life from pressure and  from the  meningitis which they excite.
Rarefying ostitis  and gummatous periostitis are often  observed, with
consecutive  eburnation, as are also  circumscribed gummata.   These
lesions  may develop in the diploe, or  in the pericranium, or in  the
dura, involving the bone  subsequently.
    When placed upon the cranium the gummatous lesions exhibit a
circinate arrangement and cause  but  scanty suppuration. Frequently
small and multiple gummata will involve a considerable extent of sur-
face, circumscribing a large  portion of the internal or the external
table, which eburnates, becomes ischaemic, and necroses.   When the
pericranium alone is involved, the external table is destroyed.  When
the syphiloma is located in the  dura mater, it is the internal table
alone that  is involved.  When  syphilomata of the pericranium  and
the dura are developed on opposite  portions  of the same bone, com-
plete perforation may result.  This  may  also follow  from a  gumma
developing in the diploe.
    Gummata of  the dura mater  are accompanied by a circumscribed
pachymeningitis, which is sometimes hemorrhagic.   Frequently these
gummata developing upon the dura are  followed by no external signs,
though sometimes they may consecutively involve the  soft tissues  and
suppurate.   Dry caries resulting in the  formation of stellar cicatrices, 
SYPHILIS OF  THE BONES AND  JOINTS.
425
sometimes in complete perforation, due  to  gummatous  infiltration
followed by absorption, is comparatively rare.   Usually the soft parts
are involved, and there is the ordinary form of caries or necrosis.
   The external exostoses  of the cranial  bones are similar to those
observed in the  other parts  of the body.  Exostoses encroaching upon
the brain are interesting from the fact that they sometimes  occasion
compression symptoms and excite meningitis or encephalitis.
   These projections are noticed over the frontal, parietal, temporal,
and occipital bones.
   Some instances of general hyperostosis due to syphilis have been
observed.
   The bones of the face, particularly those of the  nose, are favorite
seats of gummatous infiltration.   The affection may develop primarily
in the bone, or may be secondary to ulcerating or tubercular gumma
of the soft parts.  The  superior maxilla frequently exhibits  these
lesions, particularly the alveolus,  the  palatal  plate,  and the  nasal
process.  The disease usually goes on to necrosis.
   The vertebrae exhibit the  ordinary bone-lesions of syphilis, but
are perhaps  especially apt to  suffer from circumscribed gummata.
Caries and necrosis may  develop, followed  by spinal  deformity,—
syphilitic Pott's disease.   As in tubercular disease of the spine, the
cord and its envelopes, the spinal nerves,  and the surrounding parts
may be affected either  by pressure of the infiltrate or by involvement
in the inflammatory process.
   Osteosyphilosis of the foramina may from  the swelling cause pain,
analgesia, or paralysis,  due  to pressure  upon the spinal nerves.
   The tibia is more often involved in tertiary syphilis than any other
of the long bones. Caries, necrosis, and exostoses  are frequently
noted.
   The Phalanges.—Syphilitic dactylitis appears  in the form of  a
gummatous deposit, which may involve the subcutaneous connective
tissue of the fingers and toes, together with the periosteum and bones
of these  parts.   This  involvement appears in a superficial and in  a
deep form.
   In the superficial form there is gummatous infiltration of the sub-
cutaneous tissues,  which  subsequently involves the  ligaments sur-
rounding the  joints.   If the  toes are affected  they generally exhibit
the lesions through their entire length.  In the fingers the hardening
and enlargement are commonly limited to  a single phalanx.
   Syphilitic  dactylitis is characterized by a  slow, painless  swelling,
most marked  on the dorsal  aspect of the finger, and rarely extending
farther up than the metacarpo-phalangeal articulation.  There is some 
426        GENITO-URINARY DISEASES AND SYPHILIS.

discoloration of the  affected area; the region of the  joint becomes
swollen,  and from softening of  its ligaments there results preter-
natural mobility.   These enlargements exhibit little tendency towards
softening and ulceration.  Hydrarthrosis is rarely observed.
   This form of the disease develops as a late secondary or distinctly
tertiary manifestation.
   The deep form appears as a specific osteomyelitis and  periostitis.
It  usually involves an  entire carpus or tarsus, though it may be con-
fined to  the  opposing  extremities of two phalanges.  The proximal
phalanges of the fingers are commonly attacked,  often several at one
time.  When the  metacarpal bones are also involved, these are gen-
erally of  the thumb and the index finger.
   This  form occurs late  in  the disease, from five to fifteen  years
after the appearance of chancre.   It is chiefly limited to  the bones
and  the  periosteum, the integument being seldom involved.  Some-
times, however, when the process is rapid and extensive, ulceration,
caries, and necrosis result.   As the joint becomes involved, the carti-
lages are eroded and crepitus  may be detected.   From infiltration of
the ligaments and capsule the function of the joint may be seriously
interfered with,  the  latter  being  sometimes  rendered too  loose, or,
again,  from extensive  swelling motion  being almost entirely  pre-
vented.  Even  when ulceration  does not take place  there may be
shortening or deformity of the bone  consequent upon dry caries or
interstitial absorption.
   Syphilitic dactylitis  occurs much more frequently in  hereditary
than in  acquired  syphilis.   The  fingers are  less frequently affected
than the  toes.
                    SYPHILIS  OF  THE JOINTS.
   Arthralgia.—During the secondary period arthralgia is  a common
and  early  manifestation  of constitutional  disease.  This  sometimes
precedes the eruption, and  may be unaccompanied  by fever.  Pain,
which is  often much w^orse at night, is the only symptom.   There are
no discoverable lesions.
   Synovitis may develop at the same time; usually it comes later;
it may be either polyarticular or  monarticular, or may appear in the
form of hydrarthrosis.
   Acute polyarticular  synovitis is characterized by practically the
same pathological changes  that  are  observed, for instance, in poly-
articular  rheumatism.
   Reference to  the symptomatology and diagnosis of this affection
has already been  made.  In one or two weeks,  especially if specific
treatment is instituted,  resolution takes place. 
SYPHILIS OF THE BONES AND  JOINTS.
427
   Acute  monarticular  synovitis exhibits the same symptoms as the
polyarticular form of the affection, except that  the disease is strictly
confined to  one joint, usually the knee, is intensified, and is much
more liable to become chronic.   Moreover, it  yields slowly to treat-
ment.  This monarticular form of trouble sometimes follows the poly-
articular involvement, resolution taking place in all but a single joint.
Pathological changes are in this case more pronounced.
   Hydrarthrosis, or chronic hypertrophic synovitis,  pursues prac-
tically the same course as chronic synovitis from other causes.  There
is thickening.  The synovial membrane  is tufted, and there is a gum-
matous infiltration extending even to the articular  cartilages and  the
ligaments.  There is a marked effusion  into the joint, and ultimately
it may be rendered useless, either from  limitation  of motion or from
absolute fixation.  When  there  is extensive involvement of the car-
tilages and  bones, osteophytes  may form, resulting  in  partial  or
complete bony ankylosis.
   Gummatous arthritis, a late manifestation of syphilis, is char-
acterized by the development of gumma, primarily of the ligaments or
articular cartilages, generally accompanied by  the  synovial changes
encountered in hydrops articuli,—i.e., thickening and  tufting of  the
synovia.  In certain cases  the  nodular  gummatous infiltration may
be distinctly felt in the general swelling involving the joint.
   The amount  of serous  effusion varies greatly.   Either resolution
may take  place or the joint-cavity may open  and suppurate.  The
joints may  be secondarily involved from gummatous or ulcerative
processes of the  overlying parts, or of the bones entering into  their
formation.
   The joints  most frequently involved  are the  sterno-clavicular  and
the knee;  the  elbow, the wTrist, and the  ankle follow next in order of
frequency.
   Symptoms.—Gummatous synovitis  when it develops  first in  the
capsular synovia  causes  few symptoms aside  from  an  apparently
movable, circumscribed  tumor.   Exceptionally the wiiole joint  be-
comes quickly swollen, and there are limitation of  motion and rapid
muscular atrophy.  Ultimately there are more or less fixation and per-
manent deformity.  If the bone is involved in the gummatous process
the swelling is  usually more marked, the  articular extremity of the in-
volved bone becoming distinctly thickened, and muscular atrophy is  ex-
tremely rapid.   The subjective symptoms are often in their mildness
out of proportion to the apparent severity  of the lesions.  With a greatly
swollen and inflamed knee-joint the patient may be able to walk with
comparative  ease and comfort.  If, however, the cartilage has been 
428        GENITO-URINARY DISEASES AND SYPHILIS.

eroded there may be total  disability, and in any event there is likely
to be more or less pain, particularly severe at night.
   Diagnosis.—The comparative  rarity of syphilitic  joint affections
and their similarity to tuberculous involvement usually lead to an in-
correct diagnosis and to the needless loss or sacrifice of an articula-
tion.  This is particularly true of the knee-joint.  Syphilitic synovitis
presents no  clinical feature  in  its course by which it can be distin-
guished from  other forms of synovitis.   The  therapeutic test should
be employed in all doubtful  cases.  In the acute forms of the  affec-
tion  the absence of heart-lesions  and failure of antirheumatic reme-
dies  may suggest the true nature of the synovitis.
   Chronic syphilitic hydrarthrosis, in the absence of a history or other
signs or symptoms of syphilis, cannot be distinguished from tubercular
synovitis except by the therapeutic  test.  Under the  use of mercury
and  potassium iodide enormous effusions may slowly disappear.
   Gummatous arthritis and synovitis can be positively diagnosed only
by the evidence offered by other lesions  of syphilis, such as ulcerating
gummata of  the skin.   Tubercular arthritis differs  from the gumma-
tous in the fact that it is often, though not necessarily, associated with
characteristic tuberculous lesions  elsewhere, that it is more prone  to
ulcerate and  open externally, and that it produces more  rapid and
extensive destruction of the bone.
   Prognosis.—The prognosis of syphilitic joint disease is compara-
tively  good.  The  synovitis yields readily to  specific   treatment.
Arthritis, even though  cartilages and joints are extensively involved
and  there  are contraction and deformity, is also curable by consti-
tutional  treatment,  reinforced  in certain  cases  by sequestrectomy,
partial arthrectomy, or other surgical procedure.  Even  when total
arthrectomy is required, provided the nature of  the disease has  been
recognized, the  prognosis is infinitely better than if the joint disease
has been due to causes other than syphilis.
   Prognosis.—The prognosis of syphilitic arthritis is favorable when
the  affection develops  early in the course of syphilis and is recog-
nized and promptly treated.   Later, atrophic changes, or those due to
infection, produce permanent deformity  and disability.
    Treatment.—The treatment of syphilitic joints consists in the ad-
ministration of mercury and potassium  iodide,  except  in the forms
occurring  in  the beginning  of  the secondary period, when  mercury
alone should be given.   The  local treatment  is the same as that
appropriate  to other forms  of non-suppurative  arthritis.   Rest and
pressure procured  by splints  and bandages, counter-irritation, and
massage are indicated. 
SYPHILIS OF THE MUSCLES.
429
   Bursitis.—The  bursae may become acutely  inflamed, exhibiting
the characteristic  symptoms of this affection.   This is extremely
rare.
   Much more  common, though still  rarely encountered, is gumma-
tous bursitis, usually observed in the prepatellar bursa, appearing  in
the form of a  nodular, painless, fluctuating  swelling, which is prone
to soften and break  down.

                   SYPHILIS OF THE  MUSCLES.
   Acute  irritative myositis develops very exceptionally during
the first year  of secondary syphilis.  The symptoms are  identical
with those of  a muscular  rheumatism winch is slow in onset and
somewhat chronic in type.
   There is dull pain, aggravated by pressure or motion.  Sometimes
this  is exceedingly  severe.  The biceps and triceps  are most fre-
quently involved.  They sometimes exhibit  irritative contraction se-
riously interfering with the motion of the part  and controlled only
by constitutional treatment.
   The symptoms yield readily to vigorous mercurial treatment.
   Tertiary syphilis may attack the muscles in the form of—
    1. Chronic  interstitial myositis.
   2. Gummatous myositis.
   Chronic interstitial myositis begins as a cellular infiltration of
the muscular  fibres; the infiltrate subsequently becomes organized
into connective tissue, resulting in muscular contractures and atrophy.
   The pathological changes are most marked  in the bellies of the
muscles; the anal sphincter and the humeral biceps are most fre-
quently involved, though  contractions of the sterno-cleido-mastoid,
pectoralis major, rectus abdominalis,  masseter, and many other
muscles have been noted.
   Symptoms.—There are, in addition  to  severe  pain, slight  tender-
ness, limitation of motion, and diffuse swelling.  As the disease pro-
gresses the  muscle atrophies and shortens.
   Diagnosis.—Chronic  syphilitic  myositis when  unaccompanied by
other and more characteristic signs of syphilis may imitate muscular
rheumatism.  The  syphilitic  affection is, however, unattended by
constitutional symptoms or joint-involvement.   It develops without
apparent cause.   It  is slowly  and  persistently progressive, and  is
shortly accompanied by contracture.   Moreover, it  exhibits marked
predilection for certain  muscles.  In  all these points it differs  from
muscular rheumatism.  The therapeutic test should positively decide
the matter. 
430       GENITO-URINARY DISEASES AND SYPHILIS.

   Gummatous  myositis differs  from the interstitial  infiltration
only in the facts that it is circumscribed, forms a distinct tumor, often
involves  neighboring  parts, and exhibits  a tendency to degenerate,
soften, and discharge.
   Gummata of muscle  are usually late  manifestations of syphilis;
in the malignant forms of the disease these may develop in the first
year,  and under such  circumstances are apt to suppurate.
   Symptoms.—Usually gummata develop  as painless, slowly growing
tumors, seated at the  point of insertion of the muscle or in its belly,
movable with the latter, but fixed when it is strongly contracted; ex-
ceptionally, when infiltration is  rapid,  there may be great pain and
tenderness.  The  tumor  usually reaches the size of a man's fist.
Sometimes it grows to the size of a child's head ;  it may then simu-
late malignant  disease so closely that  the therapeutic test  alone will
enable  a diagnosis to  be  made.    These gummata are  absorbed,
soften, or become converted into dense fibroid  masses.  The  trape-
zius, pectoralis major, gluteus, biceps, and  lingual muscles are oftenest
affected.
   Prognosis.—Diffuse interstitial myositis and muscular gummata if
treated  early yield  completely to iodides  and mercury; later, when
the muscular fibres have  atrophied and cicatricial contractions have
occurred, constitutional treatment is unavailing, except to prevent fur-
ther  extension of the syphilitic process.
   Syphilitic  tenosynovitis may appear in the acute, the chronic,
or the gummatous form.
   Acute Tenosynovitis may develop in the  early secondary period,
and  is characterized  by effusion, tenderness, and swelling  along the
course of the tendon.  It subsides  quickly under specific treatment.
Several tendons may be affected simultaneously, and there may be
great  pain and  tenderness, and an associated syphilitic synovitis with
fever.  The affection is more common  in women than in men.
   Chronic  Tenosynovitis.—Rarely,  chronic  tenosynovitis  develops,
characterized by effusion and  crepitation along the course of the ten-
don.  It is accompanied by some thickening of the sheath,  especially
observed about the extensor tendons of the fingers and toes and the
biceps tendon.
   Chronic syphilitic tenosynovitis is usually painless and yields slowly
to constitutional treatment.  It  presents the same  symptoms as the
non-specific inflammations of the tendon-sheaths.
   Gummatous Tenosynovitis.—Gummata  sometimes develop  in the
sheath of the tendon.  These are  painless, and  are  either  round or
spindle-shaped.  Exceptionally the gumma appears in the  form  of a 
SYPHILIS OF THE CIRCULATORY SYSTEM.
431
diffuse infiltration.  These gummata subside promptly under specific
treatment.  They are most frequently found  on the tendo  Achillis
and the biceps  tendon.   The  diagnosis is  usually facilitated by the
presence of gummata elsewhere, particularly in the muscles.  In the
absence of these or other signs  of syphilis, a trial of specific treatment
should  be instituted.  The development of the gumma usually distin-
guishes it from other  tumors, enchondroma, for instance, since sooner
or later, in the absence of specific treatment, the gumma softens and
breaks  down, forming a characteristic ulcer.


            SYPHILIS OF THE CIRCULATORY SYSTEM.
   Heart.—Syphilitic involvement of the heart is exceedingly rare.
It usually appears as a late tertiary manifestation, according to Jullien,
about the tenth year after the  infecting chancre, though  it  may de-
velop in the first year of constitutional syphilis.  The disease  appears
as a diffuse chronic myocarditis or in the form  of gummata.
   Syphilitic Myocarditis.—Fusiform areas of  small round-celled in-
filtration of the heart-muscle first appear; these become converted
into  connective tissue and form thick, white  cicatrices.  The  cica-
trices are usually few in number, and are found in the walls of the
left  ventricle, frequently lying  just below the  endocardium  or  peri-
cardium.
   Gummatous myocarditis develops in the form of tumors,  varying
from the size of a pea to that of a pigeon's egg.  These tumors present
the same  appearance as gummata in other regions; that is, there is a
central caseous  mass, surrounded  by  a thick,  fibrous sheath, in the
periphery of wiiich the muscular fibres  are in  a condition  of fatty
degeneration.
   Endocarditis  and Pericarditis.—Syphilitic inflammation of the
membranes of the heart  is rarely primary.   It is commonly found
about the regions wiiere gummata or patches of chronic  myocarditis
have developed.  When the endocardium of the valves  is attacked,
insufficiency  may result from cicatricial contraction.
   Symptoms.—The symptoms of syphilitic involvement of the heart
or its envelopes are exceedingly vague.  Generally the affection is not
detected until it is so  far advanced that treatment offers little  prospect
of cure.   Sometimes patients complain of shortness of breath, palpita-
tion, anginose pains, or irregularity of  the  pulse.  At  the  same time
examination  of the heart  shows an increased  area of dulness, some
muffling of the  sounds, and frequently blowing  murmurs, the exact
cause and location of which it is difficult to discover. 
432        GENITO-URINARY DISEASES  AND SYPHILIS.

   In all these symptoms  there is nothing  characteristic.   The diag-
nosis can be made  only by exclusion  and by  eliciting a history of
preceding syphilis.
   Prognosis.—This must always be guarded.   The disease  passes
through its various phases so slowly and  with so few symptoms that
it is rarely suspected until cicatrices have formed.  In a large number
of the reported cases death has  been  sudden  and  unexpected.  In
three cases death occurred during defecation.
   Treatment.—The  treatment consists in the  administration of potas-
sium iodide, the  doses  being rapidly pushed  to the  extreme limit of
toleration.   At the same time remedies appropriate  to the functional
troubles, as evidenced by the clinical  symptoms, should be given.
   Arteries.—Syphilitic involvement of the arteries is generally a
tertiary lesion, but has been observed in  the  first few months of the
constitutional disease.
   Syphilitic arteritis may be acute or chronic in type.  In either case
the pathology is much the same.   There  is at first a cellular infiltra-
tion, usually beginning as a periarteritis and involving all the coats of
the vessel, causing its walls to  become irregularly  thick, hard, and
non-elastic, and  narrowing or quite  obliterating the blood-channel.
Even should the  infiltration not mechanically close the vessel lumen,
as a result  of  endarteritis,  thrombi frequently form, thus preventing
circulation through the diseased area.
   Endarteritis may be of the sclerous  or of the gummatous type.
   Sclerous endarteritis  is the  commonest form  of  the affection.
The  infiltrate  is  converted into  fibrous tissue,  producing whitish,
opaque patches  of  hardening,  which  may appear  as  disseminated
plaques or  as small  nodulations, usually  involving the entire circum-
ference of the vessel.
   Gummatous endarteritis  is extremely rare; it is ahvays associated
with the sclerous degeneration  and with periarteritis, and on section
shows the broken-dowrn, cheesy contents  of the typical gumma.
   Syphilitic arteritis affects usually the smaller arteries, and particu-
larly those of  the brain.  Ry weakening  the  vessel-walls  and by in-
creasing the blood-pressure from  local  obstruction to circulation the
disease strongly predisposes to the formation  of aneurism.
   Symptoms.—The  symptoms of syphilitic arteritis depend upon the
disturbances of function incident to the ischaemia which  follows nar-
rowing or obliteration of the arterial lumen.   When collateral circula-
tion  is readily established, but little functional disturbance may result
from obstruction of one or more vessels.  When there is no provision
for collateral circulation, however, as  in the areas supplied by smaller 
SYPHILIS OF THE LYMPHATIC SYSTEM.
433
cerebral arteries,—and it is these that are most frequently implicated
in syphilitic arteritis,—functional disturbances may be pronounced.
   Cerebral  ischaemia from  syphilitic arteritis  is  characterized by
frontal  headache,  followed  in weeks  or  months  by epileptiform at-
tacks, hebetude, somnolence,  hemiplegia,  particularly marked in the
upper extremity,  usually attacking  the right  side, accompanied by
aphasia, and sometimes coming on without loss of consciousness, and
finally by coma and death.
   When in consequence of syphilitic arteritis aneurism develops, be-
yond a history of syphilis and the presence of other manifestations of
the disease there  are no diagnostic signs which would point to the
nature  of the lesion.   These aneurisms form mostly in the brain, and
produce much the  same functional disturbances as have been described
as attendant on sclerous arteritis.
   Occasionally the  larger vessels  are  involved.   Cases of  aortic
aneurism almost certainly originating in syphilitic changes in the walls
of the great vessels have been reported.
   Prognosis.—The prognosis of syphilitic arteritis is bad.  This  is
because symptoms rarely develop till sclerosis is well  advanced, and
particularly in the case of  the brain, because the  alterations in the
nerve-structure are often irremediable.  Aneurisms occasionally yield
to constitutional treatment,  and angina may promptly disappear after
a course of potassium iodide  and mercury, never to recur.
   Veins.—The  veins rarely exhibit  syphilitic  lesions;  when  these
are present they are usually due to extension from a specific neoplasm
lying near the vessel; they are consequently observed  in  the tertiary
period  of the  disease.  Mauriac instances a single case  of phlebitis
and thrombosis involving several vessels and occurring  in the first
few months of constitutional  syphilis.

              SYPHILIS OF THE LYMPHATIC SYSTEM.
   While primary and secondary syphilis produce almost invariably
marked effects upon the lymphatic glands, the tertiary form of the dis-
ease manifests itself in the lymphatic system with comparative rarity.
   The surface glands are much more rarely involved than are those in
the neighborhood  of viscera.  Of the deep glands, post-mortem exami-
nations  have shown  that those ordinarily involved are the bronchial,
the pulmonary, the mediastinal, the hepatic, and the gastric.
   The superficial glands  most frequently affected are those in the
supraclavicular, infraclavicular,  cervical,  inguinal, and  axillary re-
gions.  Patients of a scrofulous temperament are most subject to
these enlargements.
                               28 
434       GENITO-URINARY DISEASES AND SYPHILIS.

   The sclerous  and gummatous types are recognized.  Roth are
characterized by  primary enlargement incident  to  hypertrophy and
cell proliferation.  The tumor formed is at first regular in  outline,
smooth, freely movable beneath the skin, and indurated.
   Enlargement of a single gland is rare.  Usually a whole group of
glands in one region of the body is involved.  The tumors vary from
the size of a cherry to that of a man's fist.   Usually they are no
larger  than  a hickory-nut.   Having reached this stage, the tumors
may slowly undergo  resolution,  taking  sometimes months or even
years to accomplish  this; or exceptionally they  may continue to en-
large, becoming soft,  adhering to the skin, and ulcerating, discharging
thick, yellowish pus containing shreds of necrotic tissue.  The small
opening at first formed becomes rapidly large, with indurated, ragged
edges surrounded by a brownish-red area of congestion.
   Exuberant granulations may  be formed, resulting  in  fungoid
growths.
   Specific treatment and local applications cause rapid healing of
these ulcers.   There remains a deep, irregular, pigmented scar.  Oc-
casionally these ulcerating syphilitic lymphomata become phagedenic,
exposing the patient to the dangers incident to  this form of inflam-
mation.
   Diagnosis.—The  diagnosis of  syphilitic  lymphomata is often ex-
ceedingly  difficult, and can be established only by careful attention to
the history of the case.
   Syphilitic adenopathy may closely simulate  tubercular  adenitis.
The latter, however,  is usually observed in infants,  or at least during
early adult life; is accompanied by other  evidences of a tubercular
diathesis ; attacks by preference the cervical and  submaxillary glands;
is more generalized, and forms larger tumors ; commonly exhibits sup-
purative periadenitis with formation of fistulous tracts not distinctly
ulcerative in type ; does not become phagedenic,  and is not improved
by specific treatment.  Cancerous adenopathy is nearly always sec-
ondary.  The tumor grows rapidly, becomes adherent to surround-
ing tissues, ulcerates, bleeds,  and progresses in spite  of treatment,
producing profound cachexia.
   Prognosis.—Except in cases where general ulcerating lymphomata
become phagedenic, the prognosis is exceedingly good.
    Treatment.—Early treatment nearly always occasions prompt reso-
lution.  Roth potassium iodide and mercury should be given, the for-
mer drug  in full doses, the  latter internally, and locally in the  form
of inunctions.  Even when  distinct fluctuation is  noted, the knife
may not be necessary. 
SYPHILIS OF THE LIVER.
435
   Local counter-irritation and the administration of tonic and sup-
porting treatment will hasten resolution.
   Ulcerating gummata of the lymphatic glands are exceedingly rare.
   The treatment consists in the administration of potassium iodide
pushed to its extreme limit and reinforced by mercurial inunctions.

                    SYPHILIS OF  THE LIVER.
   The  liver may be affected in  both the secondary and the tertiary
period of syphilis.  Involvement in the secondary period is exceed-
ingly rare; tertiary lesions, however, affect  the liver more frequently
than they do any other abdominal organ.
   Precocious syphilis of the  liver  appears  in the  first three
months  of the constitutional disease  as hypertrophy, which may or
may not be accompanied by pain, tenderness,  and jaundice.   The
hypertrophy is general, and may enlarge the liver to twice its normal
size.  On palpation no nodules  are found,  simply a general increase
in size.  The  prognosis is good, the enlargement gradually diminish-
ing under constitutional  treatment, till in from one to three months
the liver is again normal in size.
   Jaundice developing during the secondary  period is rarely due to
syphilis.  The great  majority of such cases,  when unattended by
hepatic enlargement, are  caused  by intercurrent affections, such as a
catarrhal condition of the bile-ducts,  and  are neither directly nor
indirectly dependent upon constitutional syphilis.
   Tertiary syphilis of the liver may appear as interstitial hepa-
titis or as gummatous hepatitis.   These tertiary lesions  are in marked
contrast to the secondary involvement of the liver from the fact that
they rarely appear till late in the disease, from the fourth to the fortieth
year.  They are frequent, they are persistent and rebellious to treat-
ment, and they produce permanent alteration in the liver-substance.
   The  abuse of alcohol, traumatism, and  carelessness in treatment
seem to be the factors which particularly predispose the liver to ter-
tiary manifestations of syphilis.
   Interstitial Hepatitis  (diffuse gummatous infiltration).—This runs
very much the course of an ordinary  cirrhosis.   It begins as a hyper-
aemia, accompanied by an abundant  small round-celled infiltration
of the perivascular connective tissue of the liver.  This cellular hyper-
plasia generally appears in the form  of a perihepatitis, involving the
capsule in disseminated patches,  and  resulting in more or less dense
adhesions to  surrounding organs.  The infiltration of  the substance
of the liver may be general, though it is commonly found in patches.
The  cellular infiltrate becomes, in  part at least, converted into con- 
436        GENITO-URINARY DISEASES AND  SYPHILIS.

nective tissue, which by its contraction causes narrowing and obliter-
ation  of  ducts and vessels  and atrophy of liver-cells.   There is at
first an increase in the size of the liver, general or localized, depend-
ing upon  whether hyperaemia and cellular infiltrates are  diffuse or
appear in  discrete  patches.  Ultimately, as the round-celled infiltrate
in part undergoes fatty degeneration and is absorbed, in part becomes
converted into connective tissue and contracts, the enlarged liver be-
comes smaller; but  this lessening  in  size does not  stop when the
organ has reached its normal dimensions ; the atrophic process steadily
advances;  the surface of the  organ is  lobulated, is marked by deep
furrows, is creased by dense fibrous bands, and the liver is  distorted
almost beyond recognition.   The contraction of the fibrous bands is
often  so pronounced that some of the  lobulations thus produced are
almost completely cut off from the rest of the  liver, seeming to  be
attached only  by the fibrous tissue surrounding the base.
   Together with  atrophy in one portion of the liver there may be
overgrowth in another.   This may be due to amyloid degeneration or
to compensatory hypertrophy, the intact portion of the liver-substance
developing so  that it may take the place of the portion destroyed.
   The furrowing and lobulation are usually much  more distinctly
marked upon the convex than upon the concave surface of the organ.
   Gummatous hepatitis is characterized by the formation of gummata
identical in structure with similar tumors observed in other portions
of the body.   These  tumors vary from the size of a pea to that of a
hen's  egg;  they are most frequently found in the  region of the sus-
pensory ligament and  along the course  of the portal vein, though they
may appear in any part of the liver ; they may be grouped  or irregu-
larly disseminated.  They are gray or yellowish in  color, and either
solid  throughout or broken down in the centre, according  to the
period of  evolution.
   As the gummata  soften  centrally, undergoing fatty and caseous
degeneration and becoming absorbed,  the  peripheral portion  of the
neoplasm  is converted into fibrous tissue, which contracting produces
on the surface of  the liver  deep irregular puckerings, sometimes so
marked as seemingly to  divide the right  lobe  of the liver  into two
halves.  In the deeper portion of the liver irregular branching nodules
are formed, in the centre of which is sometimes found a small amount
of caseous material.
   There  is nearly always associated with these gummatous lesions a
perihepatitis, resulting in dense adhesions  between the liver and the
surrounding structures ; this is particularly marked on the upper sur-
face, and may so limit the respiratory movements of the organ as to 
SYPHILIS OF THE LIVER.
437
constitute a sign of some diagnostic value.   Interstitial hepatitis and
amyloid degeneration of the liver,  spleen,  kidneys, and intestinal
mucous membrane  are  also frequently noted in connection with the
gummatous lesions.
   The gummata of the liver do not ulcerate; they develop slowly,
and may not reach their ultimate stage of cicatrization for several years.
   Symptoms.—The symptoms  of syphilitic  interstitial hepatitis are
rarely wrell marked.  In the early stage there is a feeling of weight in
the hepatic region, followed, often after a long period, by hypertrophy,
slow in development, and unattended by signs of inflammation.  Some-
times the hypertrophy is general, the lower border of the liver ex-
tending three finger-breadths below the margin of the  ribs, and re-
vealing to palpation a smooth, regular surface.  Often the  hypertrophy
is not so marked, palpation showing surface irregularities or eleva-
tions.  It is dependent upon compression of the portal vein from  peri-
vascular hyperplasia.
   Functional disturbances are limited to  general dyspeptic symp-
toms, even these not being noted at times.  As the disease progresses
and atrophy sets in, the only sign which may be considered charac-
teristic is the deformity incident to cicatricial contraction. A nodu-
lar surface, an irregular fissured border, gradually becoming less per-
ceptible to palpation  in one  portion while overgrowth is observed in
another region, and adhesions to surrounding structures, are all  signs
which would suggest syphilis.
   Icterus is  comparatively rare; haematemesis,  diarrhoea,  digestive
troubles, and  swelling of the legs develop as in the case of cirrhosis
from causes other than syphilis.
   Ascites is frequently  noted;  fluid accumulates slowly in the first
place, but on tapping reaccumulates rapidly.  Often there are no pre-
monitory symptoms ; a painless ascites gradually develops, associated
with jaundice, discolored urine, swelling of the ankles, varicose veins,
and possibly albuminuria.
   Gummatous hepatitis in  the early stages may give rise  to no symp-
toms, and may not seriously interfere with the functions  of the liver.
As the disease progresses, the accompanying hepatitis, perihepatitis,
and amyloid degeneration cause most of the suffering and interference
with general health.   The  liver is usually of normal size, presenting
to the examining finger a nodular irregular border.   Gastro-intestinal
symptoms are marked, pain may  be  severe  and constant, and, when
the atrophic process is well  developed,  bleeding from the stomach or
from the oesophagus may become  a serious complication.
   Enlargement of the spleen  and  albuminuria are commonly asso- 
GENITO-URINARY  DISEASES AND SYPHILIS.
ciated with specific hepatitis.   As a consequence of this involvement
of the liver, spleen, and kidneys the  patient wastes  and becomes
profoundly cachectic.
   Prognosis.—The prognosis of tertiary syphilis of the liver is, if the
affection is taken in its  earlier stages, fairly good.   The  gummatous
form yields more readily to specific  treatment than the diffuse or cir-
rhotic form.   When extensive fibroid changes have taken place, and
particularly when there are associated lesions of the kidneys and spleen
and marked cachexia, the prognosis  must be exceedingly guarded.
   Diagnosis.—The diagnosis of liver syphilis is founded upon altera-
tions in the  size and shape of the liver, associated with much milder
symptoms than are attendant on such alterations when they are due
to other causes.   There is usually a history  of syphilis; digestive
troubles are not very pronounced, or, if marked, do not  develop till
late in the disease ; serous effusion into the peritoneal cavity  is mod-
erate in quantity, but is quickly reproduced after having been  evacu-
ated.  These features will aid in distinguishing the ordinary cirrhotic
liver from that affected by syphilitic diffuse interstitial hepatitis.
   Gummatous  hepatitis may  simulate cancer.   The latter affection,
however, rarely occurs  except  in those past middle  age;  it involves
both lobes of the liver.  It is  not so liable to contract adhesions as
the gummata: hence its nodulations are more readily felt; it is ac-
companied by pain  and jaundice, and  produces early and profound
cachexia; it growls much more rapidly than gumma.
   Treatment.—All forms of hepatic syphilis occurring in the early
secondary period should be treated  by mercury.
   In the form generally observed—that is, as a late tertiary mani-
festation—potassium iodide should  be administered in large doses,
beginning with thirty grains a  day and running the  dose  up by five
grains a day till the symptoms yield or iodism is produced.  The dose
required is sometimes as high as two or three drachms daily.
   In addition to the potassium iodide, mercurial  inunctions  should
be given at  intervals.   Tonics, mild  stimulation, bathing, exercise,
diet, and general hygiene must  receive careful consideration.
   Amyloid  degeneration is so frequently associated with syphilis that
the latter must be recognized as an etiological factor in its production.
As when it  complicates tuberculosis, it  may  follow extensive sup-
purative processes.   It is also found, however, in conjunction with the
sclerotic or the gummatous form of hepatitis, and is  commonly com-
plicated by a similar affection of the  spleen, the  kidneys, and often the
intestinal mucous membrane.   The  liver rarely reaches the enormous
size sometimes observed in amyloid  degeneration from other causes. 
SYPHILIS OF THE SPLEEN.
439
   In itself amyloid degeneration does  not  cause ascites, and gives
rise to no functional disturbances until it is far advanced.  Ultimately
digestive disturbances  become pronounced, and, as the result of sim-
ilar degeneration of the intestinal  mucosa,  multiple ulcers  develop,
causing  blood-stained stools.  There is usually oedema, and,  if the
kidneys are also involved, albuminuria.  Cachexia is well marked.
   This degeneration is a late manifestation  of syphilis.
   The diagnosis is based on finding an enlarged, smooth, firm, non-
sensitive liver, together with other signs  of late syphilis.  In amyloid
degeneration  with  gummatous or  sclerotic  processes  the liver may
be ridged, notched, or otherwise deformed.
   The  prognosis  is  extremely grave.   The treatment is that appro-
priate to late syphilis, combined  with  tonics, stimulants,  carefully
regulated diet, and minute attention to general hygiene.

                   SYPHILIS  OF THE  SPLEEN.
   The  spleen, closely associated as it is with the lymphatic system
of the body, is frequently affected in secondary syphilis.  There is a
distinct  enlargement, usually occurring early, but sometimes not for
several  months.   This  enlargement is not followed by functional
troubles.  There  is nothing to  call  the  patient's  attention to the
swelling, and it is rarely observed  unless careful search is  made for
it.  It commonly subsides in the course of  a few weeks or months.
The pathology is probably the same as that of the lymphatic glandular
enlargement of  secondary syphilis.
   Tertiary syphilis may produce gummata  or disseminated or local-
ized splenitis, resulting ultimately in partial  cirrhosis.   These lesions
rarely betray themselves in life by appreciable symptoms.   It is only
as the result of post-mortem  examination  that their existence has
been proved.
   They may be  suspected when physical examination shows in-
crease in the volume  and consistence of the spleen and wiien deep
pressure  elicits  tenderness.  They are nearly always  associated with
similar lesions of the liver and kidneys,  the symptoms  of wiiich com-
pletely mask  splenitis.
   Pronounced leucocytosis and the finding of pigmented masses in
the blood may suggest involvement of the spleen.

                  SYPHILIS OF THE PANCREAS.
   Specific disease of this  organ may take the form of interstitial
pancreatitis or of gummatous involvement.
   These  lesions are  exceedingly rare.   Their presence is  not indi- 
440       GENITO-URINARY DISEASES AND  SYPHILIS.

cated by characteristic symptoms during life.  There is usually marked
involvement of other abdominal organs.

             SYPHILIS  OF THE URO-GENITAL  SYSTEM.
   The Kidneys.—The  kidneys are  less frequently involved in the
lesions of syphilis than are the genitals, the nervous  system, or the
liver.  They may be attacked at any  time  during the course of the
constitutional disease,  the lesions produced, with the exception of
gummata, being  identical with  those which characterize  Rright's
disease in all its varieties.
   As etiological factors,  tuberculosis, rheumatism, gout,  and alco-
holism are all of some importance, but the direct exciting cause is
either the syphilitic virus or the  irritating  toxins produced  by it in
the body and probably excreted through the kidney epithelium.
   Precocious involvement of  the kidney often  closely follows  the
chancre, and  is  manifested by  albuminuria, usually intermittent,
transitory, and moderate.   The total quantity of urine  passed  daily is
not diminished, nor is the specific gravity markedly affected.   Micro-
scopic examination  at  most may show a  few hyaline casts.  This
albuminuria develops during the  early eruptive period and subsides
promptly under treatment.
   Acute syphilitic parenchymatous  nephritis is  characterized by
lesions* of the glandular  part  of  the  organ,  producing a condition
analogous to that termed large white kidney.  It is in reality a paren-
chymatous nephritis, and differs  in no way from this  acute or sub-
acute form of Rright's disease, presenting the same complications and
sometimes terminating fatally.
   Albuminuria, granular epithelial and blood casts, lessened secretion
of urine, headache,  oedema, and other symptoms and signs of acute
nephritis, are present.
   The diagnosis is founded on  examination of  the urine and on a
history of recent syphilis or other signs or symptoms of this disease.
   The prognosis  is favorable.   If parenchymatous  nephritis de-
velops in late syphilis and is associated with gummatous infiltration
or amyloid degeneration  of  other viscera,  the chances of cure are
slight.
   Specific treatment is, however, usually curative, although the albu-
minuria sometimes  persists and the nephritis  merges into a  chronic
form of the disease.
   The more profound  kidney degenerations characteristic of  tertiary
syphilis, but sometimes occurring in  the late secondary period, are
syphilitic interstitial nephritis and gummatous nephritis. 
SYPHILIS OF THE URO-GENITAL SYSTEM.
441
   Syphilitic interstital nephritis  presents the same pathology and
lesions as the non-specific form of the disease.  The symptoms are
those of chronic Rright's disease.   This affection is more grave than
the early nephropathy.  Indeed, after fibrous tissue has once fairly
developed, complete restoration of the kidney to its normal condition
is impossible.
   There  is first a cellular infiltration of the interstitial stroma  and
of the walls of the vessels and perivascular spaces.  This infiltration
is followed by sclerosis, causing atrophy and distortion of the kidney,
particularly noticeable in the cortex.
   The symptoms of specific interstitial nephritis  are the same as
those  of the non-syphilitic  affection.   There are polyuria, lowered
specific gravity, light straw color of the urine, moderate amount of albu-
men, hyaline and granular casts, increased arterial  tension, oedema,
headache, asthma,—indeed, all the well-known symptoms of chronic
nephritis.
   The diagnosis as to the specific nature  of the  affection can be
made  only by finding other signs or symptoms of syphilis.
   The prognosis is unfavorable.
   Gummatous nephritis is rare.  The individual tumors rarely reach
large size.  Cornil states that they are usually multiple and are found
chiefly in the cortical substance  or  in the  pyramids.  Interstitial
nephritis is nearly always found in conjunction with them.
   Jaccoud  states that amyloid degeneration is by far the most com-
mon manifestation of renal syphilis.   Next in order  of  frequency
comes granular atrophy ; third, gumma.
   Wagner  describes  a fourth form, which  he calls syphilitic  glo-
merulo-nephritis.  It is characterized chiefly by haematuria and ends
rapidly in uraemia.
   There  have been a number of carefully studied  cases of diabetes
insipidus of syphilitic  origin: at least  the  prompt yielding of symp-
toms to specific treatment  suggested the syphilitic  nature  of the
affection.
   The treatment of the tertiary kidney-lesions is  conducted on the
same general principles as would  apply to cases of chronic Rright's
disease.  Mercury must be administered cautiously,  since on account
of the crippled condition of the kidneys it is extremely  liable to pro-
duce toxic symptoms.   Potassium iodide is the drug upon which main
reliance should be placed.   It must be given in full doses.
   Amyloid degeneration of the kidney is associated with one or more
of the forms of syphilitic nephritis.   Similar  degenerations of other
organs, notably the  liver and the spleen, are present,  and occasion 
442       GENITO-URINARY DISEASES AND  SYPHILIS.

profound cachexia.   There are no characteristic  symptoms.   The
prognosis is bad.
   The Ureters and the Bladder.—Syphilitic involvement of the
ureters and the  bladder, so far as symptoms are concerned, is prac-
tically unknown.  Some  few cases of  ulceration of the bladder have
been described.
   The Epididymis  and Testicles.—The  syphilitic  virus  may
manifest its influence upon these organs  either in the form of  inter-
stitial inflammation characterized by infiltration, formation of connective
tissue, and atrophy,  or in that of gummata.
   As clinically observed, syphilitic lesion of the testicle appears as a
combination of the forms just mentioned.   Roth epididymis and tes-
ticle may be  involved, the  sclerous and gummatous processes  going
hand in hand.  There  is often  an accompanying  hydrocele.   The
lesions may be  observed at almost any period of syphilis from the
second month to the twentieth year.
   Syphilitic Epididymitis.—The epididymis when involved com-
monly  presents  an  indolent, non-inflammatory,  indurated,  sharply
circumscribed gumma, usually of the right globus major.   Roth epi-
didymes may be affected simultaneously.
   Involvement of the epididymis without implication of the testicle is
rare.  It usually develops towards the  end of the secondary period of
the disease.   It  may be  observed at any time  during  the secondary
eruptions, and at this  period undergoes prompt resolution on  treat-
ment, since, like all  the secondary lesions, it has no marked tendency
towards sclerosis or caseous degeneration.
   When it develops in the late  tertiary period it corresponds  more
closely to the type of the tertiary lesions,—that is, it tends to  break
down and ulcerate.  This occurrence is much rarer, however, than is
the case with tubercular lesions.
   The enlargement never  attains great size.   There are rarely more
than two nodules, which after some months become  of almost car-
tilaginous hardness.   Exceptionally there  may  be a number of small
nodules, grouped at either extremity  of  the epididymis,  the middle
portion being spared.
   Sometimes this  affection may be acute in  its onset and accom-
panied by  inflammatory symptoms.  On  examination,  however,  a
rounded tumor  at the head of the epididymis, or at  both the  head
and  the tail, with slightly irregular surface, not adherent  to the sur-
rounding tissues, probably circumscribed, and without  fusion into the
tunica vaginalis, suggests the nature of the lesion.
   Diagnosis.—The diagnosis of syphiloma of the  epididymis is read- 
SYPHILIS OF THE URO-GENITAL SYSTEM.
443
ily made.  The absence of pain, of tenderness,  of involvement of the
skin, and of hydrocele, together with  the  infiltration of the head  of
the epididymis rather  than of the tail,  would exclude gonorrhoeal
epididymitis.
   From tubercular epididymitis a differential  diagnosis based upon
the local symptoms alone may be difficult.  The tubercular infiltrate
usually involves the caput  major, producing a hard, painless indura-
tion much like that characteristic of syphilis.   This steadily grows
larger, presents a more irregular and nodulated surface than does the
syphiloma, becomes adherent to the skin of the scrotum, softens, and
discharges, forming fistulae.   Tubercle bacilli can be demonstrated in
the discharge by inoculation.  The cord becomes indurated, and  the
seminal vesicles and prostate are usually involved
   Treatment.—Mixed treatment is indicated.
   Syphilitic Orchitis.—After  the  skin and subcutaneous  tissues
and the bones, the testicle is the most frequent  seat of tertiary syphi-
lis. This organ may be involved in the early months of the secondary
period; usually the third year is the time during wiiich tertiary symp-
toms develop.
   The affection may assume the sclerous or gummatous form, though
it must always be recognized that these two processes run their courses
side by side, and that,  while the  predominant lesion may appear as a
cellular infiltration of the albuginea and  its trabeculae followed  by
cicatricial contraction, an examination of  the diseased testicle shows
the presence of small or large gummata.  Per contra, even though the
affection  appears  to be entirely gummatous, it is always associated
with a greater or less degree of interstitial orchitis.  Whether  the
lesion conforms to the  sclerous or to the gummatous type, its onset is
insidious, and it is often bilateral.   Its course is exceedingly chronic,
and it  terminates in (1)  resolution, (2) partial or  complete atrophy,
or (3) destruction by ulceration.
   The most  important predisposing cause of  syphilitic sarcocele  is
gonorrhoeal epididymitis;  traumatism or  sexual excesses may also
lessen local resistance.
   Interstitial or sclerous  orchitis is the common form of syphilitic
sarcocele.   It  may be unilateral or  bilateral.   Eeyond a  sense  of
weight and enlargement, its onset is  characterized by no subjective
symptoms.
   The testicle enlarges  uniformly to two or three times its  normal
bulk.   It forms an indurated, non-sensitive tumor.  The epididymis
is flattened  along  its posterior border, so that  it becomes  difficult to
recognize it on palpation.  The cord is rarely involved.   The  surface 
444        GENITO-URINARY DISEASES AND  SYPHILIS.

of the tumor is  usually smooth, though it may be nodular or ridged.
Testicular sensation on pressure is lost.
   The tumor forms slowly, requiring weeks or months for its com-
plete  evolution.   It may  remain stationary for months,  and finally
subside, leaving an apparently normal testicle, or, in place of reso-
lution, there may be sclerogenesis  and complete atrophy, the  testicle
disappearing and the vas terminating in a fibrous nodule.
   It is to be noted that even though both  testicles are involved
there is not necessarily either impotence or sterility, since the infil-
tration generally spares some of the secreting portion of the gland.
   Acute Syphilitic Orchitis.—Exceptionally this  sclerous  orchitis
may depart from its ordinary type  and the symptoms may become so
acute as entirely to obscure the diagnosis.  In  this  form of the dis-
ease the testicle rapidly swells, and becomes exceedingly sensitive;
the scrotum is reddened  and  oedematous, and there is violent and
constant pain.
   Commonly but one testfcle is affected.  Acute symptoms last but a
few days.   The inflammation comes on without exciting cause, rarely
presents symptoms as acute as those of an inflammatory orchitis, and
is distinguished from gonorrhoeal epididymitis by the  fact that the tes-
ticle is primarily enlarged and presents the same form and density as
are observed  in the ordinary syphilitic  sarcocele.
   As a rule, the tunica vaginalis is not affected in syphilitic sarcocele,
or there is but moderate serous effusion.  This is sometimes  circum-
scribed, and may assume a pseudo-membranous form.  Exceptionally
the effusion is so great as to prevent palpation of the testicle.
   Gummatous Orchitis.—The development of gummata is often pre-
ceded  by  the sclerous  type of syphilis of the testicle, though fre-
quently the affection is distinctly gummatous from its onset.  In place
of the general enlargement,  or rather accompanying this,  distinct
nodules, ridges, or tumors  appear, usually on the anterior surface of
the testicle.  These tumors  increase in size.  The  tunica vaginalis
becomes adherent; the overlying  skin of  the  scrotum is infiltrated
and  reddened, and finally softening and ulceration  take  place, with
evacuation  of broken-down granulation-tissue and gummy pus.  The
resulting punched-out hollow ulcer has dusky indurated borders, and
communicates with a ragged, irregular cavity  containing gray  un-
healthy granulations.  The scar left after healing is adherent to the
testicle.
   At  times the granulation-tissue slightly  proliferates, and  forms  a
cauliflower growth projecting externally and overlapping the seat of
skin perforation; this is known as  a benign syphilitic fungus. 
SYPHILIS OF  THE URO-GENITAL SYSTEM.
445
   There are two varieties of syphilitic fungus,—the  superficial and
the deep.   Roth originate from ulcerating gummata.   The superficial
fungus starts from gumma of the scrotal tissues or of the tunica albu-
ginea.  A superficial form which is almost identical and is more com-
mon is due  to tubercle.
   Parenchymatous or  deep  fungus is usually  syphilitic.  It arises
from gumma of the testicle  proper.  The granulations grow upward
through the albuginea and the tissues of the scrotum.   At times por-
tions of the seminiferous tubules will be found in the discharge.
   Softening and ulceration  do not always take place.  As in the case
of interstitial orchitis, gumma may spontaneously,  or from the  effect
of treatment,  undergo resolution, leaving the testicle apparently  as
healthy as before the  attack, or  crippled and deformed by cicatricial
contraction.
   Diagnosis.—The diagnosis of sarcocele in its typical form is not
difficult.   This affection commonly develops when other unmistakable
manifestations of syphilis are present.  The tubercle bacillus and the
gonococcus  when they invade the testicle attack the epididymis pri-
marily ; tubercle  commonly  invades the  cord, the seminal vesicles,
and the prostate.   Syphilis,  however, hardly ever attacks the cord.
   Finally, the effect of constitutional treatment will be found a valu-
able means  of clearing the diagnosis.
   The differential diagnosis  between syphilitic sarcocele  and  that
due to carcinoma or tubercle may be tabulated as follows:
   Syphilitic Orchitis.
Syphilitic history.

Usually occurs at about
  twenty-five  or  thirty
  years of age.
Begins in the testicle.

Is situated primarily  in
  the connective tissue.

Tends to  fibrous over-
  growth.
Slow in its progress.
Skin of the scrotum rarely
  involved.
 Encephaloid Carcinoma
      of Testicle.
No history of any special
  condition.
Occurs at any age.
Begins in the body of the
  organ.
Begins by the deposit of
  small'  nodules  in  the
  seminiferous tubules.
Tends to  formation  of
  patches  of  softened,
  white,  pultaceous ma-
  terial.
Rapid in its course.
Skin of the scrotum finally
  involved.
   Tubercular Orchitis.
Tubercular history.

Not often seen after thirty.
Begins in the epididymis.

Exists primarily  in  the
  tubules.

Tends to fatty, caseous, or
  purulent degeneration.
Slow in its progress.
Skin involved  only just
  before the formation of
abscess. 
GENITO-URINARY DISEASES AND SYPHILIS.
   Syphilitic Orchitis.
Ulceration or suppuration
  rare.
Fistulae rare.
A feeling of great weight,
  with only such pain as
  results from  dragging
  on the cord.
Tumor very hard and uni-
  form.
Skin of scrotum purplish,
  but unaffected.
Testicle  of moderate size ;
  rarely exceeds twice its
  normal diameter.
Painless on pressure.
Both  testicles  often  af-
  fected.
Fungus rare.

No discharge or bleeding.

Lasts many years.

Curable.
No  involvement of  in-
  guinal glands, as a rule.
  Encephaloid Carcinoma
      of Testicle.
Ulceration  and  fungus
  common.
Fistula? common.
Pain  severe  and lanci-
  nating   in   advanced
  stages.

Soft and fluctuating.

Net-work of large veins
  over surface of tumor.
Attains great size.
Painless on pressure.
Generally only one testi-
  cle affected.
Fungus always present in
  advanced stages.
Bleeds  freely;  offensive
  discharge.
Rarely  extends  beyond
  twenty months.
Usually fatal.
Inguinal, iliac, and lum-
  bar  glands  and cord
  affected.
   Tubercular Orchitis.
Suppuration common.

Fistulae common.
Little pain.
At first hard, knotty, ir-
  regular.
Skin congested, but other-
  wise unaffected.
Of moderate size.
Often painful on pressure.
Often  both  testicles af-
  fected.
Fungus common.

Less apt to bleed;  dis-
  charge less offensive.
Lasts several years.

Generally incurable.
Usually no inflammation
  of glands.
    Lymphadenoma sometimes almost exactly simulates syphilitic sar-
cocele.   It may involve one or both testicles.   It usually spares the
epididymis.   It  forms an ovoid, hard, indolent, uniform swelling.  It
is, however, not so hard as syphilitic sarcocele.   Its  surface is always
smooth, and  does not present the slight nodulations or ridges which
are often present  in the  syphilitic testicle.   Lymphadenoma may be
found in other parts of the body.
    Enchondromatous growths may present areas  of unusual hard-
ness ; the growth  is often much more rapid and usually attains much
larger dimensions than in syphilitic sarcocele.  Local and reflex  pains
are more pronounced, and  specific treatment is without avail.  How-
ever, it  is often  necessary  to wait  before diagnosis  can  be  estab-
lished.
    In the acute  form of syphilitic sarcocele diagnosis  must be  made
by exclusion  ; that  is, when the  possibility of traumatism, of simple
inflammation, of gout, of mumps,  of tuberculosis, of continued fevers,
of violent muscular effort,  has  been  excluded, and  other  signs of 
SYPHILIS OF THE URO-GENITAL SYSTEM.
447
syphilis are  present, the syphilitic nature of the  affection  may be
suspected.
   Syphilitic fungus of the testicle may be confounded with ulcerating
carcinoma or tubercular fungus.   The ulcerating carcinoma, however,
involves the epididymis and cord, affects the pelvic and post-perito-
neal lymphatic glands, forms a large  indolent  tumor,  gives rise to
much  pain,  is attended with  bleeding  and sloughing, and freely
secretes ichorous pus.   It runs a rapid course, and is attended with
cachexia.
   The tubercular fungus differs from the syphilitic only in the fact
that the granulations are paler, of less vitality, and  not attended with
infiltration of the skin.   There is usually cachexia.
   Prognosis.—The  prognosis  of  syphilis  of the testicle  is good.
There  is rarely deterioration of the general  health, or abolition of
the sexual powers.   It cannot  be  considered as indicating  a malig-
nant form of syphilis.  Although the disease is bilateral,  it very rarely
produces complete atrophy or destruction.  Even though the testicle
seems  to be  involved as a whole, some  portion of the  glandular sub-
stance  is generally spared.
   Interstitial  orchitis, even if taken  in its early period,  may be
followed by  atrophy.  Ulcerating  gummata  rapidly  produce  most
extensive destruction.  In spite of the  preservation of virile power,
spermatogenesis may be arrested.   Even after  loss  of virility  and
fecundity, proper treatment will sometimes restore both.
    Treatment—There is  little tendency towards spontaneous cure.
Potassium iodide in full doses should be  administered, together with
mercury.  The latter drug is particularly indicated when  testicular
manifestations are precocious.
   Syphilis of the Vasa Deferentia,  Seminal Vesicles, Pros-
tate, Urethra, and Erectile  Bodies of the  Penis.—There  have
been reported a few cases of gumma of the vas, usually in connection
with syphilitic sarcocele.   This structure, together with the seminal
vesicles and  the prostate, seems to be singularly free  from the  manifes-
tations  of tertiary syphilis; at least clinical evidence of  the  frequent
involvement  of these structures is wanting.
   Chancre of the urethra has been already described.
   Secondary  syphilides, particularly the mucous  patch, have  been
observed on  the urethral  surface.    These occasion  a slight discharge,
which is sometimes mistaken for gonorrhoea.
   Gummatous ulceration is exceedingly rare, or at least is  not often
recognized clinically.  Its symptoms  are usually  confounded  with
those of chronic urethritis from other causes.  It would be difficult 
448       GENITO-URINARY  DISEASES AND SYPHILIS.

to make the  diagnosis except from urethroscopic examination, unless
induration could be detected by external examination.  It is followed
by  dense stricture formation.
    The primary and secondary lesions of the penis have been already
described.
    The erectile bodies of the penis may exhibit tertiary manifestations
in the form of  diffuse infiltration or of gummata.
    Diffuse infiltration particularly involves  the  meatus and the frse-
num, together with the  mucous membrane of  the prepuce lying to
either side of this band.  Infiltration may be either superficial or deep,
and may involve a considerable portion of the glans.  Ulceration some-
times follows.
    Gummata are usually placed  on the proximal third of the caver-
nous  bodies.   They form small or large, ovoid,  indolent,  non-inflam-
matory, cartilaginous tumors, suggesting during their early development
the presence of a foreign body in the tissues.
    Gummata and infiltrations markedly interfere with erection, making
it imperfect anterior to the seat of lesion and causing bending of the
organ.  They are  obstinate to  treatment, and are scarcely to be dis-
guished  from the  plates  of induration resulting from  non-specific
cavernitis or fibroid infiltrations.
    Diagnosis.—One  or  more  hard, painless,  slowly  progressive
nodules, growing in or from the erectile  tissues of the penis, showing
no  tendency to ulcerate, and giving rise to no symptoms other than
interference with erection, would be  almost pathognomonic of either
syphilis or non-specific indurated plaques.   Retween these two affec-
tions the therapeutic test affords the only means of distinguishing.
    The tertiary manifestations, which closely simulate various forms
of chancre, are much more chronic in their course than  the primary
lesion, occasion no adenopathy, and begin as infiltrations, which sub-
sequently ulcerate.  Moreover, there is a preceding  history of sec-
ondary syphilis, or possibly the evidence  of pre-existing lesions  of
the disease.
    Treatment.—As for all  tertiaries, the administration of potassium
iodide and mercury is indicated.

     SYPHILIS  OF  THE  OVARIES, UTERUS, VAGINA, AND  VULVA.
    From analogy it might be expected that  syphilitic involvement of
the ovary would be frequent.   Clinical  records, however, have very
little to advance in proof of  this  theory.   It  is  probable that a
sclerous  and a gummatous type of ovaritis occasionally appear as
manifestations  of  tertiary  syphilis.  This,  however, as in the male, 
SYPHILIS OF THE MAMMARY GLAND.
449
occasions no subjective symptoms, follows the law of tertiary visceral
lesions in not tending to ulcerate, and  hence escapes notice.  Autop-
sies have shown  that such lesions occur, and  a few clinical obser-
vations prove, at  least so  far as  the  therapeutic test is  concerned,
that some ovarian tumors are of  syphilitic origin.  The evidence is
strongly in favor of the view that the ovaries are far  less subject to
tertiary disease than are the testicles.
   The Fallopian  tubes are involved in gummatous lesions even more
rarely than are the vasa deferentia.
   The  uterus of syphilitic women is frequently attacked by endo-
metritis, metritis, perimetritis, and  parametritis.   The symptoms and
complications are  the same as the homologous non-specific inflamma-
tions, and often the treatment is as tedious and unsatisfactory.  There
are some reported cases of uterine tumor disappearing rapidly under
the use of potassium iodide.
   The vagina is very exceptionally the seat of  chancre.   Secondary
lesions, except the mucous patch, are  also rare.  Tertiary lesions of
the vagina, usually appearing in the form of a diffuse infiltration, com-
monly extend from the vulva or the rectum, in the latter case causing
recto-vaginal fistulae.  Exceptionally the infiltrate attacks  the vagina
alone.  The symptoms  are those of chronic vaginitis, with  marked
thickening particularly of the posterior wall, often followed by ulcera-
tion and extensive tissue-destruction.
   The vulva is a favorite seat of syphilitic lesions in all stages of the
disease.   The  chancre, secondary  syphilides, gummata, and  gumma-
tous infiltration are all frequently observed.   The tertiary lesions are
prone to develop in the seat  of primary and secondary ulcerations.
They are usually  multiple, bilateral, quickly ulcerate and spread, and
produce a thickening and  warty growth of the skin, which  strongly
suggests elephantiasis.   In the debilitated and uncleanly phagedaena
develops, with extensive tissue-destruction, and, in case of healing,
great cicatricial deformity.

               SYPHILIS OF THE  MAMMARY  GLAND.
   Chancre about the nipples is frequently  observed, nearly always
as a result of suckling a syphilitic child.
   Secondary lesions  similar to those  found on  other  surfaces of  the
body develop  on  the  tegument  covering the  breast.  Papules  are
particularly liable  to be  converted  into mucous  patches or into con-
dylomata.
   Acute irritative mastitis is exceptionally observed in both men
and women in the earliest  period of secondary syphilis.  It is  charac-
                               29 
450        GENITO-URINARY DISEASES AND SYPHILIS.

terized by swelling accompanied by moderate pain  and tenderness;
it subsides quickly, particularly under specific treatment.
   Gummatous mastitis may develop either as a diffuse infiltration or
in the form of gummatous nodules.
   Diffuse gummatous mastitis is characterized by a rather dense infil-
tration involving a part or the whole of the breast.  Roth breasts may
be attacked together  or  consecutively.   More  commonly one side is
involved.   If untreated,  atrophy and contractions  take  place, ulti-
mately leaving the breast wasted and greatly deformed.
   The diagnosis from cancerous infiltration may be extremely diffi-
cult, but will be founded upon the more diffuse form of the  syphilitic
infiltration, the absence of lymphatic involvement, the preceding history
of syphilis, and chiefly on the rapidity with which symptoms yield to
constitutional treatment.
    Gummatous nodules of the breast develop slowly, occasion little or
no pain, and are prone to ulcerate and discharge.  There is found in
or on the breast a hard, painless, non-sensitive, freely movable nodule,
which in a few weeks has reached the size of an egg, softened, become
adherent to the skin, ulcerated,  and discharged a turbid, gummy fluid.
Healing is followed by a  permanent cicatrix.
   As  in  the case of  diffuse  infiltration, these  gummata may lead to
errors  in diagnosis.  Gummata  do  not retract the nipple, they com-
monly develop before the age of cancer, and they ulcerate in a different
way from  typical malignant growths.  Usually the lymphatic glands
are not involved, and a history  or signs of syphilis are obtainable.
   Specific treatment ordinarily accomplishes prompt  resolution  of
tertiary manifestations in the  breast, and is the main test upon which
a differential diagnosis must be  founded. 
CHAPTER  XIII.
            syphilitic heredity.—hereditary syphilis.

   Syphilis is transmitted  not as a tendency or predisposition, but as
an active contagious disease.  It  may reach the child (1) by descent
from the father; (2) by descent from the mother; (3) by descent from
both parents (mixed heredity); (4) by direct infection.
   Descent from the  father, or seminal transmission, is far more
frequent than maternal descent.   It represents  the simplest form of
heredity, since  the influence  of the father, so far as the  child is con-
cerned, ceases when  impregnation is accomplished.   Provided there
are no lesions of the genital tract  causing  a  contagious  discharge to
mingle with  the  sperm,  the latter, if inoculated upon a  healthy per-
son, will not cause  the  development of  chancre;  it is as free  from
contagious properties as  other normal secretions ; yet when fertilizing
the ovum it carries with it the syphilitic infection.
   In the florid stage of a virulent syphilis the disease is most likely
to be transmitted.   A child  may, however, be born healthy  even
under such circumstances.  On the other hand, a father who has been
free from  symptoms of  syphilis for years  may, as a  rare exception,
beget a child exhibiting a virulent form of the hereditary disease.
   Descent from the mother may be  due (1) to infection previous
to conception, or (2)  to infection occurring at this time, or (3) to post-
conceptional infection.
   Maternal descent is more certain and is more potent in its influences
for harm than is that from the father, since the blighting effect of an
ovarian  infection is  reinforced by the  devitalizing influences  of a
maternal dyscrasia.
   When  the mother is infected at the moment  of conception the
case becomes in  reality an example  of  paternal heredity,  since the
germ is syphilitic not because the  ovule of  the mother is  infected, but
because of the diseased spermatozoa of the  father.  During the period
of intra-uterine life  the syphilis  acquired by  the  mother develops
and exercises its malign influence  upon blood and  the general  nutri-
tion, thus further affecting  the already diseased foetus:  hence syphilis
inherited under such circumstances is particularly liable to be severe.
Moreover,  there  are distinct  placental lesions which aggravate the
tendency to abortion and still-birth.
                                                         451 
452        GENITO-URINARY  DISEASES AND  SYPHILIS.

   In  consequence  of  cell proliferation in  the villi the vessels are
compressed and finally obliterated, and the  vascular  spaces into
which  the villi dip often disappear.  The epithelium is also thickened,
and thus there is material interference with the interchange between
maternal and fcetal  blood.   If this process is generally diffused over
the placenta, the foetus, of course, perishes.  If it is partial, the foetus
may live for a varying length of time, but will exhibit the signs of mal-
nutrition.
   Maternal heredity, most potent in the first year of syphilis, gradu-
ally becomes attenuated; but even in the later periods transmission
is  much more likely to occur than it is from paternal  syphilis of the
same stage.
   Neumann, as the result  of a statistical  study, shows that  two-
thirds  of the cases of germinal syphilis perish  either in utero or
shortly after birth.
   Post-conceptional syphilis—that is,  infection of the  mother during
the period  of utero-gestation—may be transmitted to the foetus up to
the eighth month.  After that it is probable that the child will escape,
although cases are reported showing that chancre acquired in a woman
as late as the eighth month  has  been followed by syphilis of the child.
   Syphilis derived  from the mother healthy  at the time of concep-
tion but contracting the disease  during the period of  gestation, and
infecting the foetus through the placental circulation, is  not classed by
Fournier as hereditary syphilis, since under these circumstances the
healthy  ovule  impregnated by  healthy spermatozoa  inaugurates a
normal growth  not  interfered with  till  it is well  advanced.   Lesions
are, therefore, less severe than they are when the germinal cells are
diseased.
   Mixed Heredity.—When  at the time of conception both parents
are suffering from syphilis in  its early stages, the disease is  almost
certain to be transmitted, and usually in a lethal form.
   The relative  gravity of  the three forms of descent is expressed by
Fournier's tabulation, based on  five hundred observations.   Among
the cases of paternal heredity twenty-eight per cent,  died, and thirty-
seven  per cent, showed lesions of syphilis.  Among the cases  of ma-
ternal  heredity sixty per cent, died, and eighty-four per cent, showed
lesions of syphilis.   Mixed heredity caused sixty-eight  and a half per
cent, of deaths,  and lesions in ninety-twro per cent.   These estimates
demonstrate that paternal heredity, though more frequent than the
other forms, is less than half as communicable or fatal as is maternal
heredity, and that the  latter is less virulent in  its effects than mixed
heredity. 
                      SYPHILITIC  HEREDITY.                  453

    Direct  infection implies inoculation of the child during parturi-
 tion  by the  contagious  discharges of secondary  vaginal or  vulvar
 lesions of the mother.  This  cannot be classed as hereditary syphilis.
 There seems to be no reason why  such  infection should not  excep-
 tionally take place, provided the mother is suffering from active  genital
 lesions acquired too late to  affect the child in utero.  That there is
 lacking a sufficient number  of entirely  satisfactory  reports of such
 infection  to prove conclusively  that  it exists would  seem  to show
 that  the child has acquired  a certain immunity somewhat similar to
 that  expressed by Colles's law;  in  other words, that it either has a
 latent modified form  of  the disease,  or, from  antitoxin absorption
 from the mother's blood,  has ceased to be susceptible to it.
    Syphilis  thus  conveyed  would  be acquired, not  inherited,  and
 would begin with the primary sore.
    The Period of Syphilitic Heredity.—It  is universally conceded
 that hereditary syphilis becomes milder in type and less likely to be
 transmitted in proportion to the age of  the  disease  of the  parents.
 Heredity is most  potent  and virulent in  its  first  year.  There is a
 rapid attenuation  in the  third year, after  which the influence  of the
 disease as expressed by transmission  still diminishes, but at a slower
 rate.  In the large majority of cases there comes a time when syphilis
 is no longer transmissible.  This  rule, however, is  subject to excep-
 tions, although it is true  that tertiary or late symptoms  of syphilis
 are non-contagious, and probably sequelae  of the lesions of  the  active
 period of the disease.   The  question  as  to transmission years after
 the original outbreak, and in the absence of all signs or symptoms
 of the disease in the  parents, is important.   Such transmission is
 possible, and  is, perhaps,  more common  than is generally supposed.
 Fournier states that of five hundred and  sixty-two cases of heredi-
 tary syphilis, in sixty the disease was transmitted more than six years
 after the primary infection.  Apparently carefully observed  cases  are
 recorded pointing to heredity from parents in the fifteenth  and even
 in the twentieth year of syphilis.
   Treatment exercises upon  the heredity of syphilis a more  power-
 ful  effect than time alone.   Thus, Fournier  shows  that  after the
 exhibition of the specifics the mortality in maternal heredity  is  re-
 duced from  fifty-nine per  cent, to three per cent., and that children
 born living are usually free from signs of syphilis.
   The type of parental syphilis does not  necessarily indicate that of
the inherited  disease.   Heredity in its  most malignant  form may de-
stroy the offspring of parents  suffering from mild syphilis, and, con-
versely, virulent outbreaks  in the parents may not interfere with the 
454
GENITO-URINARY  DISEASES AND SYPHILIS.
birth  of  children either  but slightly affected  or  absolutely healthy:
hence it  is unsafe to base  prediction  as to the  type  of  inheritance
upon the type of disease of the parents.
   Oonceptional syphilis is that  acquired  by the healthy mother
from a foetus  infected by the father.  In the vast  majority of cases
maternal syphilis is acquired by the mother from  direct absorption of
the poison through a breach of surface, the first manifestation of disease
then being a chancre, which is followed by a train of secondary and ter-
tiary symptoms.  She can, however, also acquire  syphilis through the
medium of the placental circulation of a child seminally infected by
the father.  This method  of contagion, long questioned, is  amply
proved.  Thus,  there are  many reported  cases  showing  that even
though the father is  free from  discoverable lesions at the time of
conception, and there is no history or trace of a primary lesion in the
woman, yet she may exhibit the phenomena of syphilis.  Provided
both husband and wife are really free, the one from contagious lesions,
the other from evidence of the  present or previous primary sore, it
will often be found that the woman has either been  delivered of a
syphilitic child or has had an abortion  or a  miscarriage  some time
before the outbreak of the  symptoms of the disease.
   Colles's law, which  states that a child  begotten  by a syphilitic
father and born of an apparently healthy mother cannot infect her,
even though it exhibit venereal ulcers  on the lips and tongue and in
suckling  cause cracks and fissures in  the  mother's nipple, was for-
merly  regarded as a positive proof that the  mother  of  a syphilitic
child was always  herself syphilitic, since only in this  way could her
immunity be explained.
   Diday applies to the  explanation of this well-known phenomenon
Pasteur's discovery that  methodical repetition of inoculation attenu-
ates and ultimately neutralizes the virus of disease.  This is shown
when animals  are  repeatedly inoculated with the virus  of hydro-
phobia.  When a woman bears a syphilitic  child the blood  freely
circulating between mother and foetus becomes a vehicle for repeated
inoculation of  the attenuating  fluid, and the  mother  is rendered
proof against  syphilis by seven  or  eight months of perfected Pas-
teurization.
   Conceptional syphilis may appear in one of two forms:
   1.  The woman may immediately after conception become languid,
weak, and emaciated, complaining of headaches, rheumatic pains, sleep-
lessness, and all the symptoms of neurasthenia.  Miscarriage occurs, and
from this she rallies very slowly.   Subsequent pregnancies take much
the same course, the miscarriages coming later in the period of  gesta- 
SYPHILITIC  HEREDITY.
455
tion.   Then living but syphilitic children, and finally healthy children,
are born.
   In many  cases  undoubted tertiary symptoms appear, such as
gumma or periostitis.  All these symptoms are usually rapidly cured
by specific treatment.
   2. The woman may  remain apparently well,  being delivered at
about full term of a child which either  at birth or shortly after ex-
hibits the characteristic lesions of hereditary syphilis.   Experimental
inoculation of such a mother with active virus will not produce chancre.
She is immune against syphilis, either because she has the disease in
a latent form or because of the protective action of antitoxins.
   The  question  as  to why  in some  cases the mother exhibits the
symptoms and lesions of syphilis and  in others showrs no sign of the
disease except the immunity expressed  by Colles's law is still un-
answered.  An ingenious and  satisfactory theory, but one still un-
proved,  explains  this difference on the ground that the unbroken
placenta proves an insuperable obstacle to the migration of the  specific
germ, but allows  the antitoxins to filter freely:  hence the mother be-
comes immunized without contracting the disease.  When through
injury or other cause  lesions of the placenta allow the maternal and
the foetal blood directly to intermingle, the mother receives into her
circulation not only the antitoxins but also the active living  germs:
hence she develops the disease, possibly in an attenuated form because
of the continued antitoxin absorption.   The same reasoning applies in
the explanation of the immunity of the  apparently healthy children
of syphilitic parents from  contracting the disease.  (Profeta's law.)
In the great  majority of cases this  is  because  they already have
syphilis  in an active or a latent  form.   In the case of seemingly
healthy children  of tainted heredity there may have  been antitoxin
absorption from the mother without infection by the germ.
   Syphilis and Marriage.—The prevalence of acquired syphilis,
the frequency with wiiich it is transmitted, the severity of its  lesions,
and  its  crippling, deforming, and often  fatal effects wiien it is in-
herited, make questions pertaining  to  the marriage of syphilitics of
cardinal importance.   Opinions upon this subject should be clear and
decided.
   From what already has been said it is obvious:
   1. That syphilis is most  apt to be inherited from  parents  who at
the time of conception are  in  their first year of the disease.  The
aptitude is greatest when both parents are syphilitic, is slightly less
when the mother  alone is affected, and is diminished  more than half
when the father alone is affected. 
456
GENITO-URINARY  DISEASES AND  SYPHILIS.
   2. That the tendency towards  heredity becomes rapidly less from
the first to the third year, and after the fourth year is rarely manifested.
   3. That time in  conjunction with vigorous continued specific treat-
ment so affects the tendency to heredity that after the fourth year it
is practically brought to the vanishing-point.
   4. That time and vigorous treatment combined cannot always pre-
vent the transmission of syphilis by heredity.   The instances in which
such transmission  has  occurred after  four years,  in spite of active
treatment, are, however, so few that they properly can be  rejected in
considering syphilis and marriage.
   The logical deduction from the foregoing summary is that men
who have syphilis which has been treated carefully for four years can
marry and will have healthy children.   When the  woman is syphi-
litic, or both  the man  and the woman have contracted  syphilis, it
would be safer to avoid conception till after a longer period.
   Prognosis of  Syphilitic Heredity.—When  conception takes
place during  the early secondary period of syphilis the usual result is
abortion, occurring  from the first to the  fifth or sixth month, the foetus
sometimes exhibiting the evidences of syphilis in the shape of large
bullae upon the  palms and soles, or other characteristic lesions, but
quite often showing nothing distinctive.   Later, wiien the virulence of
the disease of the parents is lessened by time, either abortion  occurs
when pregnancy is  more advanced, or live children are brought into
the world which at birth or afterwards  show signs of syphilis.  One-
fourth of these die  within the first six  months.  If they survive that
period the chances  for life are slightly in their favor, but the chances
for health or  freedom from disease are overwhelmingly against them.
Fournier states that, in general, the chances of transmission  are fifty
in the hundred, and that the infant mortality is forty-twro  per cent.;
in hospital practice  this mortality percentage  is doubled.
   When the question  of prognosis is considered in regard to indi-
vidual  cases, it is safe to predict  healthy children from parents who
at the  time of conception are past the fourth year of syphilis and
have been persistently treated.  Even after two years in the very great
majority of cases the same outlook is  justifiable.   In  the first year
prognosis  in  this respect must  be more guarded; but, provided  the
mother is actively treated during the whole period of utero-gestation,
the child will probably be born healthy. Exceptionally families show
an inveterate tendency to heredity little influenced by time and treat-
ment.  Fournier quotes a case of nineteen pregnancies each resulting
in still-birth.  In speaking of the prophylaxis of hereditary syphilis,
he earnestly  advises that a man wiio has been infected with the dis- 
HEREDITARY SYPHILIS.
457
ease should be forbidden marriage till time and  treatment have ac-
complished their depurative work, and should  be  shown without
mitigation and without exaggeration the evils which may result from
sexual intercourse.  He should  be  told that he  may infect his wife
directly by sexual contact, or indirectly through  the  medium  of the
foetus, and that, if she fails to abort, she may deliver at  term a wizened,
deformed,  blotchy child, which if  it  lives may  show the stunted
development  and mental  incapacity  so  characteristic  of hereditary
syphilis.
   When, in  spite of warnings, it is probable that sexual life is con-
tinued, the man  should be  subjected  to the most rapid and efficient
treatment  applicable.  When conception  has taken place from  a
syphilitic father, whether the mother  has or has  not  the  disease, she
should receive active specific treatment during the whole period of
utero-gestation.
                     HEREDITARY SYPHILIS.
   Hereditary syphilis  differs from  the acquired disease in   being
constitutional from the  first.  There  is no primary stage,—that is,
there is  no chancre,—nor in the course of its  development can the
manifestations of the disease be  classed under periods.   They may
correspond in type to  secondary or  tertiary  lesions, but a chrono-
logical order such as is observed in acquired syphilis is wanting.  For
the first two years after  birth  secondary and   tertiary  manifesta-
tions appear  side by side.   Later, at  about the  time of puberty, for
instance, if lesions appear, they belong  exclusively to  the tertiary
type.
   The local expressions of hereditary syphilis  correspond  closely
with those already described as characteristic of the acquired disease.
Thus, the  syphilides are pathologically and clinically the same, and
this is true of visceral involvements.   The main point of difference
lies in the profound alteration which syphilis  in its  hereditary form
impresses on  general nutrition and development.
   In a certain  proportion  of cases the characteristic symptoms of
hereditary syphilis develop at birth  or within a few days of this time.
Often the child remains apparently healthy for a period of from three
to five weeks, manifestations of syphilis then appearing.   It seems well
substantiated  that a child may be born healthy and may show no symp-
toms  of syphilis  for several years, after which time typical tertiary
lesions may develop.  In many of these cases it is probable that the
post-natal lesions were so few and slight that they were not observed.
The form of the disease developing more than three  years after birth
Fournier called late hereditary syphilis. 
GENITO-URINARY DISEASES  AND SYPHILIS.
   The typically syphilitic child is at birth a wasted, wizened, snuf-
fling, feeble creature, with a weak, hoarse cry, often exhibiting a bul-
lous eruption of the skin.  It has been blasted ab initio, presenting the
appearance of an advanced  stage of marasmus.   The skin  is harsh,
non-elastic, and gray or dirty yellow in color;  its appendages—the
eyelashes, eyebrows,  hair, and nails—also show imperfect or  per-
verted development. The muscles are wasted. The general  condition
is well expressed by the term  atrophia neonatorum, which,  though it
may result from a number of prenatal causes, reaches its most striking
development  in hereditary  syphilis.  Such atrophic children rarely
survive.
   When the influence of heredity is manifested  in a less virulent
form the child may be born  properly developed  and  apparently well
nourished.   In a few weeks  lesions of  the  skin, mucous membranes,
and eyes develop, corresponding in type to the expressions of acquired
secondary syphilis ; these are frequently associated with infiltrations of
the viscera and bones, which pathologically belong to tertiary syphilis.
   Following the first outbreak there is an intermediary period, lasting
a year or eighteen months, till second dentition, till puberty, or even
through  life.   It  is mainly  characterized by absence of  symptoms.
The general expression of the  syphilitic  diathesis is present, marked
possibly  by malnutrition, retarded development, wizened  face, and
sunken  nose, but there seems to be little tendency towards renewed
outbreaks of  secondary lesions.
   The  tertiary stage,  corresponding  to the tertiary period  of  the
acquired disease, manifests  itself at the period  of  second dentition,
about the time of puberty,  or towards the  end of middle life.  Its
lesions may, of course, develop at any time.

SKIN AND MUCOUS MEMRRANE  LESIONS OF  HEREDITARY SYPHILIS.
   These correspond in general with those of acquired syphilis, but
are more severe, and at times appear in the form  of diffuse infiltra-
tions.  They vary somewhat in accordance with their time of appear-
ance after  birth.  Those  which are  found  at birth are most  pro-
nounced. Thus, it is  not  infrequent to  observe a pemphigus  so
extensive that a greater part of the epidermis is  involved and is shed
in large  strips.  The mucous membrane is  similarly affected at the
same time.  The lesion at birth may be pustular or  ulcerative in type.
In either case the arrest of development,  hoarse voice, snuffles, and
other signs of the disease are usually characteristic.
   When the child is born apparently healthy, the  symptoms not de-
veloping for some weeks, the skin eruption  is commonly erythematous 
HEREDITARY' SYPHILIS.
459
and  papular  in  type,  at  least primarily, and  coincidently with its
appearance snuffles, sore mouth, hoarse voice, and general emaciation
are noted.
   Erythematous (roseolar) syphilides differ from those of the
adult only in the fact that the epithelial layer of the skin is more readily
macerated, particularly  where the integument is creased or  folded, as
about the neck, the genitalia, or the buttocks, and there results an
abraded surface, presenting the appearance of a mucous patch.
   Syphilitic  roseola is apt to develop  about  the second or third
week after birth, and first  appears on the body in the form of small,
oval, rounded, or irregular spots, dull red in color, and disappearing
upon pressure.
   Sometimes the eruption is confluent, covering large areas, with an
almost unbroken sheet of dull red color.
   It is frequently placed  about the genitalia and on the  face, thus
differing from acquired syphilitic roseola.
   The diagnosis of syphilitic roseola is sometimes difficult, as it may
closely resemble simple erythema.  The progress of the disease to the
formation of  papules, becoming  scaly  on the palms  and  soles, and
the prompt yielding to mercurial treatment are characteristic features
of syphilis.
   Papular Syphilides and Mucous Patches.—These lesions are
most marked  upon the buttocks, palms, soles, and face, but may be
diffused over  the entire body.  The  small papules are situated in
groups, sometimes rounded, more often irregular in shape,  and tend
to coalesce and form broad, flat papules.  In the corners of the  mouth
they are  converted into painful, bleeding fissures, wiiich on healing
leave permanent scars.  These scars serve a useful diagnostic purpose
in later life.   Exfoliation is most marked in the  plantar and palmar
papular syphilides, which  when  confluent may cause  the  epidermis
to be shed in  large strips,  exposing a thick, raw-ham-colored infiltra-
tion of the true skin.   This corresponds  in type to the plantar  and
palmar psoriasis of acquired syphilis, and may be complicated by pain-
ful cracks or fissures.
   Papules when exposed  to heat and moisture, as in the folds of the
buttocks,  lose  their  surface epithelium by maceration, become excori-
ated, and cause an offensive discharge.  These mucous  patches are
formed most commonly about the anus or the angles of the mouth.
Neumann states  that they never exhibit the papillary overgrowth so
common in the acquired disease.
   The papular form of hereditary syphilide is much  more obstinate
to treatment than is the roseolar form of the disease. 
GENITO-URINARY  DISEASES AND SYPHILIS.
   Vesicular syphilide appearing in the form of small discrete blebs
is  usually associated with  the  papular and  papulo-pustular lesions.
When the individual  vesicles are  large, their contents  soon become
purulent.  The  small  vesicles  are grouped, and are placed on in-
durated papules.  The eruption is rare, and is often a sign of severe
infection.
   Pustular Syphilide.—The lesions of this syphiloderm commonly
succeed the papular eruption,  though they may  be noted at birth or
may develop as  the first symptoms.  Frequently they do not appear
until several years after the first outbreak.
   The pustules vary in number,  size, and depth in accordance with
the severity of the disease.  They are  most frequently  seen  on the
buttocks, thighs, scalp, face, hands, and soles, and are said to indicate
the probability of late tertiary outbreaks.
   As in the adult, the pustular eruption may take the form of acne,
impetigo, or  ecthyma.  Syphilitic  impetigo is most frequent  on the
face  and scalp.  The axillary and inguinal regions  are also seats of
preference.  Distinct, often deep,  ulceration  beneath the crusts, and
copper-colored infiltration  of the periphery of the lesion, differentiate
the syphilitic  affection  from  simple  impetigo.  Syphilitic ecthyma
attacks  the  buttocks  and  thighs by preference,  forming  large,  flat,
infiltrated pustules, the thick crusts of which conceal deep ulcers.
   Nearly all these pustular lesions leave permanent  scars; they may
be complicated  by cellulitis  and  gangrene,  leading  to  wide-spread
destruction of the  skin.
   Bullous  Syphilide.—The  bullous  syphiloderm or pemphigus
commonly appears on the  soles, palms, fingers, toes, or  limbs.  The
eruption consists of blebs more  or  less  irregularly distended with
liquid, which may be clear, cloudy, or bloody.  It begins as dark, cir-
cumscribed infiltrates, from which  the epidermis is  shortly raised in
the form of  blebs.
   These blebs are circular or oval in shape, sometimes irregular, are
seated on inflamed reddish skin, are surrounded by a slight areola,
and have a tendency to become confluent and spread. When a child
exhibits such an eruption at birth  or  immediately after,  the presence
of syphilis should  be strongly  suspected,  and will be quite certain if,
in conjunction with the pemphigus, the general  cutaneous  surface is
yellow or muddy in hue, is without elasticity or softness, owing to the
absence of subcutaneous fat, and is for the same reason so furrowed
and wrinkled about  the face that the child presents an appearance
of senility, and if there are also other syphilitic  skin-lesions and the
child has snuffles and a hoarse  cry. 
HEREDITARY SYPHILIS.
461
   The appearance of pemphigus is  ominous, denoting an extreme
degree of poisoning by the syphilitic virus.
   When the bullae of pemphigus are filled with serum deeply stained
with blood, there may be an associated hemorrhagic syphilis,—that is,
a form of the disease characterized by a purpuric eruption, by bleed-
ing from the  mucous  membrane of the nose, mouth, and gastro-intes-
tinal tract, and by visceral hemorrhages.   The  bleeding  is due to
syphilitic degeneration of the blood-vessels, especially the  veins  and
capillaries.   These hemorrhages, usually multiple  and slight, are most
likely to occur just after birth, at  the time the cord  is tied.  Such
cases are almost invariably fatal.
   Tubercular and Gummatous  Syphilides.—Tubercular  and
gummatous  lesions may  appear at any  age, but are most common
from the tenth to the twenty-ninth year.   They may assume the dry
or the  ulcerative  form, and usually  exhibit a circular or circinate
grouping.  There is commonly but a single group.  The seats of pre-

                             Fig. 155.
Tubercular and gummatous ulceration of hereditary syphilis.
dilection are the face, particularly the  nose, and the anterior surface
of the leg.  They appear  in the  form  of painless, slowly increasing,
raw-ham-colored infiltrations, wiiich commonly ulcerate and are cov-
ered with thick crusts.  These ulcers may heal, or may slowly extend, 
462        GENITO-URINARY DISEASES  AND SYPHILIS.

forming phagedenic  or serpiginous lesions.   Non-ulcerating infiltra-
tions absorb, leaving atrophic areas;  the ulcerating lesions leave de-
forming cicatrices:  hence  the importance  of early  recognition  and
prompt treatment of these  syphilides.   They closely  resemble  lupus,
particularly when the face is attacked.   (Fig. 155.)
   Diagnosis.—The  differential  diagnosis  between  dry  tubercular
syphilide  and non-ulcerating lupus is  founded upon the dusky-red
color of the  syphilide  and the firm induration.  Tubercular nodules
exhibit a more translucent, yellowish red, and are more yielding to
pressure.   (Fournier.)
   The differential diagnosis  between  the  ulcerating syphilides  and
lupus (Fournier) is founded upon :
   1. Areola.—The  areola  of the  syphilide is dusky red, that  of the
scrofulide is lighter, sometimes of a bluish tint.
   2. Crusts.—Those of the syphilides  are more homogeneous, more
compact, thicker, and harder than those of the scrofulides.  They are
more frequently stratified and more deeply colored,  almost black or
greenish black.
   3. The  Borders  of the  Lesion.—In  syphilides  these  are always
sharply marked, elevated, infiltrated, punched out, and adherent.   In
lupus they are less distinctly outlined, are  flat, soft, often reduced to a
simple ulcerating circumference.  They are not punched out, and are
often loose and undermined.
   4. The Base of the Ulcer.—In tertiary syphilis this is deep, irregular,
anfractuous,  and exhibits a yellowish,  adherent, semi-solid covering,
representing the necrosed gummatous infiltrate.  Lupus shows ulcera-
tion  more  on a level with  the surrounding  surface, with  cherry-red
granulations, sometimes exuberant, sometimes presenting a smooth
glistening surface.
   5. Configuration  of the  Lesion.—Often,  but  not  invariably,  the
syphilitic lesions form  a complete  circle, a portion of a circle, or  ser-
pentine undulations.   The  ulcers of lupus are more irregular.
   It is not, however, on  these minor points of difference that the
diagnosis will in the main  be founded, but rather upon  the method
of evolution, the presence  or absence of other more characteristic
lesions, the  previous  history, careful  physical  examination  of the
patient, and the family history.
   The gummatous  syphilide when it  appears as a  diffuse eruption
commonly undergoes rapid degeneration, presenting much the appear-
ance of furunculosis.
   Onychia of a dry and ulcerating form, and  alopecia, are observed
in connection with the skin-lesions  of hereditary  syphilis. 
HEREDITARY SYPHILIS.
463
   The  lesions of the mucous membrane  correspond in type
with those observed upon the skin ;  thus, when pemphigus is noted,
large or  small  raw surfaces  will be found  upon the mucous  lining
of the throat and tongue; when  papular and papulo-pustular erup-
tions develop on the body, typical  mucous patches will be found in the
mouth,—that is, superficially ulcerated  infiltrations covered with a
grayish necrotic membrane.
   Not only the mucous membrane of the  mouth  and pharnyx but
also that of the nose, ear, and larynx is liable to inflammation.  In-
deed, syphilitic  coryza is one of the most  characteristic and at the
same time one of the most important of the early symptoms of syphi-
lis, since by its  interference with  respiration it materially hinders the
proper nutrition and development of the child.  This condition  of the
nasal  mucous membrane is  shown  by a thin, watery, irritating dis-
charge, which dries in crusts  about the nasal orifice;  beneath these
crusts are found excoriations  and ulcers.  The catarrhal swelling  of
the mucous membrane and the crusting produce so much narrowing
of the air-way that respiration is difficult and noisy, the latter symp-
tom giving the  popular  name " snuffles" to the affection.  Mucous
patches,  erosions,  and ulcers form  on the lips,  particularly  at the
angles of the mouth, and on the tongue, the gums, the palate, and the
pharynx.  Caries and necrosis of the  palate and of the nasal  bones
frequently complicate these ulcerations (syphilitic  ozaena).
   The  larynx  is  commonly affected, showing the infiltrations, ero-
sions,  and ulcerations noted  on other  mucous  surfaces,  and causing
the characteristic  hoarse voice.   Exceptionally  infiltration narrows
the air-passage  to the point  of producing marked  dyspnoea, or even
death.
   Later in the  course of the disease—i.e., after some years or about
the time of puberty—typical tertiary manifestations  may appear.
These are similar to those observed in the adult.  They are character-
ized by deep infiltrations, which  exhibit a tendency to break down,
forming ulcers,  which are accompanied by few subjective symptoms.
Their seat of predilection is the soft palate, but they are often found on
the posterior pharyngeal wall, the anterior half-arches, and the hard
palate.  The mucous membrane  of the  nose is also affected, and the
ulceration is extremely likely to  extend  to the  underlying bone, pro-
ducing great deformity or even complete destruction of the facial por-
tion of this organ.   The hard palate and the nasal septum are usually
perforated.
   Lupus rarely attacks either the mucous  membrane or the  bones
of the nasal  passages, being rather  sharply confined to the regions 
464        GENITO-URINARY DISEASES AND SYPHILIS.

of the anterior  nares.   In  these respects it differs  markedly from
syphilis.
   When tertiary infiltrations attack the larynx, destruction of car-
tilages may ensue, with deforming and crippling  contractures, or the
bronchi may be invaded, an obstinate  form of bronchitis resulting.
Spasm or oedema of the glottis may  cause sudden death.

            HEREDITARY SYPHILIS  AFFECTING  THE  EYE.
   Marginal  blepharitis is  sometimes  encountered  as  a result of
hereditary syphilis, appearing in the form  of small  irregular ulcers,
usually near the corners.   The  treatment is  cleansing and  constitu-
tional, together with the usual applications, particularly the  ointment
of calomel.
   The lachrymal apparatus is sometimes involved from extension of
inflammation dependent on caries of the neighboring bones.
   Interstitial  keratitis is the  most  characteristic  eye-lesion of
hereditary syphilis.  This  commonly begins as a slight diffuse hazi-
ness,  situated in the cornea itself,  not far from the centre, and at first
affecting but one eye;  usually the other eye is affected, but often not
for weeks or months.  The cloudy deposits lie in the cornea, and not
on its surface, and first appear as diffuse spots; these later become
confluent  until the wiiole cornea is opaque, a bare perception of light
remaining.  There are usually  photophobia and slight ciliary  injec-
tion.  The disease lasts for a varying period of time, weeks or months;
then  the cornea first involved  begins to clear;  the other  cornea fol-
lows  a similar course in time.   In  most instances there remains a
slight permanent haziness, though vision is good.  In severe  cases the
whole cornea becomes congested, blood-vessels developing in its sub-
stance.  Cyclitis and  retinitis  are often associated  with the corneal
lesions, and in  bad cases there may  be secondary glaucoma  and even
shrinkage of the eyeball.
   Interstitial keratitis is rarely noticed in  early infancy, but appears
usually between the eighth and  the fifteenth year, and  in children
presenting the typical physiognomy  of hereditary syphilis.
   Diagnosis.—This is in general easy  to  make.  The ground-glass
appearance in the early stages, and the dull  pink or salmon color if the
vascular stage is reached, are characteristic.   In syphilitic keratitis the
vessels are  deep and closely interwoven, producing almost the effect
of an ecchymosis.   Moreover, in  syphilis the disease is symmetrical,
there is a tendency to spontaneous cure, ulceration hardly ever oc-
curs,  and  there is but slight ciliary  congestion.   The grooves left by
the new-formed corneal vessels  are permanent, and their  discovery by 
HEREDITARY SYPHILIS.
465
a magnifying glass long after other traces of keratitis have disappeared
will often throw light on an obscure case.
   The chief diagnostic point, however, is the association of this form
of  keratitis with other lesions of syphilis.
   Iritis appears  before the end of the first six months.  It is later
than the syphilodermata and of rarer  occurrence, but it is extremely
important, since, if overlooked, it may result in permanent impairment
of  the vision.  When recognized it constitutes an almost pathogno-
monic sign of syphilis.
   The diagnosis is  readily made when attention is called to the eye,
but the  affection  may be  overlooked,  since there are few subjective
symptoms.
   When the disease is fairly developed the pupil is irregular, espe-
cially under  atropine;  the iris is  streaked with lymph, dull, swollen,
and discolored.   On very careful inspection a faint pink zone of con-
gestion may  be seen in the sclerotic, though this is often wanting.
   The prognosis is  generally good; even when the pupil has been
occluded, vigorous treatment will cause absorption of the plastic  ex-
udate.
   The treatment consists in the administration of mercury; it is often
useful to give it in combination with tonics.  When the disease occurs
during intra-uterine life, the infiltration is  liable to extend to the lens,
rendering it  opaque; the same result often follows when the disease
develops  after birth and is not recognized.  In this form of lens
opacity the operation for cataract promises little good.
   Optic neuritis, retinitis, and choroiditis are occasionally  observed
in  the course of hereditary syphilis.

          HEREDITARY  SYPHILIS AFFECTING THE  EAR.
   Extension of  inflammation from the  throat and  blocking of  the
Eustachian tube  may cause chronic  middle-ear disease, with  conse-
quent deafness.
   The  characteristic syphilitic otitis  media  is that  wiiich  develops
painlessly, usually within a few weeks  or a few months  of birth, and
gives rise to  no symptoms  except a purulent discharge, thus differing
markedly from the  ordinary suppurative otitis media, wiiich is  not
uncommon  in infancy  and  childhood.  This  syphilitic otitis yields
promptly and completely to specific treatment.   If neglected it  be-
comes chronic, producing irremediable  changes, wiiich result in partial
deafness, suppuration of the mastoid cells, and bone-involvement.
   Deafness  is characterized by Hutchinson as one  of  the  cardinal
symptoms of hereditary syphilis.  It is due to labyrinthine  changes,
                                30 
466
GENITO-URINARY  DISEASES AND SYPHILIS.
usually affecting both ears.   These changes in the case of an  infant
are unaccompanied by subjective symptoms, but result in deaf-mutism.
   When the labyrinth is attacked later, at about the time of puberty,
for instance, there may  be as a premonitory sign painless tinnitus.
Deafness develops rapidly, is complete, and is apparently causeless.
Treatment is often unavailing.

          HEREDITARY SYPHILIS  AFFECTING  THE TEETH.
   The first teeth exhibit malformations and imperfections which are
by no means characteristic of syphilis, but which may be referred to
any inflammation of the  gums sufficiently severe to interfere with the
nutrition of the tooth-sacs.  Thus, the teeth are often deficient in
enamel,  or  this  coating  is  unevenly distributed, or is  opaque and
chalky, or the dentine is soft  and friable, or the teeth are incongru-
ous in size individually and relatively, and decay readily.
   The permanent teeth  may exhibit the same perversions of growth
and nutrition  as  a result of stomatitis, whether  this inflammation be
produced by mercury, by gastro-intestinal derangements, or by local
irritation. Mercurial teeth, for example, are irregularly outlined, hori-
zontally seamed, honey-combed, scraggy, malformed, of an unhealthy,
dirty yellow color, separated too widely, and deficient in enamel.
   Fournier has written as follows concerning the influence of hered-
itary syphilis  on  the  dental  organs:  The transmitted  taint  shows
itself on the dental  system in two series  of  manifestations, of very
unequal diagnostic value: first, by retardation of evolution; second,
by arrest of growth and modifications of structure.
   Retardation of Evolution.—This generally  applies to the  entire
first denture.  In some cases it is limited to one group of teeth,—the
incisors,  for example.  A similar  retardation  sometimes is noted in
the eruption of the permanent teeth.   This is but a localized expres-
sion of the general lack  of  development  characteristic of hereditary
syphilis.
   Arrest  of Growth and Modifications of Structure.—Perversions
of growth  may be  classified under  dental erosions, microdontism,
dental  amorphism, and vulnerability.   Some  rarer peculiarities, such
as irregularity of  alignment and anomalies of reciprocal arrangement,
are not included under any of the above headings.
   The term  syphilitic tooth  implies a congenital  dental malforma-
tion, a deficiency of development stamped by syphilis on the tooth
yet unformed  during the period of its  intrafollicular evolution.  The
first dentition is not so often influenced as the second.   The  dental
malformations are commonly multiple and  symmetrical,—that is, sev- 
HEREDITARY SYPHILIS.
467
eral teeth are affected, and usually corresponding teeth  show similar
lesions.
   Dental Erosion.—This malformation may implicate any portion of
the surface  or borders of the tooth.   Its common  manifestation on
the front of the tooth is a cupping, comparable to the slight depres-
sion which would be left by the point or the head of a pin in soft
wax.  These cuppings show a dark tint, grayish, brownish, or almost
black, and  in  the  deeper depressions  enamel  is  entirely wanting.
Erosions in this form are most common on the incisors, and notably
on the superior  centrals,  and  are often arranged  in one or  more
horizontal rows.
   Faceted erosion  is not so common.  It usually  involves the cen-
tral incisors, and  shows as  an irregularity such as would be  pro-
duced by  a  file.   It is extremely  superficial,  and can often be
detected only by examining the previously  dried tooth under a mag-
nifying glass.
   The  furrowed erosion is  the commonest form, and appears as a
transverse groove, which may make the  entire circuit of the tooth, or
may be broken.  The groove may be  so  shallow as to form a scarcely
perceptible  streak, or it may be deep, as though filed, producing an
unsightly deformity, since it soon acquires a dark tint.  These furrows
are always  horizontal and usually single.   Sometimes two or  three
are noticed on the  same tooth, occupying  the portion of the crown
nearest the free. edge.   In such teeth the  free extremity is generally
worn  thin,  partly or totally deprived of enamel, rough, uneven, ir-
regular, brownish, and rapidly wears  away.   These grooved erosions
are most frequent on the incisors.
   Surface erosion is rare.  It represents simply an  exaggerated form
of the grooved erosion,  covering a large surface of the crown and pre-
senting a wide, unequal, and rough zone filled with alternate points
and sinuosities and of a dirty yellow or blackish  color.   In its  most
pronounced form it  appears  as  a  completely disorganized mass, urn
recognizable as a tooth.
   The  malformations  affecting the cutting or grinding surfaces of
the teeth present themselves under different forms, according to the
class of teeth they affect.
   The  first molar  is the only  one among  the grinders upon which
the influence  of hereditary syphilis shows  itself.  The  body of the
tooth for two-thirds or three-fourths of its height is normal; its upper
surface is atrophied, suggesting  a stump of dentine  emerging from a
normal crown.  The  masticating surface  is  rough and of a dirty-
yellow or brown tint, and wears away, producing a flat surface with 
GENITO-URINARY  DISEASES AND SYPHILIS.
a yellowish  centre  and a peripheral border of white enamel.  This
short, flat tooth has a diagnostic significance of high value.
   Upon the cuspids erosion of the free edge may appear as a simple
notch, similar to a  cut made in a piece  of wood by two convergent
strokes of a knife, or as a true atrophy, producing the appearance of a
slender conical stump grafted in a cylinder.
   Erosions of the  cutting edge of the incisors are more numerous.
There may  be an  angular  notch, serration, atrophic thinning, with
antero-posterior flattening, or general atrophy, the tooth presenting a
normal base, from  which emerges a small, rough, dirty-gray stump
with an uneven surface.
   Finally, there is the  crescent-shaped erosion characterized  by a
semilunar notch, constituting the Hutchinson tooth. The important
peculiarity of this last  erosion is the semicircular cut in the free edge
of the tooth.  The superior central  incisors are the teeth which ex-
hibit  this characteristic crescentic notch.  It is impossible to mistake
it or  seriously to consider it in connection with any other affection
of the dental  organs.  The crescentic notch is the essential charac-
teristic of the Hutchinson tooth, but is not the  exclusive one.  The
notch is nearly always bevelled at the expense of the anterior edge of
the tooth; in other words, the anterior border of the crescentic arch
is  cut obliquely from  above downward and from before backward.
The typical Hutchinson's tooth is also marked by its rounded angles,
the lateral and inferior borders merging by a curved line; it is much
reduced  in  length; sometimes  it is narrowed.   Finally, the upper
central incisors having the Hutchinson notch often deviate from nor-
mality in  direction, and their  axes in place of being parallel are ob-
liquely convergent.
   A perfect type of this tooth is best observed in youth.  It does not
protrude from the gum with a clearly cut  notch, appearing  first with
this notch either  partially or completely filled by small or apparently
atrophied vegetations of the  dental tissue.  Deprived of enamel, these
vegetations are rapidly destroyed, leaving in their place  the smooth
crescentic notch, the  depth of which progressively  diminishes with
use.   At twenty-five years  the  vault becomes nearly  flat, but even
then there remains the  bevel  of its anterior  edge.  Later  with the
wearing  of  the  tooth  the bevel  disappears,  so that beyond the age
of thirty years  Hutchinson's teeth are not to be found.  This dental
malformation commonly affects the  two  teeth  symmetrically, often
exclusively.   Sometimes it  is observed in the  upper lateral incisors,
the inferior incisors, or even the cuspids.
   In  the second dentition  dental  erosions are  met with in the fol- 
HEREDITARY SYPHILIS1
469
lowing order of frequency : first, on the first molars, particularly those
of the lower jaw ; second, on the incisors ; third, on the cuspids.  The
bicuspids and second and third molars are almost invariably exempt
from these erosions.
   Erosions  are  usually multiple  and  nearly always symmetrical.
Those of corresponding teeth maintain the same level  on the crown.
   As to the semeiological value of dental erosions, the punctate and
cup-like lesions of the crown and the saw-like erosions of the free
edge have but little value as evidence of specific heredity.   Furrowed
erosions are more characteristic, but are  also caused by other condi-
tions than hereditary syphilis.
   Atrophy of the dental  cusp, notably that affecting the  first molar,
and  constituting  the short, flat tooth, has a more precise meaning,
because this is a favorite form of  the  malformation when caused  by
syphilis.
   The best form—one which can be given as an  almost  certain evi-
dence of syphilitic heredity—is the semilunar notch of the free border
of the  central  superior  incisors.   This special form  of erosion is a
diagnostic feature of incontestable  value.
   Microdontism, the term implying an unusual smallness of the teeth,
sometimes amounting to actual dwarfing, never involves  the  entire
denture.  The superior and inferior lateral incisors are the teeth most
frequently affected.
   Amorphism indicates that a tooth has assumed  some shape other
than its physiological one.  This  growth-perversion is almost  as fre-
quent as erosion.   The teeth may present simply deviation of normal
type, exhibiting characteristics of a class to which they do not belong,
or they may be so malformed that they become true  monstrosities,
forming shapeless masses.
   Typical erosion, microdontism, and the lesions  of amorphism may
be associated.   The  tooth affected by syphilis is  always vulnerable
and  subject to secondary deteriorations.  Caries develops  at an early
age.   The first molars are the teeth most exposed to  these degenera-
tions.  They are often destroyed in youth.
   Among the least common lesions of syphilis, Fournier describes a
white linear stripe running horizontally over the crown of the tooth
from one lateral border to the  other, usually placed on the superior
central incisors, and affecting both alike.   Irregularities of implanta-
tion  are also  frequent,  the  teeth being  often separated from one
another by large empty spaces.
   It may be considered as well established, then,  that when the two
upper central incisors are stunted, abnormally narrow at  the  cutting 
470        GENITO-URINARY DISEASES AND  SYPHILIS.

edge, crescentically rounded with the convexity upward, and the sur-
face inclined upw-ard and forward instead of backward, as  in normal
teeth, widely separated, but converging at their lower edges, they are
pathognomonic of hereditary syphilis.  Other lesions of the enamel or
dental  substance, possibly with the exception of the incomplete devel-
opment of  the first molar described by Fournier, although frequently
caused by hereditary syphilis, may be  due to other dyscrasiae, and in
themselves are not characteristic.

    HEREDITARY SYPHILIS  AFFECTING THE BONES AND JOINTS.
   The  bones are much  more  frequently involved  in  hereditary
syphilis than in the acquired disease.  They are usually attacked be-
tween  the  fifth and the nineteenth year of age  (Fournier), though
they may  be  involved  at  any  stage  of the disease.  As  hereditary
syphilis develops in young  children it attacks by preference the bones
of the  cranium and nose and the  long bones,  particularly the tibia.
Later in life the skull is affected in a smaller percentage of cases, the
tibia still exhibiting lesions  most frequently.
   As  in acquired syphilis, the essential lesions  are those of periostitis,
ostitis,  osteomyelitis, and gummatous  infiltration.   They are usually
formative rather than destructive in type.
   Osteochondritis occurring  at the diaphyso-epiphyseal junction of
the long bones is  pathognomonic of syphilis.   It is characterized by
a marked widening of the  cartilaginous plate between  the epiphyses
and the diaphyses, by irregular growth of the bone layer just beneath
the cartilaginous plate, and by softening at this point of juncture,
allowing epiphyseal separation.  Microscopically  there is found  a
proliferation of cartilage cells and an  arrest in the transformation of
these cells  to bone.
   The symptoms of this form of osteochondritis are as follows:
   The bones most frequently attacked are the  humerus, radius, ulna,
tibia, and femur, but the ribs, sternum, and bones of the metatarsus
and metacarpus are also often involved.   The  more pronounced the
syphilis of  the parents  or  the nearer the date of conception to the
time at which their infection  occurred, the  more  probable is it that
several bones will be affected and the more unfavorable is the prog-
nosis as respects the life of the child.
   There is a swelling at the diaphyso-epiphyseal junction of one of
the long bones, appearing in the form of a smooth ring or collar, which
more or less completely surrounds the bone.   In the course of some
wreeks, as the swelling  becomes more pronounced, there  may be a
moderate amount of synovitis present, particularly wiien  the disease 
HEREDITARY SYPHILIS.
471
 is placed about the knee or the elbow-joint.  At this stage—i.e., that
 of overgrowth  and  infiltration—the lesion is  readily influenced  by
 specific treatment and well-regulated pressure.
    If softening and  suppuration take place there is complete separa-
 tion of the epiphyses and diaphyses, shown by preternatural mobility,
 crepitus, and syphilitic pseudo-paralysis, the affected limbs  losing all
 power.   The pus may break into the joint-cavity, destroying the car-
 tilage,  or  may  burrow into surrounding  soft parts.   The lesions of
 osteochondritis are usually multiple.
    The bones  of the skull, particularly the  parietal, frontal, and oc-
 cipital, are affected by formative lesions.
    Microcephalus, possibly  due to premature ossification of sutures
 or  lack of development of the cerebrum, hydrocephalus, or lack of
 symmetry in the shape of the cranium, may be noted.
    Lack of symmetry is especially frequent and characteristic.   Four-
 nier has described a  number of types : thus, there are the broad, high,
 bulging forehead; the bossed forehead, the projections on either side
 corresponding to the frontal  eminences, with an apparent depression
 in the middle;  and the keeled or chicken-breasted forehead,  with a
 median projection.  The asymmetry in these cases is due to formative
 osteoperiostitis  of the frontal  bones.   When the parietal bones are
 affected there results the natiform  skull, presenting apparent  broaden-
 ing of the cranium, with a central  depression, suggesting the shape of
 the nates.  When the nodes or exostoses  are found in the regions of
 the frontal and parietal eminences  they are often  called " Parrot's
 nodes."
    The degenerative lesions of the skull are characterized by tumor-
 formation, softening, breaking down,  and extensive  ulceration and
 destruction  of  bone-tissue.  After  the first few  years  of life the
 cranium  is rarely affected;  the bones of the nose, however, are not
 spared.
    The bones of  the nose  and face are  rarely affected  in  early in-
 fancy ; when they are involved later in life, it is usually from  an ex-
 tension of disease, which primarily attacks overlying soft parts.
   With  regard to the long bones, the tibia is the telltale above all
 others.  Swellings and  nodes  are the rule, deforming the diaphysis,
 either flattening out  the crest or by bony  deposits curving it until it
 has the shape of a sabre.   This sabre-shaped tibia is a most important
 evidence of hereditary syphilis.  The chicken-breasted thorax is also
 frequently observed.
   Exceptionally syphilis manifests  itself in the form of a rarefying
ostitis, predisposing to fracture. 
472        GENITO-URINARY'  DISEASES  AND  SYPHILIS.
    Diagnosis.—The bone-lesions of hereditary exostoses can be recog-
nized by the fact that  they are stationary, appear later than those of
syphilis  and are  of larger size,  are  accompanied by no  syphilitic
history or symptoms, and resist specific  treatment.  Syphilitic osteo-
chondritis, followed by separation of the epiphyses and complicated by
suppuration and sinuses, may be mistaken for a similar condition due
to non-specific  inflammations; the  latter, however, occur much later
in life, are attended with  more  acute inflammatory symptoms, and
are not accompanied by  other symptoms or traces of syphilis.
    The  characteristics of the specific and of the non-specific  osteo-
periostitis may  be thus contrasted :
      Syphilitic Osteoperiostitis.
Occurs in infants under three  months
  of age.
History of syphilis in  child  and  its
  parents.
Implication of other bones.
Coincident with the development of the
  shaft of the bone.
Other lesions of syphilis,—nodes, skin-
  eruptions, etc.
All  the local symptoms comparatively
  mild.
Disease sharply localized.
Lymphatics of limb unaffected.
Beneficial effect of specific treatment if
  employed early.
    Non-Specific Osteoperiostitis.
Seldom, if ever,  occurs  in  children
  under one year of age.
No  history of syphilis;  sometimes  a
  history of traumatism.
Usually confined to one bone.
Coexists with the ossification of the
  epiphyses.
No such symptoms.

Pain, redness, and swelling very marked.

Involves neighboring parts.
Lymphangitis sometimes present.
No such effect.
    Rickets so frequently complicates syphilis that the latter is often
regarded as the essential etiological  factor in the development of  this
disease of the bones.  This, however, will not stand fhe test of clinical
investigation.  As is the case with tuberculosis, which  often runs its
course  in conjunction  with  hereditary  syphilis, rickets is  a distinct
disease.  The contrasted characteristics of  the two affections may be
thus tabulated:
Osseous Lesions due to Inherited Syphilis.
The swellings, particularly those of the
  long  bones, show  themselves at or
  soon  after birth.
A history of syphilis  or evidence of ex-
  isting syphilis in one or both parents.
Preceded or  accompanied by snuffles,
  coryza,  and cutaneous and mucous
  lesions.
              Pickets.
Rarely appear before  six months, gen-
  erally still later.

No such history necessarily.

No such prodromata. 
HEREDITARY SYPHILIS.
473
Osseous Lesions due to Inherited Syphilis.
Prodromata recognized as characteristic
  of rickets  do not precede the bone-
  disease.

Cachexia absent or moderate.
Physiognomical peculiarities of syphilis
  present.
Circumscribed tumors  on parietal  or
  frontal bones, rarely on occiput.
Ribs not markedly affected.
Disease  of  ribs,  when  existent, not
  ordinarily  coincident  with  that  of
  other bones.
Fontanelles close at usual period.
Other  syphilitic  symptoms  present,—
  enlargement of  phalanges, metatarsal
  bones, etc.
Often accompanied by sinuses, synovitis,
  abscesses,  cutaneous ulcers, etc.
Generally disappear by resolution, with-
  out leaving any  permanent change.

Mortality  among  children  in  whom
  many  bones  are  involved   is  very
  great.
Specific treatment useful.
In the first stage there is exuberant cal-
  cification of the ossifying cartilage,
  causing necrosis of the new-formed
  tissue and a consecutive inflammation,
  which terminates in the separation of
  the epiphyses.1
               Pickets.
Pallor, restlessness,  sweating, nausea,
  diarrhoea, etc., constitute a combina-
  tion of symptoms which often precede
  the bone-disease.
Cachexia marked.
Not present as a group.

Cranial bones thickened in spots, usu-
  ally upon the occiput.
All or nearly  all involved.
Nearly always so.
Closure delayed.
Syphilitic symptoms absent.
Little external or surrounding involve-
  ment.
Usually leaves  some bending of shaft
  and  distortion of the  neighboring
  joint.
Much less.
Of no benefit.
This is less marked.  There  is often
  formed instead a soft and non-calci-
  fied osteoid tissue.
   Syphilitic dactylitis commonly develops in infants.   The infil-
tration  may affect the  subcutaneous and  periarticular tissue, or  the
disease  may begin  in the  bone or periosteum  and  later involve the
fibrous  structures about the joints.
   The deep form  is a specific osteomyelitis,  and  often destroys  the
bone and the articulation.   The  articular  ends  of  the first phalanges
are usually affected.
   Symptoms.—Syphilitic dactylitis is characterized by the appearance
of an ill-defined, fusiform, purplish  swelling, which softens, breaks
down, and discharges.   The lesions are often multiple, painless, affect
   1 This table is founded  on one published in the translation of Cornil  on
Syphilis, by Drs. Simes and White, and is compiled chiefly from the excellent work
of Dr. Taylor on this subject. 
474
GENITO-URINARY DISEASES AND SYPHILIS.
the fingers rather than the toes, and in  the  more serious  forms  lead
to destruction of tissue and marked interference with growth.
    Diagnosis.—Specific dactylitis must be  differentiated from felon,
from  rheumatoid arthritis, from  enchondroma and  exostoses,  and
from tubercular disease.
    Felon  exhibits the symptoms of acute inflammation, and is rapid
in its course.   Rheumatoid arthritis begins primarily in the joints, and
is associated  with other characteristic symptoms.  Enchondroma and
exostoses  develop  much more slowly, and  are more circumscribed.
    Tubercular dactylitis runs a slower  course, is rarely symmetrical,
sometimes shows the bacilli of tuberculosis, is not benefited by specific
treatment, and disappears very slowly.
    The treatment consists in the administration of mercury and the
iodides, combined with curetting or resection  when abscesses have
formed and dead bone is present.
    The Joints.—Fournier  describes a form of joint-involvement
which he  terms arthralgia, characterized simply by  pain.  It  is ap-
parently causeless, is irregular in  onset, varies in degree, and has a
tendency to become more severe at nights.
    The lesions of the joints  are  practically the same as those of
acquired syphilis.  Fournier describes three  forms of arthrosis.  The
first presents the appearance of simple chronic hydrarthrosis.  Close
examination shows that the affection of the joint masks a bone-lesion,
perhaps an epiphysitis or a periostitis.
   The second form presents the symptoms  of syphilitic white  swell-
ing.   There is a somewhat globular tumefaction, made up almost en-
tirely of an extensive hyperostosis of the epiphyses, aided by moderate
synovial effusion.  There are no involvement of the  integument, dis-
coloration, heat, oedema, or  inflammatory symptoms.  On palpation
the tumor is felt to be of  bony hardness.  It is not sensitive and does
not occasion pain.  Function is not materially interfered with.
   The third form presents deforming arthropathies  dependent upon
epiphyseal malformation.  The shape of the swelling is irregular and
at times extraordinary.   Osteophytes materially interfere with func-
tion, and sometimes  occasion  complete ankylosis.   When they are
developed at  an early age they are accompanied by muscular atrophy
and arrested  development of the affected part.

    HEREDITARY SYPHILIS AFFECTING THE  LYMPHATIC GLANDS.
   The enlargement of the lymphatic glands is painless, slow, and
without tendency to suppuration.  The anterior cervical group is most
commonly affected.  The tumors  hardly ever  attain large size, and 
HEREDITARY SYPHILIS.
475
remain indefinitely without marked change.  The enlarged glands of
hereditary syphilis are found in the regions  affected by  tubercular
glandular enlargements, and  in the early stage of their evolution ex-
hibit the  same symptoms.  The absence of ulcerative tendency and
of general lymphatic involvement, the permanency of the growth, and
the  effect of specific treatment make the diagnosis clear.

HEREDITARY SYPHILIS AFFECTING THE  XEKVE-CEXTRES AND NERVES.
   The Brain.—The lesions which attack the nerve-centres may
appear in the form of endarteritis, diffuse infiltration,  or gummata.
   When the brain is involved the lesions are usually multiple and
diffuse, and give rise to a variety of symptoms.
   Paralyses are among the characteristic symptoms.  These may be
limited or general, but when  they are repeated, multiple, or recurrent,
and particularly when they involve symmetrical portions of the body,
they suggest syphilis.   The three clinical types recognized in acquired
syphilis are commonly seen in the inherited disease,—i.e.,
    1.  Those characterized by sudden palsies, due to the thrombosis
of endarteritis.
    2.  Those characterized by symptoms of brain-tumors, due to gum-
matous formations.
   3.  Those characterized by headache and  various  functional or
convulsive disturbances, such as epilepsy, neuralgia, or chorea, due to
periostitis or meningitis.
   The following is a resume  of Founder's teaching.  The lesions of
the cerebrum may involve the  encephalon primarily or may extend
from neighboring parts.   Syphilis is undoubtedly  one of  the causes
of hydrocephalus.  Infiltrations and gummata of the  brain  and its
meninges have been observed at birth.   If the  child survives these
lesions they manifest  themselves later by  paralysis, paresis, or en-
feebled cerebration, shown by a certain  mental incapacity or slow-
ness, or even by actual imbecility or idiocy.  Children thus afflicted
develop slowly, talk late  and  with difficulty,  are  forgetful, and are
characterized as backward ; or they exhibit no reasoning power, speak
at most a fewr incoherent words, are subject  to fits of  ungovernable
rage, and often suffer from associated defects of vision and  permanent
or transient muscular incoordination, shown  by awkwardness, tremors,
weakness of the legs, staggering gait, etc.  These  pronounced cases
are rare, because lesions sufficient to produce them are nearly always
fatal in early life.
   Cerebral syphilis manifesting itself after the period of infancy (late
hereditary syphilis) may exhibit as its cardinal symptoms— 
476
GENITO-URINARY DISEASES AND SYPHILIS.
   1. Convulsions epileptic in type.
   2. Cephalalgia.
   3. Disturbed cerebration.
   Epileptic Symptoms.—These may develop as pure epilepsy, char-
acterized by a succession of convulsive  attacks, coming on  suddenly
in the midst of apparently perfect health, or by  epilepsy associated
with  other symptoms,  such as  recurrent, intermittent  headaches,
heaviness, vertigo, and enfeebled intellect.  As the disease progresses,
symptoms  of cerebral congestion develop, characterized  by vertigo,
tinnitus, amblyopia, loss of  vivacity, dulness, inaptitude  for talking or
for work, loss of memory, enfeeblement of reasoning power, hebetude,
paresis or  partial  paralysis, particularly of the ocular  muscles, and
finally hemiplegia.  In this  form of the disease treatment inaugurated
during the  epileptic stage, before the  advent of  other cerebral symp-
toms, is almost certainly curative.  When the disease is well advanced ■
and paresis developed, the prognosis  must be extremely guarded.
   Cephalalgia.—The forms of hereditary syphilis  characterized  in
the beginning by cephalalgia as the  major, often the sole, symptom
are well authenticated.   The pain is general, dull, and  heavy rather
than  lancinating and neuralgic, and  involves the whole head.  It is
subject  to  nocturnal exacerbations,  and  is  persistent.    This  latter
quality is most important from a diagnostic stand-point.   It is shortly
followed by other  symptoms, especially  epileptic crises,  the latter ap-
pearing in a few weeks.
   Disturbed Cerebration.—The third form of cerebral syphilis, char-
acterized by disturbance of the intelligence, usually coexists with other
cerebral phenomena.   Occasionally it appears as  the first and for a
time the only cerebral manifestation of the disease.  It may be  ex-
pressed in the form of intellectual asthenia, the child losing the faculty
of attention  and  becoming petulant, forgetful, easily  fatigued, dull,
heavy, lethargic, even torpid.  After  several  weeks or months,  head-
aches develop, followed by symptoms  of congestion   and  epileptic
seizures.
   In whatever form the disease begins, if unchecked it ends in dis-
turbance of  the intellect and  paresis or  paralysis.   Its course may
be rapid, corresponding  to  the  symptomatology of acute or subacute
meningitis or cerebral tumors, or may be  chronic, lasting for several
years.
   Diagnosis.—The  diagnosis   of cerebral syphilis  from tubercular
meningitis is sometimes impossible.  It may generally be  founded upon
the following points:
   1. Cerebral syphilis is not accompanied by fever; tubercular men- 
HEREDITARY SY^PHILIS.
477
ingitis exhibits  fever in the initial  period, and in the course of the
disease shows characteristic oscillations of temperature.
   2. Cerebral  syphilis does not cause sudden changes in the  color of
the face from  pale  to  red, retraction of the belly, irregularity of the
pulse.  Disordered relation between pulse and temperature is charac-
teristic of tubercular meningitis.
   3. The  hydrocephalic  cry, obstinate  constipation in the beginning
of the attack, vomiting, delirium, photophobia,  chewing, grinding of
the teeth, and  opisthotonos are much  more frequently observed in
tubercular meningitis than in cerebral syphilis.
   4. Tubercular meningitis often  rapidly  and markedly affects the
general condition, causing emaciation and  the symptoms  of serious
illness.  The same changes are not  so prominent in cerebral syphilis.
   The diagnosis of  syphilitic  epilepsy from  epilepsy  due to other
causes, one of cardinal importance  to establish, will depend upon the
rapid development of other cerebral symptoms characteristic of heredi-
tary syphilis.  Thus, disturbances of the intellect  are early observed ;
frequently partial palsy follows the attacks in the early stages.  More-
over, in the intervals of the attack there  are found symptoms  of cere-
bral involvement.  All these symptoms develop slowly in true epilepsy.
Finally, epileptic attacks wiiich are frequent and multiple in the early
stages, or which are partial and lateralized, are much more character-
istic of syphilis than of common epilepsy.
   It is apparent that cerebral syphilis has no individual symptoms of
its own: hence  the diagnosis will in the  main be founded upon hered-
itary specific antecedents.
   The Spinal Cord.—Gummatous  infiltration, as in acquired syph-
ilis, may involve the membranes or  the cord itself.   These lesions
may be secondary to bone-involvement; the first  symptom is usually
paralysis of the legs.  When the seat of involvement is high up  this
palsy may involve the arms also.
   The diagnosis will be founded upon  the  history and the associated
signs of the disease.   Fournier summarizes the matter by stating that
certain paraplegias of infancy  or even of the adult can originate from
hereditary syphilis.   Tabes, he states,  may have  the same etiology,
since  it is so frequently associated  with syphilis  of the adult,  and
clinical  observation of a limited  number of cases seems to establish
this fact.
   Disseminated sclerosis, he holds, is much more  frequent in infancy
and youth than is generally believed.  It offers practically the same
symptomatology as  in  the adult, and among  the etiological factors
syphilis must be admitted as an important one in certain cases.  Four- 
478
GENITO-URINARY  DISEASES AND SYPHILIS.
nier has observed as the result of hereditary syphilis isolated palsy
of the oculo-motor nerve, and quotes Nettleship's case of paralysis of
the  common  oculo-motor, the abducens, and the  trigeminal nerve.
Ormerod is also quoted as observing a case of  palsy of the  median
nerve with gummatous swelling of the trunk.

          HEREDITARY SYPHILIS  AFFECTING THE VISCERA.
    The Lungs.—The lungs are more  frequently attacked by hered-
itary than by acquired syphilis.   The  disease may appear as gum-
mata or as a diffuse infiltration.
    Gummata  of the lungs, the common  form of involvement, affect
chiefly the middle and lower posterior portions, appearing as miliary,
pea-sized, sometimes cherry-sized, nodules.
    Diffuse infiltration, the so-called white pneumonia, is often asso-
ciated  with gummata.   It may  involve  several  lobules or lobes.
The portion of the lung affected is dense and of a lighter color than
normal, due in part to the anaemia  incident to perivascular connective-
tissue growth with  thickening of the vessel-coats.  The alveoli are
filled with epithelial cells undergoing fatty degeneration.   Diffuse in-
filtration, if extensive,  is necessarily fatal at birth.  Apparently chil-
dren suffering from this lesion, even though it be limited, live but  a
few  days or weeks.
    Diagnosis.—The diagnosis of specific lung-involvement in syphilitic
infants cannot be made.   Many such infants perish of  broncho-pneu-
monia ; this, however, is an  expression of vulnerability  rather than
of the localization of a specific lesion.
    The Liver.—Examinations  of  children still-born  because of
hereditary syphilis  show that  lesions of the  liver are  most constant.
The liver may be the only viscus involved.  The  usual form  is a dif-
fuse interstitial hepatitis,  though  true  gummatous hepatitis  may be
observed at birth.   There is  marked  enlargement, the liver, always
disproportionately large in young  children, being sometimes three or
four times its normal size.
   The  only symptom wiiich excites  attention  is the enlargement.
Exceptionally, from obliteration of the bile-ducts, jaundice develops.
   The  Spleen.—The spleen is enlarged at birth or  shortly after in
about twenty per cent, of the cases of hereditary syphilis.   The lesion
usually appears in  the form  of diffuse  interstitial splenitis, and may
form a tumor three times the size of the normal organ.  The increase
in size  seems to be mainly due to a simple hyperaemia.  Enlargement
of the  spleen  is a valuable aid to  diagnosis.  Moreover, the amount
and persistence of the  swelling give an approximate indication of the 
HEREDITARY SYPHILIS.
479
severity of the  case.  Liver-enlargement is of little  value  as a con-
firmatory symptom, because, as has just been said, the liver is dispro-
portionately large in infancy and it  is difficult  to  state the  limit
beyond which abnormality begins. Moreover, causes  other than con-
genital syphilis lead to its enlargement.
   The importance of splenic enlargement  is greatest when  noticed
early,—the first three  months after  birth,—since   at  this  period
enlargement of  the spleen  due  to  rachitis can hardly come into
question.
   The Pancreas.—Diffuse interstitial infiltration  of  the pancreas
has been found  in a certain percentage of the more malignant cases
of hereditary syphilis.   There are probably  no  symptoms wiiich will
assist in the detection of this involvement during  life,  and it is always
associated with lesions of other organs far more serious and demand-
ing more immediate attention.
   The Intestines.—During  the early secondary period lesions cor-
responding in type to those appearing on the skin may attack  the
intestines.   The  passage of blood by the bowel would probably be
the only sign on wiiich a diagnosis could be formed.  Ulcerating, gum-
matous infiltrations, rare in any event, are more common in congeni-
tal than in acquired syphilis, though it must be  remembered that this
statement is founded on  examinations  of malignant and fatal cases of
congenital syphilis.
   The kidneys are rarely involved, but in  the more  malignant cases
exhibit, together  with the liver and the spleen, either the diffuse inter-
stitial or the gummatous form of degeneration.

        HEREDITARY SYPHILIS AFFECTING  THE  TESTICLES.
   This rare  manifestation of hereditary syphilis usually develops in
the first year  of life.   The testicle  slowly and  painlessly enlarges.
The  epididymis  may be involved in  the swelling, and there may be
an associated hydrocele.  Softening and ulceration rarely occur, reso-
lution ultimately taking place, often followed by pronounced  atrophy
of the gland.
   Diagnosis.—Non-traumatic  enlargement of the testicle  in infancy
should always suggest  syphilis or tuberculosis.    If the  tumor never
reaches great size,  shows  no  tendency to ulcerate, and  primarily
attacks the testes, it is probably syphilitic.
   Prompt treatment will prevent atrophy.
               DIAGNOSIS  OF  INHERITED  SYPHILIS.
   In reviewing  the general course of a case of inherited syphilis it
becomes evident  that the differences between it and the acquired dis- 
480
GENITO-URINARY  DISEASES AND  SYPHILIS.
ease are seeming rather  than real.  The primary stage in  inherited
syphilis is of course wanting, and the tertiary stage  is apt to appear
unusually early.
   Early Hereditary Syphilis.—The diagnosis of inherited syphilis in
its early stages, at birth and shortly after, will be  founded on,—
   1. A history of parental syphilis.   The probability  of the trans-
mission of the disease is increased if the parental syphilis was recent
at the time of conception and if both parents were infected.
   2. A history of abortions or miscarriages on the part of the mother,
particularly  if such accidents have been  frequent,  or of the successive
births of several living children who survived but a short time.
   3. A foetus or still-born child showing (a) osteochondritis, readily de-
tected by splitting the long bones, particularly the radius, ulna, humerus,
tibia, and femur, through  the diaphyso-epiphyseal juncture.  In place
of the regular narrow line marking the apposition  of bone to  cartilage,
there is a broad, irregular,  yellow line ; (6) enlargement of the liver and
spleen; (c)  the lesions of interstitial pulmonitis; true  gummata,  or
catarrhal phenomena, with fatty degeneration; {d) papular,  pustular,
or ulcerating lesions,  or  bullae  which  exhibit the characteristics of
syphilitic pemphigus.  Maceration of the epidermis and its  elevation
into  bullae  are scarcely  characteristic,  though distinctly suspicious.
(e) Arachnitis with hydrocephalus.  (/) Arrested development and
evidence of  profound malnutrition.
   4. A living  child prematurely born, or carried to  full term, show-
ing  the lesions  of syphilis  at  birth or  shortly developing them.
Whether  the syphilitic  child be  stunted, emaciated, wizened,  and
senile at birth, or be well nourished, cutaneous or mucous membrane
eruptions and other evidences of syphilis are often absent.  In a few
wreeks, or at most two or three months, highly characteristic symp-
toms develop.  The more prominent of these are snuffles, hoarseness
of the voice, syphilides of the skin  and mucous  membrane, enlarge-
ment of the liver and spleen, inflammation of the iris, profound ca-
chexia, and  specific inflammation at the junction of the epiphyses and
diaphyses of the  long bones, sometimes producing a condition termed
syphilitic pseudo-paralysis.
   Upon the presence of  these symptoms the diagnosis of hereditary
syphilis will be founded in the first year of life.
   Prognosis.—The prognosis of early hereditary symptoms is unfavor-
able if cachexia is marked, if there  are  intercurrent  affections, if the
symptoms show themselves early, if the nasal or laryngeal affection is
severe, if the eruptions are markedly bullar or pustulo-ulcerative, if the
enlargement of the spleen is great, if the osseous lesions are multiple 
HEREDITARY  SYPHILIS.
481
 or  extensive, and especially  if lesions of the tertiary  type develop,
 such as gummata, nodes, etc.
    Late Hereditary Syphilis.—After infancy the  diagnosis of inherited
 syphilis will be founded on,—
    1. A history of parental or infantile syphilis, or both.
    2. Imperfect or arrested development.   This is manifested by many
 symptoms, none of wiiich are  individually characteristic, but the as-
 sociation of wiiich is  pathognomonic.   The common expressions  of
 this developmental retardation or arrest are—
    (a) A low stature  and puny  development.  The figure is often
 graceful and symmetrical, suggesting infantilism or  early youth long
 after these periods have passed, or the appearance may be that  of
 premature  senility.    (6) Pasty,
 leaden, or earthen complexion.               FlG- 156.
 (c) Dryness or harshness of the
 hair, and  brittleness  and split-
 ting of  the nails.
    3. Active  manifestations  of
 syphilis or  traces of former char-
 acteristic lesions,  (a) The fore-
 head  bulging in the middle line,
 or  bossed  in  the region of  the
 frontal  and parietal eminences.
 (6) A  flat, sunken   bridge  of
 the  nose,  due  to  the  coryza
 of  infancy  extending  to  the
 periosteum of the delicate nasal
 bones,   interfering  with  their
 nutrition or partially destroying
 them,  (c)  DulneSS  Of  the  iris     Hereditary syphilis.  Cicatrices of fissured
 ,   .                              lips and gummata of the forehead and orbit. (De
 (rare).                             Schweinitz.)
    4.  Ulceration of the hard pal-
 ate and pharynx.  Thickening or enlargement of the long bones near
 the ends, or slight angular deformity, the result of the osteochondritis
 of infancy.
    5.  Hutchinson's teeth.
    6.  Traces of interstitial keratitis.
    7.  Cicatrices about the lips and nares.   These appear in the form
 of narrow,  radiating scars, extending across the mucous  membrane of
the lips,  or as a net-work of linear  cicatrices  on the upper lip  and
around the  nostrils, as well as at the  corners of the mouth and on the
lower lip.   (Fig. 156.)
                                31
 
482        GENITO-URINARY DISEASES AND SYPHILIS.

   8.  Skin cicatrices,  showing  rounded, polycyclic, or  serpiginous
outlines, especially about the  nose and the gluteal region.
   9. Periosteal nodes on one or many of the long bones, or irregu-
larly scattered over the skull.
   10. Sudden and complete deafness without  otorrhoea, or other
subjective  symptoms,  or a history  of sudden, painless otorrhoea in
childhood.
   Prognosis.—The prognosis of late hereditary syphilis  is  good so
far as  life  is concerned, although exceptionally wiien important  vis-
cera, such  as  the  lungs, the brain,  the liver, or the kidneys, are at-
tacked, death  may result before  treatment can accomplish resolution
of the  specific infiltrate.
   The treatment of  hereditary syphilis is  given in the following
chapter. 
CHAPTER  XIV.
                   THE TREATMENT OF SYPHILIS.

   The treatment of syphilis is conveniently considered  under the
following heads:
   1.  Prophylactic.
   2.  Abortive.
   3.  Constitutional.
   4.  Local.
                   PROPHYLACTIC TREATMENT.
   In discussing the treatment of a disease wiiich is thought to owe
its origin to a pathogenic organism, modern science demands  consid-
eration of the possibility of preventing the spread of the contagion, or
of eradicating it by destroying the source of infection.
   The Contagious Diseases Acts of Great Rritain and the various laws
of other countries for the restriction and regulation of prostitution aim
at accomplishing this purpose.   They represent the attempts of the
governing  authority  to protect the  community at  large from  disease
and infection by regulating the hygiene of and placing restrictions on
the class most liable to spread the disease. There can be no doubt that
these measures are of great benefit, and it has been proved that clan-
destine prostitution, out of reach  and control of these acts, is the great
source of contagion in the countries in which they have been in force.
   It may be admitted that no method has as yet been devised which
is in all respects unobjectionable  or is capable of universal application.
It may also be conceded, even while advocating the general principle
of supervisory legislation as  applied to prostitution, that in the details
of every plan yet proposed  there has been much that was defective
or positively harmful, and that the subject is still one of the unsolved
sanitary problems of the age.  The direction in which  action must be
taken, and the general character of that action, may, nevertheless, be
indicated, if not demonstrated.
   We may begin, without  much fear of contradiction, by urging the
necessity of a more general  and more accurate public knowledge con-
cerning the gravity and the prevalence of this disease.  The innocent—
who are also in this respect the ignorant—members of the community
have claims which we, who seek to fulfil the highest function of our pro-
                                                         483 
484        GENITO-URINARY  DISEASES AND SYPHILIS.

fession,—the preservation of health, individual and national,—cannot
conscientiously disregard.  Every adult citizen should be aware for his
own sake of the possibilities of contamination which surround  him;
every parent should be competent to protect his wife or children from
all indirect infection through a servant or playmate, a household  uten-
sil or a toy ; every wife should know that by permitting the approaches
of a syphilitic husband she herself becomes  liable to disease, and to
the creation of a being which has few chances for life  and still fewer
for health and happiness; and  every syphilitic should realize that, ex-
cept after certain intervals and  under proper restrictions, his marriage
is an outrage to the woman he  professes to  love and a crime against
society.
   Once let  these facts be clearly understood and this  information
widely diffused, and  an important step will have been taken not only
in preventing accidental and guiltless contagion, but also in preparing
public opinion  for the  legislative measures which are  believed  to be
desirable.  Another good  result would in all probability be a diminu-
tion  in the number of cases of  this class of disease, who, in ignorance
of the gravity of their ailment,  consult the quacks and irregular  prac-
titioners who find here their favorite and lucrative field.  It is safe to
say that the fees of the patients with venereal disease annually treated
by charlatans, advertising doctors,  and  apothecaries  would  comfort-
ably support all those younger members of the profession  into whose
hands  they ought naturally to fall and who now pass through the
usual struggle for existence.
   For these reasons—first and especially  the  public welfare, and
next our own personal interest—we should  in every proper way en-
courage the presentation of  this matter to the community at large, by
means, for example, of discussions in health societies, by proper repre-
sentations to editors of the daily press, and by careful but truthful and
forcible statements to our  friends  and  patients, who  are frequently
eager for information  on the subject.
   It may be admitted at once that  if the total abolition of prostitution
could be accomplished, and if it could be  followed by the conversion
of the army of harlots into peaceful housekeepers or sisters of charity,
and  the  transformation of their male patrons into pure, law-abiding
citizens and  fathers  of families, it would be  a most satisfactory con-
summation.  No one, however, at the present day, with perhaps the
exception of  a  few impractical clergymen and a number of enthusias-
tic and well-meaning but misguided women,  believes in the possibility
of attaining such  an end.   The accumulated experience  of mankind
constitutes a wall of unanswerable argument.   All attempts at the ex- 
THE TREATMENT OF SYTPHILIS.
485
tinction of prostitution present throughout the centuries one unbroken
record of failure.  Wherever this scheme has been tried, the sexual
impulse, the strongest to which human nature is subject, has  asserted
itself, and other laws have been violated, other and graver evils  have
resulted.  The remedy has proved worse than  the disease.   (Lecky.)
Seduction, illegitimacy, criminal abortion, and infanticide have invari-
ably followed, and the total average mortality of the  community has
been seriously increased.
   In considering the  necessity for general prophylaxis and the direc-
tion which efforts towards the accomplishment of this end should  take,
it should be remembered :
    1. That syphilis  is of great antiquity, and is likely to continue  in-
definitely.   2.  That this disease already affects a large number of the
population, and that by means of its  many  forms of  inoculation and
transmission it is rapidly spreading still  farther.   3. That the existing
means for its treatment among the poorer classes are  insufficient, and
that the establishment of institutions  for that purpose or the endow-
ment of special wards in our general hospitals is a measure eminently
worthy of the attention of the public-spirited  and benevolent.   4. That
its  most common mode of  propagation is by irregular or illicit sexual
intercourse, and that therefore we should turn our main efforts at pre-
vention  in this direction, while endeavoring at the same time and in
every decent and proper manner to guard the community at large from
the effects of ignorance.  5. That prostitution, arising in response to
the demand for this illicit indulgence, has,  like  syphilis, existed  from
time immemorial, and is not likely to disappear.  6.  That prostitutes
themselves need protection and  have claims on the humanity of the
law.  7. That by means of  supervisory legislation and control of  pros-
titution the unlawful sexual commerce of the w^orld may most readily
be  restricted  and the spread of  the disease be prevented.   8.  That
there is  sufficient evidence  that such control and restriction, though
surrounded with difficulties, is yet possible, and that the advantages to
be derived from it are highly important.
    The  only certain method of escaping the  venereal forms of syphilis
is the avoidance of  exposure.   When  consulted in regard to prophy-
laxis the physician should insist upon  this point and need not volun-
teer further information, though under proper circumstances he should
not withhold knowledge as to the means by  which the danger of con-
tagion can be lessened, if not entirely avoided.  This danger can be
diminished by (1) avoidance of intercourse when there  is  an  abrasion
or any surface break  about the  genitalia; (2) the use of covers;  (3)
the local use of protective and antiseptic ointments ; (4) thorough local 
486        GENITO-URINARY DISEASES AND SYPHILIS.

washings with mild antiseptic lotions immediately before and  imme-
diately after  coitus; (5)  circumcision in persons with redundant or
phimotic foreskins ; (6) the use of astringents by those wiiose mucous
membrane is particularly vulnerable; (7) immediate antiseptic appli-
cations to and superficial cauterization  of  abrasions  acquired  during
coitus.
   The risks of  extragenital  infection are  lessened by (1) the  avoid-
ance of prolonged contact of any portions of the body; this particularly
holds true of the  lips  and tongue ; (2) care as to the cleanliness of
eating and drinking utensils, pipes, or any article which is liable to be
contaminated by the discharge from the lesions of syphilitics; (3) the
immediate cauterization  of any  abrasion or wound which could pos-
sibly  have been infected  by the discharges  from  syphilitic  ulcers,
mucous patches, etc.
   Perhaps the  most important  means of prophylaxis is thoroughly to
impress upon those wiio  are suffering from florid syphilis the fact that
all their bodily secretions are liable to be contagious.  They must be
instructed as to  the possibility of infecting others from cigars, spoons,
forks, or other  articles moistened with their  saliva, or from razors,
manicure instruments, scissors, or knives wiiich may be stained  by
their  blood, and from handkerchiefs, sheets, pillow-cases, garments,
towels, sponges, or baths wiiich may contain the virulent discharge
from mucous membrane or skin lesions.
   The danger of conveying the contagion by kissing, by intercourse,
or by body contact of  any kind  must be clearly laid down.
   In the case  of a surgeon, accoucheur,  or dentist, the possibility
of infecting patients by  means of the blood incident  to accidental
wounds of the hands must be duly considered ; indeed, this danger is
sufficiently pronounced to forbid the performance of difficult or exten-
sive operations during  the florid stage of the disease.
   As further means of  prophylaxis, barbers, masseurs, chiropodists,
all whose occupation requires them to  treat  the skin and its appen-
dages  by instruments or  by the hands,  should be thoroughly  in-
structed as to the  possibility of  conveying the disease.  They  should
be required  to  sterilize  their instruments by heat  or other efficient
means before using them on each new client, and should be held
legally responsible for  cases of syphilis  wiiich develop in consequence
of their ignorance or neglect of  simple  precautions.

                    THE ABORTIVE TREATMENT.
   Two methods  have  been proposed for the abortion of syphilis
immediately upon the  appearance of chancre ; these are— 
THE TREATMENT OF SYPHILIS.
487
   1.  The excision or complete destruction of the  chancre and the
surrounding tissues.
   2.  Destruction of the specific virus by active constitutional treat-
ment.
   Excision or Destruction of the Chancre.—The abortion of
syphilis by excision, cauterization, or injection of the chancre has been
attempted in many hundreds of cases, but  efforts  in this direction
have almost without exception proved futile.   In a very  few of the
many reported cases excision seemed to be successful in  preventing
the development of constitutional disease ; but  it is possible that con-
stitutional syphilis  would not have developed  even if the operation
had not been undertaken, since the course of untreated cases shows
that a certain small percentage of undoubted chancres is not followed
by secondary manifestations.
   Aside from  the  attempt to abort syphilis, excision of the chancre
may be undertaken with the idea of ridding the system of  a focus of
infection, or for cosmetic or other reasons, and if total excision does
not leave a deforming or crippling scar there can be no objection to
it.  It must be borne in mind, in considering the results of this opera-
tion, that the ulceration of chancre, even though it  appear extensive
and deep, usually disappears  under constitutional treatment,  leaving
an extremely insignificant scar.  Ehler holds that excision of the initial
lesion lessens the  severity of subsequent symptoms, since  thus there
is cut  off  from the system a large amount of infection ; he also thinks
that in a certain percentage of cases the constitutional disease is com-
pletely aborted.  Fournier believes that excision gives an average of
one success in five cases.
   Probably it is safe to  assume that when the sore is seen within a
few days of its appearance  and before the lymphatic vessels and
glands in  anatomical  connection are enlarged, the disease may still be
purely local, and constitutional poisoning may be prevented by com-
plete excision of the  infected  focus: hence such a sore should be re-
moved by excision  when it  is favorably located for this operation, or
should be  destroyed by  cauterization under  other circumstances.
When  the sore is located upon the prepuce or upon the skin of the
genitalia, it, together with the apparently healthy surrounding tissue,
may be picked  up in a pair of rat-tooth forceps and  removed by a
cut with a pair  of scissors curved on the flat.   This wound may be
sutured, or, to give greater  assurance of the  complete destruction of
the specific micro-organisms, the raw surface may be cauterized with
nitric acid and dressed with iodoform or boric  acid  powder.  When
the sore is  so situated that its removal by the knife  would cause 
488       GENITO-URINARY DISEASES  AND SYPHILIS.

troublesome hemorrhage, deformity,  or interference with function
nitric acid or the actual cautery may be employed for its destruction.
    As regards protection  from subsequent constitutional syphilis, the
results are, on the whole, unsatisfactory;  but in a few cases—nine in
all—we have been able to make  observations under  unusually satis-
factory circumstances.  In these cases the  patients  came promptly
upon the development of the sore,  and  sent  for  examination  the
women with whom they had had connection, evidence of syphilis being
discovered in the latter.  The sores of the male patients were excised
and cauterized with  nitric acid.   In five of these cases microscopical
examinations showed that the sores possessed the usual characteris-
tics of hard chancre.  In one of them slight glandular involvement
had already shown itself; in the others it had not yet appeared.  The
shortest period intervening between the appearance of the sore and
inspection of it was twelve hours; the longest, five days.
    In five  of the nine  cases, including the  one  in which  there was
slight glandular  involvement,  no  further symptoms have ever devel-
oped ;  in the remaining four  the  appearance of constitutional  symp-
toms was delayed from three to five weeks  beyond  the usual time,
just as is the case when mercury  is given immediately on the appear-
ance of chancre.
    It is only fair to add that, during the time  these observations were
made, several  cases were  seen in which  excision was  not performed
on account of the anatomical seat of the sores, which were believed to
be almost certainly specific, but which healed and disappeared with-
out the development of the slightest constitutional trouble.  Only in
one of these latter cases, however, was there an opportunity for con-
firming the diagnosis by confrontation.
    In all cases in which a week or more has  elapsed since the  devel-
opment of the  sore, and  in which involvement  of the dorsal lym-
phatics of the penis or of the inguinal lymphatic glands is observable,
cauterization, as a routine  method of treatment, should be rejected, on
account of  its undoubted uselessness at that  stage in preventing con-
stitutional disease ; the pain which it causes ;  the inflammatory action
which follows it, and which often produces enough oedema and swell-
ing  to cause phimosis, and thus  convert an  open sore into a hidden
one; the subsequent effusion of lymph, which simulates true indura-
tion and confuses the diagnosis; and, finally, the greater liability to
the  production of suppurative action in the ordinarily indolent bubo
of syphilis.
   Rronson's method of hypodermic injection of mercurials beneath
and around the induration of the  initial lesion and into the indurated 
THE TREATMENT OF SYPHILIS.
489
lymphatic glands is based upon the theory of the antidotal action of
mercury when brought in immediate contact  with syphilitic germs.
The value of this method still remains to be proved, but theoretically
it should scarcely be commensurate with that of total excision.
   Constitutional Abortive Treatment.—The evidence points so
strongly to the microbic nature of syphilis and to the  specific action
of mercury in checking the virulence of  this microbe that the conclu-
sion as to the value of early administration of the antidote seems un-
avoidable.   Evidence as to the subsequent irregularity and virulence
of cases thus treated is greatly overbalanced by the testimony of many
competent observers  as to the lessened  severity of such cases.   The
question which must be considered, and which should influence the
time of administration,  is that of diagnosis.  Mercury should be given
as soon as the diagnosis is made.   This can, however, be established
only by the appearance of the secondary symptoms, since there is no
characteristic of the chancre which is absolutely pathognomonic.
   The surgeon who is daily called upon to give an opinion in cases
which involve the whole future of the individual, his relations to the
other sex, his determination towards celibacy or  matrimony, his matri-
monial relations if he should be already married, the question of the
influence of paternity, the institution of a course of treatment extend-
ing over years, the  diagnosis of any obscure visceral  troubles which
he may develop later in life, the profoundly depressing mental effect
which a knowledge of syphilitic infection usually has upon intelligent
people,—the surgeon who remembers these facts and recalls the views
already cited as to the possibility of error should surely hesitate about
beginning  a  course of  treatment which  may obscure  or render alto-
gether impossible the diagnosis.
   While it cannot be  held  that  the subsequent course of a case of
syphilis is advantageously influenced by delaying specific  treatment
till the appearance  of  secondary symptoms, on the other hand, the
gain from the immediate treatment during the primary sore is not suf-
ficient to counterbalance the doubt and  uncertainty wiiich that treat-
ment often throws about the future life of the patient.
   Mercury should not be given till the diagnosis of syphilis is assured by
the appearance of secondary symptoms.
   There  are a few necessary exceptions to this rule, which may be
included under the following heads :
   Mercury may be given at once—
   1. When the sore is distinctly a typical one and confrontation gives
confirmatory evidence.
   2. When the sore  is typical and its continued  existence would 
490        GENITO-URINARY' DISEASES  AND SYPHILIS.

destroy or imperil the conjugal relations of two people or possibly the
happiness of an entire family.
   3. When characteristically  indurated  sores show a  marked ten-
dency to spread and involve important regions.
   4. When sores are placed in such conspicuous  positions, as upon
the lips or the nose, that their continuance would involve  a general
knowledge of the patient's condition.
   5. When sores are placed in such positions, as on the finger of a
surgeon or of an obstetrician, that they may lead to the infection of
others.
   6. When typical sores appear on pregnant women.
   With these exceptions, it is the part of wisdom to wait until the
development of syphilitic anaemia or of glandular enlargement at some
point removed from the initial lesion, and not by any possibility a re-
sult of simple adenitis, demonstrates the constitutional character of the
trouble.  It is not necessary to wait for the syphilodermata.  Treat-
ment may be safely begun when, after a suspicious sore  upon the
genitals,  consecutive  enlargement  of the epitrochlear or postcervical
lymphatics follows, or an otherwise inexplicable diminution in haemo-
globin  and increase in white  corpuscles take place.
   The views expressed as to the  abortive treatment of  syphilis may
be summarized as follows:
   1. Chancres which are  seen  early (before lymphatic involvement),
and especially when  diagnosis is confirmed by confrontation, should
be excised  or cauterized in accordance  with their position.   The
prospect of  thus  aborting syphilis is slight.   It is, however, sufficient
to justify submitting a patient to the inconvenience of such an opera-
tion.   2.  Thorough  antiseptic treatment of  chancres  can have  no
abortive effect, but is valuable as a means of preventing mixed in-
fection.  3.  While it must be admitted that  mercury should be ad-
ministered as early as  possible,  the advantages incident  to  this early
treatment do not warrant its inauguration before the diagnosis  is ab-
solutely sure.  4. This diagnosis can be  absolutely assured only by
the appearance of some general symptoms, such  as blood-changes,
enlargement of distant lymphatic glands, or roseola: hence the admin-
istration of  mercury for the purpose of aborting  syphilis on the basis
of a  diagnosis founded on the  presence of the chancre  alone  is not
advisable, unless this  diagnosis is still  further confirmed by con-
frontation, or unless there are urgent reasons for attempting to  cure a
doubtful sore as rapidly as possible. 
THE TREATMENT OF SYPHILIS.
491
         THE  CONSTITUTIONAL TREATMENT OF SYPHILIS.
   The reasons  for waiting  until the appearance of constitutional
symptoms before administering mercury have already been given, and
also the exceptional circumstances under which such treatment may
be started in the primary period of syphilis.  The constitutional in-
fection may be first manifested by a rash, general  lymphatic involve-
ment, muscular, neuralgic,  or bone pains, anaemia, or the so-called
syphilitic  fever, though commonly the rash is the most characteristic
and most easily  recognized sign of systemic involvement on' which
the surgeon can base his diagnosis.
   During the period of waiting for the development of constitutional
symptoms the general  health of the patient  should be carefully regu-
lated.  He must be warned as to the importance of avoiding over-
work, mental  strain, undue exposure,  and excesses of all kinds.  He
should eschew strong alcoholic drinks, but need  not be prohibited
from moderate  indulgence in light wines at meals.  He should  be
cautioned that the use of tobacco  distinctly  predisposes to lesions of
the mouth and throat, and  should be advised to give up the  use of
this drug  in all its forms.
   The hereditary tendencies and diathesis of each individual  should
be studied,  since every depressing influence by lessening cell-resist-
ance may lead to increased virulence of the disease.  Tuberculosis in
the form  clinically recognized as  struma particularly favors virulent
manifestations of syphilis, such as deep and obstinate ulceration, os-
titis, caries, and various visceral changes.  A tubercular family  history
should, therefore, be  regarded as a  special indication for hygienic
precautions.   A patient with such a  history should spend at least a
part of each summer at the sea-shore  or in the  mountain air,  should
avoid all  causes of local  congestion,  such as chilling of  the surface,
and particularly should guard against  bruises, sprains, or  other trau-
matisms,  slight in themselves, but strongly predisposing  to the  local
development of strumous and of syphilitic  lesions.  The diet  should
be rich, of digestible fats,  and carbohydrates. Pulmonary gymnastics
should be employed, and to the  specific  treatment should be added
emulsions of partly digested cod-liver oil  in  combination  with  ferrous
iodide or  the hypophosphites.
   Both the gouty and the rheumatic  diathesis exert a distinctly un-
favorable  influence  on  the course of syphilis.  They predispose  to vas-
cular degeneration, to cerebral  disease secondary  to endarteritis, to
troublesome papulo-squamous syphilides, to iritis,  to periosteal nodes
and various other affections of the fibrous tissue.  The  diet of  such
patients should be most carefully regulated.  They should be  told to 
492        GENITO-URINARY DISEASES  AND SYPHILIS

eat sparingly of dark meats and of sugars, to drink freely of potash
or lithia waters,  and to eschew sweet wines, malt liquors, etc.   In
combination with the above treatment, short courses  of  salicylates
may be advantageously employed, and  the iodides should be begun
much earlier than in the case of previously healthy patients.
   Patients of a neurotic type  seem to be especially predisposed to
affections of the  brain and spinal cord.  The preliminary advice in
such cases must be directed to the avoidance of worry and mental
strain of any kind.  Every effort should be made to prevent that state
of nervous depression  which  the  knowledge of having contracted
syphilis so  often occasions.  Rest to the mind, and diversions of vari-
ous kinds,  particularly  those  which  require  mild exercise, such as
horseback  riding, cycling, golf,  and long summer vacations spent in
the open air, should be insisted upon.   The treatment should be  un-
obtrusive, the  prognosis to the  patient hopeful.  Long hours of  rest
are particularly desirable.  The specific treatment may be advan-
tageously supplemented by strychnine  and the hypophosphites.
   In all patients, whether robust or weak, the hygiene of the mouth,
of the gastro-intestinal tract, and of the skin should receive particular
attention, and invariably repeated examinations of the urine should
be made to determine whether or  not the kidneys can be depended
on for  the elimination of mercury and possibly the toxic products of
the syphilitic virus.
   The teeth should  be put in  perfect order by a competent dentist,
and  should be kept scrupulously clean  through the entire course of
treatment by cleansing washes, astringent mildly antiseptic  powders,
and careful removal of particles of food by means of  toothpicks  and
dental  floss immediately after eating.  Upon the health of the mucous
membrane of the mouth  depends to a  great extent  the ability of
the patient to take an  efficient quantity of mercury without causing
salivation.
   The gastro-intestinal tract  must be kept free from irritation by
well-regulated diet, by digestive and antiseptic powders, and by mild
laxatives when indicated.  Only when  the stomach and bowrels are in
good condition can the full dose of mercury be taken by the mouth  and
be absorbed  without exciting symptoms of gastro-intestinal catarrh.
The bowels aid in the elimination of mercury.
   The skin also aids in eliminating  mercury.  It should be kept in
perfect health  by daily bathing  and  friction, hot  or cold water being
employed in accordance with the feelings  of the patient.  Hot plunge
baths,  Turkish baths, and hot-air baths  are to  be  advised, unless
marked vascular  degenerations contra-indicate their employment. 
THE TREATMENT OF  SYPHILIS.
493
   When the time has come for the administration of mercury, it may
be employed in accordance  with one of the following methods:
   1. It may be given only wiien required to cause the disappearance
of actual symptoms.
   2. It may be given interruptedly in periods of varying length, with
intervals of complete rest between.
   3. It may be given continuously over long periods of time.
   Modified Expectant  Treatment.—The first method, termed
the modified expectant plan of treatment, has but little to commend it,
if we accept the germicidal theory of  syphilis, if we believe that  the
effects of the disease are wide-spread and permanent, and that these
effects are  dependent largely  on the relation between  the  original
dose of the micro-organism and  the  resisting power of the normal
cells, and  if we also believe  that mercury  exerts an  inhibiting or
toxic effect on the specific micro-organism.
   Interrupted treatment of syphilis is worthy of serious con-
sideration  mainly because it is advocated  by Fournier.  He, howT-
ever, has  frequently changed  his  method, and this fact apparently
shows that the intermittent course has often failed to produce per-
manent cures.
   Taylor holds that the time to eradicate syphilis is at the beginning
of the attack, wiien vigorous mercurial treatment is best tolerated and
is most efficient.   If the treatment is pushed for about six months he
believes that most cases will be found on their way to  recovery, and
may then have a rest in the absence of lesions and if the general health
is well maintained.  After a month without specific treatment a course
of inunctions, or a combination of mercury and small doses of potas-
sium iodide, is given.  Taylor argues  against  the continuous plan of
treatment, on the ground that mercury administered by the stomach in-
duces a condition of tolerance and after a time has no beneficial effect.
   Continuous  Treatment.—This  is the  most rational treatment
of syphilis, and is the one which is generally adopted. Mercury is ad-
ministered without interruption for a period varying between one and
three years, and in as full  doses  as the patient can tolerate without
prejudice to general health.   It is  advisable to use the same prepara-
tion of mercury throughout the treatment.   The dose is regulated by
the patient's susceptibility.  Reginning with  the  protiodide, for  in-
stance, a third of a  grain  thrice  daily, this  quantity is gradually in-
creased till slight toxic symptoms develop.  The first symptoms caused
by full dosage of the protiodide may be griping pains in the abdomen
and several watery stools a day.   When other preparations of mer-
cury  are given, and  often with the protiodides, fetor of the breath, 
494        GENITO-URINARYT DISEASES  AND SYPHILIS.

hypersecretion and ropiness of the saliva, and slight gum tenderness
may be the first indications that the drug has been  pushed  to the
limit of safety.  When it is thus determined  how much  of the mer-
curial  preparation of choice  a patient  can  take safely, provided the
symptoms of impending salivation are slight, the full dosage is con-
tinued a short time until the  more active manifestations of the dis-
ease have been combated; it is then  cut  down one-half, and  this
lessened dose, or one-half the quantity required to produce salivation,
is the quantity he is to take through the greater part of his treatment.
After the limit of tolerance  has been  determined,  if the symptoms
are not active, the patient is given a rest of several  days, until the
constitutional  effects of mercury have entirely  disappeared;  he is
then put on the half dose, and this is continued for  about two and a
half years.  In  certain  cases the quantity given may be still further
reduced to one-third the full  dose.   Frequently, as  a  result of treat-
ment,  there is an increase in general  health, markedly  beyond the
degree enjoyed before syphilitic  infection.

               SYSTEMATIC TREATMENT OF SYPHILIS.
   As a result of many  years  of experience in large  venereal hospital
services and a somewhat exceptionally rich clientele in private prac-
tice, wTe have adopted the following routine method of treating syphilis.
   The general hygienic  treatment already  described  (pages 491,
492) is inaugurated at  once; in addition, the patient's weight is re-
corded and repeated quantitative and qualitative  examinations  of the
urine are  made.
   As to the preparation of mercury which is to be administered, the
protiodide is preferable for routine  use, because clinically it has been
efficient, and possibly because the small amount of  iodine which the
salt contains may be advantageous.   Corrosive sublimate, gray pow-
der, and  chalk will also give  excellent results, and sometimes can be
taken  without irritation when  the protiodide markedly disagrees.
Rlue pill and calomel have not been satisfactory.
   As a routine practice it is well to adhere to the administration of
the protiodide, the bichloride,  or gray powder, preference being given
to the first drug, the others being employed only wiien the protiodide
produces  undue irritation  without favorably  influencing the course
of the  disease.
   When  few remedies are tried by the surgeon he  becomes more
familiar with their strength and special  properties, and hence is more
likely to employ them skilfully than if he used many salts of mercury,
the special reactions of which are unknown to him. 
THE TREATMENT OF SYPHILIS.
495
   If the  protiodide is selected, the following prescription may be
 ordered:
                    R  Hydrarg. iodid. vir., ^i;
                       Confect. ros., q. s.
                    M. et ft. pil. no. Ix.

   The patient is directed to take three pills on the first day, four on
 the second, five  on the third, and  so  increase the dose by one pill
 daily until some characteristic toxic effect of the drug  is produced.
 While thus pushing mercury for  the purpose of discovering the full
 dose, the patient must be seen at least  every second day, and  there
 must  be  some standard adopted by which  his  susceptibility to the
 drug may be determined,—that is, some characteristic symptom must
 be sought for.
   The patient's reaction to the drug is most certainly shown by the
 condition of the mouth and gums.  Mild colicky diarrhoea is frequently
 considered a sign that  the full  dose of mercury has been reached;
 this symptom, however, shows only the  reaction  of the  intestinal
 mucous membrane  to  the particular preparation of mercury that  is
 being used.  Colic and diarrhoea may occur long before enough mer-
 cury has been  given to  influence the gums, or even enough to  influ-
 ence the course of early syphilis.  These symptoms indicate defective
 absorption of the drug, and show that  only a  fractional part of the
 daily dose administered is reaching the  general  circulation : hence the
 adoption  of colicky diarrhoea as  a  gauge of constitutional suscepti-
 bility may lead to error, and may result in  insufficient treatment and
 its disastrous consequences.
   If  during early treatment colic and diarrhoea develop before the
 first symptoms of ptyalism, the protiodide should -be withdrawn, and
 in its place pills of mercury and chalk should be administered:
                   R Hydrarg. cum creta, gi;
                      Ft. pil. no. Ix.

   These pills  are administered exactly as  are those of protiodide of
 mercury,  increasing steadily until  the  limit of  tolerance—i.e., the
 minimum dose necessary to produce  toxic symptoms—is determined.
 A grain of mercury and chalk produces a somewhat more  powerful
 effect than the third of  a grain of  protiodide.
   If the gastro-intestinal irritation persists, unaccompanied by symp-
toms of ptyalism, bichloride of mercury should be administered:

                   R  Hydrarg. chlorid. corrosiv., gr. iv;
                      Confect. ros., q. s.
                   M. et ft. pil. no. Ix. 
496       GENITO-URINARY DISEASES AND SYPHILIS.

or
                   R  Hydrarg. chlorid. corrosiv., gr. ii;
                      Mucilag. acacise,
                      Aquae, aa. ^ii.
               M. S.—Teaspoonful freely diluted, as directed.

    If the change to these prescriptions is not successful in subduing the
symptoms of gastro-intestinal irritation, inunctions must be employed.
    When the  patient is  so situated that it is impossible  for him to
take inunctions, opium in sufficient quantity to control the diarrhoea
may be combined with one or other of the formulae already  given until
the full dose is determined.   It should  then be withdrawn, since it
tends to constipate, to reduce appetite, and generally to influence the
system unfavorably.   Moreover, it renders uncertain the  amount of
mercury actually being absorbed, and this is a disadvantage  of cardinal
importance, since the essential point in the treatment of syphilis is the ad-
ministration during a sufficiently long period of  the largest dose of mer-
cury which can  be taken and absorbed without prejudice to the  general
health.  Merely to order that a  certain dose of mercury be  swallowed
and to provide for its safe escort under an opiate guard from one end
of the  alimentary tract to the  other, is  not  to  treat syphilis intelli-
gently.
    The best method  of administering opium, when this is required
to determine the  full  dose, is in  the form of paregoric.  With each
mercurial pill  the patient is directed to take the  smallest number
of drops  which will  prevent griping diarrhoea; thus the minimum
efficient quantity can  be  found and can be administered in a form
towards which the stomach is fairly tolerant.
    It must be  clearly borne in mind  that salivation  is never to be
produced, and  that  the drug is pushed only until  the premonitory
symptoms develop.   These are : 1, a thickening of  the saliva and an
increase in  its  quantity;  2, boggy swelling of the gums around the
teeth, and a tendency  to bleed on slight irritation,—so-called  spongi-
ness of the gums; 3,  slight tenderness  of the  teeth when they are
snapped together,  and a feeling as though they were somewhat longer
than they should be ;  4, a metallic taste in the mouth ;  5, fetor of the
breath.
    It is only when the mouth  and teeth are clean  that these  symp-
toms are valuable as an index  that the system  is taking all the mer-
cury it  can  absorb without producing marked  toxic effects.   When
the teeth are  dirty, caked  with  tartar, decayed, and clogged with
masses of decomposing organic matter, from carelessness  in the use
of tooth-brush and tooth-wrashes, or from  neglect in seeking the aid 
THE TREATMENT OF SYPHILIS.
497
of the dentist, salivation will  occur from doses of mercury far below
those necessary to saturate the  system to the limit of safety.   Under
such circumstances it is well to wait until  the  mouth  has received
proper attention before attempting to find the minimum  toxic dose of
the drug.
   When one or all of these symptoms appear, the dose should be re-
duced at once, first to two-thirds, later to one-half that dose, if the
persistence of the mouth symptoms indicates further reduction.   This
is the  standard dose, which must be  continued, except  at certain in-
tervals  shortly to  be mentioned, over a period varying  from two to
three years.   If during this time there is an outbreak of syphilis, no
matter how mild or insignificant, the  dose should be increased to the
full dose,—i.e., that  under which  ptyalism began to appear,—and
this should be continued until the symptoms vanish, or until saliva-
tion is  so distinctly threatening that  diminution of the dose again is
necessary.
   When during the course of  treatment the mucous membrane of
the mouth becomes sore  or the gums boggy, cleansing  or antiseptic
mouth-washes, such as saturated solution of potassium chlorate, alter-
nating with  one of boric  acid, listerine and  water equal parts of
each, or phenol sodique  one part, water four parts, are indicated;
and indeed such mouth-washes  should be repeatedly used during the
whole course of syphilitic  treatment,  since they have a  marked  pro-
phylactic influence  against the development of  salivation.
   The weight during the  course  of treatment should  be carefully
noted.  This should be taken  at the first visit, and should be recorded
subsequently at regular intervals.  Stationary or increasing weight is
favorable.  A decrease without  obvious cause  should occasion grave
apprehensions  as to the subsequent course of  the disease, especially
when this decrease is rapid  and progressive.
   Under the  course  of  treatment just  described  there  is  usually
steady,  often rapid, subsidence of all  symptoms.   Glandular  adeno-
pathy diminishes, and often disappears completely, though there  may
remain traces of the original swelling; the  eruption fades, and the
agonizing pains and high temperature which sometimes usher in the
secondaries subside promptly.
   The end  to be obtained is full treatment over a long period.   Ry
way of making certain that  a proper amount of  mercury is being ab-
sorbed,- the internal administration of the drug is stopped at the end
of six weeks, and a two weeks' course of inunction in equivalent dose
(one scruple to two drachms of mercurial ointment daily) is prescribed.
The reasons  for this are that absorption from the digestive tract may
                              32 
498       GENITOURINARY' DISEASES AND SYPHILIS.

possibly be diminished in the course of time, and that an interval of
rest is  frequently beneficial to that tract.   After two weeks' inunc-
tion the mouth treatment is resumed.
    This alternation is continued for a period of two years; that is,
during  this  time there  are  six  months  of inunction  and eighteen
months of internal treatment.
    If at any time, however, the syphilitic  symptoms persist and re-
sist full doses by the mouth, the latter are  withdrawn and inunctions
are  substituted.   In  case  these  fail, hypodermic  medication is re-
sorted to.
    The Systematic Treatment by Iodides.—Potassium iodide is
the  preparation  commonly employed.   The  administration of this
drug is indicated at the end of the  second year, and should be  con-
tinued for six months in combination  with mercury, constituting the
mixed  treatment.   No  marked germicidal effects  can be claimed for
the iodides, and the reason for their use is based on clinical rather
than theoretical grounds.   It is quite certain that their usefulness is
not due to  an influence  exerted  on the residue of a prolonged mer-
curial course by virtue of which that residue is rendered soluble and
potent.   Indeed, there  is  evidence that the  administration  of the
iodides actually retards the elimination of mercury.
    In the early stages of syphilis  they are of little value, their thera-
peutic  efficacy increasing in direct  ratio with  the age of the disease.
The commonly accepted theory in  regard to their action is that  they
powerfully stimmlate the absorbent  system.  The lesions of late ter-
tiary syphilis are particularly characterized by excessive cell-growth
and accumulation of  imperfectly  organized tissue,  made up for the
most part of a small round-cell infiltrate, and due either to renewal of
activity at the seat of former disease, or to a  crippling or obliteration of
lymphatics incident to the long-continued hyperplasia of the secondary
stage.   The clinical  proof is convincing that iodides are more potent
than other drugs in promoting  fatty degeneration and  absorption of
the imperfectly organized exudates.
   The iodides  may be  satisfactorily administered in sarsaparilla as
an excipient,  not  because  this exerts  any marked alterative effect,
but rather because it disguises the taste of  the  drug.  The following
formula may be employed in the mixed treatment:

                    R Hydrarg. biniodidi, gr. iv ;
                      Potassii iodidi,  t^ss;
                      Syr. sarsaparilla? comp., f^vi.
        M.  S.—Teaspoonful in three ounces of water four times daily. 
THE TREATMENT  OF SYPHILIS.
499
   When patients object to taking this prescription, the iodide may be
given in the form of saturated solution, one drop of which represents
approximately one grain of the potassium iodide:

                     R  Potassii iodidi, 3v ;
                        Aquae, q. s. ad f^i.
   S.—Five to ten drops three times  a day in half a glass  of milk or water,
increasing the number of drops as required.

   Or  the iodide may be given  in the  form of compressed tablets,
mercury being administered at the same time, as previously  directed.
Occasionally other combinations  of iodine  are  better tolerated than
the potassium salt,  and in certain cases a combination of the three
best known salts will be found more serviceable than any one admin-
istered singly, thus:
                   R Potassii iodidi,
                      Sodii iodidi,
                      Ammonii iodidi, aa. gr. xcvi;
                      Syr. aurantii cort., f§i;
                      Aquae, f^v.
           M.  S.—Teaspoonful, freely diluted, four times daily.

   When  the iodide  is given in  the  form of saturated solution  the
taste may be almost  completely  disguised  by dropping  the  required
dose in  a glass of milk.
   When  it disagrees with the stomach,—and this is often the case,—
it may be  combined with essence of pepsin in the proportion of five
to ten grains  in a  teaspoonful.   The required dose of this mixture
can be  poured in half a glass of milk.   In a few minutes  a junket
is  formed, which can be  properly seasoned, and  which  completely
conceals the disagreeable taste of the iodide.   Moreover, when admin-
istered in this manner, the stomach becomes tolerant  to a remarkable
degree.  The most  important practical  point in securing  the fullest
good effects of the  iodides with the  least harmful results is to  give
them  in dilute solution.  The ordinary dose is given in six to eight
ounces of  water, and is  soon followed  by another tumblerful.   Hot
water still further  facilitates  the proper absorption  of  the drug.
Iodides  should be given about an hour after meals.  If they occasion
griping  pains, tannic  acid may be added to  the prescription, or  the
following formula may be used :

                     R  Potassii iodidi, ^ss ;
                        Syr.  corticis aurantii, f^vi.
            M.  S.—A teaspoonful in water  three times daily. 
500       GENITOURINARY DISEASES AND  SYPHILIS

    The iodides should be given :
    1. In the absence of symptoms, at the expiration of a two years'
course of mercury.  They should be continued for six months, in com-
bination with mercury (mixed treatment).
    2. In precocious secondary syphilis,—that is, when the lesions re-
semble  in  type  those of the tertiary period, affecting the fibrous or -
connective tissues, the bones, the nerve-centres, and important vis-
cera, or wiien they appear in the form  of deep ulcers or infiltrations
of the skin.
    3. In all forms of tertiary syphilis.
    The  dose of the iodides is, as  in the case of mercury, greatly in-
fluenced by  individual peculiarity. Except when the symptoms are
urgent and the integrity of an important organ, such as the brain, is
threatened, the initial  dose should be five grains  three times a  day.
This should  be increased by five grains every third day until the
symptoms  for which the  drug is  administered have  disappeared, or
until toxic symptoms  denote that the  therapeutic dosage has been
passed.   In the case of the iodides the production of the toxic symp-
toms is  not indicative that the full physiological or therapeutic effects
of the drug have been  obtained.  To  increase  the iodides until the
symptoms  are relieved sometimes leads to the administration of enor-
mous doses,  but the evil effects of these  are  usually far less to be
dreaded than the results of insufficiently treated syphilitic lesions of
important organs.  Thus pushed, the iodides frequently cause the dis-
appearance of osteocopic pains  and motor and sensory palsies, and
even at  times the re-establishment of mental faculties after they have
been persistently and  to  all appearance hopelessly disordered.  In
doubtful cases large and  increasing doses  may be administered for
diagnostic purposes, though it should not be forgotten that conditions
other than  those caused by syphilis may be alleviated or cured by full
doses of the  iodides, thus obscuring the value of the therapeutic  test.
    The  alleged value of tolerance of iodides  as a sign  of syphilitic
dyscrasia is without foundation.
    Since mercury and the iodides are drugs habitually used in com-
bating the  symptoms of syphilis,  and since, if  injudiciously adminis-
tered, they may bring about conditions even worse than those  for the
cure of  which they are given, the toxic symptoms which they occasion
must be carefully considered.
    The  Toxic Effects of Mercury.—Hydrargyrism.—Hydrar-
gyrism may be either acute or chronic.   The symptoms of either of
these conditions may be occasioned by the introduction of mercury
into the system, whether it be by way of the alimentary tract, through 
THE TREATMENT OF  SYPHILIS.
501
the skin, as when the drug is administered by inunction, vaporization,
or baths, or through the muscles  and subcutaneous  tissue, as when
preparations of mercury are administered hypodermically.  It should
be borne in mind that lesions of the kidney particularly predispose to
the development of hydrargyrism.
   Acute Hydrargyrism.—The mild form  of  acute hydrargyrism is
that already  described, and on its appearance is based the  dosage
of mercury during the secondary period.  The symptoms are a slight
ropiness or stringiness of the  saliva, with  increase  in its quantity.
During the night there is some flow from the corners of the mouth.
The gums are slightly congested, and  bleed readily  when touched.
This is especially noticed about the posterior molars when the teeth
are healthy, but is  frequently observed  at the roots of the lower in-
cisors, since here tartar is  prone  to  collect, and hence  the  mucous
membrane is more vulnerable.  When the teeth are snapped together,
slight tenderness will be noticed.   Close upon these symptoms, often
preceding them, come  distinct  metallic  taste in the mouth and fetor
of the breath.
   If the drug is continued after these symptoms develop, and in
some cases even  though its ingestion be stopped at  once, evidences
of salivation become even more pronounced.  The gums are greatly
swollen and  ulcerated.  The teeth are loosened, the tongue—indeed,
the whole mucous membrane of the mouth—becomes oedematous and
congested, and erosions and ulcers appear upon its surface.  There is
an enormously increased flow of saliva,  the submaxillary and parotid
glands  are swollen, cracks  and ulcers  appear at the corners of the
mouth, and the breath is indescribably foul.   In marked cases  the
patient is unable to masticate, to  swallow, or even to speak, and  the
strength fails rapidly.
   In some instances hydrargyrism expends its violence upon the ali-
mentary canal and  the kidneys, producing colicky, bloody stools, and
albuminuria.   This form  of poisoning  is, however, rare, save when
the hypodermic method is employed.
   Very exceptionally acute mercurialization appears in the form of
skin eruption.  This develops as  an erythema,  a  dermatitis, or an
eczema rubrum, and is always an expression of idiosyncrasy.
   Chronic Hydrargyrism.—In certain  cases  the administration of
mercury seems to produce a chronic  catarrh of the gastro-intestinal
mucous membrane.   The  patient  suffers  from the characteristic
symptoms of this condition, the appetite fails, emaciation is progres-
sive, albuminuria may appear, and there is  complaint of great mus-
cular weakness.  A  profound gloom  seizes  upon the patient, or he 
502
GENITO-URINARY DISEASES AND SYPHILIS.
becomes nervous  and hysterical.   Since  absolutely identical  symp-
toms may be produced by the disease for the cure of  which mercury
is  given, the determination of the  cause  of such  symptoms is very
important.
   When mercury has been administered in comparatively full doses
for a long time, and when such symptoms develop and are progressive,
it is wise to discontinue the specific drug and to devote particular at-
tention to diet, hygiene, and medication  suited to the  cure  of the
gastro-intestinal catarrh.  The improvement following such a  course
of treatment forms the best index  to the etiology of  the symptoms,
though this improvement is always  slow.
   When such symptoms  develop  in cases which have been treated
by insufficient doses of mercury it may be assumed that  they are the
effects of syphilis, and that on pushing the drug they will probably
disappear.   Albuminuria may be due to mercury or to the action of
syphilis.   The cause can be determined only by the therapeutic test.
   The effects of an overdose of mercury on the nervous system are
thought by some writers to be as difficult  to distinguish from those
of syphilis as are the symptoms in  connection with the gastro-intes-
tinal tract and the kidneys.  Hydrargyrism is said to produce trem-
blings, attacks resembling epilepsy or apoplexy, cerebral palsies and
anaesthesias,  cephalalgias and  arthralgias, disturbances of sleep, ver-
tigo, and dementia.  These symptoms  are chronic in type, and yield
slowly on cessation of treatment.   Fortunately, they are  exceedingly
uncommon.  We have rarely seen any of them.
   Treatment.—Salivation is best avoided  by minute attention  to the
hygiene of the mouth and  by  frequent inspection  of the patient, so
that the drug may be stopped or its dosage diminished on the develop-
ment of the  first symptoms.  When patients cannot be kept under
observation they should be told the symptoms of beginning ptyalism,
and  should be instructed properly to regulate the dose in the event
of such symptoms developing.   When ptyalism has developed, potas-
sium chlorate and  atropine  are the most efficient remedies.  In con-
junction with an astringent mouth-wash, used frequently, the patient
is given daily hot, sweating  baths, the bowels are opened freely, and
the kidneys are encouraged to act by copious draughts of water.
   Potassium chlorate is administered in the form  of  a saturated
aqueous solution.  A teaspoonful  of the  salt  is added  to a glass of
water, and the patient is instructed to rinse his mouth with this mix-
ture every few minutes.
   In alternation with this a disinfectant and astringent lotion may be
employed, such as— 
THE TREATMENT OF SYPHILIS.
503
                     R Acid, boric,
                       Acid, tannic, aa 9iv ;
                       Mel. rosae, fjii;
                       Aquae, q. s. ad f^vi.
                     M.  S.—Use as a mouth-wash.

   Atropine should be given in small doses, frequently repeated, until
 some effect upon the pupil is noted.  The drug may be administered
 in powder form, dropped on the tongue, and allowed to dissolve.

                     R Atropinae sulphat., gr.  ^;
                       Sacch. lactis, q. s.
                     M. et ft. chart, no. x.
              S.—One powder every three or four hours.

   In severe forms of salivation ulcerated and eroded patches should
 be touched with five  to ten per  cent, solution  of silver nitrate, and
 more powerful antiseptics should be employed, as, for instance, hydro-
 gen  peroxide in spray form, phenol sodique, or potassium perman-
 ganate 1 to 1000.
   The pain  incident to taking food may be allayed by painting the
 gums and eroded patches  with a three  per  cent, solution of cocaine
 just before eating.
   The elimination of mercury from the  system is materially hastened
 by prolonged hot-air or vapor baths, and by the administration of
 diaphoretics, diuretics, and laxatives.
   If the diagnosis of chronic hydrargyrism is assured,  withdrawal of
 the drug and the inauguration of  a tonic and  stimulating course of
 treatment are indicated.  Change of air and surroundings is particu-
 larly serviceable, especially when  reinforced  by scrupulous  attention
 to hygiene and a carefully selected  ferruginous  tonic.  In case mer-
 cury is subsequently indicated, it should not be administered by the
 mouth.
   The Toxic Effects of the Iodides.—lodism.—Under the general
 heading iodism are included the various toxic symptoms which may de-
 velop in consequence of over-dosage with this drug.  Those commonly
 observed are  gastro-intestinal  irritation, coryza, pustular skin erup-
 tion,  lachrymation, tinnitus  aurium, and mental  depression.  Excep-
 tionally neuritis and acute  oedema  of the larynx are  occasioned by
 comparatively mild doses of the iodides.
   As in the case of mercury,  iodides are most prone to produce un-
toward effects in those suffering from kidney degeneration.
   The lesions of the  iodide dermatoses may simulate  almost any of
the recognized  forms of acute  cutaneous eruption.  They commonly 
GENITO-URINARY  DISEASES AND SYPHILIS.
appear in the form of acne, but erythema, eczema, and herpes are by
no means rare.  Purpura is frequently observed, and even sloughing,
gangrenous ulcers are occasionally noted.
   These eruptions are due to idiosyncrasy and bear no definite rela-
tion to the dose  employed.  In some instances small  doses produce
toxic effects; in others heroic doses are taken with impunity.
   In the dose  ordinarily employed in  the  treatment of syphilis a
large proportion of  patients will exhibit  no symptoms whatever from
the use of the iodides.   A larger proportion will be troubled with a
coppery taste in the mouth and  with an acneiform eruption, affect-
ing the  face by preference, but often  widely distributed.  Coryza,
lachrymation, slight  conjunctivitis, and symptoms of indigestion inci-
dent to gastro-intestinal  catarrh are  also common.  A  very small
percentage of the cases will suffer from swelling of the mucous mem-
brane of the larynx and pharynx, sometimes so great as to endanger
life, and from  an especially severe skin eruption much like furuncu-
losis, which may go on to the purpuric or the sloughing form.
    Treatment—The  treatment  of iodism  depends upon  the severity
of the symptoms.   In the  milder  cases, and particularly when it is
important to continue administering the drug for the purpose of effect-
ing resolution and absorption of syphilitic deposits, the iodide may be
continued, or the dose may be  slightly increased, since in most cases
tolerance is established and the coryza and eruption disappear.   A few
drops  of  Fowier's  solution may be administered together with the
iodides.   The gastro-intestinal  symptoms are controlled by carefully
regulating the diet,  administering slightly astringent  and antiseptic
digestive powders, and giving the iodides largely diluted, preferably
in milk to wiiich  essence of  pepsin has been added.  Or,  if this
method is not feasible, each dose  of the drug should be dissolved in a
full glass of soda-wrater,  flaxseed tea, or other bland excipient.   The
tolerance of iodides  is by no means  indicative  of the syphilitic diath-
esis, nor is extreme sensitiveness to the drug the slightest index as to
the absence of the disease.

                  METHODS OF GIVING  MERCURY.
   Aside  from the dose, which must  always depend on individual sus-
ceptibility, there are certain definite methods for administering mer-
cury.  These are (1) by  mouth administration ; (2) by inunction; (3)
by hypodermic injection ; (4) by vaporization ; (5) by mercury baths.
   Mouth  Administration.—The  method of administering  mer-
cury by the mouth and the choice of preparations have already been
indicated. 
THE TREATMENT OF SYPHILIS.
505
   Though protiodide, gray powder, and  bichloride of mercury in
varying doses and vehicles  are  the most valuable drugs for adminis-
tration by the mouth, there are  other combinations of mercury which
have received  such high professional endorsement that mention of
them is not out of place.
   The  tannate  of mercury, recommended  particularly  by Allen,
Petrini, Schwimmer, and Lustgarten, is of value,  according  to this
last author, because it passes  through the  stomach  without being
acted  upon by the acids therein contained, and when  it reaches the
duodenum is converted by the  alkaline juices of this  portion of the
intestine into minute metallic globules, which are readily absorbed.
The drug is administered in doses of a grain three to five times daily,
some simple bitter, such as  extract of gentian, being employed  as an
excipient.  The following formula may be ordered:
               R  Hydrarg. tannici oxydulat., gr. iss ;
                  Acid, tannici,
                  Sacch. lact., aa gr. %.
               M. et ft. in pulv. no. i.
               S.—One powder twice or three  times daily.

   Or tannate of mercury may be given in the form of compressed
tablets, each to contain one grain.
   The  succinimide of mercury has been recommended by Jullien.
This is administered in pill form  in doses of one-third to one-half
grain  daily.  It is  said  to  cause  no gastric  symptoms and  not to
salivate.
   Calomel is frequently employed, as in the following prescription:
                    R Hydrarg. chlor. mit., gr. v;
                       Sacch. lact., sjss.
                    M. et in chart,  no; x div.
                    S.—One powder after each meal.

   Carbolate of mercury has been used in doses  of one-third of a
grain two to six times daily.
   Salicylate of mercury is warmly commended as possessing high
antiseptic powers, due to the fact that it represents a combination of
two germicidal drugs.   The dose is the same as for the protiodide.
   Biniodide of mercury, particularly in combination with ipecac, ad-
ministered  in the  form of tablets,  will,  according  to Curtis, produce
the constitutional influence of mercury without unpleasantly affecting
the mucous membranes.  One-eighth of a  grain of ipecac with  one-
sixteenth of  a  grain of biniodide may be  given ten to twelve  times
daily without producing gastric or enteric symptoms. 
506        GENITO-URINARY DISEASES AND SYPHILIS.

   Zittmann's decoction is an elaborate preparation, containing sarsa-
parilla, calomel, cinnabar, alum, anise- and  fennel-seeds, senna leaves,
and liquorice root.   The special virtue of this decoction probably lies
in the large quantity of liquid taken, since the  dose is from  a pint to a
quart, administered during the course of the day.
   Blue mass  is  a favorite with many syphilographers.   The best
combinations of this drug are as follows (Bumstead):
                      R Pil. hydrarg., ^ii;
                        Ferri sulph. exsiccat., J)i;
                        Ext. opii,  gr. v.
                      M. et in pil. no. xx div.
                      S.—One pill from  two to four times daily.

                      R Pil. hydrarg., £i;
                        Hydrarg. chlorid. mit., Qss;
                        Hydrarg. cum creta, 9ii;
                        Ext. opii,  gr. v.
                      M. et in pil. no. xx div.
                      S.—From two to four pills daily.

   The last prescription is ordered when a rapid constitutional effect
is desired.
   Inunctions  are  strongly  advised by  many syphilographers  as
representing the best method of administering mercury in the routine
treatment of syphilis.   The  objections to this  mode are its uncleanli-
ness, the skin irritation which it is liable to  excite, and perhaps chiefly
the difficulty of applying it without exposing  the patient to the risk
of having it known that he  is being treated for syphilis.  Usually,
however, a representation of the  great advantage of this method  as
regards the  attainment of permanent cure, and especially  in relation'
to the disappearance of existing symptoms, will insure the co-operation
of intelligent patients.
   The testimony as to the value of inunctions is overwhelming.  In
all the most successful centres for the cure of syphilis  inunction is
practically the chief mode of administering mercury.   This method
has for years been the mainstay for the subduing of violent outbreaks
which do not yield to the mouth treatment.  Alter seeing the striking
results consequent on  its  employment in  what might be  called the
emergency treatment, the transition from its occasional to its habitual
use in the routine conduct of syphilis  is easy and natural.
   Whether inunctions are  employed for  the relief of sudden out-
break, or, as has been recommended,  as  a means of administering
mercury in the intervals  of treatment  by the  mouth, the general
hygienic  conduct of life should be as rigidly ordered as when the drug 
                THE TREATMENT  OF SYPHILIS.              597

is given in pill form; i.e., the mouth should be put in perfect order,
the condition of the stomach attended to, etc.
   In prescribing inunctions the patient is ordered a mixture of equal
parts of mercurial ointment  and carbolized cosmoline.   Lanolin as
an excipient is too gummy, and lard speedily becomes rancid.   The
undiluted ointment is too irritating, and the oleate is unsatisfactory in
its results.
   The prescription may be written as follows :

                 R Unguent, hydrarg.,
                   Unguent,  petrolei carbolat., aa ^i.
                 M. et in part. no. xvi div.
                 S.—Use one portion at bedtime.

   Each dose may be enclosed in a compressible gelatin capsule or in
a cachet of stiff paper.  The  bulk of this prescription may be  some-
what reduced by using the pure mercurial ointment put up in cachets
and instructing the patient before using the ointment to anoint with
carbolated cosmoline the surface which is to be utilized.
   The dose of mercurial ointment for the ordinary healthy adult is
from twenty grains to a drachm daily ;  this can be tolerated  for from
two to three wreeks.  If it is long  continued without interruption,
stomatitis or dermatitis is liable to develop.
   The dose of ointment having been  settled upon, the patient is in-
structed as to its application.  He should provide himself with woollen
underclothing of a thickness suitable to the time of year and of such
quality or condition that no great loss  will be suffered from  its being
permanently stained.  This set of  underclothing should  be worn  for
from three days to a wreek without being changed.
   Whenever practicable, he  should do his own  rubbing, and before
the first  close should take  a somewhat prolonged  hot bath.   He
should  after his bath  and immediately before retiring  occupy fully
twenty minutes in rubbing in the amount of ointment prescribed for
one treatment.
   Since  this ointment  irritates the skin  if  its application is too fre-
quently repeated in one place, different surfaces are selected  on suc-
cessive nights.   These surfaces  should be comparatively hairless and
fairly accessible.  The regions of preference are the inner surfaces of
the thighs, the antero-internal surfaces  of  the arms and forearms, the
sides of the thorax, the flanks, and the antero-lateral  surfaces of the
abdomen;  sometimes  the buttocks  and the soles  and inner  surfaces
of  the foot.   When the nurse does the rubbing the whole back may
be  included.   By passing from one to the  other of these  regions in a 
508       GENITO-URINARY  DISEASES AND SYPHILIS.

definite order no one of them need be used oftener than once a week
thus giving plenty of time for the subsidence of any slight irritation
which the inunction may occasion.
    The patient should not bathe  more frequently than twice in the
week.   If,  however, there  is marked skin irritation in  any particular
locality, this whole region is carefully washed with soap and hot water
and the following ointment is applied :

                R Hydrarg. chlorid. mit., gii;
                   Unguent, zinci oxidi,
                   Unguent, petrolei carbolat., aa £ss.
                M. et ft. unguent.

    Or, if there is no indication for a mild mercurial influence, such as
would be exerted by this  mixture, the irritated surface is  cleansed,
dried, and  dusted with a mixture of starch and bismuth.  Inunctions
are taken before going to bed simply as a matter of convenience; they
may be given at any time  during the twenty-four hours.
    Under  the  routine  treatment  of syphilis already described this
method is enforced for  two  weeks at a  time once  in every two
months.   It may be kept up  longer wiien indicated, and should cer-
tainly be continued in the presence of relapsing syphilides of the skin
or mucous membranes, or in  cases in wiiich  the viscera are threat-
ened.  In the ordinary benign cases of syphilis, however, it is  not
necessary to employ this  or  any other troublesome, tiresome,  or
painful treatment to the exclusion of the administration of mercury
by the mouth.
   The portion  of this  treatment wiiich will be most seriously objec-
tionable to fastidious patients is the continued wearing of soiled under-
clothing and the avoidance of the  regular morning bath.  Neither of
these conditions is  essential to the  successful inunction treatment.
The patient may be  directed to wear the same underclothing only at
night, and may be allowed his bath, the residue of the ointment read-
ily coming  away under  the use of soap or hot water.   He can then
put on clean underclothes for the day, resuming at night after his next
rubbing the undergarments already soiled by the ointment.  The con-
tinued surface application  of that  portion of the ointment  remaining
after all has been rubbed in that the skin will receive seems to be an
important feature in bringing about full  absorption.
   It is undoubtedly true that  some persons exhibit an idiosyncrasy
against inunctions, eczematous eruptions appearing over the  entire
body, and in the blonde and thin-skinned the local irritation is some-
times so great that this  method of  treatment is not applicable. 
THE TREATMENT OF  SYPHILIS.
509
   In place of ointments mercurial soaps have been advised.  These
are, however, more uncertain  in their  effects and less accurate in
their composition than ointments, and, although cleaner, require more
time in their application.   Schuster employs a soap  commended by
Charcot, which is made of equal  parts of mercury, mutton suet, and
potash  soap.  These ingredients are gently heated,  and to them is
added enough  potassium  hydrate  to produce  saponification.  This
mixture is rubbed  into the skin for from fifteen to twenty minutes
exactly as is mercurial ointment.
   Mercury plasters have  also been proposed, but have  as  yet  re-
ceived  scanty recognition.  Chassaignac employed the  emplastrum
de Vigo cum mercurio, which contains metallic  mercury triturated
with styrax  and turpentine and  added  to  ordinary lead plaster.
Quinquaud  obtained  excellent results from a  calomel plaster made
by suspending 1000 parts of calomel in 300 parts of castor oil  and
adding 3000 parts  of melted diachylon plaster.   This mixture is
spread on linen, is  applied to the skin, and is kept on for eight days.
The plaster should  be about sixteen inches square, and  should con-
tain about three drachms of calomel.
   Hypodermic Injections.—The specific   claims  made for  this
treatment are as follows:  (1) A precise dosage is obtainable;  (2) it
saves  time and labor on  the part  of both physician and patient,
visits being rendered infrequent; (3) it  necessitates  little  change of
diet or of habits of life; (4) the  patient's  skin and digestive organs
remain unaffected, except in rare instances ; stomatitis is exceptional;
(5)  the disease is readily concealed ; (6) there is  lessened expense;
(7)  permanent  cure  is accomplished in a short  time  and  with a
minute amount of mercury ; (8) a powerful influence is exerted more
readily and  surely in the  presence of grave and threatening visceral
troubles; (9) the time required for a therapeutic diagnosis is shortened
in doubtful cases.
   Of these various claims the  one of most importance is that the
disease is permanently cured in a short time.  As to this point there
is yet no conclusive evidence.
   The prompter effect of hypodermic medication in  cases of  serious
visceral troubles  may be  doubted, as may also the claim in favor of
the  skin and digestive organs remaining unaffected.   It may be fairly
questioned whether absorption from the  subcutaneous tissues is sub-
ject to markedly less variation than that  from the gastro-intestinal
mucous membrane.   The other claims as to the value of this method
are unimportant.
   The disadvantages of the method are:  (1) It is often  extremely 
510
GENITO-URINARY  DISEASES AND SYPHILIS.
painful, and  is strongly objected to by many patients;  (2) it is some-
times followed by dangerous and even rapidly fatal toxic symptoms;
(3) it has local  sequelae, such as erythema, cellulitis,  abscess, and
sloughing; (4) it is a  treatment which cannot be carried  out by the
patient  himself,  but  usually requires frequent intervention  on the
part of  the surgeon.
    It would  seem fairly clear  that the disadvantages of hypodermic
medication as a routine treatment more than counterbalance the still
unproved advantages,  and that  it should be  reserved for  certain
exceptional cases shortly to be mentioned.
    The drugs  employed in the hypodermic method of  treatment are
either soluble  or insoluble.  In each  class there are  many prepa-
rations.   The  two most widely  used  are corrosive sublimate  and
calomel.
    The technique of the injections is practically the same, independent
of the form  of mercury employed.  The solution  or  the emulsion
must be sterilized, and the  surface  beneath which the injection is to
be driven, the syringe, and the  hands of the surgeon must receive the
same preparation as though a formal operation were to be performed.
The needle should be boiled  and the  syringe should  be  washed in
boiling water and be soaked in 1 to 20 carbolic  solution.   For most
of the  preparations the ordinary hypodermic  syringe  with a large
needle will answer.
    Since  there are reasons for believing  that the local influence of
mercury is of great advantage,  the existence of a serious lesion in an
accessible locality may occasionally determine the  site of injection.
In the  absence of such lesion  the injections are usually driven into
the upper dorsal or the  post-trochanteric  region, since these are not
subject  to pressure or  to the observation of others, and  are not spe-
cially sensitive.   Moreover,  they are covered by a thick layer of sub-
cutaneous tissue.  It is into this rather than the  muscular tissue that
the injection  should be driven,  since, if abscess occur, it  is much more
readily managed when superficial than wiien subfascial.
   The method  of throwing  in the fluid  is like  that  employed in
ordinary injections, except that special  precautions are taken  against
driving  insoluble preparations  into  a vein, since they  will probably
give rise to pulmonary emboli.   This has, indeed, occurred in a num-
ber of cases.   To avoid this accident,  the needle is first thrust in,
disconnected  from the syringe, and is allowed to remain for a moment,
to see if any  blood flows through its canal; in the absence of this the
injection is driven  in.  The puncture  points are covered, on with-
drawal  of the  needle, by the clean finger of the  operator, and are 
THE TREATMENT  OF SYPHILIS.
511
dressed with iodoform  collodion.  Unless the  fluid used  is aseptic,
cellulitis or abscess will develop.
   Most careful  antiseptic precautions may  not  prevent microbic
infection, this possibly coming from the deeper layers of the skin.
   The pain incident to these injections varies greatly.  Occasionally
it lasts  for hours or even days, and is usually more severe with the
insoluble salts of mercury.  Tenderness persists for some time, and
may be so great as  to occasion almost complete disability.
   When a soluble preparation—and the best is corrosive sublimate—
is employed, the dose is from one-twelfth to one-third of a grain dis-
solved in about twenty drops of distilled water.  A hypodermic con-
taining this quantity of  the drug may be administered daily or every
second day until premonitory symptoms of stomatitis appear.   It may
then be given at longer intervals.  When on  account of its situa-
tion an outbreak of syphilis becomes dangerous, as in the  brain, and
prompt action is imperative, larger doses may be injected.
   Sublimate injections  are specially indicated when mercury admin-
istered by the mouth occasions gastro-intestinal  irritation or other un-
toward symptoms, and wiien given by inunctions it causes  dermatitis.
These injections are also indicated when syphilitic lesions are devel-
oping in spite of ordinary treatment, when syphilomata are particu-
larly obstinate, and when, in certain cases, on account of intercurrent
disease, it is necessary to utilize the  stomach for the administration
of other drugs.  The favorite formula is the following:

                 R  Hydrarg. chlor. corros., gr. 4^;
                    Sodii chlor., gr. iiiss ;
                    Aquae destil., fgi.
   S.—One  per cent, solution of corrosive mercuric  chloride.  Ten to  thirty
minims hypodermically.

   This solution can be modified by increasing or  diminishing the
quantity of corrosive chloride, a five per cent, solution being advocated
by Lukasiewicz.
   Finger employs a one  per  cent, sublimate  solution  containing
twenty per cent, of common salt.
   The  succinimide  of  mercury, the  albuminate,  the  iodo-tannate,
the carbolate, the formamide, the benzoate, and other salts have been
warmly commended by individual observers.
   Of the insoluble salts administered hypodermically, calomel is the
type.  This is given in doses of one-half to one grain every four days,
two grains weekly, or three grains every ten or twelve days.  The
following formulae may be employed : 
512        GENITO-URINARY DISEASES AND SYPHILIS.

                    R Hydrarg. chlor. mit., gr. ss ;
                      Glycerin, purificat., gtt. x ;
                      Aquae destil., gtt. x.
                    M.  S.—Use as an injection.

                    R Hydrarg. chlor. mit.,
                      Sodii chloridi, aa, gr. i;
                      Aquae destil., gtt. xxx.

   The method of  using calomel  as formulated by Besnier in the
Hospital St. Louis  is as follows:

                       R Calomel, 1 part;
                         Vaseline, 20 parts.

   The drug is suspended  in the  excipient as perfectly as  possible.
The  mixture is boiled before  being used, and the hands of the oper-
ator, the surface into which the injection is to be  driven, and the
syringe, are sterilized.  The region of the buttocks is that of pref-
erence. The needle should be an inch in length, and should be driven
vertically into the  tissues down to the guard by one quick thrust.   It
should be  observed for a moment to see if any blood flows from it,
and, if not, the syringe should be attached and the injection driven in
slowly.
   There is nearly always marked pain, sometimes lasting for hours
or days, and this  is  followed by distinct  inflammatory reaction and
the formation of a hard, painful nodule, which  lasts for two or three
weeks.
   Severe  stomatitis is  not infrequently  observed;  this  may pro-
gressively grow worse, and in such a case would indicate the excision
of the focus into  which calomel has been injected.  Fatal gastro-
enteritis has been noted, and  embolic pneumonia has developed  in
consequence of  the calomel having been driven into a vein.
   As opposed to  these evil effects, calomel thus administered exer-
cises a prompt and powerful  effect upon the lesions of syphilis, par-
ticularly those of the secondary stage of the disease  and certain affec-
tions of the eye and connective tissues.   This effect is prolonged and
continued, the calomel presumably remaining at the point of injection
as a magazine from which steady absorption goes on.
   In the tertiary stage, in conjunction with the iodides,  this method
of treatment is extremely valuable when the  integrity of vital organs
is threatened or when the lesions  resist  ordinary treatment.  Among
the advantages of the hypodermic administration of calomel should
be mentioned its possible diagnostic value in surgical cases.   Accord- 
THE TREATMENT  OF SYPHILIS.
513
ing to Jullien, injections  of calomel will  quickly determine by their
favorable action, or the reverse, whether certain ulcerating neoplasms
are  syphilitic  or  malignant.  He  holds  that  the therapeutic diag-
nosis of  syphilis may be  clearly defined in eight  days by injection of
calomel.
   Metallic mercury is also one of  the  most popular  forms in which
the  insoluble preparations of the drug are  administered.   The dose
employed is  from five to thirty grains once weekly.  It is usually given
in the form of  gray oil (oleum cinereum), prepared by making an oint-
ment of mercury with lanolin as a  basis,  and then diluting this with
almond  or olive oil, or by triturating metallic  mercury with ethereal
tincture  of benzoin  and  oil of  vaseline.  The object of this  prepa-
ration is to secure a minute subdivision  of the metal and to obtain
complete fluidity.
   Yellow oxide of mercury is,  according  to Taylor, the insoluble salt
most used hypodermically.  This preparation seems to be less irri-
tating than  calomel and  almost equally efficient.  Watrassowski's
formula  is as follows :
                    R Hydrarg. oxid. flaw,  gr. xv ;
                      Acaciae, gr. iv;
                      Aquae destil., f.^i.

Of this,  fifteen minims are injected  at a time.
   Of the other insoluble salts  of  mercury, the  neutral salicylate in
one or  one  and a half  grain  doses weekly,  or in half-grain  doses
every three  days; thymol  acetate in one and a  half grain doses at
from three to six days'  intervals;  the black oxide; the protiodide;
the tannate; the  sulphate; turpeth mineral,  and cinnabar, may be
mentioned.
   The  preparations we have most  frequently employed in the hypo-
dermic treatment of syphilis are the one per cent, solution of sub-
limate (see page 511) and calomel prepared as  follows:

                  R  Hydrarg. chlor. mit., £i;
                     Petrolat. liquid, (purificat.), sji;
                     Lanolin., gi.
               M.  S.—Three minims equal  calomel gr. i.

   The  dose of the first preparation is from twenty to thirty minims
(one-fifth to one-third  grain of sublimate);  of the  second,  three
minims.   For the latter a special syringe  is required.
   Both these preparations sometimes caused pain, severe, prolonged,
and even incapacitating,  although previous injections were painless.
When the  injections were often repeated  the pain became  more
                                33 
514        GENITO-URINARY DISEASES  AND SYPHILIS.

severe.   Even  in the  comparatively full dosage employed in the use
of the soluble  preparations—that is, one-fifth to one-third of a grain
of sublimate three times a week—symptoms did not disappear so
rapidly but that we felt it necessary to employ inunctions and at times
internal medication.  Most of the injections  were given in the dorsal
region.   In every case, before administering  mercury in this manner.
careful examination of the urine was made for the purpose  of know-
ing the condition of the kidneys, since  in  cases of nephritis there is
always danger of fatal salivation.
   This treatment  is so conducted that we know exactly where each
injection has been driven in;  this is  particularly important when
insoluble  preparations of  mercury have  been employed,  since, in
beginning salivation, the foci of  injection  must be cut down upon at
once  and any remaining mercury  cleaned out.  For each  patient a
chart is made, roughly outlining his dorsal region.  Small circles are
drawn in the  middle of the dorsal region  from above downward,
representing  the first six dorsal spinous processes.   The first injec-
tion  is usually  administered  half an inch to the right of the spinous
process of the first dorsal vertebra, the  needle being driven  vertically
inward.  The next injection is given half an inch to the right of  the
spinous process of  the second dorsal vertebra, thus passing down to
the sixth, when injections are begun on the left side and continued in
the same way.   The method of  recording the seat of these injections
with the rough diagram just described is, of course, obvious.  In some
cases wiiere  the  back is  extremely sensitive, injections  are driven
into  the  buttock, but we  notice that in this region they are not less
painful.
   Value of  the Hypodermic Method.—After a careful review of  the
opinions of the  most distinguished  syphilographers and a  fairly ex-
tended trial of the method, it seems safe to assert that the hypodermic
treatment of  syphilis has not as yet shown results which warrant its
adoption as a routine method, to the exclusion of or in preference to
other methods,  but, on the  contrary, has some apparently insuperable
disadvantages, and  even  dangers, which render it improbable that it
will  ever be  so adopted.   This does not  apply  to the employment
of hypodermics in exceptional cases.
   Indications.—The  indications for the use of this method may be
summarized  as  follows.   Mercury  should be  administered  hypo-
dermically—
   1. In those cases in which other methods  of treatment have failed
or cannot be applied  because of especially  sensitive conditions  of
either the gastro-intestinal mucous membrane or the skin. 
THE TREATMENT OF SYPHILIS.
515
    2. In those cases in which, because of grave and advancing lesions,
 rapid mercurialization is absolutely necessary.
    3. In those  cases  characterized  by  obstinate  localized  lesions
 which can be most directly reached by this plan of treatment.
    4. Possibly in those cases in which  early differentiation between
 syphilis and malignant disease or tubercular ulceration is extremely
 important.
    5. Possibly when it is important to shorten the period of  doubt
 intervening between the  appearance of  a  chancre  and  secondary
 symptoms.   Rapid disappearance  of  an indurated  sore in conse-
 quence  of  hypodermic injection might throw  light upon the true
 nature of a suspicious  sore  without  being open to all the objections
 which attend the systematic and slow administration of mercury by
 the mouth.
    Choice of Preparations.—The soluble salts are to be preferred to
 the insoluble in the  large majority of cases, because of greater exact-
 ness in the matter of dosage and because they are  less liable  to  be
 followed by undue local  reaction or general toxic symptoms.  They
 are always to be employed when there is need for  rapid mercurial-
 ization.
    Insoluble  salts should be reserved  for  cases in which frequent
 visits to the surgeon are impossible and in which nocontra-indications
 exist.  The stability and solubility of the bichloride commend it  as
 the salt of choice when soluble  salts are employed.   Among the in-
 soluble salts calomel and yellow oxide are to be preferred.  It should
 be remembered that the  last is somewhat less  active, though much
 less irritating.  The gray oil  is the most available form of administer-
 ing metallic mercury.
    Contra-indication.—In cases of crippled kidneys, diabetes, profound
 anaemia,  marked atheroma, great debility, or any profound  systemic
 dyscrasia not depending directly upon syphilis, the hypodermic method
 of treatment is dangerous, and the case, even if urgent, will probably
 do better under some other treatment.
   Vaporization.—This  method  of introducing  mercury  into the
 system has  practically been  abandoned as a routine practice, since it
 is more troublesome than other methods, is more difficult to apply
 privately, and is in the  majority of cases not attended by better re-
 sults.  The drug  commonly employed is calomel; the average dose
 is twenty grains.
   The apparatus consists of an  alcohol lamp placed beneath a metal-
lic saucer, which  is supported om a tripod.  This apparatus is placed
beneath a cane-bottomed chair, upon which the patient is seated naked 
516       GENITO-URINARY DISEASES AND SYPHILIS.

and with a blanket pinned tightly around his  neck and dropping to
the floor, enclosing the body and the  chair in a tent.  Thirty grains
of calomel are placed in the metallic dish, the alcohol lamp is lighted,
and  the  blanket  is  draped around the patient.   The lamp is ex-
tinguished at the end of twenty minutes, and the patient is allowed to
sit for twenty minutes longer in  the calomel vapor; he  then wraps
himself in the same blanket that he  has used during the vaporization,
and retires to bed for a couple of hours, or for the night if the vapori-
zations are administered before going to bed.  There should  be some
one present, or at least within call, during these vaporizations, since
the heat  and the concentrated  attention of the patient  sometimes
produce syncope.
   This treatment is indicated when other methods have failed, and
particularly in cases of widely diffused small, hard, papular syphilides,
or when  obstinate or precocious  ulcers are  present.   It  is  then in-
valuable.
   Local  vaporization  is sometimes efficacious in the treatment of
obstinate  plantar or palmar syphilides.   The foot or the hand may be
kept in a box filled with the vapor of mercury for one or two hours
daily.
   Mercuric Baths,  Thermal Springs, and  Heat.—Mercuric
baths administered for the  purpose of causing absorption  of  the drug
have  been little employed, since  other methods are more exact and
easier of  application.  The value of such baths, however,  in com-
bating by direct  action certain  wide-spread  skin-lesions, and par-
ticularly in exerting an antiseptic effect upon pustular and ulcerating
eruptions, thus minimizing or altogether preventing  the effects of
pyogenic infection, is undoubted.
   In papular and pustular syphilides, papular and ulcerating gum-
mata, and moist papules, the baths  are very serviceable,  particularly
in cachectic  patients who do not well support vigorous treatment by
the mouth.   Tubercular  and gummatous skin  affections  are also
beneficially acted  upon by this method  of treatment.
   When the whole body  is not  involved in the lesions the partial
bath may be employed.  Lesions about the genitalia and the rectum
may be benefited by a sitz-bath, or in  case  of  plantar  or palmar
psoriasis  or  syphilitic onychia  the  hands or the feet  alone may be
submerged.
   The strength of the bath should be about 1  to 20,000.  Finger
advises that  from two drachms  to an ounce of corrosive  chloride
of mercury  should  be dissolved  in a  pint of water and be added
to the bath.   It should be at a temperature of 78° to 80° F.  This 
THE TREATMENT OF SYPHILIS.
517
temperature  should be maintained by the addition of hot water from
time to time, the patient remaining in the tub for about two hours
daily, immediately after the bath is completed retiring to bed for an
hour, or, if it is administered in the evening, retiring for the night.
   Thermal  Springs.—In this country, the Hot Springs of Arkansas,
abroad, the Baths of Aix, are widely known and extensively patron-
ized for the supposed specific effects of the water upon syphilis.   The
general opinion of the profession is, however, that the waters of these
springs have  no special  remedial value, and that hot salt baths at the
sea-shore, or hot  tub-baths at a wholesome mountain resort, wrould be
equally useful to those who derive the most benefit from the springs.
   The patients who should be  sent to the springs are—
   1.  Those whose mode of life  is unhygienic  and wiio cannot be
controlled while  under  home or other customary influence.  This
includes patients addicted to excesses, especially in the  direction of
alcohol and tobacco, and those whose devotion to work is  so close and
constant  as to interfere with  their general  health.  2. Those whose
symptoms resist full doses of the specific drugs or who are unable to
take large doses without a break-down of the  digestive apparatus or
the production of mercurial or iodic intoxication.   Under such cir-
cumstances,  should  there be involvement of the  viscera  or of the
brain  or  spinal cord, the Hot Springs treatment is  particularly indi-
cated.  3. Those who with syphilis have intense syphilophobia, and
who require the mental impression and in addition the  tonic influ-
ence of change of scene and  climate.   4. Those with defective  elim-
ination or with marked idiosyncrasy as regards either mercury or the
iodides.
   Such patients will derive most benefit from the springs; but  it  is
by no means necessary to send all wiio would be classed under any
of the preceding groups for thermal treatment.
   The course of treatment adopted at the springs has for its active
principle  the administration of  the specific drugs;  practically no de-
pendence is placed upon the waters as curative agents.  Aided by the
increased elimination and greater  tissue-activity which these waters
encourage, larger quantities of mercury and iodide  are administered
than would be tolerated under ordinary circumstances.  The mercury
is usually given in  the form of  inunctions, and, if the symptoms call
for it,  large doses of the iodides are administered.
   Fordyce states that the majority of the  patients who come to the
Hot Springs use both the hot baths and some form of mercury: hence
it is difficult to estimate the relative value of each.   Patients who do
not take mercury, but depend on bathing or on drinking the water for 
518        GENITO-URINARY DISEASES  AND SYPHILIS.

weeks and months, exhibit no change in the disease wiiich can be at-
tributed to the water.  Patients wiio  come to the springs after a long
mercurial course at home with the idea of "boiling out" the mercury,
of which  they  suppose  their system  to  be full, sometimes develop
ptyalism after a number  of baths, thus showing that the waters have
an influence in increasing capillary circulation, favoring tissue-change,
and causing greater activity in the elimination  of matter foreign to the
tissues.   Persons coming from malarial regions, though they have  had
no previous  outbreak of malaria, after one or two  weeks  sometimes
develop typical fever.  Gouty subjects are liable to suffer from out-
breaks of this trouble, and malignant  tumors  are prone to grow with
increased activity.   It seems  reasonable to suppose that the increased
tissue-change brought about by the hot baths will be useful in hasten-
ing the absorption of the  neoplasm of syphilis.   Moreover, the general
health is often benefited  by change of  air  and  scenery.
   Whatever be the action of the Hot Springs,  it is true that  under
their influence patients in a profound state of cachexia who  have been
unsuccessfully treated by competent physicians  sometimes improve
rapidly, and  that some cases of late syphilis are more quickly cured
at the  springs than at home.   This  advantage,  however,  cannot be
claimed for the early stages.  The use of  hot water internally and by
bathing undoubtedly increases  the activity of the  excretory organs,
enabling the patient to  tolerate the drug in  larger quantities.  Still,
ptyalism and gastro-intestinal irritability  frequently occur.   It  is  not
asserted that the bath treatment prevents  relapses.  Lustgarten states
that the chief benefit from  the Hot Springs is from the hot  bath.
   Sulphur baths do  not  differ in reaction from those of ordinary
springs.   Sodium chloride and iodine  brine baths seem, however, to
increase oxidation.
   The danger incident  to bath treatment lies in over-confidence in
the healing virtues of the  springs, thus  leading patients to stop all
treatment after the  symptoms have  disappeared, with the idea that
they are permanently cured,  and substituting short  and heroic treat-
ment for  the prolonged  course which they require.  This is to be
unsparingly condemned.
   Hot Baths.—The value of hot baths  as adjuvants in the specific
treatment of syphilis is beyond dispute, and  it is well to  order as  a
routine practice during the time that mercury is administered the daily
administration of  a hot-air or hot-water bath, continued  for  ten to
twenty minutes, and taken either at night on  retiring or in the  morn-
ing, according to the convenience or inclination of the patient.   The
elimination  of mercury  is  facilitated,  larger quantities are tolerated, 
THE TREATMENT OF SYPHILIS.
519
and in certain cases where without the baths doses  of  the specific
far too small  to influence  materially the lesions of syphilis produce
beginning ptyalism, efficient doses can  be given without  untoward
symptoms.
   These baths, if of hot wrater, should  be from 100° to 104° F.; if
of air, from 180° to 200° F.   In ordering  them the question of  idio-
syncrasy should be fully considered ; during their administration the
patient should have an attendant  at hand, in case syncope  be  pro-
duced.
   Heat thus  applied to the general surface increases  the elimination
of the  mercury,  even  in the urine,  probably because  of  the more
active tissue-changes excited by the bath.  Thus, when hydrargyrism
develops, the  application of the hot baths affords  one of the most
active and efficient means of relieving symptoms, since  it promptly
rids the system of the excess of mercury.  The hot-air baths seem to
be particularly serviceable, since they occasion free diaphoresis and
elimination of the mercury through the swTeat-glands ;  in consequence
of the thirst they excite, bland liquids are ingested in large quantities,
and these being taken up into the circulation tend to increase metabo-
lism.
   Hot-air baths may be administered by placing the patient in bed,
covering him  with  several blankets, which by means of a  half hoop
or other  device  are lifted in the  form  of a tent, and  then putting
beneath the tent an alcohol lamp.   It is better to have a box specially
constructed for this purpose ;  it can be made  at an expense of ten or
fifteen dollars.  In the box is a stool on which the patient sits; the
lid is so arranged that when it shuts down the head alone is left
exposed.   Around  the opening left for the neck is packed  a bath-
towel.  An alcohol lamp or gas stove within the box is lighted, the
lid and door of the box are closed, and the patient is allowed to sweat
for ten to twenty minutes.  He then takes a cold shower or sponge
bath,  and dries  himself by  vigorous friction with a coarse towel.
Unless from idiosyncrasy these baths produce weakness,  they should
be continued daily through the entire course of treatment.
   The general subject of hot baths in the treatment of  syphilis has
been investigated by Borovski.
   His clinical observations  were  made  on  twenty-eight  syphilitic
patients.  Heat was employed in the form of {a) ordinary  hot-water
baths at from  98° to 104° F., of thirty minutes' duration ; (6) artificial
sulphur baths (prepared by  adding one pound of sulphur  to  each
bath) at from 100° to  104°  F., of from  twenty to thirty minutes'
duration; and (c) hot-air baths at from 180° to 200° F., of from fifteen 
520        GENITO-URINARY DISEASES AND SYPHILIS.

to thirty minutes' duration.   His results may be summarized as fol-
lows. 1. Both tepid and hot-water baths, as well as those of sulphur
and  hot air, invariably increase  the  elimination of mercury in the
urine.   2.  The elimination  proceeds more energetically  the higher
the temperature to which the patient is exposed.  3.  The cause of
such intensified excretion of mercury should be sought in an increase
of the systemic metabolism, accompanied by the disintegration of
mercurial  albuminates.  4.  A mercurialized  patient's organism can
be completely freed  from mercury by means of the systematic  em-
ployment of heat in  one form or another.  5. In cases of mercurial-
ism, when the elimination of mercury ceases  spontaneously, the drug
can be made to reappear in the secretions by the use of hot baths.
6. Mercurial  stomatitis  can  be cured by heat more  quickly than by
any other  means.  7.  Hot-air  baths, while  inducing  an enormous
perspiration, promote the elimination  of mercury also through the
sweat-glands.   The total  quantity of sweat excreted during  a  bath
amounts to four hundred  cubic centimetres and more; that of  mer-
cury in the sweat to 1.6  milligramme and more per four hundred
cubic centimetres.  Hence, as a means of freeing the patient's system
from  mercury, they should  be  preferred to all other baths.  8.  The
appearance of mercury in the sweat naturally suggests that diapho-
retics generally are useful adjuvants in the treatment of mercurialism.
9. Tepid baths (88° F.) should be resorted to  only in cases of hydrar-
gyrosis  in which  higher temperatures are  contra-indicated on some
grounds.  10. Hot-air  baths are  borne by patients better than  hot-
water ones (98° F.), which sometimes give rise to fainting.  11. Hot-air
baths at from 170° to 180° F., of twenty minutes' duration, are borne
better than those at from 140° to 160° F., of thirty minutes' duration,
while the  physiological and therapeutical  effects of the former are
practically identical with those of the latter.   12. In persons having
an idiosyncrasy against mercury the employment of heat sometimes
affords the possibility of safely continuing mercurial treatment.   13.
Hot-air baths, while inducing intense thirst,  involve an increased in-
gestion of fluids, which in its turn leads to an increase in the bodily
metabolism.   14. As regards the elimination of mercury from the
organism,  artificial sulphur  baths do not offer any advantages  over
other baths.  15.  The time required for the complete excretion of the
metal from the patient's system varies according to the total amount
ingested, individual peculiarities  of the  patient,  temperature of the
baths, etc.   16. A simultaneous treatment of  syphilis by mercury and
heat  may sometimes effect a cure more quickly than a mercurial treat-
ment alone.   17. The  heat  treatment alone  (one or two baths daily 
THE TREATMENT OF SYPHILIS.
521
for a fortnight), however, usually proves powerless  to bring about a
cure.  18.  In a patient with a diseased vascular system the use of hot
water requires great caution.
   The local application of heat often markedly hastens the disap-
pearance of syphilitic lesions when judicious treatment is  employed
at the same time.   Heat may be applied locally in the form of baths,
lasting for one or two hours, or, wiien these are not practicable, in the
form of hot compresses  wrung  out  of hot  corrosive chloride solution
and covered with a hot-water bag.
   Indurations, gummata, periosteal nodes, and obstinate ulcerating
syphilides  are particularly amenable to the combined action  of local
heat and general specific treatment.
   Kalashnikoff observed on thirty-one patients the effect of heat ap-
plied locally to  the surface.   In cases  in which there  w-ere wide-
spread  syphilides  the  most  affected limb was placed in a hot bath
(115° F.) for half  an hour twice daily.   During the intervals warm
compresses were  kept wrapped about the  parts.  Where the  lesions
were in such portions of the body that baths were impracticable, hot
fomentations or the hot-water bag  (111° to 122° F.) were applied for
an hour twice daily, the treatment during the intervals of application
being the same as  before.  In one group no mercurials were used ; in
the other, inunctions or injections of mercury, with or without potas-
sium iodide, were  employed.  Kalashnikoff's conclusions are :
   1. Heat, applied locally,  powerfully  promotes the  resolution of
syphilides in the region treated.
   2. Syphilides of all kinds disappear more rapidly under the influ-
ence of heat than under that of a mercurial treatment.  The primary
indurated  sore is  resolved  in  from  eight to sixteen  days without
leaving any sclerosis;  roseola  in from four to eight days; papules
and superficial impetiginous syphilides in from  eight to twenty-one
days; non-ulcerating tubercles and gummata in from seven to twenty-
four days;  ulcerating tubercles and gummata become cicatrized in
from one to six weeks; periostitis disappears in from one to twenty-
four days;  osteocopic pains subside  in  from  three to  eight days.
Commensurate with these local changes,  the patient's general con-
dition is markedly improved.
   3. By the use  of heat  and mercury a more rapid  absorption is
promoted than by  the use of either agent alone.
   4. In cases of relapse the comparative  immunity of parts  treated
by heat is striking.
   5. Heat is especially indicated in obstinate condylomatous lesions
which refuse to yield to mercury or iodides. 
522        GENITO-URINARY DISEASES AND SYPHILIS.

   6. Heat is contra-indicated in patients wiiose weakness is so great
as to render  dangerous the necessary mechanical  disturbance, and
in cases of moist papules, wiiere dusting with calomel will be found
more satisfactory.
   Electric  Baths.—It  is asserted that by electric baths there can
be brought about  active absorption of mercury by the skin and that
the dosage can be accurately regulated.   The  patient is immersed in
a solution of sublimate,  through which a  current of  electricity is
passed  for the purpose of occasioning  absorption.   The apparatus
required is elaborate, and the alleged results are far from proved.
   Intravenous Injection of Mercury.—Bacelli has treated syphi-
lis by intravenous injections of corrosive sublimate solution, holding
that thus  he  secures a more  exact dosage and  a more rapid and
powerful effect upon syphilitic lesions than wiien larger doses of mer-
cury are given in other ways.  The solution he employs is thus made:

                   R Hydrarg. chlor. corros., gr. i;
                      Sodii chlor., gr. iii;
                      Aquae destil., fjii.
                S.—n\,xx to gi daily, by intravenous injection.

   The median basilic or  cephalic  vein is made prominent by wind-
ing a bandage tightly about the middle  third of the arm.  The skin
overlying the vein  having been thoroughly cleansed, the needle, which
should  have a smooth sharp point, is boiled, is attached to the  filled
syringe, and is driven directly into the  vein.  The solution is  then
slowiy injected.  Absence of pain  and of subcutaneous tumefaction
shows that the solution is passing directly into the blood-current.  In
making  these injections the syringe  and the lumen of the needle  must
be entirely free from air-bubbles.
   No accidents are reported as having resulted from  this treatment,
and  in a comparatively limited number  of cases  its curative effects
were marked.
   Dinkier, as a result of his own experiments, does not believe that
intravenous injections of mercury will ever supplant the inunction or
the hypodermic injection method commonly employed, because the
technique itself is difficult, the danger of thrombosis is ever present,
and sequelae are more likely to occur.
   On the other hand, its rapid action is said to commend it in cer-
tain conditions.  Tertiaries yield more readily than secondaries.  The
papular, macular, and squamous syphilides, condylomata, sore throat,
and  the chancre all  show improvement in the  first week,  for the
alleged  reason that the mercury circulates more readily in the blood 
THE TREATMENT OF  SYPHILIS.
523
and is  also eliminated more  rapidly.  The  frequent  occurrence of
sequelae is explained, according to  Blaschko, by the  fact that after
intravenous injection  no trace of mercury  could be found  on the
fourteenth day, while  after inunction traces  of the drug are demon-
strable  for weeks and months.
   In rapidly spreading skin  and mucous membrane eruptions, and
in grave cases of syphilis of the central  nervous system, intravenous
injections are warmly commended, some eight to twelve being em-
ployed  to subdue the more threatening symptoms; the cure is  com-
pleted by one of the usual methods of administering mercury.
   The Elimination  of Mercury.—The  elimination of mercury
begins  very shortly after the administration of  the drug:  thus, ex-
amination of  the urine  showed the  presence of mercury two hours
after hypodermic injection.
   Schuster  finds  that  mercury  is  irregularly eliminated  with the
urine usually, but regularly and completely  with the faeces, and that
this elimination after an extensive course of inunction is complete in
about six months, thus  showing that persistence of mercury in the
organism does not occur.  The  kidneys, the  intestinal mucous mem-
brane, and the  salivary glands are chiefly active in eliminating  mer-
cury from the system.
   The Use of Iodides in Syphilis.—The statement that " mercury
cures, iodine relieves, syphilis" may through bacteriological research
be proved to have a  scientific  foundation, since the former  drug is
incontestably  superior  as  a germicide.  This  may explain its  great
value in the earlier stages and the comparative inefficiency  of iodine
during  that period.  Although  this  seems to  be a well-established
fact, there is some diversity of opinion about  it, based upon the views
which regard iodine  («) as a direct  specific;  (6) as a promoter of
the eliminative  and absorptive  processes.   If  the  former view  were
correct, iodides  should be employed oftener and more freely in the
secondary stage than is  at present the custom.  The  views of those
syphilographers who hold the opposite belief have been summarized
by Mauriac, who says that though the action of the iodides may be
less rapid than that of mercury, it is deeper and more durable, and is
useful in those accidents that  are graver, more destructive, and less
liable to heal spontaneously;  their  sphere  of action is,  therefore,
much greater than that of mercury, and their relative harmlessness is
a great  advantage.   According to him, they should be employed—
(1) in the phagedenic forms of the initial lesion ;  (2) in the beginning
of the secondary period, especially to combat the fever and head-
ache; (3) in the erosive and ulcerative syphilides;  (4) in  all the 
524        GENITO-URINARY DISEASES  AND SYPHILIS.

syphiloderms  of transition, the papulo-squamous and papulo-tuber-
culous; (5) in all tubercular and all malignant  syphilides;  (6) in all
subdermic syphilitic manifestations; and  (7) in gummata or gumma-
tous exudates that break down and ulcerate.
   On the other hand, Sigmund, though he sometimes uses the iodides,
in combination with mercurials or alone, in the milder syphilitic mani-
festations, as erythema and papillary eruptions with general lymphatic
involvement, does not think it possible that they can replace the mer-
curials, and usually reserves them for employment in very marked
general lymphadenitis, in scrofulous constitutions, in rheumatoid dia-
thesis  and headaches, accompanied or not by loss of sleep, in  un-
favorable  hygienic or dietetic conditions, in diseased conditions of the
gums and teeth, and in general in all those  conditions in which  the
idiosyncrasies  of the patients  or  the constitutional  complications
contra-indicate the use  of mercurials.
   Finger believes in the  combined use of the iodides with the mer-
curials in  the later stages of the syphilitic  treatment, when, he thinks,
they are superior to the mercurials; but  Neumann often uses them
in the  mild relapses of  the secondary stages and in those of the ter-
tiary, reserving the mercurial treatment, in  the form of inunctions
preferably, for the severer manifestations of both periods.   He con-
siders the iodides especially useful in periostitis of the joints, muscles,
or synovial sheaths  of  tendons, and in the  tertiary affections of  the
eyes and internal organs, when he uses mercurial inunctions also.
   The value of the iodides is so slight in the ordinary cases of sec-
ondary syphilis that it is more than  counterbalanced by their irritant
effect upon the gastro-intestinal mucous membrane.  As a rule, their
therapeutic value increases in  direct ratio  with the age of the syphilis,
but even in early syphilis the iodide should be added to the mercurial
treatment whenever  extensive and dense  exudation has  occurred,
whether in the deeper layers of the derm, in the subcutaneous con-
nective tissue, in the periosteum or bone,  or in the viscera.
   The routine use of  the iodides has been already  sufficiently de-
scribed.  The old rule of measuring the required amount by the effect
upon the  symptoms is a useful one.   It may lead to the administra-
tion of enormous doses, but if the diagnosis be assured the evil effects
of the  drug  are not. to be  compared in gravity with those of  the
disease.   Used in this way the practitioner will often be gratified to
find  the iodides finally causing the disappearance of obstinate  osteo-
copic pains or violent cephalalgias, the resolution of large and threat-
ening gummatous swellings, the  subsidence of  periosteal nodes, the
cicatrization of enormous ulcers, the return of power to  paretic or 
THE TREATMENT OF SYPHILIS.
525
paralyzed muscles, the cessation of epileptiform convulsions, and even
the re-establishment of the mental faculties after they have been
persistently and to all appearances hopelessly disordered.
   There is nothing more satisfactory in therapeutics than the  direct
and unmistakable benefits following the administration of the iodides
in such cases.
   In doubtful  cases, for diagnostic purposes, large and increasing
doses may also be  given, sometimes with  the result of promptly re-
vealing the specific character  of the lesion requiring  treatment.  It
must be remembered, however, that other obscure conditions than
those resulting from syphilis may  be  benefited  by full doses of the
iodides, and a faulty diagnosis and  prognosis may be the outcome of
a too implicit dependence on the '• therapeutic test."   Still more dan-
gerous would be the acceptance of the rule formulated by Jullien and
H. C. Wood.  The  former asserts that " the existence of syphilis con-
tributes powerfully towards producing tolerance  of the iodides.  Ex-
perience proves, in  fact, that  in persons  free from this poison  the
toxic phenomena of iodism  are much  more  to  be  dreaded.  In the
same manner an antidote may be dangerous, or  even fatal, when the
organism is not under the influence of the poison which it is intended
to combat."  The latter says, " In all cases of doubtful diagnosis  the
so-called therapeutic test should be employed ; and if sixty grains of
potassium  iodide per day fail to produce iodism,  for all practical pur-
poses the person may be considered to  be  a syphilitic."
   These  statements,  if wrell founded, would convey an important
practical lesson of the greatest value in the diagnosis of obscure con-
ditions  suspected to be of syphilitic origin.   If unfounded, they may
be seriously misleading.
   A few years  ago this subject was discussed at length, and subse-
quently the opinions of twelve of the leading  syphilographers and
neurologists of this country wrere  obtained  by  one  of  the writers.
They without exception held the viewT  that no such rule  of diagnosis
could be formulated.
   Several formulae have already been given for the administration of
iodides.  A saturated solution (potassium iodide, 3v; water, q. s. ad Si)
is the most convenient form  in which  to  administer the drug when
it is given in ascending doses.  In addition  to  this preparation  the
patient may be  ordered compound syrup of sarsaparilla, to a table-
spoonful of which  the required dose  of  iodide can be  added,  the
patient immediately afterwards taking one  or two glasses of water or
milk.  Free dilution is of prime importance in avoiding symptoms of
gastric irritation. 
526        GENITO-URINARY  DISEASES  AND SYPHILIS.

   Rubidium iodide has been warmly recommended, on the  ground
that  it is less  disagreeable  than potassium iodide, is less liable to dis-
turb the  stomach, and is not so apt to produce acne or other symp-
toms of iodism, while it is almost equally potent in causing absorption
of syphilitic infiltrates.  Iron iodide  is also  a valuable preparation,
particularly when  syphilitic  anaemia is marked.   This  may be given
either in pill form or as  a syrup.   Lithium iodide,  warmly com-
mended  because of the large  quantity  of iodine it contains (over
ninety-five per cent.), has proved too irritating for use.
    Vegetable infusions  and decoctions are sometimes useful as adju-
vants in  the treatment of syphilis, but have no specific action of their
own.  The two best recognized are the following:

                   Succus alteram.  (MeDude's formula.)

                 R Ext. smilacis sarsaparillse fl.,
                   Ext. stillingise sylvat. fl.,
                   Ext. kappae minoris fl.,
                   Ext. phytolaccae decand. fl., aa f^ii;
                   Tinct. xanthoxyli carolin., fji.
   M. S.—Take a teaspoonful  in water three times a day before meals, and
gradually increase to tablespoonful doses.

   This  may be employed in alternation with the mixed  treatment
where daily dosing of the latter cannot be borne.  Taylor suggests as
a tonic mixture:
                 R Ext. erythrox. cocae fl., f^ii;
                   Tinct. gentian, comp.,
                   Tinct. cinchon. comp., aa fji;
                   Elix. calisayae, f^iv.
   M. S.—One tablespoonful in a wineglassful of water three times a day, one
hour  after meals.

   When the appetite, digestion, or nutrition  needs attention,  neither
of these preparations seems  to be as efficient  as the following:

                 R Strychninas sulphat., gr. i;
                   Acid, phosphoric, dil., fgiii;
                   Liq. pepsinas, q. s. ad f^vi.
   M. S.—One teaspoonful in water after each meal and before going to bed.

   Serum Treatment.—A commonly accepted theory of the day in
regard to immunity seems to rest on  the fact that  micro-organisms
produce not only substances which  act injuriously upon the  system
of their host,  but also certain products which  are toxic to themselves, 
THE TREATMENT  OF SYPHILIS.
527
and which are able to render the soil  in which they grow immune
against new infection  by the  same microbe.  The immunizing sub-
stance is  found in  the blood and  tissues, but in  some instances, at
least, is excreted by the kidneys.
   In the clinical history of syphilis there are found strong reasons
for believing that a similar substance may  be carried  either to the
child through the mother's blood, or to the mother from the  child
infected by the father.
   Profeta showed that  an apparently healthy child born of a syphi-
litic mother could not  acquire syphilis from the lesions of the mother.
Colles and Baumes observed,  vice versa, that a syphilitic  child born of
an apparently sound mother could not convey the disease to her.
   Bonaduce holds  that, particularly in syphilis, and consequently in
other bacterial  diseases, immunity by filtration  of protective serum
through the placenta would result far more frequently than is the case
were  it not that through  hemorrhages  or traumatisms the indirect
communication  between the maternal and foetal blood is made direct,
and not only the immunizing substance, but the active living micro-
organisms, are carried from the diseased to the healthy  human being,
and  thus, in  place of protection against syphilis,  syphilis  itself is
implanted.
   When the virus of syphilis has once  entered the foetus it  finds
every condition  favorable to its  development,  and it is  prone to
manifest itself in a severe form.   In consequence  there is a  large
production of the immunizing substance which is filtered through the
placenta.
   The difficulty in the practical application of these facts lies in de-
termining the  exact period  at which  this  antitoxin is found  most
abundantly in the circulation.  Moreover, the serum of the  infected
organism  contains, in addition to immunizing substances, certain poi-
sonous compounds  which  act injuriously upon the  tissues,  lessening
the resistance, and thus encouraging proliferation of micro-organisms.
Bonaduce holds that if it were possible to accomplish artificially wiiat
nature does in the  case  of the mother,—that is, to immunize against
syphilis, in accordance with Colles's law,—the Gordian knot of syphi-
litic therapeutics would  be cut.   Since  the  kidneys are functionless
in intra-uterine  life,  and since the  micro-organisms of syphilis exhibit
special virulence when they attack the foetus, there  should  be in the
circulation of the child at birth both immunizing  substances and toxic
products in unusual concentration.
   To separate these  from each other heat may be employed, since
it is well known that  the  toxins  are  destroyed,  while the antitoxins 
528
GENITO-URINARY DISEASES  AND SYPHILIS.
remain intact.  Gamaleia, Arnaud, and others have shown this in the
case of other microbes.
   On the basis of these  considerations Bonaduce has conducted a
clinical study.   Blood was drawn from three children born with all the
characteristics of hereditary syphilis.  This was allowed to stand for
a day on ice, and from it thirty-five cubic centimetres of serum were
obtained, to which one hundred cubic centimetres of sterilized Avater
were added.  This mixture was heated for ten minutes to 100° C, and
was  filtered.
   A patient, thirty-two years of age, who had exhibited for eighteen
days a characteristic chancre in the coronary sulcus, and whose in-
guinal glands were typically enlarged, received  injections  of this
serum in the subcutaneous cellular tissue.   These were administered
with all aseptic and antiseptic precautions, and the injection fluid was
kept aseptic.  There was no inflammatory reaction excited.   In all,
twelve injections wrere given in twrenty-four days;  about  ten  cubic
centimetres were administered at each injection.
   During this treatment the glandular enlargements subsided and
the ulcer grew steadily better, although  no local treatment was em-
ployed.   After thirty-five  days the ulcer was entirely healed and the
inguinal adenitis was  markedly lessened.  The treatment was begun
the 13th of November, 1892, and at the time of the report (the 23d of
June, 1893) the patient  was well, and  on the  most minute search
showed absolutely no signs of syphilis.
   Blood may be used from the placenta of a syphilitic child, or may
be taken from individuals who are  at the height of secondary syphilis,
but in all  cases the serum should be employed with  the most minute
antiseptic and aseptic  precautions.
   In Italy, Tommasoli some time since  proposed a method of heemo-
therapeutics in the treatment of syphilis.  This consists in the injec-
tion  of serum derived from the blood of lambs or  calves, the practice
being based on the theory that since these animals are immune to the
disease, their body fluids must contain some immunizing substance.
   Fournier has obtained some results  from injections of the blood-
serum of  the dog and horse, and  Pellizzari has expressed the hope
that by the injection of the blood-serum of syphilitics who are in the
transitional period between the  secondary and tertiary stages of devel-
opment all  secondary lesions may be  prevented in those who are
suffering from chancre.
   The idea of the treatment of syphilis by injections with blood from
animals naturally immune, or by injections of serum free of syphilitic
toxic properties but supposed to contain the antitoxin of syphilis, in- 
THE TREATMENT  OF SYPHILIS.
529
troduces an absolutely novel feature  in the therapeutics of syphilis.
Already numbers of successful cases have been reported.
   Experience  has shown, however,  that little  confidence  can be
placed in these.  The case contributed by Bonaduce is not conclusive,
since the diagnosis was by no means established in the first instance.
   Gilbert and Fournier obtained from the blood of two patients in
the tertiary stages  of syphilis—one suffering from  tabes, the other
from gummata—sufficient serum to carry out the  antitoxin treat-
ment in one  case.  The subject experimented on was a patient who
had received no specific treatment.  He was suffering from infecting
chancres  of the penis, characteristic inguinal  enlargements, marked
anaemia, nocturnal  headache, joint pains, and a diffuse maculo-papu-
lar eruption.  He was given injections of the serum at irregular inter-
vals through twenty days.   About an  ounce was  used for each injec-
tion.  In  all he received about ten ounces of the  serum.   As a result
of this treatment all symptoms disappeared, with the exception  of a
slight roseola.
   Encouraged  by success in this case,  Gilbert and Fournier  em-
ployed a  new method.  They inserted under  the skin  of  dogs  and
goats blood-serum, chancres, and  excised  skin  eruptions  taken  from
patients  in the primary and  secondary periods  of the disease, hoping
thus to increase the  natural immunizing powers of  the  blood of the
animals  treated.  Seventeen patients wrere treated  with the serum
obtained from these animals.   The results were contradictory.
   Cotterell  states  that he has treated  eighteen  cases of syphilis by
the injection of blood-serum of patients wiio had suffered  from an
attack of syphilis.  The details are not given, but the author notes
improvement as the result.

                LOCAL TREATMENT  OF SYPHILIS.
   The Chancre.—This lesion should be treated on general surgical
principles; the surface of the ulceration should be kept  clean by
means of antiseptic sprays or washes, to avoid mixed infection. Such
applications  are valueless  for the purpose of aborting constitutional
disease,  but are serviceable in hastening cicatrization  of the local
lesion.  The following prescriptions are useful:

                   R Hydrarg. bichlorid., gr. ^;
                      Zinci sulpho-carbolat., 9i;
                      Ext. opii aq., gr. xii;
                      Aquae ros., ffiv.
   M.  S.—Apply  by means of a pledget of cotton.   Change every  two hours.
Dilute if painful.
                               34 
530        GENITO-URINARY DISEASES AND SYPHILIS.

                     R  Acid, boric, Qii;
                        Tinct. opii, fgii;
                        Liq. plumbi subacetat. dil., f^ii.
                     M.   S.—Apply locally.

                     R  Zinci chloridi, gr. v;
                        Tinct. opii, f^i;
                        Aquae ros., fjiii.
                     M.   S.—Apply locally.

   When there is a tendency to form crusts, salves are useful:

                     R  Emplast. hydrarg.,
                        Cerat. resin., aa ^ss.
                     M.   S.—Use locally.

                     R  Iodoform., gii;
                        Bals. Peruv., sji;
                        Unguent, petrolat., q. s. ad %i.
                     M.   S.— Use locally.

   If the granulations  are  sluggish, daily touching with a five per
cent, silver nitrate solution is desirable.
   When the chancre is covered  by a tough pseudo-membrane, be-
neath which ulceration  is  extending, probably from the  reaction of
the ordinary  pus-microbes, destructive cauterization may be neces-
sary.   Nitric  acid or acid mercuric nitrate  may be  employed, the
surrounding tissues being protected by oiled cotton ; antiseptic fomen-
tations should follow.
   Gangrenous  and phagedenic chancres require the same local appli-
cations, supplemented by tonic and supportive treatment.
   Of the dry pow^ders, iodoform is the most serviceable.  It may be
administered  pure or mixed with powdered boric acid or starch, or
may be applied as  a ten per cent, ethereal spray.   Calomel mixed
with an equal quantity of lycopodium is a satisfactory local remedy.
Dermatol is an astringent, healing antiseptic, free from irritating prop-
erties and devoid of unpleasant odor.  It may be used  either as a
powTder or as  an ointment.   Aristol is  also serviceable.  The dry
powder is  inert, hence  it  should  be dusted on the  surface of the
lesion and a drop of olive  oil allowed  to fall on it from a glass rod;
it should then be covered  immediately with some thin, impermeable
substance,  under which solution takes  place slowly.   No  cotton or
charpie  should  be applied to the ulcer.   The dressing should be re-
newed twice daily.
   To chancres not covered by crusts  or pseudo-membrane and ex-
hibiting but slight inflammatory reaction, flexible collodion containing 
THE TREATMENT  OF  SYPHILIS.
531
one-tenth part of iodoform  or one-hundredth part of sublimate may
be applied.
   To urethral and  rectal chancres  iodoform  in  the  shape of sup-
positories may be applied after copious flushing with dilute corrosive
chloride solution (1 to 10,000).   These suppositories, made of cacao
butter or gelatin and of  appropriate  shape and size, should contain
from two to  five grains of iodoform.   Gray ointment diluted with
three parts  of vaseline is also serviceable in the  local treatment of
these lesions.
   Chancres  of  the  tongue, mouth, or  tonsils are treated by fre-
quent gargling with corrosive chloride solution (1 to 3000) and local
application  of silver nitrate solution (1  to  10),  sublimate solution
(1 to 20), or iodoform collodion (1 to 10).
   The  SYPHiLinES.—Skin lesions may be  benefited by applications
of mercury to the  surface  and  the  systematic employment of hot
baths.
   Erythematous syphilides usually require  no local applications.  When
they are sufficiently persistent and conspicuous to demand treatment,
the following  formulae will be found useful:
                R Hydrarg. chlorid. mit., ^i;
                   Unguent, zinci oxidi,
                   Unguent, petrolei carbolat., aa ^ss.
                M. et ft.  ung.  S.—Apply locally.
                R Hydrarg. chlorid. mit.,
                   Pulv. amyli, aa ^i.
                M.  S.—Dust lightly over the parts affected.

   Papular syphilides are often obstinate, and are especially benefited
by (1) vapor  baths;  (2)  inunction  and massage;  (3) ointments con-
taining mercury in one of the following formulas:
                R Ung.  hydrarg. nitrat.,
                   Ung.  petrolei carbolat., aa ^ss.

                R Hydrarg. ammoniat., 9i;
                   Unguent, aquae ros., %i.

   These ointments are especially serviceable in the papulo-squamous
eruptions.   When  these  attack  the hand, a region in which they are
persistently recurrent, the local vapor  bath proposed by Wells  is
particularly efficacious.   The interior of an  inverted hat-box is filled
with calomel vapor by means of  a small alcohol lamp placed beneath
a metal dish containing calomel, and the hand is introduced within
the box through a hole cut in the side. 
532        GENITO-URINARY DISEASES  AND SYPHILIS.

    Mucous Patches.—These,  for  the most part, may be  prevented
from appearing in the mouth  by taking  the precautions already men-
tioned (p. 492).   When  they appear, they should be painted  two or
three  times daily  with  a  one to  ten per cent,  solution of silver
nitrate, or touched  with the solid stick,  and an  antiseptic mouth-
wash should be used, such as the following:

                         R Acid, boric,
                            Acid, tannic, aa. Qii;
                            Mel. ros., fgii;
                            Aquae, f^vi.
                       M. S.—Use as a mouth-wash.

Or sprays of listerine, Dobell's solution, or hydrogen peroxide may be
employed.
    Sometimes a sublimate wash is useful:

                      R  Hydrarg. bichlorid., gr. i;
                         Mel. ros., f^ii;
                         Aquae, f Jvi.
                      M.  S.—Use as a mouth-wash.

    Iodine, applied to the lesions, is stimulating and resolvent:

                      R  Iodi,
                         Potassii iodidi, aa 5jii;
                         Glycerini, q. s.  ad f^i.
                      M.  S.—Apply locally.

    The scaly patches should  be touched every second or  third day
with  ten  per cent, chromic  acid solution  or  acid  mercuric  nitrate
half strength.  If they still persist, they should  be  removed by  the
sharp curette or the actual cautery.
    Ulcerated patches in the throat are benefited by the  same treat-
ment, the  lotions being used as  a gargle.   Antiseptic sprays are par-
ticularly serviceable.  In addition, fumigations may be administered,
as advised by Mauriac :

                      R  Cinnabar., gr. xv;
                         Hydrarg. iodidi vir., gr. viiss.
           M.  S.—For one fumigation, lasting twenty-five minutes.

                      R  Hydrarg. iodidi vir., ^ss;
                         Carb. lig.,  §iss;
                         Benzoin., gr. viiss;
                         Aquae, q. s.
                      M. et ft. trochisci no. xx.
       S.—One to be burned morning and night, and the vapor inhaled. 
THE TREATMENT OF  SYPHILIS.
533
   The  use of tobacco  must be given up  entirely, and  the mouth
kept scrupulously clean.
   Condylomata, if  vegetating and  exuberant, should  be cauterized
with nitric acid, acid mercuric  nitrate, or chromic acid.   These last
two drugs may produce toxic symptoms.   Indeed, death has  resulted
from the  topical application  of the latter: hence it should  not be
applied to a large surface.

                     R  Acid, chromic, gii;
                        Aquae, f^iii.
                 M.  S.—Apply locally, to a limited area.

   The vegetations may also be  destroyed by the use of the following
mixture:
                R Plumbi oxidi, gr. iv ;
                  Liq. potass, caust. (33 per cent.), n\,cxvi.
                M.  S.—Caustic.  For  external use only.

   A single application is usually efficient;  sometimes two or three
applications are  required at intervals  of  two or three days.  After
this caustic is applied, the affected  surface  is dusted with iodoform.
A cicatrix forms  in from  three to ten days.
   Bumstead and Taylor commend the following mixture,  painted
on after careful drying:

                 R Acidi salicylici,
                    Ext. cannabis indicae, aa gr. xxx ;
                    Collodion, (flexilis), |i.  M.

   Mild cases require no local treatment beyond cleanliness, drying,
and dusting with calomel.
   When the  papillary overgrowth is extensive, it should be removed
by the  knife,  the resulting raw surface being closed by skin trans-
plantation if necessary.
   Pustular and Pustulo-Crustaceous Syphilides.—It is particularly in
this class of cases that the mercury and vapor baths are serviceable,
supplemented by the calomel and zinc ointment.  (See p. 531.)  The
latter may be used  on the face  at  bedtime.  When the ulcerations
are indurated  and crusted the  following prescriptions  may be  used :

                 R  Hydrarg. bichlorid., gr. ii;
                    Unguent, hydrarg. nitratis,
                    Ung. petrolei carbolat., aa ^ss.
R  Hydrargyri oxidi rub., gii;
   Unguent, zinci oxidi, ,^vi. 
534
GENITO-URINARY  DISEASES AND  SYPHILIS.
   Leg ulcers should be cleansed, strapped, and bandaged.  If they
refuse  to heal under this  treatment, the wiiole surface and the sur-
rounding skin may be covered in with a piece of thinly spread plaster
containing  equal parts of emplastrum  hydrargyri  and  emplastrum
cerati; over this is applied a tight bandage which includes the foot
and leg.  Dressings should be repeated in accordance with the amount
of discharge.
   Tubercular Syphilides,  Gummata, and Periosteal Nodes, wiien non-
ulcerated, may best  be treated  locally by the continuous application
over their surface of the following ointment spread on a piece of lint:

                     R Ung. iodi comp., gi;
                        Ung. belladonna?,  sjii;
                        Ung. hydrarg., giii;
                        Ung. petrolei carbolat., ^iv.

   This ointment may be combined with the local use of heat, a hot-
water bag being  applied to the lesion for as many hours a day as is
practicable.
   Chronic  persistently spreading serpiginous ulceration should  be
treated by the prolonged bath,—days or  wreeks if necessary.  If this
fails the actual cautery is indicated.
   Ulcerations are curetted, cleansed, and treated  on general prin-
ciples.   Carious and necrosed bones should be subjected  to appro-
priate surgical measures.
   In  a  few reported  cases  obstinate  ulcerating  syphilitic lesions
which  resisted specific  treatment recovered promptly after an attack
of erysipelas.  There has  been no formal effort, however, to utilize
this fact in the treatment of such lesions.

            THE  TREATMENT  OF  HEREDITARY SYPHILIS.
   The treatment of inherited syphilis  may be considered  under the
following heads:
   1. The prophylactic treatment of the  parents before conception;
   2. The treatment of the mother during pregnancy ;
   3. The treatment directed  to the child.
   1. The  prophylactic treatment before conception  is  that already
described as appropriate to syphilis, except that  more  attention is
paid to the general  hygiene applicable  to the sexual relations, and
every effort  is made to suppress by full doses of mercury any mani-
festation  of active syphilis.
   Probably the most important  point in prophylaxis, as  far as  the
practitioner  is concerned,  is his advice in regard to marriage, or, if 
THE TREATMENT  OF SYPHILIS.
535
this has already been consummated, in regard to preventing concep-
tion from taking place.
   The doctrine  that it is  proper to permit  a  syphilitic patient to
marry two and a  half years  after infection is dangerous.  Though it is
true that a large proportion  of patients who marry within these limits
have healthy children, there is a minority wiio  transmit the  disease
and who infect their  wives.   The earliest period  at which  marriage
should take place with  the consent of the physician is four years, and the
responsibility of contracting such relations at an earlier period than
this should remain solely with the patient.
   If syphilis is acquired after marriage, four years at least should be
allowed to elapse before conception is permitted.
   When, in spite of due warning, or perhaps from lack of it, marriage
has taken place and the  sexual relations are established, active treat-
ment of  the diseased partner is imperative.
   2.  The Treatment  of the Mother.—Whether the  mother is pre-
viously syphilitic, or has conceived by a syphilitic  husband, or has
contracted the disease after  impregnation, she is treated in accordance
with  the principles  already laid down.   Mercury is  pushed to its full
physiological limit, and  is  advantageously combined with  moderate
doses  of potassium iodide.   Special care must be taken not to  allow
the medication  to  produce  gastro-intestinal irritation, since  this
strongly predisposes  to the production of abortion. When the mother
is thus treated she will  probably bear a living child, and one either
healthy or exhibiting syphilis in a mild form.
   3.  The Treatment of the Child after  Birth.—Since the pathology,
stages, and general course  of hereditary syphilis are similar to  those
of the acquired disease, treatment  is conducted on the plan already
described.
   In hereditary  syphilis the treatment is modified somewhat by the
following considerations:
   1.  There is always a more or less  profound  cachexia influencing
all the nutritive  and formative processes,  and in itself, aside  from
specific lesions of vital organs, threatening life.
   2.  During the  secondary period lesions  corresponding to the ter-
tiary type, particularly gummata, are frequent.
   The cachexia  and its results  are  combated by supplementing the
specific treatment by one wiiich is stimulating and supporting.  Special
attention should  be paid to the nutrition.   The nurse of  the  child
should, of course, be its mother, since  it cannot convey the disease
to  her.  If the child cannot  be  fed at the breast, its chances for sur-
vival are greatly reduced.   The selection of the most  nutritious and 
GENITO-URINARY  DISEASES AND SYPHILIS.
easily digested  artificial food then becomes a matter of cardinal im-
portance.   Tonic  treatment should be employed, iron iodide, cod-
liver oil, and preparations of the hypophosphites being most useful.
   The iodides are given in conjunction with mercury because of the
frequent early appearance of tertiary lesions.
   Routine Treatment of  Hereditary Syphilis.—The  children  of
syphilitic  parents  may exhibit  characteristic lesions at birth; they
may remain apparently healthy for several weeks and then suffer
from  typical secondaries; or they may remain free from signs  or
symptoms of syphilis through life.
   When a child shows characteristic manifestations of the disease at
birth, immediate treatment is indicated.
   When an apparently healthy child is born of syphilitic parents, the
indications are not so clear, since there is no certainty that the  disease
will  ever  develop.   As a rule,  it  is safe to wait for  characteristic
symptoms when the parental syphilis is paternal, or  is old, or when
during the whole course of gestation the  mother has received vigor-
ous specific treatment.  When parental syphilis  is maternal, is recent,
and  particularly when it has not received  appropriate treatment, the
child should be given the specifics without waiting for symptoms.
   In doubtful cases treatment should be delayed till the appearance
of constitutional symptoms.   The  first of these is alteration in the
blood: hence repeated comparative studies  should be made of this
fluid, and should there be  an otherwise inexplicable diminution of
haemoglobin and increase of white corpuscles, the diagnosis of syphilis
should be considered as  established, certainly so far as to constitute
an indication for treatment.
   The routine method of  treatment  is as follows.  The  surface of
the child's abdomen is bathed with  Castile  soap  and water, then with
a saturated  solution of boric acid, after which it is thoroughly dried.
Mercurial ointment diluted with  three parts of vaseline is then spread
on the child's  binder, and the  latter  is applied as usual  in  infants.
Half a drachm of  this dilute ointment may be used daily.   After the
binder has  been worn for twenty-four hours the abdomen is again
washed with soap  and water, followed by boric  acid solution; a half-
drachm of the ointment is then  rubbed into the skin, and the binder
previously employed  is again applied.  This binder is  changed for a
fresh one  every fourth day.
   Should the prolonged application of the ointment produce  derma-
titis, the  inflamed  skin may be bathed with witchhazel and dusted
with zinc  stearate, carbolized talc, or other healing powder, the mer-
cury then being administered in the form of  inunctions, which are 
THE TREATMENT  OF SYPHILIS.
537
rubbed into  the  back, sides, and front of the chest, and the arms,
thighs, and legs, a fresh skin surface being chosen each day.
   Exceptionally, mercurial ointment, even though  used in this way,
occasions so much  local reaction that its surface application must be
abandoned.
   When treatment by the  mouth must be resorted to, probably the
most efficient formula is the following:

                 R  Hydrarg. cum creta, gr. i-vi;
                    Sacch. alb., gr. xii.
                 M.  et div. in chart, no. xii.
      S.—One powder three times a day;  to be taken soon  after nursing.

   Bumstead and Taylor have used in many cases:

                 R  Hydrarg. biniodidi, gr. i;
                    Potassii iodid., 3iv;
                    Syr. sarsaparillae comp.,
                    Aquae,  aa f^ii.  M.

   Of this mixture a child  one month  old may take five drops thrice
 daily, increasing  the  dose by a  drop every five days.  To a patient
 over five years of age one-half teaspoonful may be given, the dose
 being gradually increased to one or one and a half  teaspoonfuls.
   Externally, at the  same time, a mild mercurial  ointment may be
 used, or, better, the following may be kept in contact with the skin
 under pressure:
                   R Ung. hydrarg.,
                      Ung. zinci oxidi, aa S;ss ;
                      Bals. Peruv., 3L  M.

   In conjunction with inunctions or the internal use of the powders
 of mercury with chalk, potassium iodide  may be given in a syrupy
 solution, in doses varying from half a grain to a grain, or, if there be
 any marked  tertiary symptoms, even  in much larger doses, three or
 four times daily.
   Occasionally nothing  whatever will be retained by the  stomach.
 Under such  circumstances  hypodermic  injections are  indicated.
 These injections are  open  to the  same objections  as obtain against
 this method in the adult.  They are, however, often to be preferred
 to internal treatment, and should be  administered in the  manner
 already described.
   The  solution of choice  is the  one  per  cent, sublimate mixture.
 (See page 511.)  Beginning with a dose  of one minim (one-hundredth 
GENITO-URINARY  DISEASES AND SYPHILIS.
of a grain) every  second day, the quantity injected  is gradually in-
creased to two, three, or four minims.
   The treatment, in no matter wiiat form, should be kept up long
after the disappearance of syphilitic symptoms, and it is well to con-
tinue the mixed treatment  till after puberty.   In  addition to the
medicinal treatment, special attention should  be paid to cleanliness
and hygiene.   If possible, the life should be out of doors, and the food
should be healthy  and invigorating.
   The indirect treatment of  the child—i.e., the  administration of
specific medicine to the  nursing mother—is of possible utility when
other methods have failed or must be temporarily interrupted. 
CHAPTER  XV.
              INJURIES  AND DISEASES OF  THE BLADDER.

   Anatomy.—The bladder, when normally distended, holds about
one pint of fluid.   Provided its walls are healthy, the urine may be
retained without risk of injury till twice that quantity  has accumu-
lated.   When from chronic obstruction  there is constant, slowly in-
creasing intravesical tension,  the  bladder  may  become greatly  dis-
tended, retaining over a gallon of urine.  When empty, or moderately
distended, the bladder  lies within the pelvis, between  the posterior
surface of the pubic symphysis and the rectum.  As it fills, its upper
portion rises from the pelvis and can be felt on abdominal palpation,
since it tilts forward and is closely applied to the belly-wall.  As ten-
sion increases, the upper posterior wall bulges upward, and may be
felt even above the umbilicus.
   The base or fundus  of the bladder, that portion lying between the
line of reflection of the vesico-rectal peritoneal fold and the  vesical
orifice, is wider and  more capacious than  the summit.   The vesical
orifice, the lowest portion of the bladder in the erect position, is placed
about one and a quarter inches behind and slightly below the middle
of the pubic symphysis ; in children, this orifice is on a level with the
upper border of the symphysis, the bladder in them lying much higher
in the abdomen.
   The upper portion of the bladder is freely movable; its  base is
more or less fixed.  It is held in place by the recto-vesical fascia, by
the intimate muscular  and fibrous attachments to the  prostate, by
the urachus and the obliterated hypogastric arteries, by its vascular
connections, and finally by ligaments derived mainly from the reflec-
tions of the pelvic fascia (true  ligaments) and from the peritoneum
(false ligaments).
   The urachus, a fibro-muscular cord,  and the obliterated hypogas-
tric arteries pass from  the  summit of the bladder to the  umbilicus.
The expansions of the  pelvic fascia  hold the neck and base of the
bladder in position.  The  anterior or pubo-prostatic ligaments from
either  side of the  lower portion of the pubic symphysis fix the pros-
tate gland and the anterior part of the bladder neck; the lateral liga-
ments embrace  the prostate  and  the lateral border of the bladder
base.   The false ligaments  or peritoneal folds are the superior, cover-
                                                         539 
540        GENITO-URINARY DISEASES AND  SYPHILIS.

ing the urachus and the obliterated hypogastric  arteries from the um-
bilicus to  the vesical apex, the lateral, reflected from the iliac fossae
to the bladder  sides, and the posterior, containing the ureters and
hypogastric arteries and bounding the recto-vesical fold.
   Peritoneal Covering of the Bladder.—The peritoneal covering of
the urachus and the obliterated hypogastric arteries passes directly to
the bladder, investing its posterior surfaces from the apex to the pos-
terior extremities of the seminal vesicles and the vesical extremities of
the ureters.   It is continued laterally to the position of the obliterated
hypogastric arteries, passing  backward  as it descends to the recto-
vesical cul-de-sac, and covering a portion of the vas  deferens.  Pos-
teriorly,  the peritoneum is reflected from the bladder to the rectum,
forming  the recto-vesical pouch.  This pouch  is usually more than
three and less than four inches from the anus ; exceptionally, the vesi-
cal peritoneum may descend as far as  the  prostate, and would then
be less than two inches from  the  anal orifice.
   When  the  bladder is empty  the  peritoneum lining the anterior
belly-wall descends as far as the upper border of the pubis, and is

                               Fig. 157.
                                                      u
   Relations of the empty and of the full bladder to the peritoneum,  a, pubic symphysis; b, ab-
dominal wall;  c, prevesical space (space of Retzius); d, suprapubic space; 1, vesical wall; 2, vesical
cavity; 3, urethra ; 4, prostate ; 5, right deferent canal; 6, urachus ; 7, peritoneum; xx, horizontal
passing beneath the symphysis; yy, plane of the superior strait. (Testut.)
reflected from this level to the vesical apex.   As the bladder becomes
distended this peritoneal  reflection is lifted upward, and the anterior
vesical wall  becomes accessible to operation by suprapubic incision
without danger of entering the peritoneal cavity.   (Fig. 157.)   When
the bladder  is moderately distended and is further elevated by rectal 
         INJURIES AND DISEASES OF THE BLADDER.       541

distention, the peritoneal reflection may be raised  twTo inches above
the upper border of the symphysis.
   Exceptionally the parietal peritoneum is adherent to the symphysis.
In this case a suprapubic cut must necessarily open  the  general ab-
dominal cavity.  There is  no means of determining the  presence of
such an anomalous condition before operation:  hence the danger
always possible in suprapubic puncture or aspiration.
   Structure of the Bladder.—The mucous membrane of the blad-
der is made  up of flat epithelium  based upon deep layers of cylin-
drical cells.  It is of  a yellowish  color, exhibiting plications which
disappear on  distention of this viscus.   The submucous fibrous tis-
sue contains elastic fibres, and by its loose attachment to the under-
lying muscles enables the mucous membrane to accommodate itself to
the changes in dimensions to wiiich the bladder is constantly subject.
In the trigonum the mucous membrane is applied directly to the sub-
jacent structure, and slight papillary outgrowdhs are sometimes seen;
exceptionally rudimentary glands are found.
   The muscular walls of  the bladder are arranged in three  layers.
The  outer longitudinal layer contributes fibres  to the formation of
the anterior  vesical ligaments.  Through or between  these musculo-
tendinous fasciculi pass the anterior vesical veins  to  join the plexus
of Santorini.   The middle layer is composed of circular fibres com-
pletely covering in the bladder.   These are thickest  about the urethral
orifice,  forming the internal vesical  sphincter.  The inner layer is
made up of  longitudinal  fibres passing from  the apex to  the neck.
The  fibres composing this  layer are grouped  in bundles or fasciculi,
which anastomose, forming a coarse net-work  and  producing the
characteristic reticulation of the inner surface.
   Vascularization and Innervation.—Blood is carried to the bladder
by branches  of  the internal iliac arteries. These  are  the superior
vesical, supplying the apex and the lateral surfaces and deferent canals ;
the middle vesical, supplying the  base of the bladder and the seminal
vesicles; the  inferior  vesicals, often from the middle hemorrhoidal,
running to the prostate, the seminal vesicles, and the  trigonum ; and
the anterior vesicals,  small and  variable, derived  from the internal
iliac  or the obturator.  These blood-vessels penetrate the muscular
coats of the bladder,  forming a  submucous plexus from which the
epithelial capillaries are given off.
   The veins of the mucous membrane, having penetrated the mus-
cular coat, form a superficial plexus, made up of  large, freely anas-
tomosing, valveless trunks, usually running longitudinally.  The ante-
rior vesical veins  pass into  the pubo-prostatic plexus (plexus of 
542       GENITO-URINARY  DISEASES  AND SYPHILIS.

Santorini), situated just beneath  the symphysis to the right and left
of the  median line ; the  lateral veins, particularly  voluminous and
numerous,  empty  into  the vesico-prostatic  plexus.   The posterior
veins, also large, pass  into the  vesico-prostatic plexus or seminal
plexus.  The  pubo-prostatic,  the  vesico-prostatic,  and  the seminal
plexus  anastomose freely, and practically  form  one  series of large
vessels,  which is emptied by all  the  veins lying near  at hand, in-
cluding  the hypogastric, the ureteric, the hemorrhoidal, the internal
pudic, the obturator, the spermatic, etc.
    The lymphatic vessels, particularly abundant in the trigonum, pass
in  the   direction of the  urachus to  the  lymph circulation  of the
abdominal parietes, or towards the base of  the bladder.

                                Fig. 158.
   Vesical triangle. (Sappey.)  1, surface of the triangle ; 2, 2, posterior angles and ureteral openings;
3, anterior angle representing the urethral opening ; 4, slight pouching behind the triangle; 5, 5, ter-
minal extremities of the ureters; 6, upper portion of the bladder sphincter; 7, constrictor muscles of
the prostatic urethra; 8, 8, plexus of Santorini; 9, 9, vesico-prostatic plexus ; 10,10, cross-section of
these veins at the point where they reach the lateral portion of the base of the bladder.

    The nerves of the bladder are derived  from the hypogastric plexus
and from the anterior branches  of the third and fourth  sacral nerves.
    At  the  bladder base lies  the trigonum, presenting a  smooth  red
surface, in the form of a nearly equilateral triangle, each side of which
is about  one and a quarter inches long.  The  angles correspond in
position to the internal vesical orifice and the two slight projections 
INJURIES AND DISEASES OF THE BLADDER.
543
or openings of the ureters.   The  triangle may be distinctly outlined
by perceptible  ridges  passing between  the  two  ureteral openings
and from these to the internal  vesical orifice.   (Fig. 158.)   These
ridges represent a reinforcement of the vesical and ureteral muscles,
designed to preserve the valve-like action of the ureters and to keep
them closed against back pressure from the bladder.  The region of
the vesical triangle is indicated on the  outer surface of the bladder by
the  position of the seminal vesicles.  When  these are normally de-
veloped, a line joining their posterior extremities  indicates the base
of the triangle; the point where the bladder-wall merges into the
mid-portion of the prostate indicates its apex.
   The trigonum and the vesical neck are more abundantly supplied
with blood-vessels  and nerves  than are  any other portions of the
bladder.
   It  follows from the position of  the bladder that it is  well  pro-
tected from direct traumatism, and that it is accessible to exploration
by combined rectal  and suprapubic palpation.  Its abundant blood-
supply assures  quick healing  of surgical or accidental wounds when
other  conditions favorable for healing are present.  The superficial
layers of flat epithelium with which the mucous membrane is  pro-
vided insure against absorption from the bladder as  long as the epi-
thelium  remains healthy and unbroken, thus protecting the system
against poisoning by toxic substances eliminated with the  urine and
guarding  the tissues locally against  infection.  The loose attachment
of the mucous  membrane to the underlying muscular tissues  and the
arrangement of the muscular coat  prevent extravasation of urine after
puncture of a full  bladder, the opening, on withdrawal of the needle
or trocar, becoming valvular by the sliding of  the  tissues.   The great
venous plexus  at the  base  of the bladder and the many large veins
passing over its surface, together with  the free intercommunication
between  all the pelvic  veins, explain  the frequency of dangerous
venous bleeding in bladder  surgery.   These facts  also show  how
important an effect  upon the bladder is exerted by any cause, such
as constipation,  producing  pelvic  engorgement.  The  particularly
generous  innervation  and vascularization of  the  trigonum and the
bladder-neck explain the greater pain and reaction from inflammation
or manipulation of this part of the viscus.

      MALFORMATIONS AND  MALPOSITION OF THE BLADDER.
  The bladder may be multiple.   Its walls may be  absent in whole
or in  part, may be hypertrophied, atrophied, or herniated.   The
urachus may remain patulous. 
544        GENITO-URINARY DISEASES AND SYPHILIS.

   Multiple bladder, in the true sense of the term, is an extremely
rare  deformity.   Usually there is a single bladder with a septum
dividing it into two portions, which may or may not communicate
with each other, a ureter opening into each portion.  More frequently
it is a sacculated  bladder.  Sometimes  the  apparent anomaly is due
to the enormous dilatation of a ureter.
   When the bladder is really multiple, as, for instance, in a reported
case in which there were  five kidneys, each  with a separate  re-
ceiving viscus, no operative  measure is indicated.  Sacculation, with
attendant cystitis from defect of drainage, would indicate simply the
treatment of the cystitis.  Enormous dilatation of the ureter, if it could
be diagnosed, would indicate the relief of the stricture or the forma-
tion of a new opening between the dilated ureter and the bladder.
   Complete Absence  of the  Bladder.—When the bladder is
completely absent, the ureters  open into the urethra, the vagina, the
rectum, or the umbilicus.  The condition may be treated by the  ap-
plication of a urinal, which prevents the garments from being soiled,
or by implantation of the ureters into the bowels.
   Exstrophy, or absence of a portion of  the bladder-wall, is by no
means uncommon.   The anterior w-all is the portion usually wanting,
though  cases are reported in wiiich the septum separating the blad-
der from the vagina or the  rectum  has been absent.   Exstrophy or
extroversion is observed most frequently in  male children, and is due
to the failure of the lateral portions of  the  uro-genital cleft to unite.
Hence in pronounced cases there is a deficiency not only in the ante-
rior wall of the bladder but also in the musculo-cutaneous abdominal
parietes and the  pelvic girdle, the  pubes not meeting in the middle
line to form the  symphysis.   This deformity is associated with epi-
spadia in the male and  split clitoris in the female, the bladder and
urethra opening in the female either into the vagina or just above it.
   From weakness of the abdominal parietes there is commonly asso-
ciated with this deformity complete double inguinal hernia, which,
descending  into the cleft scrotum,  causes  its two halves  closely to
resemble the labia majora of the female.  The  prostate is rudimen-
tary, the testicles often are ectopic.  The recti muscles pass upward
and inward on  either  side from  their insertion into the separated
pubis.  Sometimes this separation is continued upward almost to the
origin of the muscles, allowing the formation of ventral hernia.
   On examining a case of exstrophy of the bladder there is  found
presenting in the hypogastric and pubic region a bulging, moist, dark
red surface of intensely inflamed rugous  mucous membrane, sur-
rounded by an area of cicatricial tissue, uniting its borders to the 
INJURIES AND DISEASES OF THE BLADDER.
545
skin.  This projection varies in size from that of a half walnut in in-
fants to that of a man's fist in adults.   It bleeds readily, is extremely
sensitive, its lower portion is wet, and the projections marking the
ureteral orifices can  usually be found  by the  escape of urine, which
spirts from them in jets.  This tumefaction may  extend  upward as
far as the umbilicus.
   Continuous with the lower border of the  mucous  surface is the
urethra, passing as a  furrow on the dorsal aspect of the rudimentary
penis, the prepuce of which forms a large flap hanging from the under
surface of  the glans.   The pubes  may be separated for a  distance of
one or two inches.  The  seminal vesicles are either  absent or are
greatly atrophied.  The ureters are often dilated, and sometimes so
sharply bent that  consequent obstruction  and dilatation occur.  In
the female the greater  and lesser vulvar  lips are not joined ante-
riorly, and the clitoris  is split,  the vagina being  converted into  a
small channel.   Patients exhibiting this deformity are usually of poor
physical development in other respects, and often perish from ascend-
ing pyelonephritis.  As a  result of the leakage of urine  inseparable
from exstrophy, the surrounding  skin becomes infiltrated and exco-
riated, and erysipelas sometimes  develops.  Sexual desire is gener-
ally wanting, though in the female this deformity does not necessarily
interfere with parturition.
   Associated deformities are by no means uncommon.  At times the
intestine or the anus opens through the exstrophied mucous mem-
brane.  Generally the anus  is placed  farther forward than  normal.
Spina bifida and club-foot may be associated with exstrophy.
   In degree exstrophy varies from the slight  form  characterized by
epispadia and a cicatricial condition of  the skin in the neighborhood
of the pubis to the  form  in which there is separation of the pubic
bones, or,  finally, to the form  characterized by complete hypogastric
fissure with eventration. Between these extreme degrees of exstrophy
there is every gradation.  Heredity exerts no influence in causing this
deformity.
   The diagnosis of exstrophy is unmistakable.  The scar-tissue sur-
rounding the mucous membrane is congenital, and is not  due to pre-
vious destructive inflammation.
   The prognosis must be guarded, since the conditions are favorable
to kidney-infection.
   Treatment may be  either palliative or radical.  Palliative treatment
consists in the  application of a  urinal  so constructed that a hollow
rubber cup accurately fits the skin surface surrounding the cleft, and
thus enables the urine to be drained off into a reservoir.   (Fig. 159.)
                               35 
546        GENITO-URINARY DISEASES AND SYPHILIS.
Fig. 159.
   A, day urinal; 1, detachable reservoir.
B, night and day urinal; 2, detachable reser-
voir.
   Radical  operation consists in closing the defect by plastic opera-
tions, or in diverting the ureters.
   The  most successful radical operation can never make  a satis-
factorily retentive  bladder, since a  sphincter  which will be under
                                proper nervous  control cannot be
                                formed.   Plastic operations usu-
                                ally aim  to  lessen  deformity and
                                to close the bladder sufficiently to
                                allow of easy drainage by means of
                                a urinal, thus protecting the sur-
                                rounding skin from irritation and
                                enabling the patient to keep himself
                                clean.  Wood's operation is the one
                                most in favor.   A cutaneous flap,
                                the  attachment  of which  corre-
                                sponds to the upper border of the
                                cleft, is turned down from above the
                                bladder.  This flap should be of suf-
                                ficient length  to  cover entirely the
                                exposed  mucous membrane;  the
                                skin surface thus forms a new an-
terior wall  for the bladder.  The lateral borders of this flap are
sutured with catgut to the freshened  skin  borders of the congenital
cleft.   There is thus formed  a pouch, the anterior wall of skin, the
posterior of mucous membrane.  The raw outer surface of this first
flap is then covered in by two  lateral rectangular flaps which have
their attached bases placed in the inguinal region of each side.   These
two flaps are  made of such length that without undue tension they
can be  carried transversely across the raw surface of the first flap,
covering it completely.   The  free borders of these flaps are sewed
together with silkworm-gut.   Finally,  the large wound resulting from
the transplantation of these  flaps is  closed in as  far as possible by
means of silk sutures.
   In the operation by a  single flap, suggested by Roux  and modi-
fied by Maury, the incision is carried from the  outer third of Poupart's
ligament across the middle  of the perineum to  the corresponding
point on the opposite side.  The flap  thus  marked  out is dissected up
until the root of the penis is  reached, when a button-hole opening is
made and the penis  is slipped through.   A curved incision is then
carried  across the abdomen above the upper margin of the congenital
cleft, a  short flap is dissected up, and the edges  of the scrotal flap
are vivified, slipped beneath the upper flap, and secured by sutures. 
INJURIES AND DISEASES OF THE BLADDER.
547
   Smith advises a bellows-shaped flap taken from the surface of the
abdomen and folded down so that not only is the bladder covered in,
but also a posterior w^all is formed for the urethra.  This is  further
strengthened  by passing the penis under a bridge of scrotal skin and
securing it in place by sutures  until  the vitality of the  flaps is  fully
assured.
   A serious objection to all these  operations, including Thiersch's
method, is founded on the fact that from  the skin surface thus turned
in hairs grow, which encourage calculous formation.
   Closure of the bladder by direct  suture possesses the advantage
of forming a vesical cavity consisting entirely of mucous membrane.
When the cleft is narrow this operation is not difficult: the borders
of the exstrophied bladder  are denuded and  are approximated by
silkworm-gut sutures.   When there is bone-defect, an essential point
in successfully performing this  operation is the approximation of the
two pubic bones.  This may be accomplished  in  infants by gradual
pressure, applied by  means of an  elastic belt or a  spring truss.
Trendelenburg advises subcutaneous symphyseotomy of the sacro-
iliac  joints, followed by forcible lateral pressure and the application
of a gravity  apparatus.   He  used  a leather girdle crossing in front
and  attached to weights on  each side.   After the pubic bones  have
been brought together the bkdder-cleft can be readily closed by direct
suture.
   Usually the defect represented by the projecting mucous mem-
brane of the  posterior  bladder-wall is too wide to allow  of closure by
direct suture.  Under  these circumstances, and since symphyseotomy
is not practicable, because of  the difficulty of keeping the  wound
clean, there may be made an extra-peritoneal dissection of the bladder
mucosa.  The flap thus obtained is brought down to the penile furrow,
to the freshened edges of which it is sutured.  This having been done,
the prepuce is split, is  perforated at its base and  carried up over the
glans, and is  made to cover by its raw surface  the vesical flap where
it forms the urethral roof.  Finally, flaps are dissected,  as in the last
stage of Wood's operation, and are made to cover in the raw surface
resulting  from the dissection of the bladder.  There results, accord-
ing to Segond, a canal the walls of which are formed by the penile
furrow and the  turned-down  bladder, and are  hence exclusively
mucous and not liable  to favor the development of calculi.
   Poncet slightly modifies Segond's operation.   He dissects loose
the entire bladder mucosa down to the ureters, utilizing  the whole of
it to form a pouch. The objection to this operation is that the bladder-
flap thus dissected is necessarily so thin that it is liable to slough.  As 
548
GENITO-URINARY DISEASES AND SYPHILIS.
a further modification, Poncet suggests that instead of practising the
extra-peritoneal dissection of the bladder-wall the whole thickness
of the latter should be freed from its parietal attachment by a cut
carried around its borders and opening the peritoneal cavity.  Thus
there is formed a flap which includes the muscular and  peritoneal
investment of the bladder and is  not likely to slough.  The abdom-
inal defect is closed by direct suture.
   Maydl has shown that this method  is perfectly practicable.
   Extirpation of  the  mucous  membrane  of the bladder, except
that surrounding the ureteral orifices,  has  been suggested as a treat-
ment of  exstrophy,  since it does away with  the irritation  incident
to chronic inflammation  of  this membrane.   Before  sacrificing  the
mucous membrane  there  should be  at least an  attempt  made to
utilize it in closing the defect.
   Transplantation  of the ureters is a method  of treatment by no
means new, but one to which  experimental  research and repeated
clinical trials have recently called attention.  In animals  this method
has been so  frequently followed by  ascending pyelonephritis and
death  that  this sequel  has been regarded as inseparable from  the
operation.   There is, however, reason to  believe that this is avoid-
able,  and that it is due  in great  part  to narrowing of the trans-
planted ureteral orifice and  backward pressure on the kidneys.
   Maydl has successfully accomplished this transplantation by  open-
ing the peritoneal cavity at the border of the exstrophied  bladder and
removing  the whole of the  latter  except a small segment containing
the ureteral orifices.  Into the latter are passed small catheters.  The
small bladder-segment left, together with the attached ureters, is thor-
oughly mobilized; the colon is drawn  out and incised longitudinally,
and in this  opening is secured  the portion of  the bladder-wrall con-
taining the  ureters.  The mucous membrane is first sewed to  the
mucous membrane  of  the gut, then the musculo-peritoneal coating
of the intestine is sutured to the muscular wall of the bladder-segment.
Finally the abdominal wound is  closed by suture.
   Boari has described a rapid and easy method of performing ureteral
colostomy, employing a device very like the Murphy button.
   A consideration   of the various operative  methods applicable to
exstrophy leads us  to believe that in  certain  appropriate cases  the
method of  choice is direct suture of the freshened bladder-borders,
thus forming an irregular cylinder, which  acts not  as a reservoir but
as a conductor of urine, allowing a portable  urinal to be employed.
In children an effort should be  made to  close the bony  defect by
elastic or weight pressure.   Symphyseotomy is by no  means free 
INJURIES AND DISEASES  OF THE BLADDER.
549
from danger.   The  exact value of this procedure and the additional
risk inseparable from  it remain yet  to be determined.  When suc-
cessful, it enables the surgeon to close  the bladder and  a part of
the urethra by direct suture.
   When flaps are  required  to close the defect,  these should, when
possible, be of mucous membrane made  at the  expense of the ex-
strophied bladder.   It would  seem advisable to use the whole  thick-
ness of the bladder-wall.   This requires opening of  the  peritoneal
cavity, and, since the tissues operated on  are  infected,  may  cause
peritonitis.  Careful preliminary cleansing of the parts and the  skilful
use of intraperitoneal pads   should effectually  guard against  this
danger.
   Wood's operation,  while objectionable because  skin surfaces are
turned in, is on the whole the one which with the least risk combines
the greatest advantages.  The result is not so satisfactory as that fol-
lowing direct  suture, but the percentage of cases to which the latter
method is applicable is far less, and the proportion of operative suc-
cesses by Wood's operation is greater.
   Ureteral derivation is theoretically the most satisfactory  immediate
treatment of exstrophy.   Its  ultimate results are  not yet known.
   Before any operation is  performed the inflamed  skin surrounding
the bladder must be rendered healthy by cleansing washes and heal-
ing protective  salves.  Thus,  twice daily the parts may be bathed in
five per cent,  ichthyol solution, followed by  the application of a thick
zinc  paste, made by adding  four  drachms  of finely  powdered zinc
oxide to an ounce of benzoated zinc ointment.  This paste is removed
by rubbing with cosmoline.
   Following the plastic operations the  newly formed bladder-cavity
should be flushed out gently with boric acid solution or other  dilute
antiseptic every two hours;  a  fountain syringe  and  a soft catheter
answer best for this purpose.   The dressing of sterile gauze applied
loosely over the line of suture  is changed at the same time,  the opera-
tion area  is irrigated with corrosive chloride  lotion, and a clean dress-
ing is applied.   The surrounding skin surfaces are protected from ex-
coriation by the leaking urine  by thick zinc oxide  ointment. Urinary
antiseptics should be  given by the mouth,  to lessen the  danger of
ascending infection.  Should  symphyseotomy have been performed,
the wound should be closed without  drainage, and should be dressed
with gauze and collodion.
   As in the treatment of hypospadia and epispadia, repeated efforts
may be required before a satisfactory result is achieved.
   Patent Urachus.—Occasionally, as a congenital defect, the com- 
550        GENITO-URINARY  DISEASES AND SYPHILIS.

munication between the bladder and the allantois is not entirely oblit-
erated, and after birth urine escapes through the umbilicus.  This con-
dition is usually associated with some form  of urethral obstruction.
   Treatment consists  in first  rendering the urethra patulous.  This
in itself is often  sufficient to produce a cure.  If the fistula still per-
sists, an occluding dressing or the application of the actual cautery is
indicated.  Urinary concretions and suppurating pouches may form.
   Hypertrophy  of  the Bladder.—This term implies  an over-
growth  of the  vesical  muscles.   Sometimes  it  is  associated with
marked thickening  of the  mucosa.   It is always caused by increased
functional activity incident to mechanical obstruction to the escape of
urine from the bladder  or  to abnormally frequent micturition.
   In  cases  of  obstruction, particularly if it is at the vesical neck,
there is  usually coincident  with  hypertrophy a dilatation, often a
partial sacculation, of the  bladder, the weaker portions of the walls
between the  thickened  muscular fasciculi yielding.  In vigorous young
men, and this particularly  represents the type suffering from chronic
stricture, muscular hypertrophy may be universal, the resulting  in-

                              Fig. 160.
Conoentric hypertrophy of the bladder.
creased expulsive force of the bladder preventing retention and sec-
ondary dilatation.  In older men, with enlarged prostates, the typi-
cally dilated, thickened, trabeculated, and possibly sacculated bladder
develops.  Hypertrophy dependent upon frequent urination without
obstruction, as in some cases of chronic posterior urethritis, is always
concentric and lessens the size of the vesical cavity.   Cystitis is usu- 
INJURIES AND DISEASES  OF THE BLADDER.
551
ally associated with hypertrophy, adding to the thickness of the blad-
der-walls.   (Fig. 160.)
   The  ultimate prognosis of hypertrophy is bad, since  fibroid or
fatty degeneration  is  liable to occur, with consequent diminution or
entire loss of contractile power.
   Diagnosis.—This, when the hypertrophy is associated with trabec-
ulation and dilatation, is made either by the cystoscope or by examina-
tion with a vesical  sound.  Even when  the bladder is wrell distended,
the point of the explorer can be felt scraping and jolting over the
ridges made by the hypertrophied  muscular  fasciculi.   When there
is concentric hypertrophy without  dilatation, the  lessened  capacity
of the bladder and the detection of its greatly thickened walls by bi-
manual  rectal and suprapubic palpation, together with a preceding
history of  either frequent or difficult micturition, point to the true
nature of the affection.
   Treatment.—The direct treatment of the hypertrophy is unavailing.
Relief of obstruction or of the necessity for frequent micturition will
prove curative if this is  accomplished  before degenerative changes
have begun.
   Atrophy of the bladder may be caused by  distention  or by
degeneration consequent on nerve-lesion.   In old age there has been
observed a fatty degeneration  of both the detrusor and sphincter mus-
cles.  As a  result  of muscular atrophy the bladder loses  the power
of evacuating its  contents and becomes a thin, sometimes enormously
dilated pouch.  If  the sphincters, including  the compressor urethra?
muscle,  are  atrophied,  there  will result incontinence of urine;  this
symptom is usually associated with retention.
   Hernia of the Bladder.—Under this term is included  protrusion
of a part of  the bladder-wall  along the track  usually taken by intes-
tinal hernia.   Inguinal cystocele is a common form of this affection,
though there are individual instances of obturator, crural, and perineal   •>
vesical hernia.
   Inguinal cystocele may appear in  the form of a projection of the
bladder  without a true  hernial sac,—that is, without  a  peritoneal
covering,—the muscular coat of this viscus  lying in immediate con-
tact with the transversalis fascia and adhering to it.   This is the usual
form, and rarely attains large dimensions.    Exceptionally  there  is
partial or complete sacculation at  the expense of the peritoneal in-
vestment of the bladder.  Still more rarely  the herniated bladder
forms a  tumor entirely covered by its own peritoneum and invested
in an additional true peritoneal sac.  Either the summit or the lateral
surface of the bladder is the portion  found  prolapsed.   Even the 
552        GENITO-URINARY DISEASES  AND SYPHILIS.

most pronounced displacement is not sufficiently extensive  to  dis-
place the ureters.
   The herniated portion of the bladder usually presents thin walls,
is often surrounded with considerable fat, and sometimes appears as
a diverticulum with  an  extremely small opening into the general
vesical cavity, the capacity of the latter not being particulariy dimin-
ished.  From stagnation of the urine in these diverticula calculi may
form.
   The causes of  hernia of the bladder are overdistention and dila-
tation of this  organ  and a patulous condition of the hernial orifices.
When the bladder is  the  first viscus to appear in the hernial  region,
its anterior surface,  uncovered  by peritoneum,  descends, possibly
dragged down by a preceding lipomatous formation.   After this  fol-
lows  the part covered by peritoneum, forming  an artificial sac, into
which the gut may subsequently descend.  The most frequent cause
of bladder hernia is a preceding intestinal hernia, which, as  it pro-
gresses  and drags on the peritoneum  in  the  formation of a sac, in-
volves the bladder.
   Symptoms.—The characteristic symptom of hernia of the bladder
is the presence of a fluctuating  tumor, dull on percussion and varying
in size in accordance with the amount  of urine contained  in  the
bladder.   This tumor may not grow smaller, even though the bladder
be completely emptied, since it may communicate by a small  orifice,
which is closed when the patient is in  the erect position.   On lying
down, however,  and  particularly after manipulation  and  gentle
pressure, the somewiiat tense fluctuating tumor becomes small and
flaccid, and  immediately a quantity of urine can be again evacuated.
The  flaccid, inconspicuous  swelling becomes  tense  and full  when
injections  are forced into the bladder.  These  symptoms are abso-
lutely diagnostic.  In addition  there  are  frequently symptoms of
bladder irritation, such  as frequent and difficult urination, retention,
or evident cystitis.  Exceptionally, when the herniated portion of the
bladder is small, it offers no symptoms other than those associated
with an irreducible omental hernia.
   Vesical hernia  is commonly complicated by  enterocele  or epiplo-
cele.  Usually this displacement is not suspected till, in the course of
operation for intestinal hernia, escape of urine shows that the bladder
has been opened.
   Treatment for  this affection  should be operative.   A truss is  not
well  borne,  and reduction is impossible.  The  operation consists in
carefully dissecting the bladder free of its adhesions, reducing it to
its proper position, and permanently closing the hernial opening. 
INJURIES AND DISEASES OF THE BLADDER.
553
 THE GENERAL  SYMPTOMATOLOGY  OF DISEASES OF  THE  URINARY
                            TRACT.
   Pain.—Pain symptomatic of pathological conditions of the urinary
tract is subject to so many variations in degree, is so often referred
to regions other than the seat of disease, and is so affected by vesical
tension and by  micturition, that a serviceable classification of the
manifestations of this symptom is difficult.  Perhaps the subject may
be best considered under the following heads :
   1. The character and intensity of pain.
   2. The region of pain.
   3. The relation of pain to the act of micturition.
   The Character and  Intensity  of  Pain.—Pain  symptomatic of
urinary affections may vary from   an  apparent  muscular stiffness
comparable to that following active exertion,  and noticed only on
movement, or from a dull ache readily forgotten when the mind  is
employed, to  a  severe  pain distracting the attention and seriously
interfering with the business of life,  or to an unbearable anguish pro-
ducing vomiting, syncope, and sometimes death.
   The pain may be  aching and rheumatoid, as in renal congestion,
may be burning, as in cases of  prostato-cystitis, may be shooting and
lancinating, as in vesical neuralgia,  or may be tearing and  griping, as
in renal colic.
   It may be steady, as in vesical carcinoma, it may be intermittent,
as in bladder stone,  or  it may be  continuous with violent exacer-
bations, as in calculous pyelitis or acute hydronephrosis.   If the suffer-
ing incident to acute blocking of the ureter be  excepted, most of the
pain of urinary disease comes from  the bladder and prostatic urethra.
   Diseases of the  kidney and  its pelvis are comparatively painless,
provided there is free drainage through the ureter.  A calculous pye-
litis may last for years with no symptoms other than backache, aggra-
vated on  motion, or there may be  frequent  paroxysms of agonizing
pain, and  indeed this may occur in pyelitis without calculi.  These
paroxysms are due to acute retention, caused  by valvular formation,
plugging of the ureter by pus or blood, or blocking of it by calculus.
   Inflammation of the ureters in itself  occasions no pain which can
be recognized as characteristic.   It  is, however,  so frequently compli-
cated by  partial  or complete  stoppage,  with  consequent tension of
the kidney capsule, that  patients  suffering from this form of inflam-
mation are subject to violent attacks of colic.  The absolutely unbear-
able pain  of a kidney stone passing along the ureter is probably due
more to spasmodic mechanical blockage of this canal and consequent 
554        GENITO-URINARY  DISEASES AND SYPHILIS.

retention of urine in the kidney pelvis  than to  mechanical erosions
caused by the passage of an irregular foreign body.  This hypothesis
would seem to  be confirmed by the comparative  painlessness of
ureteral catheterizations.
   The pain of bladder-disease, aside from that caused by muscular
contraction incident to micturition, is proportionate  to the  intensity
of the pathological process.   Chronic cystitis causes very little pain.
Acute cystitis and acute  retention are extremely  painful.
   The suffering incident to inflammation or erosion due to a calcu-
lus or a foreign body varies greatly.  In general, large smooth  calculi
are less painful than those which are small and irregular.  Malignant
growth of  the  bladder may be absolutely painless  until it  becomes
complicated by cystitis or infiltrates the muscular walls.  Even under
these circumstances pain may be slight or bearable.  It is often, how-
ever, constant, subject to spasmodic exacerbations, and more intense
and  wearing than any other form of vesical  pain except that  due to
retention.
   Tubercular ulceration may be painless,  except during and after
micturition.  When the  lesions are situated in the trigonum they may
cause constant burning wearing pain, with  reflexes to the rectum,
anus, perineum, and inner surfaces of the thighs.
   The Region  of Pain.—Pain may be felt in  the  region involved.
Thus, in acute hydronephrosis or chronic pyelitis the pain is con-
stantly referred to the region of the kidney,  though  reflexes may be
so pronounced as to make this fact apparent only after careful ques-
tioning of  the patient.   Inflammation of the bladder  usually  causes
pain directly in the vesical region.
   Sometimes no pain is experienced at the seat of lesion, the abnor-
mal  sensation being referred to anastomosing nerve-trunks or to the
terminal extremities of the  nerve irritated.   Thus, disease of the kid-
neys constantly gives  rise to pain  which is  felt chiefly in the groin,
down the thighs, or in the testicle.  The irritation caused by stone in
the  bladder  produces urethral pain, felt a short distance back from
the meatus.  Inflammation of the trigonum  frequently causes itching,
tickling, and painful spasm of the anal sphincter.
   Occasionally the healthy bladder may be the seat of almost un-
bearable pain, due entirely  to inflammation of the kidney pelvis.
   The pain of kidney-disease of one side may be referred to the op-
posite healthy side, or to the shoulder, the groin, the urethra, the tes-
ticle, the inner surface of the  thigh, the calf, or  the  heel.  This pain
in the heel is particularly a reflex from the prostatic  urethra.
   Pain of bladder-trouble may be referred to the suprapubic  region, 
INJURIES AND DISEASES OF THE  BLADDER.
555
the  sacral or lower lumbar vertebras, the glandular urethra, the kid-
neys, the perineum  and  anus, the inner surface  of the thighs, and
the sole of the foot.  All these transferred pains may be symptoms of
inflammation of the prostatic urethra.
   Fenwick has thus tabulated the positions of painful surface areas
connected with urinary disease :
Diffused
 supra-
 pubic
 pain.
Constant.
Transient.
Unrelieved  advanced
  atonies.    Chronic
  prostatitis.
Carcinoma of  poste-
  rior wall  and base
  (advanced).
All   extravesical   in-
  flammation,—e.g.,
Rare primary ureteral
  disease.
Started by micturition.
Relieved  by micturi-
  tion.
Increased by micturi-
  tion.
Abscess,  pericystitis,  perfo-
  rating apical carcinoma.
Prostatic enlargement without
  much residual urine.
Cystitis of all grades.
Ulceration of the bladder.
Tuberculosis of the bladder.
Certain forms of prostatic in-
  flammation.
Onanitic prostate.
Sarcoma of prostate (?).
Cramp of a semi-toneless blad-
  der of stricture.
   He states that suprapubic pain of diffuse type is an expression
of disease in three structures,—the bladder, the prostate, and, in rare
instances, the ureter.  Crampy pains are usually evoked by muscular
effort and by stretching of inflamed  surfaces.   The  constant type is
more often the outcome of nerve-pressure or  inflammation, as from
carcinoma or ulceration.
   The small  area C (Fig. 161) to the inner  side of the middle of
Poupart's ligament represents a spot where tenderness is often com-
plained  of after an attack  of renal colic.  This area represents the
flexure of the  ureter over the  brim of the  pelvis, and it is here that
pain  from stone impacted  in the ureter at the pelvic brim is referred.
If the pain at C or near C be transient or relieved by micturition, it
is usually caused  by  slight stretching of the  bladder at the posterior
lateral wall or by a dilated ureter.
   The clear circle at E, overlying the ring,  often  indicates change  in
the corresponding ureteral orifice. 
556
GENITO-URINARY DISEASES  AND SYPHILIS.
   Pain from the navel to the bladder {NN)  is distinctly neuralgic,
and  apparently dependent upon irritation at the vesical orifice.  The
shadings on the outer third of Poupart's ligament, below it, and  on
the inner thigh indicate the seat of referred pain noted in advanced
carcinoma of the bladder-base or prostate.

             Fig. 161.                              Fig. 162.
Areas of referred pain, anterior surface.          Areas of referred pain, posterior surface.
                           (Fenwick.)
   The sciatic and inner thigh pains (Fig. 162) are found not only in
hard carcinoma of the bladder-base and prostate, but also  in many
cases of acute prostatic involvement.  The shading over the fourth
and fifth lumbar vertebrae indicates the seat of backache due to con-
gestion of the prostatic canal;  it may  also  represent the  reflected
pain of non-malignant vesical tumor.  The  pain  overlying the sacro-
iliac  synchondrosis is difficult to explain, but is observed  in many
vesical  cases, particularly in females with ulceration of the  bladder.
(Fenwick.)
   General penile pain is rather an expression  of congestion of the
urethra than of inflammation or congestion of the bladder or kidneys.
   Perineal and  glans  pain  may be  constant  or may be affected by
micturition.  It is thus tabulated.  (Fenwick.) 
INJURIES  AND DISEASES  OF  THE  BLADDER.
557
Constant
  perineal
  pain.
Transient
  perineal
  pain.
Constant
  glans
  pain.
Transient
  glans
  pain.
Relieved   by
  micturition.
Increased  by
  micturition.
                Chronic prostatitis.
                Commencing senile enlargement of the prostate.
                Encysted calculus at the base of the bladder.
                Carcinoma of the prostate.
                Acute prostatitis.
                Tubercular disease of bladder-base and tubercular
                  prostate (quiescent stage).
                Calculus either encysted in base, or low down on
                  posterior wall, or pouched in a depression be-
                  hind an upraised  prostate.
                Catarrhal or tubercular ulceration  of bladder be-
                  hind the trigonum (active).
                Local conditions: suburethral  abscess, inflamed
                  stricture, impacted stone, carcinoma of bulb.
Prostatorrhoea.
Catarrh of prostatic canal; swollen verumontanum.
Enlarging median or lateral lobe of senile prostate.
Before  mictu
  rition.

During mictu-
  rition.
After micturi-
  tion.
  Clot retention.
  Senile prostatic obstruction.
  Local lesions : inflammation, granular patch.
  Inflamed congenital fold, ulceration, wart, narrow
    meatus.
  Stone in the bladder.
  Tubercular and other ulceration of posterior or
    lateral walls of the bladder.
  All forms of acute localized cystitis  in any part of
    the bladder.
  Cystitis of neck.
  Vesical growth engaging or impinging on urethral
    orifice.
  Acute prostatitis.
  Inflamed onanitic prostate.
  Inflamed senile prostate.
  Severe vesical spasm of renal origin.
  Sudden ureteral block.
  Renal colic.
[ Sudden ureteral kink, as in floating kidney.
    Fenwick particularly insists  that glans pain after micturition does
 not necessarily point to stone.   The symptom can be evoked by dis-
 ease of any part of the urinary tract.
   The Relation  of Pain to the Act of Micturition.—Pain may be
 experienced before,  during, or at the completion of the act of mictu-
 rition.   The pain  may be felt in the bladder, urethra, deep perineum,
 and rectum, or in the regions already described as the seats of prefer-
 ence for reflexes.  It is  subject to variations.   It  may  be simply a
S%M ache, or  may be  burning,  shooting, darting, neuralgic, and
almost unbearable. 
558        GENITO-URINARY  DISEASES AND  SYPHILIS.

   Even though reflexes are  present, the  pain is usually located at
the seat of disease, and  is generally more  or less persistent, the act
of urination exaggerating it.
   Pain  preceding micturition is due to  a hyperaesthetic condition
of the vesical  mucosa or the prostatic urethra.   This hyperesthesia
may be caused  by various neuroses, by congestion,  or by inflamma-
tion,—the tension of the full bladder causing distress.  If the urine is
strongly  acid  or concentrated, as in cases of rheumatism, gout,  or
acute fevers,  even the  healthy  mucosa may be irritated, and  may
be the seat of burning or discomfort, relieved by emptying the bladder.
Exceptionally pain before urinating is a symptom of disease of the
kidney pelvis.
   Micturition pain is also occasioned by irritable or inflammatory
conditions  of the bladder or prostate, since the muscular contraction
required to expel urine necessarily disturbs the hypersensitive tissues.
Ulceration or inflammation of the vesical neck is particularly liable to
cause urination pain.   The sensation may  be aching,  burning,  or
shooting and darting, distinctly neuralgic in type.
   Pain  after urination, generally considered characteristic of stone,
may be  caused by any  inflammatory or ulcerative  condition of the
bladder-neck.  In many cases it is probably due to fissure or erosion,
and  is comparable to the pain felt after defecation  in cases of  anal
fissure.   The  probability that  this  is the  cause of the severe forms
of suffering is still further increased by the fact  that it is commonly
associated  with  tenesmus and  involuntary contraction of all the
perineal  muscles, and that it is relieved by  local applications.
   Aside from pain due to distinct lesions  of the urinary tract, there
is apparently  a  pure neurosis  characterized by continuous or inter-
mittent pain amounting sometimes to veritable  anguish felt in the
bladder,  suprapubic region, or perineum, by frequent urination,  and,
unless the desire  to  empty the  bladder is at once  gratified,  by in-
continence.  There is usually  nocturnal remission, the patient sleep-
ing soundly for  several hours.   The  symptoms  vary in intensity;
active pursuits, either of mind or of body, cause marked temporary
amelioration.
   Exploration  proves the urethra and bladder to be exquisitely sen-
sitive.   This condition is termed irritable or neuralgic bladder, and is
sometimes a symptom or prodrome of tabes.
   When pain at the end of urination is greatly increased by walking,
exercise, or jolting, and is relieved by rest in  bed and  by urination
in the dorsal decubitus, it is  probably due to  calculus or  foreign
body. 
INJURIES AND DISEASES OF THE BLADDER.
559
   The pain at the end of micturition caused by tubercular ulceration
at  the neck of the bladder, or exceptionally by cystitis, may also be
relieved by rest and be aggravated by motion, but  not to the same
extent as is observed in calculus.
   Frequency of Urination.—Most  men empty the bladder upon
rising in the morning,  during the after-breakfast defecation, at  noon,
in  the late  afternoon,  and before going to bed, passing from six to
twelve ounces of  urine at each act of micturition.   In warm  weather
urination is less frequent, the skin relieving the kidneys.
   The  bladder is said to be  irritable when  the desire  to urinate
comes too  frequently.   This irritability may be entirely  of psychic
origin,—as, for instance, the frequent micturition of the student sub-
ject  to examination,—or it may  be due to habit,  though,  unless the
frequency be  continued  through  the  night, this does  not  lessen the
absolute capacity  of the bladder.
   The  irritability may also be caused by reflexes from the  rectum,
the urethra, the prostate, the testicles, or the kidneys.
   It may be  due to increased  secretion on  the part of the kidneys,
as  in diabetes.  In this case the bladder  is  not, properly speaking,
irritable,  since  it  contains  urine  comfortably up  to its full  normal
capacity, but  has  to be  frequently emptied  because it is  so rapidly
filled.
   The frequency of quantity and of irritability are thus tabulated
by Fenwick:
Persistent
 excess.
Transient
 excess
 (usually
 diurnal).
  A.—The Frequency of Quantity.
(Much urine, which is passed often.)
High
  specific
  gravity.
Low
  specific
  gravity.
Low
  specific
  gravity,
  clear.
Sugar.

No  sugar,
  thirst.
but extreme
Albumen with casts, but
  without pus or resid-
  ual urine.
No  albumen,  but with
  residual urine.
  Diabetes mellitus.


j  Diabetes insipidus.
  Chronic Bright's disease,
    such  as  granular kid-
    ney, amyloid kidney of
    advanced scrofulous or
    syphilitic affections.
  Back renal  pressure from
    atony or  direct  renal
    irritation  of  prostatic
    origin.
(a) Sexual excess or debility (without inflammation).
  Dietetic idiosyncrasy,—tea, beer, etc.
(b) Hypochondriasis, hysteria, nervousness. 
560        GENITO-URINARY DISEASES  AND  SYPHILIS.
 B.— The Frequency of Irritability.
(Little water, which is passed often.)
1. Without
  obstruc-
  tion to
  the
  stream.
With ob-
struction
to the
stream.
The fre-
  quency
  of  inca-
  pacity.
The fre-
  quency
  of over-
  flow.
(a) With-
  out pus.

(b) With
  pus.

(c) With
  prostatic
  "threads"
  of pus.

Diurnal.

Nocturnal.

Diurnal
  and  noc-
  turnal.
Frequency
  at night
  nearly
  as pro-
  nounced
  as in day.
Age, 30-45.
Age, 45-70.
Blood, lithiasis, phosphaturia, oxaluria, dyspepsia.
Various irritants  in  renal  pelvis and ureter,—e.g.,
  stone, tubercle.  Movable  kidney.  Cystitis of all
  grades.  Catarrhal  or tubercular ulceration of the
  bladder.  Hard cancer.
Micturition reflex, excited by transient inflammation
  or congestion of the prostatic mucous membrane,—
  e.g., gout, catarrhal prostatitis, masturbation, pros-
  tatic tubercle, and stone.
Stone,  stricture, prostatitis,  muscular atony of low
  degree, vascular growths of female urethra.
Enlarged and  congested prostate without much resid-
  ual urine.

Enlarged prostate with  residual urine.  Cancer of
  prostate.
C.—Physical Irritability.
Non-inflammatory  con-
  ditions.
Inflammatory conditions.
Contraction due to habit.
Contraction due to obso-
  lete or advanced tuber-
  cle of the  bladder; to
  advanced   interstitial
  cystitis following gonor-
  rhoea, stone,  enlarged
  prostate, perimetritis.
Spinal atony (tabes), advanced stricture.
Advanced atony of prostatic enlargement.
    The treatment of frequent urination is founded on the  detection
and removal of the cause, and is given in the sections devoted to the
consideration of cystitis,  stone, stricture, cancer, etc.
    There is, however, one form of frequent urination which appar-
ently  is  purely  functional.  In  the  absence of urethral lesions or
pathological  conditions of the urine the  patient is  unable  to retain
his water more  than one or two  hours at a  time.  The  desire to
urinate, if not immediately gratified, becomes irresistible.   The blad-
der is completely emptied at each act of micturition.  There is usually
moderate polyuria.
    This  condition may be due  to  masturbation,  may follow  sexual
excess or prolonged  sexual  excitement, or may develop without ap- 
INJURIES AND DISEASES OF THE BLADDER.
561
preciable cause. It usually affects young unmarried men.  In the cases
we have observed from four to six ounces could be retained comfort-
ably ;  efforts to retain more than this caused great  distress.   In  one
case between seven  and eight  ounces of clear urine of low specific
gravity (1010) were passed every one and a half to  two hours during
the day.  The desire to urinate, if resisted, caused so much suffering
that the patient was  unable to attend dinners  or any form of social
entertainment which  would prevent  him from urinating the moment
he felt this inclination.  His sleep was uninterrupted, and if his blad-
der was emptied immediately on rising he experienced no distress,
usually passing from twelve to twenty ounces.
   In deciding that this  frequent micturition is purely functional  it
must  be remembered that a similar  bladder-irritability is sometimes
symptomatic of spinal sclerosis,  particularly  that  form  associated
with exaggerated reflexes: hence bladder-symptoms should  always
lead to an investigation  as to  the condition of the central nervous
system.
   A  bladder abnormally small from  congenital  formation, from
long-continued nocturnal and  diurnal  incontinence, or from cica-
tricial contraction, may cause a form  of frequent urination difficult to
distinguish  from  that which is purely functional.  The frequency, if
due to contracted bladder, will necessarily be both nocturnal  and
diurnal, and a test of the vesical  capacity by means of sterile injec-
tions will demonstrate the nature of the affection.  It must be remem-
bered that the frequency  of polyuria  is normal, hence the quantity of
urine  which the patient passes must be known.
   The treatment of this  purely functional frequency is at first  mainly
dietetic and hygienic.  Since the desire  is often not felt  when  the
mind  and body are actively engaged, riding the bicycle seems particu-
larly serviceable, both for its direct effect and for its general influence
on the health.  All causes of prostatic  congestion  or hyperaesthesia
must be removed.  Sexual excess, prolonged sexual excitement,  and
constipation are to be avoided  most carefully.  Daily cold enemata
of salt water  (a drachm to  the pint) are serviceable  as  means of
emptying the  lower  bowel.  Hemorrhoids should be  cured, a  re-
dundant foreskin removed, varicocele  relieved by a suspensory or
subjected to radical operation;  in fact, every possible cause of reflex
excitability should receive attention.
   The local  treatment has for i's object  the relief of hyperaesthesia
and congestion of  the  prostatic urethra.   This is  accomplished by
full-sized cold steel sounds, the direct application of electricity, instil-
lations, rectal  irrigations,  applications of heat  or  cold, and prostatic
                               36 
562        GENITO-URINARY  DISEASES AND SYPHILIS.

massage.   The details of these methods are given in the section de-
voted to the treatment of impotence.
   The medicinal treatment should be  confined in the main to con-
structives, tonics, and stimulants.  Potassium bromide theoretically
should be serviceable, since it lessens reflex excitability.  We have
generally  found it  useless.  Hyoscine and hyoscyamine in doses of
from one two-hundredth to one one-hundredth of a grain  thrice daily,
and belladonna suppositories, each containing one-third of a grain of
the extract, have given us better results than any of the  many drugs
commended.
   It should be  clearly recognized that this affection when it has been
of long standing is extremely obstinate to treatment, and that cure, if
it can be accomplished at all, is at the expense of months of patient,
not too officious, treatment.  Marriage, with its consequent regularity
of sexual  relations,  favorably affects, or even entirely cures,  this form
of frequent urination.
   Frequent  urination due to a bladder small from conformation or
because of prolonged  non-retention (habit frequency) is best  treated
by daily progressive dilatation, accomplished by means of a fountain
syringe, elevated three feet above  the bladder, and a short urethral
nozzle or soft rubber  catheter.  The urine  is passed, and  the blad-
der is then distended with warm sterile four per cent, boric acid solu-
tion  till further injection becomes unbearable  to  the  patient.  The
injected liquid is allowed to flow  out slowly, and  the distention is
repeated.   This  treatment is  repeated daily  or every second  day till
from eight to twelve ounces of urine can be retained comfortably.
   Hydraulic distention  is absolutely inadmissible when the bladder-
cavity is lessened because of tubercular involvement.
   Alterations in the Stream.—Urine driven by a healthy bladder
through a normal urethra should, unaided by abdominal  strain, flow
from the  meatus in a steady twisting stream, which, if it  be directed
horizontally forward, should fall from three to five feet away from the
vertical line of the body.   When the muscular walls of the bladder are
weakened, or when the  urethra is obstructed, this  stream  is neces-
sarily altered in volume, force, and direction.  Irregularity in mus-
cular  effort or sudden blockage of the urethra breaks the continuity
of the stream.
   A small, forked,  badly aimed, but forcible stream points to narrow-
ing at or near the meatus.
   A  forcible, large stream, suddenly and  for a time permanently
interrupted, points  to stone or other foreign body in the urethra; a
stream becoming  slowly smaller and  less forcible, and ultimately 
         INJURIES AND DISEASES OF  THE  BLADDER       5(53

dropping directly down from the end of the penis, points to enlarge-
ment of the prostate or to urethral stricture placed far back; it also
may  be  due  to  acute  congestion, chronic prostatitis,  atony  of  the
bladder, tumor-formation, or extra-urethral pressure.
   A stream which has become gradually  small and lacking in force,
and which is  suddenly arrested, may be due to congested stricture,
congested enlarged prostate, or impacted stone.
   A fairly forcible  stream  which is intermittently and irregularly
stopped  for a moment at a time—the so-called " stuttering urina-
tion"—is due  to vesical spasm, and is either a neurosis or a reflex.
   Suppression of urine  indicates either failure of the kidneys to
secrete or blocking of the ureters.   In either case uraemia ultimately
develops.
   Sudden ureteral  obstruction is accompanied by characteristic and
unmistakable  symptoms.  Failure to  pass urine and emptiness of the
bladder, as shown by bimanual palpation, will distinguish suppression
from retention.
   Retention of Urine.—Retention implies  inability to empty  the
bladder.  This may be  due to atony or paralysis of  the detrusor
muscles, to  reflex spasmodic  action  of the sphincters, or to obstruc-
tion at the neck of the bladder or in  the urethra.
   Locomotor ataxia, Pott's  disease, general palsies, sclerosis, and
severe cerebro-spinal injuries may, by interference with  the  vesical
centre of the  cord, occasion paralytic retention.  The  muscles may
be directly paralyzed by over-distention, by inflammation extending
from the mucous coat or from the peritoneal  investment, as in peri-
tonitis, or as the result of degeneration consequent  upon prolonged
exhausting diseases.
   Spasmodic retention may follow shock or injury, operations upon
the spermatic cord, the rectum, or the testicles, or prolonged  volun-
tary  retention.   Obstruction  at the vesical  orifice  may be  due to
tumor, impacted  stone, clot, foreign body,  or prostatic hypertrophy.
   Retention  may be of sudden or of gradual onset, and may  be
partial or complete.
   The retention of sudden onset is typified by that observed in cases
of rupture of the urethra, or of impacted stone, or of reflex spasm
following operations on the anus.   The symptoms in these cases are
so characteristic that a mistaken diagnosis is scarcely possible.  These
are pains felt  in  the  region of the bladder and steadily increasing in
intensity, recurrent unavailing efforts at micturition with a constant
torturing desire, extreme tenderness  over the  region of the bladder,
and the  formation of a distinct tumor, dull on percussion, globular 
564        GENITO-URINARY DISEASES AND  SYPHILIS.

in shape, and  sometimes extending as high as the umbilicus.  Rectal
and suprapubic palpation show that this tumor is fluctuating, and that
it occupies the position of the distended bladder.
   Gradual retention  may  develop  so insidiously  that  it  is  not
suspected until direct  examination shows  the presence of bladder-
distention.  Urethral stricture, lesions of  the cord,  intracystic and
extracystic bladder-growths  or inflammations,  enlargement  of  the
prostate, and atrophy of the  detrusor muscles are common causes of
this form of retention.   The early symptom is frequent micturition,
the stream passing with little force and often with  much diminished
volume.   This frequency is due to the fact  that the bladder is  unable
to empty itself entirely, a certain amount of residual urine remaining.
   Even when the vesical muscles are healthy, if the  flow of urine is
so obstructed  that the time  required to empty the  bladder is unduly
prolonged, the involuntary detrusor muscles,  becoming tired, relax
before the bladder  is  thoroughly empty, thus  allowing  a certain
amount of residual  urine.   This residual  urine is proportionate in
quantity to the  degree of obstruction encountered  in  the urethra
and to  the loss  of tone  of the bladder-muscles.  When sterile and
moderate in  amount the only symptom it  causes is increased fre-
quency of urination.  The reason for this  is obvious: if the bladder
cannot hold more  than ten ounces comfortably, and if, when it is full,
an unsuccessful effort is made to empty  it, five ounces remaining,
the desire to  urinate will again occur when five more ounces have
been  secreted by  the  kidneys, since the bladder will then contain
ten ounces.  Its capacity as  a receiver of  urine from the  kidneys is
lessened proportionately to the amount of residual urine it contains.
   When the retained  urine exceeds  four to six ounces, because of
the frequent urinations and the more or less sustained tension, there
develops a certain degree of chronic congestion of the bladder, which
is often markedly  increased by cystitis and fermentation of the stag-
nant urine.
   As the obstruction gradually increases, and as the muscles become
atonic or atrophic  from congestion, inflammation, and overstretching,
the bladder is more and more  dilated, until, finally, it may  reach
enormous proportions.   When this gradual retention occurs in the
course of fevers,—typhoid, for instance,—it is probably due  to  de-
generation of the  detrusor muscles and to  abolition  of the normal
reflex.  The  bladder  may  then  slowly distend, giving  rise  to no
symptoms  other than apparent incontinence,  the  sphincter muscle
yielding when the intravesical tension becomes sufficiently high and
allowing the urine to trickle slowly away.  The same gradual  unsus- 
INJURIES AND DISEASES OF THE BLADDER.
565
pected distention develops in chronic prostatic overgrowth, the symp-
toms suggesting incontinence  rather  than retention, and the true
condition not being suspected till inspection  or palpation shows a
hypogastric tumor.   The appearance of this tumor is seen in Fig. 163.

                             Fig. 163.
Tumor formed by the distended bladder.  Gradual distention from hypertrophied prostate.
The patient  from whom this photograph  was taken  complained of
urinary incontinence, and was brought by  his physician  because of a
supposed solid growth in the hypogastric region.  Bimanual palpation
at once proved that this mass was the distended bladder.
   When associated with fevers, and, indeed, under all circumstances,
incontinence of urine should lead to careful examination for an over-
distended bladder.
   When the bladder is able to empty itself partially, the retention is
incomplete.  When no urine can be passed, it is complete.  In either
case there results an abnormal  intravesical tension, intermittent when
the function of micturition is not  entirely suppressed, continuous and
steadily increasing in  case of complete retention.
   The Effects of  Retention.—Guyon and  Albarran  have shown
experimentally that even a moderate amount of retention causes dis-
tinct vesical congestion, followed, if the retention  is not relieved, by
ecchymoses, bloody extravasation, involving the  whole  thickness of
the bladder-walls, and pronounced epithelial  desquamation.   The
ureters and the kidney pelves  and  tubules show the  same changes,
—i.e., intense congestion and parenchymatous ecchymoses and epi- 
GENITO-URINARY  DISEASES AND SYPHILIS.
thelial degeneration and  shedding.  The  peritoneum  overlying the
bladder is often  congested and  ecchymotic, and the intestines and
abdominal viscera participate in the general vascular  engorgement.
Ultimately the bladder ruptures into the peritoneal cavity.
   As a result of over-distention the detrusor muscles of the bladder
are paralyzed, remaining absolutely flaccid, even though the urine be
drawn.   The  desquamation of the stratified  pavement epithelium,
which when normal and  unbroken prevents  absorption  from the
bladder, exposes the lymph- and blood-channels, thus allowing toxic
substances and micro-organisms contained in the urine to poison the
system.  When the vesical tension is  very pronounced, the down-
ward current of urine passing from the kidneys to the bladder ceases,
and, if there is concomitant infection, this  will rapidly reach the kid-
ney pelvis  by way of the ureter, though reversed peristalsis or back-
ward regurgitation as the  result  of  vesical tension has  not  been
shown experimentally.  Ultimately the sphincter  muscle at the vesi-
cal orifice  of the  ureter becomes insufficient, since even inert bodies,
such  as powdered charcoal, will, if injected into the bladder, ascend
in small quantities into the kidney pelves.
   There is, however, not a free mingling  of the ureteral and vesical
urines ; chemical examination usually shows distinctly less urea in the
former than in the latter.   Death results from uraemia; very excep-
tionally in men from rupture.   The temperature in the absence of
infection is normal or subnormal.  The extent and severity of the
lesions just described are dependent on the degree of vesical disten-
tion, and this in turn is proportionate to the duration of the complete
retention.  It  is  not  till acute  retention  has  lasted for more  than
twenty-four hours that dilatation of the ureters, of the renal  calices,
and of the canaliculi will be inaugurated.
   As a result of experimental  research  and clinical study, the im-
mediate effects of extreme acute distention of the bladder may be
summarized as follows.  The bladder,  prostate, ureters, and kidneys
are enormously congested.  The muscles  of the bladder become in-
sufficient, and  their  fasciculi are  often mechanically separated by
the distention, producing the ribbed or trabeculated bladder.  The
kidneys, at first excited  to  increased activity, as pressure increases
secrete  slowly or not at all.   The whole urinary tract is ripe for
infection, and absorption from this tract takes place readily.
   If micro-organisms  are  introduced into the bladder they very
rapidly produce cystitis  and quickly reach the kidneys.  The intro-
duction of similar organisms into the healthy bladder is without evil
effect, since the flat epithelium prevents their entrance into the tis- 
INJURIES  AND DISEASES OF THE BLADDER.
567
Fig. KJ4.
 sues, and the intermittent stream  of  water from the ureters keeps
 them from ascending along these channels.
    Chronic retention produces pathological alterations which are less
 immediately  threatening than those of acute  retention.   There  is
 chronic congestion of the  entire urinary apparatus, with pronounced
 susceptibility to infection.   When the retention is  moderate and in-
 complete  these  changes are limited solely to the bladder,  since the
 ureters  and  kidneys  are
 reached  only when vesical
 tension has been extreme.
    The first effect of  in-
 creased vesical  tension  on
 the  kidneys is  the marked
 increase  in secretion,  the
 latter due  possibly in part
 to bladder reflex, probably
 in the  main to  congestion.
 Later  the  urine is  dimin-
 ished in  quantity.  Excep-
 tionally, after relief of ten-
 sion, anuria develops; more
 frequently  there  is  pro-
 nounced  polyuria.
    The fever, if it develops,
 is nearly ahvays  due to con-
 comitant infection, and  not
 to  retention  itself.   The
 temperature is  normal  or
 subnormal in  both  acute
 and chronic retention.
   Although the immediate
 effects  of chronic retention,
 the use of the term chronic
 necessarily  implying  that
 the retention is incomplete,
 are less serious than those of acute  retention, the ultimate results are
 equally disastrous, the bladder dilating and losing  tonicity, and the
 ureters, kidney pelves, and kidneys becoming involved.
   The bladder muscle  may be completely and  permanently  para-
 lyzed, or, where the retention  is  partial,  particularly  in  case of
stricture,  it may  be greatly  hypertrophied.   This hypertrophy is
none the  less followed by dilatation of the  ureters  and their  pelves
Hypertrophied bladder from urethral stricture.
       tion of ureters and kidney pelves.
Dilata- 
568        GENITO-URINARY DISEASES  AND SYPHILIS.

and  profound  alterations in the  structure  of the  kidneys.  (Fig.
164.)
   The general treatment of acute and of chronic retention calls  for
relief of tension as soon as possible, and the observance of rigorous
antiseptic precautions in the use of the catheter.   Sudden evacuation
of the bladder in cases of chronic  retention often  occasions bleeding
not only from the  bladder, but also from  the kidneys and into the
substance of these organs. This is less liable to occur when the urine
of acute retention  is drawn.   It is due  to the  rapid  diminution of
pressure to which the engorged vessels have long  become accustomed.
The renal congestion is often evinced by blood-casts.
   After the first partial or complete evacuation there may be such
marked relief of congestion that the power  of micturition is restored.
Usually catheterization must  be continued for  some  time.   When
there is polyuria—and this is  frequently the case—it is important to
catheterize the bladder frequently.  This manipulation may have to
be repeated every two hours.   The intervals should be such that not
more than eight to twelve ounces shall accumulate before being drawn.
   From an etiological stand-point retention of urine may be classified
as follows;
   1. Retention  due  to  paresis  or incoordination of the bladder
muscles.
   2. Retention from congestion or acute inflammation.
   3. Retention due to blocking of the urethra by clots, foreign body,
stone, or portions of new growth.
   4. Retention caused by prostatic enlargement.
   5. Retention caused by stricture.
   6. Retention due to traumatism.
   1. Retention of Urine due to  Paresis  or  Incoordination of the
Bladder Muscles.—Under this  heading  are  classed  those  cases in
which narrowing or pathological  alteration  of the channel of exit  for
the urine plays no part.   There is no preceding history suggesting
urethral stricture or prostatic  enlargement.  The cause of retention is
either failure of detrusor power or loss of control over the sphincters,
these not relaxing as they normally should when  the detrusors con-
tract.  This form of retention is common in cerebral injury, in hemi-
plegia, in paraplegia, in spinal injury or disease, in  Pott's  disease, and
in spinal ataxias.   In ataxic cases the retention may be from sensory
failure, the patient not perceiving when the bladder is full; a catheter
must  then be used  not according to a feeling of vesical repletion, but
at certain definite times.
   The retention sometimes  observed in shock, hysteria, peritonitis, 
INJURIES  AND DISEASES OF THE BLADDER.
569
 paravesical inflammation, exhausting  diseases, neurasthenia, and vol-
 untary postponement of the act of micturition may be partly spas-
 modic, but is probably due in the main to muscular atony and dis-
 ordered reflex action.  Retention following operations about the anus
 or  complicating a full rectum is  usually spasmodic,  the sphincter
 being excited to undue irritability not only by the nervous reflex, but
 also by the vascular engorgement consequent on these operations.
    Symptoms.—Retention, whatever be its cause, is characterized by
 the same symptom,—i.e., the formation of a fluctuating tumor in the
 bladder region.   In cases of paraplegia or abolition of sensibility the
 pain and frequent efforts at urination are wanting.  Under other cir-
 cumstances, if the retention has been of sudden  onset, the distress it
 occasions  is characteristic  and  unmistakable.  Since the urethra is
 patulous, there develops, usually before there is much back pressure
 exerted in the  direction of the  kidneys, a dribbling of urine, the in-
 continence of retention, which  is  misleading.  A  patient who com-
 plains of incontinence should always  be examined for retention.
    Diagnosis.—The  probable absence of urethral or prostatic ob-
 struction will be founded on the patient's previous history, or, if this
 is unobtainable, urethral exploration will show that the way to the
 bladder is  unobstructed.   Spasm  of the compressor  urethrae may
 be misleading, but this yields completely to the gentle steady pressure
 of a steel sound.
    When retention  develops without apparent  cause in a person
 who gives  no previous  history  of  urethral or bladder trouble, the
 neuropathies must be suspected, and search should be made for cor-
 roborative signs of ataxia.
    Treatment.—Retention which is a local expression of hysteria or
 neurasthenia is  usually  relieved  promptly by a  hot-water enema
 (103° F.), followed by a hot sitz-bath  or general bath.   The patient is
 directed to pass the injection while still in the bath, and usually will
 urinate without  difficulty  during the act of defecation.  This treat-
 ment is efficient in retention  from constipation,  anal operations, in-
 flammation,  shock, or prolonged voluntary retention.
   In case neither the  hot bath nor  the enema is applicable, a sup-
 pository may be  given containing a quarter of a  grain of belladonna
 and half a grain of the watery  extract of opium.  By the mouth may
 be administered a drop of tincture of ferric chloride every five minutes,
 or sweet spirit  of nitre, half a  teaspoonful in half a glass of water
 every fifteen minutes.
   These medicinal measures are, however,  dangerous,  since they
waste time and, except with hysterical patients, are unavailing. When 
570        GENITO-URINARY  DISEASES AND SYPHILIS.

the hot enema and bath fail, or if these cannot be applied, catheter-
ization is indicated.  This must be practised with  precisely the same
care as would be exercised by the surgeon were he about to perform
a major operation, since it has been shown that, from the intense con-
gestion which always accompanies retention, the bladder is peculiarly
vulnerable to sepsis and the kidneys are ripe for an ascending infec-
tion.
   The surgeon, having prepared his hands, and  having provided a
sterile instrument and sterile  lubricant, has the urethra flushed out
with a dilute antiseptic solution flowing from the short urethral nozzle
under a pressure of about two feet, and the penis and glans thoroughly
cleansed by soap and water, alcohol, and corrosive sublimate solution,
and drawn through a slit in the centre of a sterile towel.  The evacu-
ating instrument, preferably a  soft rubber catheter, about No. 16  F.,
is then lubricated, introduced as far as the membranous urethra, and
attached to an irrigating bag containing a hot dilute antiseptic solution
(1  to 20,000 bichloride).  A half-pint  of  this  solution is allowed to
flow through the catheter, thoroughly irrigating the anterior urethra:
the irrigating bag is then disconnected, and the catheter is passed into
the bladder.
   In acute retention, if moderate in  degree  and associated with
previously healthy urinary organs, there is little danger  in emptying
the  bladder completely.   When  retention has been chronic and
progressive, and particularly when there is also infection, the sudden
emptying of the bladder is liable to be followed  by severe hemor-
rhage, which, involving the kidneys and their pelves, may result in
partial or complete suppression of urine and may prove fatal.   When
retention is due to central  nervous lesion, as in Pott's disease or in
ataxia, or to muscular degeneration, as in typhoid fever or in arterio-
sclerosis, regular, frequent aseptic catheterization is indicated.
   As a means of lessening pelvic congestion, and  hence  making
the bladder less vulnerable, the bowels must be opened  regularly by
enemata.   The  catheterization must be practised  as  frequently as is
required to prevent abnormal vesical tension.  Since retention during
its early stages,  and always  after it is relieved,  occasions polyuria, the
instrument may have to be passed four to six times in the twenty-four
hours.  If at any time more than  twelve ounces are drawn, this indi-
cates that the intervals between instrumentation are too long.   Prac-
tised with due attention to cleanliness, these catheterizations prevent
cystitis, since they relieve the venous engorgement, which is the most
potent predisposing factor to infection.
   In all these  cases  urinary antiseptics  should be administered by 
INJURIES AND DISEASES OF THE BLADDER.
571
the mouth, and  careful attention  should be given to the diet and to
general hygiene.
   2.  Retention of Urine from Congestion or Acute Inflammation.—
When, as the result  of  a  severe  gonorrhoea, an irritating injection,
rough sounding, or  a prostatic abscess, retention develops, this is
due in the main to  blocking of the urethra  or vesical  neck by vas-
cular engorgement and inflammatory swelling, though spasm reflexly
excited plays an important  part  in making  the retention complete.
The detrusors, till paralyzed by overstretching, are  healthy  and act
vigorously,  but cannot  overcome  the  obstruction  offered  by  the
sphincters plus the temporarily obstructed urethra.  In certainly the
vast majority of cases neither spasm nor acute  urethritis  is com-
petent to cause complete retention.  When this develops  there is
usually a pre-existing lesion,  such as  stricture of  large calibre, or
moderate prostatic enlargement,  not  sufficiently  obstructive in  the
absence of acute inflammation  to cause even partial retention.
   Symptoms.—Aside  from the characteristic symptoms of retention,
the determination of the cause of this condition will depend in  the
main upon the preceding history.   If symptoms of enlarged  prostate
or of long-standing gleet are absent, and if in the  course of an acute
gonorrhoea,  for instance, retention develops, the cause of this  must be
looked for either in  the  urethra—usually in  its membranous part—
or in the prostate.   Before exploring the urethra the prostate should
be palpated  per rectum; if this is normal in size and non-sensitive,
urethral inflammation and spasm may be suspected as the cause of
retention.   In this case  the  hot bath  and  hot enema are indicated,
since instrumentation  should be avoided because of the danger of in-
fecting the bladder.   If these measures, reinforced  by opium supposi-
tories  or morphine injections, prove useless, a silver  catheter should
be passed, since the urethral spasm is usually so tight that it effectively
resists the soft  instrument.  This instrument causes such agonizing
pain that it is well to administer  ether to the first stage each time it
is used.   It  should be preceded by urethral irrigation, and should be
withdrawn while an antiseptic  solution is flowing through it.
   When the  prostate felt  through the  rectum  is  large, hot, and
tender, recourse may  be had to hot baths, enemas, and  opium,  but
there is little hope of relieving vesical tension by these means unless
the swelling is  purely congestive.  In  that  case  it should  subside
promptly under treatment, and palliative  measures should be efficient.
Should they fail, the  catheter must be used without delay, not only
for immediate  relief,  but also because by  regularly emptying  the
bladder this viscus is  less  likely to become infected.  The prostatic 
572        GENITO-URINARY DISEASES AND SYPHILIS.

abscess should  be  opened  as soon  as it is  detected, preferably
through the perineum.
   3. Retention of Urine from Sudden Blocking of the Urethra or
the Vesical Neck.—This form of retention  may be due to the lodge-
ment of a  stone  or foreign body in the urethra, to a pedunculated
bladder-tumor situated near  the neck of the  bladder and acting as a
ball-valve, or to blood-clots sufficiently firm to plug the vesical orifice.
   Urethral calculi and foreign bodies have  been considered in an-
other part of this work.
   Blood-clots rarely cause  retention when the  urethra  is unob-
structed.  They  are  liable to  cause  intermittent blocking of the
urethra, but are ultimately expelled.   In  cases of prostatic hyper-
trophy or  stricture, clots  may cause absolute  retention  and  may
seriously interfere with catheterization.
   Symptoms.—Retention of urine from vesical clots will give no char-
acteristic symptoms other  than those of sudden  retention.  Bloody
urine containing  small clots may have been passed before the reten-
tion develops.  There is a history of  previous hemorrhage, or there
is a sufficient  cause, such as traumatism, for  extravasation of blood.
The catheter enters the bladder readily, and, even though it is almost
immediately blocked by a clot, draws some  bloody urine ; suction by
a syringe draws out fragments of clot and allows the urine to flow.
   When the retention is  due  to  a  pedunculated tumor or a small
movable calculus, the symptoms may  be precisely the same as those
which characterize retention from  clot,  since there are  likely to be
haematuria and sudden stoppage of the stream of urine.   If, however,
the catheter is passed well  within the  bladder, its eye is  not blocked,
the urine flowing freely.
   Diagnosis.—In deciding whether retention is due to blood-clot,
small, movable kidney, stone,  or pedunculated tumor, the history of
the case and the course of the  symptoms will usually lead to a cor-
rect  opinion.  Thus,  stone is  preceded by  renal  colic, by frequency
of urination, and by pain felt just  behind the meatus at the end of
the act. When it is displaced from the neck  of the bladder by a metal
catheter a  characteristic grating may  be felt.  The  urine  which is
drawn contains but little blood.
   A pedunculated vesical tumor  may  cause an obstruction which
readily yields  to the catheter  and which bleeds freely.  The nature
of the obstruction would  be open  to suspicion  if, in  the absence of
symptoms  of stone, the patient complained of occasional apparently
causeless profuse  haematuria; if on the relief of retention no  clots
were  drawn, the  urine flowing freely as soon  as the eye  of the cath- 
INJURIES  AND DISEASES  OF THE BLADDER.
573
eter reached the bladder;  and if  urination in the dorsal decubitus
prevented the stoppage of the stream.  Finally, cystoscopic examina-
tion should definitely settle  the matter.
   Treatment.—Retention from blood-clot does not  necessarily call
for immediate catheterization, since,  provided there is no  urethral
obstruction, as the clot softens and disintegrates it is passed sponta-
neously; indeed, it is more likely to escape through the natural pas-
sage  than  through a  medium-sized catheter.  A  hot  bath and  an
opium suppository or  a morphine  injection to relieve the associated
spasm of the sphincters, and efforts at urination  made with the pa-
tient in the  dorsal decubitus and  with the pelvis elevated, usually
result in relief.
   Should these measures fail, the patient is placed on his back with
the pelvis elevated, and a large woven catheter is passed till its eye is
 just  within  the  internal vesical sphincter.   This decubitus  favors
gravitation of the clots to the upper posterior  portion of the bladder,
where they are less likely to block  the catheter before the main bulk
of the urine has been  drawn off.
   When the catheter becomes obstructed from lodgement of a clot in
its eye, a drachm of dilute antiseptic solution should be  injected forci-
bly.  If after several repetitions  of this manoeuvre it is apparent that
the catheter cannot be kept clear  long enough to allow the urine to
flow in sufficient quantity to relieve tension, an eight-ounce hard
rubber syringe, with  a  piston which  fits accurately, should be  at-
tached to the end of the catheter and the  clots should be sucked out.
Should this  method fail, a large evacuating  litholapaxy-tube should
be passed, and through it the blood should be  aspirated.
   If because of a large prostate the evacuating tube cannot be passed,
either perineal or suprapubic cystotomy  is indicated, in  accordance
with the cause of the bleeding.   In any event  the  retention must be
relieved and the bladder freed of  clots, since the presence of blood
in the urine markedly favors the development of cystitis.  Emptying
the bladder is the most  efficient means of stopping further bleeding
if this is of cystic origin.
   Retention due to a pedunculated cystic tumor  can be  relieved by
catheterization, the instrument pushing aside the growth and prevent-
ing it from acting as a plug.  The  same treatment is appropriate  to
calculus lodged in the  vesical neck.

     RETENTION  OF URINE FROM FROSTATIC ENLARGEMENT.
   Of all forms of urinary  retention that  due  to hypertrophied pros-
tate is  the most frequent.   This  complication   of  hypertrophy  is 
574        GENITO-URINARY DISEASES  AND SYPHILIS.
infinitely more serious than the  disease which causes it.  It is due
to the in-creased  resistance to the escape of urine offered  by altera-
tions  of the bladder-neck,  elongation and deflection  of  the  pros-
tatic urethra, and diminution in the calibre of the latter.   The walls
of the vesical orifice are thickened, and the opening is raised above the
level of the bas-fond, thus leaving a pouch.   The overgrowth may in-
volve one or all of the prostatic lobes; usually the entire prostate  is
enlarged.   (Fig. 165.)  From overgrowth of the middle lobe more or
Hypertrophy of the lateral and median lobes of the prostate.  (Watson.)
less  of a projection is formed at the vesical orifice.  The  enlarged
lateral lobes narrow the urethra and force it to one side or the other,
in accordance with the position of greatest overgrowth.  (Fig. 166.)  As
a result of  this obstruction the bladder-muscles become weakened,
at least so far as their propulsive power is concerned.  There is 
Fig. 166.
/\
y **
*#t
A

'4 .**
*,*
*%^-
✓>•*
F^J
V#
Mf*
r*fci»c

?a%*£
*W
'i*'
fc^l

v ,j' / »
Hypertrophy of the lateral lobes of the prostate. (Watson.) 
 
INJURIES  AND DISEASES  OF THE  BLADDER.
575
always very  marked hypertrophy of individual  fibres or  fasciculi,
forming prominent ridges.   The general symmetrical hypertrophy so
frequently observed  in  partial retention following stricture is  rarely
found when  obstruction  is  due  to  prostatic hypertrophy.   Vesical
inertia is also encouraged  by muscular  degeneration incident to
atheroma, which so often  complicates enlarged prostate, cystitis, pro-
longed venous congestion, and over-distention.
   As a result of overgrowth the prostatic  urethra may be double
or even  triple its normal length.  The vesical orifice  and prostatic
urethra are encroached upon at the expense  of the lower and lateral
walls.   The  superior wall preserves its normal direction.   This fact
is important as  bearing upon the  proper use of  catheters  for the
relief of retention.
   The  prostate may be  tough and fibrous,  presenting an  obstacle
which will yield only to rigid instruments,  or  may be so friable that it
is bruised and lacerated by even soft  rubber catheters or exploring
bougies.   Its dimensions as felt  by the  rectum  do not  necessarily
indicate  the degree of urethral obstruction it  occasions.
   Symptoms.—During the earliest stages of prostatic enlargement no
symptoms are  excited  upon the part of the  bladder;  as the  growth
increases, elevating the internal vesical orifice, there is partial reten-
tion, a certain amount of residual urine remaining after each micturi-
tion. This, if it is sterile and does not  exceed four to six ounces,
causes no  symptoms other  than a  slight increase  in  frequency of
urination and a habit of rising once in the  early morning  hours to
empty the bladder.
   As the obstruction becomes  more pronounced, residual urine in-
creases in amount, the  desire to  urinate comes more frequently and
is more  imperative,  especially at night, there is  usually slowness in
starting  the  stream,  and  this is projected with less force.   Finally,
there is  distinct vesical atony, the walls of the bladder yield  to the
slowly increasing tension, and  that  viscus becomes greatly dilated,
sometimes extending above  the umbilicus.   This dilatation involves
the  ureters  and the  kidney pelves.  The secreting  portion of the
kidney becomes insufficient, a  condition  of  uraemia develops, char-
acterized by  gastro-intestinal disorders and  steady deterioration in
health, and  death ensues.   When the  bladder reaches an  extreme
degree of distention there is a constant dribbling of urine.  It should be
noted that this train  of  pathological changes may be evolved without
the patient having the faintest conception  that there is a condition of
vesical tension, the symptoms of which he complains  being simply
frequent micturition, especially  aggravated at night, often attributed 
GENITO-URINARY  DISEASES AND SYPHILIS.
to polyuria, and  ultimately followed by incontinence of urine, diffi-
culty in  starting the stream and  loss in  its force, and apparently
causeless  digestive troubles.  Should cystitis intervene, the vesical
symptoms become so marked that they will scarcely be overlooked.
There are then pain, tenesmus, and all the  phenomena of bladder-
inflammation aggravated by the retention.
   If,  in  the  course of chronic  incomplete  retention,  the enlarged
prostate  becomes suddenly  congested from infection, exposure, sex-
ual excesses, indiscretion in diet, or other sufficient cause, there will
result  acute retention,  characterized by  restlessness,  pain  in the
bladder, and futile efforts at micturition.  This acute retention is often
not complete, the patient being able to pass a portion of his water, but
only after violent straining.
   Diagnosis.—Retention due to prostatic enlargement is observed in
men past middle age.   There is a history of frequent urination, be-
ginning with night rising and slowly becoming more marked.  Until
an extreme degree  of  tension is  reached, this frequency is  always
most marked in the night  or early morning.  Rectal examination
shows an  enlarged  prostate, and  rectal and suprapubic  palpation
demonstrate a full bladder.  On  passing  the catheter the urethra is
found to be abnormally long.  To measure the urethral length, the
catheter is introduced till  the water begins to flow; its shaft is then
pinched with the thumb at  the point corresponding  to the meatus.
The  urethral length  is  determined by withdrawing  the catheter and
measuring the distance  from  the thumb to the eye of the instrument.
Normally this should be about eight inches.  Finally, the pathogno-
monic symptom of acute retention is failure to pass  water from a full
bladder.
   Partial retention, if  moderate  in degree and unaccompanied by
cystitis, occasions little or no pain.
   The previous history, the prostatic enlargement, recognition of the
full bladder by bimanual palpation, the increased urethral length, and
the withdrawal by catheter of residual urine immediately after mictu-
rition are  sufficiently diagnostic of this form of retention, ordinarily
due to acute congestion of an overgrown prostate.
   Partial retention with great  tension,  characterized by constant
dribbling, can  be determined by the most  superficial palpation or
inspection.
   Treatment.—Complete retention from prostatic enlargement always
requires prompt mechanical or surgical intervention.  The time spent
in palliative measures is wasted, and may give an opportunity for the
development of irremediable lesions.  With very few exceptions, it is 
INJURIES AND DISEASES OF  THE BLADDER.
577
Fig. 167.
possible to pass an instrument into the bladder.  The surgeon should
be provided with soft  rubber  catheters, each  having a large sunken
eye and a solid end (Fig. 167), flexible
woven olivary (Fig.  168)  or  conical
catheters (Fig. 169), elbowed catheters
(Fig. 170),  double-elbowed catheters
(Fig. 171), stiff English cylindrical cath-
eters (Fig. 172), and  one or two long
full-curved  silver prostatic catheters
(Fig. 173), calibre 18 to 20 F., twelve
inches in length, and with  an unusu-
ally long curve.  The  calibre of the
soft instruments should be  from  14 to
18 F.  A glass  irrigating  apparatus,
provided with  a conical glass nozzle
which can be fitted into the  ends of the
catheters, a sterile lubricant, and  a sufficient number of sterile towels,
also must be provided.
                              Fig. 168.
Soft rubber catheter.
Olivary catheter.

   Fig. 169.


Conical catheter.

   Fig. 170.



Elbowed catheter.

   Fig. 171.

Double-elbowed catheter.

     Fig. 172.
                          Cylindrical catheter.

   If the history of a case suggests the possibility of stricture compli-
cating enlarged prostate, the  soft, flexible, bulbous, or olivary bougies
will be  required.   A preliminary  rectal  examination having been
made, the urethra thoroughly flushed out, and  the penis and glans
                                37 
578        GENITO-URINARY  DISEASES AND  SYPHILIS.

cleansed as for an operation, a slit is cut in a sterile towel, and through
this  the  penis is slipped; thus the manipulative area is surrounded

                              Fig.  173.
                         Silver prostatic catheter.

by a sterile surface.  The surgeon, having sterilized his hands, lubri-
cates a boiled or  otherwise  sterilized soft  catheter of medium size,
passes it to the compressor urethrae muscle, attaches  its  free end to
the irrigator, and washes out the anterior urethra ; he then endeavors
to pass  the instrument  into the  bladder.   When gently repeated
efforts,  continued for one or two minutes  at  most, fail, the  rubber
catheter should be attached to the irrigator, and should be withdrawn
while a dilute antiseptic solution (four per cent, boric acid) is flowing
through it.   An elbowed catheter {coude) is then tried.  The slight
angle at the end of this instrument is of service, partly because it
enables it readily to override obstacles, and  partly from the fact that
the bend keeps the extremity of the instrument applied to the upper
urethral wall.  It will be remembered that  the obstruction is found
mainly in the lower and lateral walls of the urethra,  the upper por-
tion remaining  comparatively normal.  Hence, if the  end of the in-
strument is kept constantly in close contact with this normal surface,
it  can be readily guided into the bladder.  The tip of the elbowed
catheter must, therefore, be kept against the urethral roof.
   Should the elbowed catheter fail to gain an entrance, the  double
elbowed or bi-coude catheter may be tried.
   In the event of this failing, a soft rubber catheter of small calibre,
No. 10 to No. 12 F., is  slipped on  one of the  iron wire stylets with
which English  catheters are provided.  The extremity of this stylet
stops one inch short of the eye of the catheter.  To the soft  rubber
catheter, thus made rigid but with a perfectly flexible end, a long curve
is given by bending the wire.   This corresponds in general with that
of the prostatic silver catheter.   This long curve keeps the tip of the
instrument  apposed to the urethral  roof  and thus guides it into the
bladder.   The rigidity imparted by the stylet enables enough pressure
to  be applied to overcome any  resistance  offered by the close appo-
sition of tough fibrous walls, and the flexible end readily finds its way
 
INJURIES AND DISEASES OF THE BLADDER.
579
 over or around abrupt projections.  All these manipulations must be
 conducted with  the utmost gentleness, yet the most skilful manipu-
 lation will occasion bleeding because of the intense congestion which
 always accompanies retention.
   Should the soft  catheter threaded on the stylet fail to pass, the
 long prostatic silver catheter may be used.  In passing the catheter it
 must be  borne in mind that the urethra  is always lengthened, some-
 times two or three inches, and  that the bladder may not be reached
 because of failure on the part of the surgeon to pass his instrument
 far enough.   Sometimes  a  long flexible  rubber or whalebone guide
 can be made  to pass the obstruction, and a tunnelled catheter can be
 passed over it, as  in cases of stricture, although this  procedure is not
 so uniformly  useful in  cases  of prostatic retention.   Should  gentle
 efforts with all these instruments, continued  not  more than  two or
 three minutes for each, result in failure  to reach the bladder, supra-
 pubic aspiration is indicated.
   A method of treatment attended with more  immediate risk than
 aspiration, but which has given  satisfactory results where there is  no
 hope of relief by catheterization, is suprapubic puncture by means of
 a curved  trocar and canula.
   In cases of retention from  prostatic  enlargement uncomplicated
 by infection, and particularly when there  have been no previous futile
 attempts  at instrumentation, the soft rubber  catheter or the flexible
 woven elbowed catheter usually enters the bladder without difficulty.
 When this end  is accomplished the surgeon's serious responsibility
 practically begins.  If as a result of long-standing vesical tension there
 has been  dilatation of the ureters or of the kidney pelves, with marked
 alterations in  the kidney structure, and particularly if there has been
 previous infection, or if this is carried in by instrumentation, sudden
 evacuation of urine may be  followed  by suppression, uraemia, and
 death, occurring  in  either a few  days or a few weeks.  When the
 kidneys are comparatively healthy, sudden complete evacuation  of
 the bladder-contents, by interfering with the conditions of pressure
 to  which  the  blood-vessels  have become accustomed, may occasion
 severe hemorrhage not only in the bladder but in the kidneys them-
 selves.  This,  even when slight in degree, by favoring the develop-
 ment of  cystitis, may constitute a grave  complication.   If profuse it
 becomes serious, not only  because of its  systemic  effect,  but also
 because by clotting and obstructing the catheter it interferes with the
 flow of the urine.   To avoid bleeding the urine should be drawn off
slowly, with the patient in a recumbent position.  Except when  the
distention is slight and of short duration, the bladder should  never 
GENITO-URINARY  DISEASES AND SYPHILIS.
be completely emptied at the time of the first catheterization.   When
the urine is clear and sterile, about half the bladder-contents should
be allowed to remain.   When there is blood or pus in  the urine, all
of this should be drawn from the bladder, but without  allowing this
viscus to be entirely empty at any time.  This end  is attained in the
following way : Before passing the catheter the bladder is palpated, to
enable the surgeon roughly to determine the amount of tension.   The
catheter is introduced  and somewhat more  than half  the  retained
urine is drawn.   This may be two to  three pints.   Eight to twelve
ounces of a warm sterile four per cent, solution of boric acid are then
injected into the bladder by means of the irrigator, and immediately the
same quantity of mixed boric acid solution and urine is allowed to
escape.   This partial filling and emptying of the bladder is continued
till the  blood and pus disappear and the liquid evacuated has the
colorless appearance of the boric acid solution.  The catheter is then
slowly withdrawn, with the boric acid solution still flowing through it.
    The immediate dangers of tension having been thus removed, the
subsequent treatment of the  bladder must be clearly formulated.
    The invariable rule  of treatment in these cases should be regular
evacuation of the bladder, the number of catheterizations required
daily being regulated by the  activity of the kidneys.  Four to  eight
times in twenty-four hours are usually sufficient.  Each time enough
urine is withdrawn to lessen distinctly the residual amount.   This
residuum is then replaced  by boric acid.   By the end of a week the
bladder can usually be  completely emptied without  fear  of ill results.
    Even after the bladder begins to recover its tone and the patient
regains  some power of passing  his water, he  should be cautioned
against  throwing aside  his catheter so long as his efforts at micturi-
tion are painful and are attended with much straining and with a
feeble and insufficient flow of urine.  Continuance of catheterization is
particularly to be insisted on when there is cystitis,  since the abortive
straining efforts  at urination markedly increase local congestion.
    If the urine  has  remained sterile, and  if the patient  has regained
the power of passing the greater part of his water with comparatively
little effort, it is then safe to discard  the  catheter, since a moderate
quantity of sterile residual urine is hurtful only so far  as  it lessens
bladder-capacity.
    When the passage  of a soft instrument is  difficult, is extremely
painful, and is attended with much bleeding, and this is particularly
the  case when  there  have been previous unsuccessful attempts at
catheterization,  and when there  is cystitis with purulent, often am-
moniacal, urine, the objects  for which the instrument  is used—i.e., 
INJURIES AND DISEASES OF THE BLADDER.
581
efficient bladder-drainage and  relief of local  congestion—cannot be
attained, since frequent passage of the instrument is impracticable.
Under these circumstances continuous catheterization is  serviceable.
When retention is  complicated by fever, continuous catheterization
finds its most useful application.  (Guyon.)
   Guyon and Michon have made an experimental and clinical study
of permanent or continuous catheterization, and give the following in-
dications for its  employment and directions as to the proper method
of applying it.   They hold that the continuous catheter  enables  the
surgeon to evacuate and cleanse the bladder  and put it at rest;  also
that by its use the  urethra can be protected and  pathological condi-
tions of this canal can be favorably  affected.   It  is particularly in
prostatics  that  permanent  catheterization   accomplishes  its  good
offices.  In them it is  indicated when  symptoms  of infection  are
threatening or  have developed, when catheterization is difficult, and
when haematuria is severe.  After cystotomy and internal and  ex-
ternal urethrotomy, it is  well  proved that the  permanent  catheter
prevents infection.  Following  such operations, when the urine con-
tains no microbes  the catheter can be  omitted, but when this fluid
is septic it should always be used.
   Guyon has employed the permanent catheter in fifty-six prostatics
with infected bladders.  As to  its value in the treatment of this form
of vesical infection, of forty-nine prostatics in whom it was employed
during acute exacerbations of chronic cystitis, thirty-eight  were cured.
In the cured cases the defervescence was rapid and definitive.  If
elevation  of temperature  continues when the permanent catheter is
skilfully applied and is working properly, it indicates that this mode
of treatment is insufficient and that cystotomy should be performed.
Epididymitis was observed in but two of one  hundred and five cases,
and  in one of  these  the bladder  was infected.   But one case of
hgematuria was noted during the use of the catheter.  This was due
to too rapid evacuation of the bladder-contents.
   In non-infected  calculous patients cystitis  does not follow the use
of the catheter, the urine  remaining perfectly clear.   The permanent
catheter, since it provides for continuous drainage, is usually followed
by rapid defervescence in the first twenty-four hours of its use.
   The permanent  catheter is serviceable in the  treatment of haema-
turia having its  origin  in trauma of the prostate inflicted during efforts
at catheterization.  This is the common  cause of bleeding in pros-
tatics, and sometimes  the hemorrhage is profuse and persistent.   A
large double-eyed woven catheter is introduced into  the bladder,  the
clots are sucked out by a syringe, and either this catheter is left in place 
582        GENITO-URINARY  DISEASES AND SYPHILIS.

or a smaller one is inserted.  Even  in  cases of bleeding from vesical
tumor with infected bladder, from the time of insertion of the perma-
nent catheter  defervescence  is rapid and blood disappears, doubtless
owing to  the  physiological rest given  to the bladder-walls.  In the
same way bladder-pain is relieved.
   In the treatment of retention  of urine  the permanent catheter is
indicated, aside from acute infection and difficulties in catheterization,
in advanced hypertrophy with great distention, polyuria, and exces-
sively frequent urination, when the  patient is so placed  that regular
sterile catheterization cannot be practised.   When in the course of in-
termittent catheterization the introduction  of the instrument becomes
difficult, it is well to advise patients to practise for some hours or days
permanent catheterization;  the effect  of  the  instrument thus  used
is to cause softening and dilatation of  the  urethra, allowing  an easy
passage of the catheter.  This permanent  catheter does not lessen
prostatic  enlargement;  it simply relieves congestion by providing for
free drainage.
   As to  the pain excited by this  method  of treatment, the  catheter,
far from  causing distress, often gives entire relief from  the urgency
and strangury which mark cases of pronounced infection.  When pain
is caused, this is due to improper application of the method.  During
the first hours exceptionally there  is a sense  of weight and incon-
venience.   This quickly subsides, and the catheter  may then often be
continued for weeks without causing any suffering.
   The permanent catheter confines the patient to bed.  The woven
gum instruments are best suited to permanent  catheterization.  If  an
elbowed catheter is employed, this  should be thin-walled, of  as large
calibre as possible, and  provided with two  large terminal eyes. They
are placed in  the turned-up portion, and  hence not likely  to be oc-
cluded by the  bladder-walls.
   The self-retaining catheter  is also useful.   This is of soft rubber,
18 to 22 F., and is provided with lateral terminal  projections, which
disappear when it is drawn tightly  over the metal  carrier.  It is thus
introduced; the carrier is then withdrawn, and the elasticity of the
instrument causes  the  projections  to reappear.    The surgeon  is
enabled to determine how far the tip of the instrument is passed into
the bladder by gently drawing the catheter out until he feels the resist-
ance  caused by these rubber projections when the narrowing of the
vesical neck is reached.  When this resistance is felt,  it  is certain
that the catheter eye lies just within the grasp of the internal vesical
sphincter.  If the elbowed catheter is used, the exact depth at which it
must be maintained is determined by gently withdrawing it when the 
INJURIES AND DISEASES OF THE BLADDER.
583
contents of the bladder are almost evacuated and noting the moment
when the stream ceases to flow.  It  is then passed in again until the
stream begins to flow, and is fixed at this point.
   To determine positively that the instrument is properly placed and
completely evacuates the bladder, after the stream has  ceased to
flow sudden pressure is made in the  hypogastric  region.   If  the
bladder is empty there will be no jet of urine.   Next a definite quan-
tity of antiseptic solution is injected  into the bladder; all of it should
be returned immediately.  Next the end  of the catheter  should  be
watched, to see that the urine drops  steadily and continuously.
Securing the catheter for continuous catheterization.
   When by all  these tests the  surgeon is sure that the catheter is
properly placed, it may be  secured  in position.   The proper placing
of the instrument is the most important part of the whole procedure.
If the urine does not  flow  drop by  drop, or if there are  pain  and a 
584
GENITO-URINARY DISEASES AND SYPHILIS.
desire to urinate, this is usually because the catheter is passed too
deeply, and is corrected  by drawing it out a little.
   The  fixation  of the  catheter is  accomplished  either by passing
threads around it immediately beyond  the  urinary  meatus and knot-
ting them to the suprapubic hair, or, better, by fastening these threads
to strips of rubber adhesive plaster an inch wide applied to either side
of the penis, passing from its root to the coronary sulcus, and secured
in place by two or three circular strips, not passing entirely around
the penis, and a narrow gauze bandage.   The threads attached to the
catheter are passed through holes cut in the free ends of the longi-
tudinal plaster strips.  (Fig. 174.)  Or  four  threads may be secured
to the catheter just beyond  the urinary meatus, and  these may be
carried to safety-pins secured in a double spica of the groin.  (Fig. 175.)
                              Fig. 175.
Securing the catheter for continuous catheterization.
  The penis is then enveloped in an antiseptic dressing.  A square of
gauze made of ten  or twelve layers is folded in the form of a triangle ;
the apex is secured to the catheter just beyond  the meatus by a silk
thread and rubber  bandage;  the base  is wrapped around  the  penis.
By  means of a piece of sterile glass  tubing a clean rubber drainage- 
INJURIES  AND DISEASES  OF THE  BLADDER.
585
tube is attached to the end of the catheter, and is passed into a urinal
which is half filled with antiseptic solution.  A careful watch must be
kept to  see that the urine is flowing steadily.
   The  catheter  is  changed  every one or two days, the anterior
urethra receiving a thorough irrigation at the time of  changing.   The
catheter is left  open when it is employed for the purpose of a drain,—
that is,  when it is  used to combat infection.  When the  bladder is
aseptic  and the urine sterile, the  catheter is opened only at regular
intervals, depending upon the amount of urine secreted.   This form
of intermittent  drainage  is absolutely indicated  when  long-standing
retention is being  treated.   If the urine contains pus  or blood, the
residuum which it is considered desirable to leave in the  bladder is
replaced by boric  acid  solution.  The bladder is  not  entirely emptied
for several days.
   Continuous catheterization  occasions  a  mechanical   urethritis,
which  promptly disappears  when the catheter is removed.   Some-
times abscesses develop, particularly at the scrotal angle of the penis,
due to  pressure exercised by the instrument on  account of the penis
being allowed  to  hang directly downward.   Infection of the bladder
may occur either from direct extension of urethral inflammation or as
a result of the decomposition of the urine with which the  interior of
the catheter is  continually moist.   This  accident may  be  avoided by
changing the catheter daily, keeping its end beneath the surface of a
strong  antiseptic solution contained in a clean  urinal, and  twice daily
flushing the urethra with hot sterile four per cent, boric solution, cor-
rosive  chloride solution  1  to 10,000, or silver nitrate solution  1 to
 1000.  This flushing may be accomplished by means of an irrigating-
bag  hung four feet above the level of the patient's bladder.  The
nozzle  of the bag is attached to the  catheter, and the latter is slowly
withdrawn till  the antiseptic solution escapes from the meatus. From
half a  pint to  a pint of the solution is used to wash  out the  anterior
 urethra; the  irrigating-bag is  then disconnected, and the catheter
is pushed in till  it occupies its  proper position.  Ulceration of the
urethral floor  may be avoided by supporting  the  penis so that it is
prevented from hanging vertically.
   Continuous catheterization having been kept up for eight to sixteen
days, and fever, pain, blood, and the greater part of the  pus having,
disappeared, the  patient can  resort to intermittent catheterization.
Exceptionally  the  bladder can be emptied  by  muscular  effort, the
cure being complete.  This  result,  however, cannot be looked for in
retention caused by prostatic overgrowth.
   Patients whose symptoms have been relieved  by continuous cathe- 
586
GENITO-URINARY DISEASES AND  SYPHILIS.
terization should be told to resort again to this measure should they
experience difficulty in  passing the instrument.  The catheter may
be worn at night or for several hours at a time during the day.
   The indications for continuous catheterization and the methods of
employing it in  the treatment of retention may be  summarized as
follows:
   1. Continuous catheterization  is indicated in  retention following
wounds or rupture of  the urethra.  It is particularly indicated when
prostatic retention is not amenable to repeated catheterization and is
complicated by bleeding or by infection and fever.
   2. The catheter chosen must  be  large, thin-walled, and  carefully
made; the catheter eye must lie just within the internal vesical sphinc-
ter, and must be kept  open.   The  instrument should  be  changed
every second day.  Its free end should be kept beneath the surface
of an antiseptic lotion held in a urinal so placed as to be beneath the
level of the bladder.   The urethra should be flushed out twice daily
with a pint of dilute antiseptic  solution. When the urine is sterile, the
bladder need not be washed ;  when it contains pus or blood, it should
be  irrigated at  least twice daily.   The catheter  should drain the
bladder  continuously when it is employed for the relief of partial  re-
tention without  marked vesical tension complicated by  cystitis and
fever.   It should drain  the bladder intermittently when the  urine is
sterile and when it has been introduced for the  relief of retention
with marked vesical tension.
   Continuous catheterization relieves tension, cures cystitis, makes
the passage of instruments easier, and in general value and varied
applicability is second only to intermittent catheterization.
   Aspiration.—When catheterization fails to relieve retention from
an enlarged prostate, aspiration is the operation of  choice.   This is
safe and easy, and can be repeated very often without  causing com-
plications of any kind.
   The  bladder is outlined by percussion and palpation, the supra-
pubic region is thoroughly cleansed as for a formal surgical operation,
the large aspirating needle is boiled, and the surgeon's hands are steril-
ized.   With a sterile sharp-pointed  tenotome a  puncture  is  made
through the skin of the middle line immediately above the symphysis
pubis, and the aspirating needle is thrust  downward and backward
through this incision into the bladder.  The lessened resistance will
determine when it has  penetrated  through  all the walls of this
viscus.
   The  bladder is  partially  or completely  emptied, in accordance
with the duration of retention and the amount of vesical distention. 
INJURIES AND DISEASES OF  THE BLADDER.
587
The aspirating  needle is  then  withdrawn, while  suction  is  still
maintained, thus preventing infection of the needle-track with the
urine.
   These aspirations may be repeated three or four times a day for
one or two weeks without  infecting the bladder, and usually without
causing suppuration of the prevesical cellular tissues.   It is  worthy
of note, however, that a few  cases of extra-vesical abscess have been
reported, but only when there has been pronounced cystitis.
   Incomplete Retention.—Patients suffering from acute retention
may be able to pass a portion of the  urine, but so  little that it does
not materially lessen vesical tension.   The  symptoms are practically
the same as those characteristic of complete retention, and the treat-
ment should be conducted  on the same lines.
   There is one form of partial retention  due to enlarged prostate
which does not imperatively  call for instrumental interference.   It is
inaugurated in a person who has for some time been urinating fre-
quently by still greater frequency,  and  by more marked delay  in
starting the stream.  This is followed by pain and tenesmus, increased
by the act of urination, relieved for a time afterwards, but  shortly
recurring.  Little urine is passed at a time.
   These symptoms denote the onset of cystitis, or, if this is already
present, an acute exacerbation of the inflammation.   Rectal  exami-
nation shows a moderately distended, tender bladder.   The obstruc-
tion to the passage of urine has been augmented by inflammation, or,
in the absence of infection, by acute congestion.
   Guyon advises, under such circumstances, abstention  from cathe-
terization until the symptoms of acute cystitis have abated, since the
patient is suffering more from congestion or inflammation than from
the partial  retention.   Rectal palpation and examination of the urine
will show  moderate retention and cystitis: hence even exploratory
instrumentation is unnecessary.
   The patient should be  given a hot general bath  and a hot saline
enema, and should then be  put to bed.  Turpentine stupes are ap-
plied over the suprapubic region, opium and belladonna  suppositories
are given in accordance with the severity  of the pain,  and diluents
and antiseptics are administered by the mouth.   Leeches to the peri-
neum and the suprapubic region are serviceable.
   Under this treatment acute symptoms subside in a few days, and
the power to urinate freely and painlessly is regained.  Although the
symptoms  ameliorate, it does not necessarily follow that the vesical
tension is entirely relieved.  This can be determined only by bimanual
palpation and examination  for residual urine. If tension persists, the 
 588       GENITO-URINARY DISEASES  AND SYPHILIS.

 catheter should  be regularly employed as  advised  in the treatment
 of acute retention.
    Treatment of  Chronic Incomplete Retention.—After  the  surgeon
 has relieved  the acute retention of prostatics, has  checked bleeding,
 and has cured  or alleviated the  chronic cystitis from  which these
 patients usually suffer, directions  must be given which will prevent a
 return of complete retention and which will keep the bladder in the
 best condition to resist microbic invasion and  preserve  it from the
 effects of abnormal tension.   This necessarily implies the habitual or
 intermittent use of a catheter.   Perhaps a point of prime importance
 is to convince these patients that the catheter does  not cause vesical
 atony and cystitis, but protects against these sequelae of prostatic en-
 largement ; that its use does  not abolish  the  power of urination, but
 may restore  it;  and that it  is  infinitely better to draw the water
 through an instrument than to pass it at the  expense of prolonged and
 violent  straining  efforts.
    Instruction must next be given in the technique of catheterization.
 The mere mechanical part is learned quickly enough.  The instrument
 which in  each case enters the bladder most readily and gives least
 pain is  the best.   This may be a soft rubber catheter, an elbowed or
 double-elbowed catheter, the stiff English instrument, or exceptionally
 even the silver prostatic catheter.
   The number  of catheterizations a day must be  regulated by the
 activity of the kidneys and by the frequency with which the patient ex-
 periences a strong persistent desire to urinate.  In mild cases suffer-
 ing only from frequent urination at night the passage of an instrument
 before retiring is  usually sufficient.  During  the day there  are no dis-
 tress, but little delay or straining, a free flow of urine, and  no disturb-
 ing frequency.  In more advanced cases where the urine is still passed
 freely and painlessly, but there is a large residuum with troublesome
 frequency, the catheter may have to be passed two or three times in
 the day.  Where there is chronic cystitis or  congestion with frequent,
 urgent,  painful, and inefficient urination, the catheter may have to be
 used every two or three hours ;  when the  urine is purulent its evacu-
 ation  should always  be  followed by vesical and urethral irrigation.
 When catheterization becomes painful and fails to give relief, continu-
 ous catheterization should be practised for a few days.
   Minute directions  should be given  patients concerning the care of
 instruments and a cleanly method of using them.   They must be
 taught the importance of using sterile catheters in  accordance with
modern surgical  principles.  This is  especially necessary when  cys-
titis has not developed.  The various ingenious contrivances in which 
INJURIES AND DISEASES  OF THE  BLADDER.
589
patients carry their instruments—for instance, flat boxes and hollow
canes—are not  to be commended, since  it is almost impossible to
keep catheters clean when they are thus  stored.  Catheterization is
troublesome at best, and thoroughness in carrying out antiseptic  de-
tails should not be sacrificed to convenience.
   The most comfortable catheter  having been  selected, the patient
should procure twice as many of these as are required in a single day,
a fresh instrument being used for each catheterization.  In the  selec-
tion of these instruments it is worthy of note that those of  American
make are quite as good as the imported ones, and that the Lisle thread
and linen catheters are practically as serviceable  as those of pure silk.
In addition to the catheters the patient  must secure a metal box ar-
ranged  for their  sterilization  by  paraform,  a  deep  narrow  speci-
men jar filled with a slightly antiseptic  lubricant, a bottle  of tablets
of corrosive mercuric chloride for making a solution of 1 to 1000 in
which the hands  can be washed,  a roll of bichloride  gauze, and a
package of absorbent cotton.  If there is cystitis, an irrigating-bag and
a standard antiseptic solution from which the dilute washing lotions
can be  made must also be procured.   He should have prepared a
dozen clean towels which have been boiled and  sun-dried  or baked.
The  catheters are washed  in  green soap and hot  boiled water,
washed again in hot water,  dried  with  a clean towel,  and wrapped
each in a piece of bichloride  gauze cut to an appropriate size.   They
are then loosely  wrapped in a towel and placed for ten minutes in an
oven kept at about 160° F.  They are finally  stored  in  the  metal
paraform box for twenty-four hours.
   As each catheter is required for use it is taken from  the box, and,
with its gauze wrapping still unfolded, is placed on a clean towel.   The
patient then removes the lid from the lubricant jar, scrubs  his hands
thoroughly with soap and hot water, washes them in bichloride solution
1 to 1000, scrubs the glans penis with a pledget of cotton dipped in this
same solution, again washes his hands in the bichloride solution, un-
wraps the catheter, dips it for a moment in a pitcher of hot, recently
boiled water, hot boric acid solution, or 1 to 10,000 corrosive chloride
solution, to remove  the  paraform  vapor, dips it into the  lubricant,
places a clean towel around the penis, and introduces the instrument.
If irrigations are not practised, the  end of the catheter is closed with
the  finger  before  it is withdrawn,  thus  preventing  leakage of  urine
along the whole course of the urethra.   The  catheter  thus used is
immediately washed and  syringed  out with hot soapsuds,  is dipped
for a moment in  boiling water, is then shaken to dry out its interior
as thoroughly as possible, is wiped dry, and is wrapped in a  clean 
590        GENITO-URINARY  DISEASES AND SYPHILIS.

towel.  At night the hands are cleansed, and the catheters which have
been used during  the  day are  again  wrapped  in  bichloride gauze
baked  for  a  few minutes, and put in  the  paraform-box.   This  box
should be provided with two shelves, each containing enough catheters
for twenty-four hours' use.
   This  technique is undoubtedly troublesome, but the majority of
intelligent patients, if they fully understand  its importance, will cheer-
fully carry it out.   In travelling, the catheter-box lubricant, antiseptic
towels, gauze, and absorbent cotton, a small basin, and a narrow  pint
jar can readily be packed in a valise.   The basin is for the corrosive
sublimate solution 1 to  1000, the narrow jar for  the same solution 1
to 10,000.   Tablets can  be procured  containing sublimate in such
proportions that one added to a pint  of water will make a solution
of the  proper strength.   Enough catheters should be sterilized before
starting to  last two days.   As  each  is  used it should be  cleaned as
thoroughly as circumstances will allow and wrapped in a towel.   In
the course of twenty-four  hours there will probably  be  an oppor-
tunity  for  procuring boiling water, when the catheters which have
been used  can be syringed  out and thoroughly cleaned.  The baking
is not  absolutely essential,  since its main purpose is to dry the inte-
rior of the instruments and thus prevent them from deteriorating.
   There are many simpler methods of practising cleanliness in cath-
eterization.  We believe the method given above is the most efficient.
   When  cystitis is present  irrigations are extremely  valuable.  A
fountain syringe is  used, and in general a solution is employed which
does not excite inflammatory reaction.  Even when the urine remains
sterile, should frequent catheterization occasion a  simple urethritis,
the anterior urethra should  always be irrigated just before the instru-
ment is passed into the bladder and during its withdrawal.
   A patient  suffering  from enlarged  prostate  should also be given
careful instructions in  regard  to the  prophylaxis of  the congestive
attacks which so frequently cause acute retention.
   The diet must be so regulated that  the urine  shall be unirritating.
This necessarily implies treatment for oxaluria, excess of uric acid, or
other abnormal  condition.  Diluents should be  given with the same
end in view, but not to  the extent of markedly increasing the polyuria
which  is usually present.   The surface circulation  should be  stimu-
lated by bathing, friction, and massage.   Open-air exercise is desirable
for its  effect upon the general  health.   Even horseback-riding or the
use of  a bicycle is sometimes  followed  by beneficial results.   Tonics,
stimulants, and nutrients  all have their value.
   As  a means  of avoiding local congestions the  patients  must be 
INJURIES AND DISEASES  OF THE BLADDER.
591
particularly cautioned against constipation, chilling of the surface, wet
feet, resisting the desire to urinate, sexual  excess, indulgence in alco-
hol, or overeating.  The treatment directed to lessening the hyper-
trophy is discussed under a separate heading.

            RETENTION  OF URINE FROM STRICTURE.
   The retention of urine  from stricture must be distinguished from
that dependent  upon enlarged prostate, since the  treatment  of  the
two affections is widely different.  In both cases  there  is usually a
preceding history of frequent urination with slowness in starting the
stream.  Prostatics, however, have most difficulty at night and in the
early morning.  During the day the water flows with comparative
freedom and  without much  delay.   Examination per  rectum will
usually show enlargement of the prostate.  In cases of stricture  the
frequency is most pronounced in the day, the delay in  starting  the
stream is less marked, and there is liable to be more dribbling.  Until
retention is well advanced there is distinct remission of symptoms at
night.  A history of previous gleet or of injury to the perineal or the
penile urethra is usually given.   It must be recognized that sudden
retention may develop  in  cases of stricture of large calibre without
a preceding history of frequency.
   The  diagnosis is generally  founded  upon  exploration of  the
urethra  with  acorn-bougies  and  digital  examination  through  the
rectum.
   There is probably incomplete  retention in the majority of tight
strictures, but of a degree insufficient to  produce dangerous vesical
tension.  Any  cause  of congestion and urethral spasm, particularly
sexual indulgence, excess  in drink, chilling of the surface, or the pas-
sage of a catheter, may make the retention complete.   This form  of
complete retention is, however, of  short duration.
    Treatment—Since the  bladder  has a tendency to become hyper-
trophied rather than dilated, it is rare in the case of stricture to find
it  enormously distended.   Even  when  the tension is still  moderate,
the suffering is so intolerable that the help  of the  surgeon is  de-
manded.   Since spasm and  congestion play  the major role, a  hot
bath, hot enemata, opium and belladonna suppositories, and hot tur-
pentine stupes over the hypogastrium may be tried.  If these meas-
ures fail, the  surgeon should promptly proceed to instrumentation.
On the chance of the stricture being of large calibre and of  the reten-
tion being caused mainly by muscular spasm, an effort may be made
to  introduce a steel sound, 16 to 20 F., into the bladder.  If this fails,
fine conical and rat-tailed  soft catheters  should next be tried.  These 
592        GENITO-URINARY  DISEASES AND SYPHILIS.

failing, filiform whalebone bougies should be used, and gently manipu-
lated till one enters the bladder.  Should the filiform  fail, aspiration
is indicated.  When the filiform has entered the distended bladder, it
may be tied in place, with the  full assurance that enough urine will
leak out beside it to relieve tension, and that the stricture will be suf-
ficiently softened to allow of the passage of larger instruments.
   This is the simplest course, and probably the safest in the majority
of cases, especially when patients are  treated at their own homes.
When  they are under hospital supervision, however,  good results will
be obtained, and more expeditiously, by cutting  the stricture to full
calibre  at once, and practising continuous catheterization  by means
of a large soft  instrument,  not emptying  the bladder immediately
if  there has been  long-standing retention with  marked vesical
tension.
   When a filiform  cannot be  passed, aspiration is indicated, because
this often so relieves congestion and spasm that the stricture will sub-
sequently admit an instrument.
   Tapping the  urethra at the  apex of the prostate is a means of re-
lief applicable when an aspirator is not obtainable.  It is more diffi-
cult than aspiration, is  attended with  much more danger, and, so far
as the  relief of retention is concerned, is not  more efficient.
   Retention of  Urine from   Traumatism.—Under  this  heading is
included that form  of  retention which follows direct injury of the
urethra or  the  bladder.  Retention following general trauma, such
as that observed in the aged after  contusion  of  the hip or frac-
ture of the  thigh, is  probably due  to  disordered  reflexes (inhibi-
tion of the  detrusors or spasm of the sphincters), and is  elsewhere
described.
   Rupture of the bladder  may cause  retention, partly because the
urine escapes through the rent,  partly from muscular palsy.   Lacera-
tion or rupture of the urethra always causes retention.  The symp-
toms  and treatment of these  injuries have  been considered under
separate headings.  The general indications are immediate closure
of the  rupture  and drainage  of the  bladder  either by  continuous
catheterization or by the perineal drainage-tube.

                     INCONTINENCE OF URINE.
   Incontinence of urine results from inability of the  bladder to act
as a reservoir,  and is  characterized  by the  involuntary, sometimes
the unconscious, escape of urine.   Guyon distinguishes as true incon-
tinence that in  which  the   urine escapes without previous  urgency
or even desire, thus excluding, for instance,  those cases of prostato- 
INJURIES AND  DISEASES OF THE  BLADDER.
593
cystitis in which  the  desire is so imperious  and irresistible  that  the
patient cannot withstand it.   He thus tabulates true incontinence :
Inconti-
 nence.
Without material
  lesions  of  the
  urinary tract.
With material le-
  sions of the uri-
  nary tract.
Incontinence from nerve-lesions.
Incontinence from nervous affections.
Incontinence of children.
                [  Mechanical incontinence.
                  Incontinence of tuberculosis.
                  Traumatic incontinence.
                  Incontinence from urethral
                   insufficiency.
                  Incontinence of stricture.
                  Incontinence  of   enlarged
                   prostate.
Without retention
  of urine.
With retention of
  urine.
I
   Incontinence  without  Lesions of the Urinary Tract.—In-
continence due to  nerve lesion  is usually preceded by retention, the
urine escaping drop by drop from  the  overfull bladder.   The  con-
ditions,  such as the palsies  and degenerations, which occasion this
retention have been already  mentioned.  The appropriate  treatment
is regular aseptic evacuation  of the bladder.
   Incontinence of nervous affections often appears in the form of an
unconscious escape of  urine  from the bladder, which is never over-
distended.  Hysteria, neurasthenia,  and. epilepsy occasion  this form
of incontinence.
   Epileptic incontinence is  of  special interest, since it may be the
only symptom to excite suspicion of the nervous affection.  Trousseau
states that adults who, without  lesion of the urethra or bladder,
wet  their beds at  night should be  suspected of epilepsy.   In these
cases suspicion as to  epilepsy having been excited will lead to the
detection of other  symptoms, which may justify a  positive  diagnosis.
In hysteria  and neurasthenia the  condition is rare.   Any violent
emotion, particularly fright, may occasion this form of incontinence.
   Incontinence of children is  essentially a  functional disease.  It
usually begins  about the fourth or  fifth year, but sometimes is  con-
tinued from early infancy.  There is a natural tendency towards  cure
at the period of puberty, but many cases  persist  beyond this time.
It is almost invariably  nocturnal.  Exceptionally it  is both  nocturnal
and diurnal..   The cause of this incontinence js unknown.   Heredity
is a distinctly predisposing factor.    The possibility of epilepsy as an
etiological factor should always be carefully considered.
   Trousseau classifies this  affection as a  neurosis, characterized by
excessive irritability and exaggerated  tonicity of the vesical muscles.
Perhaps the most  satisfactory explanation is that  which  attributes
                                38 
594
GENITO-URINARY DISEASES AND SYPHILIS.
this  perversion of function to an increased  irritability of the pros-
tatic urethra.  It  has been already  shown that  as the bladder be-
comes distended the internal vesical sphincter yields, and the pros-
tatic urethra forms a portion of  the urine-containing cavity.  With
the yielding of the vesical sphincter  and the  penetration of the urine
into the prostatic urethra normally there may be felt merely a slight
desire  to  urinate.   It  is only when the  vesical tension  reaches a
certain point that the desire  to  micturate is felt strongly.  In cases
of posterior urethritis, because of the increased sensibility of the pros-
tatic urethra, the  moment the internal vesical sphincter yields and
allows the urine to reach this inflamed mucous membrane, the desire
to urinate is urgent, imperative, and often irresistible.  In the case of
a  child with a hyperaesthetic  posterior urethra,  and with spinal re-
flexes  much more readily excited than in adults, particularly during
sleep,  the  escape of the first few drops of urine into the prostatic
urethra is probably sufficient  to  set in active operation the nervous
and muscular  mechanism of micturition.  During the day cerebral
control is  usually able  to inhibit  this  reflex; but when the prostatic
urethra is particularly irritable   the  reflex  is excited so suddenly
that urination takes place before the  child has time to control it by a
conscious effort.
    Diagnosis.—Refore  deciding that a child who wets  his bed at
night or soils  his clothing in  the  daytime is suffering from a purely
functional  trouble, diabetes,  polyuria,  vesical tuberculosis,  cystitis,
nephritis,  calculus,  and  foreign  body must be  eliminated.   If the
urine is perfectly normal, and is not excessive  in quantity, and if urina-
tion is painless and  is normally  accomplished, these various causes
of incontinence can  be eliminated.   Epilepsy must be  excluded by
having the child watched through several nights.
    Treatment.—Since incontinence in  children is often due to an ex-
aggerated reflex, a careful search  must be made for any abnormality
which may  indirectly  lead  to  such  increased   reflex excitability.
Thus, the anus and the  rectum should be examined for polyp, eczema,
fissure, or seat-worms.   The  urethra should be explored for narrow-
ings or valvular formations, and, since most children are phimotic, it
is well on  general principles to practise circumcision.   This in itself
is often curative.  Errors of diet must be carefully corrected, and the
urine rendered bland by giving water and milk in abundance.  Liquids
should not, however, be given in  the evening.  The total quantity of
urine passed in twenty-four hours should be measured.  This may
show that the incontinence is really due to over-distention, the patient
secreting during the night more urine than the bladder can retain. 
INJURIES AND DISEASES OF THE BLADDER.
595
   The general system should  be strengthened by exercise in the
open air, regular bathing, massage in the case of very weak children,
and the  administration of tonics.  Compound syrup  of  the  hypo-
phosphites in doses suited to the age is particularly serviceable.   It is
well to encourage the child  in  the habit  of defecating immediately
before bedtime.  This end may be accomplished by the regular use
of enemata.   If  the examination  of  the urine shows oxalates or
other sediments in excess, the appropriate  dietetic regulations should
be enforced.
   It sometimes  happens that a habit of nocturnal incontinence  is
due originally to  carelessness.   The child, though awakened by the
desire to urinate, prefers wetting his bed to getting  up.   Shortly he
is so  imperfectly awakened  that,  though  micturition  is  partially
volitional, he is practically unconscious of the act.  It  will be found
that the urine is passed at about the  same hour every  night.  If the
nurse is directed  to inspect the  child hourly for two or three nights,
the time of semi-conscious urination may be determined.
   In these cases a cure may be accomplished by having the  child
waked at about one  or two in  the morning, or an  hour before his
habitual time of involuntary micturition, and made  to  empty his
bladder.  This treatment may be reinforced by a system of rewards
and punishment.  The child should never  be severely disciplined,
since perhaps  in the majority of cases the disturbance  of  function is
entirely beyond his control.
   As further means of lessening the tendency to nocturnal enuresis,
the application of a bandage about the waist  of the child, with a pro-
jection in the  back so that he is compelled to lie on his side, sleeping
on a comparatively hard bed with covering just  sufficient for neces-
sary warmth,  the elevation of the foot  of the bed, and counter-irrita-
tion in the form  of blisters  over the  lumbar spine, have  been tried
with apparently satisfactory results.
   Medicinal  Treatment.—The drugs  administered  for  the  cure of
enuresis in children are belladonna, atropine, hyoscine or hyoscya-
mine, potassium bromide, and quinine.
   Belladonna, the drug upon which reliance has been  chiefly placed,
is administered in ascending doses until either the physiological  effect
is obtained or  the incontinence is cured.   This drug is  pushed to the
limit of safety; thus, a child  four years  old may be given an eighth
of a grain of belladonna extract, four drops of the tincture, or one to
two minims of the fluid extract of the root in the evening.  Or the
drug may be given in the form of suppository, the dose then  being
slightly larger.  Hyoscine or hyoscyamine may be employed in  doses 
GENITO-URINARY  DISEASES AND  SYPHILIS.
of the two-hundred-and-fiftieth of a grain ; potassium bromide, five to
fifteen grains; quinine, two to ten grains.
   If the desired result is not quickly accomplished, no benefit is ob-
tained by continuing these drugs.   Sometimes the enuresis is  appar-
ently cured at once.  Under these  circumstances the dose  should be
gradually lessened.  If there is temporary relief followed by relapse,
the dose may be cautiously increased.  Quinine has been particularly
commended by Potts, on the theory  that enuresis is probably caused
in the greater number of cases by failure of the higher centres to con-
trol properly the reflex act by which the bladder is emptied.  Quinine
was  given in full  doses as a stimulant to the  inhibitory  centre, with
strikingly satisfactory results in the few cases in which it was tried.
   3Iechanical Trecdment.—When the methods already discussed have
failed, the prostate and the urethra should receive direct mechanical
treatment.  This  may be applied in the form of (1) sounds, (2) elec-
tricity, (3) instillations.
   Its object is to relieve the hyperaesthesia  and  congestion of the
prostatic urethra and to stimulate the sphincter muscle.
   The passage of a cold  steel sound of such  size  that it enters the
bladder without the employment of force is usually  efficacious.  This
sound  should be  left in place for from  three  to five minutes, and
should be passed every third or fourth day.   It is scarcely  necessary
to insist upon the  observance of antiseptic precautions.
   If after three weeks of sounding and a fourth  week of rest symp-
toms are not improved, electricity should be employed.  This is ap-
plied by means of a urethral electrode shaped  like  a sound and with
the rather sharp curve appropriate to the urethra of children.  It is
vulcanized to within  an  inch of  its extremity.    This  electrode is
passed into  the  urethra  until its metal extremity lies within the
membranous and prostatic portions of this canal.  It is then attached
to the faradic battery, the other electrode  of which is applied over the
perineum or  to the lumbar spine.  The patient is given fifty slow in-
terruptions, the  current being  so  regulated that it does not cause
pain.  This treatment is repeated  every  three  or four days.  Unless
the electrode is kept  perfectly clean it may cause cystitis.  Imme-
diately after use it should be scrubbed in hot water and green soap,
rinsed  in water recently boiled, washed in  a two per cent, formalin
solution, and wrapped  in sterile gauze.   It should  then  be stored in
the paraform-box already described, and should be washed  in hot
recently boiled water before  it is used again.
   If in three or  four weeks electrical treatment does not improve or
cure the  enuresis, instillations of silver nitrate  may  be employed. 
INJURIES  AND DISEASES  OF THE  BLADDER.
597
From three to five drops of a two to  five per cent, solution are in-
jected into the membranous or prostatic urethra every third or fourth
day.   Should this  method fail,  recourse  must again be had  to  the
local application of electricity, and  this should be continued over a
long  period,—from six to eight months, or even a year.
   To summarize these  methods of treatment according to their effi-
cacy, it may be said  that  if the enuresis  is  purely functional, many
children will get well after attention to their general hygiene, if they
abstain from liquids  in  the evening, empty the bowels and bladder
before going to bed, and rise once during the night to micturate.
   Though it is customary to advise as the next  means of treatment
the administration of drugs, we are in general opposed to this,  be-
lieving that better  results are more promptly attained by local treat-
ment, provided the attendant  is fairly skilful in  the use of urethral
instruments and recognizes the importance  of  thorough cleanliness
in all his manipulations.
   When  the  enuresis has lasted past the age of puberty, medicinal
treatment  is likely to be  of little avail.  Here the best results will
be obtained from the use of sounds and instillations.   These sounds
should be  carried up  to full calibre, the meatus being cut if necessary.
   Incontinence with Lesions of  the Urinary Tract.—When
enuresis is not functional, but is due  to hypersecretion or to  tuber-
culosis, for instance, the  cause  must receive treatment.
   Incontinence without retention of urine is necessarily dependent
upon a patulous condition of the sphincter.  This may be caused by
lodgement of  an irregularly  shaped  stone, by  which  the  vesical
sphincter is kept open but  is not  occluded.  This form of inconti-
nence, Guyon states, is observed only in children.
   Such a condition  should be treated by  pushing the stone back
into  the bladder and removing  it by  litholapaxy, or, in case this is
impossible, by  perineal section.
   Tubercular  ulceration may  infiltrate  and entirely destroy  the
vesical sphincters, resulting in an intractable form  of  incontinence,
the nature of which  is rarely  doubtful, since it  develops only in  the
advanced stage of vesical tuberculosis.
   Incontinence due to  contusion or  overstretching of the prostate,
such  as occurs in perineal  lithotrity or in digital examination  of  the
female bladder through the urethra,  may persist indefinitely.  To-
nicity of the sphincter muscle is best  restored by the  application of
local  electricity.
   Incontinence due  to fistulous opening of the bladder is elsewhere
discussed. 
598        GENITOURINARY DISEASES AND  SYPHILIS.

   Guyon describes under the heading urethral  insufficiency a form
of incontinence characterized by involuntary escape of urine  caused
by the slightest muscular effort, such as coughing, laughing, or strain-
ing, or even by standing.  The urethra is perfectly normal.  Women
especially suffer from this form of incontinence, because of atonicity
of the vesica] sphincter.   Sometimes it is seen  in men  after stretch-
ing of the prostatic urethra or the use of very large sounds.
   Electricity  supplemented  by instillations is serviceable in these
cases. In women, when this method of treatment fails and the escape
of urine is profuse, as a last resort the urethra may be freed by dis-
section through the greater part of its length, given a half or a three-
fourths twist in its long axis, and sewed  in this position.
   Incontinence of retention is the ordinary form  of  incontinence,
and is observed particularly in those suffering from enlarged prostate
or from stricture.  Distinction should be made  between this form of
incontinence, in which the urine dribbles without either the volition or
the consciousness of the  patient, and the urgent, imperious urination
of cystitis  or of irritable  bladder.  The true nature of this  incon-
tinence is of course at once recognized by vesical palpation, and the
nature of the obstruction  is determined  by the previous history and
by urethral examination.
   When in this form of incontinence the urethra is patulous and is
of normal length, the cause must be sought in the nervous system.
   As for treatment, this is  directed to the relief  of the retention
rather than to the incontinence, and has been already discussed.

                           HEMATURIA.
   The vascularity of the urinary tract and the readiness with which
it becomes engorged  are reasons why blood  is so  frequently found
mixed with the urine.  The bleeding may be profuse and from ap-
parently  slight  causes.   Guyon gives the exciting causes of hemor-
rhage as traumatism, congestion, inflammation, organic disease, foreign
bodies;  or, as a still more simple classification, the  bleeding may be
mechanical, inflammatory or congestive,  or organic.
   It is important  not to regard the color of the urine as sufficient
evidence of the presence of blood, since an excess of uric acid or bile-
pigments, or the ingestion of senna, rhubarb, or carbolic acid, or the
presence of haemoglobin, will give a reddish  or a brownish tint, abso-
lutely like that  due to the presence of blood.
   It is upon microscopical and chemical examination that the diag-
nosis must be  founded.  The color may vary from a  rosy  red to a
deep brown.   When together with blood there is pus, as in cases of 
INJURIES AND DISEASES OF THE RLADDER.
599
acute and chronic cystitis, the  blood may be  found entirely in the
sediment, being somewhat irregularly  mixed  with this  deposit and
imparting none of its color to the supernatant liquid.
   The lower  the specific gravity of the  urine the more readily the
blood dissolves in it, and  hence the slower the clot-formation.   This
fact has an important  bearing  on treatment, suggesting the use  of
diluents when there is danger of retention from clotting.
   The clots which are passed have no diagnostic significance, with
one exception: a long, thin, rounded  clot in the shape of  a  small
earthworm  must  necessarily have  been moulded  in the ureter, and
hence indicates either renal or ureteric  origin of bleeding.   Short
cylindrical clots have not the same significance, since they may have
been formed in the urethra.
   The clots may be dark red and readily broken up, or tough and
yellowish red, suggesting the  appearance of  organized tissue.   A
microscopic examination  is  required to distinguish these fibrinous
clots from fragments of neoplasm.
   Since  congestion is so  important a predisposing condition to  haem-
aturia, it sometimes happens that symptoms of  this engorgement will
precede hemorrhage.  There may be a sensation of weight and dis-
comfort rather than actual  suffering, or an  attack  of kidney  colic.
These pains are of brief duration, are felt in the region of the kidneys
or along the ureters, and strongly point  to the renal origin of bleeding.
Such premonitory pains are rarely felt in bleeding from the bladder.
   The source of  haematuria is sometimes indicated by the  color  of
the blood or by the time of its appearance in the urine.
   Blood which appears with the first jet of urine (initial  haematuria),
the remainder of  the liquid  remaining clear, must necessarily  come
from some portion of the  urethra.   In this case the quantity of  blood
must be very slight, otherwise it would escape externally if it came
from the anterior urethra, or would flow back into the bladder if from
the prostatic urethra.  Usually when the blood  conies from the  pros-
tate there is also terminal  haematuria;  that is, the last portion of the
urine may contain blood, or almost pure blood may be passed.
   When all the urine contains blood, but that last passed contains
the greatest quantity, the last few drops micturated being nearly pure
bright blood, the probability of  the vesical or prostatic origin of the
bleeding is very strong.  If blood is  passed only at the  end of mic-
turition (terminal haematuria), the blood must necessarily come from
either the bladder or the prostatic  urethra.  It is particularly in  pros-
tato-cystitis  that  terminal  haematuria is observed.  The bleeding is
not profuse, and is associated with  other symptoms of cystitis, notably 
600        GENITO-URINARY DISEASES AND SYPHILIS.

frequency and urgency.  In severe injury to the kidney or malignant
growth of this  organ, the blood may be bright red and the haematuria
may appear to be terminal.  When bleeding follows  traumatism its
origin will often be indicated by the character and seat of the injury.
Thus, in case of gunshot wound in the lumbar region the appearance
of blood in the urine would necessarily indicate injury of the kidney,
while haematuria following a kick in the hypogastric region would
suggest contusion or rupture of the bladder.  Rlood  escaping inde-
pendently of the act of micturition must come from  some part of the
anterior urethra.
   The quantity of blood in the urine is of some diagnostic value. If
the bleeding is  apparently causeless, intermittent, and profuse, it is
usually due to renal or vesical tumor.
   Bleeding may be caused by certain drugs: chief among these are
cantharides and turpentine.  It is sometimes a symptom of mercurial
poisoning.   Ingestion of certain  foods is occasionally followed  as a
result of idiosyncrasy by the appearance of blood in the urine.
   Blood may appear in the urine  in the  course of haemophilia, or
because  of  parasites (filaria sanguinis hominis),  closely simulating
the surgical forms of haematuria.   When it is due to  infectious fevers,
such as  variola or  scarlatina, to dyscrasiae,  such  as scurvy or  pur-
pura, or  to hysteria, it is not likely to be confounded with haematuria,
which is mainly  local  in origin.   Nearly all forms of  nephritis  may
cause bleeding, slight in amount and not  persistent.   The associated
signs and symptoms of the nephropathy suggest the nature of the
hemorrhage.
   When haematuria follows sudden muscular  action or apparently
insufficient violence, this is probably  due to the development  of a
lesion  the  presence of  which has been hitherto unsuspected.   The
conditions which commonly precede the bleeding are tumor, tuber-
culosis, and nephritis.
   In general terms, when urination  causes  bleeding, stone, tumor,
or tuberculosis may be suspected.  Haematuria due to new growth,
whether  this be  of the bladder or of the kidney, is usually profuse,
apparently causeless, intermittent, made worse by exercise, not cured
by rest.  Guyon  states  that vesical bleeding  occurs more frequently
and persists longer  than that of the kidneys.  The exceptions to this
rule are so frequent that it  is of little diagnostic value.  As the disease
progresses, paroxysms have a tendency to occur more  frequently.
   A tumor, if not  placed near the vesical  neck, may  occasion no
symptoms  other than .haematuria, and in its early stages  may readily
escape detection  by palpation.   The renal  origin may be suspected 
INJURIES AND DISEASES OF THE ELADDER.
601
after elimination of the vesical source of the hemorrhage.  This sus-
picion will  be changed to a surety if associated with the bleeding, or
preceding it, there have been attacks of renal colic.
   Guyon  calls  attention  to a symptom which  may aid in making a
differential  diagnosis.  In kidney tumor the blood sometimes suddenly
disappears, to return  as suddenly.  These  alternations are repeated
at short intervals.  It may be for  only a few hours that the urine re-
mains limpid, and then the blood again  appears, often  containing a
clot moulded in the ureter.  This sudden clearing of the urine is due
to temporary blocking of the ureter; the bladder  then contains only
the excretion of the  healthy kidney.   When,  together with  blood,
renal blood-casts are  found, the origin of the bleeding  is positively
indicated.  Attacks of renal colic are equally characteristic.
   In determining the source of bleeding, evidence afforded by analysis
of associated symptoms and by direct examination must be carefully
considered.  If the bladder is sufficiently affected to  cause bleeding
from  its mucous membrane there will usually be frequency, urgency,
and pain if the case be inflammatory, mechanical, or traumatic ; or a
bimanual examination will show some  alteration in the vesical walls
or in the prostate if there be infiltration or tumor.
   Vesical  tumors are usually complicated by cystitis, due to  cathe-
terization.   This is not so common in renal tumors, or, if it develops,
follows the bleeding by a longer interval, and is much more amenable
to treatment.
   The first symptom of tumor of the bladder is haematuria,  unless
the growth is placed near the vesical orifice, in which case frequent
micturition may precede the appearance of blood.   (Fenwick.)
   The bleeding  from chronic Bright's disease is moderate ; excep-
tionally it is intermittent  and profuse.   Other symptoms of the dis-
ease,  and  particularly the  results of  urinary  examination,  suggest
the cause of  hemorrhage.   The hemorrhage of syphilitic glomerular
nephritis can be  diagnosed  only by the  associated symptoms of the
disease.
   Haematuria of renal tuberculosis is characterized  by pain, often
amounting  to true renal colic, pus  in the' urine, which  persists, and a
moderate amount of blood, appearing intermittently.   Renal calculus
also occasions but a  slight amount of bleeding and  causes  pain in
the back which is reflected in various directions.   The bleeding, the
attacks of colic, and the pain are relieved by rest.  The same  ameli-
oration is not noted in either tuberculosis or new growths.
   Stone in the bladder, in  addition to the  typical symptoms, causes
blood in moderate quantity.  At times when the stone is complicated 
(302        GENITO-URINARY DISEASES AND SYPHILIS.

by enlarged  prostate  blood is  the only symptom.   Bleeding  from
tuberculosis of the bladder is also slight, occurring particularly at the
end  of  micturition.   The  symptoms are much  like those of stone.
Acute posterior urethritis also occasions bleeding at the end of urina-
tion.  The effect of rest upon symptoms of stone is so marked and
immediate that this is a diagnostic sign of distinct value.  Haematuria
which is not materially influenced by either exercise or rest is usually
due  to  tuberculosis, new growth, or acute inflammation.  The renal
and vesical hemorrhage following catheterization of an overfull bladder
has been already discussed; acute  cystitis may exceptionally cause
such free bleeding that the term  hemorrhagic is  applicable.  A few
reported cases seem  to prove that varicose veins of the bladder may
by rupturing give rise to serious,  even fatal, hemorrhage.  Enlarged
prostate may also cause spontaneous bleeding.
   The  final determination as to the source of haematuria must de-
pend upon cystoscopic examination.  Practically it is only in cases of
malignant growth, or possibly in those of tuberculosis, that associated
symptoms fail to suggest the origin  of the blood.  The examination
may be  made either in  the interval between attacks  or during the
course  of the bleeding, but if the hemorrhage is even moderate in
quantity and from the vesical region, nothing  can be seen, since the
fluid injected into the bladder at  once becomes opaque from admix-
ture with blood.  If the bleeding is  moderate and of renal origin,  by
using the irrigating cystoscope the blood may be  seen  escaping from
the ureter.  The bladder should first be emptied of its bloody urine,
and  then filled quickly with clear fluid.  A  bloody jet may be seen
escaping from the ureter before the liquid  contained in the bladder
becomes too deeply stained to allow of  further examination.
   It is always best  to make a cystoscopic  examination in the inter-
vals of  bleeding, but when hemorrhage is supposed  to be  of renal
origin and is slight in amount, it will  be impossible to determine
from which ureter the blood  comes  unless  the  cystoscope is used
while bleeding is still going on.
   If an examination made after bleeding has ceased shows that the
bladder is healthy, this of  course points to the renal origin of bleed-
ing.  If, on repeated trials, the urine previously having been nearly
or quite free from blood, the introduction of the  cystoscope at once
occasions such free  hemorrhage that  examination cannot  be made,
this  itself is indicative of the vesical origin of the hemorrhage and
almost positively points to  new growth.
    Treatment of Haematuria.—During an acute  attack of bleeding,
whatever be its cause, rest in bed, liquid  diet,  preferably milk and 
INJURIES  AND DISEASES OF  THE BLADDER.
603
buttermilk, diluent drinks, for the purpose of lessening the tendency
to coagulation, and a solvent condition of the bowels procured  by
enemata are advisable on general principles.
   Medication by the mouth is of little value.  Guyon  speaks well
of turpentine.  This may be  given in three-drop doses hourly for six
or eight hours, preferably well diluted in the  form of a mucilaginous
emulsion.  Ergot  and ergotin have been  strongly commended, and
may be  given in full doses,—a  drachm of the  former or five grains
of the latter at hourly intervals.  Oil of erigeron also seems  service-
able at times,—five drops in  an  emulsion every hour.  Gallic acid is
credited with some haemostatic powers.   It  may be  given  in ten-
grain doses every  hour.
   We have little  confidence in any of these drugs.   They  are ser-
viceable as adjuvants, and should  be given when the hemorrhage is
moderate and persistent.  When the bleeding is profuse and threat-
ening to life, and there are associated with it restlessness and  anxiety,
tenesmus, pain, and often an  over-distention of the bladder from clot-
ting and urethral  obstruction, the  best results will  be obtained by
quieting the  circulation, and  lessening spasm  by a full dose  of mor-
phine, and emptying the bladder by the catheter and suction  syringe.
This may be  followed  by irrigation with a hot astringent antiseptic
solution, such as silver  nitrate  1 to 2000,  hydrastis an ounce to one
pint, carbolic  solution 1 to 200, or five per cent, antipyrin solution.-
Antipyrin possesses  distinct  value  as  an  analgesic,  and  is  credited
with being a powerful haemostatic.   Continuous catheterization is then
indicated till the bleeding ceases.  If the use of the catheter is  imprac-
ticable, perineal cystotomy is  the operation of  choice,  followed by the
removal of clots by the  scoop or the finger, assisted by lavage with a
bichloride or antipyrin solution, and the insertion of a large drainage-
tube.
   Most minute antiseptic  precautions must be observed in all these
manipulations, since the  urinary tract in case of  bleeding is peculiarly
susceptible to infection,  which if once started is liable to  resist  treat-
ment and extend  rapidly to the  kidneys.   The  dangers are particu-
larly great in cases of neoplasm.
   The bleeding of prostatics, dependent upon  the intense engorge-
ment which complicates retention, if profuse  and threatening to life,
is best  treated by  evacuating the blood by means of a catheter and
syringe  and keeping  the bladder empty by the retained catheter.   If
the clots cannot be removed  in this way, perineal or  suprapubic cys-
totomy is indicated.  If  bleeding persists, pressure above  the pubis,
applied by means of compresses, must be tried. 
GENITO-URINARY  DISEASES AND SYPHILIS.
   Hemorrhage from  prostatitis and  prostato-cystitis  is sometimes
beneficial,  since it  relieves engorgement.   If moderate, it is often
benefited by balsams combined with diluents and by the rectal use of
opium.  The  same  treatment is applicable  to tubercular  cystitis.
Further detailed treatment of haematuria  is given in the sections
devoted to  the pathological conditions which cause it.

       WOUNDS, CONTUSION, AND RUPTURE  OF THE BLADDER.
   The bladder when empty  is so deeply placed, so well protected
by the bones of the pelvis, and, moreover, so movable,  at least in its
upper part, that it usually escapes the effects of  even severe trauma-
tism.   When force has been  applied sufficient  to fracture the pelvic
bones or to cause disjunction at the pubic symphysis, even the empty
bladder may be bruised, punctured, or lacerated.  Horns, weapons,
or pointed  stakes may wound this viscus  when  driven  into the peri-
neum or rectum, through the  obturator or sciatic foramen, or above
the pubis.  Bullets may reach the bladder either through the outlets
of the pelvis or directly through its bony substance.  Rough instru-
mentation  may cause  laceration of the vesical walls.  Finally, when
the bladder is full or overdistended, force applied from without, even
though insufficient to cause disjuncture of the pelvic bones or super-
ficial  bruising,  may  occasion either  contusion or rupture of the
bladder.
   Wounds of the  Bladder.—The term  wound implies a solution
of the continuity of the soft  parts extending from the skin surface
down to the bladder-lesion.  Rupture and contusions will be sepa-
rately considered.   Nearly all  wounds  of  the  bladder can be classed
as contused  or lacerated, including  under  these headings gunshot
wounds.
   Incised wounds  are usually inflicted by the surgeon, either inten-
tionally, as in cystotomy, or accidentally, as in  extirpation of pelvic
tumors.  In the latter  case prompt closure of the wound by suture is
nearly always followed by immediate  union,  the danger  incident to
this accident lying in the risk  that it may be overlooked.  When the
wound does not entirely penetrate the visceral wall,  involving, for in-
stance, the  serous and  muscular coats only, the mucous coat remaining
intact prevents extravasation, and cicatrization is unhindered.
   Direct punctured wounds, such as would be inflicted  by a sword
or a stiletto, are rare.
   Contused and lacerated wounds, the common variety, are usually
inflicted by way of the perineum or the rectum,  as the result of a fall
upon  a stake or a paling, or are  due to wounding by firearms.   They 
INJURIES AND  DISEASES OF THE BLADDER.
605
are also  caused by inadvertence in surgical manipulations.  Thus,
Neumann in extracting a stone adherent to the vesical wall in a boy,
aged nine,  tore an  opening through both bladder  and rectum.  In
accordance with the portion of  the  bladder involved the wound is
termed intraperitoneal  or extraperitoneal.   From the stand-point of
prognosis this classification is highly important.
   Symptoms.—The symptoms of wound of the bladder are—1, escape
of urine through the wound ; 2, frequent straining efforts at urination,
with the passage of blood  or bloody urine ; 3, the detection of an
opening  in the bladder by  means  of  a probe passed through the
wound, or  of a sound  passed through the urethra, aided by digital
examination per rectum, or by a combination of these methods ;  4,
shock.
   All these symptoms may be  absent except blood in the urine.
Escape of urine through the wound can take  place  only when the
tract of the latter is  of some size and is fairly direct.   In the case of a
small wound, such as would be made by a twenty-two-calibre pistol-
ball, the  tract remains direct only so long as the bladder maintains
the same degree  of distention as at the moment of wounding.  In
consequence of the traumatism the urine almost immediately escapes,
and as the bladder  contracts the opening through its walls no longer
lies in the same line as the wound of the parietes.   Moreover, con-
traction of the muscular layers makes the opening through their sub-
stance smaller, and the mucous membrane has a  tendency to pro-
lapse, and  thus  occlude the wound more or less completely.  It is
only when the wound is large  and direct that this  pathognomonic
sign of bladder-rupture will be found.
   Though  tenesmus and the frequent voiding of  a small  quantity
of blood or bloody urine are noted as a rule, these symptoms are not
invariably excited.  There may be absolute inability to pass anything
from the bladder by the urethra.  Introduction of a probe into the
bladder through the wound  is most difficult where this viscus has
changed  the relation of its wounded  wall  to the parietes, though
when this manoeuvre is successful, and when the probe can be made
to strike  a metal catheter carried  through the urethra into the bladder,
the diagnosis is, of course, certain.
   Complications of Wounds of the Bladder.—Immediately following
a wound of the  bladder  hemorrhage may prove a  serious complica-
tion ; this, when so violent as to threaten  immediate death,  nearly
always comes from the large vascular trunks in the pelvis, and not
from the  bladder-wall.
   In a  few hours  or  days  usually, but sometimes in cases of gun- 
606
GENITO-URINARY  DISEASES AND SYPHILIS.
shot wounds not until after one or two weeks, septic peritonitis  may
develop from  intraperitoneal wounds, or septic  cellulitis from extra-
peritoneal wounds.
   The remote  complications are fistulae, which may pass from the
bladder to the vagina, to the rectum, or to  the external skin  surface,
and concretions  which may be formed around foreign bodies, such as
shot, bullets, fragments of the garments, or splinters of bone.
   Diagnosis.—When the typical symptoms are present the diagnosis
is easily made.  When these symptoms are  mainly wanting  and the
presence of bloody urine and a wound of  entrance  passing in the
direction of the  bladder are the only signs  suggestive of the lesion,
examination of the  vesical  walls by means of a sound passed  through
the urethra, aided by digital exploration through the rectum, is indi-
cated.   If this is not conclusive in its results, the injection and imme-
diate withdrawal of a measured quantity of  dilute antiseptic  solution
may prove serviceable.   (See Rupture of the Bladder.)  If this does
not clear the  diagnosis, the cystoscope should be used, the  bladder
being first washed  clear of blood  by irrigation with a hot antiseptic
solution.  If there is too much blood in the bladder to  allow of the
use of the cystoscope, suprapubic or perineal cystotomy should be
performed for the purpose of establishing  the diagnosis, the choice
of operation depending on the position of the external wound.
   Prognosis.—This depends upon whether  the wound is extraperi-
toneal or  intraperitoneal.  The intraperitoneal wounds are generally
fatal from septic peritonitis, though recovery from extravasated urine
becoming encysted  and  absorbed, or from  closure of the bladder-
wound by adherence  of bowel or omentum to its peritoneal aspect, is
possible.
   The prognosis of  extraperitoneal wounds is much more favora-
ble ; in the absence of lesions of other organs the large majority will
recover.   Large, clean, direct wounds, and wounds  inflicted  by vul-
nerating bodies  entering through  the rectum or the vagina, usually
drain well.  The outlook for gunshot wounds is favorable in  propor-
tion to the freedom with which  urine  escapes to the surface: hence
wounds of both  entrance and exit are less serious than wounds of en-
trance alone.  When from lack  of thorough  drainage extraperitoneal
urinary extravasation and cellulitis occur, the symptoms become pro-
nounced at about the end of the first week.
   Treatment.—Since extravasation of urine  and subsequent septic
inflammation are the main  dangers incident to wound of  the bladder,
the most important indication in the treatment of these wounds is so
to provide for  drainage of the bladder that there can be no accumu- 
INJURIES  AND DISEASES  OF THE  BLADDER.
607
lation of urine, and hence  no condition  favoring escape of this fluid
into the peritoneal cavity or the cellular tissues.
   When the wound is intraperitoneal, it is safe to assume that blood
and urine have already entered the  peritoneal cavity.  Hence imme-
diate laparotomy is advisable, followed by careful toilet of the perito-
neum, closure of the bladder-opening by suture, closure of the wound,
and either suprapubic  or perineal drainage or permanent catheteriza-
tion. In  case the  catheter is repeatedly blocked by  clots,  drainage
by  incision should  be resorted to  at once.  The urine  should be
rendered  antiseptic by the administration of salol and  boric acid, and
all manipulations must be conducted with the utmost cleanliness, since
the wounded bladder  is strongly predisposed  to cystitis.   When the
wound is extraperitoneal, suprapubic or perineal drainage is indicated
in accordance with the position and direction of the wound.  Suture
of the bladder is in these cases rarely practicable.
    Hemorrhage is  treated in  accordance with general indications,—
i.e., when it is moderate, injections of hot astringent antiseptics (four
per cent, solution of antipyrin) may be  employed, together with the
internal administration of ergotin.   When it is severe  and persistent,
it may require packing, the application of forceps, or incision, exposure
of the bleeding points, and ligation.
    Peritonitis requires immediate laparotomy, cleansing, and thorough
drainage.
    Pelvic cellulitis is  treated by free incisions carried deep into the
perineum, the ischio-rectal  fossa, over the pubis  into the  space of
Retzius, or wherever else there is a  uro-purulent infiltration.
   Contusion of  the Bladder.—Contusion  of  a healthy bladder
without rupture of its walls, though proved to be  possible by a few
reported cases, is  probably a  rare form  of injury.  Theoretically it
may be produced by the causes which occasion rupture of this viscus,
particularly by force applied to the anterior abdominal wall when the
bladder is overdistended.   It  is easy to  imagine that if this force is
concentrated it may cause rupture of some of  the blood-vessels lying
in or beneath the mucous  membrane, and thus may  cause bleeding
into the bladder.
   The symptoms  of  this  injury are commonly partial  or complete
retention, tenesmus, pain, tenderness, and the passage of blood-stained
urine and of clots.   Shock should be moderate or altogether wanting.
It  is possible,  particularly in  a bladder which  has  been the seat of
disease, that bleeding may be  persistent and severe.
   The diagnosis is of importance, since  this injury must  be distin-
guished from rupture.   Examination with the cystoscope after bleed- 
608
GENITO-URINARY DISEASES AND SYPHILIS.
ing has stopped  may aid in excluding rupture.   Most  reliance can
be placed  on injection of the bladder with a  measured quantity of
antiseptic solution.   If such a solution is  forced in under moderate
pressure, is retained for  two or three minutes, and  on being with-
drawn by a catheter is found to have lost nothing in volume, it is fair
to assume  that there is  no breach in the continuity of the vesical
wall.
    Treatment.—The  treatment of contusion depends entirely on the
severity  of the symptoms.   When  bleeding  is slight  and  there is
little or no retention, rest, the mouth administration of urinary anti-
septics, and  the  control  of  tenesmus and pain by  hot baths, hot
abdominal  compresses, and  opium and belladonna suppositories will
fulfil the therapeutic indications.   Even when there is some  obstruc-
tion by blood-clots to the free passage of urine, it  is well  to abstain
from interference, provided  dirty instruments have not  been passed
into the bladder previously and the urine is sterile.  Should retention
become well marked, a  sterile full-sized catheter  should  be passed
immediately, under the antiseptic cautions described when treating of
retention, and  the  clots sucked out by a syringe,  or, if this  fails, by
means of the large evacuating catheter and aspirator of a litholapaxy
instrument.  If there is  persistent bleeding, continuous catheteriza-
tion is indicated.   Should the hemorrhage  be profuse, suprapubic
cystotomy  should  be performed; the bleeding points can  then  be
subjected to direct  treatment.  If there  is cystitis, clots should  be
evacuated,  even though there is no retention, and the bladder should
be irrigated twice daily with a mild antiseptic  solution (silver nitrate
1 to 1000,  boric acid four per cent., or Thiersch's solution).
    Rupture of the Bladder.—This injury  may be  either  intra-
peritoneal  or extraperitoneal.   It may be  traumatic or  pathological.
So-called idiopathic cases are always  secondary to some obstructive
or degenerative factor.  It usually occurs at about the prime  of life.
    The causes of rupture of the  bladder  are  predisposing  and ex-
citing.
    Of  the  predisposing causes the one of greatest  importance  is the
condition of distention.  Indeed, it  is difficult to  imagine how the
empty viscus can be  ruptured unless there  are  extensive concomitant
injuries.
    Alcoholism  is a predisposing factor, but  mainly because it  tends to
encourage  a condition of  over-distention of the bladder, from the fact
that it stimulates the kidneys, and  so obtunds  sensibility  that the
desire  to micturate is not  noticed, even when the bladder is full.
    Fixation  of the bladder by pelvic cellulitis, degeneration of its 
INJURIES  AND DISEASES OF  THE BLADDER.
609
walls from chronic cystitis or atheroma,  and disturbed  innervation,
may also be counted as predisposing factors.
   The exciting causes  are fracture of the  pelvis, separation of the
pubic  symphysis,  violence applied  either  directly or indirectly, and
muscular strain.   Thus, kicks in the stomach, falls upon  the ischium,
and the straining incident to parturition, defecation, urination, or lift-
ing, have caused this injury.
   Vesical tension from acute retention of urine, or from injections
practised for the cure of cystitis or in the preparation for stone oper-
ations, may cause  rupture of the  bladder without the intervention of
strains or traumatism.
   Thus, Dittel performed suprapubic cystotomy for the removal of a
stone in  a child aged three.  The bladder was injected with not more
than three  ounces,  and the colpeurynter contained not over four
ounces.   The  patient  perished the next day in collapse, with symp-
toms of  pericystitis.   In the  posterior wall of the bladder there was
found a tear two-fifths  of an inch in length, running into a diver-
ticulum.  This caused infiltration of the pericystic cellular tissue.
   Pathological rupture—that in which  the bladder-walls give way
from over-distention, without the  intervention of force—is usually due
to an enlarged prostate, since, in the case of stricture,  the urethra
usually ulcerates posterior to the seat of narrowing, and tension is re-
lieved by extravasation of urine  into the periurethral cellular tissues.
It is probable  that  the  majority  of cases of rupture attributable to
muscular strain will exhibit pathological changes incident to urethral
obstruction, the great  thickening  of the bladder-walls occasioned  by
such obstruction proving no safeguard against this accident.  Cystitis
in these cases is usually complicated either by ulceration  or by saccu-
lation, thus  leaving  a weak portion, which may rupture from  slight
causes.
   The  seat of rupture may  be  either intraperitoneal or extraperi-
toneal.  Fenwick  states that it is intraperitoneal in  eighty-eight per
cent, of  cases.   Ulmann  estimates  the proportion at eighty-five per
cent.  The greater frequency of intraperitoneal rupture is partly due
to the fact that the area  covered by the peritoneum is larger and is
less reinforced  by the pressure of closely attached surrounding tissues.
Moreover, the peritoneum  is less elastic and distensible than the other
coats,  and, splitting  suddenly, tears the muscular and mucous coats
with it.  Direct force applied to the hypogastric region usually causes
a tear of the  upper and  posterior bladder-wall.  Ruptures due to
fracture of the  pelvis  and spontaneous ruptures are apt to be extra-
peritoneal.  The rupture  is commonly single, is vertical or oblique
                                39 
610
GENITO-URINARY  DISEASES AND  SYPHILIS.
in direction, and when intraperitoneal the peritoneal aspect is most
extensively torn.
   Symptoms.—The symptoms of rupture of the bladder are a sense
of something giving way within the  abdomen, hypogastric pain, often
agonizing, constant desire to urinate, passage of a few drops of blood,
or of blood-stained urine,  or failure to  pass anything, and severe
shock.
   Following  these symptoms,  under appropriate treatment  reaction
usually takes place, and there is a period, varying from hours to days,
during which the patient suffers from pain and tenderness in the hypo-
gastric region, tenesmus, and  a  constant desire to  micturate,  and
passes little or no urine.
   Exploration of the hypogastric region demonstrates percussion dul-
ness and a sense of resistance  closely simulating that of a distended
bladder,  while  rectal  examination may show effusion into Douglas's
cul-de-sac or  the cellular tissues lying at the base of the bladder.
There then follows, in  accordance with the  location  of the rupture,
either septic peritonitis, usually terminating fatally in five days, or cel-
lulitis, which progresses more slowly, and  is attended  with the symp-
toms of septicaemia, sometimes running a course of several weeks.
   Diagnosis.—The diagnosis of rupture  of the bladder is founded
upon the history of the case, the symptoms already detailed, notably
shock, tenesmus, urgent desire to micturate, which the patient cannot
satisfy, or frequent urination and the passage of  blood, and  upon the
results of direct  examination.   All  the  subjective symptoms may be
excited by contusion of the abdomen ; if there is also contusion of the
bladder the urine will  contain blood.   The bladder may be ruptured
without exciting a single characteristic symptom.   Coates reports two
cases of rupture of the posterior wall in which the lesion was not sus-
pected during life, no signs of acute peritonitis having developed.  The
peritoneal cavity was flooded with sterile urine;  death was attributed
to absorption  of the urine by the peritoneum, with a consequent toxic
effect upon the blood.   Even when  the classical symptoms of rupture
of the bladder  are present,  it is only after exploration that a positive
opinion can be expressed.
   The  simplest method of exploration consists in the  passage of a
thoroughly sterilized silver  catheter.  If this draws off bloody urine
and  clots, the probability of rupture is strong.  If on manipulation of
the  shaft so that the tip is made to traverse the  inner surface of the
bladder  this  tip repeatedly catches  at one point, and apparently can
be passed through the bladder-wall, so that it can be  felt immediately
below the skin  or  mucous membrane surface  by palpation in the 
INJURIES  AND DISEASES OF THE  BLADDER.
611
hypogastric region or through the rectum,  there  can no longer be
doubt about the existence of a rupture.
   When this means of exploration fails, the cystoscope is available,
but only after active bleeding has. ceased.
   The injection of an antiseptic solution is by no means an infallible
test, since even an extensive rupture may so quickly close  by inflam-
matory adhesion that a solution injected with gentle pressure fails to
break  this down, and the total  quantity injected is at once returned.
   Weir states that this  injection method  (Cabot's) is made more
reliable by several repetitions, enough fluid being driven in each time
markedly to distend the bladder.  The method is rendered still more
serviceable by preceding the injection by a careful  digital examination
of the rectum, followed by the insertion and distention of  the Barnes
bag.   The bladder is then injected with a known volume of fluid.  If
there results rapid  increase  in pelvic tumor and dulness,  as  detected
by suprapubic examination, this must  be due either to the distended
bladder or to extravasated fluid.  In the latter event failure to recover
by catheterization all  the fluid injected will show the presence of an
extraperitoneal rupture.  In  case there is developed no  suprapubic
dulness, but all the fluid is  not recovered,  there  must be either an
intraperitoneal  or a subperitoneal postero-inferior rupture.   In the
latter  case withdrawal of the Barnes bag and a second digital exam-
ination of the rectum will show the  increase of extravasation.   The
injection of air is not more reliable as a means of diagnosis than is
that of water.
   In case  of  doubt  there should  be no  hesitation  in   performing
either a subpubic or  a perineal cystotomy  and  thoroughly exploring
the bladder by the finger and by sight.  Always, when instruments are
used for diagnostic purposes,  the principles  of  surgical  cleanliness
must be minutely observed, and if a rupture is found, operation should
be performed at once.
   Prognosis.—Rupture of  the  bladder results fatally in  a large pro-
portion of cases, and the prognosis is particularly grave when the  rent
is complicated by fracture of the pelvis and when it is intraperitoneal,
death resulting in the great majority of these  cases in the first five days.
Spontaneous recovery, though  possible, is  so rare as to constitute  a
surgical curiosity.   The extraperitoneal tears are somewhat less fatal,
but in the  absence of  proper surgical intervention the  majority of
these  perish.   The  prognosis  is  undoubtedly  better to-day, when
antiseptics are generally employed in the treatment of bladder-lesions,
than in the former  septic period.   The urine when  first extravasated
from a healthy bladder is a sterile fluid and does not cause inflamma- 
612        GENITO-URINARY  DISEASES AND SYPHILIS.

tion.  Hence, if not infected by the use of dirty instruments, it under-
goes changes slowly.
   The conditions for germ-growth are, however, so favorable that
the slightest infection is followed by rapid and extensive suppuration.
Sieur proves by a statistical study that  the mortality from traumatic
rupture of the  bladder has been reduced in the  last fifteen years
from  ninety  to  a little over fifty per  cent.  He tabulates  eighteen
cases of extraperitoneal rupture treated by operation ; of these, ten
recovered.   Thirty-four cases of intraperitoneal rupture were sub-
ject to operation, with fourteen recoveries.  There is every reason to
believe that these statistics would have been still more favorable had
operation  been performed earlier.
   Schlanger notes ten recoveries out  of twenty-two operations for
intraperitoneal rupture.  Seven  out  of ten were cured when  the
rupture was extraperitoneal.
    Treatment.—If the wound is intraperitoneal, an  immediate lapa-
rotomy, thorough  cleansing of the peritoneal cavity, and closure  of
the bladder by suture are indicated.  It is important that this opera-
tion should be performed immediately,—that is, before the beginning
of peritonitis.  When exploration fails to show whether the rent is
intraperitoneal or  extraperitoneal, suprapubic cystotomy should  be
performed and  a  diagnosis thus  made; if further room is required,
the lateral incisions of Trendelenburg, or even symphyseotomy, may
be necessary.
   The suture by which intraperitoneal bladder-wounds are closed is
applied exactly as is  the  Czerny-Lembert  suture  in dealing with
wounds of the gut: that is, the  stitches are  placed  about six to  an
inch; the first row, preferably of fine sterile catgut, closes the rent,
each  stitch including all but the mucous  coat of the bladder; this
line of union  is then  turned in by a second row of Lembert sutures;
the needle is passed in  and out on one side of the wound vertical to
its length, and, including the serous and muscular coats, it crosses the
wound and is passed  in and out  as before on the opposite side.  If
these sutures are knotted the peritoneal  surfaces are brought in appo-
sition, and inflammatory agglutination takes place in less than twenty-
four hours.  Clinical experience shows that  when the sutures have
been  properly applied  there is no tendency  to the reopening of the
wound.  To make sure that the wound has been thoroughly closed,
the bladder should be moderately distended with mild antiseptic solu-
tion ; if apposition is perfect there will be no leakage.  The perito-
neum should be thoroughly cleaned of clots and of extravasated urine.
This is best accomplished by dry sponging.   When  septic peritonitis 
         INJURIES AND DISEASES OF THE BLADDER.       61.3

has already been excited, hot irrigation with normal saline solution is
indicated, followed by  drainage-tubes, or  the  antiseptic tampon  in
accordance with Mickulicz's method.   In large, irregular, contused or
lacerated wounds of a diseased bladder the line of suture cannot be
trusted.  The wound should be rapidly closed by a continuous catgut
suture,  and gauze  drainage running down to the region of injury
should be continued for several days.
   When suprapubic cystotomy has been  performed  for exploratory
purposes and the  rent is found  to  be extraperitoneal, it should be
thoroughly cleansed and closed by interrupted suture.  The results,
so far as the closure of the wound is concerned, are not so satisfactory
as those obtained by the suture of intraperitoneal openings.   Hence
a drainage-tube or a gauze tampon should lead to the seat of injury,
thus providing for the  free escape of urine in case the sutures should
give way.
   The after-treatment of operation  for bladder rupture consists  in
the employment of continuous  catheterization for from three to eight
days, after which the patient is allowed to urinate.   The method of
using continuous  catheterization is the same as that described under
the treatment of retention  from prostatic enlargement.  Extraperito-
neal  ruptures  are  treated by  permanent  catheterization,  supple-
mented by  antiseptic irrigation  of the  bladder practised night and
morning.  If the surgeon  distrusts   the  permanent catheter, as he
should  do in most  cases with extensive  and complicated  wounds,
suprapubic  siphon  drainage or the  insertion of a tube through the
perineum is indicated.
   Pain, particularly that referred to the  rectum and running down
the thighs, and rigors and fever, point to extravasation and cellulitis,
and indicate either a suprapubic or a perineal cystotomy.  The supra-
pubic operation is preferable unless oedema, tenderness, and swelling
show that the perineum is the seat of infiltration. 
CHAPTER  XVI.
                     examination  of the urine.

    In interpreting the results of urinary examinations the constituents
of the patient's diet must be known and controlled.  Under certain
conditions the diet alone may be responsible for an albuminuria or a
glycosuria; and it would be obviously misleading to make a quanti-
tative determination of urea or of lime, for example, without knowing
the character of the patient's food.  Alterations in the urine are thus
clinically reliable only when the diet, regimen, and life-conditions of
the patient have been taken into careful consideration.
    For the purposes of the present work the analysis  of the urine
may be conveniently divided  into  three groups of estimations.   In
the first group are the  estimations of the quantitative alterations of
normal constituents; the second group comprises the estimations of
abnormal substances ; while in the third group are the determinations
of the urinary sediment, which are of especial importance to  the
surgeon.
    Alterations in the Quantity of Urine.—The normal quantity
may vary from one  to five pints  per diem, depending  upon  various
obvious conditions; the  average  is from two to  three pints.  The
quantitative variations are  classified under the headings  polyuria,
oliguria, and anuria. Strictly  speaking, polyuria and  oliguria need
refer only to the amount of water, but generally the constituents are
more or less altered.
    Polyuria is an excess in the total  bulk of urine beyond the physio-
logical maximum, and  the excess may reach two gallons, or even
more.   Polyuria occurs  in  diabetes mellitus, insipidus, and phos-
phaticus;   in interstitial  nephritis and  amyloid degeneration of  the
kidneys; following a crisis  in fevers and during  convalescence from
many diseases ; and in many functional and organic diseases of the ner-
vous system, such as conditions of  excitement, nervous tension, and
overwork.   Periodical polyuria is observed  during the absorption of
large exudations,  and is  sometimes  a suggestive  symptom of hydro-
nephrosis or obstructing  renal calculus.
    Oliguria, or  quantitative diminution of the urine, is present in
fevers  and  infections ;  when the balance of the circulation is dis-
     614 
EXAMINATION  OF THE  URINE.
615
turbed, or when  local conditions, as pressure upon renal vessels  by
tumor, ascites, or torsion, interfere with the local renal circulation;
in acute glomerulonephritis and acute and chronic parenchymatous
and septic or suppurative nephritis ; in  many cases of hydronephrosis,
renal calculus, tuberculosis, or malignant disease of the kidneys; and
in some nervous  diseases.
   Anuria is  the complete suppression  of urine.  There  are two
varieties.
   In one the main fault  lies in the renal structure;  it occurs in
some  cases of nephritis, especially the post-scarlatinal  nephritis, in
the intoxications  of the infectious diseases, especially cholera, and in
profuse diarrhoeas.  Exceptionally it is due to the pressure of a tumor
or of  ascites,  or  may be produced  by poisons, such  as cantharides.
In these cases the symptoms of uraemia appear early.
   The second variety  of  anuria is due to reflex inhibition.  It is
seen in hysteria and in other  functional and organic nervous dis-
eases, and it is in these  cases  that the condition may persist, lasting
many days without  causing threatening symptoms.  Apparently it is
shown that a calculus by blocking one ureter or  irritating the pelvis
of one kidney may cause complete bilateral  suppression, and com-
plete suppression has been produced by torsion of the vessels of one
floating kidney.   It  also occurs in intestinal strangulation or other
obstruction.   In  these cases the symptoms of uraemia are for a long
time deferred.
   Alterations  in the Specific  Gravity.—These  are important,
because, if the total  quantity  of urine be borne  in  mind, they are
often an index of the quantity of metabolic excrementa.
   The normal specific gravity may vary from 1015 to 1030, averaging
about 1018 to 1020.
   With a normal elimination  of the metabolic products the specific
gravity will be high  in  oliguria  and low in polyuria in proportion to
the concentration or dilution.   Low specific gravity of the  urine in
parenchymatous  nephritis is a sign of  diminished elimination of the
organic constituents ; the low specific gravity in interstitial nephritis is
largely due to dilution.   In chronic nephritis a sudden fall in specific
gravity is often a prodrome of  uraemia.  The specific gravity is re-
duced by decomposition within the bladder.  The high  specific gravity
in diabetes mellitus is not always proportionate to the amount of sugar
in the  urine.
   Alterations  in Color.—Normally the urine is a clear straw-yel-
low.   It is dark in most febrile conditions.  Bile gives it a brownish-
yellow color, often with a tinge of green  ; the foam formed by shaking it 
616        GENITO-URINARY  DISEASES AND SYPHILIS.

is yellow,—a condition, however, which may be produced by an excess
of urobilin.
   An excess of the aromatic sulphates gives the urine a deep-brown
color, also seen in cases of pathological urobilin.   Blood tinges the
urine from a pale pink to a deep red.
   Alkaline urine is a cloudy, flocculent yellow.  A great deal of pus
produces a milky opacity.  The appearance in chyluria is  that of
thin  cream.
   Carbolic acid and the  many allied  coal-tar compounds appear in
the urine in part as hydrochinone, which colors  the  fluid a smoky
black; others, as  the  coal-tar  antipyretics, sulphonal, and the allied
hypnotics, may produce haematoporphyrinuria, with the evolution of
a pink or red color.
   The color of the normal  urine is largely due to urobilin and uro-
erythrin, and varies considerably.  The color in polyuria is generally
pale, in oliguria intense.
   Alterations in Reaction.—The reaction of the total day's urine
is faintly acid, due to acid phosphates and urates.   There is generally
an alkaline wave at the height of digestion.  The acidity is especially
increased in fever, in diabetes, and often in the blood dyscrasiae.
   The reaction is alkaline in phosphaturia, and in all conditions as-
sociated  with  decomposition  of the urea within the tract, particularly
in cystitis.  An animal diet increases the acidity, a vegetable diet
decreases it.
   When large  transudations  are being formed, the acidity of the
urine is increased ; it is decreased when the transudates are being ab-
sorbed.  The urine is alkaline during an attack of paroxysmal haemo-
globinuria and following serous transfusions or large subcutaneous or
intravenous saline injections.   There are some obscure alterations of
metabolism in which the urine  is alkaline.
   All the mineral acids and most organic acids, especially boric and
benzoic acids, increase the acidity of  the urine.  The hydrates and
carbonates of sodium,  potassium, calcium, and magnesium, and the
salts of the vegetable acids which are eliminated as alkaline carbon-
ates,—acetic, citric, tartaric acids, etc.,—diminish the acidity or render
the urine alkaline.
   Quantitative Alterations of Normal  Constituents.—Chlo-
rides.—The chlorides in the urine are of sodium, potassium, ammo-
nium, and magnesium.   The amount  corresponds to from one and a
fourth to three drachms of sodium chloride daily.
   The elimination  is  increased in all  conditions in which there is
blood in the  urine; following  the absorption of large exudates; in 
EXAMINATION  OF THE  URINE.
617
poisoning by pyrogallic  acid, methyl chloride, and  all other agents
which disintegrate the blood ;  in malaria and acute interstitial  hepa-
titis; and following a chloroform narcosis.   The  elimination is de-
creased in fevers, and especially in  the  exudative  stages of pneumo-
nia and the acute serous inflammations  ; in poisoning by phosphorus
and carbon monoxide; in  some cases of chronic  nephritis; in dila-
tation of the stomach, and in all cases of  profuse intestinal discharges.
The  chlorides are  estimated  as silver chloride by the volumetric or
the gravimetric method.
   Sulphur.—Sulphur exists in the  urine mainly as preformed sul-
phates of sodium, potassium, and calcium, as the ether sulphates, and
as neutral sulphur.  The total quantity  corresponds  to from one and
five-tenths to  three grammes of sulphuric oxide per diem; the ratio
of the preformed to the  ether sulphates varies from ten to  one to
eighteen to one.
   The  aromatic sulphates are strikingly increased in  many con-
ditions :  in most infectious fevers, and  especially in advanced tuber-
culosis;  in intestinal putrefaction  of all kinds,  and  in  intestinal
obstructions;  in internal suppuration, especially of  the large serous
membranes, in internal gangrene, and in rapid muscular atrophy due
to any cause;  in diabetes; and in poisoning by the  phenol com-
pounds, thymol, ichthyol,  camphor, phosphorus, the salicylates, and
the aromatic oils, as terebene, etc.
   Indican is one of the ether sulphates  (indoxyl-sulphuric acid), and,
as it possesses  a striking  reaction, it has been largely taken as the
most  available clinical representative of  this group.  A  convenient
test for indican is to add to ten  cubic centimetres of urine one or two
cubic centimetres of a twenty per cent,  aqueous solution of plumbic
subacetate, and  filter; to the filtrate  is added an  equal volume of a
one-half per cent,  solution of ferric  chloride in strong hydrochloric
acid, and the  mixture thoroughly shaken, when the indigo-blue re-
action appears, and the coloring matter can be extracted with chloro-
form. If intestinal conditions can be excluded, a strong reaction of
indican can be taken as evidence of rapid disintegration of albumen
somewhere in the system.
   The neutral sulphur constitutes about fifteen per  cent,  of the total
sulphur;  it consists of organic compounds.  It is strikingly increased
in all cases of  obstruction of the  common bile-duct, and to  a less
extent in non-obstructive jaundice.
   Sulphur may also appear in  the urine in the form of sulphuretted
hydrogen.  It may enter the urine through fistulous tracts, may pene-
trate the  bladder from adjacent necrotic  areas, and may be evolved 
618
GENITO-URINARY  DISEASES AND SYPHILIS.
in the urine of severe cases of cystitis through the action of a special
bacterium.
   The amount  of  total  sulphur should  be  estimated as barium
sulphate; the  aromatic  sulphates are estimated by the Baumann-
Salkowski method;  the  presence of sulphuretted hydrogen can  be
determined  readily by its odor and its reactions with the metals.
   Phosphates.—Phosphates are present as the diacid, acid, and
simple sodium, potassium, calcium, and magnesium  phosphates, the
ratio of the alkaline to the earthy phosphates  being as 2.5 to 1.  The
total amount corresponds to from three to four grammes of phosphoric
oxide daily.  The acid salts are most soluble, the basic least of all.
True phosphaturia,  an actual increase  in  the  elimination of phos-
phoric oxide, is very rare, though it does occur in some cases  of
obscure diabetes phosphaticus, in saccharine and insipid diabetes, and
in tuberculous  bone disease.  An excess does not occur in rachitis or
osteomalacia.
   There is a form of so-called phosphaturia with alkaline urine, and
the consequent precipitation  of the phosphates, not  connected  with
cystitis or other inflammatory condition: while it is quite certain that
this is not dependent on  an excess of eliminated phosphates, it is not
known whether it is caused by an increased alkalinity of the blood
(which  may  be due  to the diet) or to a reflex  secretive  anomaly  of
the kidneys  secondary to  some functional  neurosis.  It is especially
seen in neurasthenics with gastric disturbances.  The phosphates are
of surgical interest because of their precipitation by the alkaline urine
of cystitis and  the relation of the sediment  to calculus.
   The total phosphates  are estimated by  titration with uranium
nitrate.   The phosphatic precipitate of  alkaline urine has a whitish
color, and is  dissolved by the addition of sufficient acid to render the
urine acid in reaction.
   Carbonates.—There is carbon dioxide in solution in the urine,
and the alkaline calcium, magnesium, and ammonium carbonates exist
in minute quantities.  They are increased by fever, by  a vegetable
diet, and particularly in the alkaline urine of cystitis, when the carbon
dioxide is derived from the decomposition of urea.
   Sodium is present in the  urine to the  extent of from four to six
grammes  (estimated as  oxide) daily.  It is especially decreased  in
fevers, and is increased in haematuria.
   Potassium.—The amount of potassium  eliminated in the urine is
not much affected by fevers, but it is markedly increased in conditions
of rapid breaking down  of tissues, as acute yellow atrophy of the
liver, internal suppurations, and haematuria. 
EXAMINATION OF THE  URINE.
619
   Ammonia.—The quantity of ammonia eliminated daily is from one-
 half to one gramme; this is much increased in fever, in most hepatic
 diseases, and in diabetes. Very large amounts of ammonia are formed
 in the alkaline decomposition of  cystitis.
   Magnesium and calcium are eliminated to the extent of 0.12 gramme
 and 0.25 gramme  respectively daily.   The  proportional excretion is
 less in infancy, in old age, in  pregnancy, in  fevers, and  in profuse  in-
 testinal discharges.  An excess  is seen in some cases of phthisis, of
 organic brain disease, of diabetes, of ostitis, and of tumors  of bone,
 also in chyluria.  The calcium elimination  (as well as  absorption) is
 normal in both rachitis and osteomalacia.
   Urea.—The amount of urea normally excreted varies from twenty
 to forty-five grammes daily.  The formation and elimination are  in-
 creased in fever, in bacterial or leucomaine intoxication, in conditions
 of tissue-absorption due to any cause, as  in the  severe anaemiae, in
 scorbutus, diabetes, and chronic constipation, during the absorption
 of exudates or transudates, by hot or cold baths, and by many drugs,
 as chloroform, caffeine, morphine, and the salicylates.  The  elimina-
 tion  is decreased in starvation  and malnutrition; in nearly all the
 acute and chronic hepatic diseases, especially acute yellow atrophy;
 in nearly all cases of organic renal disease, with  the exception of pri-
 mary interstitial nephritis.  Of drugs, the bromides especially reduce
 the urea.
   It is irregularly increased or decreased in various functional  and
 organic nervous diseases.  The quantitative estimation of urea can be
 appropriately  accomplished by the hypobromite  method with the use
 of Marshall's  apparatus. A much more accurate  but  more difficult
 determination is to make a total  nitrogen estimation by the Kehldahl
 method.  Crystals of urea  nitrate (Fig. 179, 6) may be prepared  for
 microscopic examination by the  addition of an  excess  of nitric acid
 to a concentrated alcoholic  solution of urea, made by adding alcohol
 to urine which has been evaporated to a syrupy  consistence, filtering,
 and again evaporating.
   Uric Acid.—The daily elimination ranges from one-tenth to  one
 gramme.   It is increased in acute fevers ;  in all  conditions associated
 with  exudation;  in leukaemia, in some  dyspepsias, in phosphorus
 poisoning, and in some nervous diseases.   The salicylates,  alkaline
 carbonates, glycerin, and  hot baths  are  believed to stimulate  the
 output of uric acid.  The  elimination is decreased in some  cases  of
nephritis, in diabetes, the anaemias, and lead poisoning, and by qui-
nine and  alcohol.   The  excretion in lithaemia, gout, and rheumatism
is irregular, and variations are inconstant both  during  and between 
620
GENITO-URINARY  DISEASES AND  SYPHILIS.
attacks, so that the amount is not an index of the presence or severity
of any of these conditions.  Uric  acid  should be estimated by the
Salkowski silver method.
   Kreatinin is eliminated to the extent  of one gramme daily.  Aside
from the fact that it is increased  in all conditions  of rapid tissue-
disintegration, as in fevers, suppuration, and gangrene, we  have  no
knowledge of it which has a clinical application.
   Like uric  acid, it reduces cupric  sulphate  in alkaline solutions,
and may thus give rise to fallacy  in  the test  for sugar by Fehling's
solution.
   The compounds known  as  the xanthin bases exist in traces in
normal urine.  They are increased  in  leukaemia and  in  some con-
ditions of auto-intoxication.
   The many compounds of the aromatic series normal in urine are,
apart from the diet, due to bacterial  disintegration of proteids either
in the alimentary tract or in the  tissues.   They circulate partly as
oxyacids and partly as ether-sulphates, under which heading patho-
logical alterations have been included.
   Closely allied to the xanthin bases and the aromatic series are the
ptomaines and toxins, of which normal urine contains a trace.  They
are increased in many conditions,  and  are to be viewed as  elimina-
tions of poisons absorbed from  the alimentary tract or from  diseased
areas formed in the body by the chemical actions of bacteria or  by
an altered metabolism.   The clinical  examination of these substances
has not yet been formulated.
   Oxalic Acid.—Normal urine contains a trace of ammonium ox-
alate, 0.05 gramme.  Although  the  oxalates in the diet are  partly
absorbed and partly eliminated, the normal oxalic acid  in the urine is
not derived from the diet, but is a product of metabolism.  The amount
is strikingly increased in diabetes,  in jaundice,  and in many cases of
chronic gastritis and enteritis;  to a less  degree in the infectious dis-
eases and in functional and organic nervous diseases.  It is also cer-
tain that oxalic acid may be formed in the bladder  in  certain  cases
of cystitis.
   There is an obscure condition known as essential oxaluria or the
oxalic  diathesis, in which the elimination of oxalic acid is markedly,
though irregularly, increased.   In these cases of oxaluria  there is
an especial tendency to the formation of calculus.  Though  essential
oxaluria has been  shown to be connected with  disturbances  of either
the nitrogenous or the carbohydrate  metabolism, there are no  condi-
tions in the  urine to indicate in  an  individual case in which  direction
the disturbance lies.  The number of crystals of  calcium oxalate is 
EXAMINATION  OF THE  URINE.
621
not always  proportional to the quantity of oxalic acid in the urine,
for which reason quantitative tests are often desirable.   These may
be accomplished by the modified method of Neubauer.
   Urobilin.—A trace of urobilin is a normal product of the  renal
epithelium.   In conditions  of pathological urobilinuria the  urine  is
brown in color,—light or  dark according to the amount  of  urobilin.
It is moderately increased in the  infectious fevers, in most  cases of
acute or chronic hepatic disease,  in the essential anaemias and  other
blood  dyscrasiae, and after prolonged  ether or chloroform  narcosis.
An  excess  is constant following  internal hemorrhage,  as apoplexy,
haematocele, or bleeding with extra-uterine pregnancy.  It is best de-
tected with the spectroscope ; in alkaline urine it has absorption bands
at F;  chemically it may be tested by extraction from the urine with
chloroform, to which Lugol's solution and potassium hydrate  are then
added, when a green fluorescence is produced, which is  intense ac-
cording to the amount of  urobilin.
   HiEMATOPORPHYRiN is likewise present in normal urine as the  faint-
est trace.  It is greatly increased after internal or intestinal hemor-
rhage, in some acute febrile processes, and especially following pro-
longed use of sulphonal, trional, and tetronal.   It is recognized by its
absorption bands: two faint bands at C-D and D-E, two heavy bands
at D and b-F.   It colors the urine pink or red.
   Acetone.—A trace is present  in  normal urine.  It is in excess in
many conditions.  Fever per se can produce it; it is constant in the
infectious diseases, and in some cases of gastro-intestinal  disturb-
ances, especially gastric dilatation.  It  is  also  seen in inanition and
marasmus, in the malignant cachexias, in extreme primary or secondary
anaemia,  and after chloroform narcosis.   There  is often a  striking
excess in diabetes.
   It is  probable  that it  occurs as  a result of  disturbed  nitrogenous
metabolism, and it is seen typically in conditions associated with  rapid
tissue-disintegration, as internal gangrene.   There are  rare  cases of
idiopathic acetonuria, and  it can  be produced  by  an  exclusive  meat
diet.
   To determine its presence a few drops of a fresh solution of sodium
nitro-prusside  should be added to  the suspected urine, followed by
a few drops of sodium hydrate, when a red color will be produced,
which is turned to purple by acetic acid.

             ABNORMAL SUBSTANCES  IN THE URINE.
   The  only proteid  normal  in urine  is a trace of nucleo-albumen,
which is  derived from the epithelium.   The proteids which  may ap- 
622
GENITO-URINARY  DISEASES AND SYPHILIS.
pear pathologically in greater or less  amount are serum-albumen,
globulin, the albumoses, peptone, fibrinogen or fibrin-globulin, and
nucleo-albumen.
    Serum-Albumen.—This proteid is not  present in the urine of
healthy adults living under the best conditions of life, but traces have
been found in a notable proportion of those whose diet, hygiene, and
conditions are  poor.   It is generally found in the urine of the new-
born, and often in that of the adolescent, without signs or  symptoms
of any disease.  In otherwise healthy adults a trace may follow slight
circulatory or digestive disturbances, excesses in exercise, or immod-
erate  indulgence  in meats without symptoms of malassimilation, or
may appear in the course of  various nervous diseases.   Nevertheless,
albuminuria should always arouse suspicion.
    The amount  of  albumen which may appear in the urine varies
from a trace to three per cent, by weight; what is clinically termed a
moderate  amount of albumen  corresponds  to from one-half to one
per cent.; a pronounced amount is over one per  cent.  Since in the
worst cases the amount eliminated amounts  to no more than fifteen
grammes daily, it is obvious that the actual loss of the  albumen itself
is of very trifling consequence to the organism.
    Renal albuminuria occurs in all forms of nephritis.   The albumen
is present in large quantities in  acute  and  chronic parenchymatous
nephritis,  in small  quantities in amyloid  and  chronic  interstitial
nephritis.   Indeed, while in parenchymatous nephritis albumen is, as
a rule, constant and  at times present in such quantity that the urine
solidifies on boiling,  in interstitial nephritis it may be absent for days
at a time.
    In pyelonephrosis and hydronephrosis the  amount, while usually
small, is variable  and liable to sudden fluctuations.
    Albuminuria occurs in  all febrile conditions and in the infectious
diseases, due partly to circulatory disturbances, partly to the altered
blood, and partly to the action of fever  and toxins  upon the renal
structure.  It is seen in all  acute and in many chronic diseases of
the alimentary tract; here  again it is toxic in nature.  It occurs in
general or local  circulatory  disturbance, due in the  main to conse-
quent  disturbance  of secretion, although in chronic heart disease
structural renal change  is eventually  added.  Any form of acute or
chronic heart disease may show albuminuria.
    The most common local conditions which  disturb the renal cir-
culation are  pressure upon the renal vessels, as by a tumor, and dis-
placement  of a floating kidney.  Renal ischaemia, although  much
rarer than arterial hyperaemia or venous stasis, is not uncommonly 
EXAMINATION  OF THE URINE.
623
the cause of albuminuria, as in cholera and severe diarrhoeas.  The
albuminuria of pregnancy  is likewise to be classed as a circulatory
disturbance, although intoxication plays a rdle.
   Transfusion of the serum of a different species is always followed
by albuminuria, which occurs in some cases of transfusion of human
serum or of saline solutions.
   In the  blood dyscrasiae, severe primary  or secondary  anaemia,
leukaemia, scurvy, purpura, and the cachexia of malignant disease or
of chronic syphilis or tuberculosis, there is generally a small amount
of albumen present  in the  urine, due to slight  structural changes in
the kidney, the result of malnutrition.
   There is frequently a transient albuminuria following the convul-
sions of epilepsy or  of organic nervous disease, not seen, as a rule,
after hysterical  convulsions.  A similar albuminuria is due to vaso-
motor disturbances,  as in the so-called cyclical  or paroxysmal albu-
minuria, which is  often reflex  to a cutaneous chilling,  as after a cold
bath.  Obviously blood or lymph exuding from the  kidney-substance
causes albuminuria,  and it  is thus seen in tuberculosis, malignant dis-
ease, suppuration, or stone in the substance of the kidney.
   Many drugs and  poisons cause albuminuria by arterial hyperaemia
and irritation of the epithelium.   The most common  of these  are
chloroform, ether, alcohol, carbolic  acid, salicylic acid  and  its salts,
corrosive mercuric chloride, arsenic, iodoform, phosphorus, lead, can-
tharides, turpentine,  and juniper.
   In jaundice  and haemoglobinuria  albumen is often present.  Ex-
ceptionally it can be  produced by excessive hyperacidity of the urine,
but uric acid per se does not produce it.
   In all these instances of albuminuria globulin  is present: a strict
serum-albuminuria is an extremely rare condition.
   Subrenal or contingent  albuminuria is most important from  the
surgical aspect.  Inflammation of the mucous membrane of the pelvis
of the kidney, of the  ureter, of  the bladder, or of the urethra, hemor-
rhage from  any of these areas, and malignant or tubercular disease,
all produce albumen in the urine, in small but variable amounts.   In
chyluria, or where lymph  or pus is emptied into the urinary tract,
albumen is  likewise present.  A calculus in the pelvis, ureter,  or
bladder usually causes albuminuria, but here the phenomenon is likely
to be irregular.  Inflammation or other disease of the seminal vesicles
causes albuminuria occasionally, and it is of course seen in sperma-
torrhoea.
   Renal albuminuria  must be  distinguished from subrenal  albu-
minuria by a careful  study  of the sediment for evidences of nephritis, 
624        GENITO-URINARY DISEASES AND SYPHILIS.

and  of the whole urine for evidences of the  special causes of sub-
renal albuminuria.
   Tests  for Albumen.—The urine should be clear;  if cloudy on ac-
count of urates, these should be brought  into solution by gentle heat
(taking care to keep below the coagulation point of albumen), other-
wise the  urine  should be  filtered.   Concentrated  urine should be
diluted; to the urine of cases of polyuria  a little sodium chloride may
be advantageously added.   A layer of urine should  be  carefully ap-
plied over a layer of nitric acid; at the  point of contact a colored
ring  will form  in all  normal urine, varying in intensity according to
the amount of urates and coloring matters present.  If  albumen be
present there will be  a white ring, faint or pronounced according to
the amount of albumen.  In this  method any pinic  acids present in
the urine  are precipitated with the exact appearance  of albumen, but
the ring disappears upon the addition of alcohol.
   Or a specimen of urine should be heated to the boiling point, and
a few drops of nitric  acid  added; if a cloudiness forms, albumen is
present.   If a precipitate formed  when the  urine was boiled, it may
have been phosphates or albumen;  in the  case of phosphates  they
will  be  dissolved  on  the addition of nitric  acid, while the albumen
precipitate will be intensified.  Pinic acids react here precisely as in
the contact method.
   A more delicate test is  afforded by potassium ferrocyanide.   To
a few cubic centimetres of urine a dozen drops of acetic acid  are
added, then a few7 drops  of a concentrated aqueous solution of potas-
sium ferrocyanide.  Should albumen be present a cloudiness will ap-
pear.  Or the acetic acid may be added  to the  ferrocyanide solution
and the test applied by the contact method, with the production of a
white ring of  albumen if it  be  present.   This is probably the  best
clinical test.
   Another handy method is to add to the urine a few drops of acetic
acid, and  then an equal volume of a saturated  solution of sodium or
magnesium sulphate or of sodium chloride and heat. Albumen will
be marked by a white precipitate.
   For  an emergency test  an aqueous  solution  of  metaphosphoric
acid  may be  used by the contact method; for this purpose solid
metaphosphoric acid should be carried and a solution prepared when
needed.
   The corrosive mercuric chloride solution made from the ordinary
antiseptic  corrosive chloride-tartaric acid tablets affords another ready
and very delicate test.  Mercury is indeed one of the most delicate
reagents for albumen, and it has  found its most perfect application in 
                 EXAMINATION OF  THE  URINE.              625

 Spiegler's solution:  hydrarg. chlor. corros., 8; acid, tartar., 4; glyce-
 rinum, 20 ; aqua, 400 (this must be fresh ;  it spoils in ten days).  To
 the urine a few drops of acetic acid are added ; it is then filtered ;  the
 filtrate is applied to the reagent by the contact method;  if albumen is
 present a white ring forms.  In the application of this method it must
 be borne in mind that it is so delicate that the slightest amount of al-
 bumen is detected by it, and it is  therefore best reserved for special
 cases, as one might  otherwise be led by it into too frequent diagnosis
 of urinary  disease.   A  pathological albuminuria which can be de-
 tected by Spiegler's reagent will usually show by the ferrocyanide test.
   These methods will detect serum-albumen, globulin, and primary
 albumoses; the last reacts also to the deutero-albumoses and to pep-
 tone.
   The quantitative estimation of albumen  can be made by the pre-
 cipitation by  heat and acetic  acid, following which  the albumen  is
 carefully washed  with  alcohol  and ether,  dried, and weighed.  The
 results of estimations by Esbach's albuminometer are no more  accu-
 rate  than those obtained by careful observation of the intensity of the
 reactions to the above-given tests.
   Globulin generally accompanies serum-albumen, in the propor-
 tion  of 1 to 8 : 15.   In the albuminuria of amyloid kidney, however,
 and  in  haematuria and pyuria, the ratio of globulin to serum-albumen
 is much higher,—1 to 1.5 :4 ; thus constituting an important element
 in differential diagnosis.
   Globulin can be precipitated from the other proteids by one-half
 saturation with  ammonium  sulphate ; this  precipitate  is washed,
 dried, and weighed ; the weight compared with the weight of the total
 albumen will give the serum-albumen-globulin ratio.
   Albumoses rarely  appear in an  ordinary case of albuminuria.
 They are, however, seen in the urine of some cases of eruptive fevers,
 in osteomalacia, in many cases of  bone-tumors, and in some cases of
 leukaemia.
   Very important is pyogenic  albumosuria (formerly called pyogenic
 peptonuria; it has been shown,  however, that the  proteids are gener-
 ally albumoses  and not true peptones).   It is seen  in conditions of in-
 ternal suppuration,—meningitis, appendicitis, purulent inflammations
 of the great serous  membranes, pneumonia,  and gangrene, also  in
 tuberculosis and chronic phosphorus poisoning.
   In testing for albumoses the urine must be fresh, as the natural
 enzymes of  the urine or bacteria can  produce albumoses from albu-
men.  Since semen contains albumoses, this  must be excluded.  If
albumen be present  it should be removed by simply boiling, and the
                              40 
626        GENITO-URINARY DISEASES AND SYPHILIS.

urine filtered while hot and boiled down.   To the cold filtrate ammo-
nium sulphate should be carefully added  up to complete saturation
and  any precipitate collected upon a filter and dissolved in  distilled
water.  To this  solution is then added an equal amount of a con-
centrated sodiilm chloride solution and of acetic acid a few drops at a
time, as long as the precipitate forms; the solution is then boiled.  If
on boiling the precipitate is lessened or disappears, to reappear, after
filtration while hot, in the cooled filtrate, albumoses are present if the
filtrate responds to the biuret test or Millon's reagent.
   Peptonuria.—True peptone is rarely present;  the peptonuria has
been shown to be caused  by albumoses which are not precipitated
by a neutral saturation with ammonium sulphate, the test employed.
True peptone survives a triple  precipitation (neutral, acid, alkaline)
with ammonium sulphate,  and has been  found so exceptionally that
it possesses no clinical value.
   Fibrinuria.—The  fibrin may or may not be in actual coagulation
when the urine is voided.   It is seen in some cases of profuse haema-
turia, in chyluria, and more constantly where there is a coagulation-
necrosis, as in membranous pyelitis or in  tuberculosis of the pelvis,
ureter, or bladder.
   Fibrin threads should be  collected on a filter-paper, washed, dis-
solved in hot one-half per cent, hydrochloric  acid solution,  and the
solution  then treated for albumen.  Threads  of similar appearance
have been described in the urine as the result of the action of micro-
organisms ; these can be differentiated from true fibrin by Weigert's
fibrin-stain (a modified Gram's stain).
   Nucleo-Albumen (mucin).—A trace of this proteid exists in normal
urine, but whether preformed or not is yet to be determined.  A nor-
mal  amount never affects the appearance of the urine. A pathological
quantity is visible in the urine as a cloud, which settles and draws with
it the sediment.
   If the urine be diluted  so that the saline  concentration  is  much
diminished, the nucleo-albumen will be precipitated  by the  addition
of acetic acid.
   A pathological increase  is seen in the blood dyscrasiae, jaundice,
and  venous renal stasis, and in many local conditions, notably pyelitis,
cystitis, cowperitis, prostatitis (prostatorrhoea), inflammation of the
seminal vesicles,  and  calculus anywhere in  the  urinary tract.
   True  mucin (a glycoproteid) is very rarely present in either nor-
mal  or pathological urine.   Mucin reduces cupric sulphate in alkaline
solution,  while nucleo-albumen, containing  an atom of phosphorus in
its molecule, is distinguished by the reactions of that element. 
                 EXAMINATION OF  THE URINE.              627

    Hematuria.—A small amount of blood need not color the urine;
 considerable amounts nearly always color it from a pale pink to a deep
 red.  Accidental haematuria is that due to traumatism of any part of
 the urinary tract or to the presence of foreign bodies in the urethra or
 bladder.
    Blood may appear in the urine in any form of nephritis, from
 febrile or infectious hyperaemia to the  last stage  of degenerative ne-
 phrosis;  it is  most frequently seen  in hyperaemia  and congestion,
 acute parenchymatous nephritis, and  the acute exacerbations of the
 chronic disease, and  regularly follows renal  infarcts or thrombosis.
 Blood is irregularly present in the renal disturbances  secondary to
 heart disease.
    In tuberculosis and malignant disease of  the kidney, or of any
 part of the urinary tract, haematuria is regularly seen, although here
 the  phenomenon may vary much  as to  quantity and periods.   The
 rare echinococcus cysts of the kidney likewise  cause it.
    In the blood dyscrasiae and in  haemophilia there may be inter-
 mittent attacks of haematuria; and intermittence is the  rule in cystic
 kidneys and hydronephrosis.   Renal calculus generally causes a mild
 but constant haematuria, though in some instances it may be profuse.
 In the rare  internal  traumatisms of  the  kidney, as in torsion of a
 floating kidney, haematuria follows the accident.
   As a rule, it may be said that, with the exception of the bleeding
 from a ruptured vessel or from  tumor or granuloma of the  kidney,
 renal haematuria never presents clots.  Subrenal  haematuria is very
 common.  The same  causes that apply to the kidney hold true  for
 the pelvis.
   Stone in the bladder is a common cause of intermittent haematuria,
 but the character is not  constant.  The  tumors of the  bladder like-
 wise present intermittent haematuria  of  variable intensity,  though
 the malignant  tumors generally bleed more  freely than papilloma.
 Inflammation of the  mucous membrane  of any part of the urinary
 tract, and extreme congestion or rupture of dilated veins, may cause
 haematuria.
   In the tropics parasites, as  the distoma, frequently cause a severe
 haematuria.
   The presence of blood in the urine should  be  considered  micro-
 scopically, spectroscopically, and chemically.  The microscopical ap-
pearance will be considered under the heading  of sediments.
   Blood in the urine presents the absorption bands of oxyhaemo-
globin, between D and E, which, after the addition of a  little am-
monia and  ammonium sulphate, are merged  into the  broad band 
628
GENITO-URINARY DISEASES AND SYPHILIS.
of reduced haemoglobin between D and E, or of methaemoglobin be-
tween C and D, at D, at E, and at F.
   A delicate chemical test is that  of Struve:  Add to urine a little
potassium hydrate;  then  add acetic  acid  and tannic acid until the
urine is again acid; if blood be present, a dark precipitate will form;
this  dried  precipitate when  treated  with  ammonium  chloride and
glacial acetic acid will form the haemin crystals.
   By a careful count of  the red and white corpuscles following the
addition to the  urine of a  little methyl-violet (which tinges the white
cells), the  simultaneous presence of  pyuria can be proved  or ex-
cluded.
   With every haematuria there is obviously albuminuria.  Whether
the albuminuria be entirely dependent upon the  haematuria is a mat-
ter often difficult to decide.  The ratio of serum-albumen to globulin
promises practical assistance in deciding this matter.   In a renal al-
buminuria this  varies from 9 to 15 : 1.  The ratio in the blood varies
from 1J to  3:1.   Obviously, when  haematuria  is the cause of the
albuminuria the ratio will  approach that of the blood.   For instance,
amyloid kidney being excluded, if in  a given case the ratio of the
serum-albumen to the  globulin be 9  to 15 : 1, this  will show the
existence of albuminuria independent of haematuria.  If, on the other
hand, the ratio in a given case be 3 : 1, it is likely that the  albumi-
nuria is entirely dependent on the  haematuria.   It may be  stated,
then, that the more nearly the ratio in any  given case approaches the
blood ratio or the albuminuria ratio, the more positive the suggestion;
naturally, there will be results which fall midway, and in these cases
the test is negative.
   The spectroscope may suggest the source  of the  hemorrhage.
With cystic retention and decomposition  excluded, the presence in
the freshly voided urine of the absorption bands of methaemoglobin
suggests renal hemorrhage; the oxyhaemoglobin bands suggest hemor-
rhage from the lower tract.  Often both sets of bands are present, but
even here the predominance of the one or of the other is of diagnostic
value.
   Hemoglobinuria  is  the presence of  haemoglobin in solution in
the urine independent of  the blood-corpuscles.   It generally accom-
panies haemoglobinaemia.
   Haemoglobinuria may  coexist with haematuria.  It is seen in some
cases of severe infectious disease, in  burns of wide-spread area, in
some cases of pyaemia, and  in severe poisoning by coal-tar phenol
compounds, as carbolic acid and naphtol, pyrogallic acid, the  chlo-
rates, glycerin,  iodine, arsenic, and organic  poisons  sometimes present 
EXAMINATION  OF THE URINE.
629
in shell-fish.   Transfusions of blood or of serum, especially from a
different species, can produce it.   It  is the main sign of the obscure
condition known as  paroxysmal  haemoglobinuria.  No cases of the
parasitic endemic haemoglobinuria seen in animals have been observed
in man.
   The urine  contains, in  addition  to haemoglobin, albumen, gener-
ally hyaline casts, and  bilirubin or biliverdin, and quite often there is
a sediment of  amorphous or crystalline  haemin, while in some cases
crystals of calcium oxalate are present in large quantities.   The urine
may be alkaline.
   The diagnosis of haemoglobin is made by establishing the presence
of haemoglobin without red corpuscles  or  entirely out  of proportion
to the number of red  corpuscles.  Spectroscopically the absorption
bands are generally those of methaemoglobin, not haemoglobin.
   Carbohydrates.—Carbohydrates which appear in' the urine are
grape-sugar,  levulose, inosite, maltose, the pentoses, and lactose.
   The ordinary glycosuria  concerns the glucose group.  A trace of
sugar probably exists in normal urine, but this is never sufficient to
respond to clinical tests.
   There is  often a transitory glycosuria in cases of acute infectious
disease; in many acute and chronic  heart, lung, and especially liver
diseases; in  lithaemia and gout, where it is frequent;  in syphilis, and
in exophthalmic goitre.  This  phenomenon is irregularly seen in the
chronic derangements of the digestive tract.  It is frequent in nervous
diseases (apart from the relation of the medulla to diabetes) and in the
traumatic neuroses, particularly of the abdominal sympathetic system.
   Sugar may  appear in the urine of any form of nephritis, but it is
most  often seen in the interstitial nephritis of gouty persons.  It is
probable  that  an exclusive  starch diet or a surfeit of sugar can pro-
duce a glycosuria in  the normal  subject, but it will do so more con-
stantly in nervous overworked  individuals or in those subject to
digestive  derangements.  There  is a rare  glycosuria of adolescence,
analogous to the albuminuria.  It occurs in phosphorus and carbon
monoxide poisoning, and also in acute or chronic morphine poisoning.
Sugar is present in the  urine of pregnancy and the puerperium almost
as frequently as albumen.   It is, finally, most important as the chief
sign of the distorted metabolism of essential diabetes.
   Experimentally diabetes can be caused by injury to the medulla
oblongata or by extirpation of the pancreas, and a renal glycosuria
can be produced by the administration of phloridzin.
   Qualitative  Tests  for Sugar.—Before  testing for sugar it is best
to  remove, by boiling, any albumen.   It  must be borne in mind that 
GENITO-URINARY  DISEASES AND  SYPHILIS.
normal urine polarizes  light to  the  left, and that it is also a reducing
agent to cupric sulphate in alkaline solutron of a strength correspond-
ing to a two-tenths per cent, solution of grape-sugar.
    The power which sugar possesses of reducing cupric sulphate in
alkaline solution is best utilized clinically by Fehling's method.  This
is thus  applied: Take one cubic centimetre each of Solution A (cupric
sulphate 34.639 grammes,  with enough water  added to make five
hundred cubic centimetres) and Solution B (Rochelle salt 173 grammes,
sodium hydrate sp. gr. 1.34, one hundred cubic centimetres, water
enough to make  five  hundred cubic centimetres), dilute with four
times as much water,  boil, and add urine drop by drop;  sugar  re-
duces the  sulphate to  the  suboxide, with the  production of a yel-
lowish-red precipitate.   In  the  application of this method it must be
borne in mind that reduction of the sulphate, not simple decoloration,
constitutes the reaction, and that uric acid and kreatinin often cause
fallacious results.
    The fallacies of Fehling's method do not apply to Nylander's test,
and, as the fallacies of  the  latter  do not  apply to Fehling's method,
the two together  constitute an almost  infallible clinical method  of
confirming a glycosuria.
    Nylander's  test is the following: To one hundred  centimetres  of
a normal sodium  hydroxide solution four grammes of Rochelle salt
are added, and after the salt is dissolved bismuth subnitrate is added
to saturation (about two grammes).  One cubic centimetre of this
solution is added  to five cubic centimetres of the urine (which  must
be so diluted, if necessary,  that its specific gravity is not over 1020);
the mixture is slowly heated up to the boiling  point and is gently
stirred:  a  whitish precipitate forms,  which will become brown  or
black if sugar be present.   Carefully applied, the reagent  is very
delicate.
   The fermentation test should be resorted to in all  doubtful cases.
The urine should be first filtered, and, after the addition of the yeast,
placed  in a warm temperature (from 95° to 110° F.), since the fer-
mentation is then  more rapid and  complete and the urine absorbs less
carbon  dioxide.
   The most delicate reagent for sugar is phenylhydrazin: to ten cubic
centimetres of urine a few grains of phenylhydrazin hydrochlorate and
twice as much  sodium  acetate are added, and the mixture is heated
fifteen  minutes upon the water-bath, following which it is placed in
cold water.  If sugar be present, crystals of glycosphenylglucosazone
will be  formed, appearing under the microscope as yellow  needles,
often radiating from a centre. 
EXAMINATION  OF THE URINE.
631
   For a quantitative determination of  sugar Fehling's solution may
be employed; the solution should be freshly prepared and carefully
standardized ; the strength generally employed is such that a complete
reduction of the salt in one cubic centimetre is accomplished by 0.005
gramme of grape-sugar.
   Roberts has devised a convenient application of the fermentation
test which furnishes fairly accurate quantitative results.  Two portions
of the urine {circa one hundred cubic centimetres) are set aside after
their specific gravity has been determined, and yeast is added to one
portion; after the fermentation is completed the specific gravities of
the fermented  and  the control portions are again determined.   Each
degree of specific  gravity lost  in fermentation corresponds to one grain
of glucose to the  imperial fluidounce of urine.  When the amount of
C02 evolved in fermentation is measured the results are much more
accurate.   The most reliable of these methods has a variation range
of one-fourth per cent.   For accurate quantitative estimation the po-
lariscope  should  be employed, or the  amount of copper reduced by
a known quantity  of urine  should be carefully separated, washed,
dried, weighed, and the percentage of sugar calculated from that.
   The amount of sugar in the urine may be as high as two and one-
fifth pounds per  diem, but  one-fourth  that amount is a heavy glyco-
suria. The specific gravity of  urine usually bears a rough relation to
the amount of  sugar  it  contains, but exceptions  to  this  are not un-
common.
   Large amounts of sugar are practically seen only in true diabetes ;
in the other varieties  of glycosuria the amount rarely reaches two per
cent.
   Of the other forms of sugar, none have any clinical significance in
their relations to  the urine, except  lactose, which not uncommonly is
present in the urine of the nursing mother.
   Choluria.—In  jaundice  the biliary coloring matters are always
present in the  urine,  the salts of the biliary acids seldom.   In fresh
icteric urine the  pigment is bilirubin  in alkaline combinations ;  on
standing the bilirubin is oxidized to biliverdin, or to lower compounds,
—changes also which occur in the bladder in  cases of  cystitis in a
jaundiced subject.
   The urine has a yellow-greenish color.  Allowed to come in con-
tact with  old nitric acid, a green  color forms at the point of  contact
(Gmelin's test): this reaction  can be made more striking if the acid be
dropped upon a  filter-paper through which  the  urine has been  fil-
tered. The salts of the bile  acids cannot be demonstrated by clinical
methods. 
632       GENITO-URINARY DISEASES AND SYPHILIS.

    The urine may contain bile in any acute or chronic disease of the
liver or the bile-tracts;  it is  especially marked in obstruction of the
common duct.  It is generally seen following attacks of hepatic colic
even though the mucous membranes  and the  skin show no trace of
jaundice;  it likewise follows operations upon the liver or the bile-
tracts.  It  is very doubtful whether choluria dependent  on haemato-
genous icterus exists.
    Cholesterin is not found in jaundiced urine.  It may be seen in
cases of severe cystitis,  in tuberculous nephritis, in chyluria, and fol-
lowing prolonged ingestion of potassium bromide.
    Cystinuria.—Cystin in the urine is  generally accompanied by cada-
verin and putrescin.  It has  been recorded as a family disease.  It is
seen  in acute yellow atrophy  of the liver,  occasionally during the
course of  infectious diseases, and in the peculiar condition known as
idiopathic cystinuria, some cases of which have been shown to be due
to a specific form of albumen putrefaction within the alimentary tract.
It is best  diagnosed by  the sediment, and, as it may be insoluble, a
trace appears as a sediment.
    Melanin.—A trace of melanin or melanogen appears in the urine
in most cases of  melano-sarcoma, and also, though less often, in car-
cinomatous processes ; it has been seen in marasmus.   The pigment
is generally in solution, but there  may  be a  sediment of blackish
granules.   The urine is dark, but the color may  develop  only after
exposure to the air.
    Diacetic acid is  seen  in the urine under conditions similar to those
in which acetone appears, and it is generally accompanied by the lat-
ter.  It occurs in  high fever, in infectious processes, in metabolic auto-
intoxications, and in diabetes.  It gives a Bordeaux-red reaction with
ferric chloride, but there are many fallacies inseparable from the test,
and for a reliable estimation a distillation is necessary.
    Lipuria.—Fatty acids are normal  in the urine, but fat probably is
not. The fatty acids are increased in  fever and in acute and chronic
hepatic diseases, and are present in great  excess  in diabetes  and in
the ammoniacal urine of cystitis.
    The term  lipuria is  generally limited to the presence of free fat,
not fat in degenerated renal  epithelium, etc.  A large quantity of fat
will cause a whitish cloudiness in the urine, but this condition is rare.
More  often the fat appears as a  scum floating upon the urine, but
generally it must be  searched for with the microscope;  with this
instrument the fat-globules are  easily recognized.  If the  urine be
extracted with ether  and this  evaporated upon a filter-paper, a fat-
stain will be left upon the paper which will blacken with osmic acid. 
EXAMINATION  OF THE URINE.
633
   Fat may appear in the urine in the last stages of nephritis and in
pyelonephritis; in acute and chronic hepatic and pancreatic disease ;
in pregnancy; in the cachexia of phthisis and other wasting diseases ;
in diabetes, and in  chronic  phosphorus poisoning.   It is more  con-
stant in long-standing suppuration, especially of the bones and joints,
in malignant tumors of these structures, and in pyaemia and gangrene.
   Lipuria is constant with chyluria, and is found when a cyst or an
abscess ruptures into the urinary tract; it is likewise generally found
after fractures or operations upon bones.
   Chyluria is thus named because of the milk-white appearance
of the urine.  The urine in this condition contains albumen, globulin,
fibrinogen and fibrin-globulin, blood, fat, tissue-cells,  cholesterin, and
lecithin.  On standing, more or less  fibrin always  forms, and  often
complete coagulation occurs. Generally the urine contains these sub-
stances only  at some time of the day, while at other times it is clear.
   The cause is almost always the filaria sanguinis hominis, but how
the parasite brings about this phenomenon is not understood.   It has
been generally supposed that chyluria is  caused by an abnormal
communication between the lymph-channels and  the  urinary tract,
the lymph thus mingling directly with the urine.  The constituents
of the  fluid, however, are not the same  as those of lymph: there
is no  sugar  in chyluria, while sugar is  abundant in the lymph, and
furthermore  the  amount of fat present in chyluria  far exceeds the
quantity contained in lymph.

                   THE SEDIMENTS IN  URINE.
    Normal urine  may be entirely free from sediment; it often con-
tains urates.  To preserve  urine  for  examination of the sediment,
chloroform is a convenient  agent.  An analysis is  facilitated by cen-
trifugation.
    Blood.—The causes have  already been given.   Upon the study
of the sediment often  depends the diagnosis of the  source of the
hemorrhage, and whether or not there is an albuminuria independent
of the haematuria.
    Since inflammation  or  tumor of the bladder-walls, severe  and
advanced enough  to cause vesical bleeding, generally renders the
urine  alkaline, blood in acid  urine points  to the  ureter or kidney,
while  blood in alkaline  urine points  to the bladder.  To this rule
there  are many  exceptions, since there  is  not  infrequently vesical
hemorrhage  without alkalinity of the urine,  and the renal lesions
which  cause hemorrhage may coexist with or arise in the course of
chronic cystitis. 
GENITO-URINARY DISEASES AND SYPHILIS.
   The appearance of the blood  in the urine often suggests the
source.   As before mentioned, profuse hemorrhage  with  clotting
rarely comes from above the bladder.
   If the red corpuscles  are much altered, deprived of their haemo-
globin (shadow-cells), and  especially if they present fragmentation, a
renal origin is strongly suggested.   Crenation, however, is largely a
physical condition, and does not suggest the source.
   If the blood conies  from the kidney, hyaline and often blood-casts
can  generally be found  after careful centrifugation.  In rare  cases
pieces of tissue will suggest the seat of lesion.
   In vesical haematuria more of the lining epithelial cells are present
than when the blood  comes from  the ureter or the pelvis; the cells
cannot be differentiated, but the degree of desquamation which often
occurs in cystitis is not observed in ureteritis or pyelitis.
   To determine whether pus coexists with blood, the red and white
corpuscles  should be counted  by mixing the sediment in salt solution
colored with  methyl-violet, and employing the ruled slide of the
Thoma haemocytometer.  A large excess of  white corpuscles would
point to  a coexisting pyuria, which might serve as a point of  diagno-
sis between renal tuberculosis and malignant disease or other kidney
conditions.
   To determine in a doubtful  case whether an albuminuria is de-
pendent  upon or simply coexists with a  haematuria, in the absence
of all  other signs of  renal disease,  careful computation and  com-
parison of the amount of blood and albumen present are necessary.
Goldberg has  thus formulated a method of settling  this point.  The
blood is evenly mixed into the mass of urine and the  cells are counted
with the Thoma-Zeiss haemocytometer.   If there are  no more than
three thousand cells per cubic centimetre and the urine gives an albu-
men reaction with nitric acid, the  albuminuria  is not dependent  on
the haematuria, as that amount of blood will give no such reaction for
albumen.  If the number of red blood-cells per cubic millimetre is di-
vided into the percentage of albumen (as determined by the  Esbach
method), any figure below one-thirty-thousandth means that the albu-
men is due solely to  the blood ; any figure over one-thirty-thousandth
indicates an independent albuminuria.   For example, two cases may
be given:
   1. In a given specimen of bloody urine from urethral hemorrhage
there were one hundred thousand blood-cells in each cubic millimetre,
and  the  quantity of albumen  was one-third per cent.  The  propor-
tion  then stands 100,000 cells per cubic millimetre: J of 1 per cent.
albumen = CTnrVuir:  hence an albuminuria due solely to the blood. 
EXAMINATION OF THE  URINE.
635
   2. In the urine of renal tuberculosis, the number of cells, the per-
centage  of albumen, and the ratio were thus expressed: 10,000  cells
per cubic millimetre :  5 per cent, albumen = -g-oVo- '•> therefore there
was independent albuminuria.
   Pus.—A few  leucocytes  are  occasionally seen in  normal urine,
especially of women.   As  a pathological  condition  it is  a frequent
phenomenon.
   Small  amounts  of  pus may appear in the urine of any case of
nephritis,  but only  in  septic nephritis,  pyonephrosis, and tubercular
and malignant  kidneys are large amounts of renal pus formed.  In
cystic kidneys and  pyonephrosis  the pyuria is often intermittent, and
may appear in large quantity in a sudden attack of polyuria.
   In pyelitis and urethritis suppuration may be  free,  but it is most
profuse in cystitis, particularly in the tubercular and obstructive forms
of the disease.  A sudden  discharge of pus may mean the rupture of
an abscess into the urinal tract,—from the periurethral  glands, the
prostate or seminal vesicles, the  pericystic  region, or the  perirenal
tissues.
   When a quantity of pus precedes the stream the origin is obviously
urethral;  when a few  drops follow the stream  the origin may be in
the prostate gland,  the seminal vesicles, or the bladder.  As  a  rule,
pyuria due to urethritis clears on standing, that due to cystitis does not.
   Pus in acid urine generally comes either from above or  from below
the bladder, since the  urine in cystitis is  usually alkaline.  This rule
has many exceptions.  If the pus-cells are much degenerated, this sug-
gests a  high origin; renal abscess often presents tissue-fragments, and
hyaline casts are often present in renal pyuria.  In pyelitis the pus-
cells are sometimes grouped about large cylindrical plugs which come
from the  papillary  ducts.  The  pyuria of cystitis is  accompanied by
a large  number of the  lining epithelial  cells, more numerous than in
pyelitis.  The  ammonium carbonate  in  strongly alkaline urine may
convert pus into a colloid mass, so that pus-cells cannot be recognized.
   Pus in the urine forms a whitish cloud,  often stringy,  on account
of the  increased quantity of nucleo-albumen present; this circum-
stance hinders  the  separation of the pus for microscopic study, but
the difficulty may be obviated by the  addition of a little dilute acetic
acid to  the  sediment.  For microscopic study  the pus should be
removed upon cover-glasses  and fixed by passing through the flame.
Stained with the  Ehrlich triple stain, pus-cells generally present  neu-
trophilic granulations, but in many cases of gonorrhoeal pus a striking
number of eosinophilic granulations are present.
   Pus should always be stained for tubercle bacilli; the more care- 
636        GENITO-URINARY DISEASES AND SYPHILIS.

fully and thoroughly  this is done the  more often is tuberculosis
found to be the cause of pyuria.  The best clinical staining method is
Gabbett's:  the dried and flamed cover-glass preparation is stained for
two minutes with carbol-fuchsin hot  or cold (to  one hundred cubic
centimetres of a  five per  cent, solution of carbolic  acid add one
gramme of basic fuchsin  dissolved in ten cubic  centimetres of alco-
hol) ;  it  is  then decolorized and  counterstained  with  a  solution of
one gramme of methylene blue in one hundred cubic centimetres of
a twenty-five per cent, solution of sulphuric acid ; the tubercle bacilli
are red, all tissue  and other  bacteria are blue.  The tubercle bacilli
may be found  isolated;  more commonly they  show  a  fasciculated
grouping.  (Fig. 176.)
   For the pyogenic organisms a simple watery solution of methylene
blue or any other basic stain suffices ;  an especially good general bac-
teria stain is prepared by adding half a gramme of thionine  dissolved
in ten cubic  centimetres of alcohol  to ninety cubic centimetres of a
five per cent, solution of carbolic acid ; stain  for a few minutes.  The
colon bacillus, the most frequent and virulent microbe of  the urinary
tract, appears in the form of short rods with rounded ends, irregularly
grouped and  extracellular.  (Fig. 177.)
   The typical gonococci exist as reniform diplococci situated within
the pus-cells and not stained by Gram's method.  In the  early stages
of inflammation they are found  as  a practically pure culture, in pus
containing  little  or no epithelium ; exceptionally there is mixed infec-
tion with the ordinary pyogenic bacteria; later squamous and tran-
sitional epithelium is mixed with the  pus, and mixed infection is the
rule, pseudo-gonococci sometimes appearing; these are extracellular
and  are larger than  the gonococci.   In the late stages of chronic
urethritis gonococci disappear, many different microbes then being
found  in the  urine.  They may be  made to  reappear by exciting an
acute urethritis.   (Fig. 178.)
   To  determine  whether or not an  albuminuria depends upon py-
uria, the urine should be added to an equal volume of  one  per  cent.
solution of acetic  acid and the pus thoroughly mixed; then a pinch
of methyl-violet is added, a drop is placed  upon the  ruled slide of
the Thoma haemocytometer, and the pus-cells  are counted.  With
another portion of the  urine  an albumen estimation  is made with
Esbach's albuminometer; one  hundred thousand pus-cells per cubic
centimetre correspond to one per cent, of albumen.  If the pus-cells
are thoroughly  mixed the results  are fairly  accurate.  The greatest
defect of the method is dependent  on  the inaccuracy  of Esbach's
albuminometer. 
Fig. 176.
4$h
mm
h'"
fc«3
M


££\


^
/
V


^
t'igap



■::*
ifi-*1.""'-V".,.:«i ^.-^V "

I' s
S&£x


fertfi"!
■■•W*"'

•-"(-V'S
m
  1. Isolated tubercle bacilli.  2. Bacilli grouped in fasciculi (common grouping). 3. Fasciculation

more marked.  4. Bacilli massed, showing curved and sigmoid grouping,  5. Bacilli irregularly

massed.  (Guyon.)
98 
 
Fig.  177.
• ft*
0>'<
X'ySJ&fri.
■:.'&*

rfe;


Vfc-',
|P



4~  \


y

If



w;;',0'.

'**£
■ ■•:■--, *\Vv









■:■■ j( v  .  *«-?.■;*•


               9
»
>H
1. Purulent urine containing a pure culture of colon bacillus (X 300).  2. The same (X 800).
           3. Mixed infection, colon bacillus and a small bacillus.  (Guyon.) 
(pw
  f

if -
M
f^r.a/y^.tY'it-yA      « V;','
'.-■'■>.-■,      •,•;;--.'■-,'■/;'.''  \ 0 • t



2



A'
\V-:
*.~ v'.V-'-Jit..' '/imSKSS^/U




   1. Mixed infection;  acute  urethritis.   2. Mixed infection;  subacute  urethritis.  3. Pseudo-
gonococci  and mixed infection; subacute urethritis.  4. Subacute urethritis, showing a common
form of saprophytic micro-organism.  5. Subacute urethritis, showing a rare form of saprophytic
micro-organism.  (Guyon.) 
EXAMINATION  OF THE  TJKINE.
637
  Epithelium.—Normal urine contains a few desquamated cells, es-
pecially in women.  The large squamous cells come from the prepuce,
the meatus urinarius, and the  vagina.  Large cylindrical cells  come
from the urethra.  The  epithelial cells of the bladder, urethra, and
pelvis of the kidney cannot be  differentiated in urinary sediment, as
they are of the  same type.  Those of the superficial layers are small
cylindrical  cells of polygonal  form, those from the deeper  layers are
oval, with long processes ; they are generally more or less degenerated.
A large excess of these generally points to vesical disease, as the ureter
and pelvis do not shed so many.
   The cells from the secreting tubules of the  kidney are, as a rule,
much smaller than the cells  of the subrenal tract,  and their nuclei
are proportionately larger and more granular.   They are  polygonal
in shape, and are seen in all  degrees of degeneration,—cloudy swell-
ing of the protoplasm, moderate fatty degeneration, and complete con-
version of the protoplasm into  fat, with  disappearance of the nuclei.
They may  occur isolated, in  groups  as shed, or in  the  form of epi-
thelial casts.   They  indicate  nearly always an inflammatory and
degenerative  process in the kidneys.   Cylindrical whorls have been
described in  the urine of cases of amyloid  kidney, but they are in-
constant.
   Tissue in Urine.—In some cases of cystitis, following traumatism,
prolonged retention of urine,  protracted  and obstructed  labor, or in-
carceration of a retroverted pregnant uterus, large particles of necrotic
bladder-tissue may be passed with the urine ; not only mucous mem-
brane, hut  fibrous and muscular tissue as well.   Fragments  of vesical
cancer and papilloma sometimes appear.  In renal abscess necrotic
tissue may be  voided.  In tubercular nephritis  cheesy detritus,  de-
generated tissue, and fibrous  and elastic fibres  are often present.
Renal cysts sometimes empty their contents into the urine.   Dermoid
cysts may ulcerate into the bladder  and the heterogeneous contents
be expelled.  Faeces are seen in cases of recto-vesical fistula.
   Parasites  and  Bacteria.—Echinococcus  cysts of the kidney
or outside  of it may empty into the  tract;  there will be a  gush of a
milky turbid fluid containing  a high percentage  of albumen, pus,
blood, and the hooklets of the  entozoa.  In rare instances small por-
tions of tissue or concretions may be  passed.   These  attacks may
occur periodically, and  between attacks the  urine may present no
evidences of disease.
  In the tropics the distoma haematobium often becomes  lodged in
the mucous membrane of the ureter or bladder and gives rise  to haema-
turia, pyuria,  often lipuria, and  discharges the eggs, which are 0.12 by 
GENITO-UKINAKY  DISEASES AND SYPHILIS.
0.04 millimetre  in  size and have generally one  oval end  and one
pointed end.  The  eustrongylus  gigas, common in the pelvis of the
kidney of canines, is  very rare in  man.  Ascarides have been seen
in the urine only in  cases  of recto-vesical fistula.  In a few  cases
nephrophagus sanguinarius, rhabditis genitalis (in  females),  and pso-
rosperms  have been  found, accompanied by haematuria, which they
provoke.
   The embryos of the filaria sanguinis hominis may appear in the
urine, generally enclosed in blood-clots, and accompanied by a great
deal of blood, pus, and fat.  They are well stained by the basic aniline
dyes.  They appear in the urine only periodically.
   Normal urine in the bladder contains no bacteria.   In the decorm-
position of normal urine schizomycetes, fermentation-germs, and the
micrococcus  ureae play the most  active roles.  In  the  decomposition
of diabetic urine the  saccharomycetes are present  in large quantities,
to be replaced by  hyphomycetes after the sugar has been  decom-
posed.  Many forms of cocci, bacilli, and spirilli take part in the am-
moniacal  decomposition;  the most prominent is the micrococcus
ureae, which forms chains or rows of large cocci.  Sarcinae may appear
in normal urine.
   Pathogenic  Bacteria.—The  staphylococcus  pyogenes (generally
the aureus), the streptococcus pyogenes, the bacterium coli commune,
and the proteus Hauseri are the most common pus-organisms.  The
gonococci may come  from the urethra or from the bladder.  Rarely
the diplococcus  pneumoniae, the  typhoid bacillus, and the spirillum
Obermeieri have been found in the urine, particularly  accompanying
a haematuria.
   The pus-organisms may be found in any case of inflammation of
the mucous membrane of the urinary  tract, in acute nephritis and
renal abscess, in recto-vesical fistula, and in some cases of pyaemia,
erysipelas, and malignant endocarditis.
   In genito-urinary tuberculosis the bacilli may appear in the urine.
A portion of the  sediment should be injected  into the subcutaneous
abdominal tissues of a guinea-pig and the animal killed in from  three
to four weeks; from the enlarged lymph-glands near the point of in-
jection  cultures  should be made  upon glycerin-agar.  This method
should  be employed  in any suspected  case where the bacilli cannot
be detected in the  sediment. Tubercle bacilli may be found in the
urine of acute general tuberculosis.  In rare  cases of actinomycosis
of the urinary tract the fungi have been found in the urine.
   The tubercle bacilli must be distinguished from the smegma bacilli.
Unfortunately, this is  impossible by staining methods.  For  complete 
                 EXAMINATION  OF THE  URINE.              639

 descriptions of the bacteriology of the urine the text-books on bacteri-
 ology should be consulted.
   Urinary Oasts.—Casts should always be viewed as pathological.
 While it is true that they are sometimes found in urine free from albu-
 men coming  from  apparently healthy  kidneys,  they are  probably
 always due to slight  circulatory  disturbances, or to malnutrition or
 toxic irritation.
   Casts are of the following varieties : hyaline (including cylindroids),
 granular, fatty, waxy,  leucocytic, blood, epithelial, amyloid, and bac-
 terial.  They are  thus amorphous, granular, or cellular.
   Hyaline casts are of a pale, almost transparent appearance, homo-
 geneous,  the edges sharply outlined, and stain well with Lugol's solu-
 tion  and the  acid stains.   They may be  wide or narrow; as a rule,
 they are more narrow in sympathetic renal  involvement and in inter-
 stitial nephritis, more wide in parenchymatous nephritis.  Blood-cells,
 pus-cells, urates, epithelium, and  bacteria often adhere to them, and
 they may be slightly granular.   Hyaline casts are seen in the urine of
 all varieties of nephritis, in all degrees of arterial and venous conges-
 tion, in renal  irritation by the toxins of the infectious diseases, foods,
 poisons,  digestive diseases, and  in auto-intoxication,—for instance,
 that  following an  attack of epilepsy.  They therefore do not indicate
 an inflammatory  nephritis.  Cylindroids are  like  hyaline  casts  in
 structure, but are long and twisted; they  may accompany  hyaline
 casts in any case, but are  most common in children, and in venous
 congestion of the  kidneys.
   Waxy, colloid, and amyloid casts are rare.   Waxy casts are often
 long, have abrupt  broken ends, and are frequently covered with cells
 and  crystals.   The fibrin  casts are very rare, also the amyloid casts,
 which show the characteristic  stain-reaction with  Lugol's  solution or
 iodine-green;  but, as  waxy casts often take a tinge of these  stains,
 distinctions are frequently difficult.   These casts  always  indicate
 organic renal disease.
   Granular  casts are clinically divided  into the pale and the dark.
 The granulations consist of a proteid degeneration, although fatty de-
 generation and  fat-drops  may  be present in granular casts.   They
 come from  degenerated epithelium or  from  epithelial casts.   They
 always  indicate organic kidney disease, and are  most abundant  in
 parenchymatous nephritis.
   Epithelial  casts  are probably formed by a  desquamation  of the
 tubular  epithelium, which  makes a regular mould, with the edges of
 cells in  all degrees of degeneration closely apposed.  When the de-
generation is extreme the cell outlines are lost and a granular  cast 
GENITO-URINARY DISEASES AND  SYPHILIS.
results.   They occur in  all varieties of organic renal disease, but
especially in parenchymatous nephritis.
   Blood-casts  are  formed  in the tubules by coagulated blood, and
are especially seen  in  acute nephritis; they must be distinguished
from hyaline casts with red blood-cells adherent to them.  Degener-
ated blood-casts become granular casts.
   True leucocytic casts are very rare ; those which appear as such
are generally hyaline casts covered with pus-cells.
   Bacterial  casts  consist of bacteria massed together, and look like
granular casts, but are easily differentiated by staining; they are some-
times seen in septic  nephritis and pyelonephritis.
   Unorganized casts of blood-pigment are rarely seen in the urine
of cases of venous renal congestion. Casts of urates are quite common,
and signify nothing if they are certainly distinguishable from hyaline
casts  covered with  urates.  In all ammoniacal urine detritus casts
may be formed, very irregular in outline and appearance.
   Spermatozoa.—These may appear in  the  urine following coitus
(days after coitus in women), and in any condition of irregular leak-
age  or  discharge  from the  seminal  vesicles, such as that which is
common  in  posterior  urethritis.  In  spermatorrhoea the cells are
generally entangled  in the  threads  of nucleo-albumen.   They are
especially  well  stained (with  color  differentiation) by Unger's dye:
methyl-green,  0.5  gramme; water,  100 cubic  centimetres;  strong
hydrochloric acid,  four drops;  stain several hours.   They are ex-
ceptionally accompanied  by granules and  amyloid bodies from the
prostate gland.   The latter are normal in extreme old age; they are
small, round, glistening, yellowish-brown bodies, which may form the
nuclei of stones.
    Sago-bodies of globulin are also seen in the  urine of cases of true
spermatorrhoea; they are  formed and exist normally in the seminal
vesicles.
              CRYSTALLINE  SEDIMENT OF ACID  URINE.
    Urates.—The crystalline sediment of the urine depends upon the
reaction.   In acid urine a reddish precipitate is generally composed
of urates ; if  the color  of the urine is pale, the  urate sediment is cor-
respondingly pale.   These urates will pass  into solution if the urine
is warmed.  They appear as the acid and neutral  urates of  all the
normal bases of the urine, and are generally amorphous in form.
They form fine  granules, often  closely packed in  groups, of  a faint
yellowish  color, which dissolve  when the  urine  is heated, and also
dissolve upon the addition of an acid, but  soon reform as crystals of
uric acid. 
Fig. 179.
   1- Irregular form of uric acid.   2. Calcium sulphate.   3. Rare  forms of ammonio-magnesium
Phosphate.   4. Ammonio-magnesium phosphate (artificially  precipitated).   5. Cystin  (artificially
Precipitated).  6. Urea nitrate (artificially precipitated).  (Guyon.) 
Fig.  180.

/■■'r\

^


9

d'n
Z/\


1. Uric acid.  2. Sodium urate.  3. Calcium oxalate. 4. Acid calcium phosphate.  5. Ammonio-
                  magnesium phosphate. 6. Ammonium urate.  (Guyon.) 
EXAMINATION  OF THE  URINE.
641
   The  urates are increased in febrile states, in venous renal con-
gestion, and  in  concentrated urine.   They frequently  form  calculi;
sodium urate (Fig. 180, 2) is most often the basis of concretions, but
stones of ammonium urate occur.
   Uric Acid.—The crystals of  uric  acid appear in  many forms:
rhombic tablets with broken edges, whetstone-shaped, long, needle-
pointed spars, and prismatic forms (which are the most  characteristic)
of a yellow color, often cling together in groups.  (Fig. 179, 1;  Fig.
180, 1.)   They may be  colorless.  They dissolve upon the addition of
an alkali (but not of ammonia), and crystallize again upon the addition
of a mineral acid.  They also react to the murexide test.
   Calcium oxalates appear as colorless octahedral or dumb-bell crys-
tals, with many modifications in size and form.  (Fig. 180, 3.)  They
are soluble in mineral acids, but not in acetic acid.  The number of
crystals  bears no relation to the amount of oxalic acid in the urine.
Such crystals often appear in  healthy urine.   They are formed in
excess in idiopathic oxaluria.
   Calcium sulphate appears as long, colorless needles (Fig. 179, 2);
also as dumb-bells, insoluble in acids or ammonia.  These crystals
are rarely seen, but  occur in the urine of some cases of calculus.
Calcium carbonate occurs also as dumb-bell crystals.
   Hippuric  acid  appears  rarely in the  form of  rhombic  crystals,
soluble in ammonia, but not in acids: these crystals follow the inges-
tion of benzoic acid and of the many fruits which contain it.
   Bilirubin or haematoidin crystals are  small, yellowish-red, rhom-
bic forms, or bunched needles;  sometimes, also, yellowish-brown,
amorphous masses.  They are soluble in an alkali or in chloroform,
and they respond  to Gmelin's  test.   They are  present  in some cases
of jaundiced urine, in acute yellow atrophy of the liver, and in acute
phosphorus poisoning;  also in  severe  cases of the infectious dis-
eases.
   They are often seen attached to  cellular elements, and then sug-
gest some local lesions of the urinary tract; they have thus been seen
in pyelonephritis,  cystic kidneys, cancer of the bladder,  renal or vesi-
cal tuberculosis, and severe toxic nephritis.
   Leucin  and Tyrosin.—Leucin is generally in solution in the urine,
but may appear as round balls of crystalline structure.  If a solution
is warmed with mercury  oxydul-sulphite the mercury will in  the
presence of leucin be thrown down in the metallic state.
   Tyrosin appears as  bunches of needles, insoluble in acetic acid,
but soluble in ammonia and hydrochloric acid.  The collected crys-
tals should be dissolved in ammonia, recrystallized by evaporation,
                               41 
642        GENITO-URINARY  DISEASES AND SYPHILIS.

and  then submitted to Millon's  reagent, to which they respond posi-
tively.
   Leucin and tyrosin are found in cases of acute yellow atrophy of
the liver, in acute phosphorus poisoning, in internal gangrene, and in
severe cases of the infectious diseases.
   Cystin.—In all  cases leucin and tyrosin are  accompanied by
cystin, but cystin may appear alone.  (Fig. 179, 5.)  Cystin crystals
look  like those of uric acid, but differ in that they are soluble in am-
monia.   They are insoluble  in acetic acid and alcohol, and polarize
light to the left.
   Cystin crystals appear in  the urine in the severe micro-organismal
infections, in gangrene, and in idiopathic cystinuria.  They may form
a calculus.
   The soaps of calcium and magnesium occur occasionally, and form
crystals which resemble those of tyrosin and cystin, but do not give
their reactions.
   An excess of  xanthin  bases in the urine may  form a sediment of
crystals which resemble those of uric acid, but are soluble in ammonia;
they may form calculi.
   In faintly acid or neutral urines certain crystals form, which are to
be classed with  the alkaline sediment.  They are triple  phosphates,
basic magnesium phosphates, and  neutral calcium phosphates; they
form especially when the  urine is becoming alkaline.  An excess of
the crystals of triple phosphates in acid urine suggests phosphaturia.

                  SEDIMENT  OF  ALKALINE URINE.
   Phosphates.—The  acid or  basic  phosphates may be amorphous,
small granules.  The acid calcium phosphate (Fig. 180, 4), a rare form,
is  present  in the urine of those suffering from  imperfect nutrition.
Triple phosphates may be seen in weak acid, neutral, or alkaline urine;
most marked in alkaline decomposition.  They are large octahedral or
prismatic forms,  but in ammoniacal urine  present innumerable varie-
ties.   (Fig. 179, 3, 4; Fig. 180, 5.)  The basic magnesium phosphate
appears as refractive rhombic tablets.   The neutral calcium phosphate
is generally in the form of large  needles or prisms massed together.
These  forms all intermingle and have endless variations.   Phosphates
are dissolved by acids; they commonly constitute the outer coats of
nearly all vesical calculi, but may form the entire  stone.
   Ammonium urates (Fig. 180, 6) appear as round balls of dark color,
often with spicules.  They  rarely  form  calculi.   Dissolved in acetic
acid  they recrystallize as rhombic uric acid.
   The  carbonates of  the  alkaline  earths appear in the urine  as 
EXAMINATION OF  THE URINE.
643
dark masses of granules;  they dissolve with effervescence  in  acetic
acid.
   Cholesterin crystals may occur in  urine of any reaction, but are
seen most  typically  in  alkaline urine.   Exceptionally they occur in
severe cystitis and in chyluria.  They appear as flat plates, with broken
or cut-out corners.
   Indigo crystals may form in the alkaline urine of  normal subjects,
but when found in acid urine they suggest an excess of indolsulphuric
acid and the allied aromatic compounds of the  ether-sulphate  series,
due to tissue-decomposition, such as internal  suppuration, gangrene,
etc.  They appear as fine blue needles  and crystals. 
CHAPTER  XVII.
          cystitis.—vesical  tuberculosis.—vesical fistula.

   Cystitis is an inflammation of the bladder due to germ-infection.
   The sudden acute congestion due  to retention, chilling, irritating
conditions of the urine, or foreign body, is not considered as a true
inflammation, since, unless there is  added to this congestion germ-
infection,  the  condition is transitory, and is  attended by no lesions,
barring vascular engorgement.   Yet while the congestion lasts the
symptoms, with  the  exception of pus and  micro-organisms in the
urine, are identical with those  of acute cystitis.
   Classification.—Cystitis, in accordance with its clinical course, may
be acute or chronic.  From  the pathological stand-point the disease
may be—
   1. Superficial or catarrhal.
   2. Interstitial.
   3. Pericystic.
   Further  subdivisions, sufficiently indicated  by their  names, are
pseudomembranous cystitis and gangrenous cystitis.
   Etiology.—The causes of  cystitis are predisposing and exciting.
The predisposing causes  are those which favor congestion and reten-
tion, the  latter condition implying  the  former,  since  an over-full
bladder is always  congested.   A normal bladder containing normal
urine which is evacuated at  proper  intervals is not  readily infected.
Even though germs be carried  directly into its cavity, by dirty instru-
ments  for instance, the  resistance of the healthy tissues  is sufficient
to prevent penetration and multiplication of micro-organisms.
   The causes of vesical congestion are—1. Retention of urine.  The
vesical congestion is in proportion to  the acuteness of the retention:
hence a sudden distention of the bladder is a more favoring factor in
the development of cystitis than is a gradual accumulation of urine.
2. Trauma.  This  may be due to jar,  strain, contusion or laceration,
rough  instrumentation, or bruising by  a  stone or other foreign body.
3. Muscular  contractions abnormally frequent or prolonged.   These
may be excited reflexly by lesions, irritations, or inflammations of the
rectum, sexual organs, kidneys, or urethra, or may be due to hypersen-
sitiveness of  the micturition centre, to habit, to polyuria, or to  acute
     644 
CYSTITIS.
645
congestion.  4. Abnormal  conditions of the urine.  If the  urine  is
essentially changed in any of its characteristics, it will eventually act
as an irritant to the vesical mucosa.   If it is strongly acid, markedly
alkaline, or of  very low or  very high specific gravity, it occasions con-
gestion.  Thus,  the gouty and  rheumatic, dyspeptics suffering from
oxaluria, phosphaturia, or other urinary changes, diabetics, cachectics
with haematuria, persons who have been severely burned, and those
who have ingested overdoses of drugs such as cantharides, turpentine,
the balsams, alcohol, or arsenic, are  predisposed to cystitis by vesical
congestion.  5. Tumors and calculi.  It should be borne in mind that
tumors and calculi  do not in themselves  cause cystitis, but merely
predispose to its development by the  congestion which their presence
occasions, and by the admixture of blood with the urine, thus rendering
it alkaline and peculiarly rich as a culture fluid.   6.  Surface chilling,
as from getting the feet wet or sitting on the damp ground, may cause
a sudden and very marked congestion of the  bladder, though never
a true cystitis.  7. Prolonged sexual excitement or excess in  sexual
intercourse is a potent factor in the production of bladder hyperaemia.
8. Cardiac weakness, venous  obstruction, and atheromatous degener-
ation of the vessels are factors often operative in the aged,  which
when  combined, as is often the case, with an enlarged and inflamed
prostate, and hence with retention of urine, make the  development of
cystitis nearly certain.   9.  Lesions of the central nervous system by
destroying vaso-motor control and favoring retention of urine strongly
favor the development of cystitis.
   Congestion of  the bladder is, then, the condition which most pre-
disposes to cystitis.   When to the congestion is added retention, par-
ticularly if of an alkaline and  albumen- or blood-containing urine, the
most favorable  conditions for germ-infection are present.  It is clear
that several of the causes of acute congestion may be  operative at the
same time: thus, during acute fever there may be atonic retention
of urine which  is irritating from the pyrexia; or after spinal  injury
there may be vaso-motor  dilatation, combined with  retention from
detrusor paresis.
   The exciting cause of cystitis is local  infection.  This infection  is
commonly due to catheterization and urethritis.   Infection by way of
the ureters may also take place, but  probably not unless the kidneys
are diseased, though it has been demonstrated that apparently healthy
kidneys may eliminate pyogenic organisms.
   Pericystic suppuration  may also  occasion  local bladder-infection
by destroying the bladder-wall and discharging pus into its cavity.
   Wreder has proved that infection is not always due to catheteriza- 
GENITO-URINARY  DISEASES AND SYPHILIS.
tion or to extension of inflammation from the urethra. The microbes
may enter the bladder from the kidneys, by the agency of the blood-
or lymph-channels, or they may pass directly  from the rectum, this
direct passage being particularly liable to take place in cases of con-
stipation, inflammation, hemorrhoids, tumors of the rectum, or lesions
of the prostate.
   It is now commonly recognized  that normal urine is  sterile.  In
the urine of cystitis have been found a great  number of organisms,
many of  them  without pyogenic action.   Of the  micro-organisms
which occasion cystitis the colon bacillus is the one most frequently
found.   After  this come the staphylococci and streptococci of ordi-
nary pus.  The  position of  the gonococcus as a direct producer of
cystitis has not yet been definitely ascertained.   It seems clear that it
may invade a  part  or even the whole of the trigonum, but there is
evidence that  the remaining  vesical mucous  membrane is at least
partially immune to its  attack.   Cases of true bladder-inflammation
traceable to gonorrhoea are usually due to mixed infection.
   The tubercle bacilli will  be discussed under the head of Tubercu-
losis of the Bladder.  In themselves they are not able to cause general
cystitis, but they strongly predispose to mixed infection.
   Germs exert  their injurious action upon the bladder-tissue either
directly or through  their ptomaines.  The inflammation they produce
is increased by the ammoniacal fermentation of the urine  which they
bring about.   This  fermentation is due to the decomposing  action of
microbes upon urea, ammonium carbonate being formed.   This con-
verts the pus into a ropy, gelatinous mass, renders the urine markedly
alkaline, and makes it  thick,  foul, and ammoniacal.  Practically all
the pyogenic germs and many others found  in  the urine of cys-
titis produce this ammoniacal fermentation.  As a result the  urine be-
comes intensely  irritating: hence the cystitis is aggravated.  It must,
however, be borne in mind that this fermentation  is the  result of
cystitis, and not  its cause.
   A condition essential to  the formation of ammoniacal  urine is re-
tention, which  must at least be partial.  Even when retention  is present
this fermentation takes place to a minor degree or not at all when the
urine is acid and contains but little urea and when the pus-formation
is slight.  Retention of an abundant purulent secretion and secretion
of urine rich  in urea are most favorable for this fermentation. It is
absolutely diagnostic of cystitis, though care must be taken to see that
the urine has undergone this fermentation at the time of passing, since
under certain conditions it may take place very shortly afterwards.
   Cystitis has for its seats  of predilection the trigonum, the urethral 
CYSTITIS.
647
orifice, and the  region about  the  ureteral openings.  It is in these
regions  particularly that the  most pronounced  lesions are usually
found, even though the entire  vesical mucous membrane is involved.
   Superficial or catarrhal cystitis in its acute form is characterized
by a reddened, oedematous, ecchymotic mucous membrane the vessels
of which  are markedly engorged.  Erosions  or distinct ulcerations
may develop.   Exceptionally  shreds  of necrotic mucous membrane
are passed.   The  urine is usually acid, and contains pus and much
bladder epithelium.
   When superficial cystitis becomes chronic, reddening of the thick-
ened mucous membrane is no longer pronounced.  Indeed, this may
assume a yellowish hue with prominent veins and areas of exfoliation
colored gray-white by thin layers  of pus or urinary salts.   From the
oedematous  and congested mucous  membrane small  polyps may
grow, and the inner surface of the bladder is often trabeculated from
muscular hypertrophy.
   The urine is alkaline; when markedly so from ammoniacal fer-
mentation, there is often found overlying the mucous  membrane a
dirty-whitish deposit of muco-pus.
   Interstitial  cystitis exhibits the mucous membrane lesions of a
superficial inflammation.   The  inflammation extends  more  deeply,
however, involving particularly the connective tissue, but not entirely
sparing the muscular fibres.   From the inflammatory infiltration the
folds of the mucosa become prominent, causing ridges to be formed,
which are readily felt on exploration by a sound.  Small  abscesses
develop in the submucous connective tissue or in the muscular coats.
These abscesses commonly open into the vesical  cavity, leaving diver-
ticula which  are slow to heal.  Exceptionally such abscesses extend
outward, involving the  perivesical tissues and resulting in localized
pelvic cellulitis  or in peritonitis.   If the active disease is arrested,
organization and cicatrization take place, producing more or less dis-
tortion  and contraction,  sometimes  sufficient to lessen greatly the
vesical capacity.
   Pericystitis is  separately considered.
   Membranous cystitis, variously described as exfoliative,  croupous,
diphtheritic,  and  desquamative, is  characterized  by the  discharge
through the  urethra or through  a wound  of the  bladder  of  flakes,
masses,  or  complete moulds of  the bladder,  made  up  of  tough,
fibrinous, structureless membrane containing the remains of broken-
down epithelium.
   Stein  states that of fifty reported cases,  forty-five occurred in
women, and  mostly in connection with labor or  with serious uterine 
648
GENITO-URINARY DISEASES  AND SYPHILIS.
troubles.  The pathology seems to vary somewhat in different cases.
Thus, Cabot, in practising suprapubic cystotomy, found a thick mem-
brane which could  be readily peeled off the diseased surface of the
bladder.   It was  composed almost entirely of epithelium, and was
nourished by papillae thrown up from  the connective tissue below.
It was about one hundred times as thick as normal epithelium should
be.  Stein, in examining shreds in a case of his own, found that the
mucosa and submucosa had come away entire.
   Adami states  that microscopical  examination has usually shown
the casts to be composed  of a large amount of  fibrin in which are
incorporated the  inner layers of the  bladder-wall, including not only
the epithelium but a certain amount  of muscle-tissue.  He holds that
true exfoliative cystitis  is probably due to arrested  circulation from
long-continued pressure.   It is practically a  necrosis of the inner
layers of the bladder.
   Gangrenous cystitis  is characterized by sloughing of the mucous
and muscular coats of the bladder.   It is occasionally noted in acute
septic processes, in cancer of the bladder, and as a sequel to extensive
trauma.
   Alexander describes a nodular, glandular cystitis characterized by
the appearance of small nodules disseminated over the bladder sur-
face resembling tubercles.  These nodules are made up of vascular
lymphatic tissue arranged in circumscribed foci.   He states that cys-
titis complicated by these nodules is extremely chronic, and  subject
to relapses, and that pain and hemorrhage  are pronounced.
   Symptoms of Cystitis.—It should be borne in mind that there are
no subjective symptoms which point  absolutely to cystitis,—pain, fre-
quent micturition, and pus  in the urine, symptoms usually considered
diagnostic of bladder-inflammation, being  present when the prostatic
urethra alone  is involved.
   The symptoms  of cystitis are—1, pyuria; 2, frequent urination;
3,  pain ; 4, muscular spasm ;  5, haematuria ; 6, fever.
   Of these symptoms  pyuria is the  only one which is constant: the
others  may be so slight as not to be noticed, or  may be altogether
wanting.
   Pyuria.—This symptom is constant, and under certain conditions
is almost pathognomonic of cystitis.   Together with pus  there is fre-
quently found blood, and there is always a  superabundance of mucus
and bladder epithelium.  When the  urine is acid, there settles from it
standing a white  sediment of pus, and over this a  cloud of mucus.
When the urine is neutral  or alkaline, particularly when  ammoniacal
decomposition has  taken place, there is often a viscid, ropy deposit 
CYSTITIS.
649
of muco-pus.  The turbidity of the urine varies in accordance with
the severity of the inflammation.   Frequently in chronic  cases the
last two or three drachms at the end of micturition are made up of
almost pure muco-pus.
   Microscopical examination of the sediment shows abundant blad-
der epithelium, pus, often blood, micro-organisms, and in alkaline urine
crystals of the triple phosphates.
   Frequent Urination.—This  symptom  develops partly because the
bladder-walls are  abnormally sensitive to tension, partly because the
prostatic urethra is inflamed and hypersensitive :  hence the desire to
urinate becomes imperious as soon as  the first drops of urine come
in contact with the post-urethral mucous membrane.  Frequent urina-
tion is aggravated by the erect posture, by bodily activity, by jolting
or jarring, and by any of the causes which tend to increase congestion
of the prostatic urethra.  At times the patient is forced to micturate
every few minutes, and is absolutely unable to retain his water when
the desire is felt; usually, however, it  can  be retained one or two
hours.
   The frequent urination which  so often accompanies chronic cys-
titis, particularly when there is a  mechanical obstruction  to the free
passage of urine,  may occasion  an enormous  hypertrophy of the
muscular trabeculae, with a sacculation  of the weaker portions of the
vesical walls lying between these  interlacing fibres.  The sacculated
bladder thus formed is particularly difficult to treat, since the decom-
posing purulent urine lying in these diverticula is most  difficult to
reach and remove by the ordinary methods of bladder-washing.  The
urine is usually ammoniacal.
   It is worthy of note that when there is frequent urination, and
especially strangury, there  may be some kidney albuminuria due  to
congestion of these organs.   Usually the quantity of albumen in the
urine is proportionate to the  amount of blood  and pus which it con-
tains.  Exceptionally in chronic cases there may be a leakage through
patches denuded of the surface epithelium.
   Pain.—This in the acute cases is  constant,  with  exacerbations
taking the form of intense burning, with irresistible desire  to pass
water  and violent straining (tenesmus).  It is usually aggravated by
the act of micturition, and is more or less relieved after the bladder
is emptied.  Exceptionally, as in the case of stone and  acute gonor-
rhoeal  prostato-cystitis, the pain is most intense after micturition.  It
is felt in  the prostate  and bladder, and radiates from there to  the
hypogastric region, the sacrum, the rectum, the end of  the penis, and
down  the  inner surfaces of the thighs.   In very acute cases  when 
GENITO-URINARY  DISEASES AND SYPHILIS.
there is prostato-cystitis the patient is compelled almost constantly to
make violent and most painful straining efforts at urination, with the
evacuation of but  a  few drops  of blood-stained  water at a time
(strangury).
   Muscular Spasm.—As a result of inflammation reflex excitability
is markedly exalted.   It is to the overaction of the sphincter muscles
that much of the pain in cystitis is due.   These are thrown into tonic
contraction, or sphincterismus, thus  increasing congestion and exciting
pain, very much as  do the anal sphincters in acute proctitis.  By their
tonic contraction they resist the  attempts of the detrusors to  empty
the bladder, yielding  only after long effort, and then but partly, thus
occasioning strangury.  Or the contraction may be so obstinate that
there is complete retention of  urine.  Very frequently the tonic  spasm
is replaced by clonic contractions, which suddenly shut off the stream
when it is started, especially when the last few drops are being voided.
From the  closely connected  nerve-supply,  the  sphincter ani  some-
times participates in this tonic contraction, thus adding to the distress.
   Haematuria.—The  passage  of almost pure blood, especially when
it comes at the end of urination, is  characteristic of inflammation of
the prostatic urethra rather than of cystitis.   After micturition is com-
pleted the bleeding may still continue from this region and flow back
into the  bladder,  rendering  the  urine alkaline and  predisposing it
to ammoniacal fermentation, with marked aggravation of the cystitis.
From the  bladder-walls  in hyperacute cases there is usually some
bleeding.   This is slight, and the  blood is intimately mixed with the
urine.
   Fever.—In the beginning of an acute  cystitis, fever and the asso-
ciated symptoms of depression, nausea and constipation, are frequently
observed.
   Fever is, however, by no means an invariable symptom.   When
it reaches a high grade, and is prolonged and is paroxysmal in type, it
may be taken as a sign that cystitis is not  the only cause.  In these
cases a  careful examination usually shows that either the prostate or
the kidneys are  seriously involved.
   Diagnosis.—Frequent urination,  pain,  and pus in the urine  are of
themselves not enough to make the diagnosis of  cystitis complete.
   In cases of chronic inflammation there may  be no  symptoms ex-
cept pyuria.   When, together with some or all of the symptoms given
above, the bladder is  tender  on  suprapubic and  rectal  palpation,
when the  urine passed in three  portions  shows  greatest pus-tur-
bidity in the last, when the flat bladder epithelium  is  very  abundant,
when intravesical injections show that the  bladder is  hypersensitive 
CYSTITIS.
651
 to tension, and when the urine at the time of being passed is ropy and
 ammoniacal, the diagnosis of cystitis can be made  confidently.
   In many cases these characteristic features of  bladder-inflamma-
 tion are not present.  The diagnosis may then be made by cystoscopic
 examination; or a soft  catheter with a central  terminal opening and
 provided with a broad  elastic hollow flange just behind  this opening
 and so  stretched over  a  carrier that the flange is  obliterated may be
 introduced into the bladder.   On withdrawing the  carrier the elas-
 ticity of the rubber causes the flange to resume its shape.   The cath-
 eter is  then  drawn out till the flange  catches against  the internal
 vesical  sphincter, and is secured in  place by a small weight attached
 to its free end.  The bladder is thoroughly washed out with normal
 salt solution, and  the catheter is left in place for an hour, the urine
 which  flows through it being collected.   It is  obvious that any pus
 found in this urine must come  from the  bladder or the kidneys, since
 the flange effectually shuts off the prostatic urethra from the bladder.
   Prognosis of Cystitis.—Provided there is no lesion which tends in-
 definitely to  prolong vesical congestion, the prognosis of acute cystitis
 is favorable.   The  inflammation which frequently  accompanies stone
 or tight stricture of the urethra, or even  enlarged  prostate, can  be
 completely cured by removal of the  exciting cause.   Cystitis due  to
 gonorrhoea or rough instrumentation usually runs  a rapid and favor-
 able  course.   It often  happens, however, that  some infection of the
 mucosa remains, which is  stimulated to renewed activity whenever
 normal emptying of the bladder is interfered with,  or when sexual or
 alcoholic excess or intercurrent  disease causes pelvic congestion and
 irritation.  The cure is probably more  often relative than absolute,
 since it is considered established when  micturition  is accomplished
 normally and when the urine is apparently clear.
   The final conclusive proof of cure should  be  founded upon the
 results  of microscopic examination.
   If the centrifuged sediment of twenty-four hours' urinary secretion
 is found to be free  from pus, the patient may  be  considered cured.
 If, on the contrary, pus  is found,  even  though it be in small quan-
 tities, perhaps scarcely enough to form shreds, some focus  of infection
 still remains, and  is liable to light up an acute inflammation under
 favoring circumstances.
   The prognosis of chronic cystitis is less favorable than that of the
 acute.   It is  not,  however, absolutely bad.  Surgical treatment  of
 stricture and  enlarged prostate  shows that, after removal  of the pre-
 disposing cause, bladders which have been inflamed for years, and
which are greatly dilated and  atonic,  may regain power and may 
652        GENITO-URINARY DISEASES AND SYPHILIS.

apparently become healthy.    This was considered the exception, at
least in prostatics, .until  recently.  In fifty-two per  cent.,  however,
of a considerable number of  cases of prostatic overgrowth,  subjected
to castration, the  symptoms of a previously intractable cystitis disap-
peared, so that a more favorable view may now be taken of the pros-
pects of such patients.   As a rule, though the active symptoms  may
be subdued or may entirely disappear, some suppuration persists.
   It may happen that from infiltration of the bladder-walls, followed
by fibroid change and contraction, the vesical cavity becomes  greatly
reduced, so that the bladder  can contain but a few ounces at  a time.
More frequently, particularly in the  case of  prostatics, there is  dila-
tation with an incurably thickened suppurating mucous membrane.
   In its relation to involvement of the kidneys, and  consequently to
the life of the patient,  the prognosis of acute and chronic cystitis is
somewhat different.
   Lipowski states that the  conditions favoring ascending infection
are moderate  retention and  a strong, irritable bladder, which drives
urine back into the ureter at the moment the  orifice of this canal is
opened to expel its contents.   These conditions are fulfilled in cases
of stricture, hypertrophied prostate,  acute  inflammation, and  spastic
affections   during the  first  period of cystitis.  The  inflammation
markedly  increases the irritability of the yet strong bladder-muscles.
Hence it would seem to follow that the greatest danger of kidney in-
fection from the bladder exists in the  early  stages  of cystitis; later,
when  the submucous  and  muscular coats  are infiltrated and the
vesical contractions are feeble, intravesical  tension is  not  sufficiently
high to overcome that exerted by the stream of urine descending from
the kidney.  Tubercular cystitis, according to Lipowski, forms  an ex-
ception to this rule.
   Treatment of Cystitis.—From what  has  been said concerning the
cause of cystitis, it is plain that the prevention of this disease depends
upon the avoidance of local congestion and of the entrance of germs
into the bladder.
   Local  congestion  is avoided by attention to the rules of hygiene.
Rest in bed is  not  desirable.  Indeed,  in cases of partial urinary
retention  it  seems  to  favor  rather  than lessen  pelvic congestion.
Regular daily exercise  in  the open air, such as driving, walking, or
riding  the horse   or bicycle, in accordance with the  strength of the
patient, is  to be  commended.  The  diet  must be  so regulated that
digestion is perfectly performed;  even slight  gastric or intestinal dis-
orders render the urine distinctly irritating.
   Usually diluent drinks are serviceable,  particularly at night, since 
CYSTITIS.
653
 the urine is most strongly acid during the  small hours.  Natural
 mineral waters may be ordered  in accordance with the dyscrasia of
 the patient. Thus, lithia water  would be  indicated in  the  gouty or
 rheumatic,  ferruginous waters in the anaemic or in those subject to
 looseness of the  bowels.
    Careful  attention should  be  given to the  condition  of the skin.
 The patient should bathe daily in either hot or cold water, according
 to preference.   This bath  should be followed  by vigorous friction.
 The sweating-box described  under  the  treatment of syphilis is par-
 ticularly serviceable, and may be used daily when there is  no idio-
 syncrasy and when it does not  produce weakness or debility.  The
 feelings of the patient will be the best guide in deciding on this course
 of treatment.  The sweat should be followed  by a cool sponging and
 vigorous friction.
    Regular evacuation of the bowels is a matter of cardinal impor-
 tance.   It has been shown experimentally that rectal obstruction is
 almost immediately followed by the appearance of enormous numbers
 of colon bacilli in the urine, coming either through the kidneys or
 conceivably directly from the rectum to the bladder through the thin
 intervening walls.  A daily bowel movement is best procured by ex-
 ercise and diet.  If these means are  not efficient, mild  salines, such
 as Hunyadi water, may be administered in the early morning, or rectal
 enemata of normal saline solution may be given.
   An examination of the urine should be made to determine the
 presence of excess of  uric acid,  oxalates, or other ingredients which
 are irritating to  the vesical mucosa  and which  can be lessened by
 appropriate diet  and medication.  Chilling  of the  surface, wet feet,
 prolonged standing, elaborate  meals, highly  seasoned foods, pastry,
 sweets, alcohol, and rhubarb are to be avoided.
   When there are local causes for reflex irritability, as hemorrhoids,
 varicocele, tight prepuce, or narrow meatus, these should receive ap-
 propriate surgical treatment.   Urethral causes of bladder-irritability
 or of partial retention of urine,  such as stricture of either large  or
 small calibre, should be relieved  as promptly as possible.
   As a means of preventing  direct infection when this is threatened
 because of inflammation of the urethra or of the  prostate, or because
 of proposed surgical interference, it  is well  to render the urine not
 only bland  but even  mildly  antiseptic.  This end  may be accom-
plished by the  administration of  salol and  boric  acid, as already de-
scribed (five grains of  salol four times a day;  five to ten grains of
boric acid four times a day).
   It must be borne in mind that the very conditions which call for 
654        GENITO-URINARY DISEASES  AND SYPHILIS.

surgical intervention are those which favor the development of cystitis
and, moreover, are those in which cystitis is most dangerous.  The soil
has  been prepared in advance.  The chief difficulty to be overcome
in avoiding the infection  of  this soil arises from  the  fact that it is
almost impossible to render the urethra aseptic.  In practising intra-
vesical treatment through  the urethra, the hands of the surgeon, the
penis,  the glans, and the  urethral orifice of the patient should be
sterilized,  as  is  customary in  the preliminary preparation  for any
formal operation.   This implies  scrubbing with soap and water, fol-
lowed  by alcohol,  finally by  sublimate  solution 1  to 1000.  A more
efficient  antiseptic  solution is made by adding to  this solution two
and  a half per cent,  of carbolic  acid.   Full  irrigations  of four per
cent, boric acid solution, largely through its mechanical  action, and
partly through its feeble bactericidal power, may clean the urethra so
that a sound may be introduced sterile into the  bladder.  Metal in-
struments are boiled, rubber and gum instruments are either boiled
or sterilized in the paraform  apparatus.   The  lubricant is put in the
steam sterilizer for fifteen minutes  before being used.   The urethra is
cleansed as described  in  the treatment  of retention  from prostatic
enlargement.  Either the solutions already mentioned  may be used,
or one made up of 1 to 4000 sublimate solution containing one-half
of one per cent, of carbolic acid.
   When operation is required, the urine is usually already purulent.
Whether this  is the case  or  not, before operation  it  is well  to flush
out the entire urethra  and bladder with  one of the  antiseptic solu-
tions already given or with salicylic  acid  solution, followed by a 1 to
8000 sublimate  solution containing one-half of one per cent, of car-
bolic acid.   After operation the bladder and urethra should be flushed
with silver nitrate  solution 1 to 1000, and  the  after-washings  may
be with solutions of sublimate and carbolic acid, or of silver nitrate,
or simply with hot sterile water containing six per cent,  of common
salt.
   Thiersch's solution and boric acid are difficult to prepare promptly.
If the Thiersch solution be made at the  time  it is required (salicylic
acid, one-half drachm ; boric acid, three and a half drachms in pow-
der added  to a quart of hot water), the powder dissolves  too slowly.
If the cold solution has been standing for some time, it should always
be sterilized by boiling immediately before it is  used.  Boric acid also
dissolves slowly, and bacteriological experiments show that it has little
more effect in killing germs than has salt and water.   Salt dissolves
at once, and  is more  cleansing than simple water.   Salicylic acid,
besides being an admirable germicide, has the extra  advantage, first 
CYSTITIS.
655
pointed out by Bryson, of penetrating farther and cutting deeper into
the thick pus of catarrhal  inflammation than  any other  substance.
Therefore it  is well to have  a solution of salicylic acid in alcohol,
eight grains to the ounce;  half a grain of salicylic  acid to the ounce
is as effective, a germicide  as Thiersch's solution, and consequently
by adding one ounce of the  alcoholic salicylic acid solution to one pint
of hot water there results a mixture which can be made promptly and
is quite as effective as that of  Thiersch.
   Acute cystitis, or violent  congestion typified by cantharidal poison-
ing, is treated by hot baths, rest in bed, elevation of the pelvis, and
thorough evacuation of the lower bowel, best procured by salines and
cold enemata of salt water.
   For the relief of the frequent  painful urination belladonna and
opium suppositories are indicated.   These should be repeated hourly
till they accomplish the purpose  for  which they are given (watery
extract of opium,  one-half  grain ;  extract of belladonna, one-fourth
grain).   Hot compresses should be applied to the  entire abdomen,
and should be changed frequently.   Diluents  and sedatives should
be given by the mouth.  In severe  cases leeches to the perineum and
the hypogastric  region are  extremely serviceable.   If there is  fever
with consequent strongly acid urine, to the copious draughts of water
should  be added potassium citrate or acetate, in doses of ten grains
six times daily, or spirit of  nitrous ether in drachm doses hourly, or
liquor potassii citratis may be administered in tablespoonful doses well
diluted every one or two hours.  Salol and  boric acid should always
be given for the purpose of  rendering  the  urine slightly antiseptic.
When the symptoms are unusually severe, patients often assume the
knee-elbow position, since thus the pressure of  the abdominal viscera
is taken from the bladder and venous engorgement is lessened.  This
position is serviceable, and should  be advised  when it is not spon-
taneously assumed.  When large  doses of opium  fail to relieve pain
and spasm, the ice-bag introduced into the rectum may be of use.
   When the symptoms are  purely  the  result of  congestion—i.e.,
when  there  is no vesical   infection—all intravesical  manipulations
should  be avoided, unless  retention  threatens, though  it has  been
shown that pain may be relieved promptly and for several hours by
the instillation of fifteen drops of a one per cent, solution of cocaine.
In certain cases of gonorrhoeal prostato-cystitis where the inflamma-
tion is limited to the prostatic  urethra and the portion of the trigonum
nearest  the vesical orifice, an instillation of ten drops of a five per cent.
solution of silver nitrate will give almost immediate relief.
  The bleeding of acute inflammation is usually slight, and is often 
656        GENITO-URINARY DISEASES AND SYPHILIS.

of advantage, since it lessens congestion ; it requires no special treat-
ment.
   Should retention supervene, if  it is  entirely due  to  spasm and
congestion, an attempt should be  made to  relieve it by a hot genenil
bath, the  patient being directed to micturate while still in the tub.
Hot  compresses or turpentine stupes to the abdomen and full doses
of opium and hyoscyamus or belladonna are also indicated.  When
retention  is complete and distention pronounced, there should be no
hesitation in employing the catheter, ether being given if this manipu-
lation is excessively painful.
   In the course of a week to ten days the acute  inflammation will
subside, and,  provided there  are  no local  conditions  which tend in-
definitely to  prolong congestion, convalescence may be  complete.
Usually the  disease becomes chronic,  and may  thus continue  for
years, giving rise to no symptoms other than a small quantity of pus
in the urine, but being subject to acute exacerbations.
   Treatment of chronic cystitis will not be successful unless the pre-
disposing causes, such as urethral obstruction, stone, and tumor, are
removed.  The  diet should be so  regulated  that the food is thor-
oughly digested  and the  gastro-intestinal tract kept free from irrita-
tion; highly seasoned articles, desserts, and alcohols are in general
to be avoided.  The natural mineral waters are  useful as diluents,
and  may be taken between meals.  Saline diuretics—and among these
potassium citrate is the most valuable—should be given, well diluted,
in quantities  sufficient  to keep the urine nearly neutral  in  reaction.
In the absence of a rheumatic diathesis, and particularly where there
is an associated anaemia, the ferruginous mineral waters are of use.
   Of the long  list of drugs used by the  mouth  comparatively few
have any real value.  Benzoic acid often does good when the urine
is markedly alkaline, and  hence  irritating.   It  may be given  in five-
to ten-grain doses  six times a day.  The  dose is regulated by the
effect upon the urine.   The balsams are  extremely useful  in both
subacute and chronic cystitis.  Of these sandal wood oil is one of the
best, given either in the form of an emulsion or in a capsule.   In the
latter case it  should be combined with oil of cinnamon, and  should
be taken  one hour after meals.  The following prescription  may be
used:

                       R 01. santali, tt\,x ;
                          01. cinnamomi, Tt^ii.
                       Ft. capsula i.
   Sig.—Take  three such  capsules daily, one  hour after each meal, gradually
increasing the number. 
CYSTITIS.
657
   To be effective, the  sandal wood  oil must be given in full doses.
This is often impossible, because of the gastric  derangement it occa-
sions.
   Salol and boric acid are  valuable from their germicidal qualities.
They both tend to correct digestive disturbances  rather than to pro-
duce them.
   Of the many other drugs which have been  recommended and
which are commonly employed, perhaps  the most useful are pichi
extract five grains every two hours in capsules; cantharides in drop
doses  every one or two hours as  a stimulant in  extremely chronic
cases; turpentine five to fifteen drops in emulsion every three hours ;
oil of eucalyptus five to ten drops in  emulsion every two hours ; fluid
extract of buchu or uva ursi in drachm  doses every two  or three
hours; arbutin  in  doses of  three  to five  grains three to six times
daily.
   Generally, if predisposing causes are  removed, the bladder put
at rest, and the urine rendered  unirritating, stimulant, and slightly
antiseptic, so that  ammoniacal fermentation does not  take place, the
symptoms rapidly improve,  and  the patient recovers.  If, however,
these  milder hygienic  and medicinal methods fail and free  vesical
suppuration  continues,  local treatment is indicated.   This may be
applied either by instillation  or by irrigation.
   The method of employing instillation has been described already
under the treatment of  posterior urethritis.   Irrigations are practised
with  a fountain syringe fitted to either a short urethral nozzle or a
soft rubber catheter of  comparatively full  size.   Irrigations with a
short  urethral nozzle may be  employed when the vesical tonicity is
good  and the bladder  has the power of completely  and painlessly
evacuating its contents.   In chronic cystitis this condition is ex-
tremely rare: hence the method of choice is usually that with the
catheter.
   Instillations are indicated when inflammation  is particularly se-
vere at or about the neck of the bladder.  This is usually shown by
the symptoms, strangury being  always most pronounced when in-
flammation is thus located.   These instillations act directly upon the
prostatic  urethra and .the neck of the bladder.  They may at first
seem to aggravate  tenesmus and pain, but this is shortly followed by
marked relief.   The solutions of choice are those of  silver  nitrate
with a maximum strength of five  per cent.  It is well to begin with
a one-half per cent, solution and gradually increase the strength till
the symptoms are  relieved.
   Instillations are repeated every second, third, or fourth day,  in
                               42 
658        GENITO-URINARY  DISEASES AND  SYPHILIS.

accordance with  the  reaction  they excite.  The immediate pain they
cause  may be  lessened by  preceding them  by an application of
cocaine.   When  it is desired to affect a larger surface of the bladder
two  to four drachms may be employed.   The  strength of the  silver
solution when it is thus used  should not be more than one per cent.
when the treatment  is inaugurated.   It is well to begin with half a
grain to  the ounce.   Silver nitrate  instillations are particularly ser-
viceable in gonorrhoeal  cystitis, and  in those chronic, non-tubercular
forms of inflammation which  are not dependent  upon urethral ob-
struction and retention.
   Sublimate  instillations are useful in  tubercular cystitis.   They
also  render good service in the inflammation due  to gonococci,  colon
bacilli, and  ordinary  pyogenic  microbes.   This method of treatment
was  first  popularized by Guyon,  who reported extraordinarily suc-
cessful results.   The  quantity injected into  the  bladder should be
from one to two drachms, and that  into the posterior  urethra from
five to fifteen  drops.   Weak solutions are first  employed (1 to 4000),
and the strength is gradually increased (1 to 500).  These instillations
may be repeated every second or third day, and should be preceded
by irrigations unless the bladder is extremely irritable.
   Irrigations are given  as already described and with strict attention
to cleanliness.   The  quantity injected varies  in accordance with the
capacity and irritability of the  bladder.  It is a  good  rule not to  inject
a sufficient bulk of fluid to cause pain from tension.
   The most  efficient irrigation is that of silver nitrate.  The  solu-
tion  employed varies in strength from 1 to 4000 to 1 to 500.  In
extremely chronic  cases much stronger solutions  than  these  are not
only tolerated but are beneficial.  The urine  is  first  passed.  The
bladder is then irrigated with boiled water until this comes away clear;
finally one or  two ounces of the  silver solution are thrown in and
allowed to escape almost immediately.  Strong silver irrigations are
repeated daily or every second or third day, in accordance with the
violence, of reaction.   When they excite  severe pain and apparently
aggravate symptoms,—and this is particularly likely to occur in tuber-
cular cystitis,—other antiseptics should  be employed.  After  silver
nitrate the most efficient lotions are those of pptassium permanganate
1 to  4000 to 1 to 500, boric acid five to fifteen grains to the ounce,
creolin one to five per cent., corrosive sublimate 1 to 20,000 to 1 to
5000, carbolic  acid 1 to 500, antipyrin two to five per  cent., and
ichthyol  one-half to two per cent.   When even the  weakest of these
antiseptics occasions  pain and marked reaction, and when it is cer-
tain that these sequelae are not due to bladder-tension incident  to the 
CYSTITIS.
659
injection of too great a  quantity at one time, recently boiled seven-
tenths per cent, sodium chloride solution may be employed.
   It'should be  clearly understood that in cases of chronic cystitis
the bladder mucosa is infected not only upon its surface but also in
its depth, and that no antiseptic can reach germs which are embedded
in the tissues.   The function of lavage is not to render the  bladder-
wall  sterile, but  rather to remove decomposing  pus and  urine,  to
inhibit or destroy those germs which lie upon the surface, to stimulate
healthfully the chronically engorged vesical walls, and to leave in the
bladder  a residuum which will prevent further fermentation of the
urine, with its irritating effect upon the mucosa.  It is therefore well,
after having practised irrigation, to leave  from  half a drachm to an
ounce of antiseptic solution in the bladder.  This is particularly indi-
cated when evacuation of the last few drachms of urine is painful.
   No rule  can be given as to the number of irrigations which are
indicated.  Where there  is profuse suppuration with rapid decompo-
sition, ammonuria, and retention, the  bladder should  be washed out
at least twice daily, and  often this  process can be advantageously re-
peated three or four times.   Where the cystitis is slight in grade and
the urine is not decomposed, irrigations may be practised every two  or
three days.  Daily irrigation at least is generally required.
   When in spite of instillations and  irrigations, or because of pain,
spasm, and  undue reaction,  these  methods of treatment  are not
practicable,  the  cystitis  becoming  steadily worse, and constitutional
symptoms developing, permanent  catheterization  is indicated.   The
technique of this method  is fully described under the treatment of
retention from  prostatic  obstruction.  If  the catheter is  properly
held  in place, the bladder is constantly drained and thus put at  rest.
Through this catheter are practised irrigations with the solution which
excites least inflammatory reaction.
   If these methods of treatment do  not relieve the patient and  it is
evident that his  strength is  rapidly  failing from septic  absorption,
suprapubic or perineal  drainage is indicated.   Unless there is some
distinct reason for choosing the suprapubic route, as, for instance, the
necessity for operating on a vesical tumor or for treating a tubercular
ulcer, the perineal incision should be the one of choice,  except in cases
of vesical and prostatic tuberculosis.
   When the  cutting  operation is forced  on the surgeon in  place of
catheterization and irrigations, because of the pain and reaction which
they excite, forcible dilatation of the prostatic urethra is a most im-
portant procedure, since this will always  for  a  time and often  per-
manently relieve the violent and exhausting tenesmus from which this 
660        GENITO-URINARY DISEASES AND  SYPHILIS.

class  of patients habitually suffer.  The bladder  is entered through
the membranous urethra.  The drainage-tube  should be of large
calibre, about the  size of the  little finger, and  its walls  should he
sufficiently  rigid to prevent  flattening  from pressure of the tissues.
The  incision is  packed with  iodoform gauze, and  the perineal drain
is  attached to a rubber tube  which passes  beneath the surface of an
antiseptic lotion held in a suitable receptacle.  The latter  should be
so arranged that it is always beneath the level of  the bladder.  This
perineal tube secures continuous drainage  and  absolute rest, and
enables the surgeon to employ irrigations to the best effect.

                    PERIVESICAL INFLAMMATION.
   Two forms of perivesical inflammation are described by Halle, the
cicatricial and the suppurative.
   Cicatricial pericystitis  is the result of chronic pelvic cellulitis, and
is  characterized by  accumulations of sclero-adipose tissue  about the
base and sides of the bladder.  The perivesical tissue becomes dense
and greatly thickened,  and firmly mats the pelvic organs together.
The  masses of this tissue, by forming about the vesical insertion of
the ureters, may produce occlusion of these canals.
   Suppurative  pericystitis appears in the form of abscesses, develop-
ing in the normal fibro-adipose tissue surrounding the bladder.  Usu-
ally these  abscesses are  secondary to  prostatitis  or cystitis.  It  is
evident that they may form  in  case  of wound or ulceration of the
bladder.  The  ulceration may  be tubercular or  malignant.   More
commonly it is erosive, and is caused by stone or foreign body. The
abscesses of parenchymatous cystitis  may  rupture  externally and
affect the perivesical tissues ;  usually they discharge into the bladder.
Suppurative pericystitis due to stone ulcerating through the bladder-
wall  is localized and develops slowly.   It  may discharge upon the
skin  surface, usually in the perineum, or empty  into the  rectum or
the peritoneal cavity.
   Prevesical Abscess.—There is one form of perivesical  inflamma-
tion  which, from the  fact that  it is often primary and if promptly
recognized can be successfully treated, requires special consideration;
this is prevesical suppuration, or abscess in the space of Retzius.
   This space  is  entirely external to the peritoneum,  and serves  in
part  to give the  bladder  room to expand and fill with urine.  It  is
bounded anteriorly by the pubis and  the anterior layer of the trans-
versalis fascia of Cooper, behind by the posterior layer of that fascia
and by the bladder.  That part  of the space which extends upward
beyond the pubis is limited  above by the line of union  of the two 
CYSTITIS.
661
layers of fascia which are given off at the lower border of the sheath
of the recti muscles posteriorly, and has for its lateral limits the union
of these layers with the  aponeurosis  of the transversalis and oblique
muscles.  Below, the space is limited to the prostatic sheath and the
superior aponeurosis of the true pelvis.
   Suppuration in  this  region may be caused by traumatism, oper-
ative or otherwise, or by infection of  neighboring organs, such as the
bladder, prostate, uterus, etc.  Englisch, quoted by  Thorndike, classes
all cases of prevesical suppuration under three  headings : (1) those
caused by traumatism ;  (2) those caused by metastasis ;  and (3) those
caused by direct extension from neighboring organs or tissues.
   It is evident from the boundaries of this  space that pus may open
through the anterior abdominal wall, into the rectum, the bladder or
urethra, the perineum, or the peritoneal cavity.  A certain proportion
of these cases give a tubercular history, but  proof  as to the causative
agency of the tubercle bacillus is wanting.
   Symptoms.—The  symptoms of prevesical suppuration are vesical
tenesmus and irritability,  pain, not sharply localized, often  referred
to the bowels and associated with digestive disturbances, the forma-
tion of a tumor occupying the position of a distended bladder and
discoverable  on suprapubic or bimanual  palpation, local tenderness,
and usually constitutional symptoms  of suppuration.
   Diagnosis.—The formation  of inflammatory infiltration behind the
pubis associated with  symptoms  of  vesical  irritability would in  the
absence of cystitis be sufficiently characteristic of prevesical inflam-
mation.  When cystitis is present the persistence of the tumor after
thorough evacuation of the bladder-contents would also  be pathogno-
monic.  WTien the abscess points forward in the middle line, perhaps
the only condition with which it is likely to be confused is post-rectal
suppuration, the  pus then  lying behind  the rectus  muscle  and  be-
tween it and the layer of fascia which descends directly to the pubis.
In this case the pus would be limited laterally by the borders of  the
recti muscles and would extend upward.   The induration of  prevesi-
cal inflammation extends laterally beyond the limits of the recti mus-
cles, and is usually symmetrically developed in  the  two sides.  Ex-
ceptionally the abscess  extends towards  one side only.  We have
operated on one such  case where because of associated intestinal
symptoms the condition was diagnosed as incarcerated hernia.  Care-
ful bimanual palpation suggested the true nature of the affection, and
the presence of pus was confirmed by an incision.
  Prognosis.—This is favorable,  especially when the  condition is
properly diagnosed  and  treated by early evacuation  of  the pus.  Of 
662        GENITOURINARY DISEASES AND SYPHILIS.

Englisch's thirty-three reported cases four died from a general purulent
peritonitis  following  perforation of  the  abscess  into  the  peritoneal
cavity.
    Treatment.—Suppuration requires evacuation  and drainage.  In
the absence of pointing, incision should be made  in the middle line
directly over the pubis.   Drainage should be secured by gauze pack-
ing.   The same rule applies to all perivesical  suppuration.  The pus
should be evacuated as soon as it is detected.
   In the treatment of that form of  chronic perivesical inflammation
which is characterized by the formation of masses of fibro-lipomatous
tissue attention should first be  directed to the cure of the condition
which has produced or is keeping  up pelvic  cellulitis.   This may be
an untreated cystitis, with diverticula, or, in the case of women, endo-
metritis and perimetritis.  Hot rectal douches of normal saline solu-
tion and massage through  the rectum  and over  the  pubis may be
serviceable.

                 TUBERCULOSIS  OF  THE BLADDER.
   Tuberculosis  of  the  bladder is  a disease of  early and middle
life, occurring  chiefly between the ages  of fifteen and forty ; it has
been  observed, however, in children four or five years old, and Tapnt
noted a case  occurring in a  man  at the extreme age of ninety-seven.
It is  found more frequently in  males than in females, and is usu-
ally associated with tuberculosis of  the  seminal vesicles and of the
prostate.
   Etiology.—The predisposing  causes have been  found to be  a gen-
eral  tubercular tendency, often inherited, together with an infectious
cystitis, generally gonorrhoeal in  origin.
   The exciting cause  is infection with  the  tubercle bacilli.  This
infection may  be primary  or secondary.  The secondary  infection
may  be  ascending  or descending.   Herberg, from the records  of
several  thousand autopsies, finds that genito-urinary tuberculosis  is
secondary in two-thirds of all cases, and that when it is primary it
generally affects the  sexual organs.  Primary tuberculosis  of the
urinary organs is  most likely  to attack the kidneys.   Secondary
infection usually takes  place directly  from  the  prostatic urethra,
Krzywicki stating that this gland is affected in ninety-three per cent.
of cases of genito-urinary tuberculosis, or indirectly through the ureter
from  renal tuberculosis.  Fournier  holds that direct inoculation  is
possible during coitus by tubercular mucus from the vagina entering
the male urethra and  infecting the bladder.  An ascending infection
from  the epididymis and vas undoubtedly occurs. 
VESICAL TUBERCULOSIS.
663
   It is impossible to say with certainty that a given case of vesical
 tuberculosis is primary;  we must almost always remain in doubt as
 to the presence or absence of the disease in the kidneys.  Frequently
 its existence there may be demonstrated, but it may be present, and
 to a formidable extent, without  a single diagnostic  symptom having
 shown itself.  When  both  bladder and  kidneys are involved, it is
 impossible to determine, even by post-mortem examination, in which
 organ the disease was  primary.   Nor do the symptoms throw light on
 the matter, since in the earliest stages of surgical tuberculosis, when it
 appears  to be primary in the  bladder,  an examination may  show
 nodulations of the prostate and seminal vesicles, or renal haematuria
 may prove that the kidneys are already involved, although no symp-
 toms  indicating the  implication  of these organs  have  manifested
 themselves.
   Halle says, " The absolute absence of symptoms in the tubercular
 lesions of the kidney and ureter cannot be too strongly emphasized.
 Often the  only indications are  failure of the general health and  an
 indolent bacillary  pyuria, and even  this may be lacking if the ureter
 has become speedily obliterated.  These diseases, therefore, at their
 beginning,  and even  up to an  advanced stage, are  frequently  not
 recognized.  It is  only when  the bladder becomes affected and the
 pains of cystitis or cystalgia manifest themselves that medical advice
 is sought.  Often even then the attention of the physician is entirely
 directed to the dominating painful vesical symptoms, and he is apt to
 attribute to the bladder alone  phenomena which  arise  from  renal
 lesions.  Bearing  these facts in mind, it will be found  that in many
 patients  the  urinary tuberculosis, considered as primarily vesical or
 prostatic, and  classed among  the  ascending  tuberculoses, has  in
 reality begun insidiously in the kidney.   Autopsies support this view.
 In many cases  of  wide-spread tuberculosis of the urinary tract it is
 possible to demonstrate the greater  age of the renal lesions."   Halle
 concludes,  " In a word, I am of  the  opinion that urinary tuberculosis
 begins in the kidney oftener than clinical observation would lead  us
 to suspect, and that it is especially a manifestation of general tuber-
 cular infection localizing itself in the kidney, which it reaches by way
 of the circulation."   It must be  remembered that even though  the
 kidneys are tubercular and constantly  discharge tubercle bacilli  the
 bladder may  remain entirely healthy.
   Exceptionally, by the  method of exclusion Ave can arrive at a diag-
 nosis of primary, hence  haematogenic, cystitis.  The observations of
 Weigert, Heller, Weichselbaum, and others have shown that the blood
is one of the principal channels by which tuberculosis is propagated 
664       GENITO-URINARY DISEASES  AND SYPHILIS.

throughout the system.  Pathological anatomy tends to confirm this
theory.  The initial changes are found to be grayish miliary tubercles
situated  on the  superficial layer of the epithelium.   Ulceration is
always a later  stage.   Clado, having  previously wounded the vesical
mucosa of  a rabbit, gave it a subcutaneous injection of tubercle bacilli.
It developed vesical tuberculosis.
    Pathological  Anatomy.—In well-marked cases of tubercular  in-
flammation of the bladder there is a pericystitis, characterized by yel-
low, fibro-lipomatous infiltration and degeneration ; the bladder-walls
are thickened and rugous.  The mucous membrane is ecchymotic in
spots.  Granulations can rarely be seen, but when visible they appear
as fine gray  dots, sometimes confluent,  but  never in  such masses
as  are seen in the kidney.   Ulcerations, either single  or multiple,
are found  in the mucous  membrane.  Their edges are irregularly
excavated, their  base  a greenish gray covered with thick pus.  In
depth  they are very variable, sometimes  only invading  the  mucous
membrane, and again they may even  perforate the bladder-walls and
produce  perivesical  abscesses, or fistulae opening into  the  rectum,
vagina, or  hypogastrium; fistulae, however, are  rare.   Microscopi-
cally, it is  seen that the tubercular granulations arise in the super-
ficial layers of the mucous membrane, and in these lesions, which are
commonly  in or near the trigonum, the tubercle  bacillus and many
septic bacteria will be found.
   Symptoms.—Vesical tuberculosis may develop so insidiously that
its presence is not suspected  till a urinary examination, made in the
course of an  examination for life  insurance, for  instance, shows the
presence of blood.  In these cases there have  been no symptoms, or
perhaps,  when  questioned, the patient will remember that  he has
been slightly troubled by a somewhat frequent urination, chiefly after
meals and  during the night.   The urine is clear and limpid, is passed
every hour or  so, and the frequency, which  in  children may cause
nocturnal incontinence, is aggravated by the dorsal decubitus.
   Haematuria  in many cases is an early symptom.  The bleeding is
slight, spontaneous, and sometimes terminal, a few drops of pure blood
following the  claret-colored urine.  It  often  stops  as suddenly and
inexplicably as it begins, and may not  reappear  for days or weeks.
This symptom  becomes gradually less prominent as the  disease pro-
gresses.   Exceptionally  there may be a  profuse  hemorrhage, but
where this  occurs the presence of vesical tumor should be suspected.
   Pain,  when pronounced, usually denotes the  onset of cystitis, to
which  the  tubercular bladder is  almost inevitably doomed.  The
usual cause of cystitis  is catheterization, but it develops spontaneously 
VESICAL TUBERCULOSIS.
665
in the absence of instrumentation.   Cystitis having been inaugurated,
pain becomes one of the most constant, prominent, and  harassing
symptoms of the disease.  The patient is tortured day and night by
urgent desire to urinate and by violent tenesmus, sometimes recurring
every few minutes, and the pain may be felt at all stages of urination.
These symptoms are  most pronounced when the tubercular process
attacks the  region of the trigonum ; when the lesions involve  other
parts of the bladder it may happen  that an advanced stage  of vesi-
cal tuberculosis will be reached before the slightest symptom of pain
manifests itself.
   Retention of urine occasionally results from spasm and inflamma-
tory obstruction of the internal urethral orifice, and again true incon-
tinence may arise from destruction of the neck of the bladder by the
tubercular process.
   Pus is present as an evidence of cystitis rather than of tuberculo-
sis.  Before mixed infection has taken place the urine is limpid or at
most faintly tinged with blood.
   The method of staining the tubercle  bacillus has been given.   The
best ways of establishing its presence are by cultivation on  artificial
media and by inoculation of the lower  animals. Many examinations
and efforts at culture  are often required before the bacillus is found.
   In the female a painful zone  of ulcerations may sometimes be seen
at the meatus urinarius,  extending thence up the urethra.
   Diagnosis.—Probably in  a  large majority of  cases  tubercular
cystitis is not  suspected till  the disease is well  advanced and  has
spread wide of the bladder.   Warren says,—
   "Perhaps the  reason that more than any other leads genito-uri-
nary tuberculosis to be  overlooked is  the  readiness  to rest content
with a diagnosis of  'idiopathic cystitis'  in  cases in which pyuria
and irritable bladder are the conspicuous symptoms, and in which
a few microscopic examinations of the  urinary  sediment fail  to show
casts, renal  epithelium,  or  crystals, the latter fact  being often as-
sumed, under  these  circumstances, to free  the  kidneys  from sus-
picion of being involved.   ' Idiopathic cystitis,'  in   the sense  of a
spontaneously occurring inflammation  of the mucous membrane of
the bladder,—an inflammation  without a well-defined cause, that is
to say,—I do not believe exists.  If inquiry  is pushed far  enough,
some  condition of  which  such  as  the following  are  the  most
familiar  examples will be found to have originated the trouble: gon-
orrhoea ;  stone; lithiasis; stricture; prostatic hypertrophy and  its
consequences; the use  of instruments; acute  over-distention of the
bladder,  such  as  occurs sometimes in childbirth, or by  voluntary 
GENITO-URINARY DISEASES AND SYPHILIS.
effort, as with the insane ; profound narcosis from opium or alcohol;
the ingestion of certain irritating drugs, for example, cantharides;  in
connection with certain diseases of the spinal cord, etc.
    " If, in the absence of these or other well-defined causes, a patient
has symptoms of cystitis, it is strongly suggestive of tuberculous dis-
ease in the genito-urinary tract, probably located in the kidneys, the
prostate, the seminal vesicles, or possibly in  the bladder itself; but
this is thought to be rarely  the starting-point of the disease."
    Konig states that half the patients who complain of pus and mucus
in the urine as the principal symptom are  tubercular;  it is certainly
the case that tubercular cystitis is by no means a rare disease, and
that the bladder  is frequently affected, apparently primarily.
    There is no pathognomonic  sign or symptom of tubercular cystitis
except  discovery of the bacillus in the urine.  This is usually diffi-
cult, sometimes impossible.  Tuberculosis should, however, be sus-
pected when (1) there is a characteristic family history;  (2) there have
been frequent urination and  haematuria without discoverable cause;
(3) cystitis develops and persists in the absence of the ordinary pre-
disposing and  exciting causes;  (4)  the epididymis, cord, prostate,  or
seminal vesicles  show  signs of tubercular  involvement;  (5) there
are signs and  symptoms of tuberculosis in other parts of the body;
(6) tuberculosis is apparently the only cause  which can satisfactorily
account for symptoms.
    The final  diagnosis in the event of failure to find tubercle bacilli
in the  urine may be made by a cystoscopic examination. The  find-
ing of  disseminated  or grouped tubercles,  or of  ragged,  irregular,
punched-out necrotic ulcers,  will be conclusive.  It may happen that
the appearances are not typical, that the infiltrated rugae may simu-
late neoplasm, or that no lesion is found, though the bladder is un-
doubtedly tubercular.
    Treatment—If vesical tuberculosis is recognized in its early stages,
before the onset  of cystitis,  minute attention to general hygiene,  care-
ful avoidance  of the causes  of vesical congestion,  such as chilling,
constipation, or resisting the desire to urinate, and the administration
of salol and boric acid in small  doses (three  grains of each thrice
daily), for  the  purpose of keeping the urine antiseptic, represent  all
that should be done, aside  from the administration of tonics and
tissue-builders, such  as preparations of cod-liver oil, and a change  of
climate when the patient's circumstances will admit of this.
    It is particularly important to avoid instrumentation at  this stage
of the disease.   It has already been shown that, because of the con-
stantly infected condition of  the anterior urethra, it is impossible to 
VESICAL  TUBERCULOSIS.
667
introduce an instrument into the bladder and be absolutely certain
that its tip is sterile.  Infection  once started  is practically incurable,
and not only introduces the element of pain, but markedly stimulates
the extension of the tubercular  process:  hence the passage of an in-
strument simply for the purpose of  exploration is contra-indicated.
   If, however, there is strong reason  to  believe  that  the tuber-
cular infiltration  is  primary in  the bladder, has not extended be-
yond this viscus, and  can be  entirely  removed by operation, the
passage of a cystoscope for the  purpose  of corroborating  this belief
might be permissible, but only on condition  that the surgeon is pre-
pared to follow this  ocular examination by immediate operation, con-
ducted for the purpose of  entirely removing the  seat  of disease.
Unfortunately, we can never be certain  that tuberculosis is  strictly
limited to the bladder, and we know by  statistical  study that it is so
limited in but a very small percentage of cases.  Hence this exami-
nation, though theoretically desirable, is practically not  to  be recom-
mended.
   When cystitis has developed, the same strong reason against the
introduction of a sound, catheter, or cystoscope does not obtain, though
the bladder is  often extraordinarily irritable, and a violent reaction
may be excited by the most gentle instrumentation.
   The treatment of cystitis is conducted  in accordance with the prin-
ciples already laid down.   Medicines are administered by the mouth
which  render the urine bland  and exert a stimulating, healing,  and
antiseptic influence  upon the vesical mucosa.  The severe pain  and
violent tenesmus are best  allayed by suppositories of opium  and
belladonna or hyoscyamus.
   The local treatment must be conducted with great care.  We have
known a single instillation  of a five per cent, solution of silver nitrate
cause a degree of pain and tenesmus which confined to bed for weeks
a patient who until this was  given  had been  comparatively comfort-
able.  In general silver nitrate is unsuited to these cases, and this fact
is  so well known that a prolonged and violent reaction following its
use is held to suggest the tubercular nature of the inflammation.
   The most successful treatment yet reported is that of instillations
of corrosive mercuric chloride,  suggested and practised by Guyon.
He uses a solution of 1 to  5000, gradually increasing the strength up
to  1 to  1000.  The reaction  excited is  usually slight  and transitory.
Sometimes it is severe and lasting.
   The bladder should be  entirely empty.  This may require the use
of  a catheter.  In that case the  instillation should be made through
this instrument.   When the  urine contains a large quantity of viscid 
GENITO-URINARY DISEASES AND SYPHILIS.
mucus this will prevent the medicament from coming directly in con-
tact  with the mucous  membrane:  hence, unless there  is extreme
sensitiveness,  instillation  should be preceded by  lavage, great care
being taken to avoid painful tension from injection of too much of
the fluid at one time.  The bladder having been emptied and cleaned,
from twenty drops to two drachms of the corrosive chloride solution
are instilled and are allowed to remain  in the bladder.  The  initial
dose is not over twenty drops of a solution of 1 to  5000.  The  quan-
tity and strength are increased carefully, the surgeon being guided in
this matter by the degree  of the pain and reaction  which are excited.
It is important  to place the eye of the catheter or the nozzle of  the
instillator just within the grasp of the compressor urethrae muscle, so
that  the whole  prostatic  urethra may be washed by the instillation,
since cystitis  is  always  accompanied by inflammation of this portion
of the urethral mucous  membrane.
   The treatment is repeated daily, or every second or third day.
   Instillations of a ten per cent, mixture of iodoform in glycerin or
oil have also been employed, apparently  with beneficial effect.
   Operation is  particularly indicated when the pain and urgency be-
come unbearable and are not controllable by safe doses of narcotics.
Under these circumstances there will often be infiltration of the pros-
tate and seminal vesicles:  hence complete eradication of the disease
will  be  no longer practicable.   The operation is then performed as a
measure of relief and not as one of cure, the  bladder being drained
through either a perineal  or a suprapubic opening.   Often this drain-
age gives immediate and complete relief.   Sometimes pain and tenes-
mus  persist.   The suprapubic cystotomy is to be preferred, since  the
bladder is more liable to be opened at a point  somewhat  removed
from the  most active region of the  tubercular process.  A perineal
wound  is very apt to become infected, whereby  troublesome fistulae
are formed.
   The suprapubic operation also possesses  the advantage of allow-
ing the surgeon to inspect the interior of the  bladder and to  treat  di-
rectly intravesical  lesions.   These may  be  thoroughly curetted and
well  rubbed with iodoform, or may  be  destroyed  by the application
of the actual cautery. Following these procedures there are  some re-
ported cases of  cure.  Were tuberculosis more often confined to  the
bladder, this form of intervention would promise brilliant results.
   Having opened and drained the bladder above the  pubis and  de-
stroyed or removed tubercular ulcers, the vesical  mucosa is kept as
clean as possible by irrigations with normal salt  solution or a weak
antiseptic, provided it does not excite too much reaction.  Sometimes 
VESICAL  FISTULA.
669
as a result of this treatment cystitis is cured and the tubercular pro-
cess appears to be checked, the suprapubic opening closing on  re-
moval of the drainage-tube.   There is, however, a constant risk that
the  abdominal  wound may re-ulcerate and break down and an ab-
dominal hernia be the outcome.   In less favorable cases the tract of
the  drainage-tube often becomes tubercular.
   During the  whole  course  of local treatment the  importance of
general hygienic measures must be remembered.

                  FISTULA OF  THE  BLADDER.
   Vesical fistula is an ulcerating tract leading from the  bladder to
the  surface of the body or to  some  neighboring viscus.  It is usually
due to the failure of a surgical or an accidental wound to heal, but may
be caused by erosion from a calculus or foreign body, burrowing of a
pericystic abscess, or ulceration of a tubercular or malignant infiltra-
tion.  The fistulous tract  may run directly or deviously to  the skin
surface, or may form a communication between the bladder and the
bowel or the female genital tract.   The nomenclature of these fistulae
is indicative  of their course :  thus, they are termed vesico-perineal,
vesico-hypogastric, vesico-gluteal, etc.   Pathologically these ulcerating
channels  are identical with urethral  fistulae ;  they may  burrow in
many directions and open by several orifices;  they often  develop
lateral blind  diverticula, and they become densely indurated.
   Symptoms.—Cystitis is a symptom  common to all forms of long-
standing vesical fistula.  Other symptoms vary in accordance with
the  seat of the extravesical  opening.   When  this is  upon  the skin
surface there is an obvious escape of urine.
   The urine  may dribble almost constantly or may flow intermit-
tently. When the tract is narrow, and particularly when the open-
ing in the tract is valvular, the quantity escaping will be insignificant.
When conditions the reverse of these obtain, all the urine may pass
through the  abnormal opening.  The  skin surrounding the  external
opening of the  fistula shows the excoriation, inflammation, and infil-
tration described when treating of urethral fistulae.   During the  act
of micturition, or  when intra-abdominal pressure  is increased  by
muscular  contraction, as in the act of  lifting, coughing, or  defecation,
there is increased flow of urine from the opening.
   When the fistula  opens into the rectum, if the channel  of com-
munication  be  narrow, there  may be  no symptoms  suggesting this
communication other  than a urinous  discharge occurring with the
passage of often well-formed  stools.   Usually, however,  the  symp-
toms of this  fistula are sufficiently characteristic.   There  is a more 
GENITO-URINARY DISEASES AND SYPHILIS.
or less constant escape of urine from the rectum, and gas and faices
are passed by the  urethra.  We  have seen  a case due to cancer of
the bowel, in which nearly all the faeces were passed by the urethra for
several months.  Faecal masses, by blocking the urethra, often cause
retention of urine.   Cystitis under such circumstances is  extremely
severe.
    When there is communication between the bladder and the small
intestines, gas, remnants of food,  and traces of  bile will  be  passed
per urethram, but  the  solid particles found in  the urine probably
will not exhibit the characteristics of faeces.   There will be no urine
escaping by the rectum,  or none which  can be  recognized as such,
since it is thoroughly mixed with the rectal contents.
    Diagnosis.—When the  fistula opens  externally  the diagnosis  is
based  on—1,  escape  of urine, particularly marked  during abdominal
straining; 2,  escape  of colored fluids injected into the bladder;  3,
urethral  examination, a sound being passed into the  bladder and a
fine probe being introduced along the fistulous tract; 4,  cystoscopic
examination;  5, injection of hydrogen peroxide  along the fistulous
tract, bubbles then escaping per urethram at the next act of mictu-
rition ;  6, palpation,  an  area  of induration  sometimes  being  per-
ceptible from  the external opening directly to the  bladder-wall.
    When the fistulous opening is tortuous and  narrow, exploration
with a probe is, of  course,  impossible.
    When the fistula opens into the bowel the diagnosis may be more
difficult.   The passage of air  at the end of  micturition and with a
bubbling  sound is  in itself pathognomonic.   The  detection  of  frag-
ments of  partially digested food or of faecal masses  in the urine, the
finding of urinary  salts in the liquid passed per anum,  the detec-
tion of an opening into the rectum  by direct examination through a
speculum, the finding of a bladder-opening by  the cystoscope, and
particularly the discovery of a  sufficient cause for such a lesion, as,
for example, malignant or tubercular ulceration or large stone, would
lead to a correct diagnosis.  Colored solutions, such as methyl-blue,
if injected into the bladder, may appear in the stools, thus positively
establishing the existence of a vesico-rectal fistula.
    The differential diagnosis between vesical and  urethral fistula is
based  upon the fact that  urine escapes from the latter only during or
after micturition, and that colored  fluids injected into the bladder will
not escape through the fistulous opening until the patient  urinates.
    Treatment—Fistulae  due to tubercular and malignant infiltration
and ulceration are  incurable.   The appropriate treatment  is  that di-
rected against the  cystitis.   Perineal or  suprapubic drainage may be 
VESICAL FISTULA.
671
required.  Fistula following  stone operation, if  small and compara-
tively recent, may be cured by regular catheterization, combined with
antiseptic washing of the  bladder and  cauterization  of the fistulous
tract, preferably  with the galvano-cautery.  If after this treatment
the fistula persists, permanent catheterization continued  for  two or
three weeks  may be tried.  This failing, the fistula should  be  laid
open to the bladder, its Avails dissected out, and the wound treated as
it would be after  the operation of lithotomy.
   When the fistula opens  in the gluteal region or in the neighbor-
hood of the hip-joint, after a  preliminary effort at closure by catheter-
ization  median  perineal  lithotomy should be  performed, and  the
bladder should be drained immediately through this opening.
   Small recto-vesical fistulae not due to tubercular or malignant in-
filtration are treated on the same general principles.  At  first cathe-
terization should  be tried, combined with cauterization of the fistulous
tract through the rectum, after which a permanent catheter should be
worn with the patient in ventral  decubitus.
   This failing, if the tract is extraperitoneal,—that is, if it lies below
the recto-vesical peritoneal fold,—it may be operated on as described
in the treatment of urethro-rectal fistula.
   When the fistulous tract is intraperitoneal and when it persists in
spite of the palliative means described, a formal operation is indicated,
since the ultimate outlook of these cases if untreated is absolutely bad,
death resulting from ascending nephritis.  Immediately preceding the
operation the bladder should be  thoroughly irrigated with dilute anti-
septics, preferably corrosive  mercuric chloride  1 to  5000 containing
one-half of one per cent, of carbolic acid.  This is followed by irrigation
of silver nitrate 1 to 500.   The peritoneum is then  opened just above
the pubis, the communication between the bowel  and  the bladder is
rendered accessible, and the intraperitoneal operative area is packed
off from the general peritoneal cavity by gauze sponges ; the bowel is
then dissected loose, the opening into it is closed by Lembert sutures,
and the bladder-wound is closed by a double row of catgut sutures,
the first continuous and including all its  coats  except the epithelial
layer of the  mucous membrane, the second interrupted (Lembert)
and including only the peritoneal, muscular, and submucous invest-
ments.   This operation is always dangerous,  since  the bladder is
invariably infected, and peritonitis may result.
   In the after-treatment the bladder is drained for from three to five
days by permanent  catheterization, and is irrigated twice daily with
lotions of silver nitrate  1 to 1000, boric acid four per cent., or salicylic
acid one-half per cent. 
CHAPTER  XVIII.
                     CALCULUS OF THE BLADDER.

   Vesical calculus is a concretion of the solid urinary constituents
of such size or so placed that it does not escape through the normal
passages, but remains in the bladder.
   Calculi may be generally grouped under the following headings:
   1. Those formed from the normal constituents of the urine,—uric
acid, the phosphatic, the mixed, and the urate calculi.
   2. Calculi formed of salts found in normal urine, but never present
in excess except in disease,—the oxalates and carbonates.
   3. Concretions formed from  elements entirely  foreign  to normal
urine,—cystin, indigo, and xanthic oxide.
   The large  majority  of  stones are  formed  of uric  acid and  the
urates ; the phosphatic and  mixed calculi come  next in  order of
frequency ;  and  last come the  oxalates and  rarer forms,—indigo,
xanthic oxide, etc.
   Uric acid calculi are formed in acid urine.  Originating in  the
pelvis of the kidney, they descend through the ureter to the bladder,
usually  causing that form of  violent and paroxysmal  pain which is
termed  renal colic.  Once in  the bladder their further growth is due
to accretion of uric acid  alone, or they may form  nuclei for the de-
position of other elements.  Uric acid calculi are  generally smooth,
spheroidal, moderately hard, and yellow to reddish brown  in color.
   High living and a gouty diathesis are factors predisposing to  the
formation of these concretions.   They occur at the extremes of life.
   Urate Calculi.—The  sodium, potassium, and ammonium urates,
though  rarely forming large stones, are  constantly and copiously de-
posited  as sediment in febrile affections, and  when from  any cause
the urine becomes markedly concentrated.  The urate calculi are ob-
served almost exclusively in  children.   In  the adult they may form
the nuclei of large concretions made up of divers elements.  They
are grayish yellow in color.
   Phosphatic  calculi follow the uric acid and urate concretions in
order of frequency; there are three varieties.
   1. The amorphous calcium phosphate rarely forms a calculus of
itself.  It is commonly deposited in layers about calculi of other salts,
     672 
CALCULUS  OF THE  BLADDER.
673
or is intermingled with them, sometimes reaching considerable size.
It crumbles easily ; its color is a dirty brown or white.
   2. The triple phosphates (ammonio-magnesian  phosphates) are
commoner in calculus formation than calcium phosphate.  Such cal-
culi are  crystalline and of a whitish color.   Formed in ammoniacal
urine only, they are vesical in origin and frequently complicate cystitis.
   3. Mixed fusible calculi, being composed of the triple phosphates
and calcium phosphate, are not uniform throughout, forming about a
nucleus of calcium oxalate, uric  acid, foreign bodies, etc.  They ap-
pear as masses which resemble white friable mortar, and are formed
in ammoniacal urine.
   Calcium oxalate calculi, like  those of  uric acid, are of renal ori-
gin, and occur most  frequently in patients suffering from oxaluria, a
diathesis associated with indigestion and neurasthenia.  These are the
hardest of all stones, and are usually small or of medium size, sphe-
roidal in shape, dark  brown or black in color, and have a tuberculated
surface, giving rise to the name of mulberry calculus.  Amorphous
urates and phosphates  are often deposited  between the tubercu-
lations.
   Calcium carbonate calculi are rare.  When found they have been
multiple,  small, weighing from thirty to forty grains each, and hard
and lamellar in structure, similar to  the calcium oxalate calculi.
   Cystin Calculi.—Cystin as a  major constituent of  calculus is ex-
tremely rare.  As is the case with the uric acid and calcium oxalate
calculi, cystin concretions  originate in the  kidney.   In  appearance
they are irregular and knotty, sections showing no attempt at crystal-
lization, waxy and yellowish white at first, but turning to green after
long exposure to  the  air.
   Xanthin is another rare constituent of calculus.  Indigo does not
form a calculus in itself, but may be so important an ingredient that
it gives the stone its typical color.  It occurs in cases of liver disease
associated with cystitis.
   A calculus is named from its preponderating element,  but usually
there is  found one salt  serving as a nucleus, with layers  of different
salts superimposed.   Thus, the phosphatic calculus is  often found to
have in its centre  a minute  concretion of  calcium oxalate or uric
acid.  On dissolving out the salts of even the smallest  calculus there
will be found an albuminoid or colloid framework upon which these
have crystallized, and which serves to agglutinate the mass.  Rainey
and Ord have demonstrated the tendency of crystalline salts when in
solution with colloid or albuminoid substances to assume rounded or
spheroidal forms in crystallization.   It is certain that the development
                               43 
674       GENITO-URINARY DISEASES AND  SYPHILIS.

of stone is not wholly due to the mere presence of an excess of any of
the urinary salts, for copious deposits of uric acid and the phosphates
may exist for years without any evidence of calculus formation.
    If, however, at a time when the  urinary salts are in excess, any
renal or vesical irritation is lighted up, by means of which blood and
serum are intermingled with the urine, furnishing an albuminoid sub-
stance which favors the agglutination  of the small crystals, calculi may
form, and, once formed, tend to increase in size.
    Vesical calculi, when free, are  usually spheroidal.  They may be
irregular from multiplicity and erosion, or from having been moulded
in a diverticulum or in  the prostatic urethra.   Ord  holds that calculi
split spontaneously because, incident to changes in the specific gravity
of the urine, the colloid  framework  becomes swollen by absorption
of a liquid of different density, and the concretions fracture along the
lines of  deposition upon this framework.
    Etiology.—It is  evident that for  calculi to form two main factors
are requisite:  first,  a diathetic tendency to  over-elimination  of the
urinary solids which form the basis of calculi; and, second, local con-
ditions which cause these solids to  conglomerate.
    The  diathetic tendency is  strongly marked  in  certain  localities,
but these are so wide-spread, so totally different in  climate and sur-
roundings, and the diet and  habits of the  people so differ, that  no
general law can be deduced which  bears on calculus formation.
    There is a popular belief  that a limestone soil which  furnishes
hard drinking-water predisposes to calculus; but, although the dis-
ease is  quite  common in many limestone districts, it is equally com-
mon in sandstone districts;  moreover, there is no reason why the
ingestion of lime should cause uric acid  deposits.   Vesical calculi are
found in cold as well as in warm countries; for instance, in  Southern
China  and in Northern Scotland.   They are more frequent in the
central  United States than in New England and the Southern States,
and one section of a single State may furnish more cases than another.
    Urinary calculi are found  from extreme youth, even in  the foetal
bladder, to old age.
    In the statistics of Civiale, Coulson, and Thompson, compiled from
10,467 cases, 62.33 per cent, occurred in persons under twenty years
of age ; these cases  were taken from hospital  patients  representing
the poorer classes.   Sir Henry Thompson, in  a  series of private cases
numbering 798, operated for  vesical calculus  93 times  in patients
between the ages of sixteen and  fifty years;  527  times in patients
ranging between fifty and seventy;  175 times in patients over seventy;
and but 3 times in patients under sixteen. 
CALCULUS  OF THE BLADDER.
675
   He believes that calculi are so frequently found  in  hospital and
charity practice in patients under twenty years of age because of the
bad hygienic surroundings, irregular diet, and  malnutrition  of  chil-
dren in the lower walks of life.
   He accounts for  more than  sixty-six per cent, of his private cal-
culus patients being over fifty years of age  on the ground that the
upper and middle classes of society are predisposed to the uric acid
diathesis after the age of fifty, because then vital activity diminishes,
and consequently comes the desire for rest and a sedentary life, with-
out commensurate lessening of the quantity and variety of food in-
gested.   It would therefore seem  that insufficient clothing,  lack of
proper nourishment, and improper hygienic surroundings among chil-
dren predispose to  calculus-formation, while among adults the same
effect is produced by conditions of a very different character.
   The relative  difference  in  the  length and dilatability of the male
and the female urethra probably explains the greater frequency of cal-
culus in men.  A small uric acid stone reaching the  female  bladder
has little tendency to  linger there,  the  short, wide urethra allowing
it to pass without producing even  a  sensation of uneasiness.  The
vesical calculi observed in women  are usually incrustations  about  a
foreign body.
   Symptoms.—Preceding the formation of a stone there may have
been a history  of gravel,  of oxaluria, of heavy  deposits of  urates.
When the stone is of uric acid and is formed in  the kidney, lumbar
pains, haematuria, and renal colic  often  precede its arrival in the
bladder.  It  may, however, reach  this viscus  without exciting the
slightest symptom.
   Having reached  the bladder, the stone acts as a sterile foreign
body, producing irritation  and congestion, and thus favoring the de-
velopment of cystitis.  Frequent  micturition,  pain,  haematuria, and
reflex disturbances are the prominent symptoms.
   Frequent  Urination.—This symptom is most marked in the day-
time : it is aggravated by motion, and  relieved  by rest.  The desire
to  urinate comes  suddenly and is  almost irresistible.  The patient
may be compelled to urinate every two or three hours, or in some
cases even  every few-  minutes.   The act of urination is often ac-
companied by much tenesmus,  in which the rectum  participates, so
that prolapse of the bowel, particularly in children, is by no means
uncommon.  A small stone irregular in shape produces a more aggra-
vated condition of frequent urination than a large, smooth calculus.
An encysted or adherent stone, or one which lies at the base of  a
bladder so changed in shape that the calculus is not liable to come in 
GENITO-URINARY  DISEASES AND SYPHILIS.
contact with  the  vesical neck, will often give rise to no marked fre-
quency of urination.  It is to  be  noted that frequent urination is a
symptom of  so many other bladder  conditions that in itself it  does
not necessarily suggest the presence of  stone.
   Exceptionally there  is sudden stoppage during the passage  of a
full-sized stream.  This is observed chiefly in young persons and in
patients having small  stones, since it is due to the dropping forward
of the calculus into the  vesical  orifice of the urethra.   It is extremely
suggestive of calculus if it can be obviated by the patient urinating in
certain positions, as, for instance,  when lying on the back.   As  with
frequent micturition, sudden interruption of the stream is a symptom
of inflammatory troubles of the  vesical neck;  and is  not pathogno-
monic  of stone.
   Pain.—The pain  of vesical calculus is  usually referred to the
lower  urethral surface,  about  an inch posterior to the glans.   It is
burning and stinging in  character, and is less pronounced in  old  men
than in children, prostatic enlargement in the former  preventing the
calculus from coming in contact with  the vesical neck.
   Pain is most marked at the  end of urination, because then the
inflamed mucous  membrane  is brought in  direct contact with the
stone.  The intensity of pain varies proportionately to the degree of
cystitis and the size and nature of the stone.  Small stones, especially
if they are rough, cause more suffering than do large ones.  A history
of pain pronounced during the early stages of stone, and gradually
lessening,  suggests that  a small rough stone has become covered  with
mucus or with phosphatic  deposits,  thus  forming a smooth surface.
A stone may be carried for years without exciting the slightest pain.
   Haematuria is  of  importance  only  when associated  with other
symptoms.  It is caused by the mechanical friction and scratching of
the calculus, and is most pronounced when the bladder is congested,
as in cystitis.  It  is markedly aggravated  by motion.  The  blood is
most apt to be voided towards the close of urination.
   Reflex  Disturbances.—Priapism has  been noted as a  reflex,  par-
ticularly in children;  in them it may lead to the practice of mastur-
bation, since pain is  referred to the  end  of the penis, and  there is
commonly pulling and handling of that  organ in instinctive efforts to
obtain  relief.   Reflex pains felt  in the rectum,  the  perineum, the
hypogastric region, the small of the back, and on the outer surface of
the thighs, the lower  leg, or the foot, are frequently noted.   There is
a peculiar pain in the foot, known as  podalgia, which is sometimes
symptomatic of stone;  it is  frequently located in  the neighborhood
of the  ball of the great toe, but may extend over the whole sole.  It is 
CALCULUS OF THE BLADDER.
677
most commonly observed in the gouty and rheumatic.  It disappears
as soon as the calculus is removed.  Pain may also be felt in the
upper extremities of the lungs.
   Rectal prolapse,  hemorrhoids, and subconjunctival hemorrhage,
though not absolute in their  significance, may aid in diagnosis,  since
they are symptomatic of the violent straining efforts which frequently
accompany the act of urination.
   True inflammation of the bladder is likely to occur sooner or
later, though some cases of stone may last indefinitely without this
complication.   It is  usually caused  by instrumentation ;  but the in-
tervention of this  agency is  not necessary for its development.   It
aggravates  the symptoms already given, and  causes  a heavy deposit
of muco-pus in the urine.
   Diagnosis.—The diagnosis of stone  is founded  upon  physical
examination.   The symptoms above described, either singly or alto-
gether,  may be excited by any inflammation or irritation  at the neck
of the bladder independent of its cause.  Pain referred to the under
surface of the glans penis and felt most acutely at the end of urina-
tion, sudden interruption of  the full  stream, relieved by change of
posture and not occurring when certain postures are assumed, and
hsematuria,  can be considered only as  strongly suggestive  of stone
and as calling for direct examination.
   The examination is  conducted—1, by bimanual palpation;  2, by
intravesical  exploration with instruments, including (a) stone-searcher
or sound;   (6) lithotrite; (c)  evacuator attached to  aspirator;  {d)
cystoscope ; 3, by direct examination  of the  bladder through either
a perineal or a suprapubic opening.
   1. Bimanual palpation is thus practised in the male:  the patient
having passed his water is directed to lean well forward over the back
of an arm-chair, for instance,  with the legs moderately separated and
the abdominal muscles relaxed.  The surgeon then introduces one
or two fingers of the  right hand into the rectum and with the four
fingers of the left hand presses upward  and backward, directly over
the pubis,  towards the  base  of the bladder.   In place of  standing,
the patient  may  lie on  his back, the head and shoulders  elevated,
the thighs flexed ;  the  right and left hands are used as just described.
In thin  subjects and in those with not too muscular abdominal walls,
the presence or absence  of calculus of even small size can be readily
determined.
   In the female examination  is made through the vagina, the bladder
being palpated by the ordinary bimanual manipulation.
   2. Instrumental exploration is inaugurated by passing  a stone- 
GENITO-URINARY  DISEASES AND  SYPHILIS.
searcher.   The requirements of a satisfactory vesical sound or stone-
searcher are  that it should have a straight shaft fully ten inches long,
and a short curve near the tip.  Two instruments should be provided,
one with a very slight curve, the other with an abrupt curve, permit-
ting it to be carried into the pouch behind the prostate.   The calibre
should be about 13 F.  (Fig. 181.)  It is desirable to begin the exami-
nation with the bladder fully distended, and to allow the urine gradu-

                              Fig. 181.
                            Stone-searcher.

ally to escape, the search being continued.  For this reason, and be-
cause it allows of an approximate estimation of the size of the stone,
Thompson's  stone-searcher is particularly serviceable.   (Fig. 182.)

                             Fig. 182.


                        Thompson's stone-searcher.

The  solid steel sounds  shaped as already described, and provided
with flat handles, are the instruments of choice.
   These sounds are passed with the patient in a recumbent or semi-
recumbent position, with shoulders raised and thighs flexed and sepa-
rated.   Should cystitis not be present it is particularly important to
conduct  all  manipulations in accordance with the  rules already laid
down for antiseptic instrumentation of the  urethra  and the bladder,
since it is now universally recognized that the passage of instruments
is probably the most prolific cause of bladder-infection.  The instru-
ment, having been sterilized and lubricated, is introduced without dif-
ficulty if the operator  remembers that its curve does not correspond
with the fixed curve of the normal urethra; at the time the extremity
of the instrument traverses this region  downward pressure must be
made with the fingers  on each side of the penis, so as to elongate and
straighten out the urethral  curve.  Even after the sound has traversed
the membranous urethra  it  is often arrested  at the internal vesical
sphincter, and when in this position a comparatively roomy prostatic
urethra may allow of some degree of lateral motion.  It is important
to remember that the  sound is not satisfactorily introduced into the 
CALCULUS OF THE BLADDER.
679
adult bladder unless at least eight  inches of the straight shaft have
been passed, and that when it has properly entered it can be easily
rotated almost, if not quite, around its long axis.
   The bladder having been entered, the cavity of this viscus should
be systematically explored.  The  sound  is  partly withdrawn  and
pushed back again with comparatively rapid motions, the handle being
elevated and depressed.   The withdrawal is at no time sufficient to
engage the  curve of the  instrument  in the  prostatic urethra.   The
back of the sound should then be turned towards one  side  of the
bladder, and the  point, directed towards the opposite side, should be
made to traverse the  arc of a circle, sweeping transversely through
the bladder from above  downward.  This motion, begun with the
inner end of the  sound at the bas-fond, is continued while the sound
is gently drawn outward until the curve reaches the vesical neck.  It
is  then pushed in again until the posterior wall of the  bladder is
touched.  The point is now turned to the opposite side and the same
manoeuvre is repeated.  If the stone is not found in this manner, the
searcher is  again introduced to its  full length, and the tip  is turned
gently towards the  floor of the bladder, and rotated quickly from
side to side, while the instrument is gradually withdrawn until its
curve catches the vesical neck.  The anterior wall of the bladder may
be explored by pressing it down by suprapubic pressure till the tip of
the instrument can  reach its surface.  Where there  is  an  enlarged
prostate and the base of the bladder  is depressed, it is well to elevate
this portion of the  viscus  by a finger introduced into the rectum,
while the exploration with the sound is continued.
   If these manipulations fail to  detect the stone, the urine should
be gradually withdrawn, and as the bladder  contracts  they should
be repeated.   Thompson's searcher should  be used under such cir-
cumstances.
   The presence of stone is denoted  by a distinct click, which can be
both felt and heard.   The feeling is that of a  sound coming in contact
with a hard body, the click  like that of a piece of metal striking the
sound. It is important to bear in mind that this click should be heard
and not merely felt.  The attachment of sounding-boards or of tubes
to the searcher is of no practical help to the  surgeon himself, though
both are useful for class demonstration.  Suprapubic auscultation is
said to be helpful.
   The size of the  stone may be  estimated by a searcher provided
with markings on its shaft and with a sliding collar.   (Fig. 182.)   By
passing this collar to the meatus after the stone is first touched, and
then marking the point at which the sound ceases to come in contact 
680
GENITO-URINARY  DISEASES AND SYPHILIS.
with it as it is  slowly withdrawn, the diameter of the  stone may be
determined, this being, of course, the distance between  the collar and
the meatus.
    The surgeon  may either fail to detect a stone which is present or
imagine he has detected a stone which  is not  present.  Failure to
detect a stone wiiich is present may be due to—1, the more or less
encysted condition of the calculus, leaving little or none of its surface
exposed ;  2, the presence of a diverticulum with a very  small opening
containing the  stone ; 3, the fixation of the stone to the summit or
the anterior wall  of the bladder by adhesions ;  4, the covering of the
stone with lymph or blood-clot;  5, the lodgement of the stone in a
deep  post-prostatic  sinus or between the lateral or upper walls of
a prostatic overgrowth and the vesical mucosa; 6,  failure to enter
the bladder with the sound, the prostatic urethra being dilated and
the vesical orifice of this canal being obstructed by prostatic over-
growth.
    The surgeon  may believe that he has detected stone when none
is  present from—(1) incrustation of a tumor with lime  salts; (2) a
fasciculated condition of the bladder, especially when associated with
ulceration and  partial incrustation; (3)  possible bony growths de-
veloped from the pelvis ; tumors ; faecal impaction in the rectum ; and
undue prominence of the promontory of the sacrum.
    Examination by the lithotrite is of advantage in enabling the sur-
geon to determine the exact size of the stone, to ascertain whether or
not it is adherent, and to make a rough estimate of its hardness.  As
a means  of  simply detecting the stone it  is no more serviceable
than  a  stone-searcher  of  similar curve, and  is  more  difficult of
manipulation.
    The evacuating-tube attached to an evacuator is probably the best
stone-searcher  if the calculus is very small.  As the  liquid in the
evacuator is driven forcibly in and then aspirated, the small calculus
will be brought against the opening of the catheter with a sharp and
unmistakable click.   It should be noted that  if the  eye of the tube
is carried  too near the vesical wall this will be sucked in and will give
a jarring sensation, or if the joints of the instrument are loose there
may be  produced a sound which will  closely simulate the click of a
stone.  This instrument is useless  when the stone is encysted or
adherent.
    An examination  with a cystoscope is  of service  as a means of
finding stones which cannot be reached by the sound,  corroborating
diagnosis,  determining whether a stone is adherent or  encysted, and
discovering the  condition of the vesical mucosa. 
CALCULUS  OF THE BLADDER.
681
   Because of the thoroughness with which the bladder can be ex-
plored by  the  cystoscope,  direct  examination through a  perineal
opening will be  rarely required, even in obscure cases, except when
the stone is encysted or when the concomitant disease of the bladder
is so inveterate and pronounced that prolonged drainage is indicated.
In such cases, where the perineal depth is not too great for explo-
ration, the perineal route may be chosen, as giving a lower mortality.
The suprapubic  route, however, gives the most room, and is usually
most serviceable when the diagnosis is doubtful.
   It is apparent that the diagnosis of calculus is  founded solely on
direct examination.
   Aside from  containing a small quantity  of blood and perhaps an
excess of deposits, the  urine may remain  for a  long time normal.
Stone in itself will not cause cystitis.  It simply predisposes to infec-
tion.   When infection has taken  place,  often from the introduction
of a sound or other instrument into the bladder, all the symptoms
are aggravated.   Pain becomes more severe and constant, frequency
and urgency of urination are more pronounced,  bleeding  is freer,
and tenesmus is more  distressing.  It is, however, clear that these
symptoms are indicative rather of cystitis than of stone.
   Prognosis.—A vesical  calculus may, in  the absence of cystitis,
from the frequency and difficulty of micturition,  cause hypertrophy
and thickening of  the  bladder-walls, dilatation of the ureters  and
kidney pelves, and  a chronic  congestion of the whole urinary tract,
strongly favoring infection.  Cystitis once started is constantly aggra-
vated, and  may  extend deeply.   Exceptionally the calculus ulcerates
through the vesical walls, forming  a pericystic abscess.
   Royden  records the case of a man aged sixty-four years, who
suffered from intermittent haematuria for ten years.   There were no
other symptoms.   Finally repeated sounding  caused  cystitis.  After
a few attacks of  severe pain he passed some fragments  of stone.
Following this, the urine became normal and he regained his health.
Shortly cystitis  again developed, and was characterized by tenesmus
and pain referred to the end of  the penis.   The  patient  suddenly
became collapsed, with distended abdomen  and all the signs of peri-
tonitis.  Autopsy showed that a diverticulum containing a number of
concretions had ruptured, allowing the urine to escape into the general
peritoneal cavity.
   From constant engorgement the prostate slowly enlarges, and, by
obstructing the outflow of the urine, favors retention, with reflux of
septic fluid into the ureters and kidney pelves, and  consequent pyelo-
nephritis.  Hence the prognosis of untreated calculus is grave. 
682
GENITO-URINARY DISEASES AND SYPHILIS.
   A vesical calculus  may excite no symptoms.  Morris records the
case of a man who, at the age of sixty-six, learned by an attack of
haematuria  that  he had vesical  calculus.  This patient  died  after
thirteen years, of carbuncle of the neck.   He  never had a bladder-
symptom, and his first attack of haematuria was also the last, although
he never submitted to operation.
   Morris states  that if, after years of comfortable life with a stone in
the bladder, painful symptoms should  necessitate an operation, the
patient  is only too  likely to succumb from suppression of urine or
from  suppurative pyelonephritis,  because  the ureters are usually
greatly dilated  and  the renal  tissue atrophied.  He also calls atten-
tion to the fact that spontaneous fragmentation of stone may occur,
leading to complete  disintegration and expulsion of the fragments.
   Prophylaxis.—The  presence of gravel in the urine, or other evi-
dence of supersaturation with  solids, such, for  instance, as heavy de-
posits, should lead to  such hygienic and dietetic regulations as would
naturally tend to lessen the specific gravity of  the urine passed.   Of
prime importance  is  the careful regulation  of the stomach,  since
when the functions of this organ are interfered with, even to a slight
degree,  the  quantity of uric  acid in the urine is markedly increased.
   Systematic  exercise should be prescribed, and  the bowels  kept
fairly soluble, preferably by  salines administered in the morning on
rising and  at night  just before retiring.   This latter time  is particu-
larly one of  choice in the case of an alkaline mineral  water, because
the urine naturally becomes most acid during  the small hours of the
morning.   The liver should be occasionally stimulated to full activity
by  small  doses  of  calomel frequently repeated, or by a blue pill.
Supersaturation of the urine is avoided by diluting it with water or
bland liquids.   These must not be  taken in  sufficient quantity to
cause indigestion.   Since salt renders uric acid more soluble,  it is
well to use  this liberally with food.
   When there is gravel-formation, or quick deposit of uric acid  after
passing water, direct solvents should be employed intermittently. Of
these salicylic  acid or  potassium salts are among  the most  useful.
Piperazin is also of  service in preventing stone,  since it has the
power of dissolving uric acid, and also of making oxidation more
complete.   It is best given in large quantities of water; fifteen grains
may be dissolved in a pint, this whole portion  being taken in divided
doses during the day.  It should not be administered in pill form.
It has been  stated that this drug will not only prevent formation of
uric acid stones, but  will  even dissolve those already formed, and
also the colloid matter which is always found as the medium in which 
CALCULUS  OF THE  BLADDER.
683
the formation of the calculus takes place.   Clinical evidence of such
action is wanting.
   Alkaline urine will also slowly dissolve pure uric acid:  hence
when for any reason  operation  is inadvisable, it would seem worth
while to render the urine alkaline by the administration of full doses
of potassium  citrate,  this drug  being eliminated  as the carbonate.
When the urine  shows  excess of phosphates,  a tonic treatment,
together with the use of nitrohydrochloric acid, is indicated.
   The  formation of  stone  can  sometimes be prevented by careful
attention to  the  bladder.  Remedies designed to render the urine
bland and unirritating act locally,  since they lessen  the bladder-irri-
tation, and thereby the secretion of albuminoid or  colloid  material,
without which calculi  will not form.  When there is  obstruction to
the free evacuation of the urine, regular drainage of the  bladder by
means  of a catheter  is serviceable ; and when  there  is cystitis, the
administration by  the mouth of substances which are antiseptic when
eliminated by the  urine, and direct irrigation of the bladder, should
be practised.  The antiseptic drugs administered by the mouth have
already been considered,  as have also the local washings appropriate
in cystitis.
   Treatment.—Stone  having once  formed and having been detected
by direct examination, it  remains to advise treatment.   At one time
attempts at removing calculi by  the injection of solvent lotions into
the bladder, or by the administration of medicines which when elim-
inated with the urine were supposed to dissolve the calculi, were
popular.  These methods are, however, so utterly wanting in evidence
as to their efficiency that they are not worth considering.
   The  two  received  methods of  treatment  are  (1)  litholapaxy,—
crushing and evacuating ; (2) cystotomy,—removing the stone through
either a perineal  or a suprapubic incision.   Litholapaxy is  in  both
adults and children the method of  choice.
   Preliminary Preparation.—Whether the operation  be crushing or
cutting, the preliminary preparation of the patient  is about the same.
Except in  old feeble  prostatics,  rest in bed  is desirable for two  or
three days.   This  has a markedly beneficial effect upon the  cystitis,
since the calculus is kept  quiet and does not mechanically irritate the
bladder.  The bowels should be  regularly opened by salines and ene-
mata, and  the urine rendered bland by milk  diet and diluents, and
slightly antiseptic  by  salol and boric  acid.  Haematuria will usually
cease promptly as  the  result of rest.   Cystitis should be modified  by
irrigations or instillations.   When the circulation is feeble, tonics and
strychnine  are indicated. 
684        GENITO-URINARY DISEASES AND SYPHILIS.

   On the night preceding  operation  the  patient should be given a
laxative and a general hot bath, and should have the "pubes and peri-
neum shaved, and the whole operative area, including the penis and
glans, treated as is customary in preparation for formal operations —
i.e., cleansed with antiseptics and  covered in by an antiseptic gauze
dressing.
   An enema should be given not  less than four hours before opera-
tion.  Immediately before operation the dressing is removed, and the
whole region again cleansed by  green  soap, benzin,  alcohol, and bi-
chloride.  This preparation applies to litholapaxy because that oper-
ation may have to be supplemented by lithotomy,—from jamming or
breaking of the lithotrite, for instance,  or because of an unexpectedly
large stone.
                          LITHOLAPAXY.
   To perform the  operation an  instrument for  crushing the stone
and one for evacuating the fragments after crushing are needed.  The
operation in its entirety was first  practised by Bigelow in 1878, and
has since then largely supplanted all cutting operations.

                             Fig. 183.
                          Bigelow's lithotrite.

   The crushing instrument, or lithotrite, devised and since perfected
by Bigelow (Fig. 183), is the one commonly employed, and perhaps is
more satisfactory than any of the many modifications since suggested.
(Fig. 184.)
                              Fig. 184.
                           Weiss's lithotrite.

   The instrument as now  made contains a male  and  a female
blade, so arranged that they can be separated or approximated by a
sliding motion.  As soon as  the calculus is grasped  the blades are 
CALCULUS  OF THE BLADDER.
685
locked by a turn of the  collar of the handle; this turn  at  the  same
time brings a powerful screw in proper relation with a set of threads,
so that on turning the knob of the extremity of the handle the male
blade is forced downward and thus crushes the stone.  Especial at-
tention is devoted to the construction of the jaws and teeth;  these
are so made that clogging by the lodgement  of masses of crushed
calculi is impossible.  Instruments made with wide fenestrae passing
completely through the female blade are liable to have fragments jam
so firmly that to remove the instrument  without laceration of  the
urethra suprapubic cystotomy may be required.  The male blade—
i.e., the  sliding one—has blunt, pyramidal  projections on the jaw, so
that the cusps alone catch the calculus.   As the latter is broken  the
fragments are shed to the sides, instead of being jammed against the
female blade.  The latter is fenestrated only at its base, to  receive
a spur on the base of the male blade, thus preventing the clogging of
its heel by small fragments.   (Fig.  185.)  The tip of the  female blade

                            Fig. 185.
Jaws of Bigelow's lithotrite.
 is slightly prolonged and curved back, thus allowing it to slide readily
 into the urethra, and also lessening  the  danger of penetrating the
 vesical mucosa as the blades are brought together.
   The advantages  of this instrument are that it is powerful, does
 not jam, is simple in construction, and enables the operator to search
 for the calculus, grasp it, and crush it without taking his hands from
 the handle and without having to pause to separate the blades again
 by unscrewing.
   The evacuating instruments  required  in  the operation of litho-
 lapaxy are full-sized catheters of varying sizes, straight, or with a very
 slight curve at the end, provided with eyes fully as large as the calibre
 of the tube, and  an  aspirating apparatus, which consists  of a thick
 rubber bulb with  a wide-mouthed glass  receiver attached below and
an opening and stopcock  above, so that it can be completely filled
with water.  (Fig. 186.)   It has  a  double stopcock on the side, the 
686        GENITO-URINARY DISEASES AND SYPHILIS.

latter fitting to the catheters externally, and internally connecting
with a  fenestrated tube, which penetrates one or more inches into
the bulb.  The aggregate emptying power of  these fenestrae is greater

                              Fig. 186.
Bigelow's evacuator and tubes, with metal cup and soft rubber tube for filling.
than the open end of the tube, so that in forcing water into the blad-
der it rushes in through these small lateral holes with greater velocity
than through the large opening at the end.  Thus there is little dan-
ger that fragments will be drawn up into this  tube from the  receiver
and driven back against the walls of the bladder.
   Opebation.—Ether is administered,  the  urine  is  drawn,  and  the
bladder  is irrigated  with an antiseptic, either silver 1 to 5000 or a
sterile saturated solution of boric acid ;  six ounces of boric acid solu-
tion  are then  injected, preferably through the  evacuating  catheter
which the surgeon intends to  use.   The  patient is  placed upon his
back, the shoulders are  raised,  and  the  thighs  well separated and
slightly flexed.  The  lithotrite is  introduced  exactly as a sound is
passed, the surgeon  standing at the patient's left;  spasm of the com-
pressor urethrae muscle is overcome by the weight of the instrument.
It  must  be remembered that the weight of the lithotrite and its long
shaft  place a powerful lever in  the hands of the surgeon, which, if
used  improperly, may cause urethral rupture.   When  the  beak of
the instrument enters the bladder the handle will  lie between  the
thighs.   The surgeon then passes to the patient's right.  The beak 
CALCULUS OF THE BLADDER.
687
should be gently pushed onward until it touches the posterior wall
of the bladder, when the blades are separated until the male blade
touches the neck of the  bladder;  they are  then closed rapidly.  If
the calculus is caught, it  should be fixed by a turn of the collar and
then  crushed by turning the screw-handle.  If the  calculus is not
caught in the  first  manoeuvre, the beak of  the  instrument should
be gently turned from one side to  the other, alternately opening and
closing the jaws.  If it still eludes the grasp, the lithotrite should be
turned with the beak directly downward, thus  exploring the region
behind the prostate.
   Whenever the  calculus is grasped it should be firmly fixed by a
half-turn of the handle, and  the instrument should then  be turned
so that its beak points upward, and be withdrawn so that the stone
will be, as nearly as can be guessed, in the centre  of the  bladder.
By this manipulation the operator  can assure himself that he has not
grasped a portion of the mucous membrane, and can proceed to crush
the  stone by rapidly screwing down the  handle.   These manoeuvres
are  repeated until the stone is  reduced to small fragments.  Were
the  operation to terminate here, as was at one time advised,  it would
be lithotrity, the older method being to allow patients to evacuate by
natural efforts  the  fragments of stone thus  crushed.   This  is, how-
ever, highly undesirable,  for obvious reasons.
   The tightly closed lithotrite having been withdrawn,  an evacu-
ating catheter  of as large a  size as can  be introduced through the
urethra is passed.   The  extremity of this instrument being kept well
against the  urethral roof, when it  reaches the membranous portion
of this canal its outer extremity is  carried downward, pressure being
exerted at the  same time at the root of the penis by the  index  and
middle finger of the left hand placed on either side of this organ, thus
relaxing the  suspensory  ligament  and straightening out the  urethra.
This manoeuvre is especially useful when, as in this  instance, it is
necessary to pass an instrument the curve of which is less than the
fixed curve of the urethra.
   The  evacuating  bulb, filled with warm boric acid  solution or
sterile wrater, is then connected  with the  catheter,  the stopcocks
between the  two are turned on, the bubbles of air contained in the
catheter are  allowed to rise to the top of the bulb and are squeezed
out, the stopcock there  being turned on for a  moment, and then,
by gentle slow pressure, about half the  fluid in the bulb is allowed
to pass through the  catheter into  the bladder.   After waiting a few
seconds for the fragments to settle about  the  base  of the  bladder,
the  pressure on the  rubber  bulb  is suddenly relaxed, and  thus the 
GENITO-URINARY  DISEASES AND SYPHILIS.
fragments are  sucked up  into the glass receiver.  This process of
alternately distending the  bladder and sucking out the fluid is con-
tinued, the catheter being carried in different directions, until no more
fragments escape.   This may be determined by auscultation over the
bladder during the process of aspiration, any fragments which remain
being heard to  click against the evacuating catheter.  The catheter
should then be withdrawn, the  stone-searcher introduced, and careful
search made for any remaining calculus; none being found, the oper-
ation is completed.
   In  place  of the  aspirating instrument  used  by Bigelow,  it  is
worthy of  note that if the fragment is thoroughly  pulverized the
natural expulsive force of the bladder is sufficient entirely to evacu-
ate the fragments.  This may be accomplished by introducing a full-
sized catheter, distending  the  bladder by a gravity-bag  or syringe,
then allowing the contents to flow away in  a full-sized stream.   It is
obvious, however, that this method  of evacuation  is  not so sure as
that  provided by the Bigelow apparatus.
   The only serious complication liable to occur during the course of
litholapaxy is  the clogging  of the blades.   This should be obviated
by rapping them sharply and quickly together several times.   If this
manoeuvre fails, the tip of the instrument  should  be brought up
against the pubis and suprapubic cystotomy performed.  In case the
bladder should be ruptured, immediate suprapubic  cystotomy and
drainage would be indicated.
   The further treatment is so directed  that the patient is kept quiet
in bed on a milk diet for five to seven days, or until  pus and  blood
disappear from the urine.  During this  time  salol  is given by the
mouth and  the bowels are kept open  by enemata. For the first
twenty-four hours  after operation  the  whole  abdomen should be
covered with hot antiseptic compresses, changed every two hours.
   Cuyon warmly commends the retained catheter as an after-treat-
ment of litholapaxy, keeping it in place for twrenty-four hours.  Many
of his  cases had been  infected for a long time, and were old  pros-
tatics with phosphatic calculi, the class in whom vesical operation is
likely to result fatally.  His results were most favorable, and seemed
to indicate that the retained catheter distinctly lessens mortality in
infected prostatics with  vesical  calculi.
   Chismore describes  a modification of the  Bigelow operation em-
ployed  by him  in fifty-two cases.   His  patients were all  old, and
many of them were prostatics.   He had  no deaths.  He believes
that  his method is  particularly applicable to  cases of senile atrophy
with pouched or irregular  bladder.   These conditions, together with 
CALCULUS  OF THE  BLADDER.
689
the consequent alterations of the vesical orifice of the urethra, make
it impossible to command considerable portions of  the  cavity of the
bladder with the lithotrite, or indeed with any instrument introduced
into the urethra or through a perineal  incision, besides favoring the
escape and retention of fragments of calculi during litholapaxy.
   Chismore  substitutes local for general anaesthesia, and conducts
his crushings  in a series of short office-sittings.   He  empties the
bladder, injects one  or two fluidounces of a four per cent, solution
of cocaine hydrochlorate, gently inserts the lithotrite,  and seizes and
crushes the stone.  If a large  fragment  apparently  disappears, he
makes no prolonged attempt to  find it at that sitting.   He  crushes
as long as fragments are readily found, wTashes out the pieces, and
stops the  moment spasm of the bladder, unusual distress, or symp-
toms of exhaustion occur.  He does not hesitate to leave some pieces
after crushing, but removes them after the reaction due to operation
has subsided, and as soon as they can be felt with a searcher, usually
within a week.  He repeats his partial operations and evacuations
until the bladder is clear.  As these patients  usually  have strictures,
or at least a narrowed urethra,  a period of preliminary dilatation is
often necessary.
   The male blade of his lithotrite is  hollow,  and is  attached to an
evacuator of  simple  and ingenious construction.   As  the stone is
crushed it is evacuated through the male blade.  This avoids repeated
passing of instruments, and is also a valuable means of drawing into
the grip of the lithotrite calculi which otherwise could not be reached ;
for when  the  instrument is opened, if the bulb of the evacuator is
compressed and then suddenly released, fine fragments will be drawn
through the canula of the male blade and into the  receptacle placed
externally, while fragments too  large to  pass  will be sucked exactly
into the grip of the instrument.   When no more pieces of stone are
readily found, Chismore washes  out the bladder with warm boric acid
solution.  This operation is  conducted in his office, the patient paying
visits as often as is  required.  Following operation there is usually
an immediate sense of relief;  the reaction  is  slight.    The patient's
sensations will prove a valuable  guide  as to the presence or  absence
of further  fragments.   When frequency,  tenesmus, purulent  urine,
and a sensation of  stone occur, the searcher  is used,  the presence
of a stone determined, and  the operation repeated.
   Perineal litholapaxy possesses the advantages of allowing the in-
troduction of a larger and stronger instrument  than could be passed
through the urethra, and of subsequently providing  for direct con-
tinuous drainage.
                               44 
 690       GENITO-URINARY  DISEASES AND SYPHILIS.

    Reginald Harrison is perhaps the  strongest advocate of this pro-
 cedure.  He thus sums up the chief points in favor of perineal litho-
 lapaxy :  " (1) It  enables  the operator to crush and evacuate large
 stones in a short space of time.  (2) It is attended with a very small
 risk to life as compared with  other operations where any cutting is
 done, such as lateral  or  suprapubic lithotomy, and is  well  adapted
 to old and feeble subjects.   Swinford Edwards has shown  that the
 latter operation  for  large stones has a mortality  somewhat  about
 fifty per cent.  (3) It permits  the  operator to wash out the  bladder
 and any pouches connected with  it  more effectually than by  the
 urethra,  as  the  route is  shorter and the evacuating  catheters em-
 ployed of much larger calibre.  (4) The surgeon can usually ascer-
 tain, either  by exploration  with the  finger or by  the  introduction
 of forceps into the bladder, that the  viscus is cleared  of all debris.
 (5) It enables the surgeon to deal with certain forms of prostatic out-
 growth  and  obstruction complicated  with atony of the bladder in
 such a way as to secure not only the removal of the  stone  but the
 restoration of the function of micturition.  (6) By the subsequent in-
 troduction  and temporary retention of a soft rubber drainage-tube
 states of cystitis due to the retention of urine in pouches and depres-
 sions in  the  bladder-wall are  either  entirely  cured or are  perma-
 nently improved.   To lock  up  unhealthy ammoniacal urine in a
 bladder that cannot properly empty itself after a lithotrity is to court
 the formation or recurrence of a phosphatic stone.  Hence it is well
 suited to some cases of recurrent calculus.
    " It is well adapted for some cases of stone in the bladder compli-
 cated with stricture in the deep urethra, as it enables the surgeon to
 deal with both at the same  time.   Nor does it expose the patient to
 the risk which may be attendant where lithotrity is performed with a
 weakened or permanently damaged  urethra."
   Harrison  demonstrated that crushing  forceps shaped somewhat
like the blades of a lithotrite, and not exceeding in circumference that
of the ordinary index finger, are sufficiently powerful to pulverize any
stone that can be thoroughly seized.  The fragments may be subse-
quently withdrawn by means of evacuating catheters passed through
the wound, or even by forceps.  If care is taken to make the perineal
opening of a size corresponding to  that of the evacuating  catheters,
which should be  as  large as an ordinary index finger, the bladder is
readily kept distended during the necessary manipulations.
   The opening is  made  into  the membranous  urethra at the apex
of the prostate on a grooved  staff passed along the urethra.  Through
this  opening is  first  passed the Wheelhouse tapering  gorget, and 
CALCULUS  OF THE  BLADDER.
691
guided  by this instrument the index finger is introduced into the
bladder.
   Litholapaxy in Children (infancy to puberty).—There has long
been a popular belief that in children lithotomy is a safer operation
than litholapaxy.   Recent statistics have established  beyond cavil the
areater safety of  the latter operation.
   Of 1213 cases performed by eleven operators the mortality was
2.22 per cent.; perineal lithotomy gives a mortality twice as great as
this; suprapubic  lithotomy one more than five times as great.  The
combined  statistics of Cabot and  Barling are still more  favorable to
the crushing operation: perineal  lithotomy, 602 cases, 19 deaths,—
a percentage of  3.1; suprapubic  lithotomy, 637 cases, 84 deaths,—
a mortality of 13.1 per cent.; litholapaxy, 284 cases, 5 deaths,—a
mortality of 1.7 per cent.
    No age is exempt  from calculus, since  it has been found in the
foetal bladder.  About half of  all  cases of vesical stone are observed
in children: hence  in them operation for its removal is frequently re-
quired.  Keegan  states that  the urethra of a child from three to six
years  of age  will  usually accommodate a  No. 6 to  No. 8 English
lithotrite, while a No. 12 to No. 14 can be passed  into the urethra
of a child of eight to ten years.
   Otis has  shown that  in  children as in adults the small diameter
of the urethra may be greatly increased with entire safety.  He states
that the  proportionate relation  between  the  circumference  of the
urethra  and  that of the  penis which he  believes to exist in adults
holds  good in children.  Thus, with a penile  circumference of one
and a half inches, as in a child from  two to three years of age, the
size of the urethra  would  not  be  less than fifteen millimetres.  For
every  quarter  of an  inch added to the penile circumference two
millimetres may  be added to the  urethral calibre.  It should be re-
membered that this indicates rather the distensibility than the actual
calibre of the canal.
   Recurrence of stone may be observed after  any operation.   Kee-
gan states that after an extended experience he is convinced that this
recurrence in male children does not follow litholapaxy oftener than
it follows lithotomy.
   There are certain objections to the operation of lithotomy which,
even were its mortality as low  as that of litholapaxy,  should have due
weight in deciding for one operation or the other.  Thus, the space in
which manipulations must be conducted is extremely  small, often pre-
venting the introduction of a finger  along  the  staff.  Of course this
can be obviated by  making no digital exploration of  the  bladder, the 
692
GENITO-URINARY DISEASES AND  SYPHILIS
small forceps being passed  in  directly and the  stone thus removed;
but in this case the surgeon cannot be sure that the bladder is en-
tirely empty.  The high position of the bladder in children, the  deli-
cacy and  mobility of the deep  urethra, the danger of wounding the
bulb in making an incision which is sufficiently large, and the possi-
bility of the operation being  followed by sterility are all factors which
should be considered in cutting for stone in children.
    Cabot says that  his  experience  has  proved that the urethra and
bladder of children are extremely tolerant of instrumentation: hence
he advises litholapaxy for small stones or those of moderate size (from
three-fifths to four-fifths of an inch in diameter), and for larger stones
perineal lithotomy, unless they are of unusual  size (from one to one
and a half inches in diameter), when suprapubic cystotomy is indi-
cated.  It is fairly easy to determine the approximate size of calculi
in children by bimanual palpation.   Guided by this, the appropriate
method is selected.
    After  due consideration   of  the  opinions  of others and an ex-
tended personal experience,  we believe the following conclusions to
be justifiable.
    In every case of calculus in male children litholapaxy,  on account
of ease of performance, low mortality, speedy recovery, and absence
of danger  of emasculation, should  be the  operation of predilection,
division of the meatus being freely resorted to if that portion of the
urethra offers an obstacle to the introduction of  instruments.
    The lithotrite and evacuating-tube should be of such size that they
can be inserted into the bladder without much effort or over-distention,
and great gentleness should be observed in  passing these instruments.
Keegan says, " When I advocate litholapaxy as being the best opera-
tion, in my opinion, for the great majority of stones occurring in male
children and  boys, I do so with a very important reservation,—viz.,
that no one should attempt  to perform  it in boys until he has  first
gained some  practical  experience of it in adult males.  The surgeon
who meets with cases of stone only at rare intervals during his career
will be acting more wisely if he adheres to lateral lithotomy or supra-
pubic cystotomy.  It is  his misfortune and not his fault that he has
not been afforded many opportunities of gaining a practical familiarity
with the use of the  lithotrite.  Should he  aspire to performing this
operation widely and successfully in male children and boys, he must
provide himself with a large assortment of fully fenestrated lithotrites
of small size, made from the best  steel which  money can purchase,
by thoroughly reliable workmen. His set of lithotrites, all fully fenes-
trated, should range from No.  4 or  5 at the bend of the blades to 
CALCULUS  OF THE  BLADDER.
693
No. 10 at  the  end of the blades (English scale), and his evacuating
catheters or canulae should be fitted with serviceable stylets."
  The instrument should be withdrawn and reintroduced as seldom
as possible.  If, however, a lithotrite which fits the urethra tightly has
been used, it is well to change this  for one of smaller size before pul-
verization of the  fragments, since the entrance of the calculus sand
into the urethra, by making the shaft of  the instrument rough and by
becoming deposited on the mucous membrane, may render the with-
drawal of the  full-sized instrument exceedingly difficult.  In seeking
for or attempting to seize the stone,  care should be taken to avoid such
wide separation of the blades as will  bring the male blade in frequent
contact with the vesical  neck.   The  crushing  should invariably be
done only after rotating  the  blades  into the centre of the bladder.
Every particle of the calculus  should be  evacuated.   Copious irri-
gation of  the  anterior urethra through a soft catheter carried to the
compressor urethrae  muscle  aids in freeing it from fine solid particles
which may be lodged on its surface.
   Rest in bed, milk diet, and sterilization of the urine by boric acid
or salol given  internally, both before and after the operation, are valu-
able adjuvants.  During  the operation  every  antiseptic precaution
should be observed.  Southam very properly emphasizes the impor-
tance {a)  of this preliminary  sterilization of the urine by the adminis-
tration of salol and boric acid, and  if need be by irrigation of the blad-
der, and {b) of the avoidance of  shock by thorough protection of the
patient against surface chilling.
   The exceptional cases of calculi  which are both  large and  hard
may be best treated  by suprapubic lithotomy, but neither unusual size
nor a moderate degree of density should of itself be thought positively
to contra-indicate litholapaxy.
   Perineal lithotomy  has now a very limited field, and should be
employed chiefly in those cases in which the stone is thought to be of
small  or medium size, and in which  no lithotrite, however small, can
be introduced with safety.
   Coxtra-indications to  litholapaxy are—1. Tight fibrous stricture
of the deep urethra.   This  contra-indication is not absolute, since
the stricture may be divided by  external incision and the  stone then
crushed and  evacuated.   Median perineal litholapaxy or lithotomy
is to be preferred.   2.  Severe chronic cystitis, for the cure of which
permanent  drainage, supplemented  by  irrigations,  is  indicated.   3.
Organic  visceral lesions which  make the prolonged  administration
of an anaesthetic especially dangerous, as haemoptysis, atheroma,  or a
history of apoplectic attacks.  Under such circumstances Chismore's 
694        GENITO-URINARY DISEASES AND SYPHILIS.
 operation or lithotomy is indicated.  4. A nucleus that  cannot  be
 comminuted  or removed through  the  evacuating-tubes, as a pipe-
 stem or  a  lamp-wick.   5. Sacculation  or encysting of the  stone
 Even though  the  calculus can be reached by the lithotrite, attempts
 to  seize  and crush it  are dangerous,  since the  vesical  walls sur-
 rounding it  are  thin  and  extremely vulnerable.   The suprapubic
 operation is  indicated  in  these cases.   6. Large  size  and  unusual
 hardness.  (Figs.  187, 188.)  A very few stones come in this category.
 Small hard stones  should  be taken out by perineal lithotomy.  Ex-
 ceptional hardness, combined with great size, is the only clear indi-
 cation for suprapubic lithotomy in  adults before middle age, except
 the  presence of stone in diverticula, or its association with tumor
 or  other conditions requiring for their treatment the suprapubic
 incision.
    The  most recent statistics of operation performed upon calculus
 patients ranging from puberty to middle age are as follows: perineal
 lithotomy, 226 cases, 22 deaths,  9.7 per cent. ; suprapubic lithotomy,
 159 cases, 18 deaths, 11.3 per cent.; litholapaxy, 485 cases, 22 deaths,
 4.5  per  cent.   It is clear from  these figures that  litholapaxy is the
 operation of choice. Exceptionally it may be undesirable or impos-
 sible.
    The superior value of litholapaxy in old age, as shown  by statistical
 evidence, is even more striking than in childhood or middle age.  This
 is as follows : perineal  lithotomy, 69 cases, 13 deaths, 19 per cent.;
 suprapubic  lithotomy, 91 cases, 17 deaths, 18 per cent.;  litholapaxy,
 581  cases, 40  deaths, 7 per cent.   In old age the special contra-indi-
 cations to litholapaxy, in addition  to  those mentioned  as applying
 from puberty  to middle  age, are—(1) Enlargement of the prostate so
 pronounced that the lithotrite either cannot be introduced, or if suc-
 cessfully passed cannot  reach the  stone, even though an effort  be
 made to  lift this  from  the post-prostatic pouch  by a finger in the
 rectum.   (2) Atony of the bladder.
   Complications of Litholapaxy.—It may happen  that the surgeon,
 having taken  it for granted, because of the history of  the patient,
 that the urethra will receive his  instruments, finds  some obstruction
 which  prevents them from passing.   Usually this is because of a
 narrow meatus.   In that case it  is  at once obviated by meatotomy.
 It may be from an anterior stricture.   This should be treated by in-
 ternal urethrotomy, the  patient then wearing a continuous catheter
 for a few days after litholapaxy.   If the stricture  is deep and dense,
this  indicates  median   perineal  lithotomy or litholapaxy  together
with urethrotomy.  If the  obstruction is in the prostate and cannot 
CALCULUS  OE THE BLADDER.





              Fig. 187.
695
Uric acid calculus. Exact size.  Weight, nine and one-half ounces.  Removed by suprapubic section.
Fig. 188.
&0*%
m

''"*• 1*
sat-. .}*.'3r4.   .:"•'"*■•  *-,/ h



Uric acid calculus. Exact size.  Weight, nine and one-half ounces. Removed by suprapubic section. 
GENITO-URINARY  DISEASES AND SYPHILIS.
be overcome without the use of force, the crushing operation must be
abandoned.
   It may happen that though the urethra receives the lithotrite, the
smallest evacuating-tube which the surgeon has fails to pass.  If the
stone is crushed before this is discovered, it constitutes an embarrassing
complication, since, even after the finest practicable fragmentation, it
is comparatively unsafe to allow the fragments to be passed through
the urethra.  It is with the idea of avoiding this complication that we
have  advised injection of the bladder through  the evacuating-tube
which the  surgeon  intends to  use.   He  will then discover before
having crushed the  stone  that the tube cannot  be passed, and can
either procure a smaller tube  or at once proceed  to remove the stone
by the appropriate cutting operation.
   If the stone has been crushed and  no evacuator can be intro-
duced, but a staff can  be passed,  lateral lithotomy should be  per-
formed and the fragments removed by the scoop and irrigator.
   The  lithotrite  may jam with the  blades so widely open  that
their  withdrawal when in this position would almost certainly entail
laceration of the urethra.  If  a series of quick jarring  closures fail to
free  the  blades, they should be turned forward  against the anterior
surface of the  bladder and be cut down  upon  above the pubis; or
they  may be reached and cleared by perineal incision.  Bending of
the blades may require similar operations.   Should the blades break,
the shaft should  be removed, if possible, without the exertion of
force; the fragments can  then be taken  out by a median perineal
operation.   It  is to the credit of the instrument-makers that  very
few lithotrites have been bent or broken in crushing stones.
   The bladder  may  be ruptured  during preliminary injection or
during attempts at evacuation  of the stone fragments. Rupture during
injection would be suggested were it found impossible to move the
blades of the lithotrite freely  in the  bladder  for want of room,  thus
showing  it to be partly or completely empty.   If this  accident oc-
curred during the use of the evacuator, unusually free bleeding would
be noted, and  the liquid injected would fail to  return, the mucous
membrane being  constantly sucked  into the  eye of the evacuating-
tube,  in whatever position this might be placed.
   As sequelae of litholapaxy there  may develop—(1) Shock  or col-
lapse, resulting fatally in a few hours.  (2)  Hemorrhage.   (3) Sup-
pression  of urine,  which may  be fatal in one or two  days.  This is
observed in old persons with  crippled kidneys, in whom the slightest
interference is  liable so  to  disturb equilibrium that the kidneys be-
come insufficient.   (4) Urinary fever.  This may be transitory, pass- 
                CALCULUS  OF THE BLADDER.               697

ing off in from twenty-four to forty-eight hours, or may develop into a
true septicaemia.  (5) Ascending pyelonephritis, with the development
of surgical kidney.  (6) Prostatitis and epididymitis.  (7) Pelvic cellu-
litis extending from a pericystitis.  (8) Phlebitis involving primarily
the prostatic plexus, sometimes extending to the whole pelvic venous
system, and causing extensive thrombosis with oedema of  the legs, or
septic embolism and death from pyaemia.   (9) Peritonitis.   This, may
be caused by  extension of inflammation due  to trauma inflicted on
the bladder-wall.  With the exception of  uraemia of the  aged, these
complications  are rare if proper care is  taken, and can be readily
avoided.
                          LITHOTOMY.
   Lithotomy, as this word is used in surgery, indicates  an incision
into  the bladder for the removal  of  stone.   The bladder may be
opened through the perineum by lateral, bilateral, median, or medio-
bilateral incisions.  It may be opened through the abdominal walls
by a suprapubic incision.
   Perineal  Lithotomy.—In many of the cases not suited to the
operation of litholapaxy the stone may be removed through an incision
which involves the perineum and the neck of the bladder.   Some few
surgeons still  hold  that this operation is  the  one  of choice in young
children, basing  this opinion upon its low  mortality. Though the
mortality is undoubtedly low in children, that of litholapaxy is still
lower, as has  been abundantly proved  by modern  statistics.
   In all forms of perineal lithotomy the following anatomical land-
marks should be considered.  The perineum is triangular  in form,
having its  apex at  the symphysis  pubis, and for its boundaries the
rami of the ischia and pubis laterally, and an imaginary line passing
through the centre of the anus and connecting the tuberosities of the
ischia.  The perineal centre is a point  midway between the  centre of
the anus and the perineo-scrotal junction ; it marks the middle of the
lower edge of the triangular ligament.   Just in front of this point are
the bulb of the penis and its arteries.   The raphe extends  in the mid-
perineal line from the anterior edge of the anus up over the scrotum.
Beneath it there are no arteries of importance.
   The depth of tissue between the skin and the bladder  in the male
adult varies from two and a half to three inches when measured near
the base line  of the perineum, and  about an inch  in the  anterior
portion.
   Lateral Lithotomy.—The following instruments  are  needed  for
the lateral operation:  a lithotomy knife; this is a scalpel with a 
698        GENITO-URINARY DISEASES  AND SYPHILIS.

three-inch blade and a moderately heavy  handle (Fig. 189)'; a probe-
pointed bistoury, for enlarging the  prostatic incision, should  this be

                              Fig. 189.
Lithotomy knife.
necessary; a large curved lithotomy staff (Fig. 190), grooved on the
under surface  or  on the side; the lateral groove is preferable, be-

                              Fig. 190.
Grooved lithotomy staff.
cause it  is more easily felt by the finger in the wound; the groove
should be deep enough to prevent the knife from slipping out when
once engaged;  straight and  curved lithotomy forceps (Fig. 191), the

                              Fig. 191.
Stone forceps (curved).
straight  answering  for most purposes except when  the  calculus is
lodged in a pouch posterior to the prostate, when the  curved forceps
will be required; a  scoop (Fig. 192) for dislodging the calculus from

                              Fig. 192.
                             Calculus scoop.

a sacculation, for removing debris, etc.;  a catheter en chemise, or a
Buckston-Browne air-tampon, for controlling  hemorrhage, should it
be excessive. 
CALCULUS  OF THE  BLADDER.
699
   The  catheter  en  chemise is  made  by  passing  a gum  catheter
through the centre of a piece of  gauze or muslin four inches square;
the muslin is slipped along the catheter till it is about one inch from
its eye ;  it is then firmly wrapped with  silk about  the point of punc-
ture, thus securing it in place and allowing the muslin or gauze to
hang free as would a petticoat.  When needed to stop bleeding, this
catheter is passed into the bladder through the wound, and the space
intervening between the muslin and the catheter shaft is then packed
with iodoform or  other  antiseptic  gauze.  Buckston-Browne's air-
tampon  acts as does the Barnes bag, being  inflated  after it has been
put in position : the air-bag  surrounds a catheter.
   A lithotrite should be  provided, in case the stone should be too
large to be removed whole, and also the surgical instruments  required
in all  cutting operations,—i.e., haemostatic forceps, tenacula, grooved
director, and probe.  Preliminary disinfection of the urethra and the
operative region having been accomplished, and the rectum having
been emptied, the patient, thoroughly anaesthetized, is placed on the
table, and previous to operation the stone is again sought for.   Unless
it is found at this time, the operation should  be postponed.   If it is
detected, the urine is  drawn by a catheter, and from six  to  eight
ounces of boric  acid solution or other antiseptic  are  injected; the
patient is then brought to the edge of the table with his thighs well
separated and flexed  on  the abdomen and  the  legs flexed on the
thighs, the position being  maintained  either by assistants or by me-
chanical contrivances.   The buttocks  should project slightly  over the
end of the table.   The grooved staff is then passed  into the  urethra,
and if  possible the stone is  again  felt with it.  Its tip being  well
within  the  bladder, the curve of the  staff is pulled up against the
symphysis ;  its shaft should be exactly in the middle line or inclined a
little towards the right groin.  The surgeon, having placed the staff as
he wishes it, directs an assistant to hold it exactly in this  position.
The incision is made from a point  an  inch  and a  quarter in  front of
the anus and a little to the left of the raphe, downward and  outward
for three inches, to about  the middle of the space between  the anus
and the tuberosity of the ischium, inclining  slightly more towards the
ischium  to avoid  injuring the rectum.  The first incision is deeper
anteriorly, and divides the skin,  superficial fascia,  transverse perineal
muscle, a few posterior fibres of the  accelerator urinae, branches of
the superficial perineal vessels and nerve, and the inferior edge of the
superficial layer of the triangular ligament; at  the  posterior portion
of the incision the inferior hemorrhoidal vessels and nerves are laid
bare.  All freely bleeding  vessels are at once secured by haemostatic 
700
GENITO-URINARY  DISEASES AND SYPHILIS.
forceps, which are not removed till the operation is completed.   The
space containing the membranous urethra bounded by the superficial
and deep layers of the triangular ligament having been thus opened,
the surgeon  introduces  his finger into the wound  and feels  for the
groove of the staff.   Finding it, and with his left forefinger as a guide,
the point of the knife is passed into the groove, and, by either pushing
the staff and  knife backward together or following the groove with the
point of the  knife, the bladder is entered at its  neck.   To extract the
calculus easily it  is necessary to incise the left  lobe of the prostate:
this is accomplished by depressing the knife so that the greatest  cut-
ting pressure is brought to bear on the heel of the blade.  The blade
of the knife  should be kept parallel with the external wound.  This
cut divides the deep layer of the triangular ligament, the anterior
fibres of the levator ani,  a portion of the compressor urethrae muscle,
the left  lobe of  the  prostate,  the  membranous and  the prostatic
urethra, and  nicks the vesical neck.  A deep incision into the neck
of the bladder may cause serious hemorrhage from wounding of the
prostatic plexus of veins, or, by opening the recto-vesical fascia, may
allow of urinary  infiltration.  If the  staff is kept well up against the
pubis and the blade of the knife is not permitted to leave its groove,
the  incision  into the prostate  and the neck of the bladder is not
likely to be too deep.  The entrance of the knife into the bladder is
marked  by a rush  of urine  or  of the fluid injected.  The prostatic
wound may  be enlarged during the withdrawal of the knife,  endan-
gering the rectum.   The better  plan is to  make the wound as free as
is required, by depressing the handle during the  passage of the knife
inward,  when its tip is  engaged in  the  groove of the  staff.   Having
thus  opened the prostatic urethra and the vesical neck, the left fore-
finger of the operator, guided by the  groove of the staff, is introduced
into the bladder; when the stone is felt the staff  is withdrawn.
    The  operator's finger being  within the bladder, the closed forceps
is introduced along this as a guide  until  the blades are well inside.
It is then  opened and rotated on its long axis  to the  right, thus en-
abling the right-hand blade to  act as a scoop, which  slides beneath
the  calculus.  When the stone is firmly  grasped in the forceps it is
removed by traction  made upward  and  forward in the line of the
pelvic axis.   A slight  rocking  motion  often assists  in its  delivery.
When the stone is oblong or irregular in  shape it is important  so
to grasp it  that its  smallest dimensions  shall be presented to the
opening.
    In children the use  of  a blunt  gorget—i.e., a broad,  straight-
bladed knife with a blunt probe-point which follows the groove of the 
CALCULUS OF THE BLADDER.
701
staff—is of use, owing to the prostate being a rudimentary body and
the vesical neck not being of sufficient  size to allow of the introduc-
tion of the finger.  The forceps, guarded  by the  flat  surface of the
gorget, are introduced, with somewhat more of an inclination towards
the symphysis than in the adult, owing to the relatively high position
of the bladder in children.
   Failure to find  the  calculus at the  first  trial  may be due to  its
lodgement behind the prostate.  Repeating the attempt and meeting
with no success, the curved  forceps  should be substituted and intro-
duced with the points downward and the handle slightly raised, when
the calculus will usually  be found.  If the calculus cannot be removed,
owing to the  edges of the wound overlapping, the fingers may be used
as retractors or a sufficient incision made with the probe-pointed knife,
the incision being preferable to tearing the  wound in the effort of ex-
traction.  The bladder  should  be explored with either the finger or a
sound after the stone has been extracted, to  be  certain that no other
stone  remains.  Every  portion of its walls should be felt.   This is
accomplished by making  suprapubic pressure while  the examining
finger is in the bladder.
   Soft calculi, by breaking into several pieces  from the pressure of
the forceps, usually prolong the operation and necessitate the use of a
scoop and careful irrigation in order that  all the fragments may be
removed.  Sometimes,  in spite of every precaution, a  small fragment
remains, forming a nidus for new concretions,  thereby necessitating
a second  operation.  Recurrence  of stone, however, does not prove
that operation was  incomplete, this frequently taking place when it is
absolutely certain that the bladder has been emptied.
   Other complications  may occur.  Among them is excessive hem-
orrhage  following the  first  incision, and due  to wounding of the
artery of  the bulb, either from its anomalous position  or because the
incision is carried  too  far forward; or the  distended hemorrhoidal
vessels may be the source of the bleeding.  Hemorrhage from such
a source  is easily  controlled by  means of  haemostatic forceps, re-
placed by ligatures  at the termination of the  operation if the  bleeding
continues.
   Hemorrhage  from  the  deeper  incision  is  rarely profuse, and
usually stops from the  pressure of the fingers or of the instruments
introduced.  These  proving  insufficient, a catheter en chemise, or a
Buckston-Browne tampon, may be inserted after  the removal of the
calculus ;  this usually controls  it.
   Through careless manipulation the  staff  may not enter  the blad-
der, but may be caught in a pouch of the  urethra.  Should such an 
702
GENITO-URINARY  DISEASES AND SYPHILIS.
accident occur, the staff should be withdrawn and reintroduced until
it is brought in contact with the stone.
    It has happened in lithotomies performed on children that, owing
to the small size of the incision in the vesical neck and the prostate,
efforts at introducing the  finger into the bladder have resulted  in
tearing the  membranous urethra completely across and pushing the
bladder up  out of the pelvis.   Such an accident demands suprapubic
cystotomy, the passage of  a catheter from the bladder out  through
the urethra, and the suturing of the torn ends of the urethra.
    Wounding  the rectum, due  to insufficient lateralization of the
knife,  sometimes  occurs;  the wound  usually  heals spontaneously,
though a fistula may follow.   To guard against such a result, the
rectal wound should be stitched as soon as discovered.
    Peritonitis has resulted from opening the posterior wall of a con-
tracted bladder:  to obviate such an  accident, the bladder should be
moderately  distended with fluid, and the knife  should not be carried
too far forward into the wound.
    The perineum  may be so deep that  it will be impossible to in-
troduce the finger into the bladder to guide  the forceps to the stone.
Should such perineal  depth  be  anticipated, some other operation
should be chosen.  When this  condition is discovered  after the in-
cision has been made, a blunt gorget, with thin  but not  sharp edges,
may be used to guide the forceps, the gorget being withdrawn as soon
as the  stone is grasped.
    Formerly the gorget was considered an instrument of necessity in
all  lithotomies, as was  a broad probe-pointed  knife used in making
the prostatic wound.   At present it serves as a guide to the passage
of other instruments  into the  bladder, its edges not being sharp.  It
is  also used to enlarge the wound in the prostate, its point being
engaged  in  the groove of the  staff;  in this case its edges  should
be sharp.
    Prostatic enlargement may  necessitate  the use of  the gorget
instead of the finger  as  a guide.  In these cases there  may be such
extreme  rigidity of the  neck of the bladder that full dilatation of the
prostatic urethra  will  be required before instruments can be passed.
Dolbeau's bladed dilator, constructed on the umbrella principle, and
opened out  after  introduction  into the wound  along the groove of
the staff,  is then  serviceable.   Forcible dilatation of  the  prostatic
urethra has  been followed by  complete disappearance of the urinary
symptoms.
    It  may be  hard to complete the operation because of the size of
the stone.   A calculus over two inches in diameter could scarcely be 
CALCULUS OF THE BLADDER.
703
removed  through  the  perineal  opening  unless the  incision were
dangerously large  or the tissues seriously bruised.   Bimanual  pal-
pation should ahvays detect a stone of this size, and should prevent
the  surgeon from  making efforts at removal by perineal operation.
In case previous examination has been neglected and the bladder is
already open,  the stone may be crushed and removed in fragments.
   Sacculation may make the operation difficult.  The stone may be
freed from its  fixed position by stretching the opening in the sac by
means of the  finger or by notching it in several places with a blunt-
pointed knife.  It  is often  impossible  to remove a sacculated stone
through a perineal opening: the high operation  should then be per-
formed.
   After-Treatment of Perineal Lithotomy Cases.—The bladder, having
been cleared  of calculi and incrustations, should  be well  irrigated
with hot sterile water (110°  F.).  This removes small fragments and
clots and serves to control hemorrhage.
   Should hemorrhage from the bladder-neck or the prostate persist,
the  air-tampon  or  the catheter en chemise  is inserted.  This may be
removed within seventy-two hours.
   When there is cystitis, particularly if this is of long standing, peri-
neal drainage  is indicated.   This is best secured by a full-sized  gum
catheter (30 F.) the tip  of which lies just within the vesical sphincter.
A rubber tube  conveys the urine to a vessel under the  bed or at a
lower level than the bladder, the free end of the tube being  sub-
merged in an antiseptic solution.   A light gauze dressing and a T-
bandage complete the toilet of the wound, drainage being continued
until the urine is clear, usually from three to eight days.   The cath-
eter is changed  every  second  day ;  the  bladder is  irrigated twice
daily, and each time this is done the gauze dressing is changed.
   Should there not have been cystitis, artificial drainage is unneces-
sary ;  if hemorrhage does  not  require  packing of the wound, a pad
of iodoform gauze is loosely applied to the perineum, care being taken
that it does not  prevent the free escape of  the urine from the wound.
This escape continues for  several days, and then stops for a  day  or
two, owing to inflammatory swelling, then is again noticed, but be-
comes less marked till it ceases on final closure  of the deep wound.
   The patient should  lie on his back in  bed, suitable absorbent
material (pillows of oakum enclosed in one layer of gauze,  and fre-
quently changed) should be placed so that it will catch the urine, and
his thighs and buttocks protected  from irritation  by the urine by
alcohol baths  followed  by  liberal applications of thick zinc ointment,
boric ointment,  or carbolated cosmoline. 
704        GENITO-URINARY DISEASES  AND SYPHILIS.

   Immediate suture of the perineal incision has been tried, but is
attended with great risks, owing to the fact that the deeper portion
of the wound, being more or less bruised by instruments, may slough,
and  in  the absence of drainage  cause cellulitis.  If the  wound is
allowed to remain open and heal  slowly, granulation proceeds from
the bottom surfaceward.
   The patient should remain in bed from four to twenty-eight days,
according to the rapidity with which the  wound closes. In children
closure  of the wound takes  place rapidly.
   Median Lithotomy.—In this operation  the  line of  incision follows
the raphe between the scrotum and the anus.   The patient being in
the same position  as  for lateral  lithotomy,  a staff  grooved on its
under surface is introduced  and held with its  shaft at right angles to
the plane of the body, its curve hooked up  under the symphysis pubis.
The point of the knife—preferably a narrow straight bistoury—is in-
serted at the perineal centre just posterior to the bulb of the urethra,
and pushed on until  its  point engages the groove of  the staff at  the
membranous urethra, where an incision  is made about an inch in
length.
   The surgeon introduces his left  forefinger  into the wound and
carries it through the prostatic urethra into the bladder.  The staff is
withdrawn and the forceps  introduced.   Should the  parts resist  the
introduction of the finger, the prostatic urethra should  be dilated by
means of  Dolbeau's dilator.  It is best to overcome the resistance of
the parts with the  finger, owing to the danger of laceration in using
instruments.  A grooved  director may  be introduced along the staff
before its withdrawal, the finger following the director, thereby allow-
ing more room.  The incision divides the skin,  the superficial fascia,
the sphincter ani,  the  lower edge of  the  triangular  ligament,  the
compressor urethrae, the membranous  urethra, and the apex of the
prostate.  No vessels of any size are encountered.
   The advantages claimed  for this operation are that there is no risk
of injury to the seminal vesicles  or the ejaculatory ducts, and that,
no arteries of any size being divided, the hemorrhage is slight.  There
is some  risk, however, of wounding the bulb of the urethra, an acci-
dent the dangers of which are much exaggerated.
   Dolbeau modified the median operation by introducing a lithotrite
through the wound, crushing the  stone,  and washing  out the frag-
ments at one  sitting.  Owing to the  development of litholapaxy, his
operation  has fallen into disuse.
   Bilateral Lithotomy.—The  incision is crescentic, the  centre  of
the curve  lying from one-half to three-quarters of an inch in front of 
CALCULUS OF THE BLADDER.
705
the anus, and its arms extending  on each side to a point midway be-
tween the anus and the tuber ischii.  The incision is  deepened  till
the membranous  urethra is exposed.   The urethra is opened in the
groove of the staff, and  Dupuytren's curved double lithotome cache
is introduced along the  staff into the bladder.   This instrument has
the curve of a sound, and is provided with two sharp blades, capable
of divergence from the staff, so that after introduction into the bladder
through the  urethra  they  may be expanded.   Upon the withdrawal
of the opened  instrument a  wide incision is  made in both lateral
lobes of the prostate.  When the lithotome touches the stone in the
bladder it is turned with its curve downward, and the staff is with-
drawn ; the blades  are then opened to the desired width, and the  in-
strument  is withdrawn, the lobes of the prostate being divided from
within outward.  As the instrument is withdrawn it should be kept
exactly in the middle line, and its handle should be slightly depressed.
The  finger  is then introduced  into  the  bladder as a guide to the
forceps, and the stone is extracted as by the lateral method.
   The advantages claimed  for  bilateral lithotomy are the  free en-
trance into  the bladder and the lessened danger of wounding the
larger blood-vessels.
   Medio-bilateral Lithotomy.—Civiale's operation is a modification
of the preceding.   The  first incision, made in  the median  line, is
deepened until the membranous urethra is opened, care being taken
not to wound the bulb.
   A straight lithotome is then introduced, which upon its withdrawal
divides both lobes of the prostate as in the bilateral method.
   The bilateral and medio-bilateral operations  are not practised to
any great extent  at present, partly because they give but little more
room than the median  and lateral operations, mainly  because they
require a special instrument.
   Perineal lithotomy is indicated for the  removal of small  hard
stones which cannot be crushed.  The lateral operation is  the  one
of choice.  If there is a  dense stricture of the membranous  urethra,
or if the  stone is  not more than half an inch in  diameter, median
lithotomy is  indicated;  should  this  not  give  sufficient room, the
lateral lobes of  the prostate may  be nicked by a blunt-ended knife or
the straight double-bladed lithotome.
  The sequelae of lithotomy are much the same as those of lithotrity ;
there is, of  course, greater likelihood  of  troublesome  hemorrhages
from  the  prostatic plexus, and  of infiltration and cellulitis of the
pelvic cellular tissues, because of  the incision carried  through the
prostate.   Shock, collapse,  urinary fever, thrombosis of the  pelvic
                               45 
706        GENITO-URINARY  DISEASES AND SYPHILIS.

veins,  septicaemia, pyaemia, and  peritonitis have all been recorded as
following perineal lithotomy.
   As remote  sequelae, vesico-rectal or urethro-rectal fistulae, vesical
or urethral fistulae, and sterility are possible.  Though it would  seem
difficult to wound and obliterate both ejaculatory ducts in the operation
of lateral lithotomy, there is sufficient clinical evidence that this some-
times occurs.
   Suprapubic  Lithotomy.—Pierre  Franco in  1561  is  credited as
having been the first to extract a calculus through an opening above
the pubis.   He deemed  the operation  too dangerous  to be repeated,
and performed it only as a last resort.  The first to perform it in this
country—according to Agnew—was Professor Gibson, of the Univer-
sity of Pennsylvania.  Unfortunately, the  case died from peritonitis.
   With the advent of methods by which the extraperitoneal anterior
portion of the bladder was made accessible, the suprapubic operation
has gained in favor, and  is distinctly indicated for the extraction of
stones which are  encysted  or are too  hard and large for lithotrity.
(Fig. 193.)
   In  preparing  for operation the suprapubic and perineal regions,
the penis, scrotum, and urethra should  be thoroughly cleansed as for
any formal surgical procedure.  The rectum is emptied by an enema
just before the operation.
   The patient, having been anaesthetized, is  placed  flat upon his
back, with  the pelvis and shoulders  slightly  raised to relax the
abdominal  muscles.   The operating-table  should be so arranged that
the patient can in a moment be placed in the Trendelenburg position,
should  this be required.   The varying relations of the peritoneum
to the parietes of the hypogastric region, in accordance with vesical
distention, have been already noted.  Distention of the  bladder rolls
back  the loosely attached  peritoneum  and exposes  considerable
bladder-wall not  covered  by that membrane.  Distending the rectum
elevates the posterior portion  of the bladder.
   Distention of both bladder and rectum lifts the bladder up against
the pubic walls anteriorly,  and,  since it cannot sink  down into the
perineum, it stretches  up  into the abdominal cavity.  (Fig. 194.)
   The device  for increasing the peritoneo-pubic  space by distention
of both  bladder  and rectum is known  as  the  " Garson-Petersen
method," and by it this space is increased to its utmost extent.
   For the distention of the rectum a dilatable rubber bag,—" Peter-
sen's  rectal colpeurynter,"—collapsed and well oiled, is  introduced
into the rectum above the sphincters.   The bladder is  then emptied,
and washed out with warm boric solution, and the rectal bag is dilated 
Fig. 194.
Fir.. 193.
    Bladder distended.  Pr, peritoneum : s, symphy-
sis ;  V, bladder ;  P, penis ; Sr, scniUnn ;  /.', reetum ;
 17, urethra.  (Antal.)
    Bladder distended and lifted upward by the rectal bag.  Pr, perito-
neum ;  V, bladder ;  U, urethra ;  P,  penis ;  Sr, scrotum ; Prs, prostate :
It, rectum.  (Antal.) 
 
CALCULUS  OF THE BLADDER.
707
to  the required extent;  usually eight ounces of fluid are forced in.
A  quantity greater  than this may cause  laceration of the rectum.
Following the dilatation of the rectum the bladder should be injected.
From eight to ten ounces usually suffice  for adults.  The gauge of
the amount to be injected is the pressure on the bulb of the syringe or
the height to which the bladder rises above the pubis.   Fluid should
never be injected forcibly.
   In children the amount injected  should depend upon the age of
the patient and the size of the lower bowel.  Four ounces are enough.
Owing to the fact that in early life the bladder is an abdominal rather
than a  pelvic organ, injections of this viscus and the Trendelenburg
position will frequently accomplish the desired displacement, disten-
tion of  the rectum being unnecessary.
   There have been so many reported cases of rectal  rupture follow-
ing the  use of the colpeurynter that some surgeons absolutely reject
this appliance, holding that  moderate injection of  the  bladder and
elevation of the pelvis will give the desired room.
   The bladder and the rectum having been distended, an incision is
made from a little below- the upper  margin of the  pubis upward in
the median line of the abdomen for three inches.   The cut is carried
down in the middle line between the recti  and pyramidales muscles,
dividing the sheath of the  rectus and  the layer of transversalis fascia
which bounds the prevesical  space anteriorly ;  the posterior layer of
this fascia should prevent the peritoneum from being seen.  The pre-
vesical  fat, having been exposed, is stripped upward and  backward,
carrying the peritoneum with it; unnecessary tearing or bruising of
this fibro-adipose tissue favors urinary infiltration and prevesical  sup-
puration.  Even'under the most favorable circumstances infection of
this loose  tissue is likely to take place ;  when  the bladder is infected
the danger is, of course, much greater.
   To avoid prevesical abscess in  cases of septic cystitis, Senn advises
that the operation be performed in two stages.  After exposing the
anterior bladder-wall and arresting hemorrhage, the wound is packed
with iodoform gauze and  dressed antiseptically.  At the end of five
days the dressing is removed, and, if the wound has remained free
from infection, it will be found  covered with  healthy granulations,
which close all channels of communication between the wound and
the prevesical  space.  The bladder  is then opened and drained in
the ordinary  manner.  Local anaesthesia with cocaine  is  sufficient
for the  secondary  operation.   The  following statements are made
by Senn relative to the  suprapubic  method  as  performed in  this
way: 
GENITO-URINARY DISEASES AND SYPHILIS.
    " 1.  Necrosis and phlegmonous inflammation of the margins of the
wound  and the tissues in the prevesical space—cavum Retzii—not
infrequently  occur as  complications of suprapubic cystotomy if the
operation is  performed for affections  complicated by septic  cystitis.
2. Suprapubic  cystotomy in two stages greatly diminishes, if it does
not entirely overcome, this source of danger.   3. In the first opera-
tion the bladder is freely exposed in the usual  manner, when the pre-
vesical fat is dissected away over a vertical oval space at a point corre-
sponding to the location of the proposed visceral incision, after which
the wound is packed with iodoform  gauze and the external dressing
applied in such a manner that it cannot be  displaced.   4.  The in-
cision in the bladder and the intravesical  operation are postponed
until the external wound  has  become  covered with a layer of active
granulations, which usually requires from four to six days.   5. The
second operation can be  performed with the  aid of cocaine,  without
general anaesthesia.  6. This  modification of suprapubic cystotomy
diminishes the immediate risks of the operation  and affords protec-
tion against a number of serious post-operation complications."
    When the operation is completed at one sitting, the bladder-wall,
having been clearly exposed, is hooked up by a tenaculum and an in-
cision is made large enough to admit the index finger.   Through each
border of the bladder-opening a thread is passed, by means of which
the wound can be held forward and kept open.   Should it be neces-
sary to enlarge the opening, this may be  done with a  probe-pointed
bistoury and forceps.  The calculus is removed by the scoop or for-
ceps ; if it is encysted, it should be shelled  out with extreme gentle-
ness, the opening into the bladder from the diverticulum being nicked
and stretched should this be necessary.   After removing the major
calculus, search should be made for any remaining calculi  or frag-
ments.  Some  stones are so large that the  parietal incision  may be
too small for their  delivery  (Fig. 195); one  or  both recti  tendons
should then be cut.
    The condition of the prostate should be noted, and any small out-
growths preventing  the  outflow of urine should be  removed, since
they are predisposing factors to calculus-formation;  their  removal
lessens the chance of recurrence  and frequently relieves troublesome
urinary symptoms.
    After-Treatment of Suprapubic Lithotomy Cases.—The after-treat-
ment of the  bladder, the stone having been removed, depends upon
the condition of its walls.  Provided these are  in a fairly healthy con-
dition, immediate  suture  of the bladder-wound is safe.   When the
surgeon believes before operation that the case is one for immediate 
Fig. 195,
Vesical calculus almost completely filling an hypertrophied bladder. 
 
CALCULUS  OF THE BLADDER.
709
 suture  of the vesical wound, it is well  not to carry the incision  of
 the bladder-wall too close to the pubis, for when the bladder collapses
 the wound may be inaccessible.
    A double line of sutures should be used : the first, a running stitch
 of fine catgut, approximates  the cut edges  or raw surfaces of the
 mucous membrane ; the knots should be placed on the vesical aspect
 of the bladder;  the second, an interrupted suture of  fine catgut, six to
 the inch, includes everything down  to the mucous  membrane.  To
 determine whether or  not the lines of suture are tight enough, the
 wound may be filled with  water and the bladder distended with air;
 any leakage will become at once apparent.  Should there be doubt as
 to leakage, the prevesical space may be drained for forty-eight hours.
 It is well always to provide against the bladder-stitches failing to hold,
 by packing with gauze down to the line of suture for at least two days.
 The sutures for closing the parietal incision should have been placed
 at the time of operation and loosely knotted.  If the bladder-stitches
 hold and the  wound remains clean, the parietal sutures  may be tied
 down on the third day.
    Continuous catheterization is indicated for from three to five days,
 supplemented by instillations of mild antiseptics if there is moderate
 cystitis; injections  should  be  avoided.
    Should there be marked  cystitis and the bladder-walls be  in  an
 unhealthy condition, suture of the vesical wound is  not advised.   In
 such cases  drainage should be  through the wound until  the  urine
 clears up or  is passed normally through  the urethra.  To facilitate
 irrigation, two tubes passing  to  the base  of the bladder and fenes-
 trated for an inch only are  stitched to the most dependent part of the
 parietal wound; in case  one should become clogged the other is
 available.  The bladder-incision is sutured  tightly  about these tubes ;
 unless  this is done the surface of the wound is constantly bathed in
 urine.  To prevent this, Cobbe has suggested capillary drainage.  A
 single glass tube is introduced through the suprapubic incision,  its
 rounded end  reaching  to  the most dependent  part of the  bladder
 when the patient is in the dorsal  decubitus.   This glass drainage-tube
 is attached to a  rubber  tube, which is conducted into a bottle of anti-
 septic solution placed at the  bedside.  Through these  tubes is  run a
 long wick  of  iodoform  gauze.  This capillary drainage, though par-
 tially successful, will not keep the wound dry.
   Siphon drainage is  somewhat more effective.  Cathcart has de-
 vised an apparatus  which he thus describes:  " Besides  a douche-can,
some india-rubber  tubings, and  a pail, Ave require a screw-clamp, a
small glass Y or T tube, a second  piece of glass  tubing bent  like a 
710        GENITO-URINARY DISEASES  AND SYPHILIS.
Fig. 196.
capital letter S, and a third piece, bent at a right angle, to go into the
bladder.  These  are  joined together as illustrated in  the diagram
                           (Fig. 196), and  the  apparatus  works as
                           follovvs:
                              " The douche-can filled Avith Avater is
                           fixed above the head of the patient's bed,
                           the Y tube is fastened with a large safety-
                           pin to the  edge  of the mattress opposite
                           the patient's pelvis or loins, and the part
                           below the Y is made to hang over a pail
                           on the floor.  The  screAV-clamp  Avhich
                           controls the rubber  tubing betAveen the
                           douche and one arm of the Y tube is
                           then relaxed, so  as to allow the Avater to
                           flow very slowly, in fact, only by  drops.
                           It  accumulates in the  S tube, and, as it
                           tends to  run  out,  produces a  negative
                           pressure  in the other arm of the Y tube,
                           —that  is, the one  which is connected
                           with the  tube in the bladder.  It thus
                           withdraws urine from the bladder, and
                           this in turn, as it runs doAvn the S tube
                           into the pail, increases the negative press-
                           ure in the bladder  arm of  the Y, and
                           so on.
   " The amount of negative pressure obtainable depends on the dis-
tance between the branching point  of the  Y tube  and end  of the
india-rubber tube above the pail; about a foot will generally be found
sufficient.  A very small  outlet at the clamp is all  that is required,
and at the fastest the flow into the clamp arm of the Y must be less
than the possible outfloAv through the stem beloAV, othenvise there
could be no negative pressure in the bladder arm of the Y tube. This
will be better understood by considering Avhat avouM happen if the
conditions Avere  reversed.  If Ave Avere to diminish the  outlet beloAV
the Y tube and increase the inlet on the douche arm, the Avater Avould
flow up the  bladder arm of the Y into the bladder.   Thus, nothing is
gained by increasing the rapidity of the floAV beyond a steady dropping
from the clamp.   The accumulation in the S tube Avill transform this
into a rapidly intermitting Aoav, with Avhich the urine from the bladder
is mingled.
   "The apparatus has  worked very satisfactorily after operations
for extroversion of the bladder, as well as after suprapubic cystotomy,
Cathcart's siphon drainage. 
CALCULUS  OF THE  BLADDER.
711
and may be found useful after other operations on the genito-urinary
tract, and possibly as a  means of draining the pelvis in septic con-
ditions."
   The drainage-tubes  having been placed, the  prevesical space is
irrigated,  carefully dried, and packed Avith iodoform gauze, the upper
part of the abdominal incision  is closed by a buried catgut suture
through the  fascia  and  muscles  and a superficial interrupted suture
to the skin and underlying fascia, a  dry dressing is applied to the
wound, the skin of the  loAver abdomen is covered Avith a thick paste
of boric or zinc ointment,  a large sterile  absorbing dressing of gauze
and cotton is  applied to  the hypogastric region, and an oakum pad is
placed beneath the  patient's  buttocks.  The bladder should be irri-
gated and the packing changed  every four hours when the urine is
foul and constantly escapes into the Avound.
   When  suprapubic cystotomy must be  performed  for calculus,
under circumstances which render the  development of cellulitis from
infection of the prevesical space probable, it Avould seem wise, after
having  removed the stone, to  close  the  bladder by  suture, even
though it  be diseased, thoroughly cleanse the prevesical space, pack it
lightly with sterile gauze, and drain the bladder  by permanent cath-
eterization or by median perineal  urethrotomy.  If the bladder-
stitching  is carefully performed, even though  definitive union does
not take  place,  the  prevesical space will  be  saved from constant
soaking with septic urine for at least three or four days.
    Complications and Sequelce of Suprapubic Cystotomy.—During oper-
ation there may be troublesome hemorrhage  from the large veins
in the perivesical tissue;  these  are readily secured by haemostatic
forceps.   Removal  of the  rectal bag and evacuation of the bladder-
contents are indicated Avhen bleeding is  unusually  free and from many
points; under these circumstances the  time spent in trying to secure
each vessel is Avasted, since the bleeding is  due  to the venous  en-
gorgement caused by the pressure of the bag and the vesical tension.
The bladder-wall may bleed freely and persistently, requiring the ap-
plication of several ligatures.
   The peritoneum may be opened; this  usually occurs  before  the
bladder has  been punctured and Avhile the wound is  still  sterile.
The opening should be closed at once by a fine catgut suture.
   Rupture of the rectum by the colpeurynter, if detected, should be
treated by immediate cceliotomy  and suture.
   Shortly following suprapubic cystotomy, the complications common
to all operations on the urinary tract may develop,—i.e., shock, col-
lapse, retention, cellulitis, septicaemia, pyaemia, etc. 
712
GENITO-URINARY  DISEASES AND SYPHILIS.
   Prevesical  suppuration  is a  common, often a fatal,  sequel.  It
develops in from three to five days, sometimes Avith evident symp-
toms of inflammation  and suppuration,—i.e., local tumor, pain and
tenderness, and general elevation of temperature.  Usually the onset
of this complication is insidious, the condition of the  patient suggest-
ing uraemia rather than suppuration ; local symptoms are but slightly
marked,  or are completely absent, and  the temperature is normal
or subnormal.
   When prevesical suppuration and advancing periAresical cellulitis
are suspected,  the suprapubic Avound  should be opened freely, the
space in front of the bladder thoroughly explored and drained, and
the bladder itself drained by perineal incision.
   The  suprapubic Avound may refuse to close, leaving  a fistula.
This rarely happens unless there is  obstruction to the Aoav of urine
through  the urethra  or the suprapubic Avound becomes tubercular.
The treatment is that generally applicable to vesical fistulae: urethral
obstruction is removed, the bladder is subjected to permanent cathe-
terization, and the fistulous opening is cauterized.
   Hernia sometimes follows suprapubic cystotomy, the cicatrix of
the parietal  incision  yielding to  intra-abdominal  pressure.   The
transverse cut  dividing the attachment of the recti muscles is  much
more liable to be  folloAved by this  complication than  is the ordinary
vertical incision.   It is treated by a truss or by radical operation.
   When the bladder is sutured by silk threads, these by escaping
into the vesical cavity may form foci for neAv calculus-formations.

               FOREIGN BODIES IN  THE  BLADDER.
   In addition to  calculi there has  been found in  the bladder an
almost  unlimited  variety of  foreign  bodies, such as fragments of
catheter, hair-pins, pipe-stems, lamp-AAicks, pencils, spicules of bone,
bullets, shot,  etc.  These may  enter the bladder  by  Avay  of the
urethra,  may be  driven into  the viscus  by direct violence, or may
gain  access by a process of ulceration.
   Portions of catheter are more frequently found  in  the bladder
than any other foreign body.  The breaking of a soft instrument  in
the urethra or bladder usually occurs Avhen patients catheterize them-
selves.   Either from ignorance or from carelessness, they continue to
use a catheter after it has become weak and brittle.
   The  mechanism by which foreign bodies  introduced  into the
meatus reach the  bladder has been described already in considering
foreign bodies in the urethra.   Often the introduction of these bodies
is suggested  by a form of sexual perversion.   Sometimes they are 
CALCULUS  OF THE  BLADDER.
713
passed in for the purpose of allaying the intolerable itching and burn-
ing Avhich are symptomatic of posterior urethritis and are referred
to the urethra just behind the meatus.
   Foreign bodies driven  in by force may be pieces of bone, bullets,
shot, fragments  of  clothing,  sometimes splinters of wood.   Foreign
bodies Avhich enter  the bladder by the process of ulceration are frag-
ments of bone and the contents of the intestinal canal.  Dermoid cysts
and extra-uterine pregnancies  sometimes discharge into the bladder.
Morris says, "Among surgical  catastrophes and  miraculous recov-
eries is the case of a pair of pressure  forceps  left in the peritoneal
cavity  at  an  ovariotomy, in Avhich ulceration of the vesical Avail
occurred and the forceps entered the bladder and were  then success-
fully removed after a long interval."  Morris quotes Guyon and Hen-
riet to the effect  that a foreign body once fairly Avithin the cavity of
the bladder will usually  occupy a transverse position  betAveen the
summit and the neck  and  rather  nearer the  neck.   In the empty
bladder this is the only position  which bodies not longer than four
inches can take.  A body five  inches long assumes either a vertical
or an oblique position.
   Symptoms.—As  in the case of  stone, foreign bodies in the bladder
may remain quiescent  for a long period.   Commonly  they produce
frequent urination, tenesmus and pain, haematuria,  and, sooner or
later, cystitis.   If from their shape  they exert constant pressure in
one portion of  the bladder, ulceration and perforation  take  place,
with either the formation of a limited  abscess  opening externally or
into one of the neighboring viscera,  or diffuse cellulitis.
   Unless the body is expelled shortly after it is introduced, or is of
such a nature as to be sloAvly disintegrated, there  is  no tendency
toAvards spontaneous evacuation  through the urethra.   It soon be-
comes incrusted  Avith urinary salts and grows progressively larger.
   Diagnosis.—There is nothing in the symptomatology of a foreign
body to distinguish  it  from stone.   Frequently careful questioning
will elicit a history  of a catheter having been broken in the bladder,
or of a body which has been introduced into the urethra having dis-
appeared, or of a traumatism, such  as  gunshot wound  in the vesical
region.  In  the  absence of such history, the diagnosis  is sometimes
possible after  exploration with  a  vesical sound and  bimanual pal-
pation.  Thus could  be felt a portion of umbrella  rib or slate-pencil,
for instance.  The  most  reliable  means of diagnosis is  cystoscopic
examination.  This will determine the shape, nature,  and  position of
the foreign body, and will enable the surgeon to select the safest and
most efficient methods of removing it from the bladder. 
GENITO-URINARY DISEASES AND  SYPHILIS.
   When first  inserted, foreign bodies are comparatively easy to ex-
tract, since there is then no cystitis and little incrustation has taken
place.   These  cases, however,  rarely present themselves  for treat-
ment until cystitis  has reached such a stage as to cause almost un-
bearable suffering.   The  body  is then thickly crusted with urinarv
salts.
   If the history of the case or cystoscopic examination shoAvs that the
bladder contains a  portion of a catheter, it is permissible to attempt
first to free it of its incrustation by the gentle use of a lithotrite, and
afterwards to grasp it in the jaAvs of this  instrument and remove it.
If possible, one end should be seized.  To accomplish this the cath-
eter must be grasped repeatedly in  various positions, and only very
gentle traction  must be exerted when the attempt is made to extract
it.  If properly grasped, it will come without force.   If caught in the
middle  and not crusted, even  though doubled, it may sometimes be
drawn out without injuring the urethra.   If this requires the least
force, the attempt to deliver it through  the urethra  should be aban-
doned.
   Mercier has devised a special instrument for Avithdrawing  pieces
of catheter.  It consists of two  blades like those of  a lithotrite. The
male blade terminates in a hook with the point directed doAvmvard.
When closed this  hook slips  into a fenestration in the female blade
and  the instrument presents a  smooth rounded end.  The catheter,
being grasped  transversely, is  doubled  up and  draAvn through the
urethra.
   Foreign bodies,  such as seeds, shot, and pieces of twigs or leaves,
may be removed by the tube and evacuator employed in litholapaxy.
If the body  is of such shape  or size that  it cannot  be  taken out
through  the  urethra, cystotomy is indicated.  Before the  advent of
cystitis, either  the suprapubic or the perineal route may be chosen.
If the foreign body is of large size or irregular in shape, or both, the
former route is to be preferred.   As soon as the body is removed the
bladder-wound should be sutured with catgut.  Stitches for closing
the parietal  incision should be introduced but not tied  down, the
wound  being alloAved to  remain open  for three days.  If the blad-
der-suture still holds  and the parietal incision is sterile, it is then
closed.   Permanent catheterization is desirable in these cases, though
not absolutely necessary.
   When the bladder is infected, or if the foreign body is of such size
that it may be readily removed through a comparatively small open-
ing, the perineal incision  is the  safest.   The after-treatment  is that
applicable to perineal urethrotomy. 
CALCULUS OF THE  BLADDER.
715
   In Avomen  the greater distensibility of  the  urethra makes  the
extraction  of  foreign bodies  much easier.  Probably hair-pins  are
more frequently  found  than  any  other  foreign  body.   A special
Fin. 197.
            Hook for the extraction of hair-pins from the female bladder.

instrument is used by French surgeons  for  their  extraction.  (See
Fig. 197.) 
                       CHAPTER  XIX.

                   CYSTOSCOPY.--VESICAL TUMORS.

                           CYSTOSCOPY.
   Visual examination of the  bladder  through the  urethra was first
made practicable by Dr. Max Nitze, of Berlin.  Cystoscopes, as now
made, are from ten to a little over eleven inches long, terminating in
short beaks, three-fourths of an  inch long, Avhich contain the illumi-
nating apparatus,  an  incandescent lamp, and  the  Avindow through
which  the bladder can be seen.  (Fig. 198.)   The  shafts of the in-

                              Fig. 198.
                           Leiter cystoscope.

struments  contain the  optical apparatus.   The calibre of the cys-
toscopes is from 22 F. to 25 F.  The beak makes an angle of one
hundred and  forty-five degrees Avith the  shaft, and the window and
electric light are usually on the inner surface of the beak.  Through
the windoAv the opposite section of the bladder-Avail is reflected upon
the hypothenuse of a  right-angled  prism, and  thence  through the
shaft of the instrument to the eye of the observer.  The minute in-
verted image,  righted and  focussed  at the ocular end of the  instru-
ment by means of tAvo plano-convex lenses, is finally magnified by a
lens in the funnel-shaped eye-piece.
    The windoAv and light  are sometimes placed on the outer  surface
of the beak, thus bringing  the base of the bladder directly into vieAV.
(Fig. 199.)
    Some  cystoscopes  are provided  Avith  a channel  through which
     716 
CYSTOSCOPY.
717
the bladder can be irrigated, thus enabling this  viscus to  be seen
under varying degrees of tension, and providing the  surgeon with
a means of evacuating the  fluid contained in the bladder, should it

                            Fig. 199.
Cystoscope with the light and window on the outer aspect of the beak.
become turbid, and replacing it Avith a clear fluid, without removing
the instrument.  There  is also a catheterizing  cystoscope, provided
with a canal through which can be passed a ureteral catheter.  (Fig.
200.)  Finally, there is an  operating  cystoscope, which enables the
surgeon to remove small outgrowths from the vesical mucosa.
   Cystoscopes are made in Berlin, Vienna, and Paris.  In choosing
instruments it is  Avell to see that the optical apparatus gives  a per-
fectly clear picture, and that the incandescent lamp is in good Avork-
ing order.  Some instruments  are  so constructed that should the
lamps burn out the tips  containing  them will have to be sent to the
manufacturer  for the insertion of new lamps.  It is desirable either
to secure  a number of tips,  or to purchase  an instrument to which a
new lamp can be attached by any instrument-maker.
   If the  surgeon expects to make many urethroscopic examinations,
he will need at least three instruments.
   When but a  single instrument  is used, this should be supplied
with the irrigating apparatus, and should have the windoAv and lamp
on the  concave side of the  flexure.   As a rule, it is well to become
accustomed to the use of one instrument before trying others.
   The catheterizing  cystoscopes are mainly serviceable in enabling
the operator to irrigate during the course of an examination,  and to
examine thoroughly the base of the bladder and the ureteral orifices.
The attempt to pass a catheter into these  orifices fails in many cases.
As the  source of light,  a  storage battery  supplied with  a rheostat
should be used.   An ordinary immersion battery will, however, prove
satisfactory. 
718        GENITO-URINARY DISEASES  AND SYPHILIS.
Fig. 200.
    Immediately after being used, the shaft and beak of the instrument
 are cleansed with  soap  and  hot Avater, particular  attention being
 directed to flushing out irrigating canals; the latter should be Avashed
                   out  with a five per  cent, formol  solution.  The
                   instrument is  thoroughly dried, by being placed
                   either in an oven or in  a receptacle containing
                   calcium chloride, and is finally stored in a para-
                   form disinfecting box.
                       Method  of   Using the  Cystoscope.—When  re-
                   quired  for use, the cystoscope is  attached to  the
                   battery, and the current is turned  on till  the lamp
                   burns with a  bright  white  light;  the current is
                   then turned off.  The shaft of the instrument is
                   dipped in sterile  water or boric  acid  solution, is
                   wiped dry with a sterile towel, is lubricated with
                   glycerin, and is introduced into the bladder;  not
                   till its  shoulder has  passed  entirely Avithin  the
                   viscus is the light  turned on.
                      To  make  a  satisfactory  examination  of  the
                   bladder it is essential that it should  contain at
                   least four  ounces of clear  fluid, and  that  the
                   urethra  should   be  sufficiently   capacious  and
                   direct in course to admit the cystoscope.
                      When practicable,—that is, when the consent
                   of the  patient can  be gained and there are no
                   contra-indications to  the  employment of  a gen-
                   eral  anaesthetic,—ether should be given.  Local
                   anaesthesia  by  means of  cocaine  usually  makes
                   the  procedure bearable.   Four  drachms of a
                   twenty  per cent,  solution of this drug injected
                   through the catheter  or the irrigating  cystoscope
                   are recommended by Fenwick, but a better and
                   safer way of applying this is by means of the in-
                   stillator:  the barrel  of this instrument is filled
                   Avith  a  four per  cent, solution  of cocaine,  the
                   catheter end is then  introduced into the urethra,
                   and  as  soon as pain is experienced one or two
                   drops are injected.   When  the prostatic urethra
Catheterizing cystoscope.  .      ,  ,     ,,     „,.        .      1 j.-    •„
                   is  reached,  a  drachm of the  cocaine solution is
injected, the syringe being  removed  from the catheter as  often as
is necessary for refilling.
    The  urine,  when it is  clear,  is  the  most satisfactory  medium
 
CYSTOSCOPY.
719
through which the examination can  be conducted.   It  should be
alloAved to accumulate till from  five to eight ounces are in the blad-
der.  When the urine is turbid, as  from blood or pus, it should be
drawn by means of a Neiaton catheter, and  the  bladder should be
well AA'ashed Avith a  one-half per cent,  carbolic acid  solution or a
three per cent, boric  acid solution.  In  thus Avashing the bladder it
is well  not to evacuate it wholly at any time, as complete emptying
encourages bleeding.   When the fluid finally comes away clear, five
ounces  of the antiseptic solution are injected and are allowed to re-
main in the bladder, the catheter being removed.  Very little blood is
sufficient to make the cystoscopic examination unsatisfactory.
   For satisfactory examination  the patient should lie upon a table
with his buttocks slightly projecting  over the edge and his thighs
Avidely separated, his  feet resting on chairs or on a shelf provided for
this purpose.  The surgeon sits on a  chair or  stool  between  the
patient's legs.  When ether is given,  the lithotomy position  is most
convenient.
   The cystoscope, having been  tested as to its lamp and the proper
working of its visual apparatus, is lubricated with glycerin, and is in-
troduced exactly as  though it  Avere  a  sound, until the  elbow  has
cleared the internal vesical sphincter.  This is denoted by  the sudden
cessation  of resistance,  by the  ease  Avith which the  instrument is
rotated on its long axis, and by  the position of the  shaft, Avhich  lies
about parallel with the long axis of  the body or even pointing some-
what downward.  The light is then turned on, and the  surgeon pro-
ceeds to make  a systematic examination of every portion  of the
bladder, avoiding, as  far as practicable, prolonged contact of the lamp
end of the cystoscope Avith the bladder-walls, since there is danger of
slight burning unless the lamp  is supplied with  a  perforated  hood,
which  keeps  it everyAvhere  surrounded by  liquid.   In a  bladder
moderately  distended the  lamp can be  allowed  to  burn for an
hour Avithout  materially  changing the  temperature   of the  fluid
about it.
   The method of conducting the examination must be  learned by
experience; rules giving the angles at which the shaft of the instru-
ment should be held  are Avorthless.  The instrument can be pushed
in or partly withdrawn, can be  partly or completely rotated, or can
be lateralized to a limited extent.  By these various motions the entire
healthy bladder may  be seen.
   The base  of the  bladder  and the trigonum,  as representing the
region most  prone to pathological alteration,  should  be inspected
first; after that the  posterior surface,  the vault, and the anterior 
720        GENITO-URINARY DISEASES AND  SYPHILIS.

surface are systematically explored ;  finally  the vesical orifice of the
urethra is examined.
   The surgeon  must first teach himself to bring closely into vieAv
every portion  of the  inner  surface of the  bladder.   The phantom
bladder, cadavera, and  sexual neurasthenics, who are ahvays bene-
fited by prolonged and painful manipulation, offer the  best opportu-
nities for  learning this part of cystoscopy.  Finally  comes the right
interpretation of  Avhat is seen.   This requires a Avide  clinical expe-
rience.  In the hands of one Avithout experience the cystoscope be-
comes, in most cases, simply a surgical toy.
   Cystoscopic Diagnosis.—The mucosa of the normal bladder is
straw-yellow in color, with arborescent vessels upon  its surface  and
slight but distinct trabeculae.  Depression of the shaft of the cystoscope
and  half rotation show-  the base and the trigonum, suggesting, says
Fenwick, " a sandy shore;"  at the  posterior angles of the trigonum
are the ureteral orifices,  each  appearing as a depression or slit placed
in a little ridge of mucous membrane.   At intervals  of from thirty
to sixty seconds, not synchronously, these ureteral orifices gape  and
discharge  a swirl of urine.   Occasionally, in place of  the  ridge there
is a  distinct  conical projection marking the ureteral  orifice,  exhibit-
ing a motion of recession  and protrusion.   Failure to  find the ure-
ters  in the healthy bladder is generally due to incomplete dilatation
of this viscus, the openings of these ducts being concealed in the folds
of the vesical  mucosa,  and  appearing when these folds  have been
obliterated by the proper amount of vesical tension.  The vesical ori-
fice of the urethra is examined by withdrawing the cystoscope till the
greater part of the field of vision is occupied by a dark crimson, sharply
marked fold strongly contrasting with the yellow glare of the  bladder
surface still perceptible through that part of  the Avindow which is not
yet Avithin the  vesical neck.   The crimson color is due to transmis-
sion  of light through this fold.  Its outlines are determined by rotating
the cystoscope.  In case  air has entered the bladder during the prelim-
inary Avashing or injection, it forms a round, movable, shining bubble,
from the convex  surface of which the cystoscopic lamp is reflected.
   It is possible to mistake  for a tumor the projection  of  mucous
membrane sometimes seen about the ureteral  orifice.  The  position
of the projection and the intermittent  jets  of urine  should  prevent
such an error.  The rugae, if not sufficiently distended, have been mis-
taken for  papillomata; a further  injection should make the nature of
the projection sufficiently clear.
   Blood  deposited on  the base of the normal bladder may present
the appearance of a severe subacute  or  chronic cystitis. 
CYSTOSCOPY.
721
   In the acute or chronically inflamed bladder the rugae may closely
simulate  papillomata, particularly if the  inflammation is localized in
one portion of the bladder, as is sometimes the case.   Femvick de-
scribes as one of the appearances of certain forms of chronic cystitis
a polyhedral or  rectangular quilting of the bladder, Avith projections
between  the seams of SAvollen, almost translucent, mucous membrane
presenting the appearance of a patch of gelatinous polyps.  A similar
condition at the base may produce small conical projections, or these
may be caused by dilated mucous  glands or vesicular  inflammation.
The vesicles formed  are round, translucent, and small,  from the size
of a pin-head to that of a shot, and are especially numerous over the
trigonum.
   Hemorrhage beneath the mucous membrane of the bladder causes
the formation of a yelloAv, partly translucent, projecting tumor, not
unlike papilloma.  The  diagnosis will be founded on   the  presence
of blood-infiltration  and discoloration of the  surrounding mucous
membrane.
   Acute and chronic cystitis present a coloration varying from  deep
red to yellow, according to the intensity  of the inflammation and the
stage of  the disease.  The proper interpretation of color-variation,
swelling, pigmentation, exfoliation, and trabeculation must  be based
upon  a  previous  careful  cystoscopic examination of  the healthy
bladder.
   Tubercular cystitis presents features  which may render its  diag-
nosis by cystoscopic examination  impossible.  The lesions, usually
located on the base  or the posterior wall, are not unfrequently asso-
ciated with small papillomatous outgrowths.   When sharply outlined
ulcers develop, the diagnosis, in the absence of an  acute or a chronic
cystitis,  is  not difficult.  When there are  general infiltration  and
thickening  of the surrounding  mucosa,  and especially  when  there
is  papillary outgrowth, great care should be exercised in forming an
opinion as  to the tubercular nature of the lesions from  their appear-
ance through the cystoscope.
   Diverticula, calculi, and foreign  bodies, such as  needles  and por-
tions of ligature, are  readily detected by the cystoscope.   This instru-
ment, however,  finds its most  useful place—1, in the diagnosis of
bladder-tumors ; 2, in determining the question in cases  of haematuria
and pyuria as to the vesical or the renal origin of the blood or pus.
   The cystoscope should not  be  used till  all other means of  diag-
nosis,  except exploratory  incision,  have been employed  and the
evidence derived from  them has been   carefully Aveighed.  Its use,
particularly when there is  haematuria with  sterile  urine, should  be
                               46 
722        GENITO-URINARY DISEASES  AND SYPHILIS.

preceded  by preparation for operation Avhen symptoms  and other
means of  diagnosis have  made it  probable that operation will be
required.   Having by the cystoscope demonstrated the need of oper-
ation, as in the case of a tumor, for instance, this should be performed
Avithout further delay.
   Cystoscopic Diagnosis of Vesical Tumors.—It must not be forgotten
that  even by the expert the  interpretation of bladder-pictures  has
been  misleading.  Tumors have been diagnosed by  the  cystoscope
Avhich could not be found  on  opening the bladder.  Per  contra,
tumors Avhich  Avere  not seen have been  found  and  removed by
suprapubic cystotomy.
   The position  of  the tumor,  particularly in  regard to its com-
pressing  effect  upon one or both ureters, should  be carefully noted.
In case of such pressure the intermittent forcible jet from the ureter
is not seen.
   The size of the tumor is not easily determined, since this, as seen
through the cystoscope, varies in accordance Avith  the  distance of the
AvindoAV from  the object inspected.  Practice Avith objects of known
dimensions will enable the operator to form a fairly good estimate.
   The shape of the tumor, the presence or absence of a pedicle, and
the number of  tumors, should be investigated.  Information gained by
direct inspection is not only valuable from  a diagnostic stand-point,
but may determine the manner of subsequent surgical intervention.
   Positive determination  as  to  the benign or malignant  nature of
a growth is  often impossible, since, even  Avhen the latter is removed
by cystotomy, it may happen  that this  question cannot be  settled till
a  microscopic  examination   has  been  made.   Distinctly pedicled
groAAdhs,  particularly  those  presenting  long,  regular, undulating
fringes,  are usually benign.  (Fig. 201,  A  and  B.)  Such groAvths
about the  urethral orifice  may be  detected by the use of the irri-
gating cystoscope, the  injected  stream  SAveeping the fringes away
from  the  AATindow and the  light, which  they sometimes completely
cover.
   Sessile caulifloAver groAvths (Fig. 201, C) or irregular, ragged papil-
lary projections from an ulcerated or indurated surface are indicative
of malignancy.  A localized induration of the bladder-AA^all, the form
in Avhich malignant groAvth often appears, may sometimes be detected
by distending the viscus to its full capacity.   The fluid is then allowed
to escape,  the  suspected  induration being  kept  under observation.
Usually such infiltration can  best  be found by  digital  examination.
A diagnosis between carcinoma and sarcoma cannot be made.
   The backward projection of an hypertrophied prostate may suggest 
Smooth pedicled epithelial growth.  (Albarran.)
Villous epithelioma.  (Albarran.)





               C
Lobulated epithelioma.  (Albarran.) 
Fig. 202.
Myxosarcoma.  (Albarran.) 
TUMORS OF  THE  RLADDER.
723
an extension backAvard of a cancerous infiltration of this gland.  Fen-
wick states  that in malignant extension the groAvth  breaks through
towards the middle or the base of the trigonum, whilst the intra-
vesical outgroAvth of enlarged prostate is found near the vesical orifice
of the urethra.
   The determination of the vesical or renal origin of blood or pus in
the urine must at times depend absolutely upon cystoscopic findings.
Any of the  modern cystoscopes, but particularly  those designed  for
catheterizing the ureters, bring the orifices of these channels clearly
into viewr.   If the blood or pus is discharged freely, the irrigating cys-
toscope  must be used, othenvise the fluid  in the bladder becomes
opaque so quickly that nothing can be seen.  By subjecting each ure-
teral orifice to careful scrutiny, the  SAvirls of blood-stained, or in case
of pus opaque AAdiite, fluid ejected into  the comparatively clear blad-
der-contents Avill make possible a positive diagnosis.
   In obscure diseases  of the  bladder or  kidneys, Avhen all  other
means  have failed  in establishing  a  diagnosis, the use of the cysto-
scope is indicated,  provided the bladder  can  retain four ounces of
fluid and the urethra is pervious to a 22 F. to 25 F. instrument.
   We can reasonably expect to determine by  this instrument the
presence or absence of tumors, stones, foreign  bodies,  diverticula,
ulcerations, the extent and character of a cystitis, the condition of the
ureteral orifices, the functional activity of each kidney, and the source
of blood or pus in the urine.

                   TUMORS OF  THE BLADDER.
   Tumors of the bladder may be  benign  or malignant.
   Benign tumors  are the papillomas, the adenomas, the fibromas,
the myxomas, and cysts.
   The  malignant groAvths include carcinomas, sarcomas, and mixed
tumors, except the  fibromyomas.   Carcinomas may be squamous or
glandular.   The  sarcomas may be round-celled, spindle-celled, mel-
anotic, or mixed, as fibrosarcoma, lymphosarcoma, and myxosarcoma.
(Fig. 202.)
   Of all bladder-groAvths, more than half are malignant, carcinoma
being found more frequently than all other bladder-tumors combined.
   Of benign growths, papilloma is  commonest.  Next in order comes
the myxoma, or so-called bladder polyp.
   The seat of bladder-tumors is usually about the base, in the region
of the trigonum.  Exceptionally, when single, these groAvths are found
involving the  upper two-thirds of the bladder-Avails.   The mode of
attachment of the tumor to the bladder-wall varies in different cases. 
724        GENITO-URINARY DISEASES  AND SYPHILIS.

Sometimes it is attached by a long slender pedicle; or the pedicle
may be  broad, and there  may  be infiltration  of the  surrounding
bladder-tissues ; or there may be no pedicle;  or the entire thickness
of the bladder may be  involved, the infiltration extending beyond
the area  apparently diseased.  Men are more frequently affected Avith
bladder-tumor than are  women.  The tumors  may develop at any
age, but are commonest betAveen the fortieth and the sixtieth year.
   Albarran  states that vesical tumors are multiple in twenty-five per
cent,  of  cases.  Small, single, well-pedicled tumors are likely  to be
benign; large, infiltrating, sessile tumors are commonly malignant.
   Papilloma.—Papillary tumors are multiple in about forty per cent.
of all cases.  (Fenwick.)  They may be pedunculated or sessile.  They
may form a villous surface, made up of closely grouped fine papillae
springing from the mucous membrane,  or may appear in the form
of a cauliflower growth, each of the papillae  sending out offshoots;
in the latter case they usually rise from a comparatively small  stalk.
It must be borne in mind that  all tumors of  the bladder may be
covered by a villous surface.  In the true papillomata,  hoAvever, the
tumor is  composed entirely  of papillae.  Each papilla  is made  up
of a central capillary loop, together with a stroma of delicate fibrous
tissue, covered with layers of  cylindrical  epithelium corresponding in
type with  the normal vesical  epithelial cells.   These papillae are
planted upon a fibro-muscular base, and the Avhole mass may be ses-
sile, covering a comparatively  large area, or may be pedunculated, the
stem sometimes being half an  inch in diameter.  In some cases papil-
lomata form compact masses Avith villi  of  only moderate length.
   Certain transitional forms  are described  in which the histological
structure of the cells suggests  that these  tumors may be  transformed
into epitheliomata.  Villous tumors  are prone to bleed from partial
strangulation of their blood-supply incident to muscular contraction,
and from the fact that  the delicate, loosely floating papillae  are  likely
to become detached.  These may be encrusted with urinary salts.
   Clado  ealls attention to the fact that papilloma,  though classed
with the benign tumors histologically, often  returns after removal,
presenting  then the features of an epithelioma.
   Myxoma.—This tumor is much rarer than  papilloma.  It  is most
frequently encountered in  childhood, and is probably in some  cases
congenital.   The  myxomata  are often multiple  and pedunculated,
and are much like similar  tumors found  in the nose.   Their stroma
is made up of fibrous and mucous tissue well vascularized.  They are
hard or soft in accordance with the  preponderance of the mucous or
of the fibrous tissue. 
o^
X'
At"
\^%t...    ///>f*A v   •   ■''■■'  ■'■;■   i
 
 
TUMORS OF THE  RLADDER.
725
   When multiple, several tumors  may groAv from a single pedicle;
this, by elongating, may allow the tumors to  slip through the  female
urethra and appear at the meatus.   The mucous membrane about the
attachment of the pedicle is not infiltrated.  These tumors may recur
even after a seemingly thorough removal.
   Fibroma.—Tumors of this variety in  the  bladder are excessively
rare.  They resemble in structure fibromata formed elsewhere in the
body, and  are generally sessile ; they grow from the submucous coat
of the bladder, and are covered Avith unaltered mucous membrane or
villi.
   Myoma.—Myomata of the bladder Avere supposed by Virchow to
be merely prostatic  outgroAvths, but Belfield  has demonstrated that
there may be myomata of the  bladder pure  and simple.  They are
seldom  pedunculated, but  are  protruded from the muscular coat,
often appearing on the outside of the organ as Avell as in the interior.
They sometimes  attain a large growth, sufficient to be mistaken for a
uterine fibroma, and are extremely  vascular.
   Sarcoma.—Tuffier quotes Feirwiek, who  has collected fifty cases
of vesical sarcoma, as saying that in children these groAvths are often
multiple, sessile  or  subsessile, generally polypoid in form ;  in  the
adult they are more often  simple  than  multiple, and are peduncu-
lated  in only ten per cent, of cases.  In  thirty-four and a half per
cent,  of cases they are of the round-celled  variety, and in  almost
seventeen per cent, spindle-celled.   They attain a considerable size,
sometimes that of a foetal head.  They are generally composed  of
purely sarcomatous elements, yet villous papilloma degenerating into
sarcoma has been observed.  Sarcomata are usually multiple.   They
commonly groAv  from the neighborhood of the ureteral orifices, or
from  the  mucous  membrane  lying between  these openings.   In
women  infiltration frequently extends along  the urethra.  From  its
rapid groAvth, sarcoma  is  likely to pass  beyond the limits  of  the
bladder, invading the pericystic tissues and  finally the  bones of the
pelvis.
   A feAV cases of angioma, enchondroma, and  lymphadenoma have
been noted.
   Carcixoma.—This may appear in the form  of squamous or tubular
(lobulated) epithelioma or alveolar cancer (carcinomatous epithelioma).
(Figs. 203,  204.)
   Vesical  cancer is  usually sessile, involves  the Avhole  thickness of
the bladder-AA'all, and presents an  uneven, often ulcerating, surface;
it is hard on palpation, is surrounded by peripheral  induration, and
is frequently multiple.  The groAvth  is  extremely sIoav.  Extensive 
726
GENITO-URINARY DISEASES  AND SYPHILIS.
ulceration  is  rare;  metastasis  is also sometimes entirely Avanting.
The affection occurs most frequently in men, and behveen the fiftieth
and the sixtieth year.
    At times the  growth is pedunculated, suggesting the appearance
of papilloma.
    On intravesical examination these growths  are  found  to vary
greatly in appearance.   They may form irregularly projecting masses
covered with normal mucous membrane, or they may appear as com-
paratively flat areas of induration, the surface of Avhich may be smooth
or ulcerated. In some cases there is bulk sufficient almost entirely to
fill the bladder;  very frequently the surface is covered by a papil-
lary growth.  Infiltration and induration are the most characteristic
features.
    When by rectal examination a hardening of the bladder-Avail can
be felt, this  is almost pathognomonic of cancer.
    Although extension of the  disease to  the iliac and  abdominal
glands and  thence  to the abdominal viscera occurs, extension to
neighboring organs appears to be rare.  Watson quotes  Barling to
the effect that  in only three  out of fifteen cases of carcinoma of the
bladder did extension to neighboring  organs occur; and in nine, in
the  same series of cases,  secondary deposits Avere found  in other
organs.   Of forty-nine cases, thirty-three had, as secondary changes,
hydronephrosis or pyonephrosis, or both.
    Watson  adds, " The  remarkable tendency of carcinoma of the
bladder to remain localized for very long periods has been commented
on by various writers, and  is generally explained by the absence, ac-
cording to some  investigators, or by  the  meagreness, according to
others, of the supply of lymphatic channels in the bladder.   Barling
quotes Hoggan  with reference to this  matter as  folloAvs: ' There is
but one set  of lymphatic vessels over the bladder, except at the tri-
gone.  This single layer commences on the deep or mucous surface
of the muscular coat, beginning as loops or chains around the smaller
arteries or veins within that coat, as though destined to absorb their
exudations  rather than  those of the  mucous membrane.  These
lymphatics  concentrate into  tAvo main sets, one going back to the
neck of the  bladder, the other towards the  urachus.'  These are said
by the text-books to empty into  the internal iliac glands, but Hoggan
says this is incorrect.   At the trigone there  is a second set of purely
collecting lymphatics arising in the mucous membrane and  connecting
with the deeper  set.   This lack of direct  connection of the larger
portion of the  lymphatic channels Avith  the mucous membrane ex-
plains the failure of the  neighboring  glands to become involved in 
TUMORS OF THE  RLADDER
727
some cases or their tardy infection in others.  This also explains the
extraordinarily long course of the disease that has been noted."
   Symptoms.—The  benign bladder-tumor may exist for years and
excite no symptoms.
   Usually hemorrhage is a symptom Avhich first suggests the possi-
bility of a bladder-growth.  This hemorrhage occurs without apparent
cause, its onset is sudden, and it disappears as quickly as it comes.
If the bleeding is  copious, if the last urine passed contains more blood
than that first evacuated, if the  blood  is bright red in color, if clots
are passed, and if gentle  instrumentation occasions free  hemorrhage,
all the characteristic features of bleeding from  bladder-tumor will be
present.
   This bleeding may last a day, or may continue  for Aveeks, may be
so slight as to excite no  constitutional symptoms, or may be severe.
Exceptionally,  as a result of intravesical bleeding,  dense clots so
obstruct urination that immediate operation is  necessary.  Frequent
recurrences of the bleeding may exhaust the patient, and may finally
occasion death.  It must be borne in mind that the amount of bleeding
is by no means commensurate Avith the size of  the  tumor.  At times,
in place of haematuria, or associated Avith it, there  is Avhat  Ultzmann
calls fibrinuria,—that is, in place of  pure blood  the albuminous con-
stituents of this fluid are  exuded through the distended vessels in the
region of the groAvth.   The urine Avhen passed  coagulates.
   Pain usually  is not severe,  except  when there is accompanying
cystitis.   It  is  especially  marked when the tumor is placed in  the
region of the vesical neck and is reflected to the hypogastric region,
the anus, the testicle, the penis, and  doAvn the thighs.   It is  most
marked on the completion of urination  and when  the bladder is in-
vaded by a malignant groAvth.  Benign  tumors often cause no pain.
   Frequent urination is  not a constant symptom.   When noted it is
not aggravated by exercise, and is not  more marked at night.  Pain
and frequent urination  are constant and distressing symptoms when
the bladder  has  become infected;  they are then  due to the cystitis
rather than to the tumor.
   The passage of fragments of the  tumor is  the only absolutely con-
clusive  sign  of bladder-tumor,  aside from  direct  examination.  A
microscopical examination is  necessary to determine the nature of
the  fragments  passed, since  coagulated  fibrin or  blood-clot may
readily be mistaken  for a neAV growth when examined macroscopi-
cally.
   Diagnosis.—This is  founded on  the  sudden, apparently causeless
free bleedings  recurring  Avith increasing frequency, the passage of 
728        GENITO-URINARY DISEASES  AND SYPHILIS.

tumor-fragments, examination Avith the cystoscope (see Cystoscopy),
combined rectal and suprapubic palpation in the  case of malignant
growths (see p. 677), and exploratory perineal or suprapubic cystot-
omy.  Myxomata and non-infiltrating growths cannot be detected by
palpation.
   The passage of irregularly shaped clots, superabundance of epi-
thelial cells, absence of  fragmentation in the blood-corpuscles, ab-
sence  of kidney albumen, and the presence of absorption bands of
oxyhaemoglobin on  spectroscopic examination, would indicate at least
the vesical origin of the bleeding.
   The successive appearance of single symptoms  strongly points to
vesical tumor; the  immediate association of several symptoms is the
rule in cystitis.  In the latter the appearance of pus is  never long
delayed ; in tumors it is often delayed.   In tumors that infiltrate the
bladder-Avail, in contradistinction to pedunculated neoplasms, hemor-
rhage  may be a late symptom, Avhile, on  the other hand, the irrita-
tion of the muscular Avail induces frequent  urination at an earlier
period than in tumors Avith  a pedicle.   Haematuria, intermittent or
profuse and lasting a long time, Avithout  other symptoms, is always
suggestive  of vesical tumor  rather than  of  cystitis.  There  may be
little hemorrhage in some extensive tumors of the bladder, but every
neoplasm of the bladder must at some time be associated Avith more
or less bleeding, usually more than in cystitis.  In  any case in which
doubt  exists, if the usual treatment for  cystitis is not folloAved  by
benefit, a tumor is probably present.
   A bladder which contains  a tumor  is  peculiarly susceptible to
infection, and, as the  supervention of  cystitis greatly increases the
suffering of the patient  and  adds  materially to the  risk  of surgical
intervention, it is best  in suspected cases to pass no instrument into
the bladder until all preparations are made to operate at once in case
a tumor is found.
   Prognosis.—In even benign tumors the outlook  of a case allowed
to run its course is  unfavorable.  Very exceptionally individual poly-
poid growths  are discharged spontaneously.   As a rule,  the groAvth
is progressive.
   From mechanical action a large tumor of the bladder may cause
displacement of neighboring  organs,  pressure upon  the  rectum, or
partial or complete obliteration of the ureters or the urethra.  Cystitis
is  a  constant accompaniment, and is usually severe.  The common
cause is uncleanly catheterization.  It is sometimes complicated by a
pericystitis causing fibro-adipose deposits, which limit the movements
of the  bladder. 
TUMORS OF  THE  RLADDER.
729
   The patient  ultimately perishes, either from exhaustion incident
to  hemorrhage or from ascending  pyelonephritis.   The course of
these cases is often extremely sIoav.
   When the tumor is thoroughly removed the prognosis in benign
cases is good, though recurrence may take place.  Even in malignant
groAvths a thorough remoA^al in the early stages  may accomplish radi-
cal cure.
   Treatment—It  is of cardinal  importance in  cases of  suspected
bladder-tumor to avoid infecting  the vesical  mucosa Avhen  such in-
fection has  not  already taken place.  The diagnosis  having been es-
tablished, there  is but  one treatment to be  seriously considered,—
complete removal  of the groAvth.
   The palliative  treatment of tumors of the bladder is confined to
checking bleeding and relieving pain.   This treatment  may be re-
quired because  of reluctance on  the part of the patient to consent
to operation; more frequently because by the  time a positive diag-
nosis of tumor is made infiltration has already  extended Avide of the
bladder, and a radical operation  is no  longer  possible.   The treat-
ment of haematuria in general is  that  applicable to the  relief of
vesical congestion.   Direct local treatment may be conducted by hot
injections of alum four drachms to the pint, hydrastis two ounces to
the pint, or  acetanilid five per cent, solution.  When clots are present
and produce retention, these should be aspirated through a catheter
or litholapaxy evacuating tube.  If bleeding persists in spite of injec-
tions, or if  these produce great pain and  seem to increase hemor-
rhage, permanent  catheterization is indicated.   If this is unsuccessful
because  the catheter  becomes blocked  by clots,  perineal  drainage,
with the insertion of a large tube, is advisable.  Through  this  tube
the bladder can be abundantly  flushed Avith  comparatively strong
astringent injections.   Should these means fail to arrest the  bleeding,
and should life  be immediately threatened by its  continuance, the
bladder should  be opened above the pubis, the edges of the vesical
wound  sutured  to the parietal incision, and, drainage-tubes having
been carried  to the  region  of the ureters,  the  bladder should be
firmly packed with iodoform gauze.
   Pain  may be quieted  by instillations of  cocaine.  Usually mor-
phine hypodermically  will be required  for  its relief.  Cystitis or re-
tention  should be  treated  in  accordance with the directions already
given.
   The use of astringents by the  mouth is sometimes  serviceable in
lessening hemorrhage ; hydrastis, ergotin, and gallic acid may possibly
exert some local influence. 
730
GENITO-URINARY DISEASES  AND SYPHILIS.
   Operative Treatment.—The  method of reaching the tumor  Avill
depend upon its size, location, and  nature.  It may  be approached
through the urethra, through  a  median  perineal  opening into  the
membranous urethra, or through a suprapubic  opening.
   Removal through the urethra  has been successfully accomplished
in the case of small pedunculated individual polypoid growths.  It is
uncertain  and not to be commended.  The instrument commonly
employed is the lithotrite, the location of the tumor having been pre-
viously determined by a cystoscopic examination.
   The perineal route,  highly  commended by Thompson, and  pri-
marily employed by him for  diagnostic purposes, is  serviceable for
the removal of polypoid growths, especially when these are placed
near the vesical orifice, though when the perineum is not unusually
deep and the  bladder is not  pushed  up  by an enlarged prostate, a
finger  passed  through this  opening into  the bladder and  aided by
pressure above the pubis with the other hand can make an  examina-
tion of every portion of the vesical mucous membrane.   The advan-
tages of this route are its much lower mortality and the thoroughness
of the  drainage Avhich it provides.  Its disadvantages depend upon
the fact that the surgeon is forced to operate through a small opening,
—i.e., the undivided neck of the bladder,—and that he must depend
entirely upon the sense of touch.
   For the seizure  and  removal of groAvths by  this  route polypoid
forceps Avith serrated blades are employed, straight and curved (Fig.
205); also forceps with cutting edges are used Avhen the groAvths  are
more dense and less distinctly pedunculated.  The patterns  furnished
by Thompson are the best (Fig. 205). The groAvth  is removed by
introducing the forceps into the  bladder, opening them  widely,  and
then closing them as near the region of the base  of the polyp as can
be calculated.   By firmly grasping the polyp it may be removed by
the forceps aided by twisting; forcible traction  should be avoided,
and Thompson especially cautions against exerting suprapubic press-
ure Avhile the  forceps are introduced in search of polypi, since thus
a fold of the bladder may be grasped and crushed, resulting possibly
in perforation and fatal  peritonitis.  As each portion of the  growth
is removed the  finger should be inserted, to determine exactly how
much has been accomplished.  Sessile groAvths,  especially if extensive,
are, of course, not amenable to this operation.
   For the performance of suprapubic cystotomy for the removal of
vesical tumors, the  surgeon should  be provided  with a rectal bag, a
catheter of medium calibre which Avill enter the bladder without diffi-
culty, a four-ounce syringe the nozzle of  \Adiich  fits  accurately  into 
TUMORS OF THE RLADDER.
731
the catheter, two broad  retractors, an electric light, iavo glass vaginal
specula,  special crushing  or  avulsion  forceps, a  Avire ecraseur,  the
Paquelin or galvano-cautery, and the ordinary operating instruments,
—i.e.,  knives,  scissors,  haemostatic  forceps, tenacula,  straight and
curved needles, a needle-holder, and a grooved director.

                             Fig. 205.
Thompson's forceps for removing vesical tumors.
   The incision is the same as that already described in treating of
suprapubic  cystotomy for the removal of large calculi.   It is  about
four inches long,  beginning a little  below the  upper margin of the
pubis and running upward in the middle line;  the skin and subcuta-
neous fascia having been divided, the deep fascia is cut in the mid-
line, between the muscles if possible.  Should the incision fall to  one
side, it should be  continued  through the muscular fibres, first being
deepened in its lower part till it opens the layer of fascia which  forms
the anterior wall of the prevesical space, exposing  the subperitoneal
layer of fat.  The finger  is then introduced doAvn behind the pubis,
with the pulp  toAvards the bladder.   It  is hooked upward, dragging
with it the  subperitoneal fat and the peritoneum, and exposing  the 
732        GENITO-URINARY  DISEASES AND SYPHILIS.

bladder.  The retractors are  applied to the bottom of the  wound
and  this is separated as widely  as possible.   Guyon advises at this
stage of the operation irrigation of the entire prevesical space with a
five per cent, solution of carbolic acid as a means of preventing infec-
tion  with urine.
   Little attention  need be paid to the veins, a bistoury being thrust
into  the bladder about half an  inch beloAV the  upper border of the
pubis and  carried  upAvard  till an incision is made  sufficiently large
to alloAV the finger to be introduced.  Through each  border of this
incision a stout thread is  passed by means of a curved needle.  The
twro  ends of the thread are knotted, and the loops  thus made serve
as retractors, keeping the  vesical Avound Avidely open.   The incision
is then enlarged  upAvard  to the  extent  Avhich digital exploration of
the  tumor  shoAvs will  probably be  necessary.  Guyon advises the
placing of tAvo or more threads  along the  border of the incision, for
the purpose of lifting the bladder up and holding  the  Avound Avidely
open, thus rendering the seat of operation accessible.   The parietal
Avound  is held open by the retractors placed one on either side.  A
third retractor placed at the upper angle is sometimes serviceable.
   It is at this stage of the  operation that the Trendelenburg position
becomes useful, the rectal bag being  removed if this has been used.
With an irrigator and sponges  the bladder is cleansed of blood-clots
and  dried.   The electric light  is  then  turned on, and the interior of
the bladder is inspected.   This  portion of the examination may be
greatly  facilitated by the  use  of a glass speculum, as  suggested by
Femvick.  The instrument  selected is from an inch to an inch and
a half in diameter; it is passed into the bladder, and  is used on the
principle of a caisson,—that is, its end  is held  in  contact Avith the
mucous membrane, and the portion thus included is thoroughly dried
by sponging.  This portion can  then  be inspected, since no  further
obscuration with  blood or urine is possible until the speculum  is  lifted
from its place, unless it includes the bleeding area or  the orifice of
the ureter.
   When the bladder is small  and not distensible, as is the case after
prolonged interstitial  cystitis, or when from the size of the tumor it is
obvious that more room will be required than is given by the ordinary
vertical incision,  the transverse cut may be made.   (Trendelenburg.)
This is four inches long, slightly convex  downward, and is  carried
along the upper  border of the symphysis.  The attachments of the
recti muscles are divided, and the prevesical space  and the  bladder
are both opened by a transverse cut.  This gives  a larger vesical
wound without endangering the peritoneum, and consequently makes 
TUMORS OF  THE  RLADDER.
733
intravesical manipulations easier.  The bladder-wound, which should
be almost as large as that of the parietes,  should be temporarily
sutured to the latter.
   Langenbuch has proposed the subpubic route to the bladder.  The
skin incision is in the form of an inverted  Y (A), the upper portion
overlying the symphysis, and the two arms running obliquely outward
parallel to the descending rami.  He then divides the suspensory liga-
ment of the penis, and exposes the anterior surface  of the bladder
below the pubis.   He holds that  this incision provides good  drain-
age, avoids the peritoneum, and lessens the risk of urinary infiltration.
It is not, however, to be  commended.
   Helferich, for the purpose of rendering the bladder more accessi-
ble, has proposed partial resection of the pubis.   He makes a trans-
verse incision along the upper border of the symphysis, being careful
to avoid the spermatic  cord; the periosteum is detached from the
bone on either side  of the symphysis external to the pubic spines,
and by means of  a chisel and mallet the central portion of the bone
is cut aAvay; this cut  does not involve the obturator foramen, and
does not destroy the continuity of  the pelvic girdle.  The mid-portion
of the pubic bones, Avith the soft parts attached, is lifted upAvard, the
resulting osseous  lesion representing an exaggerated furroAv.   The
entire anterior surface  of  the bladder is thus exposed.   This  same
end may be attained by symphyseotomy.
   Other osteoplastic  operations  have  been suggested, but are of
doubtful utility.
   The incision of choice  for bladder-tumor is either the  vertical or
the transverse.  The latter gives a wider exposure, is easier of per-
formance, and is less likely to be complicated by Avound of the peri-
toneum.  It is  open to the objection that it materially weakens the
belly-wall and is liable to be followed by hernia.
   Pedunculated growths  so placed that the bases  cannot be well
excised may be removed by Watson's galvano-cautery scissors  or by
the ecraseur, in the latter case their pedicles  being destroyed by the
actual cautery.  The bases of extensive sessile growths which have
been removed by the knife or the curette may also be cauterized.
   When the tumor infiltrates  the whole thickness of that portion
of the bladder-wall Avhich  is covered by peritoneum, this investment
should  be  dissected up  and partial  resection of the bladder  prac-
tised.  When the peritoneum  also is involved, this must be included
in the resection.   The  tumor having been pulled forcibly outAvard,
a clamp is applied tightly to the inverted bladder-walls entirely be-
yond the growth, thus forming of these walls  an artificial pedicle. 
GENITO-URINARY  DISEASES AND  SYPHILIS.
The peritoneal cavity is then opened, and the surfaces of the vesical
peritoneum which are apposed by the inversion and clamping of the
bladder are secured  by a double toav of catgut sutures.  The  peri-
toneal cavity is closed, and the tumor is removed by cutting through
the Avhole  thickness  of the inverted bladder-Avails.  Vessels which
bleed freely  may be ligated;  usually  a continuous  catgut suture
so applied that the  cut surfaces are accurately apposed will  check
hemorrhage.
   When the tumor infiltrates  the base of the bladder about the
ureteral  orifices, its thorough  removal  is often impossible Avithout
division of the ureters.  This  is not, however, an  absolute contra-
indication  to  an attempt at radical cure.   In  case of Avide-spread
disease the entire bladder has been resected.  A total resection re-
ported by  Pawlik is  most noteworthy, since the result Avas entirely
satisfactory.   The ureters were freed from their  bladder attachments
and  stitched  into the vaginal  wound;  later, through a suprapubic
incision, the bladder Avas dissected free of its peritoneal and fibrous
attachments  and Avas cut aAvay from the urethra.  Catheters were
passed through the urethra into the ureters, and the vagina was closed
externally. A fistula remained, which, after several operations, became
so small that urine escaped only when the patient Avas standing.  The
artificial bladder Avas able to retain tAvelve ounces of urine.   Pawlik
made a final report of this case two years after operation.
   When the tumor is limited  to the ureteral  region and there is
reason to believe that  its thorough removal may be followed by a
permanent cure, resection  is indicated  even though the  ureter is
necessarily divided.
   Clado, after a careful  consideration of the methods of disposing
of the ureter when malignant  tumor  involves the bladder in the
region of the ureteral orifice, comes to the folloAving conclusions:
Leaving the ureter open in the Avound after extirpation of a neoplasm
is  extremely  dangerous.   Implantation into the rectum is  almost
invariably  fatal.   Implantation  into the  colon  is  more  successful,
having thus far given four successes.  Implantation into the parietal
Avound is sometimes a matter of  necessity.  Implantation into the
vesical cavity and anastomosis Avith the ureter  of the other side are
the tAVO operations Avhich give greatest promise of definite recovery.
   Albarran proposes ligature of the  ureter  and consequent destruc-
tion  of the secreting substance  of the  kidney  of that side, holding
that  the  danger of  this operation is  much less than that  of ne-
phrectomy.   He thus summarizes the general treatment of malignant
tumors of the bladder: The patient should be  placed in the Tren- 
TUMORS OF  THE  RLADDER
735
delenburg position  and the neoplasm subjected to an examination.
If the tumor is  sessile, if-no enlarged ganglia are found, and if the
patient is in good condition, resection of the bladder-Avail is indicated.
This resection is easily performed if the  tumor is placed above the
opening of the ureters, since it is then usually accessible, enough room
being secured by an incision through the attachments of the recti
muscles.  When the tumor is  placed  posteriorly in a bladder which
is naturally deep-seated, or about the  ureteral orifice, or behind the
anterior wall of  the bladder masked by the pubic  symphysis,  partial
resection of the  symphysis or symphyseotomy may be required.
   Resection of  the  tumor is  easiest  Avhen it  is  situated upon the
upper  portion of the bladder, Avhere the peritoneum can be readily
stripped back.   After this stripping,  the tumor  Avith a  portion of
the healthy bladder-Avail  is cut  aAvay Avith  scissors  and  the wound
is  sutured.   If the tumor is  placed above the ureters posteriorly, it
may be circumscribed by an incision through the mucous  membrane
and resected from Avithin outward, no  effort then being made to strip
the peritoneum  first.   If the tumor is  placed about the orifice of
the ureter, the latter should be catheterized,  should then be exposed
by cutting through the lateral Avail of the bladder, and should be freed
and implanted  into a healthy portion of the  viscus.  (See section on
Ureters.)   If this operation is  impossible, the Avound made through
the bladder-wall for  the purpose of exposing the ureter should be
closed, and the  urine escaping through the ureteral  catheter should
be examined carefully.  If this urine is clear, shoAving that the kid-
ney is not infected, the  catheter should be AvithdraAvn, and the  ureter
should  be  ligated and divided  below  the ligature.  If the urine es-
caping through the catheter is turbid,  shoAving admixture  of pus, the
ureter should be divided and fixed to the abdominal wound.   What-
ever procedure is employed for the purpose of giving more room, the
bladder should be closed completely, a permanent  catheter should be
introduced, and  the prevesical space should be packed Avith iodoform
gauze.  Total resection of the bladder  is indicated only in the case of
multiple epitheliomata which have not yet extended beyond the mus-
cular Avail.
   Clado has collected  twenty-nine  cases of  partial cystectomy, with
twenty operative recoveries and nine deaths, and five cases of total
cystectomy, Avith tAvo recoveries (both in women) and  three  deaths
(all in men).
   The tumor  having been  removed, and hemorrhage  having been
stopped by suture,  ligature, cautery, or packing, the drainage is pro-
vided for  by tubes passing through the  suprapubic  opening,  by the 
736        GENITO-URINARY DISEASES  AND SYPHILIS.

permanent  catheter, or  by  perineal  urethrotomy.  The  bladder-
wound is closed by interrupted catgut sutures, placed about a quarter
of an inch apart, beginning below and passing upAvard.  These sutures
include the Avhole thickness of  the  bladder, except  the innermost
layers of the epithelial coat, and bring into accurate apposition the cut
surfaces;  inversion or eversion must be carefully avoided. The proper
placing of these sutures is much  facilitated by the loops placed in the
margins of the bladder-wound for the purpose of retracting it.  Guyon
sutures the bladder closely about his siphon drainage-tubes.   These
are made of rubber, are one and a half feet long, and of calibre 14 F.
They are  adherent to each other for about one inch at the vesical end,
and are so curved that the extremity passes doAvnward and backward
to the most  dependent part of  the bladder.   The  external  portion
passes over the pubis downward between the thighs, and the two un-
attached  ends are  plunged into a urinal  containing antiseptic solution.
Each  of these tubes is  provided Avith  an eye near the end of  the
vesical extremity,  and each  is notched  on its end.  They are placed
vertically one above the  other, and one usually proves the better drain.
Before closing the parietal wound, the fact that these tubes are  patu-
lous is determined by injecting fluid into one of them; this should
flow out through the other, and not  through the bladder-wound beside
the tubes.  The  external wound is then closed  by a double  toav of
sutures, one buried, of catgut, including the muscles and deep fascia,
the other, of Chinese silkworm-gut, including the skin and its under-
lying  fascia.  The prevesical space is drained by gauze packing car-
ried through the lower angle of the wound, which is left open.   The
siphon tubes are secured to the skin by sutures Avhich are  loosely
knotted.
   This is the method of  treatment practised  by Guyon,  and he
states that drainage is so perfect that the dressing remains dry and
need  not be changed for several  days.   The  external dressing is
made up of sterile iodoform gauze, secured by an abdominal binder
or double spica of the groin.   The patient is placed on his  back in
bed,  the  free ends of the siphon  tube are placed  in  an antiseptic
solution in the urinal, and  every three or four hours the bladder is
gently washed out.  The dressing is changed the fourth or sixth day,
the siphon drainage-tubes are  removed, and continuous catheteriza-
tion is practised.   The  vesical opening is usually closed Avithin two
Aveeks.  Many surgeons advise an  attempt at complete suture of the
bladder.   The rules formulated in considering the after-treatment of
suprapubic cystotomy for vesical calculus are applicable when this
operation  is undertaken for tumor.  When the  bladder is healthy, 
TUMORS OF  THE ELADDER.
737
the urine non-infected, the wound required  for  extirpation of the
tumor completely closed by suture, and the operation has not been
extensive,  immediate  vesical  and  parietal suture  and  permanent
catheterization  are indicated.   When the bladder is  infected, but the
operation has  not been  extensive, immediate vesical suture,  Avith
drainage of the prevesical space and the insertion  of a permanent
catheter or of  a  large perineal tube, is indicated.  When operation
has been extensive, the suprapubic drainage  is advisable.   Neither
the T tube of Trendelenburg, the siphon drainage of Cathcart, capil-
lary drainage,  nor any other  form of drainage  accomplishes what
Guyon and Albarran claim for their siphon tubes.
   Complications and Sequels.—These are similar to those described
under suprapubic  cystotomy for the removal of stone.  Since  an
operation for the removal of tumor is prolonged and is often attended
by profuse  hemorrhage,  shock and collapse  are  particularly to  be
guarded against.   Should the patient  escape these dangers, suppres-
sion of urine, urinary fever, or infection of the kidneys may develop.
The most frequent complication is, however, urinary infiltration with
cellulitis.   Should  symptoms  point to these  conditions, the hypo-
gastric Avound should be opened and the space of Retzius thoroughly
drained.
   Cystic  Tumors of the Bladder.—The most  systematic and
detailed study of these  rare  growths is found in Clado's treatise  on
Tumors of the Bladder.   His teaching in regard to  them  may  be
outlined as folloAvs:
   Cysts  are of epithelial  origin, or arise from foetal inclusion (der-
moid cysts).
   Epithelial cysts are equally common  in men and  in Avomen, are
observed during any period  of life  except in  early infancy,  and are
most frequent  betAveen the  thirtieth  and fiftieth years.   They are
usually placed about the base of the bladder in the region of the ves-
ical neck, probably because the vesical glands  are particularly abun-
dant  in these regions.  They  may occupy  the entire vesical cavity,
and sometimes are associated Avith cysts of the kidney pelvis.  Clini-
cally, they are distinguished according to size, as small or large.
   Small cysts appear as minute or medium-sized vesicles filled Avith
clear  fluid.  This may become turbid or  even blood-stained.  They
may be due either to alteration of the normal  vesical glands  pro-
ducing cysts of retention, or to local epithelial proliferation, followed
by central softening.
  Large  epithelial cysts sIioav a tendency to become enucleated from
the vesical Avail and form pedunculated groAvths.  Vincent records a
                               47 
738        GENITO-URINARY DISEASES  AND SYPHILIS.

case in a child between three and three and a half years old in Avhom
the pedicle was  so long that  the cyst passed  through the urethra and
presented in the vulva.
   Dermoid cysts may invade the bladder primarily or may be para-
vesical, communicating  with  the bladder by an  orifice.   Over forty
cases have been reported.  These  cysts are nearly always  observed
in women, and symptoms develop between adolescence and old age.
The tumor is usually placed at  the  base of the bladder.   Sometimes
it appears in the form of a polyp ; that is, it is pedunculated.  In this
tumor hair and fragments of  bone may be seen.  These cysts always
contain hair, and the passage of this in the urine constitutes a major
symptom.   Fragments of bone and teeth are also at times passed.
   Microscopically, these  cysts show the structure of skin Avhich con-
tains sebaceous glands and  hair-follicles in a state of physiological
activity.  Even small tumors may discharge comparatively large quan-
tities of hair for a long time.
   Thirty-two cases of  paravesical dermoid cysts have been collected
by Clado;  seven originated in the ovary, seven formed paravesical
tumors;  in eighteen the only symptom recorded was micturition cf
hair.
   The dermoid cyst usually remains latent until about the twenty-
first year,  symptoms of the  tumor becoming manifest betAveen  this
and  the fortieth  year.  The tumor is usually  placed in the recto-vesi-
cal septum, beneath the peritoneum.  In  two cases it was  placed on
the apex of the bladder, between the peritoneum and the vesical Avail.
Sometimes these cysts  reach huge dimensions, extending above the
umbilicus, and weighing over fourteen pounds.   Hair, fat, sometimes
resembling soap, teeth, or fragments of bone are constantly discharged
into  the  bladder.  In one case, owing  to pressure, retention devel-
oped.  Calculi frequently  form, having for their nuclei masses of hair.
These cysts are usually complicated by cystitis of varying degrees of
intensity.
   Paravesical Tumors.—These  may be solid or cystic.
   Myoma  is the only solid tumor.   Belfield has observed one case,
the growth springing from the  muscular tunic and projecting as a
nodule.   Verhoogen found a myoma the size of a child's head attached
to the posterior  surface of the bladder by a pedicle about as thick as
three fingers.
   Residual cysts are due to proliferation  of the remains of foetal
structures.   Englisch has described cysts of the Wolffian and MuTler's
bodies, of the prostatic utricle, and of the seminal vesicles, also of the
urachus. 
TUMORS OF  THE RLADDER.
739
   Inclusion cysts—i.e., dermoids—have been already described.
   There is but one example of simple  cyst, contributed  by Segond.
The tumor was found in the muscular wall of the bladder.  It Avas
tightly adherent.   Clado suggests that it may have originated from an
intravesical glandular cyst.
   Cysts developing in  the  prostatic utricle and seminal vesicles are
comparatively rare.  Utricular cysts are median, provided with a ped-
icle attached to the base of the prostate, and develop behind the blad-
der.  Those which arise from dilatation of diverticula of the seminal
vesicle are ahvays lateral.   The median cysts are due to persistence
of debris in the duct of Miiller.
   Hydatid cysts  develop in the  pericystic tissue.   If the cyst de-
velops in either the  anterior or the  posterior wall of the space of
Retzius, its direction of growth will be limited by the fascia surround-
ing this space.   It will then grow upward towards the umbilicus, but
will not reach higher than this point.   It may develop in the cellular
tissue separating the bladder from  the rectum, or it may occupy the
true pelvis, in this case growing upward toAvards the umbilicus.
   These cysts may be single or multiple, and are  prone to contract
adhesions to the bladder and pelvic fascia.   The primitive develop-
ment of  the tumors is in the subperitoneal cellular tissue: hence the
treatment of these cysts does not necessitate cystotomy.
   A fluctuating tumor projecting into  the hypogastrium should  be
extirpated if possible;  if this is impracticable, the lining membrane
should be removed and the cavity  drained.   A cyst filling the vesico-
rectal cul-de-sac should be reached by the crescentic perineal incision
described as appropriate for the removal of the seminal vesicles.   It
can then be enucleated, extirpated, or drained. 
CHAPTER  XX.
               DISEASES AND INJURIES  OF  THE URETERS.

   Anatomy.—The ureters are slightly flattened, tough, white, fibro-
in uscular canals, which conduct the  urine from the kidneys to the
bladder,  with the investments of which their  three coats are con-
tinuous.   On  an average  they are  from ten to twelve  and one-half
inches in length.   Exceptionally they may be longer, though a greater
length than fifteen inches  has not been recorded.  They are  about
one-eighth to one-sixth of an inch (three to four millimetres) in  diam-
eter, but are not of uniform  calibre  throughout,  being slightly nar-
roAved—(1) at a point one  to one and a half inches below the kidney
pelvis; (2) at  the point of  entrance into the bladder; (3) at the point
of crossing of the iliac artery.  When strictured the ureters may be-
come enormously dilated, reaching the size of the small intestine.
   The course of the ureters is in general downward and inward.
They are separated by an interval  of  about  three  inches  at  their
upper portion and less than two inches Avhere they enter the bladder.
Their course in their abdominal portion is indicated on the surface by
a vertical line  passing upward from the junction of the  inner and
middle thirds of Poupart's ligament.  The upper extremity of the
ureter corresponds to a point where  this line crosses the twelfth rib.
The  lower extremity of the abdominal  portion of the  ureter, corre-
sponding to the crossing of the bifurcation of the common iliac artery,
is placed slightly beloAV the point where this vertical line intersects
a line joining the two anterior superior iliac spines.   (Tourneur.)
   At its point of origin from the  kidney pelvis the ureter lies on a
plane behind  that of the  renal artery.  It passes downward and in-
ward, crossing the psoas  muscle obliquely to  the bifurcation of the
common iliac artery.  In its course it is slightly convex forward and
imvard.  About the middle of its course,  or a little below this point,
the abdominal portion of the ureter is  crossed by the spermatic
artery in the  male  and by the ovarian vessels  in the female.  In
front  lie  the caecum and  the  ascending colon on the right side, the
sigmoid flexure on the left side.
   The pelvic portion of  the ureter describes a curve with its con-
cavity fonvard, inward, and upward.  It passes beneath the perito-
     740 
DISEASES AND  INJURIES OF THE URETERS.
741
neum, along the Avails  of the pelvis, and, entering  the posterior false
ligament of the bladder, crossed by the vas deferens in the male, ob-
liquely pierces the vesical coats just  beneath the posterior extremity
of the seminal vesicle.
   The vesical portion of the  ureter, about half an inch in length,
runs obliquely inward  and forward through the muscular layer of the
bladder-walls, opening into  the  cavity  of  this viscus  by  a  slit-like
orifice.
   The muscles of the ureter are continuous Avith  those of the bladder.
Testut describes a valve-like arrangement due to  absence of muscular
tissue in  the upper wall of the  terminal  extremity  of the ureter.
This portion of the wall is  made up entirely of  a fold of mucous
membrane; intravesical tension at once presses this valve-like  fold
against the lower ureteral Avail, and thus effectually blocks the tube.
   The relation of  the ureter to the  peritoneum is extremely impor-
tant from a surgical stand-point.   Cabot has shown that this canal is
adherent  to the under surface of  the peritoneum,  being held to this
membrane by  a series of  fibrous  bands.   If  the peritoneum  be
stripped up, the ureter conies with it. He says, " The relation of the
ureter to that part of the peritoneum which becomes adherent to the
spine is, Avithin a slight range of variation, pretty constant, the ureter
lying just outside the  line of adhesion; so that, if the surgeon has
stripped up the peritoneum and  come  down to the point where it
refuses to strip readily from the spinal column, he will find the ureter
upon  the stripped-up peritoneum at a short distance outside  this
point.  On the left side the distance  from the adherent point to the
ureter is from half an inch to an  inch, while  on the right side it is
somewhat greater, owing to the ureter being  displaced to the outside
by the interposition of the vena cava between it and the spine."
   In the female the pelvic  portions  of the ureters pass first down-
ward, then  forward and inward,  in  the loose cellular tissue of the
pelvis. In the base of the broad ligament they lie beneath the uterine
arteries, which are closely  connected to them for a short distance,
then pass upward to  the uterus;  the ureters are  continued fonvard
over the anterior vaginal vault into the bladder.
   The mucous  membrane  of the ureter is  continuous with that of
the kidney pelvis and  of the bladder, and is of the type  common  to
the urinary tract.   Glands  are either  rudimental or  absent.  The
mucous  surface  is  made  up of layers of  stratified  squamous  or
transitional  epithelium.  Beneath these are  layers of  cylindrical  or
conical cells.  The deepest  layer is made up of small rounded cells.
   The blood-supply  is derived  from  branches of the  renal, sper- 
742        GENITO-URINARY DISEASES  AND SYPHILIS.

matic or ovarian, and  hypogastric arteries.  These  vessels are  ex-
tremely small.  The nerves are derived from the renal, spermatic
and hypogastric plexuses.
   From its strong muscular coat, it is evident that the  ureter is not
merely a channel through which fluid may flow by gravity and back
pressure, but takes an active  part  in conveying the  secretion of  the
kidney into the bladder.  It  is well established  that the unstriped
muscular fibres of the ureter are in a state of intermittent peristalsis.
This action goes on alternately within the two ureters, though occa-
sionally it  may be  synchronous.  The  contractions  are repeated at
irregular intervals, and  the quantity of urine discharged at each
contraction varies greatly, probably averaging from fifteen to  thirty
drops.
   Anomalies.—The ureter may be absent.  In this case the kidney
also  will be absent.  Bruner has collected forty-eight cases of this
anomaly.   It may be obliterated through a part or the  whole of its
course.
   The ureter may be multiple ;  the  supernumerary ureters often
coalesce in some  part  of their  course, but they  may remain  sepa-
rate  throughout.   Double ureter is usually associated with a kidney
which has two pelves.
   The ureter may pursue an errant  course.  This anomaly appears
to be confined to females.   Cases are recorded in Avhich the ureters
opened  into the  external urinary  meatus,  the vagina, and a pouch
near'the bladder.
   Rayer reports a case in which there was congenital absence of
the ureters, bladder, and kidneys ; a flow of  fluid having  a urinous
odor came  from the umbilicus.
   Valve-formation is an anomaly of serious import,  since  it leads to
hydronephrosis.  In place of leaving the renal pelvis by a funnel-
shaped orifice at  its lowest portion, the ureter may emerge from  the
side  of this sac,  often  at an  acute angle;  or it may run for some
distance in the Avail of the kidney pelvis.
   The operation for the relief of obstruction due  to valve-forma-
tion  was proposed and  successfully performed  by Fenger.  The
kidney pelvis is exposed by  the lumbar extraperitoneal incision. The
hydronephrotic sac is opened by a longitudinal incision, and search is
made for the ureteral orifice.  Should this  not be found, the ureter
should be  incised  beloAV the sac,  and  a probe  should be passed
through this opening into the pelvis of the kidney.   The valve, or the
inner ureteral wall, should  the obstruction  be caused by the ureter
running upward in the pelvic wall, is divided from above doAvnward 
DISEASES AND  INJURIES OF THE URETERS.
743
to the most dependent part of the sac.  The resulting longitudinal
wound may be closed by draAving its corners together, thus convert-
ing it into a transverse  wound (Fenger), by applying numerous fine
catgut sutures along the Avhole course of the incision (Mynter), or by
turning the flaps out and sewing them to the inner wall of the sac.
(Ktister and Trendelenburg.)
   Wounds and Rupture of the Ureters.—From the position of
the ureters it is obvious that wounds of these  canals, except those
inflicted during the course of surgical operations, are usually attended
by injuries of other organs  so extensive and immediately threatening
to life that the traumatism  inflicted upon the ureters is of minor im-
portance.   The ureter  may be Avounded by direct violence, as by a
stab  or a bullet, or may be ruptured by indirect violence, as by a crush
or a bloAV.  In  the course  of abdominal section for the removal of
malignant groAvth, division of the ureter is comparatively common.
   As a result of rupture of the ureter there is extravasation of urine.
Since this is sterile it does not necessarily excite  cellulitis, and in case
the ureter is  not  completely torn across the opening may cicatrize
and  the extravasated urine may be absorbed or become encapsu-
lated, in the latter case producing the condition known as pseudo-
hydronephrosis.  If there is concomitant infection cellulitis will result,
which, unless promptly recognized and treated surgically, is liable to
become rapidly  diffuse and  terminate fatally.   Following cicatrization
of Avounds strictures are formed causing hydronephrosis, and, finally,
total destruction of the kidney.
   The symptoms of Avound  and  rupture  of the ureter have not
been formulated.  When there is an external Avound passing doAvn to
the region of  the  ureter, and  urine  escapes from  this wound, the
diagnosis  is obvious.   When after a bloAV in the lumbar region there
is passage of bloody urine Avith the formation  of a post-peritoneal
tumor Avhich fluctuates and  rapidly  and  progressively  increases,
rupture of the  ureter may be suspected, and the diagnosis may be
confirmed by  aspiration.  When, some weeks  or months after injury
to the ureteral  region,  symptoms  of hydronephrosis develop, these
symptoms  will  suggest partial  laceration of the  ureter followed by
cicatricial contraction.
   Wounds of the ureter inflicted during the course of intra-abdom-
inal  operations  are usually recognized,  because the white, fibrous,
thick-walled canal is easily identified, and because there will probably
be escape of urine  into the  wound.
   Treatment.—When symptoms  point  to rupture  of the  ureter
Avithout external Avound, there  should be no hesitation in cutting 
744        GENITO-URINARY DISEASES  AND SYPHILIS.

down directly to the seat of rupture, going in behind the peritoneum,
if this  is practicable,  draining the  tissues of the extravasated urine,
and  restoring the  continuity of the  canal,  either  by suture, if  the
rupture is partial, or by anastomosis, in accordance with Van Hook's
method, when it is complete.  When there is an external Avound
through which the urine  escapes, this wound  should  be folloAved
down to the ureter, and the opening in this tube should be closed.
   If the Avound  communicates with  the peritoneal  cavity, the in-
cision  of choice Avould  be  an abdominal one; after  closure of the
ureteral opening a  fold of peritoneum  should be brought  over it on
both sides and carefully sutured.
   Extraperitoneal  wounds, if  longitudinal, do  not require suture,
since they  heal without subsequently  encroaching upon the lumen
of the canal.  If transverse and involving half of the lumen of the
ureter, even  though  they be sutured  and  unite by  first intention,
there  is  likely to  be cicatricial  contraction which will  ultimately
cause  stricture.   Schopf's  case, in which a transverse suture Avas
performed, the patient perishing about two months later of tubercu-
losis, presented an extensive cicatrix  at the  seat of union.  Tuffier's
experiments  on  dogs  clearly demonstrate   the  tendency  toAvards
stricture formation.
   Transverse wounds should,  therefore, be treated by Van Hook's
lateral implantation or by the plastic method of changing  the trans-
verse cut into one which is longitudinal.  This is  thus performed:
From  the middle of the transverse cut incisions are carried upward
and  downward through the ureteral walls for a sufficient distance;
the four corners formed by  these cross-cuts are trimmed off, and the
resulting wound is united transversely by folding the ureter on itself.
(Fenger.)
   Van Hook's method of ureteral implantation is  thus performed:
The lower end of the  ureter is ligated  from one-eighth to  one-fourth
of an inch  from its free end.  With a sharp-pointed scissors a longi-
tudinal cut is made in the lower end of the ureter, twice as long as its
diameter, one-fourth of an inch below the ligature.  The  upper end
of the ureter is split by passing a point of the  scissors one-fourth of an
inch within its lumen and cutting  through the wall.  Two  very small
needles, placed on each end of a sterilized  catgut suture, are  then
passed through the wall of  the  upper ureteral  end one-eighth of an
inch from  its  extremity; the needle-punctures are made  from one-
sixteenth to one-eighth of an inch apart, and are equally distant from
the end  of the  ureter.  (Fig. 206.)  The needles are then carried
through the slit in the side of the lower end of the ureter and along 
          DISEASES AND INJURIES OF  THE URETERS.       745

the lumen of the canal for half an inch ;  at this point they are pushed
through  the  ureteral wall side by side.   (Fig. 207.)  Traction upon
the catgut suture Avill pull the upper ureteral extremity into  the slit
made in the lower extremity.  When this has been done the ends of
the loop  are  securely  tied.   (Fig. 208.)  If this operation  has been
done through the peritoneal cavity it should be completed by covering

                             Fig. 206.
Insertion of suture for ureteral anastomosis.  (Van Hook.)
the  seat of suture by a double layer of peritoneum.  The implanta-
tion may be strengthened  by one  or two  sutures  securing the wall
of the proximal ureteral end to the margins of the longitudinal incision
made in the distal end.
                             Fig. 207.
Insertion of suture for ureteral anastomosis.  (Van Hook.)
   Kelly has successfully performed  this operation, and Emmet has
reported a case in which he was compelled to modify the technique
of suture because of  the relatively large size of the upper ureteral
segment.
                              Fig. 208.


                 Ureteral anastomosis completed.  (Van Hook.)

   When the  ureter  is torn across,  and so  much of it is destroyed
that lateral implantation is not possible, it should be implanted into
the  bladder, if this is practicable, by either the extraperitoneal  or
the intraperitoneal route;  the latter is usually the only method  of
performing the operation. 
746
GENITO-URINARY  DISEASES AND  SYPHILIS.
   This vesical implantation was successfully performed by Penrose.
In the course of an operation for malignant disease he found it neces-
sary to excise that portion of the ureter which passes through the
broad  ligament.  After cutting the uterus aAvay, the distal end of the
ureter was ligated Avith silk, the vagina Avas closed, and the peritoneum
Avas  sutured over the seat of operation.  The proximal  end of the
ureter Avas then sutured into the bladder.  An incision somewhat less
than half an inch long Avas  made antero-posteriorly into the  body
of the bladder.  A needle armed with fine  silk Avas passed through
the bladder-wall from without in at  a point about a third  of an inch
from the incision on the right and brought  out through the incision.
It Avas then carried  through  the right Avail  of the ureter close to its
extremity, back through the incision in  the bladder, and through the
bladder-wall from Avithin out, close to its point of entrance.  A similar
suture was passed on the  left side of the incision in the bladder, and
through the left Avail of the divided ureter.   Traction on these sutures
dragged the ureter into the bladder, and Avhen tied they held it in this
position.  The loose peritoneum which  formed a partial investment
to the ureter was draAvn down and sutured  to the peritoneum of the
bladder by a continuous silk suture around the line of junction of the
ureter and the bladder.  The patient  recovered Avithout complications
of any kind.
   If the ureteral defect is so far removed from the bladder that
vesical implantation is not possible, the  tAvo ends may be  brought to
the surface, as proposed by Rydygier, and an effort made to connect
them by forming a channel of skin.   Or the  ureter may be implanted
upon the skin surface or into  the colon.   Implantation into the colon
is difficult, and in the light of present  evidence is practically ahvays
followed by kidney infection.
   Van Hook thus  summarizes  his  admirable research on ureteral
surgery: "1. The extrapelvic portion of the ureter is most readily
and  safely accessible for  exploration and surgical treatment by the
retroperitoneal route.  2. Hence  all operations upon the  ureters
above  the  crossing of the iliac arteries should be performed retro-
peritoneally,  except  in  those cases  in  which the necessity  for the
ureteral operation arises during laparotomy.  3. The intrapelvic por-
tion may be reached by incision through the ventral Avail, the bladder,
the rectum, the vagina in the  female,  the perineum in the male, or by
Kraske's sacral method.   4.  The ureter  is not only exceptionally Avell
protected from injury, but by its elasticity and toughness  resists vio-
lence to a remarkable degree.  5.  The  histology of the ureters fur-
nishes most favorable conditions for the healing of wounds.   6. Longi- 
DISEASES AND INJURIES OF THE URETERS.
747
tudinal wounds of the ureter at any point heal Avithout difficulty in
the absence of septic processes, under the influence of ample drainage.
7.  In all injuries where  the  urine is septic before the operation, or
where the wound is infected during the operation, drainage must be
effected.  8. The chemical  composition and reaction of  the urine
must be studied in all  injuries to the ureter, the urine being rendered
acid, if possible, and the specific gravity kept Ioav.  9. The pelvis of
the ureter is, caeteris paribus, the most favorable  site for wounds of
the ureter, since  scar contraction  is not so likely there to be produc-
tive of ill results.  10. In aseptic longitudinal wounds of  the ureter
occurring in the course of laparotomy, suture may be practised  and
the peritoneum protected by suture.  11. Transverse  wounds of the
ureter involving less than  one-third of the circumference of the duct
should be  treated by free  drainage  (extraperitoneal), and  not  by
suture.  12. In transverse injuries in the continuity of the ureter in-
volving more than one-third of the circumference of the duct, stricture
by subsequent scar contraction should be anticipated by  converting
the transverse into a longitudinal  Avound  and introducing longitudinal
sutures.  13. In complete transverse  Avounds of the ureter at the
pelvis, sutures may be used if the line  of union be made as great as
possible.  14. In complete transverse  injuries of the  ureter in con-
tinuity, union must not be attempted by suture.  15. In complete
transverse injuries of  the  ureter  in continuity, union  without subse-
quent scar  contraction  may be obtained by the writer's  method of
lateral implantation,  as described.  16.  In complete  transverse in-
juries of the ureter very near the bladder, the duct may be  implanted,
but with less advantage, into  the  bladder directly.  17. At the pelvis
of the ureter, continuity after complete transverse injury may be re-
stored by Kuester's method of suture, providing the severed ends can
be approximated  by  slightly loosening  the ureter from  its  attach-
ments.  18. Rydygier's method of ureteroplasty in such injuries may
be tried if other methods cannot be utilized.   The primary operation
should at least fix the  ends of the tube together as nearly as possible.
19. In both transperitoneal and  retroperitoneal operations the ureteral
ends can be approximated by Van Hook's method even after the loss
of about an inch of its substance.   20. The use of tubes of glass and
other materials for the production of channels to do duty in place of
destroyed ureteral substance  must be rarely satisfactory, and, even if
temporarily successful, the duct is almost sure to be  choked by scar
contraction.  21. The implantation of the cut ends of a ureter into an
isolated knuckle of boAvel is  objectionable,—(1) because the bowel is
septic; (2) because the operation is too dangerous.   22. In  injuries of 
 748       GENITO-URINARY DISEASES AND SYPHILIS.

 the portion of the ureter within the pelvis, Avith loss of substance the
 ureter should be treated as follows: if possible, the continuity of the
 ureter should be restored by the writer's method.   23. If this is not
 possible, the ureter, if injured in vaginal operations, should be sutured
 to the base of the bladder Avith a covering of mucous membrane as
 far forward  as possible, Avith a vieAv to a future  implantation or for-
 mation of vesico-vaginal fistula with  colpocleisis.  24. In injuries to
 the pelvic ureter during laparotomy, Avhere the continuity cannot  be
 restored, and where temporary vaginal implantation cannot be effected
 in the female, or vesical implantation in the male, the proximal ex-
 tremity of the duct  should be  fastened to the  skin  at  the nearest
 point to the  bladder.  25. In ventral ureteral fistulae opening near
 the bladder the ureteral extremity  may in some instances be im-
 planted directly  into  the  bladder Avithout  opening the peritoneum.
 26. In such  cases Avhere the ureter will  not reach the bladder a flap
 may be raised from  the  anterior vesical wall  and reflected upward
 extraperitoneally, to  meet  the ureter and form a  tubular diverticu-
 lum.   27.  Such a flap may be so elongated by a preliminary opera-
 tion to transplant the peritoneum back of the fundus, or by accurately
 suturing it there at a single sitting, that median ventral fistulae of the
 ureter may be cured if they open at any point an inch  or more below
 the umbilicus.  28. Symphyseotomy is a valuable and  justifiable pre-
 liminary step in these plastic vesical operations.  29.  It is legitimate
 when both ends of a cut ureter open  upon the abdominal wall to try
 Rydygier's method.   30.  Implantation of one or both ureters into the
 rectum is  absolutely unjustifiable under all circumstances, because
 (1) the primary risk is too great; (2) there is great liability to stenosis
 of the duct at the point of implantation ;  (3) suppurative utero-pyelo-
 nephritis is almost absolutely certain  to  occur, either immediately  or
 after  the  lapse of months  or  years.   31.  Ligation of the  ureter  to
 cause atrophy of the kidney is unjustifiable.  32. Extirpation of a
 normal kidney for injury or disease of the ureter is absolutely unjus-
 tifiable, except Avhere  the  ureter  cannot be restored in one or other
 of the ways cited."
   Ureteritis.—Inflammation of the ureters is due to infection.   This
 extends from the bladder, as  in gonorrhoea,  from the kidney, as in
 pyosalpinx of haematogenous  origin  or  tuberculosis,  or from peri-
 ureteric tissues, as in  peritonitis or  cellulitis.  Congestion strongly
predisposes to infection,  and is  caused  by traumatism, pressure  of
tumors, distention of the ureters, lodgement or passage of calculus or
clot, or the passage of irritating urine.
   The lesions  produced  by ureteritis are  similar to those observed 
DISEASES AND INJURIES OF THE URETERS.
749
in cystitis.  In the  absence of distinct glands in this part of the uri-
nary tract, complications akin to folliculitis and periurethral abscess
observed  in urethritis are not likely to occur.
   As a result of hyperaemia and inflammatory swelling it is apparent
that the lumen of the ureters may be seriously encroached  upon.   If
the inflammation extends  beyond  the mucous membrane, involving
the muscular coat, there may be resulting atrophy, with loss of peri-
staltic poAver.   From long-standing inflammation and  the  deposition
of inflammatory material strictures may form.
   Jaksch reports a  case of membranous ureteritis in which trans-
lucent casts of the ureter Avere discharged from the urine.
   Symptoms of ureteritis are not definite.  It is nearly always asso-
ciated Avith cystitis  or pyelitis, the symptoms of Avhich  completely
mask  the inflammation of the  ureter.  Tenderness on palpation is
perhaps the only symptom Avhich would even suggest inflammation.
   Kelly  states that a normal ureter can be traced and immediately
examined in the upper part of the pelvic  course by introducing  a
ureteral catheter through the urethra and bladder into the ureter and
carrying it up to  or over the brim of the pelvis.  When an inflexible
catheter is thus carried over the brim the ureter is displaced upward
and straightened out.  It  can  now be palpated  almost  as plainly
through the rectum on the  catheter, and any alterations in its calibre
noted almost  as minutely, as when laid  bare  by  dissection.   The
pelvic brim can  also be felt per rectum.   This of course  applies to
women only.
   The palpation of  the ureter through the  abdominal wall for  the
purpose of detecting  tenderness is sometimes practicable, pressure
being  made at the intersection of  the  line joining the  superior iliac
spines Avith one vertical to this running  upward from the junction of
the inner and middle thirds of Poupart's  ligament.   Clinical  ex-
perience  has shown, however, that even extreme tenderness elicited
by deep pressure over this spot is not pathognomonic of ureteritis.
   Treatment.—The treatment  of ureteritis is that of  the  main dis-
ease Avhich masks it.  Casper has treated two cases of chronic ure-
teritis  in  men  by catheterization of this canal, followed by irrigation
of silver  nitrate.   Kelly has treated a  number of  cases in Avomen
by irrigation and  drainage, but rather for the relief of pyelonephrosis
than of ureteritis.
   Israel, having performed nephrotomy for the relief of  symptoms
without benefit, exposed the whole ureter.  This canal, though per-
vious, Avas chronically thickened and two or three times its normal
size, and in places Avas  almost cartilaginous.   Nephrectomy was per- 
 750       GENITO-URINARY DISEASES AND SYPHILIS.

 formed,  and a  cure resulted.  Reynier, after removing  a  purulent
 cystic kidney by nephrectomy, noted that a purulent discharge from
 the ureter persisted, associated with pyrexia.   He removed the whole
 of the ureter, thus effecting a cure.
    Stricture of the Ureter.—This may be congenital or acquired.
 The acquired stricture may be inflammatory or traumatic.   Congeni-
 tal stricture has been regarded as the commonest form of  narrowing.
 Tuffier reports  twenty-nine cases.   In fifteen the narrowing was in
 the upper part of the  ureter;  in  the remainder it Avas in the lower
 part.
    Inflammatory stricture is  apparently more  common than patho-
 logical records Avould  lead us to believe.   Watson has reported two
 cases.   Kelly has  been able  to  diagnose and successfully treat  a
 number.   It is  possible that  a  certain number of  these strictures
 were originally congenital, the narroAving not having been sufficient
 to produce symptoms till the advent  of inflammation.
    Traumatic strictures are necessarily rare, since there are compara-
 tively few  cases  of  ureteral wound.
    The  symptoms of  ureteral stricture are those of back pressure.
 Should the stricture produce complete obliteration of the  ureter, the
 kidney will atrophy.  Partial  occlusion causes hydronephrosis  and
 great dilatation of the  ureter above the seat of narrowing.
    The diagnosis of ureteral stricture is founded upon  the  develop-
 ment of  hydronephrosis, palpation in women, and direct exploration
 of the ureter by means  of catheters or bougies.  This is  now made
 possible  in men by the use  of Casper's catheterizing cystoscope.
 (See Fig. 200.)  Even under favorable conditions, however, the intro-
 duction of the ureteral catheter requires special training; in diseased
 conditions of the vesical trigonum it may be  impossible to  find the
 ureteral orifices.
    Speaking of women, Kelly states  that "A large percentage of
 cases under treatment to-day for cystitis and for irritable bladder are
 in reality  tender, thickened  ureters, and  intelligent palpation  Avill
 detect the tube, now hard and cord-like, bringing out the character-
 istic complaint of intense desire to urinate.   An enlarged  ureter can
 easily be further palpated per rectum behind  the broad ligament and
 folloAved from there up over the posterior pelvic wall."
   In one case  which he catheterized  clear urine flowed from the
 right  kidney,  but  during an  interval of ten  minutes there was no
 escape of fluid from the left.  He then persisted  in the  attempt to
get the catheter  up over the brim  of the pelvis.  Finally it passed an
 obstruction, and this  was at once  followed  by  the discharge of 
DISEASES AND INJURIES OF THE URETERS.
751
 several ounces of turbid urine.   He  subsequently dilated the stric-
 ture, by bougies.   In another case he demonstrated a stricture pos-
 terior to  the  right broad ligament, and above  this a hydro-ureter.
 He opened the ureter from the vagina, dilated the stricture at several
 sittings, and then closed the fistula.  In  the  third case he  found a
 stricture below the pelvic  brim.   He has devised a metal  ureteral
 sound  and  a  series of bougies bulbous behind  the tip.   He states
 that  simple strictures are  rarely  found ;  they are usually multiple,
 and are often  associated Avith calculus, pyelonephrosis, or tuberculous
 infiltration.
   Kelly thus describes the technique of ureteral catheterization and
 sounding in women:  " Instruments and accessories—two  Kelly's
 ureteral catheters ;  one  small-calibre female  catheter; one  syringe,
 with a graduated barrel of four or five  ounces (one hundred  and
 twenty to one hundred and fifty  cubic centimetres) capacity; eight
 ounces of a decided  blue aniline  solution;  one Sims' or  Simon's
 speculum ; two minim or cubic centimetre graduates of about sixty-
 minim capacity.
   " Many patients can be catheterized without anaesthesia. The but-
 tocks should be brought to the  edge of  the table and the legs flexed
 upon the  abdomen.  The  operator then catheterizes  the bladder.
 This urine is  set aside in  a conical glass vessel for comparison Avith
 that to be obtained from the kidneys.   The value of this will be seen
 when I say that I have frequently been able, upon draAving purulent
 or bloody urine from the bladder,  to produce  the same shade of red
 or yelloAv as that of the vesical urine by mixing  pure urine obtained
 by the ureteral catheter from one kidney with the bloody or purulent
 urine drawn from  the other.  By careful palpation the ureters  are
 located anteriorly through the vaginal wall, noting especially whether
 they  are Avell  fonvard under the bladder, or, as  often found, abnor-
 mally far back in the pelvis.
   " The  bladder is then distended Avith  from five  to seven ounces
 (one  hundred  and fifty to two hundred and ten cubic centimetres) of
 the aniline solution.   The posterior vaginal wall is retracted Avith a
 speculum, exposing the  anterior wall  up to  the cervix,  while  the
 bladder is being injected.
   " The object of this  distention of the bladder is twofold: in  the
 first place, it does away  with all the rugosities of a contracted blad-
 der, which hinder catheterization, if they do not render it impossible.
 The only rugosities left are the  prominences on  either side, through
which the mouths of the  ureters open into the bladder by a little slit
running obliquely backward in a line Avith the course of the ureters. 
752        GENITO-URINARY DISEASES AND SYPHILIS.

   " The second  reason is well exhibited pictorially by Professor
Pawlik, who was the first to demonstrate that the curved folds Avhich
cross the anterior vaginal wall  out to the lateral  Avails  and around
towards the  cervix  are valuable landmarks in finding  the ureters
which lie parallel to and just above  them.  These are appropriately
called for this reason  the  ' ureteral folds.'  They are brought out
distinctly by moderate distention of the bladder.
   "An assistant should determine that the catheter  is  clear  by
placing the end in water and  blowing  through it without touching it
with  his  lips.   The metal plug, attached by  a short chain  to the
catheter, is coated with  a  little vaseline and inserted in the outer
end, thus keeping the aniline solution from filling the lumen of the
catheter when it enters the  bladder.
   " It is noAV evident that if  clear or straw-colored fluid escapes
through the catheter it must be  urine, as the deep aniline  color of the
fluid in the bladder  renders deception from that  source impossible.
When the catheter  is  introduced  as far as the bladder, touch and
sight  assist in  its further introduction into the ureter.
   " By turning its point forward and elevating the handle, a slight
prominence is produced  on the anterior vaginal wall.   Throughout
the manipulations of the catheter this is the  constant guide  to the
vesical orifice  of the ureter.  The first step after the introduction of
the catheter into the bladder is  to try to locate the ureteral eminence
by the sense of touch communicated from the  tip of the catheter.
   " To this end the movements of the point on the anterior vaginal
wall are closely watched as it plays over the base of the bladder.   It
is made to gently glide in a fore-and-aft direction from the neck of the
bladder to the cervix, in the median  line, a little to one  side, a little
farther out, and so on until it reaches the ureteral  eminence, when it
is distinctly felt to trip, jogging  the thumb and finger in which the
catheter is held.
   " The same  movement is  repeated until  this point is exactly
located.   The attempt  is now  made to introduce the catheter into
the ureter by  carrying the handle to the opposite side, thus directing
the point towards the  posterior lateral wall of  the pelvis, when the
catheter is withdrawn  slightly,  and Avith  its  point still  down,  but
turned a little more  towards the side,  is swept downward, outward,
and  backward in  the direction of  the ureteral prominence.  With
each of these  sweeping motions the catheter is rotated until the point
is directed fully outAvard or slightly upward.
   "This  movement,  employed in  engaging the  catheter in the
ureter, may very appropriately be called fishing for the ureter. 
         DISEASES  AND INJURIES  OF THE URETERS.       753

   " As soon as the catheter enters the ureter its course is fixed, and
the tactile sense at once  recognizes that it no longer lies free in the
bladder as before.  If the catheter is  released  for a  moment the
handle does not drop, but remains in a fixed position, and forms an
angle of about  thirty  degrees Avith a line projected from the urethra.
The catheter should  be  introduced into the  ureter  until its  point
reaches the Avail of the pelvis, when the plug is  removed from the
end.  A catheter may noAv be introduced into the opposite ureter, and
both thus catheterized at the same sitting.
   " On  account of the partial occlusion of the urethra by the first
catheter, the second is slightly more difficult to introduce.
   " If it is desirable  to carry the catheter higher, even over the brim
of the pelvis  and  up  to the pelvis  of the kidney, the bladder can be
emptied by introducing a  small glass catheter under the two ureteral
catheters.  The contracted  bladder now  forms  a movable  organ,
which can be displaced  upAvard Avithout harm in manipulating the
ureteral catheters.
   " With an index finger introduced into the rectum the catheter is
lifted up and  guided while it is pushed on up over the pelvic brim
and up to the pelvis of the kidney.
   " As soon as the plug  of each catheter is withdrawn an  assistant
notes the time, so  as  to be able to tell afterAvards just hoAV long the
urine has been floAving from each kidney.   The minim graduates are
held below the catheters  to  catch  the  urine.  An average of  fifteen
hundred cubic centimetres, or about three  pints, is the  normal daily
excretion of urine.  If from both  catheters one  cubic  centimetre a
minute, or a half a cubic  centimetre from one catheter, is passed, the
number of minutes in a day multiplied by this amount gives fourteen
hundred and forty cubic  centimetres, Avhich is practically the normal
excretion.  I have frequently found just this  proportion upon esti-
mating the day's urine by the amount collected in a few minutes by
the catheters.
   u Oftener the amount  falls much below  normal.  In  disease there
is frequently a  marked difference  in the amount of urine collected
from the two sides.  One side may flow freely and  the other discharge
no urine, although this may be due to stricture, which  I have demon-
strated by pushing the catheter up beyond  the stricture  and over the
brim of the pelvis, when  immediately several ounces  escaped.   One
side may be alkaline and the other acid ;  one may be bloody or pure
blood and the other clear urine ; one may be pus and the other urine.
I have demonstrated all these variations a number of times.
  " The urine evidently flows from the kidney in little wavelets, as
                               48 
754        GENITO-URINARY  DISEASES AND  SYPHILIS.

it does not appear at the end of the catheter for from one to eight
minutes, and  then it only escapes  by drops  at intervals of a few
seconds to a minute or more.
   " Fifteen minutes is an average time for the duration of the cath-
eterization.  The urine of each side is then marked  and set aside for
examination.  The catheters  are plugged and withdraAvn,  and the
urine in each of them is added to that in the graduate from the same
side."
   When the  stricture is  not pervious from the bladder, or Avhen it is
impossible to  pass an instrument into the vesical end of the ureter,
the narroAving may be attacked from above.  These cases are ahvays
complicated by hydronephrosis: hence it is easy to enter the pelvis of
the kidney through its posterior wall.   If the ureteral orifice of the
pelvis cannot be found, the ureter can be exposed slightly beloAV this
point,  opened by a  longitudinal  incision, and explored above and
beloAV by bougies ranging in size from No. 4 to No. 12 French.
   If the instrument can be  passed  through  the stricture, it may be
treated by (1)  continuous dilatation, the bougie being left in place for
one  or two days and  then changed  to a larger instrument until full
dilatation  is reached ; (2) longitudinal  incision and  transverse union
of the resulting wound;  or (3) excision and  the restoration  of the
continuity of the ureter by uretero-ureterostomy.   If none  of these
procedures  is  practicable, the  ureter may be divided above  the seat
of obstruction, and implanted  either into the boAvel or on the skin
surface.
   Kuster, finding obliteration  of the ureter three centimetres below
the pelvis of the kidney,  resected three centimetres  of the ureter, in-
cluding the strictured portion, and fastened the distal end to the low-er
part of the renal pelvis.   The  patient was cured.  Weller van  Hook
in a  similar case performed a ureterotomy below the stricture, which
he could feel  by passing  a sound  into  the ureter and a finger in the
kidney.  As the ureter was found strictured loAver down, it became
necessary to perform  nephrectomy.   This case illustrates  the value
of catheterizing the ureter.  Cramer has operated successfully on two
cases,—one a hydronephrosis and the other a pyonephrosis,—opening
into  the ureter at the most dependent portion  of the distended part
of the pelvis.  The operation of Kuster is applicable only to strictures
near the  kidney.   It  would not  be suitable if the  ureter was per-
meable.   In the latter case the operation of Fenger, making a  longi-
tudinal incision  in the stricture and suturing in a transverse direction
immediately, as  in the Heinecke-Mikulicz operation for stenosis of the
pylorus, is to be preferred. 
DISEASES AND  INJURIES OF THE URETERS.
755
   If the  stricture  is found at a point distant from the place of in-
cision, as when the  exploration has been carried on through a wound
of the kidney, Albarran advises that there should be a patient effort
to pass through the stricture a "bougie armee," and then the ureth-
rotome devised by  him should be slipped over  this as a guide, and
internal ureterotomy follow.
   After having found one  stricture, the ureter should always  be
sounded, to determine the presence or absence of others.
   Calculus of the Ureter.—The  great majority of kidney-stones
either remain lodged in or near the pelvis or, having once entered the
ureter, pass into the  bladder.  This  passage is often attended by no
symptoms.  When the stone is of such size and shape that it is arrested
in its passage,  thus  blocking the ureter,  a nephritic colic develops.
   Symptoms.—The prodromal symptoms of calculus  in the ureter
may be those of renal calculus or the  passage  of gravel and small
concrements with the urine.  Often the attack comes on without pro-
dromal symptoms.  The patient is seized suddenly with an agonizing
pain radiating over  the lumbar and hypochondriac regions, along the
course of the  ureter, to  the end  of the penis, to the testicle of the
affected side,  and  to  the  inner  surface of  the  thigh.   The pain  is
usually continuous,  with  exacerbations.   It may be felt in the belly,
chest, shoulders, small of the back, or  sacrum.   The suffering is so
severe that the patient becomes blanched, bathed in cold sweat, and
sometimes collapsed.  There is often reflex vomiting.   The testicle
of  the affected  side is usually drawn close  up  to  the  external ring,
and the abdomen may become tender and tympanitic; if there has
been no infection of  the kidney pelvis, fever rarely develops.  There
is usually  a  constant distressing desire to urinate, Avith  loss of power
to empty the bladder. There  may be  anuria due to reflex disturb-
ance  of the healthy kidney, perhaps  more frequently attributable to
the fact that the patient is possessed  of but one secreting kidney, the
duct of Avhich is blocked.
   The pain and reflex disturbances  are due to retention of urine in
the kidney pelvis and the upper segment of the ureter.  For a time this
retention may be absolute, since the irritation and congestion incident
to the arrest of the  stone occasion SAvelling and spasm which are suf-
ficient, together with  the foreign body, to close  entirely the ureteral
lumen.  These  symptoms may last  a  few minutes, a few hours, or
one or two days, and their subsidence may be as sudden as their
onset.  This sudden complete subsidence indicates either retrogression
of the stone into the  kidney pelvis or its extrusion into the  bladder-
cavity.  The symptoms may subside gradually, recurring at intervals, 
756
GENITO-URINARY  DISEASES AND  SYPHILIS.
and may be followed by the gradual development of hydronephrosis.
This indicates that the stone has  been lodged in the ureter, and that
the first absolute obstruction has yielded, partly to dilatation of the
foreign body, partly to relaxation of the spasm, and has  alloAved a
portion  of the  urine  to  pass through.  Under these circumstances
kidney colic is liable to recur, but Avith less severity.
    During an attack  of  stone the  urine may be absolutely normal.
This points to the existence of one healthy kidney.  If blood is found,
it may be taken as an  evidence  that the  obstruction is not complete,
provided there  is no  reason  to  believe  that the hemorrhage comes
from the kidney or the ureter of the  unaffected side.  Immediately
on the subsidence of the attack a small quantity of blood is constantly
found  in the urine.
    Diagnosis.—The diagnosis rof impacted ureteral  stone is based on
a history of the symptoms of kidney calculus and of one or more
attacks of acute kidney colic, folloAved by the  development of hydro-
nephrosis or pyonephrosis.  Palpation either through the  rectum or
through the abdominal walls, and ureteral catheterization Avhen pos-
sible, may enable the  surgeon to form a positive opinion as to the
presence of ureteral   calculus;  but it  must be confessed that often
all diagnostic  means fail.   Thus, a  clear history may be Avanting, the
patient perhaps  having severe  abdominal  pain,  Avhich is  attributed
possibly to gall-stones  or  to some other intra-abdominal trouble.  If
the stone completely blocks the ureter, in place of hydronephrosis the
kidney may atrophy exactly as it would  do if a ligature Avere applied
about the ureter.
   Palpation will fail  certainly in a  large majority of  cases.   It may,
hoAvever, show a point of tenderness, which  if constant  is a sign of
some value in locating the stone.   If the calculus be lodged near the
vesical orifice  of the ureter it may readily be felt in  Avomen.   In men
this  is  more difficult, since the examining finger per rectum can rarely
be extended as far as the  posterior  extremity of the seminal \resicles.
Ureteral catheterization may sometimes succeed in locating the seat of
obstruction, and  may possibly indicate  the presence of stone.   Kelly
thus diagnosed a stone in the pelvis  of  the kidney, finding on the soft
catheter, AAiien removed,  indentations which could have been caused
only by calculus.  As  a further means of diagnosis, and  one ahvays
justifiable when the integrity of the kidney-substance is  threatened
by the persistence  of  symptoms,  exploration  by lumbar  incision is
valuable.  This  enables the surgeon to explore  directly the entire
abdominal ureter, and by means of bougies to determine whether or
not the pelvic  portion is patulous. 
DISEASES AND INJURIES* OF THE URETERS.
757
   Diagnosis  founded on  kidney colic is  usually fairly reliable, since
 this pain is highly characteristic.  Yet  it must be remembered that
 stone in the ureter has  been diagnosed when  the real condition Avas
 passage of a gall-stone, appendicitis, neuritis of the lumbar nerves, or
 acute intestinal obstruction.
   A careful  examination of the urine will enable the surgeon to de-
 termine whether  or  not the symptoms are  due to blocking of the
 ureter.  Moreover, the conditions with  which  ureteral calculus may
 be confounded have  usually certain  pathognomonic  features Avhich
 sooner or later manifest  themselves.   Thus, gall-stone is attended
 with jaundice, and  the  pain is  likely to be referred to the region of
 the right shoulder.   Appendicitis  exhibits increasing  tenderness on
 pressure  over McBurney's point, and the abdominal  symptoms be-
 come  rapidly and progressively Avorse.  In neuritis  of the  lumbar
 nerves the tenderness is superficial, and there is no marked  change
 either in the quantity of urine passed  or in its constituents.   The per-
 sistent vomiting of intestinal obstruction, shortly becoming faecal, and
 the obstinate  constipation, would suggest the nature of the affection.
   The symptoms are due  to obstruction, and not to the irritation
 caused by the rough  corners of a stone, and they will be as distinctly
 marked if the obstruction is due to a portion of tumor, a blood-clot,
 or a mass of inspissated tubercular pus.  The diagnosis as to the
 cause of the obstruction is dependent on  the previous history of the
 patient.
   Intermittent pyuria—that is, the passage of normal urine during
 attacks of colic, the  passage of pus in the urine during intervals—
 points to the  existence of one healthy kidney.   The blocking during
 the acute attacks is complete, hence no pus escapes into the bladder;
 during  the intervals, owing to relaxation  of  spasm or lessened con-
 gestion, part of the urine escapes on the diseased  side, carrying Avith
 it pus.   When the seat of lodgement cannot  be  detected  by rectal
 palpation or a point of tenderness on  deep abdominal pressure or the
 sensations of  the patient, an exploratory laparotomy may be justifia-
 ble.  Through this  the  entire ureter may be  explored,  and  even a
 small stone will scarcely be overlooked.   In the absence  of  pyone-
 phrosis the stone can safely be removed  through the peritoneal cavity.
 Usually these  cases are complicated by suppuration, and there can be
 little question as to the  desirability of  removing them  extraperi-
 toneally:  hence the lumbar incision and extraperitoneal exploration
 are preferable.
   The diagnosis betAveen kidney calculus and  blocking of  the ureter
from unnatural mobility  of the  kidney  is  sometimes  absolutely im- 
758
GENITO-URINARY DISEASES AND SYPHILIS.
possible.  The symptoms are precisely the same, and  in both cases
the urine may show blood after the attack is over.   A movable kid-
ney would be suggested by the prompt relief which sometimes  fol-
lows either  abdominal manipulation of the organ or the assumption
of the dorsal decubitus.
   Prognosis.—The  calculus having   passed into  the ureter  may
recede into the kidney pelvis, may pass on to the  bladder, or may be
permanently lodged.
   Calculus lodged in the ureter, if it  entirely blocks this canal,
causes rapid and complete destruction of  the secreting substance of
the kidney.  Provided the other kidney is healthy,  it is usually able
to function for both.  When the obstruction is  partial  there is back
pressure, with more or less dilatation of the ureter, kidney pelvis, and
calices, and  gradual degeneration of the kidney-substance.   The con-
gestion incident to this condition strongly predisposes to  infection.
As the ureteral walls  dilate they commonly become thickened.
   The  calculus may ulcerate  entirely through the  ureteral wall,
forming an abscess, which may  open externally in the lumbar region,
or into the colon, or may follow  the course of perinephritic abscesses.
    Treatment—Probably  no  surgeon  would  seriously contemplate
an operation for the  removal of a calculus of the ureter during the
first feAV hours of an  acute attack  of renal colic.   In the great ma-
jority of these cases the stone passes into  the bladder  and  is thence
passed  through the urethra.  Nor should operation be considered
even though the attacks of colic have been  repeated,  provided that
they have been of short duration, that  the relief  has been com-
plete  during the intervals of attack, that there  have been no symp-
toms  of kidney involvement, and that the general health remains
unaffected.
   The treatment  of these brief attacks  is palliative.   The  patient
should be given a hot bath, and a full dose of morphine hypodermi-
cally.  The  'administration of  medicines by the mouth is of little ser-
vice, since there is  usually vomiting.  A hot rectal enema is useful in
relieving the tympany, which is sometimes symptomatic of ureteral
obstruction.  When the pain is so agonizing that it seriously affects
the pulse, inhalations  of ether should be given  until sufficient time has
elapsed for  the morphine to produce  its quieting effect. We would
especially advise against passing an instrument into the bladder for
the purpose of evacuating the urine unless it is certain  that  the blad-
der is distended.  The urgent  desire to  micturate, from which patients
suffering from kidney colic complain, is a pure reflex.  There is usu-
ally retention, probably spasmodic  in nature.   It  is relieved by a hot 
DISEASES AND  INJURIES OF THE URETERS.
759
sitz-bath, the  patient being directed to urinate while sitting in the
bath.  If it should persist, the bladder forming a distinct tumor above
the pubis, the catheter  should be used, but only by a surgeon thor-
oughly skilled  in  the details  of genito-urinary  asepsis,  since  the
conditions  for ascending infection are peculiarly favorable after the
passage of  a stone.
   When it is  evident, from  the gradual development of a  hydro-
nephrosis or the repeated comparatively mild attacks of kidney colic,
that a calculus is lodged, and that the kidney is becoming seriously
affected; when during an acute  attack the secretion of the urine is
partly or completely suppressed, suggesting that the patient  has not
a healthy kidney on which to  fall back;  or when  fever and hectic
develop, together with  pus in the urine, pointing to pyonephrosis,—
surgical  interference is imperative.
   The  abdominal ureter may be  exposed in the upper part of its
course by  an  incision  parallel  to  the twelfth  rib, and a half-inch
below it, carried from the anterior edge of the sacro-lumbar  muscles
to the tip of the rib ; if the cut  be carried downward from this point
to a point  half an  inch above the centre of Poupart's  ligament, the
middle portion of the abdominal ureter may be reached.  The lower
portion is accessible through the incision made for the ligation of the
common iliac  artery.  Duval's  incision gives  most  room; it is  five
inches long, and is carried  from  a  point an inch  and a quarter ex-
ternal to the  pubic spine, and  slightly above it, to about the  middle
of Poupart's ligament; it is then turned upward in a direction per-
pendicular to that of the ligament.
   The  incision is deepened till the peritoneum is  exposed the entire
length of the  wound; this membrane  is  then  stripped  by the finger
till the ureter is reached.  The stone, if present,  can usually be felt
without  difficulty.
   The  upper  portion of the pelvic ureter may be reached  through
the incision made for ligation of the common  iliac  artery.   Cotterell
thus  exposed a calculus  impacted just below the brim of the pelvis.
The ureter was incised longitudinally and the stone removed.  In a
second case the stone was removed through an  incision in the upper
vaginal Avail.  The lower part of the  pelvic ureter can  be  made ac-
cessible  through the vaginal  vault  in  the female.   In  the male  this
part of the ureter may be exposed by Rydygier's incision for excision
of the rectum.   A long oblique cut is made through the  soft parts
parallel  to  the border of the  sacrum and  coccyx, and is  carried
down  nearly to the anus ; through this cut  the soft parts are stripped
by blunt dissection from the anterior surface of the sacrum ;  a trans- 
760        GENITO-URINARY DISEASES AND SYPHILIS.

verse incision is then carried  across  the sacrum an inch above the
sacro-coccygeal  articulation, and, by means of a hammer and chisel
the bone is cut across in the line of this incision.   The osteoplastic
flap thus made is  turned aside.   This gives free  access to the pelvic
cavity.
   Cabot places the patient  in  the Sims position, thus  alloAving the
wound to balloon out by air-pressure.  He then  introduces a sound
into  the  rectum, which serves to hold it aside.   The normal ureter
is  difficult  to find, but  if a stone is lodged in  this  portion of the
canal, it  should readily be  felt.  Cabot  advises against suturing the
ureter, since longitudinal wounds, if left to themselves, show a ten-
dency to heal.  Drainage  for the escaping urine must be provided
till the ureteral wound closes.   He states that " the only exception to
this rule  is when the ureter is opened through the vagina in its lower-
most parts, where it is in intimate relation with the vaginal wall, and
where  it is  therefore possible to get sufficient thickness of tissue for
the application of  stitches without encroaching upon the cavity of the
tube."
   A stone lodged at the vesical orifice  in the  male may sometimes
be removed by suprapubic cystotomy and the application of forceps.
Lodged in  the pelvic portion of the ureter, it may sometimes be re-
moved by  forceps passed  through an opening, made in the dilated
abdominal  ureteral segment.
   Albarran, in  a recent study of ureteral surgery,  considers as fol-
lows the surgical procedures which seem to him advisable in the
presence of a calculus, a fistula, or a stricture of the ureter seated in
the lumbar, the  iliac, or the  descending  portion of the pelvic part of
the ureter:
   The diagnosis  of the point of obstruction cannot be established in
the majority of  cases, but will be determined  at the time of  the lum-
bar incision, to which one should give the preference.   The incision
may be prolonged below, and the search continued if the calculus is
not found in the neighborhood of the kidney.  The calculus having
been located, an  effort  should be made to displace  it towards the
pelvis of the kidney, as has  been done by Israel, in order to be able
to remove it by nephrotomy.  If this  proceeding fails, a longitudinal
incision should be made in the ureter, preferably above the stone.
   Albarran prefers to  suture  the ureteral wound in aseptic cases,
but not when there is suppuration.  Before deciding upon one or the
other of  these two methods of procedure, the ureter must be cathe-
terized, to ascertain if  any other calculi be present or if there be any
narrowing  of its lumen.  The exploratory catheterization of the ureter 
DISEASES AND INJURIES  OF THE URETERS.
761
is frequently  very difficult;  sometimes an instrument  cannot  be
passed  from above downward.   In  these  cases Albarran advises
catheterization from below upward by the endoscope, or, if necessary,
by suprapubic cystotomy.
   Fistula of the Ureter.—Fistulae are secondary to wounds, rup-
ture, or ulceration  of the  ureters.  A longitudinal Avound may heal
spontaneously Avithout  the formation of either  fistula  or stricture;
transverse Avounds involving half the diameter of  the ureter, and par-
ticularly when they completely sever it, are followed by  fistulae.
   These wounds are usually inflicted during the course  of gynaeco-
logical operations.  Spontaneous fistula—i.e., that due to ulceration—
is caused by  tubercular infiltration,  malignant growth, calculus, or
foreign body;  the fistula under such  conditions is secondary to par-
tial or complete ureteral obliteration.
   A fistula may open on the  surface of the body or into the cavity of
a neighboring viscus.  The surface opening is  commonly in the lum-
bar region;  it may be found  in the  groin or in some portion  of the
anterior abdominal parietes.  Visceral opening is  commonly into the
uterus or  vagina,  but  may be  into the rectum, and very exceptionally
into the stomach.   The patulous tract is apt to be fairly direct; it may
be long and irregular.
   Symptoms.—The pathognomonic symptom of  ureteral  fistula is a
continuous  or intermittent discharge of urine.   Duplay and Reclus
state that  if the fistula is near  the kidney the flow  of  urine is continu-
ous.  If it is low down towards the vesical extremity the flow is inter-
mittent, coming in jets.  The urine may remain perfectly clear, showing
no admixture of pus or kidney albumen.
   Prognosis.—There is  little tendency toAvards spontaneous cure
of ureteral fistula.  Provided narrowing of  the orifice does not take
place,  the fistula  may produce no appreciable effect upon  the general
health. It often  happens that, because of gradual cicatricial forma-
tion and  encroachment upon the  ureteral calibre, hydronephrosis
develops.   It should  be remembered that  in case the  ureter  is  en-
tirely  divided, the  loAver  extremity  becomes  atrophic from disease,
thus making an operation for the restoration of the continuity of the
channel extremely difficult.
   Diagnosis.—The diagnosis betAveen ureteral  and vesical fistulae
can be established by injecting colored fluids into the bladder.   Renal
fistulae are fairly direct, and but a slight amount of urine escapes from
them if the ureter is pervious.  Catheterization of the ureter and in-
jection of colored fluid will sometimes be serviceable in establishing
a diagnosis. 
GENITO-URINARY  DISEASES AND  SYPHILIS.
    Treatment.—The first requisite of successful treatment is that the
ureter shall be restored to its normal calibre.  It is possible that this
may be accomplished by the use  of ureteral  bougies or  continuous
ureteral  catheterization practised through the bladder.   Usually the
ureter is impervious.   Cure may be accomplished by nephrectomy.
This  operation  has  been  many  times  successfully  performed.  It
should, however, be left as a last resort, efforts being  made either to
restore the continuity of the ureter or to implant it into the bladder.
    When the fistula  opens into the vagina, colpocleisis may be per-
formed.  This operation, first practised by Hahn, converts a part of
the vagina into an artificial reservoir for the urine.   Kelly in one case
of  uretero-vaginal fistula closed  the ureter by suture.   When the
vesical extremity of the canal is obliterated the ureter may be im-
planted into the bladder by the intraperitoneal or the  extraperitoneal
route.
    When the fistula  involves  the  abdominal  portion  of the ureter,
direct closure, splitting of the ureter and transverse suture, or ex-
cision of the diseased area,  folloAved by ureterostomy, may be indi-
cated.  When it  is placed  high in the  ureter, it may be resected,
together  with a segment of the ureter, and this canal may be sutured
to the renal pelvis.
    Tuberculosis of  the Ureter.—Tubercular involvement  of the
ureter is usually secondary to tubercular disease of the bladder or the
kidney.  The infiltration attacking a portion of the ureter and par-
tially or completely obliterating it may produce dilatation of the seg-
ment above,  and  hydronephrosis  or  pyonephrosis ;  or  the  entire
ureter may  be infiltrated, becoming a  dense,  often nodular, imper-
vious cord.
    The symptoms of tubercular infiltration of the  ureter are usually
completely masked by those of vesical  or renal disease.  In women
palpation of the lower extremity of the  ureter  through the vaginal
vault might show characteristic induration and nodulation.  In both
sexes attempts at ureteral catheterization would demonstrate  points
of narrowing.
    The treatment of ureteral tuberculosis cannot be formulated, since
this is never  encountered clinically as  an isolated lesion.  If  in the
course of a nephrectomy for tubercular  kidney the ureter is  found
involved, it should be removed with the kidney.
    Tumors of  the Ureter.—Tumors of the ureter  have been re-
ported in a few instances, this canal having been secondarily involved
by malignant  growth, extending  from either the kidney pelvis  or the
bladder.   Target, however, found  a large round-celled  sarcoma, in- 
         DISEASES AND INJURIES  OF THE URETERS.        7^3

volving the whole length of the right  ureter, and Chrobak reports a
subserous myoma.
   The diagnosis of these rare tumors is  scarcely possible.  The
symptoms are those of  ureteral obstruction.
   Prolapse of the ureter has been reported  by Caile in  a  child
two Aveeks old.  A sac which Avas supposed to  be a vesical diver-
ticulum presented at the urethral  orifice.  It was found to be a pro-
lapsed ureter dragged down by a papillomatous growth.
   Two cases of ureteral cyst caused  by psorosperms have been re-
ported, one by Eve ; the only symptom Avas profuse haematuria, which
was not attributed to the cystic formation. 
CHAPTER  XXI.
               INJURIES AND  DISEASES OF THE  KIDNEYS.

    Surgical Anatomy.—The kidneys are situated in the hypochon-
driac region on either side of the vertebral column behind the perito-
neum.  (Fig. 209.)  The  right kidney is  a little lower than the left
(three-quarters of an inch),  probably because  of  the  superimposed
liver.  The left kidney extends from the level of the interval between
the eleventh and twelfth ribs, near the spine, to the level  of the third
lumbar spine.  Each organ  is inclined forward and inward, so that
their upper portions converge.  The outer border faces up\vard and
backward, the inner downward and forward.
    The kidneys  are fixed in position by a series of short  blood-
vessels, the parietal peritoneum, the pressure of the abdominal vis-
cera, and  a  fibro-lipomatous sheath  called the renal fascia. This
fascia is formed by a splitting of the subperitoneal connective tissue,
enclosing  the kidney in a  pocket and passing inward as a single layer
to cover the great blood-vessels.  During foetal  life this investment is
purely fibrous; later there is an  abundant  deposit of fat, to Avhich
the name of  fatty capsule has been given.  The deposit of fat  is most
marked on the outer borders  and posterior surfaces of the kidneys.
It may be one or two inches in thickness, and serves to fix the organs
in a soft nidus.
    The kidney of average size is four and a half inches long, two and
a half inches broad, and one and a half inches thick.  It  weighs
about four and a half ounces.  The kidney of a Avoman is about half
an ounce  lighter.
    It is irregularly oval  in shape, with a convex  outer  border and
a concave inner  border.   It is ordinarily of brownish-red color, but
this  is subject to  marked variations, depending upon the degree of
congestion or the presence of degenerations.  It is fairly firm  in con-
sistence.  The  anterior surface of the kidney,  turned forward and
slightly outAvard,  is covered by  peritoneum in  its upper portion.
The upper extremities of both  kidneys  are capped by the suprarenal
bodies.
   The liver lies  in front of the upper two-thirds of the right kidney,
and  is often attached to  it  by a  peritoneal fold  called the hepato-
     764 
Fig. 209.
   The kidneys occupying their normal position.  1, 1, the kidneys; 2, 2, the fibrous capsule which
holds them in place ;  3, pelvis of the ureter; 4, ureter; 5, renal artery;  6, renal vein ; 7, suprarenal
capsule; 8, 8, the liver lifted up to show the relation of its lower surface to the right kidney and
gall-bladder; 9, the gall-bladder;  10, terminal portion of the portal vein, with the hepatic artery
and the gall-ducts  lying in front; 11, common  duct, resulting from the fusion of the cystic and
hepatic ducts ;  12, spleen, turned outward to show its relations to the kidney ; 13, semicircular fold
in which rests  the lower border of the spleen ; 14, abdominal aorta; 15, inferior vena cava; 16, left
spermatic  artery and vein; 17, right spermatic vein opening into the vena cava; 18, cellulo-fibrous
connective tissue which forms the renal capsule; 19, lower extremity of the quadratus lumborum
muscle. (Sapjiey.)
   Longitudinal section of the kidney.   1,1, Malpighian pyramids, umlobular; 2, 2, bilobular pyra-
mid ; 3, 3, 3, trilobular pyramid ; 4, 4, 4, 4, quadrilobular pyramid ;  5, 5, 5, 5, 5, 5, summits of the
Pyramids'surrounded by the calicos ; G,  6, columns of Bertin ; 7, pelvis;  8, ureter.  (Sappey.) 
Fig. 211.
    Split kidney.  Sinus fat removed, vessels divided close to their entrance into the kidney-sub-
stance, pelvis and calices dissected away up to the base of the papilla.  1, papillae; 2, openings ol
the urinary  tubules; 3,  line of incision of the  calyx; 4, inner  fibrous investment of the kidney;
5, cross-section of a blood-vessel; 6, renal parenchyma; x, amalgamated papUlse ; y, entrance-point
of the vessels into the kidney.  (Henle.)
Fig. 212.
    The sinus of the kidney.  The  upper and lower overhanging portions of the kidney have been
cut away and the fat and the venous trunks of the sinus have been removed.  A, renal artery ; U,
ureter; +, ►}., divided branches of  the renal artery.  (Henle.) 
INJURIES AND DISEASES  OF THE KIDNEYS.
765'
renal ligament.   Its  loAver third is in relation with  the  ascending
colon, which lies in direct contact Avith it, the beginning of  the trans-
verse colon, and the  second portion of the  duodenum, which de-
scends  vertically along  the  inner  portion  of the anterior  surface,
crossing the renal vessels and their bifurcations at a right angle.  The
inferior vena cava obliquely crosses the extreme upper portion of the
right kidney.  (Testut.)
   The anterior surface of the left  kidney is in relation with the tail
of the pancreas, Avhich rests upon  its  upper fourth, Avith the spleen
lying above and externally, and the stomach below.   The terminal
portion of the transverse colon and the upper portion of the descend-
ing colon lie directly in contact Avith its loAver half  or tAvo-thirds, con-
nected to it by loose areolar tissue, unless there be a distinct meso-
colon.
   The comparatively flat posterior kidney surface faces  backward
and imvard.  Behind  it lie the diaphragm, the quadratus lumborum
muscle, from which it  is separated by the anterior layer of the lumbar
fascia, and the intercostal and lumbar nerves, and to the inner side the
psoas muscle. Externally it extends beyond  the quadratus lumborum
muscle, and is then in relation Avith the transversalis.   The posterior
kidney  surface is entirely free from peritoneal investment, except in
the anomalous condition characterized by the presence of a meso-
nephron.
   The diaphragm immediately behind the upper posterior  surface of
the kidney is  extremely thin,  and presents  a triangular opening,
allowing  the kidney   to lie  in  almost  immediate  contact  with the
pleura.  This opening explains the frequency with which abscesses
burrow into the pleura.  The outer convex border of the kidney is in
relation Avith the spleen and  descending  colon on the left side, the
liver on the right side.  The inner concave border,  resting on the
psoas muscles, presents a fissure  termed  the hilum, into Avhich pass
the blood-vessels and  ureters ; it is about tAvo inches from the median
line, and  is about one and a half inches in depth.   The  important
structures coming off from  it are  the  veins, placed  anteriorly, the
arteries, behind the veins, and the pelves  and ureters, posteriorly.
The renal arteries and veins  are  on a level with the space betAveen
the spines of the first and second lumbar vertebrae.   The hilum ex-
tends to a considerable  depth within the substance  of the kidney,
forming a central cavity known as the sinus.
   The kidney is enclosed in a proper  capsule of  fibrous tissue, be-
neath which lies an investment of unstriped  muscles.   The solid part
of the organ is  composed of the cortical layer, containing the  Mai- 
766        GENITO-URINARY DISEASES AND SYPHILIS.
Fig. 213.
 pighian glomeruli, which are the beginnings of the uriniferous tubules
 and the medullary layer, containing the straight and spiral portions of
 the uriniferous tubules, as well as the collecting tubules.  These col-
 lecting tubules are arranged in separate  pyramidal masses, the pyra-
 mids of Malpighi, the apices of which form papillae projecting into the
 sinus.  (Fig. 210.)   They are separated from  each other by the cor-
 tical substance, which envelops them on all sides, except in the region
 of the papillae.  The papillae project into the calices or infundibula
 which are  the small diverticula  into which the  ureter  subdivides.
 When the ureter reaches the  sinus, having passed in by the  hilum
 it dilates into  a funnel-shaped sac, called the pelvis.   From this sac
 pass a few major channels, each of which divides into several smaller
 ones, the calices, these in turn terminating about the openings  of  the
 papillae.   (Fig. 211.)  Usually the calices  are  as numerous  as  the
 papillae; sometimes two papillae open into a single tubule.  The num-
 ber of calices  is usually from eight to twelve.   Each  is about two-
 fifths of  an inch long, and is  in calibre  No. 6 to No. 10 F.  Several
                        of these  small canals  unite to form a series
                        of three  or four larger canals, which open
                        into the  pelves  of the  kidney.   (Fig. 212.)
                        There are usually three of these large branch-
                        ings of the pelves,—an  upper, a median, and
                        a lower.   They vary greatly  in  length  and
                        calibre. The pelvis, which receives the urine
                        from the calices, is about  an  inch high  and
                        not quite  an  inch wide, and runs  directly
                        into the ureter.   (Fig. 213.)   Sometimes the
                        junction  of these two  channels  is  marked
                        by a slight constriction.   The pelvis is placed
                        within the sinus, but extends upward beyond
                        the limits of this opening.  In front of it lie
                        the  vessels ; behind it lies the posterior renal
                        artery, when this vessel is present. The por-
                        tions which extend beyond the kidney have
                        the  peritoneum and the fatty capsule in front,
the psoas muscle  posteriorly.   The duodenum is in relation  with the
anterior surface of the right pelvis.
   The  arteries  of  the kidneys  divide  into  four  or five branches,
which enter the hilum and lie between the renal vein and the ureter.
Within the  sinus  the branches of the artery run beside the calices
(infundibula) and are embedded  in  fat.   The  right renal artery is
slightly longer  than  the left, as it has to  cross the vertebral  column;
   Renal pelvis dissected from
the pyramids.  P, pelvis;  U,
ureter.  (Henle.) 
         INJURIES  AND DISEASES OF THE KIDNEYS.       767

for a similar reason the left renal vein is longer than the right.  The
renal veins leave the kidneys at the hilum, and, passing in front of the
renal arteries, empty into the vena cava ; the spermatic vein joins the
renal vein on the left side.
   The blood-supply to  the kidneys is particularly abundant.  The
renal artery may pass as a single vessel to the hilum, or may divide
into several branches before  reaching  this point.   These branches
are named, according to their distribution, superior, middle, and  infe-
rior.  The posterior branch passes downward and backward to enter
the hilum behind the pelvis.
   The veins are proportionally as numerous and  large as the  arte-
ries.  In the sinus there are a number of branches, usually lying  in
front of the arteries ; these fuse into the renal vein.  This is a short,
valveless trunk passing to the vena cava.  The perinephric veins are
large and numerous  and communicate with the blood-vessels of the
kidney.
   The lymphatics pass to the glands of the lumbar plexus lying near
the hilum.  The nerves are abundant and supplied with ganglia ; they
come from the sympathetic system.   In the stroma of the kidney are
found muscular fibres, especially about the papillae.
   Anomalies of the  Kidney.—The kidneys may vary from  nor-
mal in number, size, shape, position, attachment, and mobility.
   There may be more than two kidneys, or there may be congenital
absence  of  one kidney.   This  latter has been  noticed sufficiently
often to warrant the suggestion that the  surgeon, before performing
nephrectomy, should make sure of the presence of  two kidneys.
   Roberts  collected  twenty-nine cases of solitary kidney, twenty-
two of which occurred in males and six in females.   The sex was not
given in one case.  In  sixteen  cases the left kidney Avas absent,  in
thirteen the  right.
   Ballowitz has made an extensive collection of cases of congenital
absence of one kidney.   He found that the deficiency was more com-
mon on the  left than on the right side, and that the single kidney was
usually normal in position and shape, but enlarged.  A single  kidney
has sometimes a double vascular  supply and two ureters,  though
showing no  other signs of fusion.  Morris  states  that congenital ab-
sence of one kidney can be expected once in  every three thousand
nine hundred and ninety-tAvo and tAvo-fifths cases.
   The kidney may be congenitally enlarged ; this condition is usually
associated Avith atrophy, or possibly with absence, of the other kidney,
and is compensatory.  A single large kidney seems  to be perfectly
competent to carry on the functions of both organs, since  there are 
768
GENITO-URINARY DISEASES AND SYPHILIS.
many autopsies recorded shoAving that  the bearers  of  this malfor-
mation have lived to an advanced age and perished of other diseases.
Thus, Conder reports one such case, the patient dying at the age of
seventy-two.
   Variations in shape may be due to overgrowth or malformation of
neighboring organs or  structures.   Usually these  are  true growth-
perversions, and they may assume a great variety of forms.
   The upper extremities of  the  kidney may be joined by a bridge
over the abdominal aorta and inferior vena cava, the  organ assuming
a horseshoe shape ; this connection may consist of true kidney struc-
ture  or may  be merely a band  of connective tissue.  The kidneys
may be fused along their whole  inner surface, forming one  large oval
or rounded organ, with  blood-vessels and excretory ducts attached to
its centre  or  possibly to one side.  Fusion  usually results  in appar-
ently one  large kidney, or in  the sigmoid or horseshoe kidney above
described.  Morris, on the basis of over fourteen thousand  autopsies,
states that there  is one horseshoe kidney in every sixteen hundred
examinations.  Fusion  may present certain bizarre  forms, as in  a
case  reported  by Gruber, in which one kidney Avas superimposed upon
the other, the long axes of the organ lying at  right angles to each
other,  and both  being  displaced from  their normal position.  The
kidney may also be found extremely lobulated.   This  condition is
normal in the foetus.  When it persists it is due to arrested develop-
ment.  Double ureter and multiple arteries and veins are often noted.
Fused kidneys sometimes reach enormous sizes.
   The position of the  kidney may vary from the  normal  in practi-
cally any direction except posteriorly.  The  kidney may lie too high,
but this is extremely rare.  It is often found over the sacro-iliac ar-
ticulation, and has been so widely displaced that it has been found in
the canal of Nuck.  Both kidneys may lie to one side  of the vertebral
column, either about their normal position or in the pelvis.  The kid-
ney may be  tilted,  rotated, or turned  on its long  axis.  The hilum
may look forward, outward, doAvmvard, upAvard, or  backward; this
malposition may be associated with fusion.
   The attachment of the kidney is necessarily anomalous  when it is
fixed in a  faulty position.
   The anomalies of mobility are of sufficient surgical importance to
receive special consideration.   The other growth-perversions usually
excite  no  symptoms, and  are of importance to the surgeon prin-
cipally because they  may cause errors in  diagnosis and treatment.
Thus, a malformed abnormally placed kidney first  discovered during
the course of abdominal palpation for the detection of the cause of 
INJURIES AND DISEASES OF THE KIDNEYS.
769
obscure gastro-intestinal troubles might readily lead to serious error;
the removal of a diseased kidney would necessarily be fatal should
this happen to be an instance of solitary kidney;  an attempted ne-
phrectomy on a fused kidney would result disastrously.   When the
kidney is fixed in a faulty position it usually gives  rise to no symp-
toms.  Morgagni, however, states that aortic aneurism was caused
by the pressure of horseshoe  kidney, and  Neufville records the case
of a woman, twenty-five years old, previously free from symptoms,
who in consequence of the sudden  congestion of a horseshoe kid-
ney developed thrombosis of the large veins, Avhich was followed by
death.
   The only operation  practicable  for the relief of symptoms due to
a kidney congenitally fixed in  a faulty position is nephrectomy.
   Floating  kidney is a congenital anomaly in the attachment of
the organ.  Movable  kidney  is the  result of injury, sprain, or the
dragging or weight of  neighboring  viscera.  The floating  kidney  is
completely enveloped  in a fold of the peritoneum, and  is loosely
attached to the posterior abdominal Avail by a mesonephron: hence
it lies Avithin the peritoneal cavity.  A movable kidney lies behind the
peritoneal  cavity.   Its  undue  mobility is due either to failure of the
perinephric fat to give  proper support, sometimes from rapid absorp-
tion of this adipose layer, or  to stretching of the  ligamentous and
vascular attachments of the kidney itself.   Sometimes these attach-
ments instead of stretching drag with them the  attached viscera, as
the colon and stomach of the  left side and the duodenum of the right
side, giving rise to marked gastro-intestinal disturbances.
   A differential diagnosis between floating and movable kidney can-
not be made,  since the range  of motion is sometimes greater in the
latter condition than in  the former.
   Movable  kidney is seven times  as  frequent  in women as in
men.  The causes of unnatural mobility are relaxation following preg-
nancy, injury  in the lumbar region, sprain, and  rapid  absorption of
fat from the affected capsule, such as occurs in acute wasting diseases.
Tight lacing is apparently a common cause of abnormal mobility in
the right kidney, since  thus the weight of the liver is throAvn down-
ward and backward directly upon the organ.  The greater frequency
with which the right kidney is affected  is explained  by its  relation to
the liver and the greater length of its artery.
   Hydronephrosis and calculus may also cause undue mobility, since
they increase the bulk and weight of the organ and by pressure and
tension loosen its attachments.
   Symptoms.—The cardinal symptom is pain, usually referred to the
                               49 
770        GENITO-URINARY DISEASES  AND SYPHILIS.

lumbar region.  This may amount to simply a dragging and Avearing
sensation, made worse by exertion and relieved by rest; or it  may
be paroxysmal, agonizing in type, exactly resembling  the attacks of
renal colic caused  by blocking of the  ureter and sudden  tension.
These paroxysms  recur  at  irregular  periods, are  rather sudden in
onset, and  often follow fatigue or active  exertion.  Frequently asso-
ciated with this pain are distinct gastro-intestinal symptoms.  If the
right kidney is  unduly movable it may partially block the duodenum,
either by direct pressure or by dragging upon it, thus  causing dilata-
tion  of the stomach and symptoms of gastric catarrh.  When the left
kidney is movable the same partial blocking or  dragging may affect
the stomach or the transverse and the descending  colon, thus inter-
fering with intestinal digestion.
   Bruce Clark has  well summarized  the  symptoms of the most
severe form of these attacks, which ordinarily begin  without warning:
'" The  patient is seized with  an acute pain in one or  other of his
kidneys.  Like most pain of renal origin, it  is very liable to radiate
down the thigh and into the groin, or may be referred to some  por-
tion  of the lower part of the  abdomen. In an  hour or two the
region of the  affected kidney, both  in  front and  behind,  becomes
acutely tender, and a local  distention of  the intestines often ensues.
More rarely  this distention  spreads  to  the  Avhole abdomen, often
giving  rise to a suspicion of peritonitis, and  seeming  to point for a
while possibly to a sudden perforation of the  intestine.   But the diffi-
culty of diagnosis, if it exists at all, soon clears up.  If  an examina-
tion  of the abdomen can  be obtained within  an hour or an hour and
a half after the onset of the symptoms, and  before the distention of
the intestines has taken place, much difficulty is not usually experi-
enced in arriving at a correct interpretation of the symptoms.  Some
enlargement of the kidney can generally be detected, and pressure on
the tumor gives rise  to a peculiar sensation of nausea, occasionally
passing on to  actual  vomiting, and often  accompanied by faintness.
But  before long a period of obscurity supervenes ;  the  abdomen,
Avhich was lax and painless, grows  tumid,  flatulent, and agonizing
when handled, and at times  a cold  sweat  stands on the  brow of
the sufferer.   This condition, in which pain  is the  prominent symp-
tom, may remain almost  unchanged  for several  days, but it usually
begins to subside after some hours, and after a few days the kidney
regains its abnormal  mobility,  of  which,  perhaps,  the  attack in
question has  afforded the first indication either to  the patient or his
medical attendant.  The  condition of  the  urine during these attacks
is  subject  to  considerable variation,  dependent  probably upon the 
INJURIES AND DISEASES OF THE KIDNEYS.
771
extent to which the  blood-supply is interfered with.  It may be
scanty and blood-stained,  or  almost porter-colored  and smoky and
bearing a marked resemblance to the urine of acute Bright's disease.
When it occurs, one of the first and most reliable symptoms  of the
abatement  of the attack is the passage of a considerable amount of
clear, pale  urine  of  a very low specific gravity  (so-called  hysterical
urine).   Occasionally  these attacks  are  accompanied by marked
pyrexia and general  constitutional  disturbance, and when  this is the
case there is some difficulty in distinguishing them from more grave
and serious affections."
   Morris  calls attention to the fact that movable  kidney and large
gall-bladder are each  more frequently met  with in  women than in
men, and often  occur in the  same person, usually in women.   The
association of the two states  he believes can be explained by the
custom of Avearing corsets, and he  thinks that while the  doAvnward
pressure of the liver induces  mobility of the kidney, the mobility of
the kidney in turn acts  upon the gall-bladder and causes  distention
by dragging upon the duodenum and  the  bile-ducts, thus obstructing
the passage of the bile.  The same mechanism explains the frequency
with which gastric dilatation and symptoms of gastro-intestinal catarrh
are associated Avith movable kidney.
   Diagnosis.—This is based on the history of a sufficient cause for
undue mobility, and of  continuous or paroxysmal pain,  often  with
profuse urination following the paroxysms, on associated symptoms
of gastro-intestinal derangement,  and on the  finding of a movable
tumor by abdominal palpation.  If a  tumor lying in the hypochon-
driac, the umbilical, or  even  the  iliac region exhibits the charac-
teristic  depression of the hilum, if the pulsation of the renal  artery
can be recognized, if  the  growth  on manipulation readily recedes
into the  loin, and if  it is of the size and  consistence of the kidney,
the diagnosis becomes reasonably certain.
   It must be remembered that mobility of the  kidney is not neces-
sarily pathological.    Franks  thus   distinguishes between  abnormal
motion and that which is natural.   With the patient in the dorsal de-
cubitus, the surgeon, standing  on the right side, places the four fingers
of his left hand beneath the holloAv of the loin below the twelfth rib.
The thumb in front encircles the abdomen just below the costal arch,
but without exercising any pressure.  The patient is then directed to
draw a full  breath.   Immediately before expiration the surgeon begins
to press with the thumb upward  beneath the costal arch and lets it
sink in  as deeply as possible,  folloAving the liver as it recedes during
expiration,  while  the fingers behind press the loin forAvard. If with 
GENITO-URINARY  DISEASES AND SYPHILIS.
the right hand a kidney can be  felt lying entirely below the grasp of
the left hand, this organ  is pathologically movable.  If the right hand
presses on this tumor whilst the left hand  relaxes its grasp gradually,
the tumor can be felt to slip suddenly between the fingers and thumb
and to disappear upward.  A kidney which descends so that its lower
half may be  felt, but which moves back to its place on expiration, is
physiologically movable.   Except in thin persons or in those with lax
abdominal walls, even the lower border of the normal kidney cannot
be felt.
    Malignant omental growths, solid tumors of the ovaries, growths
of the abdominal wall, and  enlargement  of the spleen, can usually be
readily excluded,  partly from the radical difference in the  history,
symptoms, and clinical course, mainly by  careful  palpation, followed
by colonic air-distention  and palpation and auscultatory percussion;
the kidney, except when  it has a mesonephron, lies behind the colon.
    Distention of the gall-bladder so closely simulates floating kidney
that differentiation is extremely difficult.  The symptoms which are
common to the two conditions are summarized by Morris as folloAvs:
    " Both enlarged gall-bladder  and movable kidney may present as
a tumor in the  right hypochondriac and  umbilical regions.   Either
tumor may be capable of being  pushed back into  the loin or  over to
the left of the median line.  In both cases the tumor is more or less
firm or elastic and smooth.  In  both cases it may be either very ten-
der or not at all so.  In either case it may be, or seem to be, round
or oval, or shaped like an egg, a pear, or  an orange or a sausage.11
Morris has known each  to present " a  smooth,  firm,  and rounded
projection on its surface, in the case  of a kidney due to a cyst be-
neath the front of the  capsule, in  the  gall-bladder to a calculus  in a
pouch in its anterior wall.  Both may have either a resonant or a dull
note on percussion in front.  Both  give  rise to various  dyspeptic
symptoms,—nausea, sickness, flatulence, pain after  eating, and con-
stipation.   Either may give rise to paroxysmal attacks of severe colic,
the maximum intensity of which is referred to the  situation below the
ribs on the right side of the abdomen.  In enlarged gall-bladder these
attacks are due to the sudden impaction  of a gall-stone in the cystic
duct;  in movable kidney, to kinking or rotation of the ureter or renal
vessels.  Either  may  give  rise  to jaundice, gastric  and intestinal
catarrh, or even peritonitis, though neither does so in the usual run
of cases.  With either there may be considerable displacement of the
colon and small  intestine; or adhesions  and matting together of the
intestines and omentum in front of the tumor may occur.  In neither
case does the  condition of the urine often help us, and sometimes it 
Fig. 214.
Roentgen ray shadowgraph showing calculus in the pelvis of the left kidney.  The renal artery and
                                the colon are also shown.
 
 
INJURIES AND DISEASES OF THE KIDNEYS.
773
actually misleads, as there  may be albumen in the  case of distention
of the gall-bladder or bile in the case of movable kidney.1'  The diag-
nosis betAveen  these two  conditions is obviously  not an easy one.
Mistakes will be lessened by (1) remembering that an enlarged gall-
bladder may be a movable abdominal tumor; (2) inquiring as to a
previous distinct attack of  jaundice ; (3) giving due weight to the ex-
istence of  an easily palpated  tumor:  an enlarged gall-bladder can
almost always be felt, a movable kidney (unless also enlarged) cannot
be felt so easily; (4) noting that variations in the  size of the tumor,
followed by a marked increase in the  urine voided, indicate movable
kidney  Avith temporary vascular  turgescence or  hydronephrosis;
(5)  bearing  in  mind  that a  gall-bladder Avith many calculi feels
harder than  a movable kidney; (6) observing that  a kidney has a
much Avider  range of  movement; a gall-bladder moves  only  in the
arc of a circle the centre of Avhich is a point  beneath the edge of the
right lobe  of the liver;  (7) remembering  that if the  tAvo conditions
coexist, " it is generally possible to grasp the kidney, or at any rate its
lower extremity, betAveen the tAvo hands, by pushing the tumor fonvard
and toAvards the median line with  the back of the finger-tips of the
right hand, and at the same time pressing forAvard the loin with the
fingers of the left hand.  In this way the two organs are separately
distinguished at the same  moment.   The kidney may be thus found
to move independently of the tumor formed by the  gall-bladder.
This can often  best be accomplished Avith the  patient lying on the left
side.'1  The distinction betAveen movable  kidney  and calculus  is
readily made when each has developed typically ;  when the mobility
of the kidney, though sufficient to cause blocking of the ureters, is so
slight that  it cannot be detected  by palpation, the differential diag-
nosis may be  impossible.  The  Roentgen rays promise to  render
invaluable  service  in this department of surgery.   (See Fig. 214.)
   Aspiration as a method of diagnosis  is not free from  danger, and
is apt to be misleading.
   The peculiar sickening  pain produced by palpation of the kidney
is sometimes extremely characteristic,  and is not found in omental or
mesenteric infiltrations.
   Prognosis.— The  ultimate prognosis as far as the  kidney itself is
concerned is  bad.  When  the  pain  is slight, or, if  severe and parox-
ysmal, when it recurs at long intervals and lasts but a short time and
is relieved promptly by position and  rest, and Avhen symptoms  are not
steadily increasing in severity, the outlook is favorable, and the patient
can probably be kept comfortable by the Avearing of  a proper appli-
ance.  Severe,  long-lasting pain, of  frequent  occurrence, necessarily 
774
GENITO-URINARY  DISEASES AND  SYPHILIS.
implies ultimate disorganization of the secreting substance of the kid-
ney, since this pain is due to tension or twisting of the pedicle, either
of these conditions causing profound alterations in nutrition.
    It is worthy of note that the most severe suffering is not neces-
sarily associated with the  greatest range of mobility, and there is good
reason for believing that an amount of motion which cannot be de-
tected by the most careful palpation may be sufficient to cause pro-
nounced symptoms.  It is evident  that when the  ureter moves Avith
the kidney  this canal is  less  liable  to be  blocked than Avhen it is
firmly fixed.  Sooner or  later the floating kidney profoundly alters
general nutrition, often  producing  a  condition  of  melancholia  or
neurasthenia.  The  gastro-intestinal symptoms when once Avell de-
veloped are commonly  progressive unless the mechanical cause is
removed.
    Treatment.—This is either  palliative or radical.
    Palliative Treatment.—The condition can be palliated,  often cured,
by the application of a well-fitting belt, provided Avith a wedge-shaped
pad about the size of the hand, the thin edge of which lies  on a level
Avith  the line of the ribs, while the thick border is about an inch
below the level of the umbilicus.   This pad is placed over the region
of the kidney, overlapping it below.  When a broad  abdominal band
is applied the pad is pressed backward, inward, and  slightly upward,
thus holding the kidney in place.  Corsets covering the entire abdom-
inal surface  and provided with a  suitable elastic pad  are service-
able.
    Patients must be cautioned against violent exertion  or straining
of any kind.  The boAvels must be  kept soluble, since the muscular
effort required to evacuate hardened faeces tends to displace the kid-
ney.  Digestive disturbances should be corrected by diet and proper
medication, and  due attention  should be given to general hygiene.
When in  spite  of the wearing of  a belt the symptoms of movable
kidney persist,  nephrorrhaphy is indicated.
    When  sudden violent pain shows that  the  pelvis  or ureter is
blocked, an attempt should at once be made to place the kidney in its
proper position.  In the intervals of paroxysmal  pain this  is usually
accomplished without difficulty.   Patients  suffering from  movable
kidney are apt  to be thin, with  lax  abdominal walls:  hence the kid-
ney can be distinctly palpated,  and pressure  can be so exerted that
it will slip readily into its normal place.
    During the attacks  of pain, especially Avhen  these  are  compli-
cated by symptoms of local peritonitis, this reposition may be difficult.
Nevertheless it should always be attempted,  ether being given if 
INJURIES  AND DISEASES  OF THE  KIDNEYS.
775
 necessary.  No force  should be used, since the surgeon is to a cer-
 tain  extent acting blindly.  The kidney  should be seized,  outlined,
 mobilized, and restored  to  its normal  position if possible.  Severe
 pain is quieted by a hot bath and the use of hypodermics of mor-
 phine,  repeated as often as  may be  necessary.   Hot compresses
 should be  applied over  the abdominal surface when  tympany de-
 velops.   With the subsidence of acute  symptoms reneAved  efforts
 should be made  to replace the kidney.   If these efforts fail, it will
 be because of  inflammatory adhesions.
    Operative  Treatment.—The patient  is  placed on  the operating-
 table, lying nearly in ventral decubitus, with the  side corresponding
 to the floating  kidney  up.  The head is turned to one side, the fore-
 arm brought  in front of the chest, the body slightly flexed, and the
 thighs bent.  Beneath the ilio-costal space of the sound side is placed
 a sand-pillow or roll of material about the size of a man's thigh ; this
 causes slight lateral curvature of the spine  and increases the ilio-costal
 space.
   The instruments required are a strong scalpel of medium size, dis-
 secting forceps, toothed forceps, half a dozen haemostatic forceps, tAvo
 broad right-angled retractors, tAvo large curved needles, and a grooved
 director.   Tavo assistants are required.   The twelfth rib having been
 clearly outlined, an incision is made, beginning half an inch below this
 rib and about the outer border of the  erector spinae  muscle  (tAvo
 inches from the middle line), and running downward and forAvard to-
 wards the iliac crest.  This  incision should be  three  or four inches
 long.   It  divides the skin and superficial fascia,  some  of  the outer
 fibres  of  the  latissimus dorsi, the  external  oblique,  the internal
 oblique, the posterior and anterior layers of  the  lumbar fascia, and
 the transversalis  fascia,  exposing  the fibro-adipose  capsule of the
 kidney.   If there is insufficient room for further  manipulation, the
 quadratus lumborum  muscle may be divided.  The retractors are
 passed down to the perinephric fat, and the wound is spread open as
 widely as possible.  While  an assistant presses the kidney upward
 and backward  into its normal  position  the fatty capsule is seized in
 the rat-tooth  forceps, opened Avith a knife, and then torn with the
 fingers  until the true capsule of the kidney is fully exposed.  Three
 sutures are then applied, each including a portion of the kidney-sub-
 stance half an inch in width and about one-sixth of an inch in depth,
 the kidney capsule, the transversalis fascia, and  the parietal  muscles.
These sutures should be of chromicized catgut or kangaroo tendon or
sterile silk.  They are inserted  at the convex border of the  kidney at
half-inch  intervals, making  sure that both ends  of the kidney are 
776
GENITO-URINARY  DISEASES AND SYPHILIS.
fixed, so that there shall be  no fear of subsequent rotation  of the
organ on its long axis.  The stitches  are  tied  doAvn, the incision
through the muscles and fascia is firmly closed by a sufficient number
of buried catgut sutures, and the  skin  Avound is  approximated by
interrupted stitches of silkworm-gut.   No drainage  is used.
   Many modifications of this  operation have been  suggested and
successfully practised.
   Morris draws the adipose capsule well up into the wound and cuts
some of it away, thus diminishing the size of the space in which the
kidney has wandered.   Three kangaroo tendons are passed through
the posterior surface of the kidney,—one nearer the upper, the other
nearer the loAver, end, and the third midAvay between the other two,
but nearer the hilum.  Each  suture  is buried for a length of three-
quarters of an inch within the renal substance, and penetrates about
half an inch into the thickness of the organ.  The upper suture passes
through  the upper edge of the shortened adipose capsule, the trans-
versalis fascia, and the muscles, and is tied to them ; the lower suture
is  similarly  passed through and tied to the loAver edges of the cut
structures ; and the intermediate suture is passed through both edges
of the divided capsule, fascia, and muscles, and laces all up together.
The  ligatures are then cut short  and buried in the wound ; one or two
catgut sutures bring the rest of the cut edges of the muscles together,
and the skin  is closed by silk sutures, one or two of Avhich are made
to fix the adipose capsule Avell up betAveen the edges of the skin.  The
Avound is covered by iodoform cotton-wool, and a large elastic  pad of
cotton-wool is  fastened over the front of the kidney, so as to steady
and  support  it in its new position.   The wound heals without sup-
puration, except that a track  is  sometimes left for a feAv weeks along
the course of the drainage-tube.
   Newman splits the capsule and tears it away from the surface of
the kidney, sewing this organ directly to the parietal walls. He holds
that the use of a large drainage-tube carried down to the kidney makes
adhesions more dense  by encouraging the  development of granula-
tions.   Gauze packing has been  suggested with a  similar idea in view.
   Guyon has  suggested as a further  means of securing fixation that
the portion of the kidney Avhich is betAveen the two  ends of the suture
be stripped of its proper capsule; some surgeons prefer to pass the
upper suture around  the last rib, holding that thus  only can the
kidney be retained in an absolutely normal position.
   An  extremely  ingenious method  of  fixation  has been suggested
by Vulliet, the  patient himself furnishing the suture material.  The
operation is thus performed : 
INJURIES AND DISEASES OF THE KIDNEYS.
777
   After having  exposed the kidney by the ordinary extraperitoneal
incision, freed it  posteriorly from its fatty capsule, and placed it in
its normal  position, it is alloAved to drop back into its faulty position
and the wound is packed with gauze.  The patient is then turned
back up.  An incision is made four-fifths of an inch from the dorsal
spines and parallel to their  course, three inches in length,  the middle
of this cut  corresponding to the  spine of the first  lumbar vertebra.
This incision is carried through the  skin  to  the  dorsal aponeurosis,
which is divided upon a grooved director.  On separating the edges
of the wound the Avhole series of tendons making up the attachments
of the long dorsal  muscle  is  exposed.   The one  attached to  the
spinous process of the  first lumbar vertebra is selected.   It is  lifted
up Avith a grooved director, the  index-finger is passed beneath it, and
it is torn off from above, bringing down with it a portion of its mus-
cular insertion.  A  tendinous band is thus  freed, about nine inches
long, and terminating in a bulb of muscular tissue ; this bulb is trimmed
off.  The Avound made for exposure of the kidney is then opened, the
hand is passed into the normal position of the kidney, and by bimanual
palpation the space lying betAveen the transverse  processes of  the
twelfth dorsal and first lumbar vertebrae is outlined.  The muscular
layer filling in this  space is pierced by a trocar, and the tendon is
passed through.  The  kidney is  then brought  sufficiently into  the
wound to enable  it to be tunnelled just beneath  the capsule from its
lower to its upper posterior surface near its external border.   The
tendon is draAvn through this  tunnel; its end is carried  back again
through the lumbar  muscle  and is secured in place.   Thus there is
provided a  living ligature, which retains its  vitality and  firmly and
permanently anchors the kidney in place.  Poullet has thus operated
upon one case with entire success.
   After operation of whatever character, the patient should lie in
the dorsal  decubitus for at least three weeks, should wear a sup-
porting bandage  or  corset, provided with  a pad, for six months, and
should avoid violent  strain  or muscular effort  for  a much longer
period.  The mortality of the various forms of nephrorraphy opera-
tion  is extremely low, less  than four per cent., and  the renal fixation
is usually successful.
   Delvoie, from a statistical study of two hundred  and fifteen cases,
reports one hundred and  thirty-five cures;  thirty were   improved,
twenty-five  unimproved, twenty relapsed,  and five  died.   Suture of
the fatty capsule alone Avas least successful.  Next in order of success
come  the cases in Avhich the fibrous capsule was  sutured,  next cases
in which the parenchyma was sutured without stripping the capsule, 
778
GENITO-URINARY DISEASES AND SYPHILIS.
and finally cases in  which the parenchyma was sutured  after strip-
ping the capsule; a small number of these  are reported (ten), with
but one failure.
   When the operation of nephrorrhaphy has  been carefully per-
formed twice and has  been unsuccessful, or Avhen it is impossible to
place  the kidney in the proper position, and symptoms are severe and
progressive, nephrectomy is a justifiable operation.
   Newman gives the  mortality of this operation for movable  kidney
as thirty per cent. The operation is not to be considered unless there
is absolute  certainty as to  the existence of a sound kidney which  is
able to  carry on the Avork of elimination.  For the purpose of total
removal the kidney may be reached from in front through the linea
alba or the linea semilunaris, or from the lumbar region, as  in the
operation of nephrorrhaphy.  The greater ease  of removal through
the abdominal incision, and the opportunity it affords of demonstrating
the presence or absence of the other kidney, make the anterior opera-
tion the one usually to be preferred.
   The treatment just given  for movable  kidney is applicable to
floating kidney;  in  operating, however,  the  peritoneal  cavity must
be  opened  unless the two layers of the mesonephron  are  widely
separated.
                    INJURIES  OF THE KIDNEY.
    In accordance with the  customary surgical classification, injuries
of the kidney may be  considered under the general headings con-
tusions and Avounds.   In contusions the injury to the kidney  is sub-
parietal, no external  wound leading  down to  this organ.   In  wound
of the kidney there is solution in the continuity  of the soft parts
leading to the seat of injury.
    Contusion of the Kidney.—The  cause of contusion may be
direct or indirect violence.
    Direct violence is instanced by kicks, blows, or crushing pressure,
as from the Avheels of  a cart, applied  to  the  lumbar region.   Except
in cases  complicated by fractured bones  and injury to other  impor-
tant viscera, the vulnerating body is usually small, or at least narrow,
since  there is a comparatively small unprotected space through Avhich
it can act directly on the kidney.  Duplay and Reclus state that the
force  must  be  applied suddenly and unexpectedly, thus surprising
the parietes Avhen they are relaxed,  and  when the ilio-costal space
is broadest.  Contusion from direct violence usually involves the right
kidneys of men.
    Indirect violence is instanced by contortions or flexions of the
trunk, or by violent  jarring from a fall. 
INJURIES AND DISEASES OF THE KIDNEYS.
779
   The  injury may vary  in  severity from contusion  of  moderate
severity, to laceration, or to complete disintegration of a portion or
several portions of the kidney-substance.
   Tuffier recognizes four degrees of injury.  The first degree is char-
acterized by subcapsular ecchymoses.  When the violence has been
more  marked  (second  degree), intrarenal  blood extravasations  are
found, most marked  and constant at the base of the pyramids.  In
the third degree the capsule is ruptured ; there is extrarenal hemor-
rhage, and deep, multiple, stellate fissures of the kidney-substance are
produced, most pronounced about  the hilum ;  sometimes they com-
pletely divide the kidney.  Finally the  organ may be reduced to a
pulpy detritus ;  exceptionally a large branch of the renal artery may
be ruptured.   Bleeding Avithin the  kidney is rarely profuse.   Extra-
renal hemorrhage may, hoAvever, be fatal.
   It  is evident that traumatism sufficient to  rupture  the kidney is
likely  to involve other important viscera.  Thus, Wharry records the
case of a patient Avho falling from a window struck on the right side
of the head and shoulder; the  trunk  Avas  suddenly and  violently
bent upon itself.  The  liver, lung, and kidney on the  right  side were
found to be extensively lacerated, the kidney being almost completely
torn asunder, and yet there was no injury apparent in either the tho-
racic or the abdominal Avails.  Severe contusion of the kidney is often
complicated by rupture of the liver, the spleen, the intestines, and the
lungs; the peritoneum lying in front of the kidney is likely to be torn,
particularly in  children, in whom the fatty envelope of the kidney is
wanting.  The prognosis in these cases is bad.
   Symptoms.—Symptoms of contusion of the kidney are shock, pain,
haematuria, diminution in the quantity of urine passed, and the forma-
tion of a tumor.
   Shock is usually pronounced, particularly  when the kidney is
lacerated or completely ruptured.   It is, however, not always a reli-
able symptom.  Thus, Rayer quotes an  instance in which a patient,
having struck  against an  angular projection, was so little affected
by the accident that he continued his  occupation.   He died  some
weeks later, and  post-mortem  examination showed  rupture  of the
kidney.   In cases of slight  contusion characterized by superficial or
parenchymatous ecchymoses, shock may be entirely wanting.
   Pain  is  usually the  first symptom of contused kidney.   It varies
in intensity from a sickening, weakening  ache to  an unbearable an-
guish comparable to  that  characteristic of nephritic  colic.   It is  felt
in the lumbar  region, but  usually radiates  doAvn  the  ureters, and is
often  accompanied by retraction of the testis.   It may be transitory, 
 780       GENITO-URINARY  DISEASES AND  SYPHILIS.

 or  may last for several  days.   It is often  accompanied by nausea
 vomiting, and tympany.  When it persists it is liable to be paroxys-
 mal, and is then probably due  to temporary ureteral obstruction and
 kidney tension,  caused by the passage of clots through the ureter.
    Haematuria may follow an injury to the abdominal Avail, and does
 not necessarily  indicate that the substance of  the  kidney has  been
 bruised.  When it is thus excited it is usually a sign  of a masked
 lesion of the kidney, such as encysted calculus,  which may have been
 dislodged, or a pre-existing thrombus, or tumor, or renal tuberculosis.
    When the kidney is contused  haematuria is practically constant
 and is often profuse.   Blood may appear in the urine, either imme-
 diately after the injury or not for several hours; it may persist for
 several days, or  may be abundant for a day or two and then suddenly
 cease, because the ureter is blocked by a clot.  In this case there
 will probably be severe renal colic; Avhen the clot is passed pain will
 cease, and there  will be recurrence of blood in  the  urine.   The
 quantity of blood  passed is, as a rule,  proportionate to the  severity
 of the lesion.   If,  however, the ureter is torn across, or if it becomes
 at once blocked by a large clot, the urine may remain perfectly clear,
 even though the kidney is pulpified.
    The  blood usually disappears within a week.  Sometimes it per-
 sists for several weeks,  and exceptionally,  instead of  growing less,
 it steadily augments in quantity until the patient perishes of anaemia.
 The clot, in place of passing through the  ureter, may  permanently
 occlude it, causing hydronephrosis or atrophy of the kidney.  Butler
 reports a case  in which the left ureter became thus  occluded the
 fourth day after an injury.   This Avas followed by total suppression
 of urine for fourteen  days, and ended  in death.  The  right kidney
 was found to be cystic and atrophic.  Frequent  and painful urination
 is  not an uncommon symptom  when blood is passing through the
 ureter in the shape of clots Avhich act as foreign bodies in the bladder;
 often  there is retention of urine.
    Alteration in the quantity of urine secreted  constitutes an impor-
 tant symptom of kidney contusion.   Urine may be totally suppressed
 immediately after the injury, or this suppression  may not develop until
 some  hours later.   It is often folloAved by compensatory  polyuria.
    The  formation of a tumor is primarily due to hemorrhage;  even
 though this be subcapsular the  enlargement may be palpable.  When
 the capsule is ruptured and there is free  bleeding into the perinephric
tissues, there is  quickly formed an extensive and increasing area of
 dulness  and swelling in the lumbar and possibly in the iliac region.
The hemorrhage may be so rapid and  profuse that marked consti- 
INJURIES AND DISEASES OF  THE KIDNEYS.
781
tutional symptoms develop,—i.e., feebleness and rapidity of the pulse,
pallor, coldness of the extremities, and collapse.
   Rayer states  that in intrarenal bleeding the SAvelling is  sharply
circumscribed, forms later and more slowly than in perirenal extrava-
sation, and is rounded and movable.  Perirenal extravasation is dif-
fuse.  Satisfactory palpation is  in these  cases often impossible, be-
cause  of the exquisite  sensitiveness  of  the kidney and the  regions
about  it.   When the  hemorrhage is confined  to  the  pelvis of the
kidney and  the ureter it seldom forms an appreciable tumor unless it
finds its way up  under the fibrous capsule  because of such extensive
laceration of the renal  tissue as to render this  capsule easily sepa-
rable.   Usually bleeding occurs  immediately, but Rayer reports a case
of haem atom a which Avas not observed until six Aveeks after the injury.
   Rupture may take place into the peritoneal cavity, a complication
which is generally fatal.  Intraperitoneal bleeding is characterized by
the rapid development of tympanites and signs of peritonitis, together
with symptoms of internal hemorrhage.
   Tuffier and Levi have described under the name of perinephric
sanguineous effusions a condition which  they think worthy of special
notice. They report cases Avhich, in conjunction with those of Monod
and Peyrot, establish as follows the symptomatology and  course of
this lesion: A blow or  strain is followed immediately by haematuria,
often profuse, and lasting for five or six  days.  There is, however, no
relation betAveen  the abundance or the duration of this haematuria and
the importance of the traumatism.  It is often associated with lumbar
pains  and with attacks  of pain resembling nephritic colic.   A little
later a large lumbar SAvelling appears, vaguely defined, and extending
from the twelfth  rib to the crest of the ilium.   There may be a slight
elevation of temperature.  After the  first week the urine will proba-
bly become clear. The SAvelling, however, persists.  From the middle
to the end of the  second week the  haematuria reappears  and the
tumor vanishes.  The blood in  the urine at this time is evidently not
freshly poured  out, but is dark in color and deposits a brownish sedi-
ment, instead of  clots, Avhen the urine  is allowed to stand.   These
symptoms may be followed  by  a passing polyuria.  During the first
week it is evident that  there has been a haematuria from the kidney
or its  pelvis, evacuated in part by the  ureter  and in part forming
a perirenal  SAvelling.   The  haematuria  ceases  Avhen  the  swelling
reaches its maximum of tension.  This  is followed after some days
by a sufficient reopening of the kidney-wound to permit of the spon-
taneous evacuation of  the  larger  part  of the  effused  blood.  The
reappearance of blood in the urine during the second week is there- 
782        GENITO-URINARY DISEASES  AND SYPHILIS.

fore, according to Tuffier, a favorable symptom, and  indicates  the
spontaneous evacuation of the blood from around the kidney.
   Diagnosis.—The diagnosis of contusion of the kidney is based on
—(1) The form of traumatism : thus, the sharp corner of a table
striking the side between the pelvis and the costal border, a kick or
a blow delivered  from before backward below the ribs and over the
region of  the kidneys, a crushing force fracturing the loAver ribs, or
extreme flexion or  extension of the body, would  be sufficient  cause
for kidney-rupture.  (2) The immediate  appearance of blood in  the
urine,  in  the absence of bladder-lesion.   The  rare cases  in which
such  bleeding follows simple traumatism of the back may be dis-
regarded.   If the bleeding is profuse  and exhibits  Avorm-like  clots,
it  offers  the characteristics  of  traumatic  renal  hemorrhage.   (3)
Marked diminution in the quantity of urine secreted,  or  complete
suppression of the  secretion.   This symptom may folloAv any severe
traumatism to the  abdominal  contents.  It may be of value  when
associated with hemorrhage.  (4) The rapid  formation of a lumbar
swelling associated with  extreme tenderness.  (5) Intense pain radi-
ating in the direction of the ureter and accompanied by retraction of
the testes.   (6) Subcutaneous ecchymoses developing several days
after the injury.  These may appear in the loin, or may be found in
the  inguinal region.   Dumesnil  has  particularly insisted  upon  the
importance of this symptom, and states that it is indicative of serious
injury.
   This group of symptoms is diagnostic. It has been shown,  how-
ever, that they are often not associated; thus,  haematuria,  the  most
characteristic symptom,  may be absent; but if the kidney-lesion is
extensive  a haematoma is certain to form.  When the peritoneum is
ruptured,  and extensive bleeding takes place into the  general  peri-
toneal cavity, the only symptoms pointing to injury of the kidney will
be haematuria and possibly characteristic pain;  shock and peritonitis
quickly mask the  other symptoms indicative of kidney-lesion.
   Prognosis.—Most  cases of contusions of the  kidney of the first
degree, characterized  by subcapsular ecchymosis, heal spontaneously
apparently without sequelae, and probably this is true of the  cases ex-
hibiting disseminated  extravasations into the substance of the kidney.
When the organ is extensively ruptured the prognosis is grave.   Ac-
cording to Morris, " It is largely due to plugging of the renal blood-ves-
sels and the capacity of the other kidney, if healthy, for doing compen-
satory Avork that  so many recoveries from contusion, laceration, and
puncture of the kidney take place, but the two chief conditions  upon
which recovery  depends are the escape  of the peritoneum and of 
INJURIES AND DISEASES OF THE KIDNEYS.
783
the large branches of the renal artery and vein ;  if a large branch of
the renal artery be torn, and death does not follow from bleeding,
the gradually increasing hemorrhage is likely to lead by pressure to
sloughing of the peritoneum, even though that membrane may have
escaped the original injury.11   Recovery may follow extensive lacera-
tion or even complete pulpification  of the kidney.  This, hoAvever, is
rare.  Duplay and Reclus  state that in  simple lacerations the mor-
tality is forty-three per cent. ; in laceration complicated by rupture of
other organs or fractures of the neighboring bones  the  mortality is
eighty-seven per cent.
    Complications.—Complications Avhich are  immediately threatening
to life after rupture of the kidney are shock, hemorrhage, and anuria.
Later the  chief danger is from sepsis.  The majority of contusions
escape this complication.  The conditions are, however, so favorable
for its development that it is one of the most frequent causes of death
in patients who survive  the immediate  effects of the injury.  The
usual cause of infection is the passage of a catheter, and if the kidney
capsule  has  been ruptured suppuration extends  into the perinephric
tissues.  Chills, fever, increasing pain, and tenderness in the lumbar
region, and  marked  diminution in  the quantity of urine  secreted,
should suggest the probability of infection and should lead to lumbar
incision.
   Cystitis is a complication of  great gravity;  it often folloAvs the use
of non-sterilized instruments employed to  remove clots from the blad-
der ; it may even lead to  infection of the sound kidney.  Hydrone-
phrosis may develop as a  consequence of the blocking of the ureter
by a clot; this, in case of infection, becomes converted into  pyone-
phrosis.  Traumatic  peritonitis from  the  escape  of blood and urine
into the peritoneal cavity,  and thrombosis  of the  renal  vessels, are
sequelae  that have been frequently fatal.   The kidney may be dis-
placed from its normal position, and thereafter may remain  preter-
naturally movable.  As a remote sequel of traumatism various forms
of Bright^ disease may develop.  Exceptionally the blood-clots form
nuclei for  renal stones.  Ebstein holds that  contusion is a predis-
posing factor in the development of  renal tumors.
   Treatment.—Shock, if pronounced, is treated  in accordance with
general surgical principles.  When there is reason to  believe that the
kidney is bruised, the patient is put to bed, is kept absolutely quiet, and
is given hypodermic injections of morphine for the relief of pain if this
is severe.  When the hemorrhage is profuse,  ergotin is given hypo-
dermically, an ice-bag is applied to the lumbar region, and the side is
strapped with long strips of adhesive plaster, applied as for fractured 
784
GENITO-URINARY  DISEASES AND SYPHILIS.
ribs.  In addition to the straps a broad roller bandage is applied; this
secures a compress of gauze or cotton  over the kidney.   It is unwise
to give either medicine or food by the mouth for the first few hours,
since the patient is likely to vomit, and this  may start  a  bleeding
which has already stopped.  The straining and retching which occur
even Avhen the stomach is empty are best relieved by sufficient doses
of morphine.  Thirst may be appeased by rectal injections of normal
salt solution, a pint at a time, at blood heat.
   A fairly Avell-nourished man can subsist perfectly Avell for three to
five  days Avithout nourishment of any kind, and it is wise to Avithhold
even liquid  food until the  stomach is retentive.   For three weeks at
least after suspected injuries of the kidney the diet should be liquid,
and  the intestinal evacuations  should be so regulated  as to be ac-
complished without  straining.   This may require  the daily adminis-
tration of enemata.   Morris  has seen hemorrhage brought on more
than two weeks after  the injury by the passage of solid faecal matter
through the colon, thereby giving rise to pressure against the kidney.
Coughing, sneezing,  forced  efforts  at micturition,  sitting up, any act
which may suddenly change the conditions of  intra-abdominal press-
ure,  should  be avoided. As soon as the stomach becomes retentive,
salol and boric acid  should be given by the mouth for the purpose of
rendering the urine slightly antiseptic, and the patient should drink
an alkaline  water freely, since  the loAver the  specific gravity of the
urine the less the tendency toAvards the formation of tough clots.
   Should retention of urine develop because of clots  blocking the
urethra, an  effort should be made to relieve this  condition by a hot
bath.  This failing,  the suction  catheter or the  litholapaxy tube and
evacuator may be used.  These instruments must be employed with
minute attention to  the antiseptic precautions  already described in
the treatment of retention from enlarged prostate.  Sepsis is the most
dangerous and frequent sequel, and its usual cause is catheterization.
Should the  suction  catheter or the  evacuating-tube not  succeed in
evacuating the bladder-contents, or  should there be frequent recur-
rence  of retention  from clots,  requiring repeated  catheterizations,
median perineal cystotomy is indicated, followed by the insertion of a
large tube, and by frequent irrigations of the bladder.
   Should haematuria  persist and constitutional symptoms show that
loss  of blood is producing dangerous anaemia,  surgical intervention is
imperative.   This should take the  form of an  exploratory lumbar in-
cision.   The kidney can thus be thoroughly exposed, the extent of
injury determined, and the  bleeding  stopped  by ligature of the torn
vessel,  ligation  and excision of a portion  of  the  kidney, firm pack- 
INJURIES AND  DISEASES OF THE  KIDNEYS.
785
ing, or nephrectomy.   This last operation is indicated only when the
kidney exhibits multiple and  extensive lacerations.   Lumbar incision
is also indicated in cases exhibiting no blood in the urine, but rapidly
developing a lumbar tumor associated  with symptoms  of  internal
bleeding, and in those showing the constitutional and local symptoms
of infection.
   Owing to the depth and inaccessibility of the Avounded vessels, it
may be impossible to tie them, or, even  if they were tied, the blood-
supply of the kidney might  be thereby so  curtailed that necrosis would
be certain to result.   Under these circumstances nephrectomy is indi-
cated.  Children are  less  able than adults to resist internal hemor-
rhage, but are  apparently  more likely to recover from nephrectomy.
Therefore nephrectomy in them should not be delayed  in  case of
uncontrollable internal hemorrhage from ruptured kidney.  In one of
Obalinskfs cases the indication Avhich led him  to  perform nephrec-
tomy Avas the formation in  the right hypochondrium on the ninth day
after the injury of a tender, circumscribed tumor, the size  of a child's
head. The kidney Avas immediately exposed by a lumbar incision, and
found almost completely severed and surrounded by a large quantity
of healthy urine and small  blood-clots. The fragments were removed,
the pedicle Avas tied  off, and the wound was plugged with iodoform
gauze.  The patient recovered.  Obalinski favors exposing the kidney
by laparotomy Avhen  after  injury there are  a rapidly formed tumor,
profuse haematuria, and other indications of severe hemorrhage.   This
incision furnishes an opportunity of washing out the peritoneal cavity
in case its lining membrane has been wounded and it contains  blood
or extravasated urine.
   Of one hundred and seventeen cases  of ruptured kidney collected
by Keen, sixty-seven recovered and fifty died, a mortality of forty-two
and seven-tenths per  cent.  From the fatal cases he deducts seventeen,
since in  these treatment was futile or impossible.   In one the other
kidney Avas absent, in  two both kidneys were injured, two  Avere found
dead, and twelve died of  injuries other than kidney-rupture.   This
leaves one hundred  cases, Avith sixty-seven recoveries, a mortality
of thirty-three per cent.    There were thirteen early deaths—eleven
from shock and  hemorrhage, two  from  peritonitis—and  ten  late
deaths,—eight from sepsis, two frojn hemorrhage.   In none of these
cases was nephrectomy performed,  although there  is reason to be-
lieve that nephrectomy would have  saved a number of them.   Con-
sidering the cases in which nephrectomy was performed, in five cases
of primary operation  there was one death, and  in  thirteen  cases of
secondary operation  there  Avere five deaths, apparently showing that
                               50 
786        GENITO-URINARY  DISEASES AND SYPHILIS.

after injuries of this character secondary nephrectomy is nearly twice
as fatal as primary.   Abdominal  nephrectomy  gave a mortality of
thirty-three and three-tenths per cent., and lumbar nephrectomy gave
a mortality of twenty-eight  and six-tenths  per  cent.   Hemorrhage
and sepsis caused the greatest number of deaths.
   Wounds of the Kidney.—Wounds of the  kidney, much rarer
than contusion  or  rupture,  are  conveniently classed in accordance
with their causes as gunshot, punctured, and incised wounds.
   Gunshot Wounds.—A bullet which  wounds the kidney is very
likely to  injure  other viscera.  Of seventy-eight  cases of gunshot
wound of the kidney reported by  Otis,  other A'iscera were Avounded
in thirty-three.   Balls usually pass through the kidney, sometimes
leaving  in its  substance  portions of clothing; exceptionally they are
buried in the secreting portion of the organ: thus, Simon found a
bullet encysted in the kidney parenchyma.
   The bullet may wound  simply the secreting  substance  of the
kidney,  may pass through the pelvis,  or may tear  the  great vessels.
The  modern army rifle, either at close  or at long range, may prac-
tically pulpify  the entire organ.   When the wound involves only the
kidney-substance there is moderate bleeding with  no  extravasation
of urine, and, provided other organs are spared, healing takes place
with extraordinary  rapidity.
   When the pelvis  is opened there  will be  urinary extravasation.
This, hoAvever, need not lead  to infection.   The bleeding is usually
more  profuse  than when only the  secreting substance  of the  kidney
is involved, and, unless the  ureter is  torn completely across, there
will be  haematuria.  When the large  vessels are cut, hemorrhage  is
so severe  as to threaten life.   The blood may be poured out into the
perinephric tissues, into  the  peritoneal  cavity, and  into the bladder
through the ureter.
   Punctured wounds, such  as those  made with a needle  in  kidney
exploration, are entirely safe, unless infection is carried with the vul-
nerating instrument.  When  made with a comparatively blunt  instru-
ment, as the  prong of a  hay-fork, there  are contusion and laceration
in addition to the  puncture, and the  consequences are the same as
those incident to gunshot wound.
   Incised wounds  are rare, since the  position of the kidney protects
it.  Incised wounds are  much more liable to be  entirely extraperito-
neal  than are those inflicted by fire-arms.  The wound of entrance
is often  in the lumbar region; stabs and cuts inflicted  from in front
rarely extend backward as  far as the  kidney.  As in the case of
gunshot wounds, these injuries may involve the  secreting substance, 
INJURIES AND DISEASES OF  THE KIDNEYS.
787
may open the pelvis, may divide the large vessels, or may sever the
ureter.
   A few cases have been reported in which, after extensive wound
of the lumbar region, the kidney has protruded.
   Symptoms of Wound of the Kidney.—The chief symptom of Avound
of the kidney is haematuria.  If the pelvis has been opened there will
also be escape of urine through the Avound.  Pain  may be severe,
assuming the type of kidney colic; oliguria is constant.  Exception-
ally there is complete suppression of urine.
   Diagnosis.^-The  diagnosis is based on—1, the nature of the vul-
nerating body, its direction, and the depth to which it has penetrated;
2, blood in the urine ;  3, escape of urine from the wound ; 4, exami-
nation of the kidney through the Avound or through a lumbar or an
abdominal incision.
   When the entrance-wound  of a bullet is over the kidney, and the
direction of  its track is toAvards this organ, this constitutes a reason-
able ground for suspecting injury to the kidney, since  the course of
a bullet in the body is usually  straight; haematuria would then make
the diagnosis reasonably certain.  The kidney may,  however, be in-
jured by a ball Avhich enters the body at a considerable distance from
the parietes overlying it.  Thus, Otis  mentions a case in which the
bullet entered  just  beloAV the  clavicle.  Haematuria and escape of
urine through the wound are diagnostic of wound of the pelvis or of
the ureter rather than  of the kidney.
   Palpation of the  kidney is sometimes possible through an incised
wound, such. as Avould be inflicted by a stab with  a broad-bladed
dirk; this would make the diagnosis absolutely certain.
   Prognosis.—Incised wounds of  the kidney  heal readily;  even
though the  pelvis is opened and  there is escape of urine,  this does
not materially interfere with recovery, provided the ureteral lumen
is  not encroached  on.   These injuries are  dangerous chiefly  from
primary  hemorrhage, which  is likely to be  profuse, and from the
wounding of other Auscera.  Of thirty-one incised Avounds  collected
by Duplay and Reclus, eight died.   In  six of  these the kidney-wound
was complicated by involvement of other viscera.
   In  the absence of profound shock and  severe  hemorrhage, the
prognosis of kidney-wound is  favorable, even though  the  organ is
very extensively  injured,  since in  the great   majority of cases the
wound is unilateral and occurs in persons  possessed of  a sound
kidney capable of performing the work of both.  The prognosis  of
wounds from in front, opening  the peritoneum overlying the kidney,
is much more serious than is that of extraperitoneal  wounds. 
788        GENITO-URINARY* DISEASES AND SYPHILIS.

   Gunshot  wounds commonly involve  other  viscera.   Thus of
thirty-eight cases collected  by  Duplay  and  Reclus, sixteen  died •
eleven of these deaths Avere attributable to multiplicity of the lesions.
The  complications  and sequelae of wounds of the kidney are those
described when  considering contusions ; the  danger of  infection is
greater in wounds than in contusions, since  it may reach the kidney
either from the ureter or from the parietal opening.
   Treatment.—The general treatment of wound  of the kidney is that
already described as appropriate to contusion.   The Avound itself
should  be scrupulously disinfected,  and should be drained, even
though  there be no escape of urine, since the  vulnerating body is
never sterile.
   When a bullet entering the body from in front has passed towards
the kidney, and there follow haematuria and symptoms of internal
hemorrhage,  coeliotomy should be performed at  once, since this  en-
ables the operator not only to deal with the kidney, but to recognize
and close wounds of the abdominal viscera.
   When the wound is in the lumbar region and there is doubt as to
whether or not the peritoneal cavity has been  entered, the lumbar
incision is preferable.  The indication for immediate operation, as far
as the kidney is concerned, is  hemorrhage.   The kidney having been
exposed, either by an incision through the linea alba, along the outer
border of the rectus muscle, or in the lumbar region, according to the
position of the  wound, the bleeding point is sought for and secured,
by ligature, if this is possible, or by packing in case the ligature cannot
be applied and there seems a fair prospect of saving the kidney, or
by nephrectomy.
   If the wound involves only the secreting portion of the kidney, it
should be cleaned, drained, and  packed.  If the  renal artery is torn,
or- if the  kidney is  so extensively disorganized  that repair  is abso-
lutely impossible, nephrectomy is indicated.  If the pelvis is opened,
it should be closed by suture, if possible; if not possible, provision
should be  made for lumbar drainage.   If  the ureter is torn across
its upper portion, lumbar drainage is  usually indicated, since from
loss of blood the patient is not prepared  to stand a prolonged plastic
operation.   Should  recovery take place, implantation of the ureter
into the pelvis may be effected subsequently.  Blood  or extravasated
urine found in  the  peritoneal cavity  should  of course be removed by
sponging, the kidney being then shut off from this cavity by suture of
the peritoneum.  Extensive accumulation of blood in the perinephric
and post-peritoneal tissues  should be removed, since huge abscesses
will otherwise develop if infection occurs. 
INJURIES AND DISEASES OF  THE  KIDNEYS.
789
   Incised wounds of the kidney are treated  by gauze drainage if
hemorrhage is moderate.  If it is persistent and severe, the  kidney
should be exposed by lumbar  incision, the bleeding vessels, if large,
secured by ligature, or the hemorrhage  stopped by packing, and the
kidney-wound closed by catgut suture.   Stitches are serviceable in
these cases as a means of haemostasis ; they also materially hasten the
process of cicatrization.   When a large portion  of the kidney is almost
entirely cut away, this should be removed.  If the renal artery is cut,
nephrectomy is indicated.
   Foshay studied the changes in  the  urine  after nephrectomy in
two cases, and in both found  evidence  of temporary hyperaemia of
the remaining kidney.
   Meyer,  after reporting a case of anuria following nephrectomy,
in which  nephrotomy was  performed,  remarks, " There  evidently
occurs an excessive hyperaemia in the remaining kidney immediately
after nephrectomy.   Its   presence  is  demonstrated by the  sudden
change in the transparency of the urine if  that remaining kidney had
already been  slightly affected.   It has been  observed by many Avho
have done several nephrectomies that in  a  number of cases  imme-
diately after  the one  unhealthy kidney has been removed the urine
which descends from its probably  only slightly affected fellow, and
which had formerly been found comparatively clear, Avith the help of
cystoscopy, or after nephrotomy on the other side had been done,
suddenly  becomes very   turbid,  and  presents  an unusually heavy
deposit after  short standing.   As I have  seen, it can take weeks or
months before this turbidity lessens or disappears.  In the majority
of cases it does so, hoAvever, but slowly and gradually.11
   Schede also mentions the  arterial pressure necessarily present
and suddenly increased  in the remaining  kidney after nephrectomy
on the opposite  side.  He is  inclined to  regard it as the  probable
cause of the  acute epithelial necrosis in  the  tubuli  contorti  of the
kidney, which  has been  found on  microscopical  examination of the
remaining kidney in a feAV instances after nephrectomy, and to which
the immediate fatal result of  the operation evidently was due.
   Nephrectomy.—When the wound is  extraperitoneal the lumbar
route may be chosen, though many  surgeons of experience  have
abandoned it in favor of  the abdominal operation.
   The incision should be four inches long, beginning  about two and
a  half inches from the spines  of the vertebrae, and running parallel
to  the twelfth rib, and a full  half-inch below it, in  order to avoid
wounding the pleura, which sometimes  extends down to the twelfth
rib. This Avound  may be enlarged,  if necessary, by another incision 
790        GENITO-URINARY  DISEASES AND SYPHILIS.

carried  downward from its  inner third to the  crest of the ilium.
When the kidney has been exposed, as in nephrorrhaphy, and freed
from any adhesion to its fatty capsule, and blood-clots have been re-
moved, it should be draAvn into an accessible position in the Avound
and  a double ligature  passed betAveen  the vessels and the  ureter
as far down as possible;  the  vessels and the ureter are then tied
off separately.  The kidney can  then be drawn out of the wound
and  the vessels  and  the ureter tied off again near the pelvis of the
kidney  to  prevent escape  of urine into the wound, and the pedicle
cut between the two ligatures.   The wound should be irrigated with
sterilized Avater or sublimate solution and packed with.sterile gauze,
or it  may be  partially closed and  drained with a rubber tube, which
should be removed in three or  four days.
   Nephrectomy through an incision in the  linea  semilunaris, known
as Langenbuch's operation, is indicated Avhen the Avound has probably
involved other organs and has opened the peritoneal cavity.  This
incision to allow of free manipulation should be at least four inches
long.   When bleeding points have been  secured  and  the abdominal
cavity has been  opened, as in all other laparatomies, the  opposite
kidney  is  palpated,  not only to  make sure of its  existence, but,
furthermore, to  ascertain, as far as possible, its  condition of health
and Avhether or  not it can endure  the strain  of double duty.  If it be
absent or diseased, the operation must be abandoned.   If this exam-
ination  of the uninjured kidney shows that it is probably healthy, the
intestines are pushed aside from the affected kidney,  the outer layer
of the mesocolon is  exposed, and a vertical slit is cut in it over the
kidney.  If the peritoneum or its contained viscera  have not been
wounded,  the divided  edge of the peritoneum covering the kidney
may be quickly stitched to the inner edge of the first incision through
the peritoneum of  the  anterior  belly-Avail.  When  this has been
done the operation is to all intents performed extraperitoneally; but
it  is by no means always necessary, and may often be  omitted Avith
advantage, the general cavity being  sufficiently protected by careful
gauze packing.
   If the  peritoneum has  been  wounded, blood and extravasated
urine are sponged out and  intraperitoneal injuries are treated before
dealing  with the kidney, unless there is bleeding; in that  case no
time is  lost in fully exposing the  organ.  The kidney is enucleated
from its fatty capsule as  in the lumbar operation, and the vessels and
ureter are tied off and  divided as has just been described.  It is ad-
visable in this operation  to provide drainage  through a lumbar wound
for three or four  days.  Unless there are lesions of  the abdominal 
         INJURIES AND DISEASES OF  THE  KIDNEYS.       791

viscera, or from the nature of the Avound it is probable that infection
will folloAV, the peritoneum overlying the kidney should be completely
closed by suture, and the  abdomen closed Avithout drainage.  When
abdominal  nephrectomy is performed after infection has developed,
the peritoneal cavity must be freely drained.
   In abdominal nephrectomy performed through  an incision in the
linea alba the operation is exactly the same as an ordinary abdominal
section up  to  the  time Avhen the  inner  layer  of  the mesocolon is
incised in order to reach the postperitoneal kidney-space.   Thereafter
the procedure is the  same as  in Langenbuch^ operation.   Profuse
hemorrhage from cutting  one of the large veins running along the
inner layer of the  mesocolon  frequently happens; this may be pre-
vented by  cutting  in the  line of the veins, or  by tying beforehand
those vessels Avhich inevitably must be  cut.   Drainage should be
secured through a counter-opening in the lumbar region.
   With the progressive improvement in the surgical details of ab-
dominal  operations the anterior or transperitoneal incision for ne-
phrectomy  has  been advancing in favor ; its main advantage is the
opportunity it affords of examining into the condition of the uninjured
kidney. 
CHAPTER  XXII.
                          KIDNEY CALCULI.

    Uric acid calculi are found  more frequently than any other form
of kidney stone.   Next  come  oxalate  calculi.  These are both de-
posited from acid urine,  and are partly dependent for their formation
on systemic conditions.
    Phosphatic calculi and  those  made up of calcium  carbonate are
less frequent.   They are deposited from alkaline  urine, and infection
is a strong predisposing  factor in  their formation.  Litten has shown
experimentally that temporary ligature of the renal artery is followed
by calculous infiltration  of the degenerated epithelium, Avhich subse-
quently may be transformed into true calculi.
    Cystin, xanthin, ammonium urate, or other urates are rare as the
principal ingredients of kidney stone.  It is possible that  calculi may
originate in  the renal pelvis  about a minute clot.   Exceptionally con-
cretions are found made  up  almost  entirely  of inspissated blood.
Foreign bodies serving  as nuclei are extremely  rare.  Franks has,
hoAvever, reported a case in Avhich an ordinary sewing-needle  formed
the nucleus of stone which caused an extensive perinephric abscess.
The needle had been swallowed in childhood, and had finally pene-
trated  the pelvis  of  the kidney  and  there become encrusted with
urinary salts.   Rosenstein found  a calculous  deposit  about  a  hair,
evidently from a dermoid cyst of the kidney.
   The number  of calculi  may vary from one to a thousand.  In
shape they are seldom round or regular, owing both to the shape of
the cavity wherein they are  contained and  to their restricted attrition
from motion.   One large calculus and numerous  small ones may be
found  filling up the renal pelvis, in Avhich case  the  larger calculus
acting  as  a  ball-valve may partially close  the entrance to the ureter
and only occasionally alloAv smaller calculi to pass down.   Such may
be the  case Avhen frequent  attacks of renal colic  are followed by the
passage of small calculi  per  urethram, but the general symptoms  do
not ameliorate.
   Kidney calculi are usually found in the pelvis or its branchings.
Exceptionally  they are placed in the substance of the kidney, as is the
case Avhen the urate infarcts  of the neAvly-born form true stones.  In
     792 
Fig. 215.

Various forms of kidney-stone, illustrating the irregularities in shape.   (Torres.) 
 
KIDNEY CALCULI.
793
the absence of infection calculus is generally adherent, taking the shape
of the portion of the pelvis in which it is placed, often bifurcating and
branching like a piece of coral, and representing a rough mould of the
pelvis and  its subdivisions.   (Fig.  215.)  When infection has taken
place, calculi may be found in any portion of the pelvis, perhaps most
frequently in  its  upper and loAver extremities.   Both kidneys  are
affected in about fifteen per cent, of cases.'
   A calculus of moderate size may remain indefinitely in the  kidney
without  producing the slightest  pathological change in the secreting
structure.   If the calculus is  so placed that it  suddenly and com-
pletely  blocks the ureteral  orifice, the  kidney will atrophy.   As  a
usual sequel there is gradual dilatation of the pelvis  and its branches,
due to partial  obstruction.  This may result in either hydronephrosis
or atrophy.   When infection has taken place,—and this occurs, as  a
rule,—there result pyelonephritis, pyonephrosis, and often secondary
purulent  deposits.  As  a complication  of  the kidney  infection  an
indurative or suppurative perinephritis may develop.
   Uric  acid  stones form two-thirds of all renal  calculi.  (Prout.)
They vary in size from that of a grain of sand to that of a goose-egg.
The surface is usually smooth, sometimes granular;  the color is dark
yellow or red.   The Avhole concrement may be made up of uric acid.
Frequently it is  composed of a nucleus of uric acid with  oxalate layers
placed about  this, and finally a  superficial coating  of the  earthy
phosphates.
   Oxalate stones, formed about a  nucleus  of epithelium, have been
found in  the  secreting substance of the kidney; they are apt to be
of a dark brown or black color.   When found  in  the  pelvis of  the
kidney they are generally round if  single, faceted if multiple, with  a
rough surface.  They are harder than the  uric  acid  calculi.  They
ordinarily show a nucleus of uric acid.
   Cystin  calculi are commonly made up  of  this ingredient  alone.
They are light  yelloAV in color, and  exhibit a smooth or a  rough
surface; they turn greenish or bluish  on exposure to air.
   Xanthin calculi are extremely rare.
   Phosphate calculi  do not often form the entire bulk of a concre-
ment.   They  are  usually deposited as an outer shell  upon the  uric
or oxalate stones.  They are  light gray in color  and comparatively
soft.
   Calcium carbonate  stones  are  exceptional  in  man.   Marcet has
found in diverticula of the pelvis  yellowish or grayish  concrements
of dense elastic structure made up entirely of fibrin.
  In  dealing with renal calculi  the degree  of  hardness is  of no 
GENITO-URINARY  DISEASES AND  SYPHILIS.
moment.  Owing to their position, it is impossible to crush  them or
wash them away from the pelvis of the kidney; they must either be
removed entire, or, if soft  and friable, be broken  up and  removed
with a scoop.
   Etiology.—The  formation of kidney calculi is due to the precipita-
tion  in the  kidney tubules  or pelvis of the solid constituents of the
urine.   This precipitation' always  takes  place on an  organic base.
This may be  mucus, epithelial cells, blood-clot, or  colloid material;
it  has already been mentioned that a  coagulation  necrosis  of cells
caused by interference with the circulation favors deposition of lime
salts.  All concrements, whether they be the size of a grain of sand or
of a  goose-egg, have a distinct albuminoid  framework upon Avhich the
constituents of the urine are deposited.   The difference between sand
and  sediment lies in the fact that in the former the  crystals are con-
glomerated about this organic framework.
   Diathesis  possesses a distinct influence  upon  stone-formation,
which is commonly associated with the uric a'cid, the oxalate, or the
phosphatic diathesis.  Ebstein holds that the excess of urates, oxa-
lates, or phosphates in the urine does not form stone by direct deposi-
tion  in the  excretory canals or pelvis of  the  kidney, but that these
ingredients favor a coagulation necrosis of cells, which furnishes the
organic frameAvork essential for calculus formation; the same effect
is  produced by local sepsis.
   Heredity exerts a direct influence  on  the  development of kidney
calculi.  Leroy d^tiolles records  the  fact that of  a family  of eight
brothers who  lived in various parts of  Europe under different condi-
tions of hygiene all had calculi.   Toel observed calculi and gravel
in a  mother and two daughters.
   Uric acid kidney stones have been found in the foetus.  In general
renal  calculi are most  frequently observed in children and  after the
fortieth year.   The uric  infarct of the neAvly-born, appearing as a
deposition of  red  and  brown crystals,  particularly of ammonium
urate,  in the  epithelium  of the pyramidal tubules, may account  for
the frequency of vesical calculi in children; kidney  colic is, however,
rare at an early age.
   Renal calculi are  commoner in men than in women,  the ratio
being given as three to  one.   Duplay and  Reclus, however, hold that
the two sexes are equally affected.
   Hygienic surroundings,  climate, and diet seem to have a definite
relation to the formation  of kidney stone, but one which has not been
clearly formulated.  Moist climates and sudden changes of temperature
apparently predispose to  calculus-formation. 
KIDNEY CALCULI.
795
   Men who lead sedentary lives and indulge in high living are more
liable than others to urinary concretions.  The frequency with which
renal calculi are found among the children of the  poorer classes has
been attributed to unfavorable hygienic surroundings and coarse diet.
It is believed to be due to the absence of milk from the diet of such
children.   This  is an  original observation of Mr. Cadge, and is Avell
illustrated by the story Avhich he has published in corroboration: " A
few years  ago, after removing a stone  from a  child  of  well-to-do
parents, I Avas remarking to one of my assistants that this Avas the first
instance  in my practice,  and that I attributed the general absence of
stone in such persons to the free  use of milk; the mother volun-
teered the statement that in a large family this Avas her  only  child
who never could take milk, and Avho therefore never had had any.11
   In opposition to this belief it is interesting to note  that Cantani
believes that the ingestion of starches and of milk plays a major rdle
in the production of kidney calculi.
   Symptoms.—The chief symptoms of renal calculus are pain, haema-
turia, frequent urination,  fragments of calculus  appearing with the
urine, pyuria, oliguria or suppression, and  symptoms of gastro-intes-
tinal disturbance.   A stone may, however, be present in the kidney
for  many  years,  or through  an entire  lifetime,  without  producing
symptoms.
   The  symptoms caused by  kidney stone are due to obstruction
rather than to the presence of a foreign body :  hence the position of
the stone is of more importance than its shape  or size.
   The pain of renal  calculus is commonly referred to the  lumbar
region of the affected side. It is increased by motion, by jarring, and
by pressure over the kidney.   It begins as a feeling of weight or ten-
sion rather than as an actual pain.   It is subject to sudden exacerba-
tions, often occurring at  night when  the patient is completely at rest.
Jacobson believes  that these attacks are due either to the passage of
flatus in the  colon Avhich presses  against  the kidney, or still more
probably to the fresh deposit of salts on calculi already existing either
in the renal pelvis or in one of the calices.
   The pain may be referred to the  healthy kidney or to the  bladder.
It usually radiates along  the course of the ureter and into the testicle,
and may cause  contraction of the cremaster muscle, with retraction
of the gland.  It may be referred  to the  thigh or the calf of the
leg.
   The reflexes of renal calculus occasionally take the form of intes-
tinal disturbances, characterized  by vomiting and violent intestinal
colic.  Rectal and vesical  tenesmus  are not rare.  Urgent  and pain- 
796        GENITO-URINARY  DISEASES AND SYPHILIS.

ful urination is  often so marked that attention is  diverted from the
kidney to the bladder.
   Renal tenderness elicited on deep palpation is a valuable symp-
tom.   Lloyd lays  considerable stress upon the characteristic stab-
bing pain which is  caused by deep  percussion over the loin of the
affected side.
   Attacks  of  kidney colic  are particularly characteristic of renal
calculi.   Perfectly typical  paroxysms may,  however, occur Avithout
the presence of stone.  This is proved not only by the large number
of cases reported in which, the diagnosis having been  based mainly
on this symptom, the kidney was opened and no stone found, but
also by the  cases in which, the kidney having been exposed to sight
and touch, rhythmical contractions of the ureter were observed.   This
offers another explanation,—that of ureteral colic, which may be ex-
cited  by  divers conditions, and would  naturally have  subjective
symptoms very  like those characterizing kidney colic.
   Haematuria  is usually slight and transitory, and, except after the
attacks of kidney colic, can often be detected only by microscopic ex-
amination.  Clots are rare.  The amount of  blood  in the urine is
increased by jolting, walking,  muscular  efforts,  or renal palpation;
there is  sometimes  enough to give the  urine a smoky appearance.
Sometimes bright-red blood  is passed, but this is  much more char-
acteristic of tumor than of calculi; this is true  also of clots.  Rest in
bed exerts a prompt and markedly beneficial effect upon the haema-
turia.   There  are  often  found in the  urine  blood-cylinders,—i.e.,
casts of the uriniferous tubules made up of blood-cells;  these  are
absolutely characteristic of hemorrhage of renal origin.
   Frequent urination, as a pure reflex  from renal and ureteral irri-
tation, is  often a troublesome  symptom during  the daytime, but is
relieved  when  the  patient is at rest.  Jacobson observes that  noc-
turnal and diurnal frequency of urination, when associated with  other
symptoms suggesting renal calculus, indicates renal tuberculosis with
extension of the process  to the bladder-walls,  rather  than  renal cal-
culus.   The  frequent urination of kidney calculus is  usually  unat-
tended by pain.  When, together Avith frequency and urgency, there
are marked  tenesmus and suffering during and after  the act of mic-
turition, these symptoms  are attributable to concomitant inflamma-
tion.
   The passage  of gravel or of fragments of calculi is a symptom com-
monly wanting; Avhen present it is of great value as indicating kid-
ney stone, even though its passage along the  ureter  does not cause
symptoms of kidney colic. 
KIDNEY CALCULI.
797
   Diminution or total suppression of the urine lasting  for a  few
hours is a fairly frequent symptom of kidney colic.   When it lasts a
much longer time it should be attributed to the simultaneous obstruc-
tion of both ureters, or to obstruction of the ureter of the  only func-
tioning kidney.
   Exceptionally this obstruction may begin insidiously, attracting no
attention until the symptoms of uraemia set  in.   For six or eight
days there  may be no characteristic symptoms other than failure to
pass water.   After this period constitutional  symptoms develop, in
the form of stupor, tympany, diarrhoea, subnormal temperature, dry
black tongue, often hiccough and  uraemic odor  of the breath.  The
obstruction is usually  placed  in or near the  pelvis:  hence lumbar
incision and nephrotomy are indicated.
   Gastro-intestinal disturbances are either reflex  or due to  imper-
fect  elimination  on the  part  of the crippled  kidneys.   Tympany,
vomiting, and exquisite tenderness at times complicate  and greatly
obscure attacks of renal  colic.  Chronic epigastric tenderness, feeble
digestion, and constant pain may  direct the attention entirely away
from the kidney.
   Pyuria is a sign of pyelonephritis ; it is classed as a symptom of
kidney calculus  simply because it is so  frequent  a complication;
infection markedly aggravates the  pain, the reflexes, and  the other
symptoms already described ; it also causes fever and  favors the de-
velopment of  pyonephrosis.
   Diagnosis.—The diagnosis  of kidney stone  is based  on lumbar
pain with intercurrent attacks  of nephritic colic, haematuria, the pas-
sage  of gravel or of fragments of calculi, tenderness, and the detec-
tion of a tumor.  These symptoms are rarely all present   Pain and
haematuria are the two most constant, and, with the  exception of the
passage of calculus fragments, the most characteristic.   Unfortunately,
they are also symptomatic of a number of other  abnormal conditions.
Thus, movable kidney often causes  constant pain and acute exacerba-
tions precisely like those which arise from stone.  Sometimes blood
is mixed with the urine, but only after an acute attack of pain;  the
movable kidney can often be felt in its abnormal position,  but this is
not always the case.
   Nephralgia may simulate renal  calculus in  all respects except in
the presence of blood or pus in the urine,  though Sabatier states that
this.affection also causes haematuria.  In Avomen the paroxysms of
pain are especially marked at the catamenia.   The pain may radiate
in the same  direction  as that from  renal calculus; the urine is, how-
ever,  passed in large quantities, is  of low specific gravity, is limpid, 
798        GENITOURINARY^ DISEASES AND SYPHILIS.

and  contains neither pus  nor blood, nor is there  any history of the
passage of calculous material.
   Tuberculosis of the kidney in its  early stages may simulate renal
calculus so closely that an exploratory incision will be required before
a differential diagnosis can be established.  There is haematuria Avhich
is apparently causeless, and the characteristic reflexes develop.  Renal
tuberculosis is often associated with hereditary dyscrasia and tubercu-
lar infiltration of the  epididymis, prostate, and vesical walls.   More-
over, repeated and patient search will  sometimes  show the  tubercle
bacilli.  Tubercular kidney  seems more subject to mixed infection
than is the case in calculous  kidney :  hence there is often a great deal
of pus in the urine ; this may be thick and contain caseous particles,
which  rapidly settle to the bottom of the vessel in which the urine
has been passed.
   Malignant growths are characterized by  haematuria much more
pronounced than that due to calculus,  clots often appearing in the
urine in the shape of ureteral moulds ; the growth rapidly and steadily
increases in size.   Fragments of the growth are sometimes passed in
the urine, and these in obscure cases may be the only reliable means
of forming a diagnosis.   Exploratory operation is justifiable  under
these circumstances.
   Oxaluria and strongly acid urine cause dull ache, paroxysmal pain,
and  haematuria.  The pain  is, however, not  materially increased  on
exertion, the tenderness is not  distinctly marked on deep palpation,
and treatment is followed by prompt  relief.
   Pyelitis cannot be distinguished from renal calculus with infection
except by the history of the case.  Pain  is not likely to  be so dis-
tinctly paroxysmal.
   Spinal  caries  involving the lower dorsal  or the lumbar vertebrae
may in its symptomatology closely simulate  kidney stone.  Thus,
Wright reports a case characterized by increased frequency of urina-
tion, intermittent  attacks of pain causing nausea  and vomiting, tes-
ticular  pain and  local  tenderness,  and oxaluria.  An abscess had
formed in the  neighborhood of carious vertebrae and by pressure on
the kidney had caused symptoms of calculus.
   The distinction betAveen kidney stone and gall stone may be quite
impossible during  an acute attack of pain; during the intervals care-
ful repeated examination of the urine should throw some light on  the
matter.
    Locomotor  ataxia  and hysteria  may produce  symptoms closely
simulating those of renal calculus.   Examination of the urine should
exclude kidney stone. 
KIDNEY CALCULI.
799
   It will thus be  seen that  in  many cases  a positive diagnosis of
renal calculus cannot be made.  This is well shown by the history
of renal surgery.  More than fifty cases have  been reported in which
nephrotomy or  nephrectomy  was performed  for the relief of stone
when this condition was not present.
   Morris has reported twenty-eight cases in Avhich he was unable to
confirm the presence  of a stone, although the  symptoms strongly
suggested that this was present.  Some  of the cases were suffering
from tubercular nephritis and pyelonephritis, some had  kidney ab-
scesses, some perinephritis ; the causes which  led to  operation in the
remaining  cases were movable kidney, prostatic abscess, calculus of
the prostate, encysted stone in the lower end of the ureter, the after-
effects of stone which had  passed through the ureter, simulation of
nephrolithiasis by disease of the neighboring  organs, and disease of
the vertebrae, Avith  consecutive perinephric pus-formation.   In some
cases neither stone nor  any other cause for symptoms Avas found.
   In thin persons, and when there are many concrements, on pal-
pation both tumor and crepitus can  be detected, the latter particularly
by combining palpation Avith auscultation.  This  is,  however,  excep-
tional.
   The most characteristic diagnostic symptoms, placed in their order
of importance, are passage  of gravel or of fragments  of stone, attacks
of typical renal colic, haematuria, and ultimately pyelitis.   It is clear
that prolonged study of the urine is necessary before forming a diag-
nosis, the results of this study often  sufficing to exclude affections the
symptoms of which in every Avay simulate those of renal calculi.
   It is  of extreme importance  to  determine whether one or both
kidneys are calculous, and if but one kidney is affected, whether the
other is  healthy.   The seat of pain and particularly the location of
tenderness on palpation are  valuable in determining  the kidney
affected.   The passage  of normal urine free from blood or pus  during
attacks of renal colic  points  to  the existence of  a  healthy kidney,
though the absence of this  sign—i.e., the passage of  purulent  blood-
stained urine—does not  necessarily show that both  kidneys are af-
fected, since the obstruction in the ureter of the affected side may not
be complete.  When there is pyuria  and an operation is contem-
plated, the question may be settled by the  use of the catheterizing
cystoscope.
  The final diagnosis of kidney calculus, and this  is always  justi-
fiable when the integrity of the  kidney is seriously  threatened and
when the patient's health is progressively failing, is direct exploration
of the kidney pelvis by  means of a lumbar nephrotomy. 
800
GENITO-URINARY DISEASES AND SYPHILIS.
   Prognosis.—In the absence of symptoms of obstruction or infec-
tion  the prognosis of kidney  stone  is favorable.   The foreign body
may remain  years in the pelvis or calices of the  kidney, causing  no
symptoms other than occasional haematuria or perhaps pain, and not
seriously affecting the secreting substance of the organ.   When ob-
struction  develops, if it  is transitory, due to the  passage  of a stone
into  the bladder, and is  completely relieved  by the escape of the
calculus, the prognosis is still favorable, even though these attacks of
kidney  colic  are  frequently repeated.  When the  obstruction is not
promptly relieved, but becomes chronic, the prognosis as to the integ-
rity of the kidney is grave.   When infection takes place, the prog-
nosis is ahvays  grave unless prompt  operation  is  practised.  The
combination of obstruction and infection imperatively calls for opera-
tive interference.
    Treatment.—The  preventive treatment of kidney calculus is  indi-
cated when the passage  of sand or gravel, or a microscopic examina-
tion of  the urine, sIioavs that there is an excess of solid constituents.
In case the sediment or  sand is made up  of uric acid, out-of-door ex-
ercise,  abstinence from  alcoholic  drinks, baths and surface friction,
careful  regulation of  the diet, and the ingestion of large quantities of
Avater, particularly Carlsbad, Friederichshall, and  Londonderry, are
indicated.
   When the sediment is made up of calcium  oxalate, in addition to
exercise, diet, and diluents, nitrohydrochloric acid is of service.  De-
posits from  alkaline  urine require treatment directed either  against
alkaline dyspepsia or local infection.
   Patients subject to lithiasis should eat sparingly, should especially
avoid dark  meats, sugars, highly  seasoned food,  rhubarb, tomatoes,
asparagus, and straAvberries, Burgundy, champagne, and malt liquors.
They should drink  freely of  pure Avaters, which by decreasing the
proportion of salts in the urine lessen the formation of new calculous
material,  and by increasing the volume of urine aid in the discharge
of any  that  has  already been deposited in the kidney.   Potassium
citrate,  lithium carbonate, and sodium phosphate are the most valu-
able alkaline diuretics.   These drugs  may be given in doses of from
five to twenty grains three to six times a day well diluted. Moderate
exercise is highly desirable, but it should not be carried to the point
of extreme  fatigue  or  excessive  perspiration.   All excesses should
be avoided, especially those Avhich may be followed by gastro-intes-
tinal or hepatic disturbances.
    Palliative treatment for severe pain, particularly that characteristic
of renal colic,  is mainly  limited to  the  free use  of anodynes.  The 
KIDNEY CALCULI.
801
methods of using  anodynes, and  the  doses,  have already been de-
scribed under Diseases of the Ureter.
   The curative treatment has for its  object the removal of the cal-
culus from  the kidney.   This should be accomplished  before this
organ  has become degenerated by hydronephrosis or suppuration.
The operation by which  a  calculus is extracted from an otherwise
healthy kidney or  its pelvis—i.e., before the onset of suppuration or
hydronephrosis—is  termed  nephrolithotomy.   In  the presence  of
either or both of these complications the operation for extraction has
been termed simply nephrotomy.  This  distinction  was made  by
Morris, but scarcely  seems worth preserving.
   Nephrolithotomy.—The  indication  for the  performance  of
nephrolithotomy is  harassing,  persistent pain, with frequent  over-
whelming exacerbations, yielding only to  the almost continuous ad-
ministration of anodynes, and anuria.   The route chosen is, with few
exceptions, the lumbar one.  The single advantage  presented by the
abdominal incision is that it alloAvs of exploration of both  kidneys,
thus sometimes establishing  definitely which of the two contains the
calculus.   The  incision  for  exposing  the  kidney is similar to that
already described; i.e., it is about four inches long,  carried from the
outer border of the mass of  spinal muscles parallel to the twelfth rib
and half an inch below it.   In fat patients it is not easy to  find the
twelfth rib by palpation; in these the ribs should be counted from
above downward.   If the first incision does not alloAV of full exposure
of the kidney both to palpation and inspection, it should be enlarged
by a vertical incision made at right angles to it and  carried down-
ward from  either end.   The perinephric  fat is opened widely, and
the kidney is thoroughly exposed through its entire  surface and is
draAvn well into the  wound.  It is then palpated by the fingers  of the
two hands placed on either side, special attention  being  devoted to
the hilum and to  the two extremities. If the calculus cannot be de-
tected by this means,—and this  may Avell  be the  case, since even
after the kidney has  been removed from the body palpation has  failed
to detect a stone in its substance,—an incision should be made through
the kidney-substance in the middle line of the outer convex border.
The kidney pedicle may previously be clamped either by the fingers
of an assistant or by a padded  clamp  made for the purpose, but this
is not essential.  The incision should  be large enough to permit the
finger to be introduced into the pelvis. The cavity of the latter can
noAv be thoroughly  explored, and this exploration  may be aided at
times by a metal  sound.  This instrument, however, must  be used
with great care.  Many surgeons still recommend in place  of incision
                               51 
802        GENITO-URINARY DISEASES  AND SYPHILIS.

exploration of the kidney pelvis by means of puncture with a needle •
Avhether the findings with this instrument are positive or negative, the
pelvis of the kidney should be opened.   The advantages of an incision
from the outer border of the kidney are that it allows a thorough ex-
ploration of the calices, that it passes through the least vascular  por-
tion of the kidney, and that the resulting wound unites promptly on
suture.  The hemorrhage is mainly venous, and may be easily  con-
trolled by means of sponges or gauze, even Avhen the pedicle of the
kidney has not been compressed.  After exploration of the calices and
pelvis the ureter  should always be examined, by means of a ureteral
catheter, if this can be introduced ; if not, injection of a colored solu-
tion, as proposed by Tiffany, will determine Avhether or not there is
obstruction in the course of the  canal.
   The health of the opposite kidney can be determined if the ex-
posed pelvis is thoroughly washed and  then plugged so that no urine
passes from it into the bladder.
   The stone, having been  found, is readily removed, provided  it be
small and  fairly regular in shape.  For this purpose  either the scoop
or forceps  are employed.  Branching, coral-like  stones may require
fragmentation.  Stones deeply placed in the pelvis may be thrust up
by pressure  of the  fingers working from the outside.  Mortar-like
concrements  may be removed by the douche and scoop.
   After extracting the entire calculus it is well to flush out the pelvis
and  calices with  a stream  of normal saline solution floAving under
strong pressure  (eight feet) from  a  comparatively large nozzle intro-
duced through the kidney-wound.  This is  then  closed by catgut
sutures passed deeply into  the kidney-substance and accurately ap-
posing the  borders of the incision.   If the perinephric tissue has  been
Avidely separated, it is well to complete  this operation by  inserting
sutures as  described in the treatment for floating kidney.   Drainage
of the external wound is not required.
   When the secreting substance of the kidney has disappeared and
is  represented simply by a sac in which a large calculus is contained,
nephrectomy is indicated.   This, as  a rurie, should be performed as a
second operation,—i.e., some Aveeks  or months after removal of the
stone and  after  taking every means of making certain that there is
practically no secreting kidney-substance left on the affected side, and
that the other kidney is competent to act for both.
   When infection has taken place, the parietal incision  is the  same
as that for nephrolithotomy, but the incision  into the kidney is made
at the thinnest  and  most  accessible portion of the tumor.  Since
infection is usually complicated  by pyelonephrosis,  there may  be a 
KIDNEY CALCULI.
803
large sac Avith diverticula, making the finding and removal of a stone
extremely difficult.  It is in these cases particularly that the sound is
serviceable.  It  often happens that the calculi are either not found
at all, or, if found, are only in part removed.
   In the after-treatment of  these wounds lumbar drainage is always
indicated.  Fistulae are prone  to persist in the track of the drainage-
tubes.
   As a means of surely removing the calculi and avoiding the per-
sistence of fistulae, primary nephrectomy has been proposed in cases
of  calculous  pyonephrosis, particularly Avhen the sac formed is large.
The operative statistics scarcely justify  this  procedure, though a sec-
ondary nephrectomy  may be  not  only  permissible but  distinctly
indicated.
   Thorndike has collected  one  hundred and twenty-eight cases of
nephrolithotomy,  Avith eighteen deaths, a mortality of fourteen per
cent.  Of these eighteen deaths,  ten occurred in cases which  were
suppurating at the time of operation, six in cases where there was no
suppuration, and in the other tAvo this point was not mentioned  in
the report.   On the  other hand, the cases in Avhich this  operation
has been  performed  before  suppurative change  has  begun  have
done remarkably  Avell, the percentage of  deaths  being less than five,
and NeAvman reports forty-tAvo cases with  no deaths, Avhile  Legueu
reports forty cases Avith iavo deaths.
   Duplay and  Reclus report forty-three cases of  nephrolithotomy
with six per  cent,  of deaths and three and one-third  per cent, of fis-
tulae ;  in tAvelve cases of pyelotomy (in the absence of infection) the
mortality  was  sixteen and two-thirds  per  cent., and fistulae  were
formed in tAventy per cent.  In one hundred and fourteen  cases, the
kidney being infected, sixty-six and six-tenths per  cent, recovered;
thirty-four and tAvo-tenths per  cent, developed fistulae.  Nephrectomy
was practised sixty-seven times,  Avith a mortality of  thirty-eight and
eight-tenths  per cent.   There Avere fifty-one lumbar operations, six-
teen abdominal.   The mortality was about the same  in both.
   Duplay and Reclus  particularly insist upon the importance of
operating promptly in case of calculous anuria.  They hold that this
complication is fatal in a large  proportion  of cases.   Even though the
patient recover from the first attack there  is  usually recurrence, since
anuria is an almost certain proof  of bilateral lesion.   After a trial of
prolonged hot baths, warm injections, abundant ingestion of diluents,
massage of the ureter, the use of a continuous current of electricity,
and profound anaesthetization, should anuria persist operation is in-
dicated.   Forty-eight hours  should be  the  longest time allowed for 
804        GENITO-URINARY DISEASES AND SYPHILIS.

these palliative measures.  Calculous anuria is spontaneously relieved
in tAventy-eight and five-tenths per cent, of cases.   Sixty-six and six-
tenths per cent, of operative cases recover.   (Legueu.)
   The great difficulty in  these cases is to discover the seat of ob-
struction : palpation, the history of the case, and ureteral catheteriza-
tion may determine this.  The incision should be the lumbar one, and
the Avhole of the ureter should be exposed if this is necessary.
   It is interesting to note that when kidneys have been opened with
the expectation of finding stone, but none has been discovered, re-
lief from the symptoms which  lead  to operation  has been the rule
rather than  the  exception.   Mr.  Reginald  Harrison remarks  on
this point, " I could  enumerate  many instances where I have urged
and practised digital exploration of the kidney merely for the purpose
of searching for the  cause of  painful  symptoms which have resisted
all other methods of treatment, both medical  and surgical.  I have
never had cause to regret this ; on the contrary, Avithout, I believe, a
single exception, good has  come out of  it.  It has not, however, been
always  clear how this benefit was obtained.  Let me state tAvo or
three instances.  In  the summer  of 1887 I saw at the Royal In-
firmary, Avith Dr. Davidson, a stout,  healthy  married woman, about
thirty-five years of  age, avIio for over a year had been suffering from
what appeared to be  acute attacks of renal colic attended with con-
siderable haematuria.   Various kinds of treatment had been  tried and
Avere tried, but without avail, and she was anxious to submit to any
operation that offered a prospect of relief.  I thought she had  stone
in the kidney, and advised exploration. This was done by me, and
in consequence of her stoutness  I had to make a much longer incision
than  usual, as until I got my hand  fairly within the parietal  wound it
was impossible to touch the kidney with the  tip of  my finger.   I was
enabled to  feel it thoroughly with the hand, and  I also  explored it
with  a needle in several places, but no  stone could  be found.   I
thought the organ was more movable than  natural, and  that this
might possibly be the explanation.   HoAvever, she made a  rapid re-
covery, and has remained well since.   I saw her a  few weeks ago.   I
never knew a case where the symptoms, in their kind and undoubted
severity, more  closely resembled renal  stone, yet I  am satisfied there
was  none.   I have now seen three cases of renal haematuria where
the bleeding ceased  after digital exploration, and  where the  kidney
has been well poked  about with the finger in the attempt to discover
the presence of a stone which really had no  existence.11 
CHAPTER  XXIII.
               SUPPURATIVE DISEASES OF  THE KIDNEY.

   The  suppurative  diseases of the  kidney may be arranged in two
groups.  In the first group belong those suppurations the microbes of
Avhich enter the  kidney through its  artery, vein, or lymphatic chan-
nels, or extend by contiguity from  the  perinephric tissue.  In the
second  group are those suppurations which are  due to ascending
infection along the ureter.
   Infection of the kidney by micro-organisms which are carried into
the gland  by its arterial blood is nearly ahvays secondary to pyo-
genic foci  elseAvhere.  Either ulceration  or internal suppuration may
furnish  the  germs, but usually they are  found in connection Avith
general  septicaemia, pyaemia, or ulcerative endocarditis.  Exceptionally
it  is impossible to locate a primary focus; in  such cases  we  must
either assume that there is an obscure bacterial toxaemia or  that
micro-organisms circulating in the blood have  attacked the kidneys
first.  Haematogenous suppurations are generally bilateral.
   Haematogenous infection by way of the venous circulation is  also
possible.  It has been conclusively shoAvn that septic material ascend-
ing the vena cava may  enter the kidney and produce suppuration.
   Traumatic suppuration of the kidney, unless the result of a pene-
trating wound, must be classed with haematogenous infections, since,
in the absence of bacteria, concussion or  contusion of tissue cannot
produce suppuration.  It is evident, hoAvever, that the injury prepares
a suitable  culture-field  for circulatory micro-organisms.  In the trau-
matic cases but one kidney is usually affected, and there is frequently
perinephric suppuration.
   It is often impossible to distinguish between lymphatic infection
and infection due to extension by contiguity.  As causes of secondary
infection may be  mentioned appendicitis,  perityphlitis, parametritis,
caries  of the  vertebrae, sacrum,  or pelvis, deep colonic ulceration,
abscess  of the liver or spleen,  subphrenic abscess, and urinary in-
filtration (rare).  All these inflammations  may extend to the kidney,
involving both this gland and its fatty capsule.
   The  micro-organisms commonly causative  of renal  suppuration
are the bacterium coli commune, the staphylococcus aureus, the strep-
                                                         805 
806        GENITO-URINARY DISEASES AND SYPHILIS.

tococcus pyogenes, and the proteus Hauseri.   Exceptionally infection
is due to the gonococcus,  the bacillus  typhi, the  diplococcus pneu-
moniae, the tubercle bacillus (?), actinomyces, and the  micro-oro-an-
isms of acute infectious diseases.  It should be  borne in mind  that
pyelitis is common in the course of the various infectious  diseases
and may become membranous.
   Several  important facts  must be emphasized  in  relation to the
renal suppurations Avhich result from ascending infection.   Obstruc-
tion  in the  urethra, bladder,  or ureter which interferes Avith the  out-
flow of urine produces conditions very  favorable to infection, though
it will not in itself cause suppuration.   An aseptic ligation of one ureter
causes atrophy of the kidney, but a septic ligation gives  rise to sup-
puration.  Traumatism, alteration in the character of the urine, or the
elimination  of irritating drugs, such as cantharides, produces conges-
tion, but never septic inflammation.  All causes Avhich occasion acute
or chronic congestion predispose to infection.
   Clinically, obstruction and the consequent alterations in the urine
are the conditions which most frequently render the kidney and its
excretory channels favorable culture-media for pyogenic micro-organ-
isms.  As a rule, the healthy mucous membrane of the uro-genital tract
resists septic infection, but it will not always  do so, nor is it necessary
that  there should be obstruction in order that  septic matter in the
bladder may enter  the ureters and ascend  into the pelvis of the
kidney.  It has been experimentally shown (LeAven and Goldschmidt)
that  substances introduced into the normal bladders of  animals may
ascend to the kidneys.   It is probable that under certain circum-
stances intestinal bacteria may obtain an entrance into  the kidneys
without any discoverable  break in the continuity of the tissues.
   Micro-organisms  are, then, the invariable causes of renal suppu-
rations, and the  clinical causes of congestion  can  do no more than
make the tissues  susceptible.   While it is true  that  individual  sus-
ceptibility and local  predisposition render one person more liable to
suppuration  than another, it must  not be  forgotten that  bacterial
virulence  may be so  pronounced that the most healthy tissues cannot
resist infection.
   The methods  by Avhich  bacteria may reach  the kidneys  from
beloAV are—through  the urine by means of antiperistaltic movements
of the ureters;  by  extension along the mucous membrane or the
lymph-channels of the ureters;  by penetration into the  pelvis or
ureter from the  tissues surrounding the  urinary  tract  (either  by a
rupture of an abscess into the pelvis  or the ureter, or by emigration
of the micro-organisms through the Avails). 
SUPPURATIVE DISEASES OE  THE  KIDNEY.
807
    The clinical causes of spontaneous suppuration of the kidney are—
 the acute infectious diseases, exposure  to  cold and Avet, traumatism,
 stricture of the urethra, enlargement of the prostate, tuberculosis or
 malignant disease, gout, irritation from drugs, such as turpentine or
 cantharides, and renal  calculus.   Age, sex, and occupation affect the
 development of suppurative kidney disease only so far  as they are
 associated  with predisposing  causes.   Thus, pyelitis is  common in
 old men because of prostatic  enlargement, and in young women be-
 cause they frequently  suffer from parametritis.
    In accordance with its location and  clinical course renal suppura-
 tion is termed  pyelitis, pyonephrosis, pyelonephritis, and suppurative
 nephritis.
    Pyelitis, or inflammation  of  the kidney pelvis, may be secondary
 to nephritis  (descending),  or  to ureteritis (ascending), or rarely to
 perinephritis  (contiguity); the  ascending inflammation is the common
 form.
    The most frequent predisposing and exciting causes of pyelitis are
 —(a) the infectious diseases ; Avhether in these  cases the local inflam-
 mation is due to toxins or to alterations in  the urine has not been de-
 termined ; (6) traumatism,  a rare but undoubted cause; (c) exposure
 to cold; {d) drug irritation, as from the irritating  diuretics, the bal-
 sams, the ethereal oils ;  (e) nephritis, particularly the interstitial  ne-
 phritis of the gouty ;  (/)  venous congestion,  due  either to  general
 stasis or to local stasis,  as in chronic  valvulitis, pregnancy,  floating
 kidney, abdominal tumor ; {g) perinephric inflammation ; (A) mechani-
 cal  irritation  of gravel  or calculus; {i) tubercle, malignant  disease,
 parasites; {j) and,  most important  of  all, cystitis, particularly when
 it is associated Avith obstruction.
   Pyelitis  is usually bilateral.   It varies in degree from a superficial
 catarrhal inflammation  to  a deep infiltrating destructive process.   In
 the  absence of infection there is often a  congestion  of the  mucous
 membrane  of the pelvis unassociated with desquamation of epithe-
 lium or suppuration.   Such a condition may be caused  by irritating
 conditions of  the urine.
   Catarrhal pyelitis may be acute or chronic.  In the acute form the
 mucous  membrane  is sAvollen and congested ;  there  are patches of
 desquamation;  in severe  cases the surface is covered Avith thick
 mucus mixed with blood, in which  the crystals of the urinary salts
 are deposited.   In chronic pyelitis  the  mucous membrane is  dark in
 color, there is a serous  infiltration  of  the submucoid tissues, Avith
interstitial overgrowth, many small mucus-cysts may be formed, and
in some cases the lymph-follicles become much enlarged and promi- 
808        GENITO-URINARY  DISEASES AND SYPHILIS.

nent (pyelitis granulosa).  The surface  is generally covered  with a
tenacious altered mucus, and there is general desquamation of epithe-
lium.  Ulceration may be present, Avhich  may  extend through the
coats of the pelvic wall, giving rise to abscesses or even to  infiltration
of urine.   Any pyelitis may become membranous, particularly Avhen
ammoniacal fermentation has taken place.  Indeed, a strictly catarrhal
pyelitis is quite rare.
   When the pus of pyelitis blocks a ureter, pyonephrosis or pyelo-
nephritis results.   Parenchymatous,  or  more  commonly  interstitial,
nephritis is  frequently caused  by pyelitis ; the contracted  kidney of
pyelitis, however, differs from a primary  contracted kidney  in that the
preponderance of fibrous overgrowth is in the medullary substance
instead of in the  cortex.  Amyloid degeneration may occur in one or
both kidneys when suppuration is profuse and long continued.
   Symptoms.—In many cases,  as is evident from the list of  causes, the
symptoms of a pyelitis are lost  in those of the antecedent disease. In
simple congestion of the pelvis pain in the loins  and frequent urina-
tion are the only symptoms.
   In acute catarrhal purulent pyelitis the  pain is often severe, and
may present acute exacerbations ; the kidneys are tender on pressure,
and  frequency of  urination  is marked. The quantity of urine is
usually decreased,  and exceptionally reflex anuria may  supervene.
The pain is increased by motion,  by deep respiration, or by coughing,
and may be reflected down into the penis and testicle or up towards
the shoulder.
   Vomiting is not uncommon.   Fever develops, and  there may be
chills  folloAved by profuse perspiration.   As a  rule, the kidneys,
though tender, are but little enlarged in acute pyelitis.
   The urine is generally acid, and contains a trace of albumen, de-
generated epithelium, hyaline casts, and  often pus and blood.
   In  chronic pyelitis  the symptoms are  usually less pronounced.
The  pains are not so marked, nor are the glands  so  tender on
pressure.   Fever,  if  present,  is likely  to  be  intermittent.   Acute
attacks of  pain generally  indicate obstruction.   The kidney  is not
palpably enlarged unless there  is  pyonephrosis.
   The urine is increased in amount, is  acid or neutral, and contains
nucleo-albumen,  pus,  and epithelium in abundance; blood is rare.
As in the  acute form, hyaline  casts are  common, but in a pure pye-
litis granular  cysts are rarely  seen.   If only one kidney  is affected,
there may  be  periods  Avhen,  owing to obstruction of the diseased
pelvis,  the  urine  will be  normal.   Calculi  not infrequently form in
chronically inflamed pelves. 
SUPPURATIVE DISEASES OF  THE  KIDNEY.
   Diagnosis.—Pyelitis  must be distinguished from  renal and from
vesical inflammation.    In  pyelitis  the albumen is dependent upon
the blood and pus, in  nephritis it is essential.   Granular casts  are
usual in  kidney  disease, they are not found  in  pyelitis.  The large
amount of nucleo-albumen is quite distinctive  of pyelitis.  The leuco-
cytes in the urine of  nephritis are often mononuclear, those of pye-
litis  are polynuclear.   The pain of  nephritis is  insignificant,  while
acute severe pain occurs in nearly all cases of pyelitis.
   Cystitis suppurates more freely than pyelitis, and the urine is more
likely to be alkaline ; a cystoscopic examination will  prove  the pres-
ence of inflammation.   Such an  examination may be required before
the origin of pus can  be positively determined.  The importance of
this  becomes  evident when it is  realized that  in  the absence of
ureteral obstruction polyuria and pyuria are  the most constant and
reliable signs of  chronic pyelitis.
   Prognosis.—Acute congestion and  chronic congestion of the kidney
pelvis are dangerous only because they predispose to infection.  Acute
catarrhal or purulent  pyelitis is generally self-limited unless the in-
fection has spread to the kidney-substance, the  period of disease
varying from a feAv days to a few weeks.   The prognosis and  dura-
tion  of chronic  pyelitis  depend obviously upon the cause.   When
the disease develops  without appreciable cause, or when it  is asso-
ciated Avith incurable obstruction or an inveterate gouty diathesis, the
prognosis must be guarded.
   Treatment.—The treatment of pyelitis varies in accordance with
the cause, and is also dependent in  a measure  upon the  character
of the inflammation.  Slight  cases, such as those which develop after
the exanthemata, are treated by rest, liquid  diet, and the ingestion
of diluents.  The natural tendency of this form of  inflammation is
toAvards recovery.  When the  symptoms are sufficiently  severe to
excite some constitutional reaction and to cause local pain, counter-
irritation, local depletion, hot baths, the administration of soothing or
stimulating diuretics, and careful attention to the condition of the skin
are indicated.   Pain  should  be  relieved by  morphine  given hypo-
dermically.  Inflammation  due to mechanical  causes,  such as calculus
or stricture, prostatic enlargement, or any obstruction to the free Aoav
of urine, can be cured only by surgical intervention.  Should this be-
come necessary in the course of acute pyelitis, it must  be  borne in
mind that there is ahvays great danger of converting a simple pyelitis
into a pyelonephritis  or " surgical kidney11:  hence  every antiseptic
precaution should be taken.
   The operative procedures  should  be  preceded by the administra- 
810        GENITO-URINARY  DISEASES AND SYPHILIS.

tion  of urinary antiseptics,—namely, salol and  boric acid;  benzoic
acid  should be given when the  urine is alkaline.
   We believe that the development of pyelitis as a complication of
any obstructive lesion of the urinary tract, regardless of its  seat or
cause, is a sufficient ground for operative interference when this offers
any promise  of permanently overcoming the obstruction.  The opera-
tion  should be performed early, since pyelitis associated with obstruc-
tion  means inevitable destruction of  the  secreting substance of the
kidney.
   Kelly, Pawlik, and others have treated chronic pyelitis by drainage
and irrigation through ureteral catheters.   When suppuration is sec-
ondary to obstruction caused by ureteral stricture  this treatment
may be curative, since the passage of an instrument not only alloAvs
of the introduction of antiseptic solutions, but mechanically dilates and
may ultimately cure the narroAving.  This procedure can be successful
in but a small percentage of cases, and is as yet  mainly serviceable
from the diagnostic stand-point.
   Chronic pyelitis is treated by diet, careful attention to the general
hygiene, and the administration of those  drugs and natural mineral
Avaters which we have already mentioned as serviceable in the treat-
ment of cystitis.
   Operation is rarely undertaken till pyelitis is complicated by pyone-
phrosis or pyelonephritis.  The kidney is exposed in the lumbar re-
gion, the pelvis is opened posteriorly, the borders of this opening are
stitched to the skin-wound, and the kidney is Avashed out and drained.
   Pyonephrosis.—When in the  course of pyelitis the ureter be-
comes blocked, pyonephrosis develops.  The same condition is pro-
duced by infection of hydronephrosis.  The pelvis becomes rapidly
distended, and ulceration and  dilatation of the calices occur.  When
the condition is permanent the entire kidney is riddled with abscesses.
The  obstruction is usually incomplete.
   The  pelvis may  rupture  early;   later rupture may take place
through  the cortex; in either case  there results a perinephric ab-
scess.  Exceptionally  pus may  become  inspissated, and  extreme
contraction of the kidney occur.  Pyonephrosis  may  give rise to
genera] metastasis, but this is rare.   Occasionally the  kidney forms
adhesions to  neighboring organs and may rupture into them.
   Symptoms.—In cases Avhich  follow the blocking of a ureter the first
symptom is  usually pain, which may be colicky, and is  made worse
by pressure  anteriorly, but is often relieved by pressure posteriorly.
Fever Avith chill will  likely be  the first symptom  in a case in which
suppuration  occurs in a hydronephrotic sac.  The quantity of urine 
SUPPURATIVE DISEASES OF THE KIDNEY.
811
 bears some ratio to the  retention ; in a few cases anuria is produced
 by reflex inhibition, though  this is  usually due  to defect or absence
 of the other kidney.
   A tumor may form  in the loin, tender on  pressure, fluctuating
 in most cases, but sometimes doughy, and projecting into the  ab-
 dominal cavity.  The tumor is often not perceptible.   It will be dull
 on percussion  in  the flank, but the presence of the overlying colon
 generally suffices  to  make the note on abdominal percussion reso-
 nant ; alternate emptying  and filling of the colon with air  or liquid
 may aid in establishing a diagnosis.
   If the  pyonephrosis is unilateral,  pus  may  disappear from  the
 urine at times ; if  bilateral, the pus may be reduced in quantity ;  but
 it is a clinical fact  that in some cases little apparent change occurs in
 the quantity of pus contained in the urine.
   The  variations  in the  quantity  of pus in cases of  pyelitis  are
 sometimes marked, so that a  sudden  reduction of pus in the  urine
 does not imply obstruction unless it is  coincident Avith a reduction in
 the quantity of urine.  If the obstruction is permanent and the other
 kidney is able to compensate, the quantity of urine will gradually rise
 to the normal.  Irregular fever, Avith a high evening rise, chills, and
 the constitutional  symptoms of internal suppuration are  present in
 most cases, but some run  their course Avith few  or no general  symp-
 toms.
   Diagnosis.—The diagnosis  of pyonephrosis is founded upon  the
 presence of a tumor in the region of the kidney and on intermittent
 pyuria.  The tumor cannot always  be felt, since  distention may
 take  place upward towards the  diaphragm.  When perceptible it is
 rounded in form,  obscurely fluctuating, and tender on pressure.   A
 pathognomonic  characteristic  of the tumor is its variation in size,
 dependent upon  temporary relief of obstruction and escape  of the
 purulent urine  contained  in  the kidney pelvis.  This symptom is
 closely related  to  intermittent pyuria; Avhen the pelvis  of  but one
 kidney is affected, the other remaining healthy, there may be periods
 when the  urine is absolutely normal, followed by periods during
 which there is marked polyuria,  the urine containing a large  quantity
 of pus.
   Rayer states that pyonephrosis  must be distinguished from mor-
bid enlargements  of  the spleen, liver, and gall-bladder, from renal
tumors due to causes other than pyonephrosis, such as hydronephro-
sis, hemorrhage, cancer,  tubercle, or cysts,  from  renal abscess, from
tumors of the  suprarenal  capsule, from  aortic aneurism, and  from
faecal  impaction. 
812       GENITO-URINARY  DISEASES AND SYPHILIS.

    A differentiation from hydronephrosis or perinephric  abscess is
often difficult.  Hydronephrosis is  unattended by fever,  and there
is usually but slight pain ; continuous or intermittent pyuria is absent.
Perinephric abscess is  characterized by severe pain, rapid extension
of the tumor, marked constitutional symptoms,  extreme  local ten-
derness,  and often oedema  and superficial  fluctuation.   The urine
may or may  not  contain  pus; the thigh is  often  flexed  upon  the
abdomen.  At times a  distinction cannot be  made.  This, however,
is not a matter of great importance, since the three conditions, pyo-
nephrosis, perinephric abscess,  and hydronephrosis, practically require
the same treatment.
    The distinction of pyonephrosis  from aortic aneurism  is  of great
importance, since were  aneurism present an  incision for nephrotomy
might result fatally.
    Treatment—Pyonephrosis, dependent as it necessarily is upon in-
fection and obstruction, is amenable  only to  operative  treatment.
The first step which is  taken should be in the direction of removing
the obstruction.  Morris suggests that when the obstruction is recent
and probably consists  of a  small calculus or of  a  plug of pus and
mucus, it may be displaced by  allowing the patient to drink freely of
hot liquids or by some jolting exercise, such as riding.   Massage over
the course of the ureter may sometimes dislodge  an obstruction, but
it must be performed  skilfully and  gently, since  othenvise it might
readily rupture a dilated canal.  An  expectant treatment is justifiable
only when the condition of  the patient precludes any operation, or
when the constitutional symptoms  are mild  and the obstruction is
slight,  the greater portion  of the  uro-purulent  secretion escaping
through the ureter.
    When there is  marked narrowing or complete blocking  of the ex-
cretory  channels,  associated with constitutional symptoms of septic
absorption, operation  is imperatively indicated, since there is danger
of purulent infiltration  and destruction of the secreting portion of the
kidney, and long-continued suppuration is likely  to  produce amyloid
degeneration of the  opposite kidney.  When both  kidneys are dis-
eased, nephrectomy is inadmissible, even should  this be indicated by
the extent of local infection.  It happens at  times  that, as a result
of non-interference and  because  of  complete  ureteral obstruction,
the kidney atrophies, the pus which  it contains becomes caseous, and
there is thus  effected a species  of spontaneous cure.
   The operative treatment may take the form of aspiration, nephrot-
omy, or nephrectomy.
   Aspiration gives temporary benefit, and is sometimes followed by 
SUPPURATIVE DISEASES OF THE KIDNEY.
813
cure, since, as the result of relief of tension and consequent conges-
tion, the obstruction is overcome and the secretion of the kidney is
again poured into  the bladder.  As a rule, aspiration has to be  re-
peated many times ; the purulent urine constantly reaccumulates, and
ultimately a more radical method of treatment will be required.
   Nephrotomy consists in exposing the kidney by the ordinary lum-
bar route, opening the pelvis  through the  parenchyma,  evacuating
the pus and urine, and removing  calculi if these are present.   The
ureters should be explored, and obstruction should be remedied by ap-
propriate treatment.   The perinephric tissues are thoroughly cleaned
and drained by gauze, the borders  of the kidney-wound are sutured
to the parietal incision, the suppurating cavity is packed with gauze,
and a thick, absorbent dressing is applied, the patient being placed on
an oakum mat.   In tAventy-four hours the gauze packing in the pelvis
of the kidney is replaced by a large drainage-tube, and the perinephric
packing is removed, with the exception of two or three small strips.
   Nephrectomy may be performed as a primary operation Avhen the
kidney has been converted into a thin, pus-containing  sac which is
not very adherent.   The adhesions are often dense, sometimes insur-
mountable.  It has happened to a surgeon as experienced  as Billroth
to tear the vena cava  and lose  his  patient  from hemorrhage in the
effort to remove a pyonephrotic kidney.  It is safer to postpone total
removal till it has been proved that nephrotomy and drainage are in-
sufficient to cure.  Not only  are these  secondary operations easier,
but the patient is likely to be in  much better condition to stand
them.
   Duplay and Reclus collected one hundred and six cases of nephrot-
omy performed  for suppurative disease of  the  kidney (pyelitis); the
mortality Avas thirteen and three-tenths per cent.  The mortality of
nephrectomy is estimated at  thirty-seven and  five-tenths per  cent.
They state that, even when patients are profoundly cachectic, opera-
tion and drainage  may prolong  life for several years.  This result is
due not only to suppression  of the infecting focus from  Avhich are
absorbed toxins, but also to a physiological  action which is well con-
firmed.  After free drainage,  portions  of the kidney which  remain
intact are able to resume their excretory function.  After nephrotomy
a fistula persists in about forty-five and six-tenths per cent, of cases.
This is often due to long postponement of the operation.  In second-
ary nephrectomy for pyelitis the mortality in twenty-four cases was
five and nine-tenths per cent.
   Pyelonephritis.—This term signifies septic inflammation of the
kidney  secondary  to  pyelitis.   It  is the  ascending  form of renal 
814        GENITO-URINARY DISEASES  AND SYPHILIS.

suppuration.   The  descending form  is best knoAvn as suppurative
nephritis.
   The predisposing and exciting causes of pyelonephritis are the same
as those of pyelitis and pyonephrosis.   It is merely a more extensive
and  more  dangerous stage of  pyelitis, and an  almost unavoidable
complication of  pyonephrosis.    The  infection   extends  from  the
calices into the uriniferous tubules, involving the  parenchyma of the
kidney, and converting the organ into a  mass of  small abscesses, or
perhaps one large suppurating sac.  The name " surgical kidney11 has
been applied to this form of suppurative  disease, because it has been
so frequently produced by  the use of infected instruments.
   Pyelonephritis is apt to develop rapidly  when  decomposing urine
is retained in the pelvis; it may be caused by extension of inflam-
mation in the absence of retention.
   In  the  early stages  of  pyelonephritis  the cortex of the kidney is
thin, and the capsule is  adherent to the surface and to the renal tis-
sue.   When it is stripped from  the kidney numerous small abscesses
are opened;  the kidney  is swollen,  soft,  and congested.  Section
shows  yellow streaks,  the distended  straight tubules  running from
the cortex to the pyramids.  Between these streaks the renal  sub-
stance  seems to  be  healthy.  The pelvis is congested, and exhibits
patches of ecchymosis,  or  even  of ulceration.  Instead of small  sup-
purating foci, large abscesses may form, and  break  through the  kidney
capsule.
   Microscopically, the  straight tubules  are dilated,  distorted, and
filled with  epithelial  debris, pus, urinary  salts, and micro-organisms.
The  veins are also distended with partially coagulated blood and pus.
This is in marked contrast with pyaemic processes, in which the blood-
clot and pus-formation take place within the arteries.  The Malpighian
bodies  and convoluted portions of  the tubules become  obliterated.
The  fatty  capsule is infiltrated, tough, fibrous, and  adherent in
chronic inflammation, or it may become infected and suppurate.
   The colon  bacillus  is the usual microbic cause of an ascending
pyelonephritis.
   Symptoms.—Pyelonephritis may assume the acute or  the chronic
form.   The acute form is  characterized  by  the  sudden onset of a
chill, followed by high fever, and accompanied by  severe pains in the
loins.   There is  often  delirium, and the fever may rise to 106° or
107° F., or even higher.
   Usually the  fever is continuous, Avith  remissions.  The  patient
passes  into a typhoid state ; the tongue  is dry and heavily coated;
there are rapid emaciation, often an extremely irritable condition of 
SUPPURATIVE DISEASES OF THE KIDNEY.
the stomach, and drenching sweats.   There may be persistent vomit-
ing and hiccough.  Mental dulness, semi-consciousness deepening into
coma, and finally death, follow.
   The disease is usually rapidly fatal, terminating in about ten days
or two weeks.
   It is obvious that symptoms of acute pyelonephritis are due in part
to septic intoxication, in part to uraemia.  All cases do not end fatally.
The fever may  gradually grow less, the  stomach become  retentive,
and a return to comparative health folloAv.  In such cases it seems
probable that the pus has been so placed as to be well drained into
the ureter, or that it has become caseous and encysted, the secreting
substance of the one kidney having  been destroyed, and the remain-
ing kidney having assumed double duty.
   With the lessening or disappearance of fever the  return to health
is the  exception, not the rule.   The  pyelonephritis  is more likely to
become chronic.  In this form of inflammation  the temperature may
be normal.   Commonly it is slightly and persistently elevated.
   Rayer long ago pointed out that the  chief  symptoms of chronic
pyelonephritis are often those of gastro-intestinal  irritation.  These
are chronic  dyspepsia, a dry brown tongue, secretion  of  saliva so
scanty that solid food is  refused, constipation, often tympany, some-
times  uncontrollable  diarrhoea.   The patient  is  usually  extremely
weak and  depressed, and sleeps badly.   These symptoms  gradually
become more marked, and progressive emaciation, extreme suscepti-
bility to local congestion  from exposure to cold, and frequently inter-
current febrile attacks, develop.  The symptoms are  due to uraemia
and infection combined.   Locally there may  be  neither  pain nor
tumor, and the patient may  be unaware of any urinary trouble.
   Diagnosis.—This is based upon the  presence of pus in the  urine,
pain and tenderness  in the region of the kidney, the presence of a
tumor, and  the development of  an otherwise inexplicable gastro-
intestinal catarrh.  In the absence of pyonephrosis, there are usually
polyuria  and constant pyuria.  Oliguria  is an  ominous sign.   The
urine is alkaline.   Microscopic examination  shoAvs hyaline  casts and
sometimes fragments  of renal tissue.  Exceptionally there is slight
haematuria; rarely the bleeding is free:  this is usually due to  cal-
culus.  There may be absence  of both  spontaneous and provoked
pain.   There is  frequent, often painful,  urination,  especially  during
acute  exacerbations of the chronic  inflammation.  When  pyelone-
phritis is complicated by pyonephrosis there is  also the development
of a SAvelling Avhich may exhibit variations in size ;  if but one kidney
is affected there may be intermittent polyuria and pyuria. 
816        GENITO-URINARY  DISEASES AND  SYPHILIS.

   The diagnostic  characteristics of  pyelonephritis are pyuria and
symptoms  of septicaemia.
   The differential diagnosis of chronic pyelonephritis from cystitis
may be  extremely  difficult.   Cystitis,  hoAvever, does  not produce
the constitutional symptoms, and ureteral catheterization  will  shoAv
the absence of pus from the urine as  it escapes from the kidneys.
Cystitis and pyelonephritis are often associated.  In such  cases ure-
teral catheterization,  by showing that pus  comes  from the kidney,
is  again serviceable;  moreover, fever, rapid deterioration  in health,
and  pronounced gastro-intestinal symptoms are in themselves  suffi-
ciently characteristic of the kidney affection.
   The symptoms of  renal tuberculosis  are  similar  to  those  of
pyelonephritis.  Tubercular family history, the presence of tubercular
infection in other portions of the genito-urinary tract, and the finding
of the  Koch bacillus Avill point to the nature of the disease.  There
is often mixed infection in tubercular nephritis.
   It is important to find out  whether both  kidneys are affected.
This will  be determined  by the results  of  palpation  and ureteral
catheterization.  Intermittent pyuria necessarily points to  the  exist-
ence of one healthy kidney.  When catheterization of the  ureters is
not possible, a cystoscopic examination and inspection of the ureteral
orifice  may enable the surgeon to determine whether the urine which
escapes from  the  ureter of an apparently unaffected side is clear or
turbid.  Exploration  through  an abdominal incision,  at  one time
warmly advocated  as a means of determining  the  condition of both
kidneys, is of  little  help, since  palpation through the peritoneum and
perinephric fat  gives  an  inadequate idea of the  condition of  the
secreting substance of the kidney.
    Treatment.—The preventive treatment of pyelonephritis is partic-
ularly important.   In vieAv of the fatality  of this affection, it is im-
possible to express too emphatically the  necessity for asepsis even
in so trivial  an operation  as  catheterization, especially Avhen after
chronic retention the urinary tract is predisposed to infection.
   When  pyelonephritis  has  developed it should be treated as a
combination  of  uraemia and septicaemia.   Liquid  diet, particularly
milk, the  administration of diuretics  and  of diluents,  counter-irrita-
tion over the kidneys,—in  acute  cases  by dry  cups followed by  hot
fomentations,—and the administration  of  laxatives, are indicated as
the means of combating uraemia.   Since septicaemia causes death by
exhaustion, the administration of alcohol well diluted and of as  much
nourishment as can be  assimilated is desirable.  Quinine  should be
avoided, since it is  useless in small doses, and in  full doses markedly 
SUPPURATIVE DISEASES OE THE KIDNEY.
817
congests the kidneys.   Small doses of salol and boric acid are ser-
viceable, since  they tend to prevent ammoniacal fermentation in the
kidney pelvis.
   When pyonephrosis develops in the course of  pyelonephritis, or,
even in the absence of  this, if symptoms are progressive, nephrotomy
with free drainage is indicated.   The kidney should be opened into
the pelvis on its convex border, and the examining finger should dis-
cover and break into every pus-collection of appreciable size.  Theo-
retically nephrectomy is indicated, since  the kidney is  often riddled
with multiple abscesses  ; the infection is, hoAvever, frequently bilateral.
When after drainage the  symptoms do not improve and there is a
free discharge  of pus  through the lumbar Avound, a secondary ne-
phrectomy  may be performed if repeated examinations have sliOAvn
that the other kidney is normal.   The degenerated fatty capsule is in
chronic  inflammations  often adherent  to the kidney capsule proper,
and to surrounding  organs and  structures, rendering enucleation of
the kidney  a difficult and  dangerous procedure.   The  nephrectomy
should then be  accomplished by decortication,  the  kidney  being
shelled from its  proper capsule, and a pedicle being formed at the
expense of  a portion of its substance about the hilum.
    Suppurative Nephritis.—Under this heading  are   classified
renal suppurations in which  the agents  of infection enter the kid-
neys through its vessels, through its lymph-channels, or by contiguity.
Such suppurations are seen  in  pyaemia, in endocarditis, and in the
acute infectious fevers,  as the result of  extension of infection from
adjacent tissues, or in consequence of traumatism or exposure to cold.
    In haematogenous  infections  the  condition is usually  bilateral,
though embolic infection may  occur in but one kidney.  The abscesses
are generally multiple ; single large abscesses are occasionally seen.
The haematogenous abscesses first form in the cortex; from these the
entire gland generally becomes infected. The abscesses may coalesce,
and in some cases renal disintegration goes so far that nothing re-
mains but a sac (the capsule)  filled Avith pus.   In non-haematogenous
suppuration the process may commence in any part of the kidney,
according to the origin  of infection.  The abscesses may rupture into
the pelvis or through the capsule, with the  production of perinephric
suppuration.  It is in suppurative nephritis that metastasis most often
occurs.
   When the  kidney infection is simply an expression of a general
pyaemia  the suppuration  is rarely extensive ; small abscesses form
about the glomeruli and  the  smaller  vessels of the cortex of both
kidneys,  often  with blocking of the uriniferous  tubes. The  renal
                               52 
818        GENITO-URINARY DISEASES AND SYPHILIS.

substance  is the seat  of  a  parenchymatous  inflammation.  In rare
cases of long duration  amyloid degeneration may occur.
   Symptoms.—When  suppurative  nephritis complicates pyaemia the
symptoms  are often  masked by those of the  general disease; some-
times patients  complain of violent pains  in  the  loins, and not in-
frequently  a marked oliguria (or even anuria) occurs.  Blood and
hyaline casts may be present in the urine.
   Fever of a hectic  type  develops in nearly all cases,  and  chills
occur  irregularly.  Violent attacks of hiccough  and vomiting are
sometimes  noted; these are probably uraemic.  There are generally
lumbar pains,  severe  prostration,  and the rapid development of a
typhoid  state,  the  sensorium becoming  clouded, and  the patient
dying with symptoms of both pyaemia and uraemia.  Typical uraemia
Avith convulsions has been noted in a few cases.
   The urinary changes are not  constant.  In some cases there are
no alterations other than  oliguria.  A little blood and a few hyaline
casts are often  found on microscopic examination.  Later in the dis-
ease granular casts  give  evidence  of parenchymatous degeneration.
Pyuria, especially if profuse, indicates that an abscess has been evacu-
ated into the pelvis ; this may be folloAved  by  marked amelioration in
the general condition.   In rare cases pieces  of renal tissue may be
voided.
   Diagnosis.—Since enlargement of the kidney is usually slight, sup-
purative nephritis will  not ordinarily be confused with the  extrarenal
suppuration.  The  course of suppurative  nephritis is too acute for
neoplasms; hydronephrosis,  pyonephrosis, and perinephric abscess
generally  occasion  much more marked  enlargement.   The careful
examination of the  urine, the history  of  the case, and exploration
of the lower urinary tract will usually lead  to a diagnosis.  Renal
suppuration, unless well drained, causes a  circulatory leucocytosis.
   Treatment.—This is at first expectant and symptomatic.   The
patient is kept absolutely at rest, and careful attention is paid to the
constitutional condition.   If the abscess can be clearly located, or if
the symptoms are pronounced and progressive, exploratory nephrot-
omy should be performed.  It is often the case, however, that symp-
toms pointing to the exact location of the abscess are  masked until
the condition of the patient will  not admit of an operation.  When
suppurative nephritis develops in pyaemia it  is a  local expression of
the general condition to which treatment is mainly directed.
   Perinephritis.—Perinephritis is, strictly speaking, an  inflamma-
tion  of the fibrous capsule ;  the term, as commonly used, implies in-
flammation of the fatty capsule.   Inflammation of the true capsule 
SUPPURATIVE DISEASES  OF THE  KIDNEY.
819
occurs in nearly all renal diseases.  It is frequently sclerotic, thick-
ened, and adherent to the gland; it may suppurate secondarily to
adjacent renal suppuration, or it may become involved in tubercular
and malignant processes.
   Beyond the  evidences of the  renal  or perirenal disease Avhich
causes it, true perinephritis  presents no symptom  except pain.  It
seems clearly established  that inflammation of the true kidney capsule
causes more  pain than involvement of the secreting portion of the
kidney.
   Inflammation of the fatty capsule of  the kidney  is very common,
since this  tissue possesses a Ioav  degree  of power  of  resistance to
infection.
   Perinephritis is not necessarily suppurative.   After a long-lasting
nephritis it sometimes  happens that the capsule of the kidney  is con-
verted into a dense fibrous investment, the fat having almost entirely
disappeared, or  the fatty  envelope  of the organ may  be greatly thick-
ened, shoAving an increase of both  adipose and fibrous tissue.   This
overgrowth is particularly  abundant about the  hilum, and much
resembles in  structure lipomata occurring in  other portions  of the
body.
   There  are two  forms of  perinephric abscess:  the primary, in
which the suppuration arises de novo  in the fatty capsule; and the
secondary, in Avhich the primary focus lies elsewhere.
   The  primary forms of perinephric  abscess may  arise in several
ways.  Traumatism is responsible  for some cases.  In injuries to the
lumbar region AArhen there is  penetration, laceration, or cutaneous
abrasion, pyogenic micro-organisms have direct access to the tissues,
and infection may follow; but there have been cases of perinephric
suppuration  folloAving traumatism in Avhich no  superficial injuries
occurred.  The  rare instances  in  Avhich such suppuration has fol-
lowed  severe  jarring to the trunk or heavy lifting must be classed
with the primary cases.   Many cases have  been  attributed to colds.
The infection must be explained in one of several ways : it may  have
been haematogenous, the traumatism  or the  cold having rendered
the  tissues  susceptible to the  circulatory micro-organisms;  or the
traumatism may have excited to activity a latent disease.  There may
also be a perinephritis due to actinomycosis.
   The secondary perinephric  suppurations arise from many causes.
From the  kidney secondary infection  is common.   In any case of
suppurative nephritis,  pyelonephritis, pyonephrosis,  hydronephrosis,
Pyelitis (especially  associated with calculus),  ureteritis, tubercular,
malignant,  or cystic disease, a perinephric abscess may form.   The 
820        GENITO-URINARY  DISEASES AND SYPHILIS.

infection may be due either to  the rupture of an area of renal suppu-
ration into the  perinephric tissue, or to extension  through the true
capsule without discoverable  opening.   The  infection may reach
the fatty capsule from its periphery.  Thus, perityphlitis and appen-
dicitis, parametritis  and parovaritis, malignant disease of the colon
abscess of the spleen, gall-bladder, or liver, subphrenic abscess, psoas
abscess,  or any bone suppuration, and in  rare  cases abscess of the
lung or pleura, may  be the primary focus of suppuration.
   In other cases infection may reach the  fatty tissues by the blood-
or lymph-channels.   In pyaemia or internal suppuration, in puerperal
fever, or after operations on the prostate, bladder, testicles, rectum, or
ischiorectal spaces, such an infection may  occur.  Finally, there are
rare  instances of perinephric  suppuration entirely Avithout obvious
cause, in which  an infection by micro-organisms from the colon may
be possible.  The condition is  most common in men (of one hundred
and thirty-eight  cases collected by Nieden ninety-seven Avere in men).
Most  of the cases have occurred in middle life, but there have been
cases in children (one at five Aveeks) and in persons over sixty years.
The right side has been found more often affected, and in at least two
instances the condition was bilateral.   The abscesses may be large
or small, single or multiple.   The  latter condition is most often seen
in cases Avhere  infection has proceeded from  the kidney.  The pus
may spread from the fatty capsule and infiltrate the loose  retroperi-
toneal tissue  ; in other cases it is Availed in by a strong fibrous capsule.
The  perinephric lipomatous investment is more or less necrotic, and
bleeding is  not uncommon in  the infected  area.  The pus is usually
bland and odorless;  it may, however, be fetid (intestinal infection ?),
or urinous.   According to its origin the pus may contain renal tissue,
concretions, parasites, or shreds of neoplasm.  The  kidney-substance
often  becomes secondarily involved, and amyloid degeneration may
ensue.  Metastasis to distant organs is rare.
   The main portion of the abscess is usually placed directly behind
the kidney, but  the  pus may  burroav in various  directions, and this
tendency is  of great clinical importance.  It  may descend into the
pelvis behind the peritoneum, opening into the rectum, vagina, urethra,
or bladder (in about four per  cent, of recorded cases).  It may pass
down within the sheath of the psoas muscle  and point below Pou-
part's ligament,  may follow  the iliac vessels and point in the femoral
region, or may pass  out  through the sacro-sciatic foramen and point
in the gluteal region.  Rupture into the ureter or the kidney is pos-
sible.  In a feAv cases the abscess has discharged into the colon (of
six cases, four recovered), duodenum, or stomach;  the liver may be 
SUPPURATIVE DISEASES  OF THE KIDNEY.
secondarily infected.  Rupture into  the peritoneal cavity  is rare, as
the peritoneum  becomes  thick and  fibrous as a result of  inflamma-
tion.  The upward pressure of an extensive perinephric abscess may
be sufficient to cause distressing dyspnoea.
   Perhaps  the  most frequent direction of pointing, with the excep-
tion of  those  abscesses AAdiich open  in  the lumbar region,  is towards
the pleural  cavity.  Senator long ago  called  attention to  the exist-
ence of a serous pleurisy Avhich often complicates perinephritis, even
though the abscess has not directly involved the pleura.  It has been
shown that there  is a triangular defect in the diaphragm just behind
the upper portion  of the kidney : hence there is little  to prevent the
extension of  pus  upward when the perinephric tissues  suppurate.
After rupture through the diaphragm the pus may infiltrate the retro-
pleural  tissue, penetrate  the  pleural  cavity,  causing empyema,  or
rupture into the lung,  giving rise to  pulmonary abscess.   In some
cases profuse purulent expectoration or the symptoms of suppurative
pleuritis first attract attention  to the  perinephric suppuration, though,
unless it is remembered that perinephritis  may be a causative factor,
the etiology of the pulmonary abscess or the empyema may remain
unsuspected.  In Fisher's series of ninety-four cases the pleura was
affected in tAventy-four per  cent., the  lungs in tvventy per cent., and
the pericardium  in six per cent.
   Symptoms.—The cardinal  symptoms of  perinephritis  are tumor,
pain, tenderness, and fever.   The local symptoms depend  upon the
formation of pus  and the direction of its  extension.  In  the cases
which are secondary to inflammation of the appendix, the uterus or
its adnexa, the gall-bladder, etc., the  symptoms of perinephritis are
masked by those of the original disease.  This is also true of sup-
puration secondary to infection of the uro-genital tract or which occurs
in the course of a general pyaemia.
   The symptoms are clearly marked  in cases following traumatism
or cold  or in those of haematogenous origin unassociated Avith general
pyaemia.  Pain,  chill, and fever are generally the early phenomena.
   The pain is at first confined  to the loin and aggravated by press-
ure ;  soon any motion of  the  trunk or leg of the affected side greatly
increases it.  The patient lies on his  back, with a lateral curvature the
concavity of which is towards  the  side involved; the  thigh is ad-
ducted and flexed.   At times  severe pains  may radiate into the geni-
talia, around the abdomen, or into the thigh ;  this is due to pressure
upon  the nerve-trunks.  Even in the feverless walking cases the mus-
cles attempt to protect the inflamed region ; the thigh is adducted, the
body is  bent forward, and the trunk is fixed, usually  with  a lumbar 
822       GENITO-URINARY DISEASES AND SYPHILIS.

flexure towards the inflammatory focus ; the patient limps.  In a few
cases partial anaesthesia and  paresis have  been  noted.  Since the
third and fourth lumbar  nerves  supply the muscles Avhich flex the
thigh, this symptom of flexion is  most prominent Avhere the abscess
lies directly  over them,—that is, about the lower third of the kidney.
In  some  cases  the  thigh is fixed in flexion;  in other  cases any
motion except extension may be performed painlessly.
    The fever may be high or moderate ; it is usually markedly inter-
mittent or even remittent,  and often presents the  distinct hectic type.
Chills and profuse perspiration are  common.  The  blood generally
shows leucocytosis, except when  the  condition is  secondary to bone
tuberculosis.  The gastro-intestinal tract is deranged, there are ano-
rexia, vomiting, sometimes tympany, and these disturbances may be
much aggravated by the pressure  of the abscess upon the colon, with
the production of  obstruction and consequent stercoraemia.
    The local symptoms develop  early.  There is a tender tumor in
the loin, which may be indistinctly fluctuating and irregular in out-
line.  The abscess lies  under the colon, and  therefore usually does
not produce an area of dulness on anterior percussion, but flatness is
marked in the lumbar region.
    The loin is usually  swollen;  this swelling may be so slight that
careful measurements are necessary to  demonstrate  it, or it may be
so distinct that the lumbar region protrudes.   This tumor does not
move with  respiration.   When external  pointing is  about to take
place, the skin over the  loin becomes red and  waxy, and distinct
oedema  develops; the  abscess  usually  opens  in or  near  Petifs
triangle.
    Supradiaphragmatic  symptoms often develop.  Independent of
perforation into the pleura, severe pleurisy may occur, presenting the
recognized symptoms of that condition.  In nearly all cases there is
restricted abdominal breathing, and hence some dyspnoea and an irri-
table cough.  Apart from diaphragmatic  rigidity, extreme dyspnoea
may be produced by direct pressure of a large abscess.
    In the acute cases the general strength of the patient is quickly
and markedly reduced,  prostration is extreme, and, unless there is
natural  or artificial evacuation, the patient becomes profoundly septi-
cemic, or even may succumb to  a general  pyaemia.  The tubercular
cases, however, and some of the  infective cases,  run a mild chronic
course, in which the local phenomena largely predominate.
    When the abscess forms visceral  adhesions, or shows a tendency
toAvards pointing  externally,  additional symptoms  usually appear,
though  evacuation may be accomplished  almost  without symptoms. 
SUPPURATIVE DISEASES OF THE KIDNEY.
823
 Opening into the loin  is heralded by the well-known local signs of
 abscess-formation.  Evacuation into the intestines is preceded and ac-
 companied by colicky or continuous  pains and a desire  to defecate;
 when such symptoms  arise, pus  should be sought for in the evacua-
 tion.  Symptoms of acute peritonitis may appear; these are usually
 reflex, or indicate intestinal implication rather than peritonitis.  Rup-
 ture into the kidney or the urethra is accompanied by mild or severe
 renal colics Avith frequent urination; the same pains, together with
 vesical irritability, may be present in case of rupture into  the bladder,
 though this may take place without producing any symptoms.  The
 downward and forAvard  extension of the abscess is indicated by the
 increasing area of tenderness  and the  detection by palpation of in-
 flammatory thickening  of the tissues.
    Rupture into the pleura is accompanied by severe cough, dyspnoea,
 and the physical signs of empyema; later there forms a lung abscess,
 or a pneumo-pyothorax ; such an abscess may be evacuated through
 the bronchus.
    In most cases immediately  following  rupture of the abscess there
 is marked  amelioration of general symptoms,  and the size of the
 tumor is decreased, but this may not be demonstrable. When fistulae
 have formed they will  discharge  regularly and almost continuously,
 but not unfrequently the  tracts become blocked; this  is  followed by
 prompt exaggeration of both the general symptoms and the local signs.
    Diagnosis.—Perinephric abscess may be confused  with—(a) non-
 inflammatory conditions of other tissues ; (6) inflammatory conditions
 of other tissues;  (c) neoplasms of the  kidneys or adjacent tissues;
 (d) inflammatory conditions of the kidneys.
   Of the non-inflammatory conditions, lumbago,  lumbar  or renal
 neuralgia,  renal colic and faecal impaction, are those most likely to be
 mistaken for perinephric abscess.   In lumbago the  pains are gener-
 ally bilateral, do not radiate into  the thighs, but along the course of
 the  sciatic nerve, and there is  more  tenderness over  the bony parts
 than over the loin.  The pain  in  neuralgia  is often intermittent, and
 is of a peculiar sharp quality which is  not felt in perinephritis.  In
 renal calculi there are vesical symptoms and retraction of the testicle,
 followed by blood and  possibly stone fragments in the  urine.  Faecal
 impaction  must be  differentiated  by the history and by physical ex-
 amination.
   Certain of the infectious  diseases may in their early stages simu-
 late  perinephritis:  thus,  influenza,  small-pox, and  cerebro-spinal
 fever may with their severe loin-pains and fever cause confusion until
they  have  evolved  their other characteristic signs.    Perinephritis 
824
GENITO-URINARY  DISEASES AND SYPHILIS.
may also simulate typhoid fever, but here, as in the non-inflammatory
conditions, there would be no leucocytosis such as accompanies peri-
nephric abscess.
   Of the inflammatory conditions of other tissues which may be con-
founded with perinephritis, appendicitis, parametritis, and parovaritis
are the most  common,  Avith abscess of the gall-bladder, liver, or
spleen as rare causes of confusion.
   The pain in appendicitis generally begins as an intestinal colic, and
later radiates through the abdomen or towards  the umbilicus rather
than  into the genitalia or down  the thigh.  The dulness is often in
front  of the colon, and more marked anteriorly  than posteriorly, and
the peritoneal symptoms are more pronounced.   Moreover, the point
of greatest tenderness does not coincide in the two affections.  These
elements  of difference, with the  history, will usually  determine  the
diagnosis.  Rectal exploration should also be made,  and the urine
should be carefully examined for pus.
   Parametritis and parovaritis can generally be differentiated by the
history and by vaginal and rectal examinations.
   Visceral abscesses must be excluded by the history and by physical
examination.
   Coxalgia and spinal  tuberculosis may  be closely  simulated by
perinephric  abscess.  The position  of the  leg may be the same as
in coxalgia, but the  other joint-symptoms  are  not present.   Spinal
tuberculosis causes  a marked rigidity of the vertebral column, with
tenderness over certain points, pain on concussion, with relief of pain
on extension of the  spine, and angular deformity;  these  symptoms
are absent in perinephric abscess.  Moreover,  there  is no leucocy-
tosis in bone tuberculosis unassociated with mixed infection.
   Neoplasms of the kidney or adjacent tissues are sometimes very
difficult to exclude,  since the swelling of a perinephric abscess does
not always fluctuate.  The age of the patient might suggest the prob-
ability of renal neoplasm; fever  and flexion of  the leg would  almost
positively point to abscess.   In doubtful cases a careful examination
under complete narcosis will often be necessary before deciding the
question.   The examination of  the urine  sometimes  furnishes evi-
dence of perinephritis, though, unless the  secreting  substance or the
pelvis of the  kidney  is inflamed, the  examination will be negative.
Rapidly growing  sarcomata  often cause a decided leucocytosis, Avhile
a mild leucocytosis may be present in cases of cancer; thus this sign
of abscess may  be   misleading.   In doubtful cases  an exploratory
puncture  is justifiable, since a diagnosis can usually  be made from
the material aspirated. 
SUPPURATIVE DISEASES  OF THE KIDNEY.
825
   Tumors of the liver or gall-bladder on the one side, or of the spleen
on the other, may be eliminated by the distention of the stomach and
colon with air, whereby the percussion flatness of hepatic and splenic
growths Avould be exaggerated, that of a perinephric abscess dimin-
ished.  Ovarian cysts  can usually be excluded by vaginal and  rectal
examination and by the history.
   Of the inflammatory conditions of the kidney Avhich may be mis-
taken for perinephric abscess, pyonephrosis, pyelitis, and suppurative
nephritis are  the most frequent.   The differential diagnosis is often
very difficult, but, as  the treatment of  all is nearly  the same,  the
difficulties are not discouraging.  The  tumor of hydronephrosis  or
pyonephrosis  resulting from a blocking of the ureter is of more sud-
den formation than an abscess; there is not  the marked flexion  of
the thigh, the  pain  is more paroxysmal, and there is in hydrone-
phrosis  no fever.  Examination of the urine  is in such cases most
helpful.   Pyelitis and suppurative nephritis do not occasion  swelling,
severe pain, or flexion of the thigh.   In any case where there  are
pyuria and the signs of perinephric  abscess, it will be important to
know Avhether  the  pus  comes  from the urinary tract or from  the
abscess.  In such cases methyl-blue maybe injected into the  enlarge-
ment, and*, by the use of the catheter or the cystoscope, the  time  of
the advent of  the coloring-matter from the ureter may be  noted.   In
case the abscess (or cyst or tumor) communicates with the renal pelvis
or the ureter, this should occur within ten minutes.
   The knowledge of  leucocytosis in the various renal  inflammations
has not yet been so formulated as to be of clinical service.   Careful
repeated  examinations of the urine and the history of the  case are
the most important elements in differentiating perinephric abscesses
from the renal  infections.
   Prognosis.—This is dependent upon the cause of the perinephritis.
When the perinephric inflammation is secondary to infection of the
kidney the prognosis must  be guarded.  When it follows contusion
of the kidney the prognosis is  extremely favorable if the condition is
recognized and promptly treated.  Poland's statistics are instructive
in relation to the value  of early operation.   Of  eight cases  treated
expectantly six died.   Of twenty cases treated by operation one died.
   The course of primary  perinephritis is usually acute,  the symp-
toms are severe, and the inflammation  quickly terminates in death  or
evacuation of the abscess.  In a few cases the abscess has  become
encysted, with  complete  recovery, and  the pathology of abscesses  in
other parts of the body shows the possibility of such a  termination.
   In case  of pointing the subsequent history of the  case  depends 
826
GENITO-URINARY DISEASES AND SYPHILIS.
upon the site of evacuation.  Most favorable, of course, is lumbar or
iliac evacuation, next is  rupture into the colon, then rupture into the
urinary tract, and most unfavorable is rupture through the diaphragm.
In the secondary cases the duration and  prognosis are obviously in-
fluenced by the primary conditions.
    Treatment.—When the diagnosis of perinephric abscess  is fairly
established there can be no reason  for delay in surgical intervention.
Palliative treatment is  indicated only during the time the surgeon is
determining whether or not pus is present in the perinephric region.
Before the formation of a distinct tumor  it may be quite impossible
to distinguish perinephritis from any of the forms of kidney infection.
During  this period  the treatment  appropriate to suppurative renal
disease is indicated.  This implies  rest in bed, counter-irritation ap-
plied to the lumbar region, the relief of pain by injections  of mor-
phine, the administration of mild antiseptics, diuretics, and liquid
diet, preferably milk, and regulation of the bowels  by salines or by
enemata.
   When incision is practised,  the opening should be in the lumbar
region,  and should  be sufficiently  large to allow of exploration of
the kidney and its  pelvis.  It is best to use the finger instead of the
knife to open up the abscess-cavity and break down septa.*  The ad-
mixture of urine with the pus indicates that  there is an opening into
the kidney pelvis, and  suggests exploration of this cavity and of the
ureter for the purpose of removing calculi or relieving obstruction.
Frequently the pus has  a faecal odor, suggesting a  communication
with the bowel.  This odor does not, however, indicate the formation
of an intestinal fistula, but is probably due to the  close proximity of
the focus of suppuration to the large intestine,  certain saprophytic
micro-organisms contained in the colon apparently having the poAver
to pass through its Avails.  When the abscess has burroAved widely
its accessory cavities should be  opened and drained; healing  of these
may be confidently expected after drainage of the centre of infection.
In cases of long duration and Avhere the  abscess is of large  size, the
pressure  may have caused  marked  atrophy of the kidney, or this
organ may be so extensively infiltrated with pus that nephrectomy is
indicated.  In such cases it is  safest to perform tAvo operations, let-
ting the patient recover from the constitutional effects of suppuration
before submitting him to  the shock and strain of a nephrectomy.
   When the abscess has already opened, into a bronchus or the colon,
for instance, it is  possible that spontaneous cure may result.   Sur-
gical intervention may then be delayed, provided the patient's general
condition is satisfactory and the quantity of pus  discharged is dimin- 
SUPPURATIVE DISEASES  OF THE  KIDNEY.
ishing.  Should hectic, emaciation, and loss of strength show deficient
drainage and  ptomaine absorption, the centre of infection should be
drained directly.   The after-treatment of the incision made for drain-
age is important,  since fistulae are liable to persist, especially in cases
of long-standing  suppuration  and  in those complicated  by pyelo-
nephritis.   Drainage should be thorough, and is best  secured  by
gauze packing, Avhich is so reneAved  at subsequent dressings that the
wound heals from the bottom. 
CHAPTER  XXIV.
HYDRONEPHROSIS.--RENAL  TUBERCULOSIS.--RENAL FISTULA.—PARASITES AND
                              TUMORS.

                         HYDRONEPHROSIS.
   This is a condition characterized by distention of the kidney pelvis
with  fluid, usually urine.  Morris, however, has  recorded  a case in
which the fluid Avas  composed wholly of water and sodium chloride,
Avithout a  trace of urea  or  albumen or any other characteristic of
urine.  It is associated with  pressure, atrophy of  the kidney, and in-
terstitial nephritis, the gland and  its pelvis becoming converted  into
a fibrous, thick-walled sac, in which the fluid is contained.  The cause
of hydronephrosis is obstruction to the flow of urine through any por-
tion of the urinary tract; this results in distention and paresis of the
pelvic and ureteral muscles.
   Hydronephrosis  may be congenital  or acquired,  permanent or
intermittent, unilateral or bilateral, partial or total.   In permanent
hydronephrosis the distention is continuous ;  in the intermittent form
of the affection there are periods during Avhich the obstruction is re-
lieved and the retained fluid escapes, usually into the bladder.  Partial
hydronephrosis is caused by  blocking of one or more calices; this may
be due to  stone  or to cicatricial contraction.  Total hydronephrosis
results from obstruction  of the pelvic orifice or of the tract below;
stone is the common  cause, though blood-clots, masses  of coherent
pus, fragments of tissue, or parasites exceptionally may occasion ob-
struction.   The  ureters may be blocked congenitally, or as the result
of external pressure,  traumatism, inflammation,  or lodgement of a
solid or semi-solid substance.  They may be strictured in any part of
their course.
   Congenital  hydronephrosis may be  unilateral or  bilateral.
Among the causes are imperforate urethra or ureter.   Malformation,
folds or duplicatures of the mucous membrane at the  vesical  orifice,
congenital tumors of the bladder, ureters, or neighboring organs, float-
ing kidney, and  obstruction  by the blood-vessels  of the kidney, are
occasional causes.
   Congenital stricture usually entirely obliterates the ureters.  There
may be a  narrowing at the uretero-pelvic junction, or even  a valvular
     828 
HYDRONEPHROSIS.
829
formation here.  Later in life there  is sometimes an obstruction at
this point, caused by the inflamed mucous membrane, which Kuster
states slides downward from its  attachment,  thus  creating a valve.
The ureters sometimes enter  obliquely or at an angle unfavorable to
free drainage.  This  conformation may be congenital or may be due
to gradual  dilatation of the  pelvis.   Or the  ureter may enter  the
pelvis at a  point higher than normal, thus encouraging retention of
urine and  distention.  Tension exerted  by  an unevenly distended
capsule  may so draAV upon the ureteral  orifice as to alter it in form
and interfere Avith the flow of urine.
   If the disease is bilateral it is rapidly fatal.   Hydronephrosis  may
be present at birth or may appear subsequently because of congenital
deformity.   When  the disease is congenital  the dilatation usually
attains proportionally a much greater size than when it is acquired.
Even though the congenital  obstruction is caused by an impervious
ureter, the kidney does  not atrophy, since during intra-uterine life it
secretes much more slowly than  after birth, and consequently intra-
renal pressure is not developed Avith sufficient rapidity to arrest secre-
tion before the delicate pelvic and ureteral tissues have become relaxed
and overstretched.
   The treatment is the  same as that of acquired hydronephrosis.
When there is reason to believe that the obstruction  is caused  by
movable kidney or impacted  calculus it is possible that  manipulation
through the abdominal walls, aided  by  lumbar aspiration, may re-
lieve symptoms.  When the  hydronephrosis is due to stricture or to
valve-formation, lumbar incision  followed by  an attempt to remove
the obstruction is justifiable.  Should the obstruction  be irremedi-
able, permanent drainage of the pelvis, or, if the disease is unilateral,
nephrectomy, is indicated.
   Acquired  hydronephrosis is most frequent in women, probably
because they are so commonly subject to pelvic disease  and floating
kidneys.  It may be due to pelvic tumors, particularly those of a can-
cerous nature,  displacements  of the womb, pelvic inflammations, vesi-
cal neoplasms, traumatism, unnatural mobility of the kidney, calculi,
stricture of the urethra, enlarged prostate, genito-urinary tuberculosis,
and irritable bladder.  This  last  condition is  operative  because  the
frequent act of micturition has a tendency constantly to close  the
vesico-ureteral outlets, producing  backward pressure upon the pelvis
of the kidney.
   Of six hundred and sixty-five cases tabulated by Newman, stric-
ture of  the urethra  and enlarged prostate and hypertrophy of  the
bladder were  found to be the cause  in one hundred and ninety-five 
830        GENITO-URINARY  DISEASES AND  SYPHILIS.

bilateral and  thirty-nine unilateral cases of hydronephrosis.  Next
in order of frequency come tumors of the pelvic organs, causing com-
pression of the ureters.  From this alone there were one hundred and
forty-three bilateral and forty-one unilateral cases.   Renal calculus
produces unilateral hydronephrosis more often than any other of the
causes noted,  fifty-one cases being due to that alone;  it Avas found to
be the cause of only seventeen cases of bilateral dilatation.
   In a certain number  of cases observed  at  post-mortem examina-
tions no causes have been discovered.   These may have been due to
the acute angle of entrance of the ureter into the pelvis or to undue
irritability  of the ureter.  It is possible that the retention of urine is
under such circumstances owing to paresis of the detrusor muscles, an
expression of  neurosis corresponding to the vesical retention of urine
observed, after traumatic, degenerative, or functional disturbances of
the spinal cord.
   The effect  of hydronephrosis upon  the  kidney structure depends
upon the completeness and the duration of the obstruction.  Excep-
tionally the dilatation is confined  solely to the pelvis. Usually the
kidney is involved sooner or later, forming, with the pelvis, a rounded,
irregularly nodulated tumor, varying greatly in size.   Even  in enor-
mously dilated kidneys  there may be some  remnants of secreting
substance.   As a rule, the walls of the cyst are made up of fibrous
tissue.
   Griffiths has  carefully studied the  histological  changes produced
by hydronephrosis.  There are tAvo distinct processes, one the result
of pressure limited to the tissue pressed upon ;  the other a degenera-
tion  identical  with  that  seen in  chronic interstitial nephritis, due in
part to the distention of the pelvis, Avhich by compressing and stretch-
ing the renal  vessels as they pass into  the  kidney interferes with the
nutrition of the whole organ.  Distention  of  the  pelvis takes place
mainly in a forward direction, pushing the renal vessels which lie in
front, and thus stretching and flattening them.   In the  later stages of
hydronephrosis there  is thickening of  the intima, and even  of the
media, with the formation of fibrous connective tissue, thus contrib-
uting to further diminution  in the  calibre of the  channels which
supply the kidneys Avith  blood.   Occasionally  thrombi  develop in
these A^essels.   The cortical substance of the kidney is the slowest to
disappear.
   Finally the whole  secreting substance is converted into connective
tissue.  The perinephric fat is  infiltrated and adherent.  The dilated
larger excretory tubes persist  for some time; at last even traces of
these disappear, the hydronephrotic kidney forming a huge sac, some- 
HYDRONEPHROSIS.
831
times incrusted with urinary salts.   The  participation of the ureter
depends upon the seat of obstruction.  This sac contains acid urine,
often hyaline casts and blood.  The salts are sometimes precipitated,
forming a thick, semi-liquid,  brownish  mass.  The sound kidney
becomes hypertrophied.   Symptoms are at times completely absent,
and,  provided the  other kidney undergoes compensatory  growth,
there may be no interference Avith the general health.  (Sehnvald.)
   Intermittent or relapsing hydronephrosis is characterized by an
occasional partial or  complete  evacuation of the  contents of the
dilated  kidney pelvis, folloAved  by the passage of a large quantity of
urine from the bladder.   In one case, reported by Gintrac, the tumor
was wont to subside suddenly by discharging into the colon, the sub-
sidence being  followed by copious watery stools.
   The usual  cause of intermittent hydronephrosis  is movable kid-
ney, the ureter being  flexed or  tAvisted, and remaining partially or
completely impervious till a change  in the position of the organ ren-
ders its duct patulous,  and the  retained urine freely escapes.
   Occasionally intermittent hydronephrosis may be due to a calculus,
which may act as a  temporary ball-valve,  closing the ureteral outlet
from the  kidney, but becoming dislodged when the  pelvis is much
dilated.  After the subsidence of the tumor the patient  may be free
from symptoms for months, or  even years,  or the  hydronephrosis
may recur frequently.
   Bland Sutton calls attention to the difficulty of deciding clinically
betAveen a very  large  hydronephrotic cyst and an  ovarian  or par-
ovarian cyst,  since  cysts of the  ovary and  parovarium sometimes
rupture, and  the fluid escaping into the peritoneum is absorbed by
this membrane and  rapidly excreted by the kidneys, thus producing
the characteristic symptoms  of  intermittent hydronephrosis,—i.e.,
tumor which suddenly disappears and is  promptly followed by diu-
resis.
   In nearly all cases of hydronephrosis the  obstruction is not com-
plete,—that is, there is a partial escape of urine : hence, as a rule,
there is likely to be intermittence  in  degree  of tension.  Clinically
the term  intermittent is applied only to  those cases in which the
swelling occasionally disappears completely.
   Terrier and Boudoin collected eighty-three cases of  intermittent
hydronephrosis.  They found  floating kidney the usual  cause, and
called attention to the fact that the disease eventually becomes per-
manent, oAving to inflammatory constrictions and adhesions.
   Symptoms.—Unless sufficient  urine is retained to produce a dis-
tinct tumor, there may  be no symptoms of hydronephrosis.  The 
GENITO-URINARY DISEASES AND SYPHILIS.
obstruction is usually of such a nature  that retention is gradual and
painless in its onset, and dilatation of the kidney and its pelvis is  not
suspected until examination shows a  smooth, rounded,  movable,
fluctuating tumor placed behind  the colon  and projecting into  the
abdominal cavity.  The fluctuation can  be detected only in large
accumulations.   Often there is a sense of weight and  dragging, and
sometimes there are distinct  attacks of  pain, resembling kidney colic,
due to sudden increase of tension.  Hydronephrosis develops Avithout
fever.  The intermittent form  of the disease is characterized by the
appearance of a tumor of rapid growth, Avhich  gives rise to pain, and
by sudden disappearance of  the tumor, folloAved by polyuria.  Pain
which develops during  the  growth of the tumor may be extremely
severe, and  may present all  the features of kidney colic.  The inter-
mission is sometimes as regular as are the recurrences of malarial
paroxysms.
   Diagnosis.—This is  based on the detection  of a fluctuating tumor
primarily  occupying the kidney region.  When hydronephrosis is of
such  small dimensions  that  it cannot be felt by palpation,  diagnosis
is not possible  except  in  cases  of  acute ureteral  obstruction when
kidney colic develops.
   Large  hydronephrotic  sacs are readily confounded with ovarian
cysts,  especially when  the evolution  of the tumor and its position
Avhile still small are unknoAvn.   It can readily be seen that a sac con-
taining thirty gallons, as in  a  case  reported by Bland Sutton, prac-
tically fills the  abdominal  space.  Differential  diagnosis may be  im-
possible.  Aspiration may  throw light on the  etiology of the tumor,
since the contents of a  hydronephrotic sac may show traces of urea.
This, however, is not always  the case, and it has  frequently hap-
pened that diagnosis has been  made only after incision for operation.
Ureteral  catheterization may enable the surgeon to form a  correct
opinion as to  the origin of  a cystic tumor when every other means
of differential diagnosis fails.
   Prognosis.—The prognosis  of  hydronephrosis is  favorable if the
disease is unilateral.  Spontaneous  cure may result, probably from
atrophy of the secreting substance of the kidney. The more common
terminations are pyonephrosis and pyelonephritis.  When the disease
is bilateral the prognosis is extremely grave.
    Treatment.—No internal  medication has  the slightest effect upon
hydronephrosis.   Antispasmodics may possibly be serviceable Avhen
there is reason to  believe that the retention is  due to spasmodic con-
traction of the  ureter.
    Surgical measures consist  of—(a) massage  and manipulation of 
HYDRONEPHROSIS.
833
the SAvelling;  {b) ureteral instrumentation; (c) aspiration and tapping
Avith a trocar  and canula ;  {d) nephrotomy ; (e) nephrectomy.
   Massage and manipulation of the swelling have been  successful
in dislodging  the  obstruction when it was unquestionably caused by
impacted calculus or kinks  in the  ureter produced by movable  or
floating kidney.  Vigorous kneading or rough  handling of the dilated
pelvis is not  safe, since there is a  chance of rupturing the  sac into
the peritoneal cavity or the  perinephric  tissue.   When the manipu-
lation is successful the tumor subsides,  and there is a free flow of
urine from the bladder.   The subsidence may be  permanent if the
obstruction is  caused by impacted calculus, but Avill be only tempo-
rary when it is due to  movable kidney.   This temporary relief may
be made permanent by suturing the kidney in position.
   Ureteral catheterization is serviceable when retention  is  due  to
stricture of the  ureter, to valve-formation, or to an anomalous en-
trance of the  ureter into the pelvis.  It may not only relieve tension
but may prove curative in case of stricture.   In using the  ureteral
catheter the danger of converting a hydronephrosis into a pyonephro-
sis must be fully appreciated and guarded against.   Valve-formation
should be subjected to  operation.
   Aspiration is  a treatment which may be  necessitated when the
urgency of symptoms calls for temporary relief.  There is usually  a
reaccumulation of fluid; in a certain number of cases after emptying
the sac twice or thrice the secretion has ceased and the cure has been
permanent.  This is probably due to the fact that the secreting sub-
stance of the  kidney has been completely atrophied.  The operation
is not free from risk of septic infection of the sac and the development
of pyonephrosis.
   The best results from puncture have followed Avhen this was prac-
tised upon  cases of traumatic hydronephrosis.   Morris, of eighteen
cases, reports  ten cures, five deaths,  and  three failures.   In more
than half the fatal cases, he  states, further treatment  should have
been adopted  : hence the  apparent mortality of this procedure is far
too high.   He advises,  when no particular spot is suggested by dis-
coloration or prominence, that the needle  should be driven in, on the
left side, an inch in front of the last intercostal space.  "  If there is no
indication for  operating elsewhere, the best spot to select when the
kidney is on the right side is half-Avay  between the last  rib and the
crest of the ilium, between two and two and a half inches behind the
anterior  superior spine of the ilium."   The intestine is usually in
front of the tumor  and adherent to it, and may be wounded if the
puncture is made too far forward.
                               53 
834        GENITO-URINARY DISEASES AND SYPHILIS.

   Puncture Avith the trocar and canula is a much more hazardous
operation, and should be discarded.
   When repeated aspirations have failed to give permanent relief
nephrotomy is indicated.   This operation may be performed through
either the  lateral  abdominal or the lumbar incision.   The latter is
better, since it not only avoids  the risks attending the opening of the
peritoneal cavity, but  also facilitates the performance of nephrectomy
if that operation is deemed advisable after the kidney has been ex-
plored.   The great objection to nephrotomy is the probability of the
development of  permanent urinary fistula.  In a  certain number of
cases where the  secreting substance  of the kidney has entirely disap-
peared, after drainage the sac  shrivels, and there  is a good result;
usually there is  a constant escape of urine and the cavity becomes
infected.  It  is,  therefore, Avell, in case nephrotomy proves  that it is
impossible  to restore the normal passage  from the kidney pelvis to
the bladder, to practise nephrectomy before infection has taken place,
provided the existence of a competent healthy kidney on the opposite
side is thoroughly confirmed.
   Of  eighteen  cases of nephrotomy  performed for hydronephrosis
none proved fatal. Bruce Clark states that  in more  than fifty  per
cent, of cases fistula  is  established.  Nephrotomy  is  performed as
described in the  treatment of kidney calculus.
   Nephrectomy as a primary  operation implies  immediate removal
of the entire sac.  The method of operating is determined by the size
of the  tumor.   When  this  is extremely  large  the transperitoneal
method is to be  preferred, since it allows freer access to the kidney.
When there is but moderate dilatation the lumbar incision is the one
of choice.
   Arnold  reports two  deaths  in  tAventy-six cases.   Duplay  and
Reclus state that nephrotomy gives a mortality of eighteen and eight-
tenths  per cent.,  and leaves sixty-six and six-tenths  per cent, of
cases with fistula; nephrectomy gives thirteen  and  one-tenth  per
cent, mortality (twenty-five and eight-tenths  per  cent,  after abdom-
inal  incision, six and four-tenths per cent, after  lumbar  incision).
Secondary  nephrectomy  has ahvays  been  followed  by  recovery.
These  calculations are based upon a statistical  study  of fifty-eight
cases.   Newman gives the mortality of nephrectomy as  forty-one and
three-tenths per cent.

                  TUBERCULOSIS OF THE  KIDNEY.
   Tuberculosis of the kidney presents itself in two general forms,—
acute and chronic.  By the acute form is meant the miliary infection 
TURERCULOSIS  OF THE KIDNEY.
835
 seen in cases of general tuberculosis.  Under the chronic form are
 classified those slow tubercular lesions of the gland which have been
 generally known as scrofulous pyelonephritis.
    Acute  renal tuberculosis is quite common, particularly in the
' young.  In this condition there is a marked tendency to the involve-
 ment of the entire uro-genital tract, but the tubercular deposits do not
 attain  the  dimensions nor undergo the marked retrograde changes
 which  are seen in the  chronic form.  The renal lesions rarely produce
 definite symptoms, and there is no treatment, apart from that of the
 general infection.   The presence of tubercle bacilli in the urine  is
 often of diagnostic value.   There are no surgical indications.
    Chronic  renal tuberculosis may be primary or secondary, the
 latter being the rule.
    In  the  primary infections  the  route is probably haematogenous,
 and, as in the cases of primary bone and gland tuberculosis, is unas-
 sociated Avith tubercular infection in any other part of the body ; the
 mode of infection is exceedingly obscure.
    In the secondary infections  the  primary focus may be in any part
 of the  system ; in comparison to the  total number of cases of tuber-
 culosis the kidneys are  not frequently  involved.  The relations of
 renal and uro-genital tuberculosis  are not yet fully  understood.   It
 seems  clear that three forms are encountered: the descending form,
 in Avhich the  kidney-lesion is primary ;  the ascending form, in which
 some one of  the subrenal tissues is first  infected; and the form  in
 which  various parts of the tract are simultaneously infected.  The
 relations in children and in adults are probably not identical.  Hamill
 has studied the Avell-recorded cases in  children, and concludes that
 the large  majority of these are of  the  descending form, the kidney
 being first infected.  In adults it is  clear that clinically cases of the
 ascending form are  much more frequent, though it is possible that the
 descending form is the more common type.   Taking all cases together,
 males are probably more frequently affected than are females.
    Renal tuberculosis occurs most commonly betAveen the ages of
 twenty and forty-five, though it is by  no means  confined to these
 limits.   One  case has been recorded in a male  infant three months
 old, and  several cases have been  seen in persons aged more than
 seventy years.
    In the descending  form of tuberculosis the condition in the begin-
 ning is usually unilateral, but later  in the  course of  the disease the
 other kidney  "becomes infected (ascending infection from the bladder).
 In the  ascending form the infection is usually bilateral.  In haemato-
 genous infection (descending) the tubercles are first formed about the 
836        GENITO-URINARY DISEASES AND SYPHILIS.

glomeruli and the minute vessels, but these  deposits may take place
in any  part  of  the  gland.  They gradually break down, and from
them the infection is spread by the  blood- and lymph-channels and
by contiguity.  The  mucous membrane of the calices and pelvis soon
becomes involved, either by distinct  tubercular formations or by dif-
fuse infiltration.   The breaking down of the aggregated tubercles leads
to the  formation of cavities,—the  so-called tubercular cysts.  The
contents are generally  a  yellowish-gray, blood-tinged fluid of thick
consistency and  urinous odor, compounded of pus, urine, blood, renal
tissue, tubercular matter, and  detritus, with occasional collections of
lime salts, phosphates, and cholesterin.  Tubercle bacilli can usually
be demonstrated in the  wall of the cysts, but they are not to be found
in the contents.
   Mixed infection is the rule  in the  advanced cases, and pus organ-
isms are found in the cyst contents.   The  capsule of the kidney be-
comes sclerosed  and thickened, and  may present either a diffuse or a
localized tubercular  infiltration;  it  is  tightly adherent to the  gland.
The total bulk of the organ may be considerably enlarged by massive
deposits and  the capacity of the pelvis much reduced ; or after exten-
sive degeneration there  may be marked reduction in the size  of the
organ, due to contraction  of the connective  tissue and the  capsule.
In the course of time the ureter is commonly affected, and its lumen
may be so narrowed that the tubercular kidney becomes hydrone-
phrotic  or pyonephrotic.
   The perinephric  tissue is  always thickened, and may become
tubercular either by extension  from the  true  capsule,  lymphatic
infection,  or the bursting of  one of  the  renal  cysts.   Thus peri-
nephric abscess often complicates renal tuberculosis.
   In cases of ascending tuberculosis  where a hydronephrosis often
precedes  the tubercular  infection,  the  process  commences in the
mucous membrane of the pelvis,  attacks the  apices of the pyramids,
and  gradually extends  towards  the cortex, which it involves less
profoundly than  is the case in haematogenous infection.  Obstruc-
tion, with the development of hydronephrosis and pyonephrosis, is
commoner in the ascending form.
   Symptoms.—There are  usually no symptoms so long as the renal
substance alone is affected, but pain develops when the mucous mem-
brane of the calices becomes involved or when an abscess empties into
the pelvis : hence this is often  the first symptom.  (Rosenstein.) The
pain is at first dull and  aching, and is  referred  to the lumbar region.
At times severe  paroxysms occur (renal colic), and the pain  is re-
flected to the penis and  testicles.  Pain may be increased by motion 
TURERCULOSIS OF THE KIDNEY.
837
and position.  Some patients acquire a habit of lateral curvature, Avith
the concavity towards the affected  side,  since this position lessens
their suffering.  Urination may occasion severe pain, referred to the
vesical neck.
   Urinary symptoms often  occur  early; later they are constant.
They are of great importance.   Undue frequency of urination and
slight incontinence are symptoms which,  in the  absence of  obvious
cause, should always arouse suspicion  of tuberculosis.   (Harrison.)
After infection the usual symptoms of cystitis and ureteropyelitis will
develop.
   Early in the disease the quantity of  urine  may  be normal, but is
often increased, constituting polyuria. As soon as the mucous mem-
brane becomes affected, pus and blood appear in the  urine.  Haema-
turia is  usually  slight and  intermittent;  it  may  be constant, but
there is  much  less  blood than  in  malignant disease or calculous
pyelitis.   After the abscesses have once opened into the pelvis and
mixed infection  has taken place, pyuria is  constant, except Avhen
the ureter  becomes  blocked;  this  complication is  of frequent oc-
currence, but the  obstruction is rarely  permanent.   In a  few hours
or days  the blocking material becomes dislodged, and there follows
a profuse gush of urine, loaded with pus and detritus.  At times the
tubercular matter in  the urine may be so bulky that it is with dif-
ficulty voided.   Albuminuria  is, of course,  present whenever the
urine contains blood  or pus, but  it is usually dependent upon  them.
Sooner or later, hoAvever, parenchymatous inflammation occurs  in
either the  affected kidney or its  felloAv, and there then develops  an
essential albuminuria.  The urine is usually acid in  the  absence  of
pyonephrosis or bladder infection  ; after  the advent of cystitis or when
there is  retention in the kidney pelvis, with mixed  infection, it is
alkaline.  It is turbid according to the amount of pus it contains, and
colored according to the amount of blood.
   Microscopically, pus and blood are nearly always  found, but clots
are rare.  Hyaline casts are commonly present, and granular  casts
appear when  parenchymatous nephritis supervenes.  Epithelial cells
from the kidney and  pelvis  are constant  in the  urine of cases with
advanced lesions ; renal tissue is  occasionally seen ; connective tissue
and elastic fibres are  sometimes found, and are of great  diagnostic
value, as are the  little clumps  of meal-like detritus Avhich look like
conglomerated nuclei and resist all reagents.
   Tubercle bacilli should be sought  for in all cases, but  especial
care  must be taken  that the urine is  fresh and that the smegma
bacillus is excluded. 
838        GENITO-URINARY DISEASES AND  SYPHILIS.

   Physical examination  reveals symptoms  of diagnostic value.  In
many cases a tumor is noted in the loin, due to actual renal enlarge-
ment, to perinephric abscess, or to a hydronephrosis or pyonephrosis.
This tumor may be outlined by  percussion  posteriorly, and  may be
felt through the  abdominal walls.  It may feel smooth  or nodular,
may fluctuate, and  is generally  tender on pressure.   The enlarged
ureters  are sometimes palpable.  Should the  left kidney be the one
affected, the spleen will be pushed  forward and the real trouble thus
obscured.
   The general condition of the patient is that of a tubercular sub-
ject.  There are progressive anaemia, debility, anorexia, and diges-
tive  disturbances, with emaciation and cachexia.   Irregular  fever
may be present, and often assumes a hectic  type.   Other tubercular
lesions commonly develop and alter the complexion of the  case.
   Diagnosis.—The diagnosis of renal tuberculosis is founded  upon
—(1) a  tubercular  family  history;  (2)  an othenvise  inexplicable
polyuria; (3) slight, transitory, apparently  causeless haematuria;  (4)
frequent urination; (5)  pyuria  developing seemingly Avithout  suffi-
cient cause and  persisting;  (6)  the formation of a  lumbar tumor;
(7) the development of tubercular lesions in other parts of the body,
particularly in the accessible portions of the genito-urinary tract;
(8) the demonstration of tubercle bacilli by microscopic examination
or inoculation ; (9) the development of tubercular cachexia.
   The only single sign which is absolutely diagnostic is the finding
of the tubercle bacilli.   It must be remembered that these micro-
organisms  cannot be differentiated from smegma bacilli by  staining
reaction:  hence in  collecting the urine care  must be taken to avoid
contamination from the surface of the  glans or  the foreskin.
   Often a tubercular family history cannot be elicited.  Polyuria is
a very frequent and constant symptom of early renal involvement; it
may, however, be excited by many other causes, and  is of value from
a diagnostic stand-point only when associated Avith other symptoms.
Haematuria is  to a certain extent  characteristic;  it  is distinguished
from the  haematuria caused by renal tumors by  the fact that  the
amount of blood found in the  urine  is trifling.   Unlike haematuria
symptomatic of renal calculus, it is  not markedly influenced by active
exertion.   Nor does it  promptly disappear after  rest in bed.  Fre-
quent urination is  rare, and is  commonly a sign of  concomitant in-
volvement of  the bladder;  it sometimes precedes by many months
the  development of appreciable  bladder-lesion, and  may be a renal
reflex.   Pyuria may develop suddenly  from  rupture of  a cortical
abscess into the pelvis of the kidney, profuse  discharge of pus sug- 
TURERCULOSIS  OF THE  KIDNEY.
839
gesting this  accident.  It is  commonly  due to ascending  infection,
denotes the  onset of pyelonephritis,  and is attended by the  symp-
toms of this  condition.
   The development of a lumbar tumor is of diagnostic value only
when it is associated Avith other characteristic symptoms of  renal
tuberculosis.   There  are no  peculiarities of the tubercular enlarge-
ment which would enable the  surgeon to suspect the nature  of the
groAvth  from  physical examination.   When  the tubercular kidney
becomes infected with pus micro-organisms—and  this takes place in
nearly all cases—the symptoms  are simply those of a pyelitis,  pyelo-
nephritis, or suppurative nephritis, the diagnosis as to the underlying
tubercular nature of the affection then  resting upon the results of
bacteriological examination.
   From the operative stand-point it is of extreme importance to find
out Avhether one or both kidneys are  affected.  This may  be  deter-
mined by ureteral catheterization, with the subsequent injection of the
urine draAvn from each kidney into susceptible animals.  This  is the
only reliable method of deciding as to the health of an apparently un-
infected kidney.   It has  already been stated that in  the early stages
of renal tuberculosis perfectly limpid urine may be  eliminated: hence
a  diagnosis  based on the discharge of clear  urine during periods
when the ureter  of an obviously  diseased  kidney is blocked  is
unreliable.
   Prognosis.—The  prognosis  is unfavorable,  especially when both
kidneys are involved.  Of  thirty-two cases  of renal  tuberculosis,
Roberts reports  five as  dead  six months after the  lesion was de-
tected ; five more died Avithin a year, three within two years, one lived
beyond this period; the  remaining cases are unaccounted for.  The
course  of the  lesion is much more rapid when pyelitis and pyelone-
phritis  develop.   Le  Dentu  states that death is  usually caused by
cachexia, renal insufficiency,  and gastro-intestinal catarrh.
   Tuberculosis  is apparently more virulent when it attacks the kid-
ney  than  Avhen  it  involves  the  bladder, prostate,  or  epididymis;
spontaneous cure may, however, take place by  a process of  caseation
and encapsulation.
   Treatment—In many cases,  treatment can be little more than pal-
liative.   Every effort should be made to  keep the patient in the best
possible condition of health.  This may require change of climate and
surroundings and the administration of such remedies as have been
proved  beneficial in general  tuberculosis.   For the attacks  of  severe
pain Avhich frequently occur  in  the  course  of a tubercular pyelone-
phritis anodynes are indicated. 
840        GENITO-URINARY  DISEASES AND SYPHILIS.

   Since the process is an infectious one, the treatment which is nat-
urally  suggested  is  the  complete removal of the tubercular  focus.
When  this is  limited to one portion of one kidney, surgical interven-
tion  is followed by brilliant results.   Unfortunately, in the  majority
of cases both kidneys are  secondarily involved, and  the infection is
irregularly diffused throughout their structure.  Moreover, during the
period Avhen intervention promises most—i.e., in the beginning of the
process—diagnosis is often impossible.
   When there is profuse  and exhausting suppuration, retention of
pus,  or formation of a distinct tumor, due either to perinephric abscess
or to enlargement of the kidney itself,  nephrotomy or nephrectomy is
indicated.  Even Avhen perinephric abscess has developed, unless the
patient's condition is such as to make  prolonged  surgical interference
unAvarrantable, the  lumbar incision  required for the evacuation of
pus  should be of sufficient  size and depth to expose the kidney and
enable the surgeon to remove the infected focus if this is so placed
and  is  of such size that ablation is possible.  If the kidney is so exten-
sively diseased that no portion of its secreting substance can be safely
left,  total  nephrectomy is  indicated, provided  there  is reason for
believing that the other kidney  is healthy and  competent.   Partial
nephrectomy  may be preferable  when a portion of the kidney is
apparently free from disease.  The bleeding is controlled by catgut
sutures.
   Duplay and Reclus record a mortality of forty-seven and  eight-
tenths  per cent,  following nephrotomy for the relief of tubercular
nephritis, with eighteen  and  two-tenths  per cent, of fistulae and
tAventy-six per cent, of recurrences;  eight per  cent, of cases  were
cured.    In fifty-seven  cases primary nephrectomy Avas  performed;
the  mortality was  thirty-two and  three-tenths per  cent.   These
figures favor the view that nephrectomy is  primarily a safer opera-
tion  than  nephrotomy.  There  can be  no doubt as to its supe-
riority in other respects in tubercular cases, since it gives a pros-
pect  of permanent cure and is not followed by the development of
fistulae.  It seems clear, then, that when the patient is in fairly good
condition,  is possessed of one  competent kidney, and the  diseased
organ  is hopelessly degenerated, nephrectomy  is the  operation of
choice.
   In performing nephrectomy it is Avell to remember that the capsule
of a  kidney Avhich has become degenerated as the result of tubercular
pyelonephritis has usually contracted dense adhesions to surrounding
structures, and that the  loosening of these adhesions  may be impos-
sible without  opening the  peritoneum,  tearing large  vessels, or in- 
RENAL FISTULAE.
841
juring neighboring organs:  hence it is wise to practise subcapsular
decortication, the kidney being stripped  from its proper capsule by
the finger until the hilum is reached, and the pedicle being formed of
the tissues  in this region by grasping them in a large, strong, angled
haemostatic  forceps.  On removal of the degenerated kidney mass, the
vessels may be individually secured  or the pedicle  may be ligated en
masse; it is often  extremely friable, and unless this portion of the
operation is carefully conducted there is danger of serious hemor-
rhage.  The capsule is  thoroughly curetted and packed with gauze
when there has been mixed infection.

                        RENAL FISTULA.
   Fistulae  may form spontaneously as  a  result of  the rupture of
abscesses secondary to pyonephrosis, pyelonephritis, or perinephritis,
or may be caused by traumatism or surgical intervention.  They may
pass  doAvn  to the kidney surface, to its glandular substance, or into
its pelvis.
   Fistulae  are named in accordance with  their direction and points
of opening as reno-cutaneous, reno-gastric, reno-intestinal, and reno-
pulmonary.
   Reno-cutaneous fistulae usually open in the lumbar or the inguinal
region; their course is fairly direct.
   Reno-gastric fistulae are extremely rare.  Duplay and Reclus quote
Marquezy as authority for the  statement that there have been  three
instances in which kidney stones were expelled through the mouth.
   Reno-intestinal fistulae  are  comparatively  frequent, particularly
those opening into the colon.
   The causes of fistulae are incomplete drainage, the presence  of a
foreign body, as a calculus or a drainage-tube, continuous profuse sup-
puration, as in simple or tubercular  pyelonephritis, and the constant
escape of urine, as in Avound of the pelvis or of the ureter.   Operative
fistulae rarely develop except Avhen infected tissues are involved in the
incision.
   Symptoms.—The most  obvious symptom of fistula is the presence
of an ulcerating opening from  Avhich escapes  either urine or  pus.
Because of the continuous discharge there are usually marked  ery-
thema and dermatitis about the  opening.  When these fistulae are of
long standing, diverticula are formed, the Avails become rigid, and the
tract, though fairly direct, is sufficiently tortuous to prevent the easy
introduction of  a probe.
   Reno-intestinal fistulae are  suggested by vomiting or purging of
pus and urine.  Reno-bronchial fistulae are characterized by an initial 
842        GENITO-URINARY DISEASES AND  SYPHILIS.

profuse discharge of pus, followed by symptoms much like those of a
purulent pleurisy which has broken into a bronchus.
   Prognosis.—In the absence of tuberculosis the prognosis of renal
fistulae is favorable when they open on the surface ; there is even a fair
prospect of spontaneous cure.   These  fistulae  exhibit a tendency to
contract slowly, thus  rendering drainage insufficient.  Exceptionally,
especially in tubercular cases, there  is a discharge so profuse that in
itself it is exhausting to the patient.
   Treatment.—Preventive  treatment of fistulae lies in prompt inter-
vention in cases of renal or perirenal  suppuration.  When a fistula
has formed and persists  in  spite of proper treatment, free direct
drainage is indicated,  followed by gauze packing and an effort to
make the wound heal from the bottom.  Should the fistula discharge
urine, treatment is  first directed towards rendering the ureter  per-
meable and of normal calibre.  When this is accomplished, the kidney
may be exposed and freed from  its attachments, the Avails of the renal
tract excised,  the wound closed by catgut suture, and the  parietal
tract treated in the same way.
   If the ureter cannot be rendered pervious, or if the fistula comes
from a hopelessly disorganized pyelonephritic   kidney, nephrectomy
is indicated, provided the other kidney is healthy.

                   NEOPLASMS OF  THE KIDNEY.
   Tumors may be grouped in two main classes,—the primary and
the secondary.
   The primary neoplasms comprise the following:
   A.  Epithelial Tumors.—Of these  there are several varieties.
   a. Adenomata.—Small single or multiple adenomata are of rather
frequent occurrence, particularly in  the contracted  kidney.   Adeno-
mata must be distinguished from adrenal inclusions and ectatic hyper-
plastic formations.  They spring  from  the  intratubular epithelium;
the cells are cuboidal or cylindrical, and the acini have  a well-formed
tunica propria.   Occasionally an adenoma may attain very large pro-
portions.   The  so-called alveolar adenoma is  really a neoplasm of
adrenal  structure.  An  especial variety is the papillary  adenoma,
which presents  a  papillary arrangement.   These  adenomata  may
become malignant (nodular type of cancer).
   b. Carcinomata.—These develop from the intratubular epithelium;
in them the urinary  canals  may to  a  certain  extent persist, and  if
dilated may form  large spaces.  The  much-discussed intracellular
formations of cancer-cells (coccidia)  are Avell seen in these growths.
   Cancer may be single  or multiple, and may attain tremendous 
NEOPLASMS OF THE KIDNEY.
843
proportions.  Tavo  types  may be  distinguished:  the nodular type,
including growths which  are adeno-carcinomatous  (adenomatous at
the beginning) and exhibit an alveolar arrangement, with cuboidal or
cylindrical cells;  and the infiltrating  type, including growths which
are cancerous from the beginning and shoAv little alveolar structure;
their cells are polymorphous.
   In the renal substance around the  growth a compensatory hyper-
trophy  may occur.  More often there is a parenchymatous degen-
eration with interstitial  overgrowth; at times  amyloid  degeneration.
The  central portions of the  groAvth  often soften and break doAvn,
forming cysts with  sanguinolent contents.  The pelvis  of the kidney
may  be  involved, then the Avails of the  ureter  and  perhaps  of  the
blood-vessels, and later  the adrenal and the fatty capsule ; ultimately
the infiltration may spread to the pancreas or the intestines.
   Clinically, the neoplasm  may be hard or soft, most often soft; it
may  become colloid and may form a fungus haematodes.   It has been
found associated  with testicular carcinoma and (in the aged) with
calculus.  In a feAv cases the growth has broken through the skin.
Metastasis occurs most frequently to the retroperitoneal lymph-glands,
the lung, and the liver.
   The disease is more  common in children than in  adults;  the con-
dition is most  often unilateral.  The  following  statistics  taken from
Senator (Nothnagel's System) illustrate the relations :
Cases.
433

Cases.
305 .
Primary Carcinomata of the Kidney.
            Location.
                  Right kidney.  Left kidney.
.........  201         190
Sex affected.
Males.
 199
Cases.
 96
Sex affected in Children under Ten Years.
Ages at which Affection occurs.
Males.
 58
 Years.              Cases.
 0 to 10.....157
10 to 20.....15
20 to 30.....34
30 to 40.....45
40 to 50 ....  .   42
 Years.
50 to 60
60 to 70
70 to 80
Total
Both kidneys.
   42
Females.
  106
Females.
  38
Cases.
 96
 57
 13
459
   Of cases in children under ten years of age, fifty per cent, occur
during the  first  tAvo years  and eighty-five per cent, during the  first
five years. 
GENITO-URINARY DISEASES AND SYPHILIS.
   B. Tumors of Connective-Tissue Origin.
   a. Fibromata are  frequent.  They are usually small, single,  or
multiple, hard, and spring from the intercanalicular connective tissue,
either in the medulla or in the cortex.
   6. Lipomata.—True lipomata are rare ;  they are not encapsulated,
and  lie  in the cortex; they are probably developed from inclusions
of the fatty capsule.
   c. Leucomyomata (or  lipomyomata).—These  rare  growths lie in
the cortex, and are composed of plain muscle-cells.  They are attached
to the capsule, and probably develop from embryonal inclusions  of
the capsule whose tunica albuginea contains  plain muscular tissue.
They are likely to become sarcomatous.
   Sarcomata.—These are perhaps the most  frequent renal tumors;
small and large round-celled, spindle- and giant-celled, and melano-
sarcomata are seen, either  pure  or mixed.   They spring  from  the
intertubular or the subcapsular connective tissue.
   Under the name of angiosarcomata are classed four types:  (1) the
ordinary angiosarcoma Avith many dilated vessels  possessed of endo-
thelial walls; (2) the vascular  endothelioma, which springs  from  the
endothelium of the veins; (3) the lymphatic endothelioma, springing
from the lymph-tracts;  and (4)  the perivascular sarcoma, which
springs  from the cells of the tunica adventitia of the vessels, particu-
larly the veins, presenting marked hyaline degeneration of the vessel-
Avalls.   These often bleed profusely.
   Sarcomata are  most  common in  children, are usually unilateral,
may be  single or multiple, and may develop to such an extent as to
fill the entire abdominal cavity.  Metastasis occurs, as  in cancer.

            Table of Primary Renal Sarcomata (from Senator).
Years. Oto 1 lto 2 . .	Cases 7 . . . 9	Years. 20 to 40 40 to 60 . .	Cases. 3 . . 8
2 to 6 . .	. . . 19	60 to 80 . .	. . 3
6 to 10 10 to 20 . .	3 . . . 6	Total. .	. . 58
   Females are most  frequently affected;  the  left  kidney is more
often involved than the right.
   C. Tumors of Heterogeneous Origin.
   a. Tumors of  suprarenal origin (strumae suprarenalis  aberratae)
have often been mistaken for adenomata.   They are generally small,
are found in the  cortex of the gland, and are  composed of the ele-
ments of the suprarenal capsules (epithelium and zona pigmentosa). 
NEOPLASMS  OF THE KIDNEY.
845
Similar to them  is the struma accessoria, which is attached to  the
capsule of the kidney, and which may become large.   Both of these
growths contain  much fat, and in the cells is found  glycogen: they
may undergo amyloid or hyaline degeneration.  Either of these tumors
may assume the  type of a primary suprarenal adenoma;  they have
often been mistaken for true renal adenomata.  They may become
malignant, and are then probably to be classed as carcinomata.
   B. Rhabdomyomata are  composed of striped  muscle cells; they
are rich in glycogen, but are often atypical in appearance.  They gen-
erally become sarcomatous, and then grow to large  size.  They occur
in children, and  are, according to  the theory of Cohnheim,  like  the
strumae suprarenalis aberratae.  They may contain bone- and cartilage-
cells.
   Secondary tumors of  the kidney are generally dependent upon
metastasis by either the lymphatic or  the vascular  route.  One  or
both kidneys may be affected;  the  growths are nodular, and seldom
attain large size.
   Symptoms of Malignant Tumors of the Kidneys.—The symptoms  are
those of tumor, pressure and disturbance of renal function.  Pain is
an early symptom, but may be absent; it  is  dull and dragging in char-
acter, and rarely  radiates into the genitalia.
   The urinary signs are very important.  Haematuria is profuse, in-
termittent, and apparently causeless.  Clots are often passed,  and  the
ureter may be obstructed  thereby.   Complete permanent occlusion
of the  ureter, however, is  usually caused  by direct pressure of  the
tumor.   Portions of the neoplasm may be voided.  Hyaline casts  are
common, granular casts rare.   The  hemorrhages are in some  cases
provoked by overexertion or  traumatism.  Pyuria is sometimes seen.
Haematuria in  a  child under seven years  of age  strongly suggests
malignant disease.
   Physical examination may furnish positive  signs.   The tumor is
often adherent to the posterior abdominal wall, the small  intestines
are  pushed to one  side, and the colon lies upon  the growth.   As
a rule, there is no movement upon respiration, though this  is occa-
sionally observed in  cases of tumor of  the right kidney.  The feel
of the tumor is hard, and  may be  smooth or  nodular.  Exception-
ally there may be pulsation and  a  vascular murmur.  If  the colon
is alternately filled with air and  emptied, percussion will show that
the  tumor  lies behind this  segment of the intestine.  The spleen
is displaced by a tumor of  the left  kidney, and when the  groAvth
attains large dimensions various transpositions of the organs  may be
seen. 
846        GENITO-URINARY DISEASES AND SYPHILIS.

   If one hand be laid upon the  abdomen and the lumbar region
gently tapped Avith the other hand, Guyon's sign may be elicited {bal-
lottement renal), a sign never produced by a normal kidney.
   There are gastric  and intestinal symptoms (indigestion and con-
stipation), with occasional diarrhoea.  Ascites  is often present in the
late  stages.  Pressure upon the iliac veins or  the inferior vena cava
may cause a more or less pronounced oedema of the legs, Avhile severe
neuralgias with paresis may result  from pressure upon  the ischiatic
or other  nerves.  Varicocele upon the  side of the kidney affected is
common, and is made worse by standing.
   In late stages the inguinal glands may become enlarged.  The con-
stitutional symptoms  may remain long in abeyance.  Sooner or later
the patient becomes anaemic, and a marked cachexia finally develops
with mental derangement and an irregular fever,  due  probably to
uraemia or auto-intoxication.  Symptoms of metastasis  may appear.
In some  cases  a high pulse-rate  is maintained.  Kiihn has pointed
out that  in children Avith congenital sarcomata  there is often a pre-
cocious development of the pubic and axillary hair and of the cuta-
neous pigment.
   Diagnosis.—The  diagnosis is  founded upon  profuse intermittent
renal hemorrhage, the development of a kidney tumor which is steadily
progressive, and the passage of fragments of neoplasm.
   In the early stages of tumor the diagnosis is obscure, and the con-
dition is liable  to be confounded with renal tuberculosis and calculous
pyelitis.
   Cancer of the colon may closely simulate renal neoplasm ; auscul-
tatory percussion may aid in distinguishing between these two affec-
tions.  Moreover, primary  involvement of the colon is  more com-
monly complicated by partial or complete intestinal obstruction and
by  the passage of blood-stained faeces.   Kidney neoplasm rarely
infiltrates the colon.
   Pancreatic  cysts can scarcely be distinguished from renal enlarge-
ments.  Minkowsky's  method of colonic distention with liquid may
prove serviceable in differentiating between the tAvo affections. When
the colon is filled with Avater the kidney tumor is thrust back into the
lumbar region.
   Tumors of the suprarenal capsule  do not often reach great size.
Differential diagnosis between these tumors and those of the  kidney is
impossible.
   Tumors  originating in the ovary are characterized by their groAvth
from beloAV upward, and can usually be outlined by combined vaginal
and  suprapubic palpation, although very many  kidney tumors  have 
NEOPLASMS OF THE  KIDNEY.
847
been removed during operations begun Avith the idea that the growth
was ovarian.
   The intermittent, profuse, apparently causeless bleeding of renal
neoplasm is simulated only by suppurative nephritis, purpura, and
haemophilia.  Other symptoms of these conditions Avill suggest their
presence; the  method of distinguishing betAveen vesical and renal
bleeding has been given already.   Bleeding from renal calculus is
usually excited by exercise or  jarring, and is promptly and favorably
influenced by rest;  it is  not often  sufficiently  pronounced  to cause
clots: none the less, in a reported case  operation was undertaken
for the removal of kidney calculus Avhen  the condition  present was
tumor.  Bleeding from tubercular kidney is slight, but may be  severe.
The  presence of the tubercle  bacillus  is  sometimes the only possi-
ble means of making  a  differential  diagnosis.  Differential diagnosis
between epithelioma and sarcoma is not possible.
   Prognosis.—Roberts has pointed out the  relatively sIoav course of
malignant infiltration Avhen it  attacks the kidney.  Thus, there have
been undoubted cases of renal cancer Avhich  have  survived many
years (ten to fifteen).  Sarcomatous patients live tAvo or three  years ;
in epithelioma the duration of life is someAvhat longer.  Death usu-
ally results  from metastasis; exceptionally from haematuria or renal
insufficiency.  The ultimate prognosis is absolutely bad.
   Treatment.—The treatment of malignant tumors of the kidney can
be only palliative in the great majority of  cases, symptoms being met
as they arise.   Occasionally cases are reported of successful and per-
manently curative remoA-al of  these groAvths.   Success is the  excep-
tion ; and permanence implies a certain period  of  exemption,  which,
when it lasts tAvo or three years, is likely to be prolonged indefinitely.
When a tumor is  recognizable from the exterior its extension  is usu-
ally too wide to justify the expectation  that  nephrectomy will  enable
the surgeon to remove all the scattered deposits  of disease.   As yet
but feAv operative cases have gone beyond the three-year limit.  Rarth
writes that up to June 8,  1892, he had collected statistics  of one hun-
dred cases:  forty-tAvo died from operation, twenty from metastasis,
and thirty-eight were cured.  It is to be  feared that sufficient time
has not thus far elapsed wherein to decide the  permanence of these
cures.  Sigrist collected sixty-four cases, with thirty-tAvo  deaths from
operation; in nine  there was recurrence Avithin a year  and a half,
five lived beyond two years, and one continued  well for four years.
   The kidney may be removed by the lumbar or the transperitoneal
route.  The former may be chosen for small  tumors;  the latter is
applicable to tumors  of  any size.   An incision which gives  plenty 
848        GENITO-URINARY DISEASES AND SYPHILIS.

of room is imperative.  If, after opening the peritoneal cavity, exami-
nation shows that it  is  impossible  to  remove  the  tumor  entirely,
the wound should be closed and  the  idea of  further intervention
abandoned.
   Chevalier states that the mortality for the lumbar  route is twenty-
four per cent.; for the peritoneal route, fifty-nine  per cent.; but these
figures are not to  be  given undue importance, as other factors than
the differences in  the avenues of approach to the kidney  affected the
mortality.  Recurrence is much more frequent after lumbar operation.
   In regard to the advisability of operation, Duplay and Reclus hold
that if we consider the normal evolution of the disease, which some-
times lasts for six years from the appearance of the first symptoms, it
seems proper to conclude that the efficiency of nephrectomy  is yet to
be proved.  It can be regarded only as a palliative operation planned
for the  relief of pain  and  haematuria.  It is, hoAvever, to be hoped
that very early intervention may demonstrate its  curative  power.

                      CYSTS OF THE KIDNEY.
   Cysts of the kidney are of three classes,—simple cysts, multilocular
cysts (polycystic diseases), and hydatid cysts.
   Simple cysts are  either due to constriction of the urinary canals
or of the neck of the capsule of Bowman, or are true adenocystomata.
They may be single  or double, unilateral or bilateral, small, or so
large as to constitute a clinical tumor. Contracted kidneys often con-
tain these  cysts.   They may involve either extremity of the kidney
(usually the upper), or its mid-portion.
   Agglomerated cysts  are  probably of two varieties,—the  con-
genital and the acquired.
    Congenital cystic disease of the kidney is due either  to malformation
(these cysts are often  accompanied by other uro-genital  deformities)
or to intra-uterine renal disease (embryonal nephritis papillaris); the
kidneys at birth present more or less cystic degeneration, Avhich leads
to early death through visceral compression and  dyspnoea;  in some
cases the organs  have been  so large at birth as to  cause dystocia.
In advanced  cases the  entire gland is converted into  a mass  of cysts,
although some renal tissue may  be  preserved.   Exceptionally the
disease remains latent, becoming active later in life.
   Acquired  cystic disease differs  little in appearance from  the con-
genital form, except that there is more renal tissue left intact  and  that
there are evidences that the groAvth was originally an adenocystoma.
It occurs  from the fortieth to the sixtieth year, is usually bilateral,
and  is often accompanied  by cystic degeneration of the liver  and 
PARASITES  OF THE KIDNEYS.
849
sometimes by bronzing of the skin.  In some cases it has seemed to
follow an  injury to the lumbar region.  The contents of all these
cysts are highly albuminous, and  may be  partly colloid.   NeAvman
has even described colloid plugs in the urinary canals.  Blood may
be present.  The high percentage of albumen distinguishes the fluid
from that of a hydronephrosis.
   Symptoms.—The symptoms of renal cysts are those of nephritis,
pressure, and tumor.
   Signs of nephritis are present in nearly all cases (although they
may be long deferred), and with  them are  signs of cardiac hyper-
trophy.  Albumen may be  present or  absent from the urine,  but
slight intermittent hemorrhages  occur.  The patients rarely complain
of sharp pain.   The pressure of the  groAvth may cause oedema and
pain in the legs.   Ultimately cachexia becomes marked.
   The  simple  cysts Avhich attain  large  dimensions simulate hydro-
nephrosis.
   In polycystic disease the tumor preserves  the general form of the
kidney; fluctuation is usually very  indistinct.
   Tumor, haematuria, and lumbar pain, if accompanied by oedema,
polyuria, albuminuria, and symptoms of uraemia, are characteristic of
cystic degeneration of the kidneys.
   Treatment.—Simple cysts are treated  by puncture, drainage, par-
tial nephrectomy, or total nephrectomy.   Puncture is commonly fol-
loAved by recurrence.  Drainage results in the formation of  a fistula
in the majority of cases, for the cure of Avhich  secondary nephrectomy
is required.
   Partial  nephrectomy is the operation of choice when this is prac-
ticable.  Bleeding from the renal tissue may be troublesome, but can
usually be controlled by deep catgut sutures, or, if these fail, by packing.
   Nephrectomy is often required because of the position and size of
the cyst.   When the tumor is large, the abdominal  route should be
chosen.  When  small, the kidney  may be removed through  a lum-
bar incision.   Tuffier has  collected  twenty-four  cases  of   laparo-
nephrectomy performed for  the  relief of simple cyst;  the mortality
was forty per cent.
   Cystic degeneration does not admit of surgical intervention, since
the affection is usually bilateral.  Many patients  live for years and
die of cardio-renal disease  or some intercurrent affection.

                  PARASITES OF  THE KIDNEYS.
   Echinococcus.—The  kidney is affected only in from   five  to
eight per cent, of all cases of hydatid disease, and the process is gen-
                               54 
850        GENITO-URINARY DISEASES AND SYPHILIS.

erally confined to  one kidney (usually the  left).  Any part of  the
gland may be  affected, but  the primary  cyst forms in the cortex.
The  arrangement is that of the echinococcus hydatidosus.   The cysts
may become very large (eight inches in diameter), but are usually  the
size of an orange;  they exhibit a tendency to protrude into the  ab-
dominal  cavity, may contract adhesions to the abdominal Avails and
to the viscera, and may  rupture into the pelvis,  ureter,  intestines,
stomach, pleura, or bronchi,  rarely into the peritoneum or through
the lumbar muscles.   Suppuration may occur spontaneously in  the
unruptured cyst or may be provoked by traumatism ; septic absorp-
tion  usually follows, and  general pyaemia  results.  The contents of
the cyst are slightly albuminous or mucoidal and contain the hooklets.
Hydatid cysts may  coexist in other parts of the body.
   Symptoms.—There is very  little acute pain in connection with hyda-
tid renal disease ;  there is often a sense of discomfort and of dragging;
finally, pressure-pains  develop, but not until the  disease is over a
year old.  When, hoAvever, the cyst ruptures into the pelvis a ureteral
colic  is provoked, with very severe paroxysms  of  pain;  the ureter
may be plugged by tissue or by a daughter  cyst, with  temporary or
permanent hydronephrosis.  In a few cases  a general urticaria  has
followed the evacuation of the  cyst.
   In the  event of a rupture positive diagnosis  should be made by
urinary analysis.   After rupture the  cyst becomes  infected and sup-
purates, with the production  of a pyonephrosis.   In a feAv cases direct
symptoms have been excited by pressure upon veins.   Frequent  uri-
nation was the chief symptom  in a case of Tait's.
   The tumor is round, and  may be  tender on pressure ; it may  feel
hard or  may fluctuate distinctly; the  hydatid thrill is rarely elicited
in renal cysts.
   Diagnosis.—Hydatid cysts are ordinarily to be confused only Avith
hydronephrosis or ovarian cysts.  In the absence of urinary signs the
cyst may be aspirated for diagnostic purposes,  and tissue, the hooklets,
and  succinic acid sought for.
    Treatment.—Recovery after spontaneous evacuation is  very rare.
The only treatment to be considered is  operative.   Four  operations
have been  resorted to for the cure of hydatids :                *
    1. Simple  evacuation, followed  by closure  or the injection of
iodine ; this is an unsatisfactory treatment, and the cures are few.
    2. Open incision.   The entire cyst is  evacuated, as much of the
cyst-Avail as  possible excised, the edges of the remaining  portion of
the cyst seAved to the abdominal incision, and the sac packed and left
to granulate. 
THE SUPRARENAL CAPSULES.
851
   3.  Open incision, complete evacuation of contents, followed by the
application of a five per cent, solution of carbolic acid and  closure
of the cyst without drainage.  This method has given good  results,
but the cyst should be fastened to the parietal Avail, so that subsequent
drainage, if necessary, will be easily accomplished.
   4.  Excision of the cyst,  with  partial or complete nephrectomy
as may be necessary.   Extensive  adhesions may contra-indicate this
procedure.
   Incision with free drainage is usually successful.
   Strongylus gigas, or  " palisade worm," is  a parasite of animals,
the presence of which in the kidney of man is doubted.
   Distoma h^matobium is a parasite observed among the Fellahs and
Copts.   The worm lives in  the portal vein  and its branches.   The
eggs  are found  in  the  capillaries of the mucous membrane of the
urinary tract.  Diagnosis is based  on finding the eggs or embryos.
   Pentastoma denticulatum  has been found on post-mortem  exami-
nation in the kidney of man.
   Spiroptera hominis and  Dactylius  aculeatus have been found by
Rayer in the urine.  (For detailed description  of these parasites, see
Leuckart, " Die thierische Parasiten.")

                  THE SUPRARENAL  CAPSULES.
   Surgical diseases of the suprarenal capsules have excited but little
attention.  The functions  of these organs are unknown;  it seems
certain,  however, that destruction  of both results fatally.   A few
cases of suppuration have  been  reported.   These were  probably
tubercular.   There is  experimental proof that the  tubercle bacillus
can cause non-pyogenic pus.
   Rayer has observed in infants  various neoplasms ; of these,  lipo-
mata, adenomata, cysts, angiomata, fibromata,  carcinomata, and  sar-
comata have been reported.   The non-malignant growths have not
been subjected to surgical intervention.
   Malignant tumors are mainly sarcomata.  These become adherent
to the kidney and are  indistinguishable from growths of this organ.
The symptoms of  malignant infiltration are those  of  tumor of the
kidney, with  the  exception  of the alterations  in the urine.   These
also may be found, since the kidneys are secondarily involved.
   Treatment—Removal of the growth is the  only treatment to be
considered.   This, if done at a very early date,  may be followed  by
a  cure.   The abdominal route is to be preferred.  The kidney should
be saved unless there  are distinct evidences of adhesion between it
and the diseased suprarenal capsule. 
CHAPTER  XXV.
        injuries and diseases  of the scrotum and testicles.

   Anatomy.—The scrotum is a pouch of skin and dartos.
   The skin is provided with numerous  sebaceous follicles and a few
hairs, and after  maturity becomes pigmented.  It generally exhibits
folds or rugae passing at right angles to the raphe.
   The dartos is composed of connective tissue and smooth muscular
fibres.  This is continuous with the superficial fascia of the groin and
perineum, and forms at a position  corresponding to the raphe an in-
complete septum partially separating the  two sides.  This tissue is
closely attached to the  skin, and is abundantly supplied with blood-
vessels.  By  its contraction it  draAvs the skin of the scrotum  into
folds and holds the testicles up near the  position of the external rings.
The contraction of this muscular tissue is occasioned by sexual excite-
ment, by cold, or by mechanical stimulus.
   Beneath the  dartos there is a layer of  loose cellular tissue on Avhich
the muscular skin  layers  are  freely movable, and into the meshes of
which blood effusions or dropsies may readily occur.
   The blood-supply to the scrotum is derived from the external pudic
artery, the superficial branch of the internal pudic  artery, the  cre-
masteric artery,  and the artery  of  the A7as deferens.  The lymphatics
are received by the inguinal glands.
   The points of practical value to be gathered from a consideration
of the anatomy of the scrotum are: (1) from the close attachment of
the dartos  to  the  skin, the latter Avhen  wounded  is  liable to be in-
verted, thus making perfect apposition difficult in suturing incisions
of this portion of the body ; (2) in consequence of the loose texture of
the cellular tissue lying within the dartos and the abundant vascular-
ity of the scrotum, bleeding incident to traumatism is free and is likely
to form large accumulations; (3) on account of this  same arrange-
ment, oedema  of the scrotum is pronounced from comparatively slight
causes, and when septic infection takes place there are apt to be rapid
extension and sloughing.
   The testicles are the  tAvo  glandular  organs  which  secrete the
spermatozoa.  They are held  in position  by the spermatic cord, and
are covered by  the scrotum.   They  are developed within the ab-
     852 
 INJURIES  AND DISEASES OF  THE SCROTUM  AND  TESTICLES.  853
domen  about  the  eighth  month  of foetal  life.  They then descend
into  the scrotum,  being  draAvn down by a musculo-fibrous cord—
the gubernaculum  testis—Avhich  is  attached  above  to the base  of
the epididymis and beloAV to the  scrotum.  LockAvood  states that at
the sixth to the eighth month of intra-uterine life  many of  the  lower
               Fig. 216.                            Fig. 217.
    Fig. 216.  Left testis.  1, outer surface; 2, 2, anteroinferior surface; 3, postero-superior surface;
4, anterior extremity, with hydatid of Morgagni; 6, postero-inferior extremity; 7, epididymis; 8, its
head; 9, its tail; 10,10,10, deferent canal; 11,11, spermatic artery; 12, anterior spermatic veins sur-
rounding the artery ;  13, posterior spermatic veins.
    Fig. 217.  Left testis.  1, inner  surface; 2, antero-inferior surface;  3, anterior extremity sur-
mounted by Morgagni's hydatid; 4,  postero-inferior surface; 5, head of the epididymis;  6, tail;
7, 7, deferent canal accompanied by  the deferential artery; 8, 8,  spermatic artery; 9, anterior sper-
matic plexus;  10, posterior spermatic plexus.  (Sappey.)

fibres extend into  Scarpa's triangle and the perineum ;  this may ex-
plain the  occasional presence of the testicle in  these  regions.  They
carry in their course certain coverings derived from the peritoneum.
   The testis is  a gland  of oval  form ; it  is hung obliquely in the
scrotum, the upper extremity being directed forward and slightly up-
ward.   (Figs. 216,  217.)   It  has  flattened  sides and  is  of variable 
GENITO-URINARY  DISEASES AND SYPHILIS.
dimensions, but commonly is one and a half inches or more long, an
inch broad, and an inch and a quarter from behind forward.   The
weight of each gland is from three-quarters of an ounce to one ounce,
and the left is somewhat larger than the right.
   The front and sides of the testis are convex and smooth and are
covered with the visceral layer of  the tunica vaginalis.  The tunica
vaginalis is  derived from the peritoneum during the descent of the
testicle  in foetal life. It is the serous  covering of the testis, and is
composed of two layers,—an  inner visceral and an outer parietal.
The inner visceral  portion forms a close  investment for the testicle
and epididymis, while the outer parietal portion is a loose sac invest-
ing the testis and  extending for some distance up the cord.   The
proper  covering of the  testicle is  the  tunica albuginea.   This is a
tough, fibrous investment, composed of bundles of Avhite  fibrous tis-
sue, Avhich  interlace in  every  direction.   It is  covered everyAvhere
by the tunica vaginalis, except at the points of attachment to the epi-
didymis.  At the posterior portion  of the gland the tunica albuginea
is  inverted  into the interior and  forms an imperfect septum,—the
mediastinum.  It extends from the upper nearly to the lower border of
the gland;  from it numerous septa, called trabeculae, radiate towards
the surface of the testicle, dividing the interior of the latter into many
incomplete spaces, conical in  shape, Avith their bases toAvards the sur-
face.  The trabeculae serve to maintain the general shape of the organ,
to convey the numerous  blood-vessels that  ramify in its interior, and
to act as supports to the glandular  structure of the testicle, Avhich  is
made up of lobules.
   These lobules,  in accordance Avith  the  arrangement of the tra-
beculae,  which in each testicle have been variously estimated at from
one  hundred and fifty to four hundred in number, are pyramidal in
shape.  (Fig. 218.)   According to their size, the glandular  lobules are
made up of three or more convoluted  seminiferous tubes, of which
there are more than eight hundred, variously estimated as being from
tAvo  to  sixteen feet in length.   It  is in these tubes that the sperma-
toblasts Avhich  subsequently become converted into spermatozoa are
formed.  They begin in  caecal  extremities or by intercommunication
Avith other tubes, and as they approach the apices of the cones they
become much less convoluted, finally uniting to form tAventy or thirty
ducts, Avhich from  their straight course are named the  vasa  recta.
These vessels pass upward and backAvard, penetrate the mediastinum,
and form an anastomotic net-Avork made up  of channels in the fibrous
tissue Avithout proper walls and termed the  rete testis.  These chan-
nels terminate  at the upper end of the  mediastinum  in  tAvelve to 
 INJURIES AND DISEASES OF  THE SCROTUM AND TESTICLES.  855

tAventy ducts, called  the vasa  efferentia, Avhich perforate  the tunica
albuginea, and convey the seminal secretion to the upper part of the
epididymis; they are at first straight,  but subsequently become en-
larged and convoluted,  forming the coni vasculosi, which collectively
    Fig. 218.  The lobules of the testis, the rete vasculosum, the efferent vessels, and the epididy-
 mis. 1,1,1, seminiferous lobules of the testes ; 2, rete vasculosum ; 3, 3, efferent canals ; 4, 4, 4, canal
 of the epididymis; 5, vas aberrans; 6, its entrance into the epididymis ; 7, origin of the convoluted
 portion of the vas deferens ; 8, vas deferens.
    Fig. 219.  1, efferent canal, showing its comparatively large calibre and straight direction ; 2,
 beginning convolutions ; 3, cone formed by the convolutions; 4, opening of the convoluted tube into
 the canal of the epididymis; 5, 5, the canal of the epididymis unravelled. (Sappey.)

 constitute the globus major, or upper enlargement of  the epididymis.
 (Fig. 219.)   The efferent  vessels finally open  into a  single duct, the
 canal of the epididymis,  which  constitutes  by  its convolutions the
 body and globus  minor of  the epididymis, measuring in  its natural
 state about three inches in length, but Avhen unravelled nearly tAventy
 feet.  The convolutions are held together by areolar tissue ; the inte-
 rior of the canal is lined by columnar ciliated epithelium.
    In foetal life the head of the epididymis, its  canal, the  vas deferens, .
 and the ejaculatory duct are formed from the canals and ducts of the
 Wolffian body.   The vas aberrans  is formed, from the same  body,
 persisting as a canal, running upAvard from the lower part of  the epi-
 didymis or the commencement of the vas.   The pedunculated  body
 called the  hydatid of Morgagni,  found between the upper portion  of
 the  testis and the globus major, is a remnant of the duct of Miiller.
   The  continuation of the convoluted canal of the epididymis is
knoAvn as  the vas deferens;  it  ascends at  the back  of the testicle
as part of the  spermatic cord,  Avith Avhich it is in close  relation.  It
enters  the  abdomen  through  the  internal  abdominal   ring  and 
856
GENITO-URINARY  DISEASES AND  SYPHILIS.
Fig. 220.
descends to the  pelvis, passing forward  and inward across the ex-
ternal iliac vessels and around the deep epigastric artery.  On reach-
ing the bladder it passes  downward  to the  inner  side of the ureter,
and at its  base  is joined by the seminal vesicles to form the ejacu-
latory duct.  The vas in the beginning of its  course is convoluted, but
for the  greater part is uniformly cylindrical, and  easily recognizable
from the rest of the cord  by its dense hard feeling; when it reaches
the base of the bladder it becomes markedly ampullated.  It is pro-
vided with an external cellular coat, a muscular  coat, and an inner
mucous membrane, the latter covered Avith columnar epithelium.
    The seminal vesicles are glandular pouches placed between the
bladder and the  rectum.  They are pyramidal  in  shape, with  their
bases directed backAvard,  and, although they are of very variable size
and shape in different  individuals  and often on the two sides, they
average about two and a half inches in  length and half an inch in
                             breadth.  They lie  in direct contact
                             with the base of the bladder, extend-
                             ing  from the  entrance of the ureter to
                             the  base of the  prostate gland,  and
                             are separated  from the rectum by the
    fW'^'^OiL              recto-vesical fascia.   (Fig. 220.)  Each
    \v      ^S            seminal vesicle consists of  an irregular
                             tortuous tube, giving off in its course
                             several blind pouches, Avhich are con-
    \isi^ *~  Q\:  ^v       nected  by  fibrous tissue.   This  tube
     1M:-'J. JB ifev  **?k     becomes narrowed into a straight duct,
                             Avhich  joins the  vas  deferens of the
                             corresponding side, to form the ejacu-
                             latory  duct.
                                The  ejaculatory  ducts are  about
                             three-quarters of  an inch long.  They
                             pass  forward and  upward from the
                             base of the prostate along the side of
                             the prostatic sinus, and terminate in a
                              slit placed at the  lateral margin of this
                              sinus.   The vesicles  and  ducts are
                              provided with an external  fibro-cellu-
                              lar, a middle muscular, and an internal
                              mucous  layer;  the  epithelium is co-
                              lumnar.
    The  spermatic cord is about  four inches in length, and extends
from the internal abdominal ring to the globus  minor of the epididy-
Dissection showing seminal vesicles and
       ampullae of the vasa. 
DISEASES OF THE SCROTUM.
857
mis.  It is made up of the vas deferens, or excretory duct of the testi-
cle, the spermatic artery from the  aorta, the artery of the vas def-
erens from the inferior vesical, the  cremasteric artery from the deep
epigastric, the spermatic veins, the spermatic nerve plexus, branches
of the ilio-inguinal and genito-crural nerves, and  lymphatics.  These
structures  are bound together by loose fibrous  tissue,  and are in-
vested by  the fasciae carried  doAvn by the testicle  in  its descent.
The vas deferens lies beloAV and behind the larger  anterior group of
veins and  the spermatic artery.   The veins of the cord  called the
pampiniform plexus unite into a single trunk, on  the  right side pass-
ing into the inferior vena cava and  on the left side into the left renal
vein.  The artery of the vas is in  direct relation Avith it, while the
spermatic  artery folloAvs a tortuous course through the cord.  The
nerves are  distributed throughout  the  cord,  Avith  the exception  of
filaments from the hypogastric plexus, Avhich invest the vas in a rich
net-Avork, and reflexly may cause the sickening pain of testicular in-
flammation or contusion.  The lymphatics of the lumbar  glands are
the ones first affected in malignant disease of the  testicle.

                   DISEASES OF  THE SCROTUM.
   Deformities.—Congenital deformities of the scrotum  unaccom-
panied by  malformation of the penis or malposition of  the testicles
are practically unknoAvn.   With hypospadia and hermaphroditism the
raphe becomes converted into a distinct cleft, dividing the scrotum
into two halves, much like the labia majora.   When there is an un-
descended  testicle the scrotum usually does not develop  on the af-
fected side, thus producing  some asymmetry.  At times  adhesions
binding together the scrotum and the penis are noted at birth.
   Injuries of the Scrotum.—Contusions may be extensive Avithout
involvement of the  testicles, these  organs readily  slipping from the
direct line  of pressure.  Such injuries are folloAved by  rapid swelling,
extensive subcutaneous blood  effusions, and  intense discoloration.
They should be treated by thorough preliminary cleansing of the skin,
rest, pressure, and the application of evaporating lotions.  Under such
treatment suppuration does not take place.   When the skin is  not
clean, and especially when it becomes abraded, extensive and obstinate
suppuration may occur.
   Wounds of the scrotum  are treated  upon  the general prin-
ciples applicable to Avounds of other portions of  the  body.  Haemo-
stasis should  be complete before closure, since the vessels are with-
out support, and  if not  secured  may bleed into the loose cellular
tissue, forming large accumulations of blood. 
§58        GENITO-URINARY DISEASES AND  SYPHILIS.

   At the time of suture the borders of the wound must be so approx-
imated that the tendency to inversion of the  skin Avill be overcome.
Silk or horse-hair forms the best seAving material, Chinese silkAvorm-
gut being too stiff for this delicate skin.
   After closure and antiseptic dressing the scrotum should be sup-
ported either by means of a suspensory bandage or by a crossed of the
perineum roller.
   (Edema of the scrotum may be an expression of general ana-
sarca due to lesions of the heart and kidneys, in Avhich case  it is usu-
ally pronounced,  and in some instances first  calls  attention to the
central lesion, or it  may be due to inflammation of the overlying skin
or of the testicles, local interference with circulation, as from lymph-
adenitis of the groin, infiltration of urine, rupture of a hydrocele, or
septic infection.   Simple oedema  sometimes threatens  the vitality of
the part; in this case tension is relieved by multiple needle-punc-
tures made under the strictest antiseptic precautions.  Inflammatory
oedema is treated by attacking the cause of inflammation,—evacuating
the extravasated urine by incisions, for instance, or opening abscesses.
   Emphysema may  be due to entrance of air into the loose cellu-
lar tissues through a wound, such as that produced by the trocar, or
to the escape of air or gas from a hollow viscus remote from  the scro-
tum ; as, for instance, Avhen the stomach  and  intestines  are opened,
occasioning general emphysema.  More commonly it is due to gas, the
result of fermentation and putrefaction in loco,  and this in a measure
is an index to the extent of sloughing or gangrene going on beneath
the surface.
   The treatment of emphysema Avhen it is simply aerial  and is not
a symptom of  extensive  tissue-destruction should  be conservative.
When it is due to the gas of decomposition, free incisions and vigorous
disinfection are required.
   The cutaneous affections of the scrotum are practically those
of other skin surfaces of the body, and are amenable to the  same
treatment.   It should be borne in mind, however, that the skin of the
scrotum is extremely sensitive to irritating applications, such as tinc-
ture  of  iodine, which if painted over  this region  may cause intense
pain for many hours.
   There are certain skin eruptions Avhich develop on the scrotum
Avith great frequency.   Among these are erythema, eczema,  pruritus,
and  pediculosis.   More rarely molluscum contagiosum, sebaceous
cysts, pityriasis, and scabies are observed.
   Erythema intertrigo is very frequently observed in children and
in fat, soft men, especially those who  are  rheumatic in  tendency or 
DISEASES OF THE SCROTUM
859
are uncleanly in their habits and who  are  given to exercise, such as
walking, AAdiich occasions friction betAveen moist  surfaces.
   The treatment consists in thorough cleanliness and the  interpo-
sition of a layer  of  soft muslin or lint  betAveen  the chafing surfaces,
or, better still, the application of a suspensory bandage, made of thin
gauze.  The parts are bathed in weak  solutions of carbolic acid 1 to
200 and hydrastis canadensis 1 to 20,  after Avhich they are carefully
dried and dusted Avith finely poAvdered zinc stearate powder.  In
some cases ointments give better  results.   One  of the best is that of
resorcin iavo per cent, made up Avith lanolin and lard equal parts.
   Eczema may develop in healthy persons, though  it is more fre-
quently observed in association Avith the gouty or rheumatic diathesis,
sometimes in connection Avith diabetes.  It  may  appear in almost any
of its various forms, is extremely obstinate,  and causes intense itching
and burning. There are frequently concomitant  SAvelling of the Avhole
scrotum,  deepening of the transverse rugae, and  the formation of raAV
surfaces from Avhich there exudes an offensive discharge.
   The treatment is that generally applicable to  this disease.
   Among the most useful prescriptions are the  folloAving:
                      R  Zinci oxidi,
                         Zinci carbonat., aa ^vi;
                         Glycerini, f3iv;
                         Liquor, calcis, f.^vi.
                      M.  S.—Shake well before applying.
   This should  be dabbed on  for four or five  minutes.   In chronic
cases with thickening the following may be  applied (Bulkley):
                      R  Picis liquidae, gii;
                         Potassae causticae, ^i;
                         Aquae,  f^v.
   This may be used as an antipruritic, diluted Avith  tAventy  to thirty
parts of water,  or may be rubbed directly into the infiltration.
   An excellent poAvder to be employed during the day is the folloAving:
                      R  Pulv. amyli, gvi;
                         Zinci oxidi, ^iss ;
                         Pulv. camphorae, ^ss;
or
                      R  Thymol, gr. ii;
                         Pulv. zinci stearat., £iv.
   Pruritus is most frequently  observed in rheumatic or  gouty sub-
jects.   Though  often associated with  the  lesions  of  pediculi, it may
develop independently of these.
   The  treatment  must be  in  the  main  systemic, though the local 
860        GENITO-URINARY DISEASES  AND SYPHILIS.

antipruritic applications, such as thymol, tannic acid, etc., are service-
able.   Prolonged hot bathing of the parts is useful.
   Pediculosis ultimately excites intense pruritus, though it is often
not detected  for a long time.  Careful examination  of  the  scrotum
shoAvs the parasites  at  once.  They appear  as  minute scabs, most
abundant about the root of the penis.  The ova are found on the hairs.
   The application of  an ointment of  twenty  per  cent, oleate of
mercury one part, cosmoline tAvo parts, or of mercurial ointment one
part, cosmoline three parts, rubbed into the scrotum  every night, the
excess being Aviped off Avith a soft toAvel before retiring, and the whole
region being washed Avith soap and hot Avater the folloAving morning,
will be folloAved by cure in a few days.
   Tincture of cocculus indicus applied freely after a Avarm bath and
alloAved to dry on the part is more  cleanly and efficacious.
   Molluscum contagiosum, observed mostly in children, particularly
affects the  scrotum.  The   lesions consist  of small, Avaxy, almost
spherical tumors or cysts, situated in the superficial layers of the skin.
They are  sessile, but  may become  pedunculated  when they have  ex-
isted for a considerable  time without softening.   At first smooth and
round, they become umbilicated, exhibiting a small black spot in the
centre of the depression, which indicates the opening  into the follicle.
They grow slowly, and occasion no pain unless  complicated by in-
flammation.
   They may  disappear spontaneously, but should be removed, since
they are contagious.  The contents of the  cyst may be squeezed  out
and the walls touched Avith pure carbolic acid.  Pedunculated growths
should be snipped off and their bases cauterized.
   Steatomata or sebaceous  cysts have not the waxy appearance of
molluscum, nor do they appear in  childhood.  They  are usually sin-
gle, but may be multiple.  They are soft and doughy in consistence,
and  Avhen attacked  by inflammation break  down  and suppurate.
They sometimes  attain  the  size of a hen's egg.   The thin overlying
skin becomes  adherent in inflammatory cases.  Incision folloAved by
removal of the entire sac is the only effective treatment.
   Gangrene of  the   Scrotum.—This  affection,  extremely rare,
except as a complication of rupture of the urethra or as a sequel of
extensive  traumatism, has been  attributed, Avhen it  follows inflam-
mation of the  inguinal glands or operation on these structures,  to re-
flected nerve irritation.   It is more probable that gangrene developing
apparently spontaneously, or, as in  the case contributed by Bungner,
folloAving inguinal adenitis in the  course of grippe, is  due to infection
with the ordinary pus microbes. 
DISEASES OF THE SCROTUM.
861
   Allen says, " Among the causes of this distressing and often dan-
gerous condition, aside from urinary infiltration, erysipelas, thrombo-
sis, embolism, and incidentally influenza, Ave find reference to typhus,
syphilis, gonorrhoea, diabetes, prostatic disease, pediculi pubis,  ergot-
ism, traumatism (faulty punctures and injections), and frost-bite."
   Even though the testicles be completely denuded, they should not
be removed,  since they  Avill ultimately be covered  by granulation-
tissue and their function will be preserved.
   Treatment.—Scrotal gangrene  should be treated by hot antiseptic
fomentations until the sloughs separate.   The testicle should then  be
covered as completely as  possible by suturing  the  remaining healthy
skin, the Avound  being  dressed  daily  until  complete healing Avith
gauze Avrung out of 1 to 10,000 bichloride solution or other antiseptic
lotion.
   Elephantiasis, endemic in certain countries, is rare in the United
States.   It is generally supposed to be due to the stoppage of lymph-
channels by the ova of the filaria sanguinis hominis, but in this country
it has been observed  in cases in which  the  parasite Avas not present
in the blood, and the  obstruction to the Aoav  of lymph could  be ac-
counted for by some preceding inflammatory condition, such as recur-
rent  attacks of erysipelas or cicatrization  following syphilitic lesions
or repeated attacks of dermatitis.
   Prunner states  that the  disease ahvays begins in the form of a
hard kernel under the skin,  usually at the bottom of the left side of
the scrotum.   '• In  proportion as this kernel spreads in all directions
the skin over it becomes thickened and indurated, and appears fur-
rowed, canaliculated, Avrinkled, and  glandular.  At  this period also
the loAver part of the  abdomen becomes altered in form, while the
lower extremities appear  to be getting shorter,  a result of the traction
which the tumor exercises on the skin of  the abdomen; in the  same
way the skin of the penis yields to  the  traction of  the tumor and
turns doAvmvard, beginning at the root:  hence  this organ  diminishes
in length externally until it  is completely hidden in the tumor.  Its
cutaneous covering is connected merely to the glans and forms a blind
canal, Avhose aperture is  situated in  front in  the middle  line of the
tumor and  represents a kind of continuation of the  outer extremity
of the urethra.  The skin of the  penis, hoAvever, in consequence of
the contact of the urine, becomes converted into mucous membrane."
These tumors are pyriform, and the rough, often warty, skin covering
them  is likely to become excoriated from  the  irritation of the  urine.
The growth may attain an enormous  size, AVeighing as much  as iavo
hundred pounds.   It is commonly associated  with some degree of 
GENITO-URINARY DISEASES  AND SYPHILIS.
elephantiasis of the skin of the lower extremities.  The testicles and
penis, hoAvever, remain unaffected.   (Fig. 221.)
    Treatment—In the early stages galvanism and the internal admin-
istration of potassium iodide may be serviceable.  When the tumor
                              Fig. 221.
Elephantiasis of the penis and scrotum, showing the result of operation.
attains  such size as to be  inconvenient from its weight, complete
excision of all  the diseased tissues  is indicated.   This operation  is
usually bloody, many  vessels requiring ligation.   The best means
of checking hemorrhage during removal is to transfix the tumor at its
base with  long pins, and to apply behind  these transfixing pins the
elastic ligature.  The fact that hernia frequently complicates this affec-
tion must be borne in mind in  applying these transfixing pins and
securing the elastic band.  The penis and testicles are first  freed, then
all  the  diseased tissue  is  cut away.  Even though  the testicles are 
DISEASES OF THE TESTICLE.
863
entirely denuded, this need  not occasion anxiety, since they will be
covered by granulation-tissue.
   Tumors of the Scrotum.—Epithelioma.—Aside from sebaceous
cysts, epithelioma is the most frequent form of neAv growth observed
upon the scrotum.   It is called " chimney-SAveepers1 cancer," because
it formerly attacked by preference people  engaged in this work.  In
recent years the method of  cleaning  chimneys has changed, and the
name is no  longer applicable.
   It begins as an indurated Avart,  which becomes  excoriated and
scabby on its surface ; this wart is shortly transformed into an  ulcer,
which is  characterized by hard, raised edges,  uneven surface, un-
healthy granulations, and the exudation of ichorous pus.   It is some-
times extremely painful, and steadily extends, ultimately involving the
inguinal  lymphatic glands, Avhich soften and  ulcerate.  It  is stated
that Avorkers in coal-tar are  especially liable to this form of disease.
   Treatment.—The treatment consists in the removal of the  indu-
rated tissues by an incision  carried wide of the diseased area.   Any
enlarged lymph-glands should be removed at the same time.   Thus
treated early in the course of the affection the  prognosis is favorable.
   Fatty tumors are at times observed ; they are of  importance be-
cause  of their intimate  connection Avith  the  testicle.  Diagnosis is
rarely possible  Avithout exploratory incision, because, on palpation,
they feel  almost precisely as  does an  irreducible omental  hernia.
Excision is the only treatment.
   Fibromata are rarely observed.   They are freely movable under
the skin.   They should be removed  as  soon as discovered, since in
their development they  may  form  adhesions to  the testicle, Avhich
would make subsequent operation Avithout  injury to this gland ex-
tremely difficult.  These fibrous tumors sometimes recur in spite of
their removal.
   Gummata, enchondromata, osteomata, and cysts are occasionally
observed.
                  ANOMALIES OF  THE  TESTICLE.
                           Excess.
Anomalies of
 development.
In number.
In size.
Anomalies of migration.
Deficiency.

Excess.
Deficiency.
Testicle undescended.
Testicle descended.
    Polyorchism.
    Absence, anorchism.
    Fusion, synorchism.
    Hypertrophy.
    Arrested development.
    Lying in some part of
      the normal course.
    Lying  outside of the
      normal course.
    Inversion.
(Monod and Terrillon.) 
GENITO-URINARY  DISEASES AND SYPHILIS.
   Anomalies of Number.—1.  Polyorchism.—With the exception
of the case reported by Blasius, there seems to be no Avell-authenti-
cated record of supernumerary testis.  Cases are frequently encoun-
tered in which careful examination  shows the existence  of a body
which in  size, shape, and position corresponds closely to a third tes-
ticle ; even the testicular sensation—i.e., sickening pain on pressure-
may be present.   When such  cases  have been  subject to operation,
or when an opportunity has been given for post-mortem examina-
tion, these apparently supernumerary testes have  been proved to be
encysted hydroceles, epiploceles, fibromata, or other comparatively
common pathological conditions.
   2. Anorchism.—This deformity may be unilateral (monorchism) or
bilateral.  It is usually unilateral, and the epididymis and scrotal por-
tion  of the vas are also absent.  The pelvic portion of the  vas and
the seminal vesicles are ordinarily present, though cases are recorded
shoAving that even these portions of the genital tract may be Avanting.
The  testicle may be present, but the  epididymis or vas or both these
structures  may be absent.   Bilateral anorchism  is accompanied by
absence or incomplete development  of the scrotum, a rudimentary
condition of the external genitalia, impotence, sterility, and the physical
and mental attributes of eunuchism.
   Diagnosis.—It  is not justifiable to infer that a testicle is absent
because it is not found in the scrotum or the inguinal canal.  Indeed,
a positive diagnosis of unilateral  anorchism must be based upon the
results of  post-mortem examination, since the testis may be  retained
in the abdominal  cavity.  A distinction between bilateral retention
and  anorchism can be made  by  the rudimentary condition of the
penis Avhen the testicles are absent, and by the later development of
eunuchism.
   Treatment.—Unilateral anorchism  gives rise to no symptoms, since
one testis, if it remains healthy, is competent to perform the functions
of both.  Bilateral anorchism would seem to be beyond help.  Modern
research in other  lines of Avork, hoAvever, suggests the possibility of
so modifying the  course of development that, though potency and
fertility cannot be expected, the physical and mental characteristics
of the male may be preserved.   While the removal of either testicles
or ovaries in early life usually changes profoundly all  the  character-
istics, physical and mental, of  the individual, there  is abundant evi-
dence that the testicles may lose  or may never have had the sperm-
producing power and still possess  the quality which enables them to
hold the organism in its normal groove and  to invest it with the other
attributes  of masculinity.  When testes fail to descend, as a rule, they 
DISEASES OF THE  TESTICLE.
865
are incapable of producing spermatozoa.  In spite of this imperfec-
tion of the organs the external bodily characteristics of the male are
acquired.  ;t The function of the testes  is, therefore, clearly twofold,
—viz., (1) to control and determine the development of the  charac-
teristics of the male sex, and (2) to produce spermatozoa for the re-
production  of  the  species.  These two functions are usually exer-
cised together, but that  the former may be exercised Avhen the latter
fails seems to indicate that the production of spermatozoa is the more
specialized property and attained  Avith difficulty.  In Avhat  manner
is this sexual effect of  the testes  upon the  body  produced ?  Is it
through  the medium of the nervous system  as an ordinary reflex, or
is it through the medium of some substance produced  by the sem-
inal cells (Avhether they  form spermatozoa or not) and absorbed into
the system, Avhich by influencing the nerve-centres or in some other
way  controls groAvth and nutrition?  Brown-Sequard  tried upon
himself,  when  he Avas seventy-two years  of age,  the effect  of  the
subcutaneous injection of a watery extract of the testes of a vigorous
dog two  or  three years  of age,  and  relates that after five daily in-
jections he  lost  his  feebleness,  felt many years  younger, and Avas
capable  of  doing more  Avork.  The  testicle-extract has been used
in various diseased conditions, chiefly those associated Avith  nervous
debility, but Avith only temporary results.  During the last few years
a watery extract  of the thyroid gland has been administered  Avith
signal success in myxcedema, in Avhich disease the thyroid gland atro-
phies and ultimately disappears.  The disease myxcedema arises from
the Avant of the  influence of some unknoAvn substance—Avhich the
thyroid gland, as is supposed, elaborates—upon  the  nutrition-centres
of the central nervous system.  It  may be that the testis  in like man-
ner elaborates, irrespective of its spermatic secretion, some chemical
substance Avhich  by a similar influence  not only controls the growth
and  development of the body at  puberty, but  maintains the manly
character then acquired  throughout life."  (Griffiths.)
   It is possible that the function of the testicles Avhich relates to the
preservation of masculinity, as distinguished from the function of re-
production, may be  exerted  through a definite  substance Avhich  has
distinct physiological properties of its own, manifest to some extent
whenever it is introduced into the  system.
   It therefore seems reasonable to hope that testicular injections may
exert a powerful influence on the general development of  bilateral an-
orchids.   These injections should  be  instituted  at an early age, cer-
tainly before puberty, and should  be  continued for many years.  A
trial  of this  method  has never  been made: hence the dosage,  the
                               •55 
866        GENITO-URINARY DISEASES AND SYPHILIS.

number of repetitions, and the  period of time over Avhich treatment
should extend cannot  be formulated.   It  has merely the merit of
being the only treatment thus far proposed.
   Anomalies  in Size.—Hypertrophy.—In  common  Avith  all the
genital organs, the normal testicles vary greatly in  size  and Avithout
any  definite  relation to  the  general physical development.  It is,
therefore,  difficult to determine Avhat degree  of growth indicates a
departure from  the normal.  In cases Avhere  one testicle has been
removed or has become atrophied,  the remaining gland may show so
marked an overgroAvth  as to  be properly considered  hypertrophied.
This is particularly likely to  occur Avhen there is congenital atrophy
or unilateral ectopy.  The destruction of the testicle by inflammation,
unless this occurs in early life, is not commonly followed  by enlarge-
ment of the other gland.
   Atrophy.—The Avasting which folloAvs acute or chronic inflamma-
tion  cannot properly be considered a congenital malformation, even
though this atrophic process takes place  in early infancy.  True atro-
phy is nearly  ahvays observed in cases of non-descent  and ectopy.
Even when the position of the organ is perfect one or both testes may
remain puerile.   It is  a  matter of  clinical observation that these
puerile testes may attain full  development as a result of physiological
activity.
   Synorchism, or fusion of the  testicles, is an  extremely rare condi-
tion.   It seems to have  been found  only in foetal life.  The diagnosis
of the condition is dependent upon the finding of two  cords.
   Treatment.—Hypertrophy calls for no treatment, since it is com-
pensatory and is dependent upon increased physiological activity.  It
is probable that a gland thus enlarged is  more vulnerable than one of
normal size : hence it is desirable to support it by a suspensory bandage
if the scrotum is relaxed,  and to caution the patient as to the special
danger incident to urethritis.
   The treatment  of imperfect development of  the testes promises
little.  There  is, however, sufficient clinical evidence to prove that
persistent, long-continued  treatment  may be folloAved by gratifying re-
sults.  The stimulating influence of massage regularly administered
should be borne in mind, and the effect Avhich physiological activity
has upon groAvth and nutrition should be considered in advising such
patients and in predicting as to their future.
   The transplantation  of an undescended testicle has been followed
by rapid increase in size.
   Anomalies  in Migration.—The testicle may be  arrested in its
transit from beloAV the  kidney to the bottom of the scrotum at  any 
DISEASES OF THE TESTICLE.
867
portion of its course.  It may depart from its regular path, taking an
aberrant  course, or, having descended normally,  it may assume a
faulty position in the scrotum.
   Arrest of Passage in the  Normal Course.—The testicle may be
arrested in the abdominal cavity or in the inguinal canal, or may not
fully descend into the scrotum.
   Abdominal retention, or cryptorchisin, may be unilateral or bilat-
eral.  The  testicle  may  be found  close to the posterior abdominal
Avail in  relation  to  the  loAver  border of the kidney, it may be pro-
vided Avith a long  mesorchium  alloAving it  to  move freely in the
abdominal cavity, or it may lie in the  iliac fossa close to the internal
ring.
   Griffiths,  in  an  experimental investigation on  dogs,  found that
although the abdominal  testicle develops to the time of puberty, it
never produces  spermatozoa.  When the testes of grown dogs Avere
placed in the abdominal cavity they atrophied and no longer produced
spermatozoa.
   In inguinal retention the testicle may be arrested at the internal
ring, in the inguinal canal, or at the external ring, and until it becomes
adherent by  inflammation it is usually extremely mobile.
   This variety is most  important because of its  frequency, because
from its exposed position the testicle is subject to irritation and injury,
and, finally,  because it is liable to be mistaken for hernia.
   In incomplete scrotal  descent (cruro-scrotal retention) the  testicle
lies outside of the inguinal canal, but fails to descend completely, and
is found in the  fold betAveen the  scrotum and the thigh, at varying
distances from the ring.
   When the testicle takes an  aberrant  course (ectopy) it may be
found beneath the skin of the abdominal Avail at a A^ariable distance
from the external abdominal  ring, in the crural region,  or in the
perineum.
   In perineal ectopy the testicle is found as  a distinct ovoid tumor,
lying to one  side of  the central raphe and in front of the anus.  The
cord can  often be traced from this tumor to  the external abdominal
ring, and the overlying skin sometimes presents the peculiarities of
the scrotum, the corresponding side of this  sac being  generally
atrophied.  It is easily  seen that a testis thus placed can scarcely
escape frequent injury, and inflammation and destruction of secreting
structure.
   In femoral ectopy the testicle  occupies the position of a complete
femoral  hernia, though  Curling  notes a case in Avhich the gland Avas
three inches  beloAV Poupart's ligament and behind the femoral vein, 
868        GENITO-URINARY DISEASES  AND SYPHILIS.

Avith  the  cord  encircling  this vessel.  The testicle  passes  beneath
Poupart's ligament and through the saphenous opening.
   Curling, after considering the  etiology of non-descent, maintains
that  in some cases retention is due to the small  size of  the  external
ring.  Other causes which may be operative are  the  application of a
tight-fitting truss before the descent of the testes, shortness of the ves-
sels of the cord, and a long mesorchium  preventing the testicle from
entering the canal.
   The irregular development of the gubernaculum will explain cruro-
femoral and peno-pubic ectopy.  The lower attachments of this fibro-
muscular structure are Poupart's ligament in the course of the inguinal
canal (Curling), the lower part of  the  scrotum, and the  pubic  bone.
There are also  fibres passing to the region of the saphenous opening.
Relative  over-development of certain of these bands may draAv the
testicle into a faulty position.
   As a  rule, misplaced testicles  are  undersized, though apparently
healthy until they have been  subjected to repeated attacks of inflam-
mation.  When removed  from  the  adult and examined they show
degeneration and atrophy of  the secreting structure.   This, hoAvever,
is inflammatory in nature and not inseparably connected with under-
development.  Curling  holds that undescended  testicles  are  func-
tionless so far as reproduction is concerned, and  hence that bilateral
retention causes sterility, though not necessarily impotence.
   Monod and Arthaud have attempted to demonstrate,  on the other
hand, that a retained testicle  may secrete  healthy semen and show no
degenerative changes on section, such alterations being due to repeated
inflammations to which the gland is necessarily subject from its faulty
position.   In one undescended testicle which we removed from a man
forty-five  years old in the course of  a radical operation for strangu-
lated hernia, microscopic  section of the gland, which Avas about the
size of that normally found in a child of twelve, showed it to be fully
functional, although it had been subject to a number of inflammatory
attacks.
   Incomplete  transit is most commonly manifested  in  the  form of
inguinal   retention;  the  aberrant transit, in  the form  of  perineal
ectopy.
   Complications of Misplaced Testicles.—Hernia, inflammation, and
malignant  degeneration are  the serious  complications of abnormally
placed testes.
   Hernia is an extremely common complication, and is usually of the
congenital variety,—i.e., there is a direct communication  from the ab-
dominal cavity to the  testis, the funicular portion  of the peritoneal sac 
DISEASES OF  THE TESTICLE.
869
not having become obliterated.   The funicular form is also found ; in
this the testicle is shut  off, but the peritoneal pouch which descends
with the cord still remains patulous.   Hernia is a grave complication
of misplaced testis, since it is especially liable to sudden and complete
strangulation.  Because of the presence of the testicle a retaining truss
can rarely be Avorn.
   Inflammation  frequently  attacks a misplaced  testicle, particularly
the inguinal form, since the imperfectly developed gland seems to  be
especially  vulnerable.  Inflammation may  be  due to traumatism  or
to extension of infection from the  posterior urethra.  Traumatic in-
flammation may be caused  by a bloAV or by sudden contraction  of
the abdominal muscles, Avhich pinch the  testicle in its already too
straitened environment.   It is probable that the misplaced  testicle
is not immune against  the infection which  develops in the course  of
mumps, typhoid  fever, and  other  diseases Avhich are often  compli-
cated by orchitis.  Jacobson  states that syphilis and tuberculosis have
not been observed to attack  such testes.
    Malignant Degeneration.—The  comparative  frequency with which
malignant disease  attacks misplaced testicles is generally recognized.
The predisposition is  probably due to the frequent inflammatory
attacks  to Avhich the  gland is subjected.   The growths  found  are
usually sarcoma  and encephaloid carcinoma.
    Symptoms.—Symptoms of anomalies of migration of the testis are
wanting.  Until the onset of complications there will be no  complaint,
except perhaps  slight  transitory testicular pain, caused  by  sudden
violent muscular  exertion or by bloAvs or jars  in  the region of the
misplaced gland.  The complications  are,  however, extremely im-
portant, since some of  them directly threaten life.
   The symptoms  of  orchitis are practically the same whether  the
testis is descended  or undescended.  There are  sickening, even ago-
nizing pain, radiating into the scrotum and  down the thighs, exquisite
tenderness, and often abdominal  reflexes so pronounced as strongly to
suggest acute peritonitis.  The constitutional symptoms are  propor-
tionate in severity to the degree of inflammation, and are  most pro-
nounced Avhen the  testicle becomes gangrenous, either from  the vio-
lence of traumatism or inflammation, or  from torsion; this accident
seems to be especially  common in  cases of  inguinal retention.
   Hydrocele and  hematocele  frequently complicate inflammation.
Hydrocele may be  of  the congenital variety,—that is, reducible into
the peritoneal cavity ; sooner or later it becomes  distinctly  limited.
   Exceptionally, the testicular inflammation may cause general peri-
tonitis ;  Curling has reported one death from this complication. Very 
870        GENITO-URINARY DISEASES AND SYPHILIS.

commonly abdominal  symptoms develop so  suddenly and violently
that  they closely simulate those dependent upon the presence of a
strangulated  hernia.   There may be  tympany, tenderness,  consti-
pation, and vomiting so persistent as to have a markedly stercoraceous
character.  The distinction between orchi-epididymitis attacking an
undescended testicle and strangulated  inguinal  hernia is often ex-
tremely difficult to make.
   Hernia when it complicates undescended testicle is manifested by
the usual symptoms, but Avill often exhibit the peculiarity of not being
amenable to treatment by  truss, pressure  of the pad producing so
much pain that it cannot be borne.   The hernia may pass beyond the
testis, reaching the scrotum ;  sometimes  it pushes  the testis in front of
it, thus curing the displacement.  When the hernia becomes strangu-
lated the symptoms are not different from those  commonly observed
in strangulated  hernia.
   Malignant degeneration exhibits the  symptoms A\rhich characterize
cancer of the normally placed testis, except the location of the  tumor.
The  testicle steadily and rapidly enlarges, becomes irregular in shape,
often cystic,  painful,  and involves the anatomically related glands.
The  skin is  discolored  and  marked by large veins.  In  cases of
abdominal retention the diagnosis  cannot, of course, be  formulated
until the tumor has reached  considerable size, since till then it is not
palpable.   A persistent, steadily increasing, obstinate pain should in
the case  of abdominal retention suggest the possibility of malignant
infiltration.   In  the  late course of  malignant disease the diagnosis
cannot for a moment be in doubt, since the large palpable tumor and
glandular involvement are characteristic.
   Diagnosis.—The  diagnosis of misplaced testicle is based  on (1)
the absence  of the gland  from its normal position; in infants and
young  children the  testes may be extremely small, sometimes not
much larger than a kidney-bean, and because of  their great mobility
may  be hard to find ; (2) the detection in the abnormal position of a
smooth,  usually movable tumor, shaped like a  normal testicle, but
smaller, and  yielding on pressure the testicular sensation ;  in making
this examination, unless the testis is found, the patient should  be in-
structed to cough and strain,  since thus  there may be brought Avithin
reach an undescended testis lying high up in the inguinal canal; (3)
atrophy of the  scrotum of the  side  corresponding to the misplace-
ment.  In cases of abdominal retention the only signs are absence of
the testis from the normal position and atrophy of the scrotum.
   Prognosis.—The prognosis of imperfect descent of testicles is fairly
good in young children, since ultimately the gland is likely to reach 
DISEASES OF THE TESTICLE.
871
its proper position.  This is not true of ectopy.  In case the gland
does not descend  before  birth, it commonly does so  shortly after-
wards, and no anxiety should be experienced for several Aveeks, espe-
cially if the testicles can be felt in the inguinal region and the scrotum
is properly developed.   If the descent does not take place during in-
fancy  or childhood, there is still a chance that it may occur about the
period of puberty, sometimes as the result of violent straining effort.
The gradual descent is often complicated by hernia.
    As a rule, a testicle Avhich has  shoAvn  no signs of descent  by the
sixth  year will retain its faulty position unless subjected to surgical
treatment.
    Treat mod.—It  is generally conceded that intra-abdominal  ectopy
cannot be benefited by  surgical  intervention.  The  vascular  and
nervous attachments of the  gland are  too  short to alloAv of its being
draAvn into its proper position.   A partially successful effort, bringing
it  into the inguinal canal, Avould be Avorse than useless.   Guelliot,
hoAvever, reports a most  suggestive case.   He operated for bilateral
abdominal ectopy : one testis Avas secured in the scrotum; two years
later this gland Avas Avell developed, and the boy, then eighteen years
old, Avas normal in regard to his sexual functions.   In the  semen
were  found a feAV apparently normal spermatozoa.  While it is prob-
able that patients subject to bilateral abdominal retention of the testi-
cle will  be sterile, they are likely to suffer from no  inconvenience,
since  the gland is so placed as to be protected from injury.
    Inguinal retention should  be treated conservatively Avhen  it is
observed in early life.  The gland should be encouraged to descend
to its normal  position by gentle  manipulation Avith the fingers, and
should be kept Avithout the  external  abdominal ring by the applica-
tion of a pressure bandage  or a truss, in case  this can be so  applied
as not to cause pain.
    Persistence in this treatment is justifiable to the sixth  or eighth
year if the testicle in the mean time does  not become inflamed or
shoAv  signs of atrophy.   After the sixth year the operative treat-
ment  may be  considered, but it should be remembered that sponta-
neous descent may take place  about the period of puberty; this is,
however, not the rule.  Operation is especially indicated if the mal-
formation is bilateral, if  the testicle has  been subject to repeated
attacks of inflammation, or if from its position and its chronically in-
flamed condition it prevents proper indulgence in active sports.
   Since one  of the reasons for operating  is  to encourage groAvth,
this should be undertaken before  the most active period of develop-
ment.   The ordinary position of the misplaced testicle is just within 
872        GENITO-URINARY  DISEASES AND SYPHILIS.

the external ring; an incision sufficiently large to expose it is made
directly over the gland.  The incision divides the skin, the superficial
fascia,  and the aponeurosis  of the  external  oblique, Avhich is often
very thin.   The testicle is then carefully examined, to see that it is
not complicated by hernia.   Should  this be present and should  the
vaginal tunic communicate Avith the peritoneal cavity, the hernial sac
is cut across just  above the testis,  and the distal end is closed with
catgut  sutures, thus forming a closed tunica vaginalis.  The proximal
end is  then dissected  up to the internal ring and there ligated.   After
the testicle is thoroughly exposed, the cord is stretched until the gland
hangs  freely beyond  the external  abdominal ring.  This should al-
Avays be  preceded by transverse division  of  all the  fibres  of  the
cremaster muscle  and the fibrous  envelope of the cord, leaving only
the vas Avith its vessels and  nerves.   Incomplete division  of  the
musculo-fibrous funicular sheath is the  common cause of failure in
this operation.
   The testicle having been draAvn Avell out so that it exhibits no
tendency to retract Avithin the inguinal canal, the finger is thrust from
the loAver corner of the Avound into the scrotum, tearing a way through
the loose  areolar  tissue.  The  scrotum is  then hiA'aginated until its
inner surface appears in the Avound, and the testis is fastened to it by
one  or tAvo  silk  or chromicized  catgut  sutures, Avhich include  the
proper tunic of the loAver extremity of the  gland  and epididymis and
the deeper layers of the scrotal skin.   The aponeurosis of the exter-
nal oblique is  then closed with chromicized catgut, the external ring
being made as small  as  is possible Avithout interfering Avith the circu-
lation of the cord.  The cord  is sutured to the  borders of the ring
and the Avound is  closed, a moderately firm compress being so placed
that the testicle  is  kept in  its normal position.  The operation is
simple and is  unattended with danger.  It has frequently failed be-
cause of the tendency to retraction.   This  is best avoided by making
the external ring  small and by thorough division of the fibro-muscular
structures of the  cord.
   Jalaguier reports fifteen operations of orchidopexy ; fourteen Avere
successful.   In tAvo cases at the end of thirty to thirty-six months the
testicles had become normal in size, and in twelve others at the  end
of from three to  fifteen months the  organs Avere movable,  sensitive,
of normal consistence, and shoAved no tendency to retract.  He advo-
cates the operation in children over five  years, and  in  younger chil-
dren when  the undescended testis  is complicated by painful  hernia.
Terrillon in six cases had three satisfactory results.
   When the  scrotal sac is shalloAv an  almost transverse incision is 
DISEASES OF THE TESTICLE.
873
made directly over the position  the testicle should  occupy.  After
completion of the  operation  the Avound is sutured at right angles to
its original course, thus  providing a pouch for the testis.   In very
young children—i.e., those Avho cannot be prevented from wetting the
dressings—the Avound should be thoroughly protected  by  a cotton
collodion dressing.
   Cruro-scrotal retention is usually amenable to manipulation and
the application of  a truss provided with a  Avater-pad which presses
from above doAvmvard.   Should the testis remain tightly apposed to
the external  ring,  occasioning pain  on muscular effort, the  displace-
ment should be cured by the operation indicated for the relief of  an
inguinal retention.
   Perineal ectopy should  ahvays be  subjected to  operation, since
from its position the testicle is exposed to frequent injury.   The advice
is usually given to  Avait until the third  or  fourth  year of life before
attempting replacement, mainly because after that time there is less
danger of infection through  soiling  the dressings.  We  believe it is
well to follow this plan, provided the testis is not injured  by the exer-
cises of early childhood, such as Avalking, running, and playing.  The
wound can, hoAvever, be almost perfectly protected by the application
of a collodion dressing.
   Operation  having been  decided upon, the  testicle is pushed  as
near the scrotum as possible, and an inch and a half incision is made
on the scrotal side of the  testis  and at  right angles to the raphe, ex-
posing the cord; by draAving upon  this structure and by the use  of
retractors  the testicle  can  be  exposed and the fibrous adhesions bind-
ing it to its faulty position divided.  Through the cellular  tissue a Avay
is then forced to the bottom of  the  scrotum ;  this pouch is invagi-
nated into the Avound, the base of the testis and the epididymis are
secured to it  by tAvo or  three  sutures, and the  perineal Avound is
sutured at right angles  to its  length,  thus deepening  the  scrotal
pouch.
   Pubic and crural ectopy are  so rarely found that  their treatment
by operative procedures has  not  been formulated.  A testicle placed
in front of the pubis at  the root of the  penis should be transplanted
into the scrotum  Avithout difficulty.
   In crural ectopy the testis should be  reduced into the abdominal
cavity,  together with  the  hernia Avhich  usually accompanies  it, and
should  be  retained by a truss.   Failing  this, a  protecting truss may
be applied.  If the  testis is still subject to repeated attacks of inflam-
mation, castration is generally advised, though from the surgical point
of view there seems  no  good reason why  the testis could  not be 
874        GENITO-URINARY  DISEASES AND  SYPHILIS.

placed in its proper position by freeing it and its cord and dividing
Poupart's ligament.
   Operations  for the  cure of undescended or ectopic  testicles  are
advisable only in infancy and childhood, save under very exceptional
circumstances.   Later in life these misplaced testes will nearly always
be partially degenerated and atrophied in consequence of the repeated
inflammation to which  they have been  subject.  The  secreting sub-
stance usually disappears, and  the  testis  remains an  organ Avithout
functional activity, but  vulnerable and  liable  to  malignant degener-
ation.   Castration is therefore  advisable, and is particularly indicated
because  these testes are commonly complicated  by hernia, and  re-
moval of the testis enables the surgeon to close completely the internal
and external ring and the inguinal canal, thus insuring against recur-
rence of rupture.  When  the  patient is possessed  of but  one testis,
which is misplaced or ectopic, even  though this has been repeatedly
inflamed, every effort should be made to preserve it and to place it in
its normal position.
   Treatment of Complications of Misplaced Testicle.—Inflammation.—
The  general indications in the treatment of inflammation  in an un-
descended or ectopic testis are those appropriate to a like condition
of the normally placed gland.   Rest  in bed, elevation of the  pelvis,
moderate purgation, the application of heat  or  cold, depending upon
the preference of the patient,  and  the  relief of pain by hypodermic
injections, represent  the general line of treatment.   When the inflam-
mation ranges high  and there  is doubt in regard to diagnosis, there
should be no hesitation in making an incision and exposing the gland,
since the relief  of tension  thus  secured is  immediately followed by
marked alleviation of pain.   When the testicle is subject to recurrent
attacks  of inflammation,  removal of the  gland is  the  operation of
choice.
   Hernia.—When  ectopy is complicated by hernia, and the  latter
exhibits a tendency  to push the misplaced testis before it, thus favor-
ing its descent, no  retention apparatus should be  applied until  the
gland has escaped from the external ring.   A truss  should then be so
adjusted  that  it will keep the  hernia from descending and push  the
testis still farther doAvn.   Unfortunately,  cases are  rare in which the
hernia exhibits  this tendency.   More frequently it slips beyond  the
testicle,  escaping  through  the  external abdominal  ring  before  the
gland; a truss is then insupportable, and operation offers the only
prospect of cure.  If the  patient is young  and the testicle has  not
been repeatedly inflamed,  the gland is brought to its normal position
in the scrotum and  the hernia is radically cured.  After the age  of 
DISEASES OF THE TESTICLE.
875
puberty it is usually desirable to remove the testicle, entirely closing
the rings and canal.
   Malignant growth should be treated by early and  complete re-
moval.  When the testicle is intra-abdominal this form of interven-
tion is rarely practicable until the disease has become so well devel-
oped that there is no prospect of radical cure, since diagnosis  cannot
be made until a decided tumor develops.  In inguinal ectopy enlarge-
ment of the gland may be  detected early.  Therefore  operative inter-
ference promises  better results.  Whenever an undescended  testicle
increases in size Avithout inflammatory phenomena, operation  should
be performed immediately.  The  removal  of malignant  testicle  is
usually unattended Avith operative difficulty.
   Torsion.—The undescended testicle seems to be particularly sub-
ject to the accident  of strangulation by torsion.   When symptoms of
extremely severe inflammation develop Avith unusual  suddenness and
severity and Avithout obviously sufficient cause, incision and exposure
of the undescended testis are indicated.  The cord may be untwisted
or the testis removed.  The latter course  is desirable, since testes
subject to torsion are liable to undergo malignant degeneration.
   Inversion of the Testicle.—The testicle, though it descend to
the bottom of the scrotum, may assume various faulty positions termed
inversions.   This displacement  may be anterior, horizontal, or lateral.
The horizontal form is commonest.  The testicle may  be rotated com-
pletely, the epididymis lying in front, the free border to the rear.
   No treatment is indicated in these  cases, displacement being im-
portant mainly Avhen surgical intervention is required,—for the cure
of hydrocele, for instance.  With this present in the  case of anterior
inversion, the testicle and  epididymis Avould lie  in front and not be-
hind the fluid contained in the  sac of the vaginal tunic: hence Avere
a trocar introduced  at the customary  point  it would Avound both the
testicle and the epididymis.  The possibility of inversion is a reason
for invariably examining hydrocele by  transmitted light before tapping.
Careful palpation, Avhen the sac-wall is thick or the contents are turbid,
will usually elicit the testicular sensation, suggesting the faulty position
of the gland.
   Monod and Terrillon advise that in tapping cases  Avhere the posi-
tion of the testicle remains in doubt, the puncture should be made on
the outer side of the scrotum instead  of in front.
  Of the other forms of inversion feAA'er cases have been reported,
nor are they of much surgical importance.  In the horizontal  variety
the long axis of the gland lies in the horizontal position, the epididy-
mis  looking upward.  Lateral inversion is a modification of the an- 
876        GENITO-URINARY  DISEASES AND SYPHILIS.

terior  variety.   Reversion of the testis has been  reported by a few
observers ; the upper end of the gland looks doAviiAvard.
   Luxation of the Testicle.—The testicles may be displaced by
direct  traumatism or muscular action.  The ordinary cause of this
displacement is sudden violent contraction of the cremaster muscle re-
flexly excited in the course of a severe general muscular strain, follow-
ing violence or without obvious cause.   The testis may be  fixed in the
groin external to the  ring from tonic spasm of the cremaster, may be
lodged in the inguinal canal, or may be draAvn even within the ab-
dominal  cavity;  it  is generally found Avithin the inguinal canal.  It
shortly becomes inflamed and is  subject  to  the  general  accidents
already considered  under the head of congenital displacement.
    Treatment.—The treatment of luxated testicle is prompt replace-
ment.  This usually requires the administration of ether, since inflam-
mation develops rapidly and  the  gland becomes excessively tender.
If the testicle  is held in its  faulty position by adhesions  or tonic
contraction of the  cremaster  muscle, the  operation  for  incomplete
descent is indicated, the cremasteric fibres being  cut through and the
testis replaced and held to the  bottom of the scrotum by sutures.
   Torsion of the Testicle.—Torsion or axial rotation of the sper-
matic cord sufficiently describes the nature of this accident.  It is one
of sudden development, usually affecting the cords  of undescended
testes, though by no means confined to these.  The cause of this twist
has  not  been formulated; it is probably dependent  upon congenital
malformation, since Owen has pointed out that a testis properly placed
in the scrotum  and possessed of  a  normal mesorchium  cannot  be
tAvisted.   The tAvist may be either to the right  or to the  left, and in
accordance with  its  extent and the degree of constriction  to Avhich
the vessels are  subject the symptoms are slight or severe.  In slight
cases the epididymis alone becomes infiltrated.  In severe cases the
entire gland Avith the epididymis becomes gangrenous, exhibiting ex-
tensive blood extravasations.
   Symptoms.—The symptoms of torsion are those  of epididymitis or
orchi-epididymitis.   They  occur suddenly,  often  Avithout apparent
cause and during active muscular exertion.   When  the  rotation is
sufficient to produce complete strangulation the symptoms are violent
and  rapidly progressive.
   Diagnosis.—A positive diagnosis is rarely possible Avithout direct
exploration through an incision, the symptoms suggesting an exces-
sively acute orchi-epididymitis or a strangulated hernia.  Since torsion
commonly affects an undescended testis,—this is often complicated by
hernia,—the differential diagnosis may be extremely difficult.  The in- 
DISEASES OF THE TESTICLE.
877
guinal tumor is painful, sAvollen, sometimes reddened and oedematous,
and gives  no impulse on  coughing; it develops quite suddenly after
exertion.  Vomiting and tympany are by no means uncommon.  These
symptoms are so like those of strangulation—indeed, are so indistin-
guishable from this condition—that immediate exploratory operation
is indicated.
   When the testis occupies a normal position there is little likelihood
of confounding  a twist of  the cord with hernia unless the latter has
been a previous complication, since the  cord can  be felt above the
swelling and the inguinal canal is free from hernial sac or contents.
   The diagnosis of torsion will, then, depend mainly upon the sud-
denness of onset, the severity of symptoms,  and the absence of other
sufficient causes for acute inflammation.   Moreover, the epididymis
may be  found in front  of the testis, and  in one case a nodulation
corresponding to the tAvist Avas felt.
   Prognosis.—If untreated, the testicle will  either atrophy or become
gangrenous ; gangrene depending probably upon haematogenous infec-
tion of the devitalized area.
   Treatment.—Reduction should be  effected by manipulation or by
operation.
   Manipulation Avas successful in a case reported by Nash.   A boy,
nineteen years  old, during  exercise, Avas seized Avith sudden severe
pain in the right testis.  Very shortly the gland became SAvollen and
extremely tender, Avith the epididymis in front and a knotty condition
of the cord perceptible.  Suspecting from the position of the epididy-
mis and the condition  of the cord that the  case Avas one of rotation,
Nash attempted  reduction by turning the gland to the left; this in-
creased the patient's pain, and the testis Avould not stay in position.
Rotation to the right was then tried.  This gave immediate and perfect
relief, and the gland  remained in  place with the epididymis  behind.
The patient recovered promptly.
   This case emphasizes the  importance   of  immediate treatment.
When the  patient is not seen early, and Avhen the inflammatory phe-
nomena are  pronounced, incision is indicated.  This should  expose
the testicle and cord.  If the gland is black and gangrenous it should
be removed.  OtherAvise the  cord  should  be untwisted, one lateral
surface of the testicle  secured to the scrotum by several sutures,
including the proper tunic  of the gland and  the deeper layers of the
skin, and the wound closed.  When the testicle is greatly swollen and
discolored, even though it  is not absolutely certain that gangrene has
taken place, it is advisable to remove it if the  testis on the other side
is healthy. 
878
GENITO-URINARY  DISEASES AND SYPHILIS.
   The cases of hemorrhagic infarct reported by Englisch, and attrib-
uted by him to thrombosis of the pampiniform plexus, Avere possibly
instances of torsion.

           CONTUSIONS AND WOUNDS OF THE  TESTICLE.
   Contusion.—The  testicles from their position and  mobility usu-
ally escape the effects of sudden direct pressure applied  to the region
of the  perineum  and  scrotum.  They  may, hoAvever,  be pinched
against the pubis or perineum or be bruised  by a bloAV  or a squeeze.
The lightest form of contusion—such as that sometimes experienced
in crossing the legs or riding the bicycle—is attended by momentary
sickening  pain, Avith a slight sense of soreness, which lasts  not more
than a day or iavo, and  probably is not attended by distinct lesion,
except in those avIio previously have  been subject to latent disease,
such as tuberculosis or tumor.
   Monod and Terrillon, on the basis of an experimental  investiga-
tion, classify testicular contusions as of three  degrees: the first is
characterized by minute disseminated  capillary hemorrhages into the
connective tissue lying betAveen the seminal tubules and  the convolu-
tions of the epididymis.  There is often epithelial  exfoliation from the
inner surface of the epididymis.  Larger blood  effusions characterize
the second degree, and there is laceration of the  tubules; the extrava-
sations may vary from the size of a pea to that of a cherry.  The third
degree of contusion is characterized by rupture of the  tunica albu-
ginea.   The gland is practically crushed, and there is bleeding into the
vaginal tunic, with the formation of acute haematocele.
   Symptoms.—These vary in accordance  with  the  extent  of injury.
Slight  contusions  are characterized by a  feeling of faintness, intense
sickening  pain,  retraction  of the testis,  and rather rapid  SAvelling.
When the contusion  is severe  there may  be profound  shock  or
almost instant death.
   The first  exhausting, almost unbearable anguish is  of  compara-
tively  brief duration.   There  follows a  severe,  unremitting ache,
aggravated by  standing, coughing, or straining.  This  persists until
reactionary phenomena have reached their height, and is so harassing
that  anodynes  are required for its  relief.  The  SAvelling, Avhich be-
comes perceptible Avithin a very feAV minutes and  develops rapidly, is
due in part to effusion of blood and serum into the vaginal tunic, in
part to oedema of  the loose  cellular tissue of the scrotum.  Profound
discoloration is common, and is caused by rupture of the  vessels of the
scrotum ;  exceptionally it is due to bleeding from the testis and epi-
didymis or cord.   The inflammation usually remains aseptic, reaches 
         CONTUSIONS AND WOUNDS OF THE TESTICLE.      879

its height in from five to eight days, and subsides sloAvly.  Exception-
ally suppuration  occurs.  In  this case, in place  of  subsiding, the
symptoms increase in  severity,  the  patient suffers  from  chill  and
fever, redness and oedema become especially Avell marked, and finally
fluctuation is detected.
   Prognosis.—In slight contusions, characterized by  transitory pain
and disability, lasting at most a feAv hours, the prognosis is favorable.
In the severer forms of  contusion—i.e., those putting a patient to bed
for one  or tAvo Aveeks—an opinion as to the future  integrity of the
testicle should not  be expressed too  confidently.   In  a certain num-
ber of such cases atrophy develops, apparently uninfluenced by treat-
ment.  Atrophy  may  folloAv  even slight bruises, and  is most apt  to
occur during youth ; the epididymis is usually spared.   In the severest
forms of contusion, characterized by rupture of the albuginea, atrophy
is certain to result.
   The atrophic processes may be progressive and uninterrupted, the
testicle regaining its normal size on disappearance of the inflammatory
SAvelling, and then continuing sloAvly to shrink, or the acute inflamma-
tion may be succeeded by a condition of chronic irritation, characterized
by enlargement and tenderness and occasional attacks of pain.  This
chronic pain  and  SAvelling gradually subside, intercurrent subacute
attacks becoming less pronounced, and the testicle ultimately Avastes.
This Avasting may affect only a portion of the gland, producing asym-
metry ;  but usually the  Avhole organ is affected, there remaining Avhen
the process is completed a body of varying shape, about the size of a
Lima bean or even smaller than this.
   Prognosis is then ahvays  guarded, and becomes less favorable  in
proportion to the severity and the persistence  of inflammation.
   Treatment.—Even  the mildest forms of contusion of the testicle
should not be neglected, since exceptionally  they are followed by
chronic inflammation  and atrophy.   In severe  injuries, shock  and
syncope are treated in accordance with general  principles, and the
agonizing pain is controlled by the injection of morphine.  The patient
should be placed  upon his back, with  the pelvis elevated and the
scrotum supported either by a pillow placed close to the  perineum
or by a triangular handkerchief bandage, the base of Avhich is passed
beneath the scrotum,  while its  ends are  secured to a band about the
Avaist.  To  the  injured testicle  cloths  kept  constantly wet  in  lead
water and alcohol are applied, omitting oiled  silk, since this prevents
the cooling effect of evaporation.  A  small  ice-bag is even more effi-
cient, and can be used for three or four days, a piece of lint being kept
between its surface and the skin of the scrotum.   If cold makes the 
880
GENITO-URINARY  DISEASES AND  SYPHILIS.
pain more severe, hot compresses wrung out of dilute lead Avater and
reneAved every fifteen minutes  may be employed, or lint soaked in
this  same  lotion may be applied, and over it may be placed a hot-
water bag.
   The bowels should be opened freely, and Avhen the SAvelling is so
rapid and extensive as to threaten the vitality of the parts there should
be no hesitation in cutting doAvn upon and securing the bleeding points.
Discoloration  incident to scrotal blood  effusion should not be mis-
taken for gangrene.  The patient should  be  kept  confined to bed
until the active inflammatory symptoms have subsided, and may then
be alloAved to get up, Avearing  the pressure suspensory bandage de-
scribed in the section on the treatment of epididymitis.  This bandage
should  be Avorn for months, and the patient should be cautioned
against occupations or exercises liable to cause a recurrence of inflam-
mation.   Small doses of potassium iodide and application of mild
counter-irritants to the skin of the scrotum are  serviceable in relieving
the  chronic congestion Avhich is liable to folloAV upon injury of the
testis,  and Avhich is  certain to  result in deposition of fibrous tissue
and  subsequent wasting of secreting structure.
   Epididymo-Orchitis from Strain.—This inflammation is prop-
erly  considered under the head of contusion,  since  in a certain pro-
portion of cases the symptoms are due to pinching or bruising of the
testicle.
   There develops, Avithout a preceding urethritis and Avithout obvious
cause, a swelling Avhich  closely resembles in  symptomatology and
course  either  epididymitis  secondary to  gonorrhoea or  traumatic
epididymo-orchitis.
   Terrillon records  the case of a man who, in making a violent lift-
ing effort, experienced a sudden pain in the left  testicle so acute that
he fainted.  There was no  contusion, no blood effusion.   The  testis
Avas  fixed in the left groin, and exhibited the tenderness, swelling, and
pain of acute orchitis.  Symptoms  simulating  localized  peritonitis
supervened, and lasted for eight days.  The patient  Avas  confined to
bed for three weeks.   At  the end of that time  the testicle had atro-
phied until it Avas one-fifth  its natural size ;  it Avas so  tender that
palpation  could not  be endured.  The thigh  Avas flexed, adducted,
and  rotated inward.  As two months' further rest did not relieve the
symptoms, castration Avas performed.
   From careful observation of more than a dozen of these  cases Ave
believe  that etiologically they can be classified  as   folloAvs: 1. Epi-
didymo-orchitis due to a violent contraction of the cremaster muscle,
which  by  suddenly jerking the  testicle against the pillars of the ex- 
CONTUSIONS AND  WOUNDS  OF THE TESTICLE.
881
ternal ring causes  a  bruising of  the  former,  often accompanied  by
rupture of the veins ; this is called  " Avhip-snap" action.   When the
external ring  is patulous the testicle may be draAvn within its grip
and  may be  further  bruised in  this way.  2. Epididvmo-orchitis
from rupture of the veins.   As a result of  violent muscular effort and
increased intra-abdominal pressure the often-dilated, valveless veins
of the cord become enormously congested.  This congestion is further
increased by compression on the part of fibres  which  Roux  states
pass from the rectus muscle to the inner lip of the iliac crest.  These
fibres participating in the  general  muscular  contraction  pinch the
cord against the fibrous circumference of the  external abdominal
ring.  Rupture of  vessels and  bleeding   into the cord,  the  epididy-
mis, or possibly the substance of the testicle  result.  3. Epididymo-
orchitis from  masked lesion.   In a certain number of cases  we have
been  able to trace the inflammation to  infection passing  from the
posterior urethra along the vas ; strain and possible slight contusion
were undoubtedly favoring factors.  The symptomatology and course
of the inflammation Avere not  different  from those commonly ob-
served in cases of  chronic  posterior urethritis.  Twice  we  have
observed acute tubercular epididymitis develop suddenly after mus-
cular effort.
    In accordance Avith  the cause of  the  inflammation, variations in
its clinical course are observed.   There may be an acute epididymo-
orchitis, such  as that Avhich folloAvs ordinary traumatism, temporarily
prostrating the patient and keeping him to his bed for days or weeks.
The inflammation  may  be  limited  almost entirely to the epididymis
and may run  its course in a feAv days.   Or there may be  an almost
painless enlargement, neither confining the patient to bed nor inter-
fering with his occupation, provided a suspensory bandage is worn.
    The left testicle is more frequently involved than the  right; this is
what would naturally be expected  if the theory  of venous rupture
from pressure is correct.
   Prognosis.—The prognosis of epididymo-orchitis from strain is
much better than Avhen external violence is  the  cause.  When the
lesion is simply hemorrhagic,  the blood being  found in the lower part
of the cord and about  the epididymis, with but  slight congestion of
the testicle, atrophy of this organ is not to be feared.  When the in-
flammatory attack is limited chiefly to the testicle and is  severe, there
is Avasting.
   Treatment— The treatment is that appropriate to contusion of the
testicle.  Even in  the  comparatively painless cases a properly fitted
pressure suspensory bandage  should be worn for a long period.
                                5fi 
882        GENITO-URINARY  DISEASES AND SYPHILIS.

   Wounds  of the Testicle.—Incised  wounds  of the  testicle if
kept clean heal promptly.  Such injuries are extremely rare, except
in the course of surgical operations, particularly those undertaken for
the purpose of establishing  diagnosis.   If the  proper tunic is opened
and the testis  found healthy, the albuginea  should be neatly apposed
Avith catgut sutures and the external Avound  closed.   Infection may
be followed by prolapse of the  secreting substance of the gland unless
drainage is promptly  established.   In tubercular  or syphilitic cases
the so-called benign fungus  may folloAV incised wounds.
   Punctured avounds are  usually inflicted by a  misdirected trocar.
Provided the instrument is clean, they are harmless.  If a dirty instru-
ment infects the testicle, diffuse acute orchitis may  develop, with total
destruction of the secreting  substance.
   Contused and lacerated wounds, usually inflicted by bullets, should
be treated  by thorough cleansing and abundant drainage.   When it is
evident that the testicle is extensively bruised, castration is probably
the best treatment.  When both testicles  are involved in  gunshot
wounds every effort should be made to preserve even small portions
of the secreting substance of the glands.  This is usually  practicable
if the wound is kept clean.   If suppuration  takes  place, complete
atrophy will probably be the result.
   Otis states that atrophy and neuralgia are common sequelae of gun-
shot wounds of the testes when castration has not been performed.
   On the first sign of infection after an attempt  has been  made to
close a wound of the testicle, the  stitches should be removed, the
wound widely opened, and  drainage secured by gauze packing.
   After cleansing and closure  of a wounded testis and the  application
of a proper dressing,  the part should be elevated, and should be sub-
jected to moderate pressure by means of a crossed of the perineum
bandage.   Outside the antiseptic  dressing  applied  immediately over
the Avound is placed a sufficient quantity of cotton  or crumpled gauze
to equalize the pressure of the bandage.  The bandage  should be
seven yards long and three  or  four inches Avide.   It is fixed  by a cir-
cular turn  about the pelvis,  placed beneath  the iliac crest.  It is then
carried doAvnward along the right groin, across the perineum, around
the back of the left thigh at the position of the ilio-femoral  fold, up-
ward over the trochanter and below the crest of the ilium,  completely
around the body until it is just above the left trochanter, down along
the left groin, across the perineum,  around  the  back of the  right
thigh at the ilio-femoral fold, and upward and forward over the right
trochanter.  These turns are repeated until a firm dressing is formed
which  entirely covers in the scrotum and perineum. 
              INFLAMMATION OF THE TESTICLE.            883

                INFLAMMATION OF THE TESTICLE.
   Inflammation may attack the epididymis, the testicle, or both these
structures (epididymo-orchitis).
   From the etiological stand-point the inflammations can be classed
as blennorrhagic, traumatic, infectious, tubercular, and syphilitic.
   Blennorrhagic inflammation is  usually a pure  epididymitis.   The
infectious inflammations are, as  a rule, confined to the testicle.  Trau-
matism more commonly produces a true orchi-epididymitis.   Inflam-
mation Avhich attacks one  structure primarily  so frequently  invades
the other, and this invasion may be attended by such slight symptoms,
that it is impossible from direct examination to be certain that the in-
flammation is strictly limited either  to the  epididymis or the testicle :
hence the term  orchi-epididymitis or epididymo-orchitis  is often ap-
plied to this general class of inflammations.
   Urethral Epididymitis.—Gonorrhoeal urethritis is the  common-
est cause of epididymitis.   So far as the clinical  evidence is conclusive,
there is reason to believe that the inflammation is almost entirely con-
fined to the epididymis ; it is probable, hoAvever, that during the acute
stages the testicle is more or less involved.  It is certain that the vaginal
tunic is commonly inflamed, as  is shoAvn by the development of acute
hydrocele, Avhich may make up the main bulk of  the SAvelling.
   The symptoms of this  inflammation have  been given under the
complications of gonorrhoea. It is an expression of infection carried
by the vas, and  may complicate any form of urethritis.  It is often
called  gonorrhoeal simply  because  the  gonococcus is the  ordinary
cause  of posterior urethritis.
   Epididymitis is a  common sequel of instrumental  urethritis,—for
instance,  that folloAving the use of the lithotrite or frequent  catheteri-
zation.  It sometimes complicates gouty urethritis.  Jacobson particu-
larly calls attention to this complication ; he says, " This form of  epi-
didymo-orchitis is not common, but is of great importance  from the
age and position  of the patients among Avhom it occurs and the liabil-
ity of the  urethritis to be overlooked.   In gouty urethritis the following
points will aid the diagnosis: the  scalding  or smarting is complained
of in the  deep urethra rather than  in the meatus, the discharge is not
very profuse, and being muco-purulent is whitish  rather than yellow ;
the patient is very  liable to lithiasis.  The urine is habitually very
acid and loaded with uric acid and urates.  Dry, scaly eczema is often
present, and perhaps tophi and worn-down teeth.  The  patient  has
very likely been living too well, drinking rich Avines, etc., or  in some
other way evoking into activity  a latent gouty taint." 
884
GENITO-URINARY  DISEASES AND SYPHILIS.
   We have noticed that the pure gonorrhoeal epididymitis  is much
less  likely to suppurate  than that Avhich  results from  instrumental
infection, and this is in accordance with the rule governing gonorrhoeal
inflammations,—i.e., that they are formative rather than suppurative.
Suppuration is comparatively common in instrumental epididymitis.
   The hard nodule left in the globus minor after gonorrhoeal epididy-
mitis rarely disappears entirely.  In attacks of moderate severity it
may be impossible  after a time  to decide  which testis Avas inflamed,
but  years after a  severe attack  an  examination will  usually detect
either a fibroid mass or  distinct nodular induration.   These indura-
tions are more extensive and more persistent in the epididymitis sec-
ondary to non-specific posterior urethritis.   Except during or shortly
after an acute  inflammatory period, treatment of these fibrous nodules
is futile.  The nodulation probably renders the individual sterile so
far as that single gland is concerned, but it does not attract his atten-
tion  or arouse his  anxiety, and is therefore not the cause of hypo-
chondriasis or  neurasthenia,  as  otherwise  it would be in the greater
number of cases.   With the exception of the testes, all glands atrophy
when their ducts are completely obstructed.  Curling, Hunter, Gosse-
lin, and others have long since shown that the vas may be obliterated
without interfering Avith the development or health of the testicle.
White and Kirby have  recently demonstrated  the  same  fact experi-
mentally.
   The treatment of all forms of epididymitis due to extension of in-
flammation from the posterior urethra is conducted on the lines laid
down in regard to the gonorrhoeal variety.  Urethritis Avhich is intensi-
fied  by gout should be subjected to antilithaemic remedies, and appro-
priate diet and hygiene should be ordered.  When rapid increase  of
local pain and swelling Avith rigor and fever denotes the onset of sup-
puration,  incision,  folloAved  by  irrigation  and packing, is indicated.
Even though  the abscess is extensive the testis should  not be re-
moved.  When the entire gland is evidently  sloughing, castration
should be performed.
   Epididymo-Orchitis complicating Acute  Infectious Dis-
eases.—Under this general heading are included orchitis of mumps,
variola, typhoid, malaria, scarlatina, influenza, and possibly gout.
Inflammation in most of these cases is of pure haematogenous origin,
dependent upon toxic  substances circulating in the blood.  It appar-
ently attacks primarily and  most severely the testicle.   When the
disease  develops in its  acute form  the  symptoms  are even more
marked than those of acute  epididymitis.   In the latter affection the
bulk of the tumor is formed by the epididymis, which partly envelops 
INFLAMMATION OF THE  TESTICLE.
885
the  testis as AA^ould a hand a  small  kidney.   In orchitis  the main
swelling is formed by the testicle, this  gland, even though enormously
SAvollen, maintaining its normal  form ;  the epididymis if uninvolved is
stretched as a narrow band along its  posterior border.  The general
testicular sensibility is greatly increased.  In epididymitis the tender-
ness is limited mainly to the epididymis itself.   Acute hydrocele may
occur coincidently with the swelling of the testicle, but is much less
common than when the  epididymis is involved.   Exceptionally sup-
puration ensues; this  is nearly  always preceded by great oedema and
discoloration of the scrotum and by pronounced constitutional symp-
toms.
    The differential diagnosis betAveen  orchitis and  epididymitis is
based mainly upon the form of the swelling.  When the tissues of the
scrotum become markedly oedematous, and particularly when hydro-
cele develops, a differential diagnosis  may be  impossible;  nor is this
of cardinal importance.
    Orchitis complicating  Mumps.—Inflammation  of the  testicle is
sometimes  the  sole expression of mumps; it runs an acute course,
terminating in a feAV days or a feAv Aveeks.
    It may be ushered in by a rise of temperature, and generally de-
velops from the fourth  to the  sixth  day of the disease.   As a rule,
only one testis is involved.  Catrin, basing his conclusion on a study
of one  hundred and  fifty-nine cases of mumps,  states that orchitis
occurs in one out of three cases, usually develops after the parotiditis,
and begins in  the epididymis, the body of the  gland  being subse-
quently attacked.   It  is  accompanied by fever, lasting three or four
days, and  is commoner in severe than in mild cases of  mumps.
Atrophy of the organ is rarer than  is usually supposed.  He believes
that in a certain number of cases  after a period of atrophy  and loss
of consistency the  testicle regains its original  volume and firmness.
If both  testes  become  involved  the inflammation  is usually con-
secutive.
    In contradiction to  the statement above  quoted, from  personal
observation we believe  that  the inflammation  of mumps orchitis
begins in the gland and  not in the epididymis, and that atrophy is a
much commoner  sequel than is generally conceded.  Hornus ob-
served  a fatal  case of  orchitis consecutive to mumps.   Death was
caused by peritonitis, the testicles  having been absolutely destroyed
and converted into a purulent collection.
    As to the etiology of the testicular affection, the theory of metas-
tasis is absolutely inadequate, since it really gives no explanation, but
merely a word to describe what is not understood.  An ingenious and 
886        GENITO-URINARY DISEASES AND SYPHILIS

in some respects  satisfactory explanation  is offered by Kocher.  He
states that orchitis after mumps is urethral, the specific inflammation
excited  by the organism first involving the urethral  mucous mem-
brane and then extending along the vas.   If this Avere true, Ave should
expect the inflammation to  develop first in the epididymis, as in the
case of most inflammations of urethral origin.  With the exception of
Catrin, authors generally teach  that the testis  is primarily involved.
It must be acknowledged, hoAvever, that there are no incontrovertible
arguments against Kocher's conception of the etiology, and it appeals
more directly to  the reason  than any before offered.   With a better
understanding of the germ Avhich causes mumps will doubtless come
a clearer understanding of the manner in which it reaches the testis.
The symptoms of mumps orchitis are pain, SAvelling, exquisite tender-
ness, and  fever  of moderate  degree.   Exceptionally  the attack is
ushered in Avith typical symptoms of acute peritonitis,—i.e., vomiting,
constipation, tympany, and peritoneal tenderness ; still more rarely by
acute nephritis with uraemia.
   Diagnosis.—The diagnosis is founded upon associated symptoms
of parotiditis, or, in the rare cases AAThen these are latent or absent,
upon the possibility of contagion and the exclusion of other sufficient
causes of  inflammation.
   Prognosis.—This, Ave think,  should always  be  guarded.  In light
attacks characterized  by moderate SAvelling the prognosis is doubtless
favorable.  In  severe  attacks Avith pronounced general  symptoms,
and  especially when the attack  is prolonged, atrophy is ahvays to be
dreaded.
    Treatment—The measures  already  described as  appropriate to
orchitis and  epididymitis  are  indicated  Avhen  the testis becomes
inflamed as an expression of mumps.
   As a prophylactic treatment  it is Avell to support the scrotum by a
soft  flannel binder or a  suspensory bandage, in accordance with the
age of the patient, in all cases of parotiditis.   Moreover, since this is
an infectious disease, as illustrated by the  formation of erythematous
nodules, involvement of  the kidneys or meninges, the development of
various  inflammations,  dysentery, vomiting, and  the  general symp-
toms of infection, it would seem  Avise to administer salol and boric
acid, with the purpose of rendering the urine  slightly antiseptic  and
thus preventing inflammation of  the posterior urethra which might ex-
tend along the vas.  The comparatively unyielding tunica albuginea
subjects the secreting substance of the  testis to fatal pressure Avhen
inflammation  is  pronounced or is of long  standing.   This  can  be
relieved at once by incision  or  puncture.   The profession has been 
INFLAMMATION OF  THE TESTICLE.
887
deterred from this form of intervention by the fear of hernia testis,—
i.e., extrusion of the secreting substance of the testicle.  When this
has occurred it has been in consequence of infection; even though a
certain amount of testicular substance should  be lost as a result of
incision, it is probable that the ultimate functional  poAver of the organ
would be better than it is Avhen tension has been unrelieved.
   Typhoid orchitis is commonest before the age of puberty.  As  a
rule,  it is  mild in  type and occurs  during convalescence.   It is not
definitely settled Avhether the testis or the epididymis is primarily in-
volved.  The etiology  of this condition is  sometimes dependent on
venous thrombosis, though it  may be the result of infection from the
urethra  or through the agency of the blood.  The typhoid  bacillus
has been found in suppurative cases.
   Malarial Orchitis.—This form of inflammation is chronic  in type,
with  acute paroxysms, sometimes recurring regularly.  In one  case
we noted  acute pain and exquisite tenderness developing daily  with
the regularity  that characterizes  a quotidian type of malaria.  The
condition yielded promptly and completely to full  doses of quinine.
   Le  Dentu  states that  the testicle sloAvly  increases in size, be-
coming elephantiasic.   He describes a form  of  overgroAvth associated
with  elephantiasis of the scrotum and evidently dependent upon in-
volvement of the lymphatic system.   This is characterized by recur-
rent erysipelatoid attacks, Avith gradual deposition of partially organ-
ized fibrous tissue.   It is  probable that this is not malarial orchitis,
but a distinct affection.
   The principal diagnostic features of malarial orchitis are the recur-
rence of attacks and the absence of other sufficient cause  for the
symptoms.  Full dosage Avith quinine will establish the diagnosis and
relieve the condition.
   Orchitis following tonsillitis  is an expression of infection Avhich
may  be haematogenous or may  be  carried from  the urethra.  The
course of the affection is similar to that of orchitis complicating mumps.
The disease lasts two or three Aveeks and usually terminates in resolu-
tion,  but may  suppurate or become  chronic, in either case ultimately
causing atrophy.
   Gouty orchitis is found associated Avith  the usual phenomena of
gout.   It may  be acute or chronic in type, and is likely  to  be  per-
sistent.  It may, hoAvever, alternate Avith  other gouty symptoms, dis-
appearing with the arthritis and reappearing as the latter  subsides.  It
is prone to relapse, occurring in  sudden seizures,  and may be trans-
ferred from  one testicle to  the  other.  True gouty  orchitis  is quite
different from  the epididymitis of urethral origin observed in gouty 
888
GENITO-URINARY DISEASES AND SYPHILIS
persons.  It occurs after middle life, and affects primarily and chiefly
the testes, rarely extending to the epididymis.
    Orchitis  folloaving  small-pox,  scarlatina, or  influenza has no
pathognomonic  features.   It is simply a local expression of a general
infection, due either to lodgement of micro-organisms  circulating in
the blood or to  extension by means of a phlebitis, especially of the
spermatic veins.
    Traumatic orchitis has been already discussed.
    By  Avhatever cause  orchitis  or  orchi-epididymitis is excited, the
lesions, symptoms, and terminations are practically the same, with
minor differences dependent upon a difference in the virulence of the
infection and upon varying individual poAver of resistance.  The dis-
tinction betAveen inflammations  of urethral  and those of haematoge-
nous  origin is important mainly  from a therapeutic  stand-point, since
a posterior urethritis if present should receive attention.
    The  inflammation  may  terminate in complete resolution  with
restoration of physiological function, in chronic inflammation followed
by atrophy and  loss of function, or in  abscess often complicated by
fungus of the testicle.   Gangrene is  a rare complication  occurring in
debilitated patients.  Exceptionally the inflammation extends along the
cord,  occasioning pelvic  cellulitis and peritonitis.   We  believe, Iioav-
ever,  that most of the reported  cases of this extension are in reality
instances of suppuration of the seminal vesicles.   The initial cause of
chronic inflammation  is usually a preceding acute  or.chitis, although
underlying this  there  is often a constitutional  dyscrasia. Either the
testicle becomes indurated and  completely  atrophies, or suppuration
takes  place, producing multiple abscess.
    Treatment.—Acute  orchitis is treated by the remedies and appli-
cations described as  appropriate to gonorrhoeal  epididymitis.   The
indications are  met by  rest in bed, elevation of the pelvis and the
testicles, the application of evaporating  lotions or the ice-bag, or hot
fomentations, according  to the severity of the  inflammation, securing
a soluble condition of the bowels, and the administration of febrifuges
and diuretics, and of  morphine hypodermically in sufficient doses to
control the severe pain.
    If  the  pain   is  so intense that  safe doses of morphine Avill not
relieve  it, the tunica albuginea  may be punctured.  The punctures
should be made with a straight  cataract knife ; they may be multiple
and may  be repeated  several times.  The importance of  guarding
against infection is evident.  Abscesses should be  opened and drained
by gauze packing; rheumatic and gouty cases  should  receive appro-
priate constitutional treatment, and invariably on the  subsidence of 
INFLAMMATION OF  THE  TESTICLE.
889
acute inflammation the general treatment of the patient should be tonic
and supporting.
   As soon as patients are able to  leave bed, and when the inflam-
mation is  moderately severe  this should not be under two  or three
weeks, a carefully fitted pressure suspensory bandage should be worn,
preferably that described  in  the treatment  of gonorrhoeal  epididy-
mitis,  and this should be  continued for months or until the testicle
returns to its  normal condition.  At the same time a slightly stimu-
lating  ointment applied  to the  scrotal skin will be serviceable.  One
reason that acute orchitis  and orchi-epididymitis run into the chronic
form and  produce sIoav destruction of the  secreting  portion  of the
testes  is that patients are alloAved to  be up and about before the blood-
vessels have regained their tonicity, and hence there results a condition
of chronic congestion  in  a  previously inflamed organ.  Prolonged
rest in bed and an accurately fitting pressure bandage  are the means
of treatment which offer most hope  of avoiding this complication.
   Abscess of the  Testicle.—Reference has been already made to
abscess as a comparatively rare termination of acute or chronic or-
chitis and epididymitis.  In tubercular, malignant, or syphilitic degen-
eration of the  testes  pus-formation  is  common.  In gonorrhoea and
mumps it is rarer than in other acute infectious diseases.  It is prob-
ably most frequent in the  epididymo-orchitis Avhich develops in old
men in consequence of catheter urethritis.
   A small abscess having formed  in the testis, it may become en-
cysted, undergoing caseous degeneration; or may spread beneath the
tunica albuginea,  involving the Avhole testis  and causing  sloughing,
folloAved by many openings ; or may rupture into the tunica vaginalis,
causing suppuration of this sac and  ultimately pointing externally ; or
the abscess may reach the surface  Avithout rupturing  into the  cavity
of the tunica vaginalis, inflammatory adhesions  gluing all the tissues
together before the pus breaks through the tunica albuginea.
   Sometimes.the abscess when  centrally placed may remain  quies-
cent for  an indefinite period,  occasionally exhibiting acute exacer-
bations.   It should be remembered that gangrene of  the testis may
occur as a consequence of a very small abscess.
   The symptoms of suppuration are those of an aggravated  orchitis..
Usually there is fever and the oedematous swelling of the scrotum be-
comes more pronounced.   Following incision or spontaneous evacua-
tion, fungus of the testicle may develop, the whole  of the secreting
substance of the gland being extruded.
   Treatment.—Early free  incision,  followed by  irrigation and  gauze
packing,  is the treatment best calculated to  relieve  tension, and 
 890        GENITO-URINARY DISEASES AND SYPHILIS.

 therefore to lessen the danger  of acute tissue  necrosis.   Healing is
 usually  prompt.  When the Avhole  testis  is riddled Avith abscesses,
 or when sloughing has taken place, castration is the operation of
 choice.
               FUNGUS OR  HERNIA OF  THE  TESTICLE.
    There are tAvo varieties : (1)  true or glandular fungus, made up of
 a mass of granulation-tissue, which sometimes contains seminiferous
 tubules, groAving from Avithin the tunica albuginea ; (2) false or parietal
 fungus, consisting of exuberant granulations springing from the tissues
 of the scrotum or from the surface of the tunica albuginea.
    Fungus of the testicle may be caused  by suppuration, gangrene,
 syphilis,  or tuberculosis.   Reclus  states  that  hernia of  the testis
 implies protrusion of the gland still covered with its fibrous envelope
 through an opening in  the scrotum.   Scrotal tuberculosis, inflamma-
 tion, gangrene, and traumatism  may destroy the scrotum  and allow
 the testicle to protrude.
    The older writers described a hernia testis  apparently due to simple
 infection following, for instance,  such a procedure as puncture of the
 tunica albuginea for relief of pain in a gonorrhoeal epididymitis.  We
 have never encountered such a condition, and it is probable that the
 cases described were either tubercular or syphilitic, or Avere instances
 of sloughing testis, in which the  devitalized tissues  gradually escaped
 through an insufficient opening.
    Fungus which accompanies  suppurative  or sloughing processes
 may  be  made  up entirely of granulation-tissue.   This is  always the
 case  in the parietal form of the  affection.  In the  glandular or deep
 form the tubular  structure of the testis  is  often  extruded, though
 absence of  the  tubules  in the slough and  discharge does  not  prove
 that the granulations do not grow from the gland.
    The  tubercular fungus  may  be  superficial or deep, and is made
 up of exuberant granulations from the Avails of an abscess.  These
 protrude through openings  in the scrotum Avhich exhibit  indurated,
 chronically inflamed, gradually  contracting borders; they appear as
 yellowish-red, painless,  cauliflower-like  groAvths,  overlapping  the
 scrotal defect, rarely larger than the end of the thumb, though in the
"glandular variety the greater part of the testicular substance may be
 extruded.
    The syphilitic fungus grows from the walls  of a discharging gumma;
 it may be intra- or extra-glandular;  it rarely attains the  size of the
 larger tubercular fungus.
    The  malignant fungus  (fungus  haematodes) is in reality  a neAV
 growth which has broken through the tissues of the scrotum. 
TUEERCULAR DISEASE OF THE  TESTICLE.
891
   Diagnosis.—The appearance of an irregular, red, granulating mass
protruding through an opening in the scrotum is so characteristic of
fungus that the diagnosis is formulated on sight.  The nature of the
growth  may, hoAvever, require careful  study.   The  history of the
case, particularly that of the development of the preceding orchitis, is
usually  characteristic.  The finding of the seminiferous tubules and
the detection of a distinct pedicle to the groAvth shoAV that it originates
from the glandular substance.
   Treatment.—This  depends  upon the  cause and the variety of the
fungus.  Syphilitic cases are cured by appropriate constitutional treat-
ment, supplemented by cutting aAvay  the exuberant granulations and
dressing the Avound with sterile gauze.  Tubercular  cases, if super-
ficial, may be cured by touching with caustic potash and dressing Avith
iodoform gauze.   If deep, they should be opened, curetted from the
bottom, and packed ;  if persistent and associated Avith extensive de-
generation of the testicle, castration  should be performed.  Fungus
haematodes (malignant) should be treated by castration.
   The fungus Avhich  complicates simple  abscess or  sloughing, and
which springs from the glandular substance, being made up of granu-
lation-tissue and sometimes of  seminiferous tubules, should be opened
and curetted and the resulting  Avound packed Avith iodoform gauze.

            TUEERCULAR DISEASE  OF THE TESTICLE.
   Tubercular  inflammation  may develop in  one of  two  forms:
either as a sudden outbreak Avith all the local  and general symptoms
of acute inflammation, leaving on  subsidence  an irregular nodulation
characteristic  of tuberculosis,  or  as  a slow, apparently non-inflam-
matory, almost painless formation of tubercular nodules.
   The infection may reach the testicles through the blood-channels
or may extend by continuity of structure along the vas.  Occasionally
the testicles and the epididymis are affected during the evolution of a'
general miliary tuberculosis.   The lodgement of the tubercle bacilli
may be primary in the epididymis, or  the infection may be secondary
to prostatic, vesfcal, or renal tuberculosis, or to  foci of the disease in
other parts of the body.
   So far  as  clinical  evidence goes, the  epididymis  appears  to be
a frequent  seat of primary tuberculosis; from this  organ as the
starting-point the  disease  extends along  the  genito-urinary  tract.
Saltzmann defends the theory of the  entrance of the  bacilli by way
of the blood-vessels on the ground that the arteries of the epididymis
are smaller and more  tortuous than  those of the testicle or of the
vas, and that thus bacilli floating in the  blood are  more liable to 
892        GENITO-URINARY DISEASES  AND SYPHILIS

be lodged.   Moreover, the spermatic artery bifurcates  just before  it
enters the epididymis.
   It is  possible that infection may take place during coitus.  Ver-
neuil strongly defends this theory.  He demonstrates the presence of
tubercle  bacilli  in  the discharges of patients suffering from  uterine
tuberculosis.  He also cites cases in Avhich the  disease—i.e., tuber-
cular epididymitis—appeared in  persons  of perfectly healthy consti-
tution after  sexual intercourse  and  Avhere no  gonorrhoeal  history
existed.  Further, the tubercular infection is most likely to develop at
that  age  Avhen sexual activity is greatest, and in  the early stages of
genital tuberculosis there is  no  interference Avith sexual desire or
potency.   This belief in immediate tubercular contagion is sufficiently
Avell  grounded to justify a careful examination of uterine and  vaginal
discharges in suspected cases, and, when bacilli are found, to make  it
desirable to suggest means of prophylaxis.
   Tubercle bacilli  have been found in the healthy testicle and epi-
didymis.   It is also  proved that these organisms  may circulate in the
blood Avithout obtaining  lodgement in the tissues, and consequently
Avithout  working deleteriously upon the system  until  acute  inflam-
mation, particularly that following traumatism, produces a local lessen-
ing of resistance Avhich  favors the  lodgement and  multiplication of
the micro-organisms.  This has been shoAvn experimentally by intra-
peritoneal injection of tubercular sputum folloAved  by contusion of
the testis, and it explains the frequency with Avhich an acute gonor-
rhoeal epididymitis  or an orchitis incident to traumatism is folloAved
by a tubercular infiltration.
   In the large majority of cases tubercular infiltration is first noted
in the head of the epididymis, appearing  as  inflammatory nodules
Avhich sooner or later undergo cheesy degeneration.   The epididymis
becomes irregularly infiltrated,   and the  vas  thickened,  hard,  and
nodular.   The disease also extends in the direction  of  the testis,  and
not infrequently the vaginal tunic is involved.   When the testis  is
primarily infected, similar nodules develop and shoAV a central degen-
eration, extending at the same time  peripherally, and finally forming
a comparatively large cavity.
   Though  from clinical examination in the vast majority of cases
tuberculosis  seems  primarily  to involve  the  epididymis, entirely
sparing the testis, Reclus has shoAvn by post-mortem dissection that
both  epididymis and  testis are involved in more than three-fourths
of the cases.   In  tAventy-two cases  in Avhich no  autopsy was made,
tubercles were palpably present in the epididymes and testicles in ten
cases, and only in the epididymes in tAvelve cases. 
TUEERCULAR  DISEASE OF  THE  TESTICLE
893
   Symptoms.—Tubercular epididymo-orchitis may develop abruptly
or insidiously, or may be  preceded by  certain highly characteristic
prodromal symptoms.
   The  abrupt development of  disease is usually dependent upon
slight trauma or  extension  of inflammation from posterior urethritis.
The symptoms are practically the same as  those of traumatic orchitis
or of gonorrhoeal epididymitis.  There are the characteristic sickening
pain, effusion into the  tunica vaginalis and the cellular tissues about
the epididymis, and general oedema.  Instead of  subsiding  in  the
course of a few days or one or  two weeks, the local swelling persists,
though pain may be almost entirely relieved.   In a few weeks fluctu-
ation may  be detected, and  one or more sinuses form, discharging
cheesy pus.
   This  inflammation is commonly an  epididymo-orchitis, and is
often bilateral.   It  attacks by  preference young adults, and is  first
lodged in the epididymis, the outlines of which are so obscured  by a
large bossed SAvelling that the loop formed by the vas deferens cannot
be felt (Reclus);  the vas is  often infiltrated, and  there  is generally
tubercular  involvement of the other genito-urinary organs, particu-
larly the prostate and seminal vesicles.   Except  during the  period
of acute outbreak there  is little  or  no pain.   Fistula may not form
for a long time, the acute SAvelling partially subsiding and alloAving the
nodular, indurated, and enlarged epididymis and vas to be readily pal-
pated.   Hydrocele generally develops in connection with this form of
tuberculosis, and is likely to be  of the agglutinative type.   In the dis-
charge from the  sinuses  tubercle
bacilli may  be found.
   The insidious form  of the dis-
ease is characterized by the slow,
painless   formation  of  nodules
either in the epididymis or in the
testicle,  or  in both these organs.
(Fig.  222.)  Often there are abso-
lutely no symptoms,  the patient
detecting the overgroAvth  acci-
dentally.  Sometimes  there  is a
Sense Of dragging and  Weight,  Or Tubercular epididymitis. (Monod and Terrillon.)
there are reflex disturbances, such
as frequent emissions  or sexual  hyperaesthesia, which  lead to exam-
ination of the part and discovery of  the swelling.
  The form  of  the disease  ushered in by prodromata  is probably
not primary —».e., there  is a pre-existing tubercular involvement of
 
894
GENITO-URINARY  DISEASES AND SYPHILIS.
some other  portion  of the genito-urinary  tract.   The prodromal
symptoms  are—(1) A painless, moderate urethritis, characterized by
a scanty, turbid, muco-purulent  discharge,  noticeable  only  in  the
morning.   This discharge comes and goes apparently without cause,
and  is  uninfluenced  by treatment.  (2)  Frequent urination.   (3) A
hypersensitive  condition of the prostatic urethra,  particularly to in-
strumental examination and irritating injections.  (4) Terminal hema-
turia.  These symptoms may last weeks or months before appreciable
development of lesions in the testicle or the epididymis,  and indicate
tubercular  involvement of the posterior urethra.
   In the  chronic  forms of  tubercular  involvement of the  testicle
and  epididymis  suppuration and abscess-formation  develop much
more slowly than  in the acute.   Even large infiltrations become
encapsulated and absorbed, leaving simply an irregular fibroid nodu-
lation.  We  have under  observation three  cases  of tubercular epi-
didymo-orchitis Avhich have lasted from three to five years,  which in
place of softening and breaking down have been  undergoing a steady
fibroid change.  When  fistulae are formed, usually in  the loAver pos-
terior part of the scrotum, they continue to discharge a thin  serous
fluid, often  containing broken-down granulations, until the degenerated
tissue is entirely eliminated;  they  then heal, unless there is extension
of infiltration.
   Diagnosis.—The diagnosis of  acute  tubercular epididymo-orchi-
tis is based on—(1) The apparently causeless outbreak of  acute in-
flammation.  When  traumatism,  mumps, gonorrhoea, syphilis,  and
the various infectious diseases can be excluded, tuberculosis  should
be suspected.  (2)  The presence of tubercular infiltration  in  the
prostate or seminal vesicles or evidences of  infection  in other parts
of the body,   (3) Persistence  of  swelling after  the  pain and other
symptoms  of acute inflammation  have subsided.  (4) Formation of
nodules, particularly in the region of the epididymes, Avhich soften and
break doAvn,  leaving fistulae,  in the discharge of Avhich may be found
tubercle bacilli.
   Acute tubercular epididymitis commonly develops in young adults
of lymphatic temperament avIio  have a tubercular  family history.
The  pain and swelling are  someAvhat less marked than in cases of
gonorrhoeal epididymitis, for  instance.  It must  be confessed  that in
the first one or two Aveeks of an attack it may be impossible to estab-
lish a diagnosis.  The formation of suppurating nodules is,  however,
characteristic.  The cord is  soon  involved, becoming thickened and
irregularly  bosselated.
   The diagnosis of  chronic tubercular epididymo-orchitis is based 
           TUBERCULAR  DISEASE OF  THE TESTICLE.        895

upon a tubercular history, the painless, non-inflammatory development
of infiltration, particularly in the head of the epididymis, the associa-
tion Avith non-gonorrhceal urethral discharge, frequent urination, and
haematuria, the discovery of induration or nodulation  of the seminal
vesicles  or  prostate, the gradual  extension  of the  infiltration  to the
entire epididymis and to the cord, often forming an irregular  tumor
much larger than the testicle, and finally  upon  bacteriological ex-
amination.   When there  is an  associated  hydrocele  (and  this  is
common), injection of this  fluid into the peritoneal cavity of rabbits
may in  tubercular cases cause the development  of miliary nodules.
The urethral discharges  should be carefully examined  for tubercle
bacilli.   It  must  be  remembered that  it is  possible  for gonorrhoeal
epididymitis to develop and run its typical  course in  the tubercular
subject  without  subsequent tubercular  infiltration  of  the epididymis
or testis.
    Differential diagnosis betAveen the tubercular nodule and the indu-
ration folloAving gonorrhoea  is based upon the history of a  preceding
acute urethritis and upon the fact  that  the gonorrhoeal  induration is
found in the tail of the  epididymis, while  the tubercular  nodule is
usually  in the  head.  The gonorrhoeal  nodule  exhibits no tendency
towards extension, does not mask the outlines of the epididymis, and
is not associated with palpable lesions of the cord or seminal vesicles.
    The differential diagnosis between acute gonorrhoeal epididymitis
and acute tubercular epididymitis in the absence of other tubercular
lesions  must be held in abeyance  until  the tubercular process de-
velops  with characteristic  features.  The  finding  of  the gonococcus
does not necessarily exclude tubercle.
    Prognosis.—It has been already stated  that  tubercular nodules
may become encapsulated and absorbed, leaving  a  mass of fibrous
tissue to mark their position.  This does not necessarily indicate that
a definite cure has been accomplished, since under favoring circum-
stances  the tubercular foci may again become active and Avith greatly
increased virulence.  When the infection is located  only in the epi-
didymis or testis, spontaneous cure may result from  this process  of
encapsulation.
    The course of the case will be unfavorable in direct ratio to (1) the
rapidity of development;  (2) the extent of involvement  of the gland ;
(3)  the  tendency to become bilateral;  (4) the association with diffuse
uro-genital tuberculosis.
    In any event it cannot be too  strongly emphasized that, as  in  all
other forms of surgical  tuberculosis, the prognosis is extremely grave
if the patient is  necessarily intrusted to the  vis medicatrix natural. 
896        GENITO-URINARY  DISEASES AND  SYPHILIS.

   When the tubercular process is lodged solely in the epididymis
or the testicle and  is subjected to  prompt  surgical treatment, the
prognosis is extremely favorable.   When  the affection is  bilateral
involving .the  cord, seminal vesicles, and prostate, surgical interven-
tion promises  little success; the main dependence must be placed on
constitutional  hygienic treatment.
   Treatment.—1. Palliative Treatment.—When a patient suffering from
tubercular epididymo-orchitis will not  submit to  operation, or  Avhen
the disease is  so wide-spread that its complete remoATal is impossible,
hygienic  measures adapted to tubercular patients generally are indi-
cated.   The most  efficient of these is probably out-door  life  in a
suitable climate.  The drugs most likely to be of use in this class of
cases are cod-liver  oil, syrup  of  ferric iodide, compound syrup of
hypophosphites, preparations of cinchona and kola, Avhiskey, and beef
peptonoids.   The testicles should be protected and supported by the
pressure suspensory bandage  described  in the treatment of gonor-
rhoeal epididymitis.
   2. Radical treatment, Avhen the disease  is strictly localized,—i.e.,
when it  appears in the form  of small, separate  nodules or foci of
caseation,—may consist in incision,  folloAved  by vigorous scraping of
the infected tissues and packing with iodoform gauze.
   Excision of the  epididymis or a  portion of the testis  is indicated
when there  is reason to believe that a  considerable part of the  gland
may be safely left.
   Injections  of ten per cent, emulsion of iodoform  in glycerin have
given excellent  results.  From five to fifteen drops of this mixture
should be employed for one treatment,  and should be driven directly
into the infiltrated mass, the needle being introduced  at several points
and two or three drops being deposited at each point.   This treatment
is  conducted  under antiseptic precautions, the needle-punctures are
dressed with iodoform collodion, and the testicle is supported by the
pressure  suspensory bandage. The  injections are  repeated  every
third or fourth day, depending upon the violence of the reaction.
   Lannelongue's injections of five  per cent,  solution of sulphate of
zinc have proved serviceable ;  from  three to ten drops are driven into
the periphery of the tubercular foci,  the  treatment being  repeated
every second or third day.
   There can be no question  as to the permanence of many cures
reported from the injection-treatment, though as a result the epididy-
mis becomes hopelessly obliterated.
   Castration  is  the final operation applicable to  advanced  cases.
The indications for this operation are thus formulated by Jacobson: 
TUBERCULAR DISEASE OF THE TESTICLE.
897
   "(1) Where the treatment  by erasion fails, in  lesions still limited
to the epididymis.   If one or more  discharging  fistulae still persist
here, especially if the patient is not in a position to avail himself of a
repetition of the operation at the sea-side,  castration should be per-
formed, slight  as the mischief  seems to be.  It is  only too probable
that small deposits are already making their way into the testicle itself
by spreading along the rete, a  condition extremely difficult to  make
out by external examination.  (2) Where  after erasion the fistula or
fistulae having healed, but careful watching  of the patient,  Avhich must
always be insisted upon, detects the existence  of, it may be, slight but
persistent swelling Avith night-sweats  and  loss of  flesh.   These  may
point to mischief connected with the remains of the sexual gland, and
not necessarily to that in the prostate, etc., or in the lungs.   (3) When
the body of the testicle is  involved.   When  this  remains enlarged,
irregular in outline, and liable  to  attacks  of subacute inflammation,
tenderness, and pain, castration  should be performed.   If a medical
man encourages a patient with  several  nodules in the testicle or epi-
didymis to leave these untreated, there is always a grave risk that
these, which are  already potential sources  of  mischief, will be lit up
into fresh activity, eventually fatal, by some trifling injury or pyrexia]
attack.  (4) Where the testicle remains small and  atrophied, and rid-
dled with fistulae, one  or  more of which  persist  in discharging, re-
moval of a useless and dangerous organ should always be practised.
(5) Where  a hydrocele is present, especially  if purulent.  Even in
cases Avhere a hydrocele, coexisting with tubercular disease of the epi-
didymis or testicle, resembles  an ordinary hydrocele  closely in its
naked-eye  characters,  the  presence of  bacilli must be carefully  ex-
cluded both by the microscope and inoculation-tests before the fluid
can be pronounced to be innocent."
   The curative effect of iodoform injections is not considered in this
list of indications.  We believe that this treatment should be given
a thorough  trial  before castration is advised, particularly A\Then  the
disease is bilateral.  When  castration is performed, not only the tes-
ticle but all infiltrated  skin and cellular tissue should be removed.
The cord should  be divided high up, and the vas should be followed
beyond the limits of nodulation or infiltration, even into the pelvis, if
this is required by the extent of disease.
   Villeneuve,  of Marseilles,  advised,  when  the  vas  is infiltrated
through its  entire length, that the incision for castration should be ex-
tended from the scrotum upward  parallel to Poupart's  ligament and
down to the peritoneum, Avhich should  be  separated from the lateral
walls of the bladder by the finger, using the  vas deferens as a guide,
                                57 
898
GENITO-URINARY  DISEASES AND SYPHILIS.
until the top of the seminal vesicle is reached.   The vas is divided
at this  point and extracted.  Roux suggests that Avhen the ampulla
of the vas, the prostate, and the seminal vesicles are involved, a semi-
lunar incision should be made in front of the anus, the rectum sepa-
rated from  the  prostate, a transverse incision  made  in  the  fascia
covering the seminal vesicles and vasa, and the diseased  structures
peeled off from the bladder and removed.  The  castration could be
completed after the separation and ligation  of the vessels,  by making
traction upon the vas deferens, which would come  out in its  entire
length without any further risk to the patient.
   Weir reports a case in Avhich a curved incision was made, allowing
the anus and rectum to fall back.  The incision was deepened until
the prostate and bladder-wall were exposed.  Here  the dense  fascia
binding down the vesicles to the bladder Avas cut through transversely,
giving ready access to the ampulla of the vas deferens and the seminal
vesicles.   The right seminal vesicle was dissected free from the blad-
der and removed, also the affected portion of the prostate, and sub-
sequently the other vesicle.  Both cords, with the testicles and the
whole length of the vasa deferentia, Avere draAvn out through openings
made in  the scrotum for castration.   Then  the fascia of the external
oblique  was  sutured  with catgut over a gauze drain,  and the skin
closed with  catgut.  The incision on  the left side was treated in the
same way.  The perineal wound wTas packed with iodoform  gauze
and  partially closed by two sutures on either side of the anus.  The
scrotal and perineal wounds healed satisfactorily.
   The subsequent history of  the patient was, in brief, that for the
first  four weeks  urination improved and the tubercle  bacilli disap-
peared,  but  this amelioration Avas due to the effect of a small fistulous
track which resulted from the  wound in the prostatic urethra and
which persisted for nearly seven weeks.  After its healing the bladder
irritation increased.
   Syphilis of  the testicle and  epididymis has  already been
described.   Scirrhous and gummatous orchitis are frequent manifes-
tations of constitutional disease, and are most likely to develop during
the period of life when  sexual  activity is greatest.  They may begin
insidiously or with symptoms  of acute  inflammation, and may form
nodules at the head of the epididymis, or may attack the testicle alone.
The  tumor formed by gummata is nearly ahvays painless, except from
its Aveight.  This  infiltration  may soften and break down, forming
fistulae or fungus, or may lead to atrophy of the gland.
   The diagnosis  of  syphilitic epididymitis  from  the tubercular affec-
tion  is based on the density and sharper demarcation of the syphilitic 
TUMORS OF THE  TESTICLE.
899
nodules, and particularly on the history of the case and the effect of
constitutional treatment.  Acute sypliilitic orchitis is characterized by
the primary development of the affection in the testis, by the history
of syphilis, by the absence of other sufficient cause  for the disease,
and by the effect  of  constitutional treatment.   Gummatous orchitis
differs  from  tubercular  disease in being  more  often bilateral  and
yielding promptly to treatment.  Gummatous fistulae lead down to the
testicle and  open on the anterior surface of the scrotum, differing in
both these respects from the tubercular fistulae.  The diagnosis be-
tween syphilitic  and tubercular orchitis  may be impossible from in-
spection and  palpation.  The distinction of  syphilitic sarcocele from
hamiatoma is  made solely on the history of the development of the
tumor or upon the result of aspiration.

                   TUMORS OF THE  TESTICLE.
   An  elaborate classification of tumors  of the testis, such as is given
by Monod and Terrillon, is of little practical value.  For clinical pur-
poses tumors may be classed as malignant and  benign.  The tumors
Avhich are usually malignant include carcinomata,  sarcomata, cysto-
mata, lymphadenomata  (lymphosarcomata),  enchondromata,  myxo-
mata, and  mixed tumors.   Tumors  usually benign are fibromata,
osteomata, and myomata.
   Carcinoma.—Carcinoma is the most frequent tumor of the testis.
Langhans  has contributed an  elaborate histology  of  the  affection,
based on  a study of  thirty cases.   The  tumor may be of  a  soft
(medullary) or hard (scirrhous) type.   Medullary  carcinoma is the
more frequent form.   The etiology is obscure, but is often  traceable
to trauma ; the disease exhibits a special predilection for undescended
testes, probably because these are so frequently subjected to repeated
slight injury.   Gonorrhoeal  epididymitis, syphilis, and other inflam-
mations may  act  as predisposing causes.   Paget states that  cancer
attacks the testicle in  tAvo and eight-tenths per cent, of all cases of
malignant disease.  The disease usually develops in  the adult;  excep-
tionally it attacks the testes of children.
   Kocher teaches that  the  tumor usually begins  in  the centre of
the testis, though it may originate in  any part of this gland or in the
epididymis, or may invade both  structures  simultaneously;  ulti-
mately it  extends along the cord.   Exceptionally, malignant infiltra-
tion of this structure  may develop early, in the course of  the lym-
phatic vessels.  The scirrhous tumors  are  much  smaller  than the
encephaloid, rarely reaching the size of a fist.   In both forms of the
affection  there is  rapid invasion  of  the post-peritoneal lymphatic 
900        GENITOURINARY DISEASES AND SYPHILIS.

glands, with further upAvard extension to  those of the mediastinum
or even of the neck.
   Kocher finds that more than one-half  the cases of cancer of the
testes develop between the thirtieth and the fortieth year.   Of thirty-
seven cases, tAventy-eight developed between the twenty-fifth and the
forty-fifth  year.   The soft tumor usually grows rapidly, sometimes
attaining  the  dimensions  of a child's  head.  The  groAvth in  the
scirrhous form is much slower.
   The tumor usually corresponds to the form of the testis until it
has thinned or perforated  the  albuginea, when it becomes irregular
and  nodulated.  The tunica vaginalis is partly obliterated  by adhe-
sions ;  the portions not  thus closed are filled with  blood-stained
serum.   As the tumor  proliferates it may involve and destroy  the
skin, forming a cauliflower-like mass of bleeding granulations (fungus
haematodes).
   The consistence  of the tumor varies greatly: often nodulations
alternating with areas of softening are felt through its substance; it
may exhibit parenchymatous hemorrhages or various  degenerations,
as mucoid or colloid.
   In the early stages the epididymis  may  often be felt entirely unin-
volved.   Later it becomes infiltrated and indistinguishable  from  the
mass of  the tumor.   Hydrocele or haematocele may complicate  the
affection from the beginning and conceal the enlargement.
   The swelling often develops without pain, but rarely  Avhen  the
growth  is very rapid ; reflex pains are usually indicative of involve-
ment of the cord and glands.  Testicular sensation is lost early.  The
first  symptom of lymphatic involvement may be pains  referred to the
inguinal region or the back, or  along  the course of the sciatic nerve,
or radiating down the thighs.   The  enlarged retroperitoneal glands
can  usually be  felt  on  abdominal palpation;  by pressure upon  the
veins they may cause oedema of the legs.   Cachexia becomes marked
when secondary deposits develop.
   Kocher points out the fact that in malignant tumors of the testicle
the vessels of the  cord become extremely large, thus differing from
the SAvelling caused by simple hydrocele.   Moreover, the scrotal veins
are nearly ahvays dilated.
   Diagnosis.—The  early  detection  of carcinoma of the testis is of
cardinal importance, since intervention is hopeless unless undertaken
before  involvement of the  lymphatic glands.   An apparently cause-
less induration of the testicle followed by  rapid and  progressive in-
crease  in size is highly indicative  of malignant growth, especially if
accompanied by marked dilatation  of the  blood-vessels of the cord 
                  TUMORS OF THE TESTICLE.                901

and scrotum.  When the tumor is  masked by hydrocele, the latter
should be treated by open incision, thus allowing the testis to be in-
spected and palpated.
   Malignant growth folloAving traumatism may be distinguished from
traumatic orchitis only by the progressive increase in the size of the
testis.  When the cancer is thoroughly developed it is not likely to be
confounded with any other affection.  (Fig. 223.)  The large  tumor,

                             Fig. 223.
Cancer of the right testicle. (Monod and Terrillon.)
the infiltration of the cord, the involvement of lymphatic glands, the
discoloration of the scrotum, the enlargement  of the blood-vessels,
and finally the cachexia, are all characteristic.   Gumma of the testicle
never grows larger than the size of the fist, and does not enlarge the
glands.  Moreover, it  is sometimes  bilateral, and  yields to  specific
treatment.   The distinction  from sarcoma and cystoma cannot  be
made.
   Haematocele may be mistaken for malignant disease.  There should,
however, be a history either of trauma with a growth developing
within a few hours, or of an old hydrocele into Avhich hemorrhage may
have occurred.  In  haematocele pain is an early symptom,  and the
swelling increases  intermittently and not by steady growth;  it is less 
902        GENITO-URINARY  DISEASES AND SYPHILIS.

bossed  and irregular than in malignant disease;  testicular sensation
is not so completely lost.  Tapping may establish a diagnosis, though
it must be remembered that there is  often  blood effusion into the
tunica vaginalis in cases of malignant disease.
   An old hydrocele Avith thickened sac, containing fibro-cartilaginous
material, and exhibiting a hard and uneven surface, may resemble
the hard form of the malignant disease.  When  it is impossible to
distinguish between these tAvo affections, an early incision, folloAved
by an operation appropriate to the condition found, is  advisable.
   Prognosis.—The prognosis of  carcinoma of the testicle  is bad.
Paget states  that  the  duration of life  is on  an average twenty-three
months, patients  living about six months after operation, since, as a
rule, they do not consent to surgical intervention until  after they have
suffered from the  disease for one and a half years.  When the retro-
peritoneal glands  are involved the prognosis is bad.  Death is nearly
ahvays due to metastasis.  The scirrhous  form of the disease runs a
sIoav course: Nepveu reports one case which survived fifteen years.
   A few cases of radical cure have been recorded.   Winiwarter, of
twelve cases, found one living two years and  seven months after oper-
ation.  Robin and Volkmann report four cases as living three years.
Kocher  publishes  the  records  of six  cases;  the diagnosis Avas thor-
oughly confirmed by microscopic examination;  two  were Avell  one
year after operation, one one and  a half years, one four and a half
years, one eight and a half years, one ten and a half  years;  in only
one instance  was the operation performed early.
   Mr. Butlin thus sums up the prognosis of operation for malignant
disease of the testicle  : " Castration for malignant disease is an opera-
tion  Avhich may be performed with very small danger to life.  The
operation, whether for sarcoma or carcinoma, cannot be  said to be
attended with large success,  so far as complete cure of the patient is
concerned, but there is a  great  lack of information on  this subject.
There is,  however, evidence  to  show  that it may be attended with
permanent success, and there is still further evidence to shoAV that the
operation may be  an excellent palliative measure even if it fails in its
primary object,—cure.  There is comparatively little fear of recur-
rence in situ, unless the cord is thickened or the scrotum adherent at
the time of the castration.   There is no prospect of success for oper-
ations for recurrent disease unless the recurrence is seated in the scro-
tum.  Castration  may be  performed  for  malignant disease  of both
testes; if not with a  reasonable prospect of permanent, yet certainly
of temporary relief.  Castration may be performed with the hope of
temporary relief in cases of malignant disease in children." 
TUMORS OF THE TESTICLE.
903
   Treatment.—Early castration is the  only treatment to be consid-
ered.  Any enlarged glands Avhich can be felt should be removed at
the same time if this is practicable.   These glands, when they attain
considerable  size, are  densely  adherent,  and their  removal  is ex-
tremely  difficult.  They are probably  best approached through the
peritoneal cavity.
   Sarcoma.—This may appear as a soft, round-celled tumor or as
a comparatively hard,  spindle-celled growth.   In the latter case the
sarcoma is  often mixed with mucoid, muscular, or cartilaginous tis-
sues (mixed tumor).   The  distinction between  sarcoma and carci-
noma can be made only by the microscope ;  clinically  they develop
in the same Avay, and they are equally malignant.   The sarcomata are
more  likely to have  associated Avith them different abnormal tissues;
the  presence of these may make a distinction from  cancer possible,
the  latter being usually a uniform  growth.   Sarcoma is sometimes
bilateral.  A spindle-celled sarcoma is someAvhat less malignant than
carcinoma.
   The symptoms and treatment are the same as for  carcinoma.
   Cystoma.—Morris states that  cystic disease of the testicle may
become  manifest in  the  form of a number  of minute cysts inter-
spersed  Avith other cysts  of medium size, in that  of firm,  dense,
fibrous tissue in AAdiich are numerous cysts of  varying size, or in that
of small, unequally  distributed cysts placed in  a stroma of round-
celled sarcomatous tissue.
   The contents of cysts may be clear, mucoid, or like coffee-grounds.
Sometimes they contain intracystic, caulifloAver-like groAvths, and the
stroma in which they  are  placed often exhibits areas of cartilaginous
and  sarcomatous degeneration.  The disease usually begins  in the
mediastinum, pushing  the  substance of the testicle  upward and
fonvard.
   The comparatively benign form of the disease may last for many
years, forming a smooth regular tumor of moderate size rarely larger
than the fist, which  may exhibit areas of fluctuation  or may seem to
be uniformly semi-solid.  The sarcomatous cysts grow  rapidly, attain
large size, and become bosselated.
   Cystic disease develops  Avithout pain, and does  not involve the
cord.   It is probable that the fibrocystomata may be  benign, but they
so commonly give rise to metastasis that  they  are properly classed as
malignant.   The treatment is castration.
   Enchondroma originates in the interstitial connective tissue of
the  rete testis;  it is commonly found betAveen the thirtieth and the
fortieth  year of life.   It is  rare in children and unknown in old age. 
904        GENITO-URINARY DISEASES AND SYPHILIS.

The  development  of the tumor is  as  symptomless as that of carci-
noma.   There forms a  hard, gradually groAving mass, Avhich causes
inconvenience only by its weight.  After groAving sIoavIv for some time
there may be a sudden increase in the rate of development, often
characterized by the appearance of soft, fluctuating spots in the dense
tumor.  Ultimately enchondromata  undergo metastasis.
   The enchondromata may be simple or mixed.
   Simple enchondroma is  extremely rare.   A small, dense tumor
appears not larger than a  Avalnut,  and persists, Avithout increase in
size,  for many months or even for several years.  The epididymis and
cord are not affected until the late stage of the disease.  After a long
period of  inactivity there may be rather rapid groAvth, in which case
the  enlargement becomes  irregularly lobulated  and  is  extremely
dense.
   Mixed  enchondroma contains between the  cartilaginous masses sar-
comatous  tissue.   It is more rapid in its course, groAvs to a larger size,
more commonly exhibits areas of softening,  and invades the cord.
   Diagnosis.—The diagnosis is founded upon the density and nodu-
lation of the groAAdh, its comparatively sIoav development, the absence
of pain, and  the ultimate  dissemination.  Soft or fluctuating areas
suggest a  mixed tumor and  therefore the  more  malignant form  of
enchondroma,  though   tumors  made  up entirely of  cartilage give
metastasis.
   Treatment.—Early castration is the only treatment to be considered.
   Lymphadenoma  is a rare affection,  Avhich can be  positively
distinguished from other malignant sarcoceles only by  microscopic
examination.   It does  not  reach the size of sarcoma or carcinoma,
is  not  prone  to ulcerate or to cause hydrocele, does not infiltrate the
epididymis, and causes a symmetrical  enlargement of the gland.  It
is  often bilateral, and sometimes is associated Avith lymphadenoma
in other portions  of the body.   It develops in the testes of young
men.  (Fig. 224.)
   Fibroma of the testicle is extremely rare.  It develops as a hard,
painless tumor, springing apparently from the proper tunic of the tes-
ticle, and producing pressure atrophy of the  gland.  Neither the cord
nor the epididymis is involved, and hydrocele does not develop.  It
occurs in early manhood, and may be bilateral.
   The diagnosis is made from the hardness of the tumor, the absence
of involvement of  the cord and the epididymis, the sloAvness of de-
velopment, and the preservation of  testicular sensation.
   The treatment  is excision.
   Dermoid Cysts.—Dermoid cysts, or teratomata, are congenital 
TUMORS OF THE TESTICLE.
905
growths,  containing hair, skin, sebaceous material,  bone, teeth, or
portions of other organs.  The tumor may be found in the testis or
entirely outside of it.   It is usually adherent to it, and placed betAveen
the testis and the epididymis, or in front of the testicle.  These tumors
may remain stationary, may groAv rapidly, or may suppurate.

                             Fig. 224.
Lymphadenoma of the testicle (bilateral).
   Diagnosis can be made positively only by an examination  of the
 contents of the cyst.  The fact that the tumor is congenital suggests
 its nature.   It may remain quiescent until  puberty or between the
 twentieth and the thirtieth year.   Commonly it develops in the first
 few months of life.
   Verneuil  states that there  is often a period of stagnation, during
 which the tumor groAvs  in proportion  to the general development.
 This is followed by an inflammatory period, during which there  is
 rapid groAvth.  This may not occur for many years.  When the tumor
 groAvs slowly it may reach large size without causing any symptoms
 aside from its Aveight.  The size of the  tumor may be enormous.   It
 may be as hard as an enchondroma  or soft and fluctuating.
   Myxoma, osteoma,  and  myoma are surgical rarities  Avhich
need no detailed  description.   Indeed,  these tumors have  been  so
seldom observed that their symptomatology and clinical course can- 
906       GENITO-URINARY DISEASES AND  SYPHILIS.

not  be formulated.  They are mainly important because  they  ob-
scure the diagnosis of malignant  growth.   It  is impossible,  for in-
stance, to distinguish osteoma from enchondroma except by the  test
of time.
                           CASTRATION.
    This operation, indicated when the diagnosis of malignant disease
is confirmed, would probably be attended with a large percentage of
radical cures Avere it undertaken  in  the early stages of infiltration.
During this period it is  impossible to formulate  the diagnosis.
    When tubercle or syphilis, or sufficient  cause for acute or chronic
inflammation of the testis, can be  excluded, we believe  enlargement
of this gland should be  subjected to exploratory incision, folloAved by
immediate castration if there is reason to suspect malignant groAvth,
or by microscopic examination of excised tissue in case palpation and
direct  inspection lead the surgeon to  believe that the  induration is
probably not malignant.  The exploratory incision is in  itself harm-
less, and even when the diagnosis  is apparently well  assured should
precede  castration.   We have seen a  haematocele  with Avails two
inches thick,  and  containing cartilaginous nodules, develop  abso-
lutely according to the  type of malignant groAvth, Avith the exception
of glandular involvement.  Preliminary incision would in such a case
be the means  of saving a comparatively healthy testicle.  If on  ex-
ploratory excision either a solid tumor or cystic  degeneration is found,
syphilis and tuberculosis having been excluded, the chances are largely
in favor of its malignancy.
    Castration is attended Avith little- danger.   Kocher reports but one
death in tAventy-three  cases  operated  on.   This death  was due to
pyaemia.   The  shock of Avhich so much has been written Ave have
never seen, even when  removing comparatively healthy testicles.   It
is still less  likely to  occur when  the  testicular substance has been
destroyed by infiltration.
    Preliminary cleansing of the operative region should be repeated
several times, at intervals of  some  hours, and  immediately  before
operation the  penis should  be tightly bandaged in  sterile  gauze,
since it is a frequent  source of  infection in  operations about  the
genitalia.
    The incision varies in accordance Avith the conditions.  When  the
tumor is  small  and non-adherent  and  the cord is not  involved, an
opening into the scrotum just  large enough to allow the  tumor to be
shelled out is sufficient.  If the growth is large, adherent, and extend-
ing up the cord, the incision should  be so planned that all the  adherent
skin will be removed, and should  run  parallel with  Poupart's liga- 
CASTRATION.
907
ment, half an inch above it, to the position of the internal ring.   The
incision should be made layer by layer, as this  enables  the operator
to judge of the amount of integument involved and to decide  on the
extent of interference  required.  When it is not necessary to remove
the tunica vaginalis and  there are no adhesions, the testes can be  torn
or shelled out Avith the fingers.
   In nearly all malignant cases, however, the vaginal tunic and the
greater part of the scrotal tissues of the affected side should be taken
with the groAvth.
   Bleeding  is checked  by haemostatic  forceps; the  testicle is freed
from its surroundings  and draAvn Avell doAvn, Avhile a finger passed up
along the cord determines its position  and acts as a director to open
the inguinal canal as far as may be necessary.
   The  cord is isolated above  the point of perceptible  involvement,
drawn Avell doAvn, transfixed Avith a silk ligature, tied in two portions,
cut across below the seat of ligation, and the lumen of the vas  cauter-
ized with pure carbolic acid.
   If the vascular constituents of the cord are ligated separately, three
arteries—the cremasteric, the spermatic, and the deferential—must be
tied.   The deferential artery is found close to the vas, and with it are
a feAV veins;  the cremasteric lies to the outer side of the cord, near
its surface; the  spermatic is in front of the cord, surrounded by the
anterior group of veins,  and can scarcely be distinguished from them.
Each artery should have a separate ligature, but the two sets of veins
may be tied en masse ; the divided cord should be secured with artery
forceps until the end of the operation.  The bleeding from the scrotal
tissues is controlled by forcipressure or ligatures, and redundant  por-
tions of the scrotum,  particularly those  which may be infiltrated, are
removed.  The  edges  of the wound  are then carefully approximated,
care being taken to prevent  inversion  by the dartos.   The sutures
should  be of silk, and  the last  one may secure a drainage-tube in
the lower angle of the wound if the case has been an infected  one.
OtherAvise drainage is  unnecessary.
   An antiseptic dressing is applied and held in place by the crossed
of the perineum.
   The  patient  may sometimes complain of retention of urine, last-
ing from twenty-four  to thirty-six hours.  This is relieved by cath-
eterization.   The stitches are removed on the fifth to the seventh
day.
   When the cord  is extensively involved,  the incision should be
extended up along Poupart's ligament, as already described.   It  is
deepened to  the peritoneum, which is stripped up, allowing access to 
908        GENITO-URINARY DISEASES AND SYPHILIS.

the glands of the  pelvis.   When the lymphatic involvement extends
upward beyond reach it  may be  attacked  through a transperitoneal
opening.
                           HYDROCELE.
   Hydrocele is a condition in Avhich there is an abnormal amount
of fluid about the testis  or the cord, limited by the tunica vaginalis.
Hydrocele, Avithout  further qualifying  Avords, as  " encysted" or " of
the cord," indicates a serous effusion betAveen the two layers of the
tunica vaginalis testis.
   Prolongations of peritoneum, called the vaginal processes, precede
the testicles in their  descent into the scrotum, thus forming a pouch,
into which the testicle with its epididymis is invaginated.  The funicu-
lar portion of this pouch  usually becomes  obliterated from the inter-
nal abdominal ring  to a point just above the testis, leaving a serous
sac enveloping this  organ,  in Avhich  is  normally  found just enough
fluid to  allow its surfaces  to glide smoothly  over each other.
   The invagination of the  testicle into the peritoneal pouch neces-
sarily forms  a parietal and a  visceral portion.  The  parietal portion
forms a loose investment, extending  above and beloAV the testis, and
connected by cellular tissue to the surrounding structures of the scro-
tum.  The visceral portion  invests the testis and the epididymis, con-
necting  these structures, and forming a fossa or pouch betAveen them
(digital fossa).  At the posterior portion  of the gland it becomes con-
tinuous Avith the visceral layer.  The tail  of the  epididymis  is not
included in the double serous  envelope,  since the reflection  of the
visceral layer is upon the front and  sides of  the  scrotal ligament of
the testicle, a fibro-muscular  band passing from the lower posterior
portion of  the testis  and the tail of the  epididymis  to the dartos.

                       ACUTE  HYDROCELE.
   This affection, an  acute vaginalitis, is  usually due to extension
of acute inflammation from the epididymis.   It is also secondary to
orchitis, and  may be caused by traumatism or irritating injections.
   It is  probable that  in every case of epididymitis  there is  some
extension of  inflammation to  the tunica vaginalis,  and that the acute
effusions Avhich complicate infectious diseases or catheter urethritis
are secondary to epididymitis or orchitis.
   The pathological changes in the tunica vaginalis are essentially the
same as those occurring in acute inflammations of  serous membranes
in other parts of the body.
   The effusion may be serous or fibrinous.  Serous effusion, though
common, is not often examined clinically, since it is slight, transitory, 
ACUTE  HYDROCELE.
909
and indicative of a mild inflammation.   Plastic effusion does not differ
from ordinary inflammatory lymph.  Suppuration is extremely rare.
   Symptoms.—The symptoms of acute hydrocele are masked by those
of the primary disease.  Thus, in gonorrhoeal epididymitis the usually
moderate amount of effusion into the vaginal tunic is obscured by the
oedematous SAvelling of the entire scrotum.  If effusion is abundant it
will form a  tense,  rounded  or  pyriform, fluctuating tumor Avhich is
translucent and Avhich feels like a greatly enlarged testicle.
   The pain attending acute  hydrocele is sometimes extremely severe,
corresponding in type  precisely to that of gonorrhoeal epididymitis.
This pain is  doubtless due to tension, since puncture  affords almost
immediate relief.   In addition to pain and swelling there are present
heat, redness, and scrotal oedema.  The general constitutional symp-
toms are, as  a rule, slight.
   Prognosis.—Acute hydrocele may undergo resolution;  the plastic
deposit may organize partially or completely, obliterating  the cavity
of the tunica vaginalis; the  inflammation may become chronic, con-
stituting the  ordinary form of hydrocele, and in this case organization
of the fibrinous tissue often  divides the  general cavity  into  secondary
ones, distinctly separated  from  one another;  or, finally, suppuration
may take place.
   Diagnosis.—The most  important single diagnostic sign is trans-
lucency.  This symptom  may be best elicited by the employment of
a tube about half an inch in diameter; an ordinary stethoscope will
ansAver.  One end of this tube is applied to the scrotum, the examiner
looking through the  other end while  a bright light  is held  close to
the opposite side  of the  tumor.  The method of  examining the
scrotum by  making  the  overlying tissues tense by pressure is not
applicable to an  acute hydrocele, because of the pain this manipu-
lation excites.  Another method of eliciting  translucency is  to place
against the  scrotum  the  open  end of a shallow cup in  Avhich is an
electric light.  Examinations for transmitted light must be  conducted
in a dark room.  In  case the fluid is mixed Avith blood, this  test will
be inconclusive.   The  aspirating needle will  then prove serviceable,
though before employing  this  instrument the surgeon  should be sure
that he  is not dealing with  strangulated hernia.  On  the subsidence
of acute inflammation the diagnosis can  be made without difficulty
by seizing the scrotum in the left hand and making the  skin over
the swelling moderately tense.  Then,  by  sudden pressure with the
finger of the right hand, the sensation of liquid being pressed aside
will be noted  before the comparatively firm resistance of the testicle
is felt;  or by the alternate pressure of the two hands fluctuation will 
910        GENITO-URINARY DISEASES AND SYPHILIS.
be  detected.   When  inflammation  has  still  further subsided, the
presence or absence  of  fibrinous deposits  may be  determined  by
seizing the testicle in  front and pressing  it backAvard from betAveen
the  thumb  and fingers.   Ordinarily it  readily slips back, leaving in
the  grasp the  scrotal  tissue  and  the external  layer of  the  vaginal
tunic.   If the  parietal and visceral layers of the vaginal tunic are
adherent, the testicle will not slip back from the grasp  in this way,
or,  if it does, will leave  a thickened mass betAA-een  the  thumb and
fingers.
    Examination  on the  subsidence of  inflammation will generally
shoAV thickening and induration of the epididymis.
    Double   hydrocele  is  usually  accompanied   by sterility, another
proof  of the almost invariable  association of this affection with epi-
didymitis.
    Treatment.—Acute hydrocele is treated in accordance with  general
surgical principles:  rest,  elevation of the part,  the employment of
evaporating lotions, and, later,  pressure by  the  suspensory bandage,
Avith the application of mild  absorbent ointments, are indicated.  If
the  pain becomes  unbearable  it  may be  relieved  at  once by punc-
ture, as in the case of gonorrhoeal  epididymitis.   If the effusion is not
absorbed in six Aveeks, treatment  appropriate to chronic hydrocele is
undertaken.
                        CHRONIC HYDROCELE.
    Jacobson thus classifies chronic hydrocele:

                                  1. Ordinary Hydrocele.—The fluid distends
                                      the closed sac of the tunica vaginalis.
                                  2. Con gen ital Hydrocele.—A communication
                                      exists between the cavity of the tunica
                                      vaginalis and that of the peritoneum.
                                  3. Infantile Hydrocele.—-The  tunica  vagi-
                                      nalis and the  funicular process are dis-
                                      tended with fluid, but  these  are shut
                                      off from the  peritoneal  cavity by an
                                      obliteration placed  usually at the ex-
                                      ternal ring.
                                  4. Inguinal Hydrocele.—Hydrocele in rela-
                                      tion with a retained testis.
                                  1. Encysted Hydrocele of the Epididymis.—
                                      The fluid is encysted in the neighbor-
                                      hood of  the epididymis.
                                  2. Encysted Hydrocele of the Testis— The
                                      fluid is  encysted between the tunica
                                      albuginea and the inner surface of the
                                      tunica vaginalis.
1 £
(a) Hydrocele of Tunica
     Vaginalis. — The
    fluid is in  a  sac
    connected   with
    that of the tunica
    vaginalis.
(/3) Encysted Hydrocele.
    —The fluid is in a
    sac distinct  from
    that of the tunica
    vaginalis. 
CHRONIC HYDROCELE.
911
^  A
           (a) Diffused.—The fluid forms a serous collection of the nature of
                oedema in the cellular tissue of the cord.
           (/3) Encysted.—The fluid  is contained  in a distinct sac originating
                usually (1) in some unobliterated part of the processus funiculo-
                vaginalis; (2) in a cyst formed independently of this process —
                e.g., by dilatation of persistent tubules of the organ of Giraldes.
           (a) With other Coexisting Hydroceles.—E.g.,  (1) hydrocele of the
                tunica vaginalis with encysted hydrocele of the testis ; (2) hydro-
                cele of the tunica vaginalis with encysted  hydrocele of the  cord ;
                (3) hydrocele  of the tunica  vaginalis  with diffused hydrocele
                of the cord.
           (fl) With Hernia.—E.g.,  (1)  hydrocele of the tunica vaginalis with
                inguinal  hernia;  (2)  hydrocele  of the cord with inguinal
                hernia.
     IV. Hydrocele of the sac of  a hernia.

    Hydrocele  of the Tunica Vaginalis Testis.—(Fig. 225.)  This,
 the ordinary form of hydrocele, is in the majority  of cases secondary
 to  pathological  conditions of the epididymis, testicle,  or cord.   It is
 particularly associated  with disease  of the epididymis.
    Loose cartilaginous bodies are sometimes, but rarely, found Avithin
 the sac, and  may by their continued irritation give rise to  an abnor-
 mal secretion of fluid.   Hydrocele  may be due to passive exudation
 caused by an obstruction to the return of circulation.   This exudation
 may be caused by an ill-fitting truss, by the  presence of filariae, or by
 hepatic or renal disease.  The frequent occurrence of hydrocele in
 warm climates  and in persons suffering from malaria is due to asso-
 ciated hepatic enlargements.  In general  dropsy  the  scrotal tissues
 may  be oedematous, but fluid in the tunica vaginalis is  seldom or
 never found.
    A certain number of cases seem to be idiopathic,—i.e., there is no
 discoverable  preceding inflammation of the scrotal contents.
    Chronic hydrocele may begin in the acute form, the effusion failing
 to be absorbed,  and gradually increasing  in quantity, or the  onset may
 be insidious,  the patient first detecting  the condition  by the increase
 in the size of the scrotum.
    Jacobson  holds that " in  the  great majority of cases the effusion
 of fluid commences passively, and Avithout any irritation or inflamma-
 tion to begin with, the  causes predisposing  to its production being
 the pendent  position,  the  less  vigorous condition of  the  cremaster
 and  dartos,  feebler  cardiac  circulation, deficiency of tone  in  the
 scrotal blood-vessels and  lymphatics, together with, perhaps, a ten-
 dency to venous congestion from hepatic and renal  degeneration.  All
these  conditions, Avhich  combine to  bring  about a passive effusion, 
912
GENITO-URINARY DISEASES AND SYPHILIS.
are naturally most active in middle life, this being the age when the
ordinary hydrocele of the tunica vaginalis is most frequently met with.
After a Avhile, as the  fluid increases in  bulk,  it becomes, from ex-
posure to friction, etc., liable to irritation and inflammatory changes,

                              Fm. 225.
Vertical section of hydrocele.  (Kocher.)
which show themselves both in the fluid and sometimes in the tunica
vaginalis itself."
   It is evident that from  the etiological stand-point hydroceles may
be classed as those developing primarily, and those secondary to trau-
matism, inflammation, or degeneration of the testicle, epididymis, or
cord.
   The fluid of chronic hydrocele is clear, yelloAvish, and much  like
that  found in ascites.  The specific gravity is about 1022, the reaction
is neutral or slightly alkaline, and  the fluid  contains fibrin, albumen,
and  paraglobulin.  The quantity of albumen (from  four to six per
cent.) found in the fluid strongly suggests the inflammatory origin of
the affection. 
CHRONIC  HYDROCELE.
913
   In some cases cholesterin crystals are seen in the contents of a
hydrocele, giving it a beautiful shimmering appearance.  These crys-
tals settle  on standing.   There  is sometimes  slight admixture  of
blood, the coloring-matter of which may be deposited in the form of
blackish sediment.
   The average amount of fluid is from  four to eight ounces.  This
produces a tumor of such  dimensions that it becomes inconvenient,
and  the  patient  seeks surgical  help.   Some  extraordinarily large
accumulations  have  been  observed, in  one case  more  than  six
gallons.
   Kocher in three  hundred and nine cases of hydrocele found that
fifty-seven developed in the first twenty years of life, and seventy-six
after the fiftieth year; the  remaining one hundred and  seventy-six
were observed between the tAventieth  and the fiftieth year.
   Kronlein states that thirty-nine per cent, of hydroceles are devel-
oped in the first year of  life, and forty-eight and eight-tenths  per
cent, in the first five years.   The right and left sides are about equally
affected.
   Symptoms.—The development of chronic hydrocele is  character-
ized by the absence of symptoms, the patient  experiencing no incon-
venience  aside from the weight  and size of the  tumor.  The rate of
the groAvth varies greatly.   It may reach a large size in a feAv Aveeks,
or may increase so sloAvly that a tumor of troublesome dimensions is
not formed for years.
   The tumor  is usually  smooth, tense,  fluctuating, and pyriform,
with  the  base below.   It  begins at the lower portion of the  scrotum
and grows upAvard.  The veins of the  scrotum  and cord  are  not
dilated in proportion to the size of the groAvth.  The cord can usually
be felt at the apex of  the tumor; testicular pain, Avhen elicited, gives
information not  only  as to the condition of this  organ but also as to
its position.  The skin is  smooth, Avhite, and apparently normal.   If
the tumor is held in one  hand  and  lightly percussed with one finger
of the other, a vibrating thrill  is  felt which is characteristic of fluctu-
ation.  When the SAvelling reaches  large dimensions the  penis is
practically concealed  in a  fold of the skin.   The tumor is  dull  on
percussion, is heavy, and when pushed back between the legs springs
forward again to its  original position.
   Coincidently with the accumulation of  fluid there is often  chronic
thickening of the vaginal tunic ; this exceptionally undergoes cartilagi-
nous or calcareous degeneration.  Sometimes the visceral and parietal
walls of the tunica vaginalis become adherent at points. Under these
circumstances palpation may show certain indurated spots or distinct
                               58 
914
GENITO-URINARY DISEASES  AND SYPHILIS.
Fig. 226.
  Vertical section of a hydrocele,
showing the testicle lying below
the cyst.  (Kocher.)
lobules.  It is important to knoAV the position of the testicle in hydro-
cele, since  othenvise it may be Avounded in operations  designed  for
cure.  This gland  usually lies in the  mid-posterior  portion of the
                         tumor.   Exceptionally, Avhen  there  is  in-
                         version  or Avhen  adhesions  have formed,
                         the testicle lies directly in front  of the tumor
                         and  may be readily Avounded, or it  may
                         lie at its loAver pole.   (Fig. 226.)  The po-
                         sition of the testicle is determined by press-
                         ure.   This, if suddenly exerted by  one or
                         hvo fingers over various parts of the tumor,
                         will  produce the  characteristic  sickening
                         pain Avhen the testicle is reached. Trans-
                         mitted light will better sIioav  the position of
                         the testicle.
                            Diagnosis.—The diagnosis is based upon
                         the  development  of a tumor in  the  loAver
                         part of the scrotum, its fluctuation, its pyri-
                         form shape, its projection  forAvard, its trans-
                         lucency,  and  the small  size  of the cord.
                         The light test should be conducted in a dark
room, and  the skin of the  scrotum and the vaginal tunic  should be
made tense by grasping the tumor from behind Avith the  left hand.
The electric light may be used as described under acute hydrocele, or
translucency can be  elicited by means of an  ordinary candle.  The
surgeon, having placed the patient on his back, makes the tumor tense
with the left hand, placing his right hand on the upper  convex border,
thus shading his eyes from the source of light, which  is held close to
the scrotum on the side opposite that from AAdrich the surgeon is con-
ducting his inspection.  This test Avill fail Avhen the hydrocele contains
a large quantity of  cholesterin or Avhen the fluid is turbid from blood,
fat, or spermatozoa.  Omental hernia may be slightly translucent, but
the bright  red glow so  characteristic of ordinary hydrocele is never
seen.  The final diagnosis is dependent upon aspiration.  This should
not  be  practised  until every effort has been made  to exclude the
presence of hernia.  When fluctuation,  transparency, and  testicular
sensation cannot be elicited, the diagnosis will depend upon the use
of an aspirating needle, or, better  than this, an incision,  since thus
can  be  made a thorough examination of  both the testicle and the
epididymis.
    The differential diagnosis  is to be made  from hernias, neoplasms,
other varieties of hydrocele, and haematocele. 
CHRONIC  HYDROCELE.
915
Fig. 227.
    The diagnosis from hernia, unless there exists strangulation, with
 excessive exudation and Avithout the typical abdominal symptoms, is
 usually not difficult.  In hernia there are impulse upon coughing and
 percussion resonance ; the tumor hangs directly down instead of pro-
 truding forAvard, grows smaller or disappears in the night, is reduced
 with a " flop," and  in its development is first perceptible in the groin,
 then slowly reaches the scrotum.  In none of these  respects does it
 resemble hydrocele.  In the ordinary hydrocele palpation  shows that
 the inguinal canal is  empty, fluctuation is readily elicited, and trans-
 lucency is marked.  These are all characteristics not
 found in hernia.  When, however, a hydrocele be-
 comes acutely inflamed from injury or  other cause,
 and Avhen the history of its formation is uncertain,
 diagnosis may be  extremely difficult, and must be
 based mainly upon  the absence of abdominal symp-
 toms.  Hernia  and hydrocele may coexist; in this
 case the typical  symptoms of each pathological con-
 dition may be elicited.  (Fig. 227.)
    From haematocele the more rapid groAvth of the
 swelling, the history of an  injury or recent tapping,
 and the absence  of thrill and translucency, will some-
 times aid in the  diagnosis, but Avhen the tunic of the
 hydrocele is thickened or Avhen  its  contents are opaque  diagnosis is
 impossible.
    These same  conditions  render the diagnosis from tumor  difficult.
 Tumor,  however,  is  heavier and  denser than  hydrocele,  exhibits
 marked  dilatation  of the vessels  of the cord  and scrotum, and  is
 attended by  lymphatic enlargement.  In case of doubt,  incision  is
 indicated.
    Prognosis.—Spontaneous  cure is  comparatively common in chil-
 dren.   It hardly ever takes  place in adults.  So  far as  life is con-
 cerned,  hydrocele  is  not dangerous, though it  encourages  the  de-
 velopment of hernia, may lead to testicular atrophy, and occasionally
 suppurates.  As a result of traumatism it  may rupture into the tissues
 of the scrotum.
    Treatment.—The hydrocele of  infants sometimes seems to be cured
 by the application of slightly stimulating lotions, such  as ammonium
 muriate  ten grains to the ounce of water, or an aqueous  solution  of
ichthyol three per cent.   The efficiency of these applications  is ques-
tionable,  and  it  is  probable that when the  effusion  disappears this
occurs spontaneously, practically uninfluenced by the local treatment.
   The operative treatment may be palliative or radical.
Inguinal hernia with
hydrocele. (Kocher.)
9999999 
916        GENITO-URINARY DISEASES AND SYPHILIS.
Fig. 228.
   Palliative treatment consists in evacuation of the fluid contents of
the hydrocele.  In the chronic form of the disease  there  is ahvays
reaccumulation, but this tapping may be repeated from time to time
as the necessity for it is indicated by full distention.
   The position of the testicle is first determined by means of  the
light test  and by palpation; it  is usually  found behind the sac  and
                     somewhat below its middle third.  The pres-
                     ence of  hernia  must  be  carefully  excluded.
                     Exceptionally the gut becomes  invaginated into
                     the sac of a hydrocele, and might then readily
                     be wounded  by the trocar. (Fig. 228.)  The
                     patient lies either flat on his back or in a semi-
                     recumbent position.   The skin of the scrotum
                     having been thoroughly disinfected, the sac is
                     made tense  by seizing it from behind Avith  the
                     left hand.   The trocar is plunged into the ante-
                     rior part in an upward and backAvard direc-
                     tion, care  being taken to avoid any superficial
                     vein  which  may be apparent;  the  depth to
whch the trocar is plunged should be limited by keeping the thumb-
or finger-nail in contact with  the canula at one  and a half or two
inches from  the point of the instrument.   (Fig. 229.)   By observing
this  precaution  and by thrusting the trocar in the proper direction
all danger of wounding the testicle is avoided, especially if its position
  Inguinal  hernia invagi-
nating the upper portion of
the  sac of a hydrocele.
(Kocher.)
Fig. 229.
Tapping a hydrocele.
has been before  determined.  When the sac has been emptied, the
canula is immediately withdrawn  and the small opening is closed by
a fragment  of gauze held in place  by iodoform  collodion.   In  per-
forming this operation  it is important to have the trocar sharp and the 
CHRONIC  HYDROCELE.
917
canula accurately  fitted to  it, as othenvise  the  sac  will be pushed
before the  point of the instrument and will not be  opened.  Prac-
tically the only complication which  can occur, save septic infection, is
wounding of either the testicle or a large vein, Avith the effusion of
blood into the hydrocele sac or the  cellular substance of the scrotum.
Elevation  and pressure applied by the crossed of the perineum are
usually sufficient to check this bleeding.
   The radical treatment of hydrocele is  carried out either by injec-
tion or by cutting operation.
   Injection Treatment.—The injection treatment is based on the fact
that if a strong irritant is thrown into the  hydrocele sac  there results
a fibrinous effusion, which undergoes  organization,  obliterating the
cavity of this sac.  The irritants used are tincture of iodine and car-
bolic  acid, the quantities varying someAvhat  in  accordance with the
amount of serous surface to be irritated.   Of the former drug, from
two drachms to  an ounce is employed; of the latter, about twenty
minims.  For  the performance of this operation an anaesthetic is not
usually required.   The fluid contents of the hydrocele are evacuated,
as in the  palliative treatment.   After the sac is completely empty,
iodine or carbolic acid is driven in  through the canula, and an effort
is made by manipulation to spread it over the entire serous surface
of the hydrocele  sac.  This portion of the operation is important, but
is often neglected.   The nozzle of the syringe employed for the injec-
tion should accurately fit the canula, and after the injection of a quan-
tity of iodine  tincture equal to one-tenth  to one-sixth of the amount
of fluid draAvn from the sac, the canula should be withdrawn without
disconnecting  the  syringe from it, the opening being  immediately
closed by  a pledget  of antiseptic cotton and  iodoform  collodion.
When tincture of iodine is used there results at the time of injection
a sickening pain, radiating to the small of the back and lasting from
five minutes to tAvo or three hours.  There is rapid swelling, Avith all
the symptoms of acute inflammation;  Avithin two days  the tumor is
as large as before operation, or even larger.   This is occasioned  by
the abundant inflammatory effusion.  Within four days this will prob-
ably begin to  subside, and in  three or four Aveeks will  have entirely
disappeared.   During the  acute inflammatory stage  the scrotum  is
kept  elevated  and is  dressed Avith evaporating lotions.  The  injec-
tion is usually folloAved'by a temperature  ranging  betAveen  99° and
103° F. for the first  three  days, after Avhich  it drops to  normal.
When carbolic acid is employed the pain at the time of injection  is
more transitory and the inflammatory reaction is less marked.
   Nicaise, finding the treatment of hydrocele by the  injection of irri- 
918        GENITO-URINARY  DISEASES AND SYPHILIS.

tating substances extremely painful  and cocaine  as a local anaesthetic
employed in the* ordinary Avay not free from danger, has successfully
practised the following method.  The hydrocele  is punctured Avith an
ordinary trocar  and about one-third of the fluid is alloAved to Aoav
aAvay; then about a drachm of a  one per cent. Avatery solution of
cocaine is  injected through  the canula  into  the remaining  serous
effusion.  The scrotum  is gently manipulated, and after Avaiting four
or five  minutes the remainder of  the serous fluid, Avith the cocaine,
is drawn off.  The tincture of iodine is  then injected ; after four or
five minutes it is allowed to escape.  The operation thus performed
is painless, but uncertain in its results.
   The injection operation sometimes fails.  Failure may be due—
   (1) To an insufficient quantity of the irritant;  (2) to too great dilu-
tion of the  irritant incident to  imperfect emptying of the  hydrocele
sac; (3) to neglect in so  rubbing and manipulating the scrotum that
the injected fluid penetrates all parts of the serous sac ; (4) to such a
thickening of the tunica  vaginalis that complete  collapse of the sac is
impossible.
   The method of injection is not applicable in cases of congenital,
bilocular, multilocular, or encysted hydrocele.
   Incision and Drainage.—This method consists in opening the sac
by a free vertical incision.  All the preparations for a formal  opera-
tion are made, and the patient is given a local or  a general anaesthetic.
General anaesthesia is not absolutely necessary.   Percutaneous infil-
tration Avith Schleich's stronger solution or the one per cent, solution
of cocaine will render the skin incision painless.   The injection should
be driven along the entire line of the incision, and should infiltrate the
skin and deeper connective tissue.   The parietal layer of the vaginal
tunic  is not sensitive.  The visceral layer is usually acutely sensitive,
the application of the finger or even of a smooth pair of  forceps to
this  surface  producing  the peculiar sickening  testicular pain. An
incision tAvo or three  inches  in length is made through the  tissues
of the scrotum  along the anterior and lower portion of the SAvelling,
and is deepened  until it  enters the tunica vaginalis.  The margins
of this tunic  are  stitched to  the skin Avound  by a continuous catgut
suture, the  entire serous surface is swabbed Avith pure carbolic acid
or iodine tincture, and two large drainage-tubes are  introduced, one
carried  to the top and the other to the bottom of the sac.   Or these
may be substituted by gauze packing, in Avhich  case the dressing is
renewed at intervals  of from  three  to five  days.  The  wound is
dressed with an abundance of antiseptic gauze and cotton secured in
place by the crossed of the perineum.   The dressing is repeated daily, 
CHRONIC HYDROCELE.
919
the sac being  Avashed  out Avith a  mild  sublimate solution,—1  to
3000,—and the drainage-tubes shortened as rapidly as possible.   The
stitches are taken out at the end of the first week.   This operation is
indicated—(1) Avhen injection has failed to cure:  (2) Avhen the  sac is
obviously so thickened that injection gives little promise of cure; (3)
in congenital hernias.
   A modification of the incision and drainage method is  thus  prac-
tised by Buschke.   The sac is punctured in its loAver portion Avith a
trocar and canula, and the contained fluid is  evacuated.  The  sac is
then Avashed  out Avith a three to five  per cent, solution  of  carbolic
acid, and the trocar is reintroduced into the canula, and driven through
the sac, its point coming out at its upper portion.   The trocar is then
withdraAvn, and through  the  canula is  passed a drainage-tube Avith
two or three lateral  openings.  The  canula is taken out, leaving  the
drainage-tube  in place.   This alloAvs the  inflammatory secretion to
escape Avithout accumulation  into an abundant aseptic dressing.  No
anaesthetic is required.  The drainage-tube is removed on the fourth
to the  sixth day, and a sterile dressing is applied  and  left in  place
until cicatrization is complete.  This requires from eight to ten days.
This operation  is said to be especially applicable to simple hydrocele
in children.
   Excision.—Excision of the parietal layer of the tunica  vaginalis is
performed by dissecting this tunic from the tissues of the scrotum and
cutting it aAvay, leaving only sufficient to serve  as a normal  covering
for the testicle, or even less than this.
   The field of operation  is prepared in accordance with general sur-
gical principles.   The sac is made tense by an assistant, and the scro-
tal covering is  divided by a vertical  cut running from the top to  the
bottom of the tumor.  After complete haemostasis the vaginal tunic is
incised sufficiently to admit a finger, and the condition  and  position
of the testicle are clearly  defined.  The remainder of the  sac is then
split up Avith a blunt pair of scissors, and  the tunica vaginalis is dis-
sected from the scrotum.   This can  usually be accomplished by rough
sponging, and tearing Avith the fingers, or by the use of the blunt dis-
sector.   The  bleeding points should be picked up Avith haemostatic
forceps, which should be left on until  the  operation is  completed.
When the parietal layer has been dissected free  it should be cut away
from the testicle  and epididymis as closely as possible.  Cysts or
fibrous bodies attached  to the visceral  portion of the sac should be
removed.  The Avound should be closed Avithout drainage.
   This operation may be variously  modified.  Enough of the vaginal
tunic may be left to cover the testicle;  the edges of the  vaginal tunic 
920        GENITO-URINARY DISEASES AND  SYPHILIS.

may be sutured to the borders of the skin wound and gauze drainage
may be employed; or the vaginal surfaces  may be touched with car-
bolic acid or silver nitrate and drained through the  loAver part of the
Avound.
   The  external  dressing  should  be  antiseptic  and   compressing
(crossed of the perineum), and great care should be taken to prevent
infection from soiling of the dressing Avith urine  or faeces.  Sutures are
removed on the third to the fifth day.  Packing is replaced at this
time, but very little gauze is used.   Drainage is dispensed with alto-
gether in from  seven to ten  days.   The  main complication of this
operation is  suppuration, which is  avoidable.  It  is indicated  Avhen
incision and drainage fail,  and primarily when the Avails of the  sac
are thick and degenerated.
   Zancarol  has operated  upon fifty-eight  patients Avithout a single
failure by making a long incision, excising a  large portion of the vagi-
nal tunic and  suturing without drainage.   Augagneur  reports sixty
completely successful cases.
    Choice of Operation.—Injection  is successful  in the great ma-
jority of simple cases, and  possesses  the advantages that it requires
no anaesthetic, that after-treatment  of an open wound  is not neces-
sary, and that the convalescence is comparatively sure.
   Antiseptic incision  should  be selected  (1) in cases of  previous
failure Avith  iodine;  (2) Avhere the sac is very large and has thick
walls ; (3) where, because of ill health or lessened resistance, the risk
of inflammation  after iodine is injected  is  especially to be dreaded ;
(4) in cases of congenital hydrocele ; (5) Avhere the surgeon is desirous
of exploring the testicle, as, for instance, Avhen, in addition to  the
hydrocele, there is testicular enlargement  of doubtful nature; (6)
Avhen  the  hydrocele is bilocular,  multilocular, or  encysted; (7) in
some cases  of  hydrocele complicated Avith hernia,—i.e., Avhen  the
bowel is irreducible, and from the lessened resistance of the patient's
tissues  there is a risk of  the inflammation set  up by the iodine ex-
tending to the hernial sac.
   Exceptionally the scrotal hydrocele is bilocular,—that is, there are
tAvo  distinct cavities  filled Avith fluid  and communicating Avith  each
other by a comparatively narroAv opening.   One variety of this bilocu-
lar formation is described by Curling.  It  is due to the distention of
the visceral portion of the vaginal tunic passing betAveen the  body of
the testis and the epididymis.  Normally, in this position there is a
pouch, which, under tension, may extend, forming  a  tumor, to the
inner side of the testis; the  opening into  this accumulation is  from
the outer side.   Beraud has described two cases of diverticular devel- 
                     CHRONIC  HYDROCELE.                   921

opment (Fig. 230) due to the lessened  resistance of a certain portion
of the parietal vaginal tunic, Avhich, yielding to the pressure  of effu-
sion, forms a distinct pouch.
   There  is a perineal form of bilocular hydrocele dependent upon
trauma,  causing  rupture  of a pre-existing hydrocele and an  effusion
of the contents into the perineum.  This effusion becomes encapsu-
                              Fig. 230.
    Bilocular hydrocele.  (B6raud.) H, testicle; N.li, epididymis; S, vas; T.v, cavity of the tunica
 vaginalis; D, cavity of the diverticulum ; T.c, tunica vaginalis communis ; Z, cellular tissue between
 the tunica propria and the tunica communis.  (Kocher.)

 lated.  These bilocular hydroceles are  usually translucent, but may
 reveal on examination  tAvo distinct sacs,  Avhich  may  be showrn  by
 alternate pressure to communicate Avith each other.
»    Multilocular hydrocele of the testicle may be hereditary or may be
 due to inflammatory adhesions, Avhich by causing agglutination be-
 tween the folds of the vaginal  tunic, but Avithout obliterating it,  leave
 a number of caArities into which serum can be  exuded.   On palpation
 the tumor will be found someAvhat irregular in  outline, and aspiration
 will evacuate only a small portion of its contents, not materially dimin-
 ishing the tension of the rest of the tumor.
    Excision of the sac  is the  only means  of treatment  applicable to
 this form of hydrocele.
    Congenital Hydrocele.—This  form  of  hydrocele  depends for
 its existence  upon the maintenance of a communication between the
 tunica vaginalis and the abdominal cavity.   The funicular portion of
the tunic does not become obliterated.  The fluid may come from the 
922        GENITO-URINARY DISEASES  AND SYPHILIS.

general abdominal  cavity or may be exuded  from the vaginal tunic.
It may develop in early infancy  or not until later life.
   Symptoms.—When  the vaginal tunic forms a pouch which opens
into the general peritoneal cavity and there is serous effusion into this
pouch, there will  be the  customary symptoms of hydrocele, obscured
only by the facts  that  on recumbency the tumor disappears, to reap-
                            pear Avhen the patient assumes the erect
                            position,  that there is distinct impulse
                            on  coughing, and  that  by  bimanual
                            pressure the tumor can be partially re-
                            duced into the abdominal  cavity.  After
                            the  tumor has  disappeared on recum-
                            bency, even though gentle pressure be
                            maintained  on  the  external ring there
                            will be reaccumulation on rising.  This
                            form of hydrocele is occasionally com-
                            plicated by  congenital hernia (Fig. 231),
                            though the  opening into  the abdominal
                            cavity is  usually too small to alloAv the
   congenital hydrocele with hernia.   intestine or  omentum to pass through it.
                                This form of hydrocele is compara-
tively rare.  Though we have  frequently seen children  exhibiting a
hydrocele Avhich their mothers  stated grew much smaller during the
night, Ave have observed very few cases in Avhich the tumor could be
made to disappear  during an examination.
    Diagnosis.—Hydrocele in children is so extremely translucent that
this characteristic of the growth  can  often be  perceived by daylight
through the thin tissues of the  scrotum.  The only  affection  with
which congenital hydrocele is likely  to be  confounded is hernia.  Both
tumors give impulse on  coughing,  and are reducible.  The hernia,
hoAvever, is often resonant  on percussion, goes back suddenly with a
distinct " flop," and will  not return if light pressure is maintained  over
the external ring;  or, should it overcome this pressure, the omentum
or gut Avill  be felt to slide beneath the finger.  The hydrocele is dull
on  percussion, is reduced rather gradually Avithout a distinct " flop,"
and returns Avhen the patient is in the erect position, even though light
pressure  be maintained over the external  ring, the swelling forming
gradually at the bottom  of  the  scrotum, and Avithout the sensation of
a body sliding beneath the  finger.
    Prognosis.—This is good, as these hydroceles commonly disappear
spontaneously with obliteration of  the funicular portion of the  vagi-
nal tunic.
 
CHRONIC HYDROCELE.
923
   Treatment.—The obliteration of the vaginal tunic is favored by the
application of a truss, Avhich may be required for the treatment of the
coexistent hernia.  In case  the truss is not successful  the fluid should
be aspirated.   Should it reaccumulate, permanent drainage is secured
by means of a seton or a small drainage-tube passed through and
through the  sac.   The  scrotum is then  enveloped in sterile gauze
generously applied, and this dressing is frequently, changed  being
protected from contamination with urine and faeces by an outer invest-
ment of rubber or oiled silk.  Since the tunica vaginalis communicates
directly with the peritoneal cavity, the importance of absolute  clean-
liness in operating on  congenital hydrocele is  evident.   We have
knoAvn of one death from peritonitis following the careless application
of a seton.
   The best operation, and one Avhich should be folloAved, as a rule,
when the consent of the parents can be obtained, is that of antiseptic
incision with the performance of a radical operation  for the cure of
any hernia that may be  present, and closure of the  abdominal ring in
any case.  The patient  is prepared as for the operation for  hernia,
and an incision similar to that for  a radical cure  is made.  The
funiculo-vaginal process, being identified, is  carefully separated from
the surrounding tissues and  from the cord,  divided a short distance
above the testis, and converted into a tunica vaginalis.  The remain-
ing portion  separated  from  the  surrounding  structures is  treated
as the  sac of  a  hernia, and radical   cure is performed  by Bassini's
method.
   Infantile Hydrocele.—This is an effusion into a sac formed by
more or  less of the unobliterated funicular portion of the vaginal
tunic.  This sac is closed from the peritoneal cavity above, and com-
municates Avith the tunica vaginalis testis beloAV.
   Symptoms.—The symptoms are those of  hydrocele extending Avell
up along the cord.  The tumor shoAvs no change in tension on recum-
bency.
   Treatment—Simple evacuation Avith the  finest needle of the aspi-
rator may be  folloAved  by cure,  since there is a  natural  tendency
toAvards obliteration of the sac on evacuation of its  contents.
   Should this be unsuccessful, the  use of iodine injections may be
tried.  The fluid  should  be  draAvn off with a large hypodermic needle,
and from one-half to one drachm of  official  iodine tincture injected;
this should be gently diffused  through the sac, and then, for fear of
too extensive inflammation, should be withdrawn.
   The insertion of a seton or of a small drainage-tube, indeed, any
of the well-recognized forms of treatment, will give satisfactory results. 
924       GENITO-URINARY  DISEASES AND SYPHILIS.

    Jacobson advises, as a rule, acupuncture.   The SAvelling is made
tense, and half a dozen punctures are made into the front and lower
surfaces with an ordinary surgical needle, Avhich should be  slightly
rotated before it is withdrawn.  Jets  of fluid follow each puncture;
there is a good deal of oozing, as Avell as some escape of fluid into the
cellular tissues  of the scrotum.   Dilute lead Avater is subsequently
applied, and the parts are supported.
    Bilocular Hydrocele.—This is a comparatively rare form of in-
fantile hydrocele.   The  funicular portion of the tunica vaginalis is
commonly obliterated at the  internal  ring.   BeloAV this  the  Avhole
tunica vaginalis may be patulous, or it may be closed just  above the
position of the testis.   As the fluid accumulates, sacculation develops,
the tumor extending either backAvard and downward into the pelvis,
or  more  commonly  upward  and imvard betAveen the abdominal
muscles and the peritoneum.
    Symptoms.—In addition to the ordinary symptoms of hydrocele—
i.e., fluctuation, dulness on percussion, translucency, and smooth sur-
face—there will  be found a constriction separating the tumor into hvo
portions.  Alternate pressure will shoAv that the fluid in these portions
intercommunicates, and  exceptionally, AAdien tension is not great, the
opening of communication may be distinctly felt.   It is usually placed
at the external ring.  The scrotal tumor is smaller than that formed
in the abdominal parietes.   There is distinct impulse  on coughing.
The forms of bilocular  hydrocele of the tunica vaginalis  testis  have
been described.
    Treatment.—Bilocular hydrocele is best treated  by incision, Avith
removal of the sac, or as much of it as is accessible.  Care  should
be taken to avoid opening the general peritoneal cavity.
    Inguinal Hydrocele.—The hydrocele Avhich forms in the vagi-
nal tunic of the undescended testicle may be of  the ordinary A^ariety
or may be congenital, communication persisting betAveen the vaginal
tunic  and the general peritoneal cavity.   We have  seen it distinctly
bilocular,  one pouch passing upAvard for three  inches betAveen the
peritoneum and  the transversalis fascia, the second  pouch extending
through the external ring and forming a tumor in the scrotum.
    Symptoms.—The  symptoms are those already given as character-
istic of hydrocele, except that  the  tumor is formed in the inguinal
region.
    Treatment.—Since it  is very difficult  to exclude  the  presence of
hernia, inguinal hydrocele should  be treated by open  incision, the
sac being partly or  completely removed and drainage  established.
When the testis is AA^asted the appropriate operation is castration. 
CHRONIC HYDROCELE.
925
   Fatty Hydrocele.—This has been variously described as chylous
or milky  hydrocele, and is  the  name given to a collection of fluid
resembling milk or chyle in the tunica  vaginalis testis.  It may be
produced by  lymphorrhagia folloAving an actual rupture of  the lym-
phatic channels  or by leakage  of  lymph  through the walls  of the
vessels.   This latter method is the more common, and is dependent
upon obstruction to the  return of the lymph, either by an inflamma-
tory process or by  the presence of filariae.
   It has been maintained  that the presence of fat is due to degen-
erative  changes occurring in a simple hydrocele.   Whatever the cau-
sation, the density  of the contained fluid renders diagnosis difficult,
since the important sign, translucency, is lacking.  The other symp-
toms of hydrocele, hoAvever, are present.  If  the effusion  is double
and the patient is an inhabitant of a tropical climate, an examination
for filariae should be made.
   Treatment.—Incision Avith partial excision of  the  sac  is the best
method of treating this variety of hydrocele.
   Encysted Hydrocele  of the Epididymis  and Testis.—In
this affection  the fluid is contained in distinct cysts, which  may or
may not project into the  cavity of the vaginal tunic ;  this tunic, or at
least its  parietal layer, does not form the walls of the cysts.   These
cysts may originate in the epididymis, in fcetal  structures lying near
by, or in the testicle.  (Fig. 232.)  They may  contain a milky fluid,

                             Fig. 232.
Intravaginal spermatocele. (Hochenegg.)
which under  the microscope is  found to be filled with spermatozoa
(this is particularly true of the larger cysts), or their contents may be
perfectly translucent, but  differing markedly from hydrocele in com-
position, since they contain little or no albumen. 
926        GENITO-URINARY DISEASES  AND SYPHILIS.

   Encysted Hydrocele of the Epididymis.—These cysts may be small
or large; the  small  cysts  are  usually multiple, and, according  to
Gosselin, develop in the  majority of testes after middle  life.  They
may be very minute  or as large  as a pea,  and are sometimes pe-
dunculated.  They are easily shelled out from the surrounding tissue.
Exceptionally  they contain spermatozoa.  They are placed  both on
the surface and  in the parenchyma of the epididymis.  They may
develop from  the remnants of foetal structure; more probably they
are involution  cysts, originating in  the tissue of the epididymis, but
becoming subserous.
   The large  cysts are parenchymatous, arising beneath the  outer
covering of  the epididymis and close to its upper part, or between it
and the upper part of the  testicle.   (Fig. 233.)  They lie outside of
the visceral layer of the vaginal tunic, pushing  this upAvard  as  they
become distended, and are in close contact with the seminal ducts.
They are usually single, but may be multiple or multilocular. Com-
monly the fluid  is milky from  the  spermatozoa Avhich it contains,
though it may be  limpid.  These cysts may arise either from retention
cysts  or  from the development of the  fcetal remains.  Spermatozoa
may find their entrance into them through  minute openings, difficult
to recognize at any time,  and  capable of closing long before  the cyst
is examined.  They rarely attain great  dimensions, containing on an
average not more than tAvo or three ounces of fluid.  Exceptionally
they may form large tumors.  (Fig.  234.)  They are not confined to
old age, developing at any time after full sexual maturity.
   Morris states that the  cyst  may originate " as a retention cyst due
to dilatation of a seminal  tube, OAving to some obstruction in the vas
deferens  or other part of the excretory passages  (Liston, Luschka,
and others); or as a neAv  formation  in the connective tissue betAveen
the tubes of  the epididymis  subsequent  upon  the rupture of a
seminal tubule and the escape of  some drops of seminal  fluid.   The
opening  in  the  duct  may afterwards cicatrize, so that there  need
not persist a communication betAveen the duct  and the  neAV-formed
cyst.
   " The cyst may be  formed originally in the  connective tissue, and
by gradually enlarging  may cause subsequently the rupture of a sem-
inal tubule, and thus the entrance into the cyst of spermatozoa.  (Cur-
ling.)   The cysts may  arise from the distention of certain fcetal relics
which exist in the neighborhood of the  epididymis, especially  near
the globus major.
   " The foetal structures  from which cysts of the epididymis originate
are—(1)  The paradidymis, or organ of Giraldes, a minute body, the 
CHRONIC HYDROCELE.
927
remnant of the mesonephros or  glandular portion of the Wolffian
body.   This is situated in front of the loAver part of the vas and>above
the head of the epididymis and  behind the upper part of  the tunica
vaginalis.  Cysts having this  origin are situated above the testis and
epididymis, and extend sometimes a little Avay along the cord.  They
correspond to paroophoritic  cysts in  the female.   (2) The ducts of
Fig. 233.                        Fig. 234.
Encysted hydrocele (large cysts).        Multilocular cyst of the epididymis.  T, tes-
                            ticle ;  E, epididymis displaced by the  cyst.
                            (Monod and Terrillon.)
Kobelt. Avhich are  remnants of the tubules of the Wolffian body, sit-
uated in  the  globus major.   (3) The vestiges of the  duct of Miiller,
part of which is represented by the hydatid of Morgagni, and another
part  of  the duct,  can sometimes be  traced  from  the globus major
down to  the  globus minor, along the body of the epididymis in the
digital pouch.   Cysts derived from these sources are situated betAveen
the epididymis and testis,  most frequently between the globus major
and the upper end of the testis.   The cysts which  are derived  from 
928        GENITO-URINARY  DISEASES AND SYPHILIS.

the vasa efferentia and other remnants of the Wolffian tubules  are
homologous with parovarian cysts in the female.   (4) The vas  aber-
rans of Haller, which is a diverticulum of, or a convoluted ciecal tube
opening into, the vas deferens  close to the lower end of the epididy-
mis ; this also is a part of the remains of one of the tubes of the Wolff-
ian body still in connection with the representative of the excretory
duct of that body,—namely, the vas deferens."
   Encysted Hydrocele of the Testis.—In  this affection  the cyst
grows in front of the gland betAveen the tunica albuginea of the testis
and  the testicular portion of  the  tunica  vaginalis.  It  is usually of
small size, and from  intracystic tension feels like a hard body.
   Symptoms of Encysted Hydrocele.—Symptoms  are  slow in devel-
oping,  though exceptionally, from traumatic  rupture of a cyst into
the cavity of the vaginal tunic, there  may be SAvelling and pain  char-
acteristic of acute hydrocele.   Small cysts, particularly those of  the
epididymis,  are recognized Avith difficulty even  after careful palpation.
As they increase in size they form distinct fluctuating tumors, Avhich,
if the fluid is clear, will give the test of transmitted light.  These cysts
have often been mistaken for supernumerary testicles, or, because of
tension and consequent  hardness, for  tubercular infiltration of  the
epididymis.   They seldom reach large size.
   Diagnosis is  founded upon translucency Avhen the fluid contained
in the  cyst is limpid.  Thrill, fluctuation, Avant of density and resist-
ance, and   slowness in development  distinguish these  cysts  from
ordinary sarcoceles.   In shape they are globular when  small, but if
large and multilocular the shape varies greatly.   By transmitted light
the testicle  is usually seen  lying below and  in  front of the tumor,
although it  may be  to one or the other side, more frequently  the
inner.  On palpation it is often possible to  determine that the enlarge-
ment is absolutely limited to  the upper portion of the testis and epi-
didymis, and has a tendency  to extend upAvard  along the cord, the
testis proper being perfectly normal and the tunica vaginalis contain-
ing no fluid.  At times exploratory puncture with a hypodermic needle
will be necessary before diagnosis can be established.
    Treatment—Encysted hydrocele grows so  sloAvly and causes so
few symptoms that intervention is often not necessary.   EAracuation
by means of an  aspirator or a small trocar and  canula may be  fol-
lowed by cure.   If this fails, iodine may be injected, as described in
the treatment of hydrocele, or the scrotum may  be  opened and  the
cyst dissected out.   The operation of excision is particularly indicated
Avhen the cysts are multiple or  multilocular.  When complete excision
is impossible without extensively injuring the structure of the testicle 
HYDROCELE OF  THE CORD.
929
or epididymis, the cyst-wall should be removed as thoroughly as pos-
sible, and  the remaining portion  should be cauterized with carbolic
acid.
                    HYDROCELE OF THE CORD.
   Hydrocele of the spermatic cord may be classified as—1, acute hy-
drocele ; 2, diffuse hydrocele, in reality a form of oedema; 3, encysted
hydrocele.
   Acute Hydrocele of the Cord.—This is a rare condition, seen
most frequently in young subjects after strain.  A translucent swelling
forms, containing  fluid resembling that of ordinary hydrocele.  The
effusion is limited by the investment of the cord, and is rather an acute
cedema into loose cellular tissue than an  effusion of fluid into a sac.
   Molliere holds that this acute  cedema is due to rheumatismal funic-
ulitis.  The affection develops with local inflammatory phenomena,
but without much pain.
   It may simulate an  incarcerated hernia, but may be distinguished
by its translucency, and by dulness on  percussion and absence  of
abdominal  symptoms.   The SAvelling may involve the entire cord,
transforming it into a soft sausage-shaped mass.
   Treatment.—Compresses Avet in dilute lead  Avater and alcohol and
held in place by a crossed of the perineum gauze bandage will limit
the swelling.
   Diffuse Hydrocele of the Cord.—This  is  a  general infiltration
into the cellular tissue enclosed by the fascia which invests  the cord.
The tunica vaginalis is  not affected; indeed, the funicular  portion of
this tunic is usually completely obliterated.  The etiology is obscure,
but is probably dependent on passive  exudation from the veins and
lymphatics  of the cord  due  to pressure  interference Avith return  cir-
culation.   It is  not associated with general cedema of the  penis and
scrotum, since the fibrous tunic  of the  cord  entirely separates this
structure from  the cellular tissue lying beneath the deep layer of the
superficial fascia.
   Symptoms.—The tumor forms gradually, with very feAv symptoms.
It may involve the entire  length  of the cord,  reaching from the tes-
ticle to the internal  ring and filling the inguinal  canal.  It  is broader
in its loAver portion, and may cover the upper portion of the testis and
epididymis  as a cap.   On placing the patient on  his  back and ele-
vating the  testicle the swelling gradually diminishes, but does not dis-
appear entirely.   On gentle continued pressure deep pitting may be
detected.   The  infiltration is painless unless  it be a  sequel of acute
inflammation, is doughy rather than fluctuating, and gives the test  of
translucency. 
930        GENITO-URINARY DISEASES  AND SYPHILIS.
Fig. 235.
   The differential  diagnosis must be  made from omental hernia.
This gives a more distinct impulse on coughing, is not so smooth, can
be reduced suddenly and completely, and is very feebly translucent.
In irreducible omental hernias of fat people a pre-operative diagnosis
may be impossible.
   Treatment.—When the infiltration produces a tumor of such size
as to cause inconvenience  from its bulk, incision and  drainage are
indicated.
   Encysted hydrocele of the cord, or funicular hydrocele, con-
sists of an accumulation of fluid Avithin  an  unobliterated portion of
                          the funicular portion of the tunica vagi-
                          nalis.  This  accumulation  is closed from
                          the peritoneal  cavity above and from the
                          tunica vaginalis testis below.   The hydro-
                          cele may be unilocular, bilocular, or multi-
                          locular, in the latter case forming a series
                          of small cysts along the course of the cord.
                          These cysts may be placed in the inguinal
                          canal, and are more common on the right
                          side.  They are usually observed in chil-
                          dren, and may be complicated by hernia.
                          (Fig. 235.)
                             Symptoms.—A  smooth,  dense,  ovoid,
                          fluctuating SAvelling is formed  in some por-
                          tion  of  the   spermatic  cord.   By  trans-
mitted light the tumor is found to be translucent, and the testicle can
usually be recognized beloAV it.
   Diagnosis.—This is based  on the position  of the cyst or cysts.
Encysted  hydrocele  of the  testicle, though sometimes extending up-
ward along the cord,  is attached to the testis  and the epididymis.
In hydrocele of the  cord  palpation will  shoAv that the tumor  is not
directly connected with the testicle.  Hydrocele  of the cord is  dis-
tinguished from hernia by absence of impulse on  coughing, inability
to reduce  the tumor entirely Avithin the abdominal cavity, though it is
often easily pressed back into the inguinal canal, and absence of tym-
pany and  gurgling.   The hernia is not translucent.
   Treatment.—In children spontaneous cure may occur.  Incision
followed by drainage is probably the safest method of  treatment, and
the one most certain to effect cure.  Multiple puncture is also efficient.
In elderly people, where radical measures are  not desired, repeated
tappings Avill be necessary to afford relief.
   Hydrocele into a Hernial Sac—An effusion of  serum which
Inguinal hernia, with hydrocele ol
     the cord. (Kocher.) 
HEMATOCELE.
931
may closely simulate hydrocele may take place into the sac of an in-
guinal or a scrotal hernia.  This sac may have become obliterated from
the general peritoneal cavity and contain only fluid, or it may contain
in addition to the fluid a portion of gut or omentum, the hernia being
incarcerated.   There is always more or less effusion in combination
with incarcerated hernia, and the sac not infrequently becomes thick-
ened and fibrous, closely resembling the investment of chronic hydro-
cele or a haematocele.  The symptoms are those of a hernia followed
by the development of a  fluctuating, probably  translucent tumor.
When the sac  contains both fluid and intestinal contents, tenderness
and possibly resonance  in the inguinal region may lead to a correct
diagnosis.   Frequently the diagnosis is made only after incision.
    Treatment.—Excision of the sac  and  an operation for the radical
cure of the hernia constitute the only  practicable treatment.

                          HEMATOCELE.
    Haematocele is a collection of blood or bloody fluid in  the vaginal
tunic of the testicle  or  cord or in  the substance of either of these
structures.  As is the case with hydrocele,  the effusion may be acute
or chronic.
    Haematocele of the Tunica Vaginalis.—This affection as com-
pared with hydrocele is  very rare.   It may develop in the acute form
as a result of punctured wound or rupture of the testis, or may be
caused by a blow or  by violent muscular strain.  Svalin noted blood
effusion into the  tunica  vaginalis and  the scrotal  tissues after severe
coughing.   There may be  bleeding into a previously healthy tunica
vaginalis;  commonly  it  is into a previously inflamed sac, and often
it occurs as a  complication of hydrocele.   It may be complicated by
scrotal haematoma.
    The development of acute haematocele (haematoma) is characterized
by severe  pain, which may be sickening in character, and the rapid
formation of a tumor.
    This tumor completely envelops the testicle, and  closely corre-
sponds to it in shape.
   The  blood  may coagulate or remain fluid.   The  tumor never
reaches  large  dimensions, since it  forms so  rapidly that  the  tunica
vaginalis ruptures, thus allowing the blood to  escape into the scrotal
tissues.
   Symptoms.— The distention of the vaginal tunic is usually obscured
by the concomitant scrotal blood effusion.  After  this has been  ab-
sorbed there may be  found a fluctuating tumor impervious to light
and giving on exploratory puncture blood or blood-stained fluid. 
932        GENITO-URINARY  DISEASES AND  SYPHILIS.

   Exceptionally complete resolution takes place.  Usually the tunica
vaginalis undergoes the alterations characteristic of chronic hydrocele.
   Treatment.—Acute haematocele incident to  trauma is treated by
rest, elevation of the parts, and the application  of evaporating lotions
or the ice-bag.   If the  swelling is rapid and progressive,  clots should
be evacuated through an incision, followed by search for  the bleeding
vessel.  The scrotal infiltration is quickly absorbed.   If on its disap-
pearance the vaginal tunic is found distended, its contents should be
evacuated through a free incision, since otherwise the  tunica vaginalis
becomes chronically inflamed and a chronic haematocele may form.
   Chronic Heematocele of the  Tunica Vaginalis.—This affec-
tion  is dependent upon chronic inflammation of the tunica vaginalis,
and  is properly  called peri-orchitis haemorrhagica or haemorrhagic
vaginalitis.  The blood effusion is simply a symptom of such inflam-
mation, Avhich, in turn, is generally regarded as secondary to disease
of the epididymis or of the testis.
   Gosselin recognizes three degrees of haematocele, basing his classi-
fication upon the extent of  lesion which  the walls of the sac show.
The  first degree  is characterized by moderate thickening, the vaginal
tunic being but  little altered  beyond some increase in vascularity.
There is a deposit of thin, non-adherent false membrane.  On evacua-
tion  of its contents the sac will collapse.   The second degree is char-
acterized by increased thickness  of both the vaginal tunic and the
false membranes, but the walls are too rigid to collapse on evacuation
of the contents of the sac.   The condition is progressive.
   The third degree is characterized by still greater thickening and
rigidity.  Areas  of cartilaginous  and calcareous transformation are
observed.  Barigandin described a case of ossification of the tunica
vaginalis.   In the thickened walls are often found foci of soft granula-
tion-tissue or interstitial hemorrhages.   The false  membrane, at first
deposited in a  thin  layer and extremely vascular, ultimately has its
blood-supply greatly diminished or entirely cut off by  organization
and contraction of the inflammatory infiltrate, and it is  likely to slough.
In old cases it is  so intimately connected with the tunica  propria that
it is impossible to strip it from the latter.
   The thickened sac  is made  up partly of fibrinous deposits and
partly by organization of  the infiltrate  into the subserous connective
tissue.
   On incising a haematocele blood more  or  less altered  or blood
mingled with the fluid of the  hydrocele is found.   In old cases the
blood is altered  both in color  and in consistence.   It  may form  a
chocolate-colored or black syrupy, or even a gelatinous mass.  When 
HEMATOCELE.
933
the bleeding is into the sac of a hydrocele the fluid is clear red and
contains clots.
   In recent cases—i.e., those  in which the sac is not greatly thick-
ened—the testicle may not be appreciably altered, even though  the
tumor is of great size.   As induration and thickening, in consequence
of subserous infiltration and organization,  take  place, the  albuginea
becomes involved, together Avith its  fibrous trabeculae, and there  re-
sults an atrophy  of  the tubules with fatty degeneration of their epi-
thelium.   In the   large,  greatly thickened,  degenerated sacs careful
search may fail to  discover even a trace of the testis.
   The  testicle usually  lies in the loAver  posterior portion of  the
tumor.  In  the early stages of development, before  the gland  has
atrophied, palpation, eliciting testicular sensation, Avill probably enable
the surgeon to determine  its exact position.  In the late  stages of
haematocele Avhere the sac is greatly thickened it may be impossible to
determine whether the testicle  lies in front of or behind the swelling.
In such a  case operation should  be conducted with  great  care,  the
tissues being examined before they are cut.
   Chronic  haematocele is of slow  formation, and  is most common
between  the fortieth and  the sixtieth  year of age.   It  may  grow
steadily, or may rapidly increase in size after brief intervals  of quies-
cence. The tumor is hard, painless, ovoid or pyriform in shape, Avith
smooth  or bosselated surface, showing at times spots of  softening
and possibly dense areas of calcareous degeneration.
   Diagnosis.—This is  founded  on the  smooth bossed  surface,  the
rounded or oval shape,  the tense, elastic feel, the varying consistence,
and the absence in any portion of the tumor of either a projection or
a depression  corresponding to  the position of the testicle or the epi-
didymis.   There  is  usually  a  history of traumatism,  strain, or pre-
existing  hydrocele.  The general  groAvth of the tumor  is  slow, but
it exhibits  irregularly  recurring  periods of rapid  increase in size,
attended by pain,  heat,  and swelling.  These sudden  increments  are
due to fresh hemorrhages into the sac.  The tumor is not translucent.
The final diagnosis depends upon aspiration.   For the purpose of thus
confirming the  diagnosis a needle  longer than that  employed in the
ordinary  hypodermic syringe  is required, and  it  must  be remem-
bered that the contents of the sac will  not necessarily be  obviously
bloody.
   Omental hernia  may strongly resemble a chronic  haematocele.
The latter, however, begins within the scrotum, gives no history of
having been reducible at any period of its development,  and usually
involves only the lower portion of the cord, the inguinal canal remain- 
934       GENITO-URINARY  DISEASES AND SYPHILIS.

ing free.  Unless the haematocele extends Avell up into the inguinal
canal there will be no impulse  on coughing.
    The distinction from hydrocele is dependent upon absence of dis-
tinct thrill and fluctuation, failure to detect  translucency, and  finally
the result of exploratory tapping or incision.  Diagnosis from chronic
orchitis or malignant growths may be  absolutely impossible, except
from the history.   In case of doubt there should be no hesitation in
deciding the matter by an aseptic incision.
    Prognosis.—There is no tendency towards spontaneous cure.   The
disease may,  however, become  self-limited.  It  usually progresses,
forming ultimately a large tumor, which  inconveniences  mainly by its
bulk and by the pain and disability dependent upon the intercurrent
attacks of acute inflammation.   Even  though the  patient experiences
no mechanical inconvenience  from the  groAvth, it inevitably destroys
the secreting  function of  the testicle and predisposes to suppuration
and to malignant  degeneration.  Suppuration may follow the use of
an apparently clean trocar, since the conditions are exceedingly favor-
able to germ-growth.   At times  it occurs from haematogenous infec-
tion, the predisposing cause being trauma.   The haematocele and the
scrotum of the affected side become oedematous and painful, the symp-
toms of  constitutional infection  develop, and softening takes  place,
folloAved by grumous discharge.  Some  cases of malignant degenera-
tion of haematocele  have  been  recorded.   It is  probable, however,
that in  these  the  haematocele  complicated cancer and  developed
secondarily.
    Treatment.—Chronic  haematocele  should be  treated by incision
and curetting, decortication, or castration.  Tapping and injection of
iodine, and even simple incision, operations usually curative in the
case of hydrocele, are insufficient.
    Incision followed by curetting is the simplest and most easily per-
formed of the radical operations, and is  successful Avhen the walls of
the sac have not become extensively infiltrated and rigid.  The cavity
of the cyst is opened by a free incision,  Avhich, unless the position of
the testicle has been determined previously, is  deepened with the
utmost precaution.   The contents of the sac are Avashed out, and the
whole interior is scraped smooth Avith a sharp curette.  So much of
the outer Avail of the vaginal tunic as can be easily freed is cut away,
and the  remaining portion is  sewed to  the skin.   The cavity is then
loosely packed with  iodoform gauze, and is allowed to heal by granu-
lation.
    When, because of great thickening and rigidity, with cartilaginous
or calcareous deposits, it is evidently impossible for the walls of the sac 
HEMATOCELE.
935
to come together and become obliterated, or even to produce healthy
granulations, decortication is indicated.   This is practised by opening
the tunica vaginalis and tearing and dissecting away from it the thick
layers of false membrane by means of the finger or by rough sponging;
more often the knife or scissors are required.   When the false mem-
brane has been reflected as closely as possible  to the testis and  cord
without wounding these  structures, it is cut away, the edges of the
vaginal tunic are sutured  to the skin, and the Avound is lightly packed.
   Castration  is indicated in long-standing haematoceles in old  sub-
 jects when there is reason to believe that the testicle is partially or
completely atrophied and the patient is  not in a condition  to stand a
prolonged operation.
   Encysted Haematocele of the Testis.—This is an  extravasa-
tion of blood into an encysted hydrocele.  The symptoms  are those
of sudden increase of a pre-existing encysted hydrocele, with inflam-
matory phenomena.   The tumor fluctuates at first, but is  not trans-
lucent.
   Treatment.—Either total  excision of the sac or castration is indi-
cated.
   Intratesticular Haematocele is due  to  traumatism.   After  an
injury persistent pain and SAvelling not dependent on hydrocele might
suggest parenchymatous effusion of blood, though, except by puncture,
an early diagnosis from acute orchitis would be impossible.   The  pain
of these haematomata is  said  to be extremely  severe and  persistent.
The detection of a fluctuating area in the testicle proper would indicate
incision and drainage.
   Parenchymatous  haematocele  of the epididymis  is reported  by
Jacobson.
   Treatment.—Immediately following injury of the testicle, rest, ele-
vation of the parts, and the  application of evaporating lotions are in-
dicated.  Later, on the subsidence of acute  inflammatory phenomena,
the pressure suspensory bandage should be worn.  If the pain remains
intense, the testicle shoAving a moderate increase in size not  dependent
upon  hydrocele, exploratory puncture of  this gland with  the finest
needle of the aspirator is indicated, since  these symptoms may be due
to a haematoma, which, if alloAved to remain, may produce total dis-
organization of the testicle.   The  aspirating needle should be thrust
in at the most painful spot or into any area of obscure softening  or
fluctuation, if this can be detected.  If the  needle shows that there is
an encysted blood effusion, this should  be opened, the blood evacu-
ated, and the cavity drained.
   Haematocele of the cord may be diffuse or encysted. 
936        GENITO-URINARY DISEASES AND SYPHILIS.

   Diffuse hematocele is usually due to rupture of a vein from direct
traumatism or sudden increase of intra-abdominal pressure.  There
forms quickly a doughy, sausage-shaped tumor, occupying the position
of the cord, and entirely obscuring it.  This tumor is not translucent.
   In the chronic  form of  diffuse haematocele of the cord  the blood
effusion  may  reach enormous  dimensions.   It is characterized by
great thickening of the limiting walls.
   Treatment—This has for its object the limitation of effusion and
the prevention of  inflammatory reaction.  The patient is put to  bed.
A  layer of sterile cotton is placed over the cord, and a crossed of the
perineum is firmly applied.  If in twenty-four hours it is evident that
the bleeding  has  ceased, inflammatory reaction is limited  by evapo-
rating  lotions or  the ice-bag.   Should  bleeding  persist in spite of
pressure,  incision, securing the  bleeding point, and  closure  of the
Avound Avithout drainage  are indicated.
   Encysted  hematocele of the  cord is due  to hemorrhage into an
encysted hydrocele or to the encysting of a hemorrhage into the cord.
It  begins in  the lower  part of  the  cord, forming a pyriform tumor,
Avith the  base down, which ultimately may become merged with the
epididymis and testis.
   The diagnosis  is suggested by the history of the tumor, especially
its origin, and the  absence of translucency.
   Treatment—Incision,  evacuation  of clots,  and decortication or
complete removal  of the sac are indicated.
   Loose Bodies in the Tunica Vaginalis.—It sometimes happens
that  on palpation of the testis a rather hard body,  about the size of a
kidney-bean or smaller than this, may be felt moving freely under the
finger.   This body is smooth and elastic ; its motion may be limited,
or may be so free that the body can be pushed into any portion of
the vaginal sac.  There is usually a moderate  degree of hydrocele of
a thickish consistence.  These  bodies may be cysts with thick walls,
sometimes exhibiting calcareous  degeneration, the remains of fcetal
structures ; they originate beneath  the tunica vaginalis, and become
pedunculated and  finally free, the pedicle rupturing.  Floating fibroid
and cartilaginous bodies  are also found, and are formed in the same
way, the original thickening of the vaginal tunic being due to inflam-
mation.
   Symptoms.—These bodies are commonly found accidentally, and
cause no  symptoms beyond a moderate hydrocele, with which they
are usually associated.   If they cause pain and acute vaginalitis, or
if they  are encountered during the radical cure  of hydrocele, they
should be removed. 
NEURALGIA OF  THE  TESTICLES.
937
                 NEURALGIA OF THE TESTICLES.
   Reference has  been  made already to the  intense  pain which
accompanies inflammatory conditions of the testicle  and epididymis.
There may, however, be a pain equally severe which occurs without
apparent cause in testicles  showing  no  evidence of disease.  This
pain may be in the testicle or may shoot from  this region along  the
cord in various  directions.   It may be  continuous or regularly or
irregularly intermittent.  It  is  symptomatic  of what  Cooper called
" irritable testicle," and is sometimes observed in hysterical patients.
Exceptionally the aura of true epilepsy takes the form of neuralgia of
the testis.
   Many cases supposed  to be  purely neuralgic are dependent upon
distinct lesion.  Thus, the pain may be  excited by  tumors, such as
fibromata or myomata, or by parenchymatous  blood-cysts, or by the
congestions incident to varicocele.
   The only symptom of the neuralgia  is pain.  This may be ago-
nizing  in its intensity, and may be  associated with  tonic  or clonic
spasm  of the cremaster muscle.   The testicle is extremely sensitive,
even friction of the garments or the slightest touch causing severe
suffering.  During the paroxysms of pain the testicle  may become
hard and the vessels of the  cord congested.  The neuralgia may be
dependent upon traces of a  previous inflammation, the presence of
a hernia,  or certain  systemic conditions, as  gout, rheumatism, or
toxaemia.   We believe that  careful  examination will show that  the
majority of cases are in part  due to a varicose condition of the sper-
matic veins.  It  is true that varicocele may attain enormous dimen-
sions and yet  cause no pain.  Even  slight  dilatation may, however,
occasion marked symptoms in those  who are hereditarily neurotic.
    Treatment—The  first thought, in treating this  affection, should
be to exclude organic lesions, such as blood-cyst, tubercle, hernia, or
varicocele ;  when it is evident that pain is not dependent upon a local
condition Avhich may be  remedied by operation, palliative treatment
is indicated.  A great  number of external applications and internal
remedies have been used, and often successfully.   It must be con-
fessed that certain cases  resist every form of treatment.   Among the
most serviceable  therapeutic measures are the pressure  suspensory
bandage, local applications of heat and cold, counter-irritation, freez-
ing the overlying skin with methyl chloride, blisters, galvanism, and the
ice-bag Internally there may be given aconitine in full doses, quinine,
antipyrin, acetanilid, exalgin, valerian, and hyoscine.   The general
treatment should be hygienic and, if indicated, anti-rheumatic. 
CHAPTER  XXVI.
 INJURIES AND  DISEASES OF THE SPERMATIC CORD AND  SEMINAL VESICLES.

   Attention  has been called  already to  certain anomalies of the
cord.   Thus, this structure may be absent, even though the testicle is
in its normal place, or the two cords may be fused, or one cord may
be double.  The vas may communicate directly with the ureter, as is
normal at one period in foetal life, or may be entirely wanting in its
prostatic portion, or may be fused.   The single  duct may open into
the utricle, or may continue by a distinct passage to the glans penis.
   Contusions and Wounds of  the Cord.—Contusions rarely
cause injury other  than an  acute haematocele,  the  blood which is
poured out  from the  ruptured veins  being limited  by the fibrous
sheath of the cord, thus forming a sausage-shaped tumor which may
extend  from the testicle to the  internal ring and beyond, filling the
inguinal canal.  It   is usually associated with hemorrhage  into the
scrotal tissue, which may completely  mask it.
    Treatment.—Rest, elevation, pressure, and the application  of ice
during  the  bleeding stage, folloAved by  evaporating liniments, and
possibly massage for the purpose of hastening absorption,  outline the
treatment.
   Wounds of the cord are necessarily attended by free bleeding,
for the arrest of which ligatures are  required.  If  the deferent canal
is divided, its continuity may be restored by the  ingenious plastic
method proposed by Van Hook for uniting divided  ureters.  Division
of the vas is not necessarily followed by atrophy of the testicle, even
though the operation for the restoration of the continuity of the canal
is not performed.   When the spermatic artery is divided, and par-
ticularly when the  plexus of  nerves  supplying the  testicle is exten-
sively injured, atrophy or gangrene is extremely likely to result.
   Inflammation of the Cord.—Funiculitis or inflammation of the
cord may be acute or chronic.
   Acute funiculitis may arise from extension  of a  posterior ureth-
ritis along the vas, or from phlebitis,  especially that dependent upon
rheumatism.  Two  forms  of the  affection have been  described,
serous funiculitis, or acute hydrocele, and phlegmonous funiculitis.  It
is possible that serous funiculitis (diffuse hydrocele), which forms a
rounded,  sausage-shaped,  pitting, translucent  tumor occupying the
     938 
      INJURIES AND DISEASES  OF THE SPERMATIC  CORD.   939

position of the cord, is in reality sometimes an encysted hydrocele.
It occurs as a complication of gonorrhoea or rheumatism.
   Phlegmonous funiculitis is usually traumatic in origin.   It is also
caused by gonorrhoeal inflammation of the vas and by septic phlebitis.
The sausage-shaped tumor is  extremely tender, and may develop with
symptoms characteristic  of strangulated  hernia.   Should the infil-
trate suppurate, it is likely  to invade the peritoneal  cavity in its
upAvard extension.
   Chronic funiculitis is usually tubercular.
   Treatment.—Acute funiculitis is treated by rest, elevation, and the
application  of cold, preferably in the form  of evaporating lotions.
Should the  SAvelling  be  so marked as  to  threaten  the vitality of the
testis, incision and drainage are indicated.
   Tumors of the Cord.—Lipoma is the most frequent tumor of
the cord.   It  may develop  entirely  in  the  scrotal portion of this
structure, or may extend along the inguinal canal and into the pelvis.
Lipoma may reach a large size: Wilms reports one which weighed
twenty pounds.   In the course of   its
growth the  lipoma incidentally becomes
distinctly lobulated, simulating malignant
disease, penetrating  betAveen the struc-
tures  of the cord  (Fig. 236),  and making
entire  removal without  sacrifice  of  the
testicle impossible.   Hence  the  impor-
tance of early treatment.
   Lipoma may undergo myxoid degen-
eration, and exhibit  a tendency to recur
on removal.
   The symptoms are  those of a pain-
less,  slow,  somewhat irregular,  slightly
translucent,  soft but lobulated growth in
the course of the cord.
   The diagnosis from  omental hernia
may be impossible  without  exploratory
incision. Even then the surgeon may be
in doubt, but may be guided by remem-   Lipoma of the cord. (Pean.)
bering that  the  fatty growth of an epip-
locele  is within the peritoneal sac and is often adherent to it.  The
history of lipoma  differs from that of hernia, since it gradually de-
velops along the course of the cord, grows upward, is not reducible,
and until it involves the inguinal canal will  not give an impulse on
coughing.
 
940        GENITO-URINARY DISEASES  AND SYPHILIS.
Fig. 237.
    Treatment.—Early operation is  always indicated, since when the
tumor is small it may be  entirely removed Avithout sacrificing the
cord.  When the tumor has reached a large size and it is impossible to
dissect it free from the structures of the cord, castration is indicated.
    Myoma is rare.  It may be found together with  lipoma, giving a
semi-malignant character to an otherwise benign tumor.
    Sarcoma and carcinoma are more  frequent than  myxoma.  They
both  cause  metastasis  and develop  as do  similar  tumors  in other
                          regions of  the body.   They often undergo
                          cystic degeneration.
                             The  treatment is  castration,  with re-
                          moval of as much of the  cord as possible.
                             Tuberculosis.—In the course of gen-
                          ito-urinary tuberculosis the vas is frequently
                          infiltrated.  This  is nearly always second-
                          ary to  involvement of the epididymis or
                          the prostate.   Exceptionally nodules first
                          develop  in  the vas, the epididymis being
                          apparently  healthy.  Reclus has observed
                          two such cases: in one the nodule involved
                          the cord at the  position  of the  external
                          ring, in the  other it was within the inguinal
                          canal.
                             In  the  rare cases  of primary involve-
                          ment of the vas the appropriate treatment
                          Avould be  excision of  the  affected portion
                          of  the canal, followed  by an  anastomosis
                          by  Van Hook's method.
                             Varicocele, or dilatation and elonga-
                          tion of  the veins of  the spermatic cord
                          (Figs. 237,  238), is most frequent in early
                          manhood,—that is, from about the fifteenth
                          to  the twenty-fifth year;  it is  rare in  in-
                          fancy ; in old  age it is of  moderate devel-
                          opment  and  causes  little inconvenience.
The veins of the cord are especially prone to dilatation and elongation
from  the  fact that their valves are insufficient, and  hence there is a
long column of blood to be supported.  The disease usually affects the
left testicle  (ninety per cent,  of cases), possibly because the vein, in-
stead of passing obliquely into the vena cava, as on the right side,
enters the renal vein almost at right angles to its long axis, and, more-
over, lies behind the rectum.
Varicocele.
(Osborn.) Monod and
 Terrillon. 
      INJURIES AND  DISEASES OF  THE SPERMATIC CORD.   941

   The veins composing  the spermatic plexus can be ranged in three
groups, the most anterior of  Avhich has  in its  midst the spermatic
artery, the middle  the vas  deferens, and the posterior those veins
which pass upward from the tail of the epididymis.  The  anterior
group is  the one  first affected,  or, if the dilatation affects all the
veins, is most extensively involved.   Besides the mechanical  condi-
tions favoring the  development  of varicocele, there are other causes,
such as prolonged standing  or  walking,  violent muscular exertion,
masturbation, sexual excess, traumatism, inflammation, gonorrhoeal
Dilatation of the veins in a marked case of varicocele.  (Kocher.)
epididymitis,  and  tumor-formations  in  the abdominal cavity, par-
ticularly swelling of the lumbar lymphatic glands or involvement of
the kidneys.   Hernia, heredity, constipation, have  all been assigned
as etiological factors, but their influence is not proved.  Billroth states 
942        GENITO-URINARY DISEASES AND SYPHILIS.

that varicocele  is due to a diathesis which first affects the vessels of
the pampiniform plexus, and later those of the rectum and the leg.
   Symptoms.—These may be direct or reflex.   The direct symptoms
are as follows: The scrotum of the affected side is filled Avith  a tor-
tuous mass of veins, sometimes visible through the skin, and feeling
like a bundle of worms.  The tumor formed by these veins partly or
completely disappears on lying down,  but  reappears on  standing up,
increasing  in size gradually from below upward.   Pressure exerted
over the inguinal ring does not prevent the appearance of the tumor.
The scrotum is elongated, dusky purplish in color, and  in advanced
cases the testicle of the side involved is often markedly atrophied.
    The reflex symptoms  are—(1) pain in the testicle, the lumbar re-
gion,  the hypogastrium, and often in the  penis.  It bears no relation
to the size of the tumor.  It may be  agonizing or simply harassing.
(2) Sexual  neurasthenia, characterized by mental  depression, sexual
weakness  or impotence, headache, nervousness,  lack  of power  of
concentrating the mind, and other vague general symptoms.
    Varicocele may simulate omental  hernia.   The  hernia has not,
however, the characteristic feeling of a  bundle of Avorms ; if reduced it
will not recur when pressure is  made  over the external inguinal ring,
and it gives a much more distinct succussion on coughing than does
varicocele.  The development of the two affections is quite different.
    Prognosis.—Varicocele observed in young men  subject to pro-
longed and ungratified sexual excitement is usually cured by marriage,
or, at least, it ceases to give trouble afterwards.  If moderate in degree
it has no  marked  tendency to  increase, causes little pain, and does
not appreciably alter the nutrition of the testicle.   Quenu states that
owing to the dilatation  of the veins of  the nerves there occurs a peri-
phlebitis and neuritis, which Avould account for both pain and atrophy.
Only Avhen varicocele is so pronounced  that circulation is materially
interfered  with does atrophy of  the testicle result.  Spontaneous cure
seldom occurs, except  in those rare acute cases Avhich  develop with
mild  inflammatory symptoms in consequence of strain  or exposure.
There is one form of varicocele frequently noted in old men, due to
dilatation  of the lower portion of the posterior group  of veins and
completely masking the  lower  portion  of the epididymis.   This is
frequently followed by  sclerosis of  the lower testicular segment.
    Treatment.—Treatment may be palliative or radical.
    Palliative treatment consists  in the  proper regulation of the bowels,
the avoidance of all exciting causes, such  as violent muscular  efforts
or prolonged standing, the daily  application of cold douches to the skin
overlying the  dilated veins, and the Avearing of a properly fitted sus- 
      INJURIES  AND DISEASES OF  THE SPERMATIC CORD.   943

pensory bandage.  This treatment is indicated when the varicocele is
moderate  in size, when the nutrition of the testicle is not interfered
with, and  when the reflex symptoms are not pronounced.
   Radical treatment is indicated AA<hen the varicocele is  progressive
and is well developed, when beginning atrophy of the testicle is observ-
able, and when the reflex  symptoms, particularly the sexual neuras-
thenia, are pronounced.   Cure is accomplished either by subcutaneous
ligation of the veins or by open incision, ligation, and excision.
   Subcutaneous ligation is conducted as follows.   The scrotum with
its enlarged veins is taken in the left hand, when, by rolling the thick-
ened mass of the cord betAveen the thumb and the first two fingers,
the vas deferens  may be  recognized  by its hard, cord-like  feel, and
may be slipped backAvard  and imvard  away from the  dilated veins.
By firm pressure Avith the thumb and  fingers, Avhich completely en-
circle the neck of the scrotum, the iavo  skin surfaces are held  closely
together, the vas lying behind this point of apposition, the dilated veins
in front.  A harelip  pin is inserted through the upper third of the
cord in front of the point of pressure.   A second pin is  inserted in
a  similar  way about the position of the  middle third of the cord.
The two pins when thus placed have in front of them the enlarged
veins, and behind them the vas.  A needle with an eye at the point
(Reverdin's) and threaded to  the middle of a sufficiently long ligature
is then passed into the same opening as the upper pin, but after pene-
trating the skin is carried between  this structure  and the veins till
its eye protrudes through the point of exit of the pin;  here the loop
is loosened, but not unthreaded, caught, and the needle withdrawn.
   The pin now lies beloAV the dilated veins, the double thread above.
The loop is slipped over the  point of the  pin and the two free  ends
are tied firmly beneath the shaft.  A silk thread is passed over the
remaining pin  in a similar  manner.  The pins  may remain until the
third day, an antiseptic dressing being applied in the mean time.
   In place of these  harelip pins multiple buried ligatures  may be
used.   Each ligature is applied by passing a threaded Reverdin needle
(eyed at the point) beneath the veins and through the two layers of
skin, unthreading the needle, withdrawing it until its point lies just
within the puncture, passing it above the veins  and beneath the skin
back to the  opening  through which  the ligature projects, and again
making the point appear at this opening; the ligature is then threaded
and the needle withdrawn, thus leaving  a loop completely around the
veins.  The  knots are tied down very  firmly and so cut as to allow
them to bury themselves.   Of course all these procedures are carried
on with every attention to surgical antisepsis. 
944        GENITO-URINARY DISEASES AND  SYPHILIS.

   Excision of  the  affected v^ins, Avith shortening of the cord, is
the operation to be preferred.   It is best performed  under ether,
though  cocaine  anaesthesia  makes it  almost  painless.   The operator
by palpation  finds the upper portion  of the vas and presses it back-
ward and inward away from the affected veins.  An assistant  stand-
ing to the  left of the patient  makes  firm  pressure by means of the
thumb and fingers of the right hand at the point Avhich will keep the
vas back and the enlarged veins forward.  The  surgeon, passing his
fingers lower down, again separates the vas  from the veins, and  the
assistant, placing the palmar surface of the left hand beneath  the
scrotum, presses firmly with the thumb and fingers, keeping the lower
part of  the vas aAvay from the group of dilated veins.  By slight ten-
sion with the left hand  the  skin of the scrotum  is made  taut.  The
surgeon makes a longitudinal incision tAvo inches in length over the
most prominent part of the varicocele, dividing the skin, dartos, and
fibrous  investment  of the  cord ; through each lip of  this wound is
passed a short thread, the two ends of which are seized with haemo-
static forceps; the weight of the instruments retracts the borders of
the incision, thus facilitating subsequent  manipulations.  The veins
are freed by blunt dissection for two  or three inches of their course,
and  an  aneurism needle, threaded Avith catgut, is passed beneath the
entire group at the lower end of the incision; the needle is unthreaded
and withdraAvn ; another needle, similarly threaded, is passed beneath
the veins at the upper end ; thus they are included in two catgut loops
separated from each other by an  interval of at least two inches.  These
ligatures are  tied tightly Avith a triple knot, and each is left with one
long end.   The intermediate portion of the veins is then cut out with
scissors, and  the stumps are apposed by tying the long ends of the
ligatures together.  This shortens the cord, and  thus raises the testicle.
The skin wound is closed without drainage by  two, or at most three,
interrupted sutures,  and a sterile dressing is  secured in  place by a
crossed of  the perineum roller.
   In certain cases where the  scrotum seems to be unusually lax, ex-
cision of the  superfluous skin  and dartos is  indicated.  This  is  best
performed by means  of a clamp, and if undertaken should be radical;
that is, as much skin as possible should be removed.   The clamp is
usually  placed in the middle line, and  the scrotum is drawn through
until the remaining skin is stretched taut over the testicles.  The part
included in the clamp is then cut away with the knife or scissors, bleed-
ing vessels  are secured, and sutures are applied.   The application of
the latter is sometimes difficult, and is best effected on removal of the
clamp.  Since there is a tendency for varicocele to recur, it is some- 
INJURIES AND DISEASES OF  THE SEMINAL VESICLES.   945
times necessary  to  combine ligation  and resection of the cord with
resection of the scrotum.
   When the posterior group of veins is markedly involved, forming
a doughy  tumor behind  and  below the epididymis,  these vessels
should be  ligated and excised, either through a separate incision or
through the wound  resulting from  resection of the scrotum.
   The results of the operation are usually satisfactory.  Exception-
ally atrophy or  even  gangrene  of  the testicle follows ligation of the
veins of the cord.   Sometimes  the reflex phenomena are unrelieved
or even  exaggerated,  possibly because the  neuritis originally caused
by varicocele is progressive.
lined
                   THE SEMINAL  VESICLES.
The anatomy of the seminal vesicles has already been briefly out-
    These glands  form two lobulated  pouches, lying at the base
Fig. 239.
Fig. 240.
                                       Long section of dilated seminal vesicle.
                                                 (Sappey.)

                                    of the  bladder.   The  walls of
                                    these pouches are  thin,  and  if
                                    carefully dissected can be partly
                                    extended in the form of an irreg-
                                    ular  tube, with caecal  projections
                                    and diverticula.  (Fig. 239.)   The
                                    inner surface is irregularly saccu-
                                    lated.   (Fig. 240.)  The vesicles
                                    are enclosed  in  a  dense fascia,
                                    Avhich passes from the Avails of the
                                    bladder to  the  posterior  surface
                                    of the prostate.   The vesicles in
                                    their  convoluted  form  are about
                                    two   inches  in   length,  three-
                                    quarters of an inch in width, and a
quarter of an inch in thickness.   They terminate in a duct which joins
the vas at an acute  angle just before the latter enters the substance
                                 60
  Right seminal vesicle, posterior surface, dis-
sected out. 1, deferent canal, with (1') the am-
pulla; 2, seminal vesicle, with (3) lateral pro-
longations, (4) csecal dilatations, and (5) parietal
projections ; 6, union of the vesicle with the vas;
7, ejaculatory duct; xx marks the position of
the posterior extremity of the undissected vesicle.
(Testut.) 
946         GENITO-URINARY DISEASES AND SYPHILIS.
of the prostate.   The
adherent to the  Avail

       Fig. 241.
  Deferent canal and seminal
vesicle.  A,  longitudinal, B,
transverse section; 1, deferent
canal; 2, its ampullated por-
tion ;  3, seminal vesicle with
(3') pouches; 4, terminal por-
tion ; 5, ejaculatory duct. (Tes-
tut.)
 loAver  inner portion of each  vesicle is usually
of the  vas, making  a dissection at this point
 difficult.   (Fig. 241.)  Above, the  two struc-
 tures are entirely separated,  being enclosed in
 distinct  compartments  of  the  dense fascia
 Avhich passes from the  upper  posterior Avail
 of the bladder  to the  base of the prostate.
 The upper extremities of the seminal vesicles
 correspond to about the point of entrance of
 the ureters into  the bladder, and are in close
 relation  Avith  the peritoneum,  Avhich  is  here
 reflected from the posterior wall of the blad-
 der to the rectum.   Within the fascia Avhich
 includes  in  separate  compartments the sem-
 inal vesicles and the vasa are found many mus-
 cular fibres,  apparently originating  from  the
 bladder-wall  and  the posterior  surface of the
 prostate.  (Fig.  242.)   These fibres are  par-
 ticularly abundant along the under and outer
 surfaces of the vesicles.  The  vesicles are some-
 what pear-shaped,  the narrow end running
 dowmvard and  inward.   As is the  case Avith
 all the sexual organs, they vary greatly in  size,
 bearing  no fixed  relation to the development
 of either the individual  or the other organs,
 or even to one another.   Thus it is not un-
    Horizontal section of the bladder and seminal vesicles passing through the lower orifice of the
ureters.  1, inner surface of the bladder; 2, 2', ureters; 3, intra-ureteric ridge ; 4, bas-fond; 5, seminal
vesicles; 6, deferent canals (ampullated portion); 7, interdeferential triangle ; 8, rectum; 9, prostato-
peritoneal aponeurosis ; 10, musculo-fibrous tissue enveloping the vasa and vesicles; 11,11, cellular
tissue of the pelvis. (Testut.) 
     INJURIES AND DISEASES OF  THE SEMINAL VESICLES.  94-

 common to find one vesicle  twice or thrice the  size of  its fellow
 Avithout obvious reason for this apparent asymmetry.  The portion of
 the bladder lying between the inner borders of the two seminal vesicles
 and limited above by a transverse line connecting the two  bases cor-
 responds to the  position of the vesical trigonum.   The vesicles have
 rather thin walls, made up of  fibrous and muscular tissue,  lined with
 mucous membrane in which are found many tubular glands.
    The ejaculatory ducts, formed by the junction  at an acute angle
 of the  seminal vesicles and the vasa, enter the substance of  the pos-
 terior prostatic isthmus, passing
 doAvnward and  forAvard,  and                 FlG- 243.
 opening in the  borders  of the
 utricle   or Avithin  this  cavity.
 The diameter  of their orifices is
 one-half  millimetre;  at  their
 origin it is three times as great.
 (Fig. 243.)
    The function of  the seminal
 vesicles is probably entirely secre-
 tory. Examination usually shoAvs
 a few spermatozoa, but never a
 quantity of semen sufficient  to
 suggest that this convoluted tube
 is a  receiver  and storer of the
 secretion from the testicle, such,
 for instance, as is the gall-blad-
 der for the secretion of the liver.
    The vesicles  receive   their
 blood-supply  from the  inferior
 vesical  and middle hemorrhoidal
 arteries.  The nerves come from
 the hypogastric plexus.
   Anomalies of the Seminal
 Vesicles.—The seminal vesicles
 may  be absent.   In this  case
 there is usually absence  of the
 testicles,  though   Tenon  and
 others have  reported  cases  of
 bilateral absence where the tes-
 ticles were still present;  there
 were, however,  other  deformities.    Unilateral  absence  has  been
noted in conjunction with unilateral  malformations, involving struc-
   Posterior urethra exposed by splitting its upper
wall. 1, vesical neck; 2, section of the prostate
and the urethral sphincters; 3, section of the mem-
branous urethra; 4, section of the spongy urethra ;
4',  bulb; 5, 5', cavernous bodies; 6, verumonta-
num, with (6') orifice of the utricle; 7, posterior
wall of the prostatic urethra, showing glandular
openings; 8, right ejaculatory duct exposed; 8',
its  orifice; 9, Cowper's gland; 10, its duct exposed ;
10', opening of the duct; 11, longitudinal folds of
the urethral mucous membrane; 12, bulbar cul-
de-sac ; 13, narrowing of the bulb at the beginning
of the membranous urethra. (Testut.) 
948        GENITO-URINARY DISEASES AND SYPHILIS.

tures other  than the  testicle or  the cord.  Hunter has reported
fusion of the vesicles, the ducts of  the two glands uniting and ending
in a blind  pouch.  Multiple vesicles  have been  observed.  Atrophy
of the vesicles has been  frequently noted at post-mortem  examina-
tion and quite independent of any  affection of the  urethra or the
testicles.  Communication with the  ureter also  has been  observed,
this condition, which obtains during fcetal life, having persisted.
   The ejaculatory ducts may be  partially wanting, may be entirely
absent,  or may be fused; they may  pass directly into the prostatic
utricle,  or may continue forward  into a canal opening at  some point
on the glans penis, this condition giving rise to the misconception of a
double urethra.
   Injuries  of the Seminal Vesicles.—From  their position it is
evident  that the seminal vesicles  are well  protected  against trauma-
tism, except that which is so extensive that other lesions overshadow
in importance the injuries to the vesicles.
   In the event of the wounding of  a vesicle in the performance of
surgical operations on  the  bladder the consequences Avould not  be
serious.  When  both vasa  or  both ejaculatory ducts are divided or
torn it is extremely probable that sterility will result from obliteration.
A wound of the seminal vesicle alone is of minor importance, though
it is conceivable  that it might be followed by fistula.  The treatment
of wounds of the seminal vesicles is conducted in accordance Avith
general  principles.
   Vesiculitis  or Spermatocystitis.—The  usual cause of this
affection is extension of gonorrhoeal inflammation  into the congested
seminal vesicles.   It may be due also to infection with the ordinary
pus microbes and perhaps with the  colon bacillus.   There is no proof
of the possibility of its  production  by masturbation, excessive coitus,
or direct.extension from the bladder.
   Symptoms.—The onset of acute  seminal vesiculitis is characterized
by practically the same symptoms  as those noted in describing acute
posterior  urethritis.   There are frequent,  straining,  painful  mictu-
rition, and constant or shooting  pains in the  perineum, hypogastric
region, and anus ; the pain is often  referred to the hip-joint and sacro-
iliac articulation  of the affected  side, and runs down the outer side
of the leg.   Both direct and reflected pains are made worse by mic-
turition or defecation.   At times  there are retention of urine  and
violent  rectal tenesmus, the suffering being so intense that  an opiate
is required.   Exceptionally the  disease is ushered  in with the ful-
minant  symptoms of   an acute peritonitis.   There  are  vomiting,
tympany, constipation, and  tenderness over the whole lower belly- 
    INJURIES  AND DISEASES OF THE SEMINAL VESICLES.   949

segment.  Persistent erections are frequent;  painful emissions  of
blood-stained semen are not uncommon.
   Rectal examination shows at  once a hot, tender, obscurely fluc-
tuating mass passing upAvard and outward from the lateral lobe of the
prostate, usually about the  size of the thumb, with  its upper  limit
beyond the region of the examining finger.   According to the inten-
sity of the inflammation and the amount of exudate this mass will be
hard or soft.  There is usually pronounced fever.
   Sometimes acute vesiculitis develops insidiously.  The patient  is
not confined to bed, but may complain of shooting intermittent pains
of moderate severity  in the  perineum, Avith rheumatic aches felt in
the hip, sacro-iliac joint, rectum,  and perineum,  or  down  the outer
and inner surfaces of the leg.
   Diagnosis.—The diagnosis of acute  seminal vesiculitis is  founded
on rectal examination.  When practicable this should be conducted
with a fairly full  bladder, the patient leaning forward over  a chair,
with the legs slightly separated; or he may be put in the  lithotomy
position and the  base of the bladder  outlined by bimanual palpa-
tion, the fingers of one hand being placed deeply behind the pubis,
while the index of the other hand is  introduced into the  rectum.
Palpation is the only means of making a differential diagnosis  from
prostatitis, and it must be noted that it does not enable the surgeon to
distinguish  definitely betAveen spermato-cystitis and inflammation of
the ampulla of the vas.   In  both cases the SAvelling, at least during
the acute stage, is mainly due to infiltration of the intertubular and
periglandular connective tissue.  When both sides are involved this
infiltration  may be  so extensive aS to form  a  large projecting mass
more prominent  than the  prostate and extending from the  outer
border of one vesicle to that of  the other, completely masking the
base of the bladder.  This condition  is often  mistaken  for acute
prostatitis, but  careful palpation will outline the  prostate and show
that it is normal in size.  Usually the infiltration  is not so extensive,
the inflammation  when bilateral forming tAvo distinct masses.  The
pain referred  to  the  hip-joint has seemed to us characteristic  of
involvement of the vesicles.
   Prognosis.—So far as  cure is concerned, the  prognosis must be
guarded.  Suppuration once established  in  the   convoluted tubule
which makes up  the  bulk of  this gland is difficult to cure,  since its
duct of entrance is so narroAv that it is impossible to reach  the dis-
eased surfaces  with any form of local medication.   So far as recovery
from immediate symptoms is  concerned, the prognosis  is extremely
favorable, the disease usually undergoing partial spontaneous resolu- 
950        GENITO-URINARY  DISEASES AND  SYPHILIS.

tion whether treatment is adopted or not.   There is, however, always
a possibility of periglandular suppuration, Avith the formation of an
abscess, which may rupture into the rectum, the bladder, or the peri-
toneal cavity.  The inflammation  frequently travels backward along
the vas, causing epididymitis.
   The usual  termination  of  the affection  is a chronic vesiculitis,
which causes either no symptoms  or  those of urinary or genital irri-
tability, and Avhich has an ultimate tendency to recovery, though this
may take  months or years.
   Chronic Vesiculitis.—This  is the  usual termination of acute in-
flammation.  AH the causes of pelvic engorgement predispose to its
development; its indefinite  prolongation is probably due to a stric-
tured  condition of the ejaculatory duct, which may  be completely
obliterated.
   Symptoms.—The  symptoms of chronic  vesiculitis  are  practically
those of chronic posterior urethritis,—i.e., the patient is subject to
irregular and apparently causeless attacks  of frequent, urgent urina-
tion ;  he suffers from a gleet, which  is also subject to exacerbations
and remissions, or may light up after  each  intercourse; mild attacks
of epididymitis develop occasionally; there is often alteration in the
sexual power and appetite, and frequently there are developed pro-
nounced symptoms of sexual neurasthenia,  with pains referred to the
back, hypogastrium, and thighs.
   Diagnosis.—The  diagnosis of chronic vesiculitis  is founded upon
rectal  palpation and examination of the urine passed in three por-
tions.  The patient first urinates what he judges to be a third of the
contents of the bladder; the  seminal vesicles are then milked, and
the patient again urinates, in tAvo portions; the first  portion passed
after milking the vesicles will of course contain the major part of the
fluid discharge  from these glands.
   Still another method of determining whether or not pus is  dis-
charged from the seminal vesicles is by irrigation of the bladder with
a one-tenth per cent,  solution  of  methyl-blue ; this should  be thor-
oughly washed out Avith boric  acid solution, three or  four ounces of
Avhich should be left  in the bladder; the  seminal vesicles  are then
milked, and the patient is directed to urinate;  pus or shreds which
are unstained will in this case come from the vesicles, the vasa, or the
ejaculatory ducts.
   Treatment of Vesiculitis.—The  prophylaxis of seminal vesiculitis
consists in adopting every  possible means of lessening the severity
of posterior urethritis.
   Acute  inflammation of the seminal vesicles and of the ampullae of 
    INJURIES AND  DISEASES OF  THE  SEMINAL VESICLES.   951

the vasa should  be subjected to the treatment applicable to the early
stages of acute prostatitis.  It  is evident that a comparatively slight
amount of  inflammatory SAvelling  and  epithelial  proliferation  Avill
entirely block  the  ejaculatory duct at or near its narrowest portion,
the orifice, and there is reason to believe that the severity of vesicu-
litis is  in part dependent on the degree of obstruction of the duct,
since Avhen this  is  closed there is  no escape for the muco-purulent
contents  of the vesicle.   Irritating injections  or  applications,  the
passage of instruments, or any manipulation Avhich tends to aggra-
vate the posterior  urethritis should  therefore be avoided, since  this
urethral inflammation necessarily increases the  obstruction.  During
the acute stages of inflammation all urethral treatment should cease,
with the exception of antiseptics administered by the mouth and the
use of antiseptic unirritating irrigations.  If  these irrigations add to
the severity of the  symptoms they should be omitted.
   Rest  in  bed, elevation of  the pelvis, rectal injections of hot or
cold saline solution, and hot sitz-baths or general baths are especially
useful  in lessening pain and congestion.  Usually opium and bella-
donna suppositories are required.
   Chronic  vesiculitis is probably dependent upon  narroAving of the
ejaculatory duct and consequent imperfect drainage of the suppurating
sac.
   The treatment which  is naturally suggested is dilatation of these
ducts.   They  are,  however, so small that even a filiform bougie  can-
not be introduced  into them, and it is usually impossible to find them
through a urethroscope.  The  natural course of  a fine instrument in-
troduced through  the ejaculatory duct is towards the vesicle  rather
than towards the vas, and it may be possible in exceptional cases to
use properly constructed  instruments in  such a manner that stricture
Avill be cured.
   Until recently the treatment of chronic vesiculitis has been limited
to general attention to hygiene and  applications  adapted to the relief
of the associated  pelvic congestion and posterior urethritis.   Hot
or cold rectal  injections, the use of the rectal bag, and the administra-
tion of electricity represented  all that could be done locally.
   Fuller has  proposed a method of treatment which is rational  and
Avhich  in his  hands  appears to have been  successful.  This consists
in milking the  vesicle by digital  manipulation, the muco-purulent
contents of the  suppurating  gland  being  forcibly pressed through
the narrowed  duct.   Moreover, as the result  of massage, the tonicity
of the blood-vessels  of the vesicle is markedly increased,  and  this
treatment apparently causes  complete  resolution  of long-standing 
952        GENITO-URINARY DISEASES AND  SYPHILIS.

inflammation.  Fuller thus describes his manipulation : " To accom-
plish the treatment, the patient presenting himself with a full bladder
should, while standing Avith his knees straight, bend the body forAvard
at right angles.  Then the operator should introduce the forefinger of
one hand well into the rectum, the  fist of the  other hand exercising
firm counter-pressure over the pubis.  By these means the end of the
forefinger will in all ordinary cases  reach well  beyond the  posterior
margin of the prostate.  The bodies of the vesicles can thus be de-
tected, one on each side beyond the posterior prostatic border.  (Only
the lower half of the body of the vesicle can be felt ordinarily by the
finger, the  rest being  beyond  reach.)  After the  forefinger  has been
so introduced, firm pressure should be made by its tip on the body of
the vesicle to  be treated as far back  as it is possible to reach.  Then
the finger-tip, the pressure  being maintained, should be  slowly and
firmly drawn forward along the line of the vesicle.  The  manoeuvre
is aided by the counter-pressure  over the pubes Avith the free hand.
This process may be repeated several times in connection with each
vesicle.  In this manner some of the vesicular contents, provided the
sac be diseased and distended, can be pressed out along its ejaculatory
duct and into the prostatic sinus.
   " As has been stated, the stripping  should be done on a full blad-
der, and  after the manipulation  the  urine should be voided, in order
that the surgeon may see how much  has been expressed.   This treat-
ment  should be repeated not oftener than  once in four days, and in
most cases under active treatment as often as once a week.  If  it is
done too frequently, or too severe pressure Avith the forefinger is em-
ployed, acute symptoms may be stirred  up, which may  leave  the
patient worse off apparently than before treatment was commenced,
besides at times causing an acute epididymitis."
   The pressure must be  so moderated that after treatment symp-
toms  of  acute vesiculitis will not be excited.  Massage should be
continued  from one  or two  months to a  year.  In  conducting it,
Fuller states that "the real obstacle to success does  not  lie in  the
length of the forefinger, but in the ability of the operator to overcome
the natural resistance of the perineal muscles.  When a case is  first
treated this muscular resistance is  liable  to be  very marked.   As,
however, the patient becomes by degrees accustomed to the manipu-
lations, and as the vesicular  tenderness  decreases, this  element of
muscular  resistance diminishes.   On this  account  it is always  well
with a neAv case to  be as gentle as  possible in executing treatment,
otherwise what is simply a disagreeable sensation may be looked upon
as an  ordeal. . . . 
    INJURIES AND DISEASES OF THE SEMINAL VESICLES.  953

   " If the patient continues in this latter mental state, the muscular
tension is ahvays intensified, and manipulations may be very difficult.
To overcome this muscular resistance, firm pressure Avith the closed
fist, minus the extended forefinger,  against the perineum is neces-
sary.  In  some thick-set, rigid  individuals the perineal pressure re-
quired may  be very considerable, since in such  instances counter-
pressure on the hypogastrium Avith the  other  hand accomplishes but
little.
   " In such cases the muscular  effort required  to enable the fore-
finger to  perform  the  necessary  stripping may be greater than an
operator who is  not physically fairly  robust  can command.   As an
aid in  making perineal pressure Avhere much resistance is encountered,
the knee corresponding to the arm used in manipulating can be made
to play an important auxiliary rdle in  pushing against the elbow.  In
order  to  carry out this manoeuvre a chair is drawn up  behind the
patient as he  stands with his body "bent  forward, in the ' leap-frog'
position, and ready for the treatment.   Then the  foot of the operator
corresponding  to the  hand  to  be aided is placed on the chair, thus
bringing the knee up to the level of the elboAV.  By this arrangement
the muscles  of the thigh and leg, as Avell as of the arm and shoulder,
all working together, can furnish pressure sufficient to overcome the
resistance of the most rigid perineum.  It is only occasionally that
such  extensive muscular  efforts  are  called  for.   In weakly, loose-
fibred individuals little or no  perineal pressure is required to reach
the vesicles, or even, if need be, much further.  In fact, in such cases,
with a little counter-abdominal pressure, one  can easily engage the
tip of  the  forefinger in the sigmoid flexure."
   Cystic Swelling  of  the  Seminal Vesicles.—Usually  as the
result of obstruction of the ejaculatory ducts, conversion of the whole
vesicle into  a  large single cyst or distention of one or more of its
diverticula may  occur; in  the latter case the enlargement  will be
made  up of a number of smaller  cysts.  This affection may run its
course without  exhibiting symptoms other than those  incident  to
chronic inflammation until  the tumor reaches sufficient size to pro-
duce pressure effects.   Cases are reported in which the cyst reached
enormous dimensions.   In one case quoted by Jacobson ten pints of
brown serous  fluid were drawn off.   After two tappings the cyst did
not refill.
   The diagnosis is based on  rectal  palpation.  This condition can
scarcely be  differentiated  from dermoid cysts, or cysts  due  to the
rapid  development of the  remains of  foetal structures.
   Treatment—The treatment in  such cases is aspiration, Avhich may 
954        GENITO-URINARY DISEASES AND  SYPHILIS.

be twice repeated.   In case this  fails, permanent drainage may be
established through a perineal opening, or the cyst may be excised
through Zuckerkandl's, Von Dittel's, or Kraske's incision.
   Spermato-Cystic Concretions.—These  concretions are prob-
ably formed originally because of  obstruction of the duct.  They are
made up of spermatozoa, mucus, and  epithelium,  and  are Avhitish in
color, becoming darker with age and undergoing calcification.  Their
importance  lies in  the fact that  they may occlude the  ejaculatory
duct, thus predisposing to sterility.  The symptoms are pain on emis-
sion, associated perhaps Avith the symptoms of posterior urethritis,
such as frequent urination and tenesmus.
   The diagnosis will be made  on rectal examination, Avhich may
demonstrate one or more hard bodies  in the seminal vesicles.
   Treatment consists in breaking up these concretions by pressure
through the rectum exerted against a full-sized  sound passed into the
urethra.
   Tuberculosis of  the Seminal Vesicles.—Tubercular vesicu-
litis is nearly ahvays secondary to involvement of the prostate and the
prostatic urethra or the epididymis, though clinically cases are some-
times observed in which distinct nodulation of  the vesicle can be felt,
the prostate  being apparently healthy, and symptoms  pointing to
involvement of the  prostatic urethra being  absent.
   Tubercular vesiculitis is characterized by the  formation of a smooth,
nodular, hard  or semi-fluctuating tumor, easily detected on rectal pal-
pation.  Both  seminal vesicles are  often  involved, and  the fibrous
tissue lying between them is infiltrated, forming  a mass  practically
continuous Avith the prostate  and entirely  obscuring the  base of the
bladder, which normally can be felt.   The infiltrated mass is rarely
sensitive, and  in the absence of involvement of the prostatic urethra
causes feAv symptoms, except possibly  sexual erethism,  bloody semen,
pain during or after  ejaculation,  and  finally sterility and impotence.
The infiltrate  often breaks down, discharging into the rectum and
perineum ; after discharge spontaneous cure may follow.
   Seminal vesiculitis is essentially an affection of the adult, and is
usually associated with involvement of the prostate and  epididymis.
The invasion  of these structures is often  simultaneous.  Clinically,
we have many times noted tubercular  vesiculitis precede by weeks or
months palpable lesions of the epididymis; we have never met with
a case of tubercular epididymitis in Avhich  the  seminal vesicle of the
affected side Avas not invaded, though primary involvement of the
epididymis undoubtedly occurs.
   Diagnosis.—The diagnosis of tubercular vesiculitis is founded upon 
    INJURIES AND DISEASES  OF THE SEMINAL  VESICLES.   955

the discovery of an irregular, nodulated, non-sensitive  groAvth occu-
pying the position of the seminal vesicle, and associated with other
symptoms or signs of genito-urinary tuberculosis, such  as nodulation
of the epididymis, frequent urination, with passage of blood and the
finding of tubercle bacilli in the urine or the semen.   The ejaculation
of bloody semen  in the absence of other cause,  such as gonorrhoeal
spermato-cystitis, is especially characteristic.
    Tubercular vesiculitis occurring in the course of  gonorrhoeal pos-
terior urethritis can be recognized only by the gradual development
of a nodular semi-fluctuating tumor.  The termination is usually in
suppuration and the formation of fistulous tracts. Spontaneous cure
has been reported following evacuation of abscesses.
    Treatment.—In the absence of symptoms, and when  nodulation of
the epididymis is non-progressive, treatment may be confined to the
general hygienic, dietetic, and medicinal measures applicable to gen-
eral tuberculosis.  As in all inflammations or infiltrations of the pelvic
viscera, regular evacuations from  the bowels  are of  extreme impor-
tance, and as a means of lessening local congestion  the urine should
be  rendered unirritating and should be passed  at regular intervals.
If in spite of careful treatment inflammation is steadily  extending, Ave
believe that  excision of the infiltrated vesicle is indicated, even though
experience has shoAvn that a feAV of these cases after discharging un-
dergo resolution.
    The operation of excision is  neither difficult nor especially dan-
gerous.   The  objection to it is dependent upon the  facts  that the
prostate is commonly involved, that the bladder-walls are  frequently
infiltrated, and that complete removal is followed by the formation
of a fistula,  which is  likely to become tubercular through its whole
extent.
    Excision may be  accomplished through Kraske's incision for ex-
cision of the rectum, the bowel being carried to one side after partial
excision of the sacrum, or through Zuckerkandl or Von Dittel's incision.
The first consists in a semilunar cut extending from one  tuber ischium
to the other and SAveeping  convexly  in front of the  rectum.  The
perineal muscles and  the  pubic portion  of the  levator ani muscles
are divided, exposing  the  prostate  and the  seminal vesicles.  Von
Dittel, after  passing a catheter into the bladder and filling the rectum
with gauze,  to which  a string is attached, places the patient in the
ventral  decubitus, Avith the thighs  hanging over the  end of the table.
The incision is  then  made,  beginning at  the  coccyx and  carried
directly in  the middle  line to the middle of the perineum, making
a semicircular  SAveep around the anus.  This cut  is deepened, the 
956       GENITO-URINARY DISEASES AND SYPHILIS.

rectum being pushed aside until the seminal vesicles are reached.  It
must  be remembered that the latter are enclosed in a tough, fibro-
muscular  investment.  This  must be split before the vesicles are
shelled  from their position.  After thorough removal and curetting
the cavity should be packed with iodoform gauze.   When operation
cannot be undertaken, injections of a ten per cent, emulsion of iodo-
form in glycerin may be driven directly into the infiltrate through the
boAvel by means of a long needle.
   Malignant growth  of the seminal vesicle is  always  secondary
to malignant groAvth of the adjoining organs. 
CHAPTER  XXVII.
               INJURIES  AND DISEASES OF THE  PROSTATE.

    Anatomy of the Prostate.—The prostate is a genital organ, the
 bulk of which is made up of glandular tissue and smooth muscular
 fibres.  As is the case with all genital organs, it varies greatly in size ;
 in children it is rudimental.  At the age of puberty it grows rapidly,
 but does not attain its full development until about  the twenty-fifth
 year;  at about  the  fiftieth year there  is a  further increase of  size.
 On an average  the  normal  adult prostate is about  one and a  half
 inches wide at its base and one to one and a quarter  inches long and
 three-quarters of an inch thick.  It weighs  about six drachms.  In
 shape  it somewhat resembles a Spanish chestnut, though this is sub-
 ject to many variations.   It may be thin or thick, wide or narrow,
 short or long, symmetrical or irregularly developed.   To the exam-
 ining finger it is  often cordate, presenting a central notch at its base.
 The prostate is made up of two lateral lobes connected by an  isthmus,
 which, from its thickness and from the fact that it sometimes forms a
 distinct projection, has been called the third lobe.  It is placed behind
 and slightly below the symphysis pubis, lying between the posterior
 layer of the triangular ligament and the  neck of the  bladder, which
 is surrounded by its  base.  The under or posterior surface often pre-
 sents a central  furrow dividing  the  organ  into two distinct lobes.
 This surface is in intimate relation with the  rectum, from which it is
 separated by a fibro-muscular layer of fascia. The anterior surface
 faces  towards the pubis, from which  it is separated  by the plexus
 of Santorini  and the pubo-prostatic ligaments.   The   lateral surfaces
 are in relation with  the levator ani muscles, to  which they are at-
 tached by fibro-muscular fascia;  the vesico-prostatic  plexus  of veins
 is found in this region.  The base of the prostate embraces the  neck
 of the  bladder, forming a portion of its sphincter  muscle.   The apex,
 placed slightly below the loAver border of the symphysis, is continuous
 with the external vesical sphincter.
   Through the mid-portion  of the prostate forming the isthmus pass
 the  urethra and the ejaculatory ducts, and in this portion are also
placed  the verumontanum and the prostatic utricle.
   More than three-fourths of the bulk of the prostate is made up of
                                                         957 
958       GENITO-URINARY DISEASES AND SYPHILIS.

smooth muscular fibres.  These enclose the ducts and acini of many
compound racemose glands.  In these acini, after the age of puberty,
are frequently found albuminoid sympexes.   The greater number of
the excretory ducts open upon the floor  of the prostatic sinus, passing
somewhat obliquely.  Some  open into  the  sides or the roof of the
canal,  and  some into the prostatic utricle.   These glands are most
numerous in the posterior lower portion of the isthmus (middle lobe).
   The blood-supply of the prostate  is  derived  from the  internal
pudic,  vesical, and hemorrhoidal arteries.  The veins are particularly
numerous, and form a rich plexus about the sides,  base, and anterior
surface of the gland.  The nerves are from the hypogastric plexus.

          CONTUSIONS AND WOUNDS OF  THE PROSTATE.
   Contusion of the prostate is probably a  commoner accident
than is generally supposed.  It  may be  caused by  kicks or  blows in
the posterior perineum, or by jars such  as may be  received in horse-
back or bicycle riding.   The  symptoms  are those  of acute  prostatic
congestion,—i.e., deep-seated  pain, tenesmus, moderate ardor urinae,
frequency and urgency of urination, and sometimes a sense of rectal
fulness.  These symptoms subside in a few hours or a few days, and,
unless  there has been a preceding latent lesion, are unattended by
sequelae.
   The pathological alterations which take place from comparatively
slight contusions are unknown,  since they never  result fatally.  It is
possible that in the severer  forms there  are slight multiple  paren-
chymatous hemorrhages.
   Wounds  of the  prostate,  except  those  inflicted during the
course  of a  surgical operation, are of minor importance, since this
gland is so placed that the vulnerating body which  reaches it  almost
necessarily involves other and  more important structures.   Incision
into the prostate practised during the course of surgical operations is
unattended by danger, unless the rich plexus of  veins  placed at the
borders of  this  gland  and above  it is  also involved.   The hemor-
rhage then  may be serious or  even fatal.   From the prostate itself
bleeding  is  usually moderate, or,  if severe, is readily  controlled by
packing.
   Should infection occur, wounds of the prostate  may be extremely
dangerous, since septic phlebitis may result, rapidly extending along
the large, freely anastomosing pelvic veins, and causing septicaemia or
pyaemia.   If suppuration takes place  in the coats of the veins, they
may undergo fatty metamorphosis and  break down, causing  serious
hemorrhage. 
INJURIES AND DISEASES OF THE PROSTATE.
959
   Prostatic wounds involving the urethra are subject to the dangers
of internal hemorrhage and urinary infiltration.  The blood may flow
backAvard into the bladder, filling it Avith a thick, clotted mass, Avhich
may be extremely difficult to dislodge.  If the bleeding  is profuse, a
hard, globular tumor may form above the pubis.
   Prognosis.—Wounds of the prostate, particularly those which do
not involve the urethra, heal promptly, provided they are kept clean.
When the urethra is opened there is little danger of urinary extrava-
sation if  abundant  provision is made for drainage.  These wounds
generally heal  kindly, and are seldom followed  by urinary fistula or
interference Avith  micturition;  exceptionally the  formation of a  pros-
tatic cicatrix  interferes Avith the action of the vesical sphincter and
causes a more or  less permanent condition of incontinence.
   When the prostate is extensively injured and the capsular invest-
ment  widely  torn, dangerous  complications, such as pelvic cellulitis
and even peritonitis, may follow. The lacerated and contused wounds
caused by forced  catheterization, as a rule, heal  kindly, provided the
urine  is  not  infected.  If this fluid is septic and if the prostate  is
already infected, abscess-formation, phlebitis, and infiltration, ending
in septicaemia and death, are common.
    Treatment.—A wound  of the prostate not involving the urethra
should be cleansed  and packed with  sterile gauze.   If in the course
of twenty-four hours urination becomes  difficult, consequent  upon
inflammatory action, a permanent catheter should be worn for tAvo or
three  days, in the manner  described when treating of retention of
urine from  enlarged prostate.   If the prostatic urethra or the vesical
neck has been opened,  a soft catheter should be passed through the
urethra into the bladder, and retained there for several days, and the
perineal wound should  be cleansed and packed.  If it is impossible
to introduce an  instrument into the  bladder, median perineal ure-
throtomy should be performed, and a large, soft drainage-tube should
be carried through this  opening into the bladder and retained  there.
If there is bleeding, the catheter en chemise should be introduced.
   When the  wound has been caused  by forced catheterization and
the bladder is full  of blood,  this should  be  Avithdrawn by suction
through  a large woven or metal catheter, or through the evacuating-
tube used in  litholapaxy,  if this instrument can  be introduced.  A
full-sized  catheter is  then passed into  the  bladder and is retained for
several days, the bladder and urethra  being flushed out several times
daily Avith a mild  antiseptic solution.
   Should symptoms of local abscess or septic infection  develop, the
prostate should be opened by median  perineal  urethrotomy and thor- 
960        GENITO-URINARY  DISEASES AND  SYPHILIS.

ough drainage secured  through this opening.  If after Avounding  the
prostate  by forced  catheterization no instrument can  be  introduced
into  the  bladder,  median cystotomy  should be  performed.  When
hemorrhage into the bladder  is unattended  Avith symptoms of dis-
tention or local  inflammation,  surgical intervention may be delayed,
provided the urine is sterile and the urethral instrumentation has been
practised  with proper  antiseptic precautions.   There is, however,
ahvays a  risk of bacterial infection: hence it is wiser to disintegrate
the clots by vesical irrigation and at the same time keep them sterile
by using antiseptic solutions.  Carbolic acid  1  to 500 and corrosive
mercuric  chloride 1 to 4000 will usually suffice.  Urinary  antiseptics
should at the same time be given by the mouth.

                           PROSTATITIS.
   Inflammation of the prostate may be acute or chronic; it has also
been  classed as follicular,—i.e., confined to the glands and  periglan-
dular tissue,—or parenchymatous, attacking the entire organ.
    Causes.—The immediate cause  of prostatitis is infection.  It is
true that inflammatory  reaction invariably folloAvs traumatism, but in
the absence of infection this undergoes prompt  resolution.   Infection
may be conveyed along the urethra, as in the case of gonorrhoea; may
be either haematogenous or carried by the urine,  as in prostatitis which
complicates small-pox, scarlet fever, typhus, typhoid, and other infec-
tious  diseases; or may reach the prostate by contiguity of structure,
as from periprostatic suppuration.
   Congestion is a  condition which strongly predisposes to infection,
and  which  is apparently essential to its  development.   Congestion
may be due to traumatism, as  from instrumentation or jarring of  the
perineum, excessive  venery,  constipation, masturbation,  prolonged
ungratified  sexual  excitement, hemorrhoids, irritating applications,
strongly  acid  or alkaline  conditions  of the  urine, urethral calculi,
varicose  condition of  the prostatic  plexus, over-distention  of  the
bladder, atheromatous vessels, chilling, over-fatigue, and a variety of
other causes.
   The common  causes of acute prostatitis are the  backward  ex-
tension of gonorrhoeal urethritis and the introduction of unclean in-
struments.  The bicycle has been arraigned as a frequent exciter of
prostatic inflammation.   Careful investigation convinces us that  bi-
cycling does not predispose to diseases of the  prostate or othenvise
injuriously affect the gland, especially if a correct  attitude be main-
tained.  Every surgeon sees cases of transitory prostatic irritation,
nearly ahvays due  to the use of a saddle Avhich presses on  the peri- 
INJURIES AND  DISEASES OP THE PROSTATE.
961
neum.   There are some patients with  sensitive  prostates in whom
the jarring inseparable from  riding always produces an aggravation
of symptoms.   These are, however, few, and the great majority of
such patients experience  distinct relief, due  probably in  the main to
the beneficial effects of exercise, yet doubtless in part to direct stimu-
lation of the prostatic circulation.  With a proper seat which supports
the Aveight on the tuberosities of the ischium Avhen the patient assumes
the correct  position, Ave believe that bicycle  riding is  entirely unob-
jectionable so far as the prostate is concerned.
    In the early stages of acute prostatitis there are marked dilatation
of the prostatic plexus of veins and increased vascularity through the
entire gland ; the inflammation, usually beginning in the mucous mem-
brane of the urethra, extends primarily along the ducts of the glands,
and secondarily, when these have become obstructed, forming suppu-
rating retention cysts,  through the  parenchyma of the organ.  Ab-
scesses  may appear  in the  form  of small multiple  foci or as large
collections.  The small foci represent the glands transformed to sacs
containing  mucus, epithelium, and pus, the  ducts being partially or
completely obstructed.  As the inflammatory secretion increases in
quantity the glandular capsule may rupture, several of the suppurating
glands becoming confluent, forming large accumulations.   The ejacu-
latory ducts are ahvays involved in the  general catarrhal inflamma-
tion, and frequently become occluded  from  inflammatory swelling
and epithelial proliferation.   There results  tension in the seminal
vesicles  and the ampullae of the vas.   This increases congestion, and
thus strongly predisposes to further extension of inflammation.   The
prostatic utricle is also  involved.
    Exceptionally inflammation extends beyond the proper capsule of
the gland, involving the  tissues lying between the prostate and  the
rectum, or  even the subperitoneal connective tissue.  This peripros-
tatitis may be due to rupture of the pus through the glandular capsule,
or to transmission of infection through the medium of the veins and
lymphatics.  The infiltration may undergo resolution or may suppu-
rate ; suppuration is commonly encountered on the posterior surface
of the gland,—i.e., between it and  the rectum.   It  may form an
abscess  completely surrounding the vasa deferentia and the seminal
vesicles  without exhibiting any tendency  to rupture into them.
    From this brief outline of the pathology  of the inflammation it is
evident  that prostatitis  may be manifested in the form of acute hyper-
aemia and swelling, usually secondary to acute catarrh of the prostatic
urethra; in that of acute folliculitis, the inflammation involving not
only the prostatic  urethra, but also the  prostatic ducts and their ac- 
962        GENITO-URINARY DISEASES AND SYPHILIS.

companying glands, and transforming them into sacs filled Avith muco-
pus ; in that of a large destructive abscess due to fusion of the smaller
suppurating foci; or in that of a periprostatitis.
   Symptoms.—The  symptoms of  prostatitis vary in accordance with
the form and severity of the attack.  In the mildest form,  character-
ized by acute congestion, there are feelings of Aveight in the perineum,
shooting pains, frequency of urination, and possibly difficulty in start-
ing the  stream  and failure  to  experience complete relief after the
bladder is apparently empty, pain  on defecation, and tenderness and
enlargement.  When inflammation is more pronounced, involving the
glands and their ducts, the symptoms already noted are  increased in
severity; there is often the sensation as though a foreign body Avere
stuffed in the rectum ; urination is frequent and urgent; a small stream
is passed without force, and often intermittently, and the pain is severe.
When there is an abscess-formation in or about the gland  both local
and general symptoms are usually pronounced.  There is  constant
pain in the perineum,  aggravated  by urination, defecation, or motion
of any kind ; sitting down or crossing the legs is particularly painful.
There is a constant, urgent, wearing desire to urinate, each act of mic-
turition voiding a small forceless stream.  Defecation may cause great
anguish.  Painful erections are frequently observed.  Rigors or chills,
followed by fever and headache, are nearly constant.  As the swelling
becomes greater, urination  is correspondingly more difficult,  until
finally complete retention  may  result.   Hemorrhoids often  develop,
caused  by pelvic  congestion, or possibly by the constant  straining
efforts at urination which prostatitis often occasions.
    Diagnosis.—The  diagnosis of acute prostatitis is  founded on the
detection by rectal palpation of a hot, tender tumor occupying the
position of the prostate.   This, in  conjunction with some  or all of
the above  symptoms, and especially with fever and with pain Avhich
is  especially severe during defecation and at the end of urination, is
sufficient to establish the diagnosis.
    Prognosis.—The  prognosis of  acute prostatic congestion, in the
absence of  infection, is extremely favorable ; even when there has been
infection, provided the urethra is  free from  abnormal narrowing and
there is  no local or general cause for chronic  congestion, recovery is
the rule.   When follicular or parenchymatous suppuration has taken
place, the prognosis is still favorable, although there is always danger
of septic phlebitis.   The glandular abscesses commonly rupture into
the urethra, and this is considered a favorable termination.  So far
as relief of immediate  symptoms is concerned, this is  undoubtedly
correct; but when  the  abscesses  are  of considerable size this ter- 
INJURIES  AND DISEASES OF THE PROSTATE.
963
mination is less favorable, since there is often left a pouch or cavity
which will continue to suppurate indefinitely, thus maintaining a con-
dition of chronic prostatitis, and  in  which the  urine  is lodged, de-
positing calculi, which ultimately burroAv through  the prostate  and
cause uro-purulent infiltrations of the surrounding tissues or fistulae.
    Acute  parenchymatous prostatitis characterized by rapid, purulent
breaking down of the  entire gland may result fatally.
    Segond in  one  hundred  and fifteen  cases  of  prostatic abscess
noted rupture into  the urethra in fifty-five.   The ordinary directions
of pointing were towards the  urethra, the rectum, and the perineum.
The pus  may  exceptionally point in the inguinal  or the  obturator
region ; with extreme  rarity in the space of Retzius, in the peritoneal
cavity, or through the  sciatic foramen.
    Forgue reports that forty-three cases out of a total of sixty-seven
opened into the rectum.   In  twenty-one of these pus was evacuated
into both the rectum and the urethra.   The opening of such abscesses
into the recto-vesical  space is usually attended with the formation of
multiple fistulae, which are difficult to cure.
    Segond calls attention to the frequency of phlebitis when prostatic
abscess is not properly drained.  About forty per cent, of the deaths
are due to this cause.   He reports the total mortality as thirty-four in
one hundred and fourteen cases.  This is extraordinary, and is not to
be accepted as the usual result.  The mortality in our experience has
not been above tAvo or three per cent.
    Treatment.—The treatment of acute prostatitis is that already out-
lined  in the section devoted to the treatment of gonorrhoeal prostatitis.
This consists in rest in bed, elevation of the pelvis, counter-irritation
or local depletion by the application of counter-irritants or leeches to
the perineum, followed by hot  fomentations, hot or cold rectal  douches,
the use of  opium and  belladonna suppositories, the internal  adminis-
tration of  urinary antiseptics and bromides, and the ingestion of large
quantities of water.  The diet  should  consist principally of milk.  Hot
hip-baths  or hot general baths markedly diminish the pain and tenes-
mus, and  may  be administered several times a day,  the patient being
subsequently well Avrapped  up.  The temperature of the water should
be at  least 105° F.  In the beginning of the attack the boAvels should
be freely opened by salines.  After this there should be no effort to
procure evacuation  for several days, unless there is reason to believe
that the rectum is filled with faecal matter.
   The  most  troublesome  complication is retention of urine.  This
is overcome by the introduction  of  a soft catheter.   When this is
especially  difficult or painful there should be given an anaesthetic, and 
964        GENITO-URINARY DISEASES  AND SYPHILIS.

an instrument  having once been introduced  should  be left in place
until the acute  symptoms have subsided.
   When an abscess opens into the urethra spontaneously or as the
result of catheterization, on the subsidence of acute symptoms every
effort should be made to cause cicatrization of the cavity.   If this is
small, spontaneous healing often takes place.  If it  is large,  suppu-
ration  continues, kept up in a measure by the urine, Avhich, lying in
this sac, decomposes,  becomes irritating, and often deposits  calculi.
The  tendency of this  ulcerating sac is towards  gradual  extension,
destroying the  proper capsule  of  the prostate  and  causing  either
extravasation of urine or periprostatic  abscess.   Obstinate  fistulae
are likely to form as the ultimate result  of these untreated abscess-
cavities.
   As  soon as  the acute inflammatory symptoms have subsided, the
suppurating cavity should  be washed out twice daily.  This  is ac-
complished as  folloAvs.  By means  of a  finger introduced into  the
rectum the prostate is Avell  milked and  the  abscess  emptied of its
pus.   The patient is then directed  to  urinate, and the urethra and
bladder are irrigated with a mild antiseptic  solution;  boric acid or
silver nitrate answers well.  The prostate is again milked, and the
patient evacuates that portion of the irrigating  fluid Avhich has entered
the bladder.  This is repeated two or three times at each treatment.
   When there is no tendency toAvards the  spontaneous evacuation
of the  abscess  through the urethra, and  the chills, fever, and throb-
bing pain in the perineum persist, and there is marked increase in the
SAvelling, the pus  should be evacuated by perineal incision.  There
should  be no  hesitation under  these  circumstances in performing
the operation,  since, unless  the  abscess  ruptures into the urethra,
it is  liable to burst  through the capsule of  the gland, infiltrate the
deep pelvic tissues,  and not infrequently cause pyaemia and death.
The  operation  should be conducted under an anaesthetic, the pros-
tate being exposed by a semilunar  incision  in front of the rectum,
deepened by gradual dissection.   The  focus of suppuration may then
be detected by  the exploring needle.   When the tumor is obviously
fluctuating it may be opened by a long, straight bistoury thrust in the
middle  line of  the perineum directly in front of the rectum, with its
back towards  this structure and guided towards  the  abscess by a
finger  introduced  through the anus.   After opening  the abscess the
cavity should be flushed out, and should be  drained either by gauze
packing or by tubes.  Urethral  fistula occasionally follows, but usu-
ally closes spontaneously.
   The treatment of periprostatitis  and  periprostatic abscess  is the 
INJURIES AND DISEASES OF THE PROSTATE.
965
 same as that described as applicable to prostatitis.   The pus  is apt
 to point in the  posterior or anal perineum and to invade the ischio-
 rectal space, inasmuch as its  origin is behind  the  middle perineal
 fascia.
    Chronic Prostatitis.—Following  an acute attack of prostatitis,
 or secondary to posterior urethritis or cystitis without a history of an
 acute attack, the  prostate may  become chronically inflamed.  The
 exciting cause is infection, the predisposing  cause congestion.   This
 congestion may be due to long-continued  irritating injections, exces-
 sive  coitus, masturbation, hemorrhoids, habitual constipation, irri-
 tating conditions of the urine, or any  of the conditions which have
 already been mentioned as causing pelvic engorgement.
    The pathology of the affection varies.  There is practically always
 chronic posterior  urethritis.  Associated with this  there may be  a
 catarrhal condition of the prostatic glands, attended by distinct dilata-
 tion of their ducts  and  acini  and  marked  thickening  of  the peri-
 glandular tissue.
    There may be  one  or  many abscesses  discharging into  the pros-
 tatic  urethra through  openings  insufficient  for thorough  drainage.
 These are'attended by general  engorgement, and  ultimately result in
 the development of  fistulae, or in cicatricial  deformity or atrophy of
 the prostate.
    Symptoms.—The  symptoms  of chronic prostatitis are practically
 those of posterior  urethritis.  There is increased  frequency in urina-
 tion, deep perineal pain Avhich radiates to the  rectum, scrotum, and
 down the thighs and is made worse by exertion, slight tenderness in
 the perineum, thickening and  sometimes irregular nodulation of the
 prostate.  After urination and during defecation there is a viscid
 milky discharge, containing pus, columnar epithelium, and amyloid
 prostatic bodies.  The  pain is often severe at the end  of  urination,
 and may  be felt either in  the  deep perineum or in the urethra, a
 quarter of an inch behind the meatus.  It is burning in character.
 After  defecation there may be severe burning perineal pain, lasting a
 few minutes or  for several hours.  There are frequent intercurrent
 subacute attacks of inflammation, and  these  patients very commonly
 suffer from headaches or muscular and joint pains similar to those due
 to toxaemia from other causes.  There are often loss of sexual desire,
great weakening of sexual power, and frequent pollutions.   On rectal
examination the prostate may be unduly sensitive at some portion of
its surface.  It  may or may not be enlarged, and sometimes  is dis-
tinctly bossed or asymmetrical.   The urine passed after milking this
organ  contains a considerable quantity of pus.   The  introduction of 
966        GENITO-URINARY  DISEASES AND SYPHILIS.

an instrument into the prostatic urethra gives more pain than is  nor-
mal, and its  point may become  engaged in an abscess-cavity.  The
most pronounced  symptom in these cases is the profound alteration
of disposition.  These patients become melancholic, neurasthenic, and
invalided.
   Prognosis.—In chronic prostatitis the  lesions of which are mainly
congestive, Avith follicular catarrh not yet having developed to distinct
abscess-formation, there  is a  tendency  towards  spontaneous cure.
Small abscess-cavities also heal.   The  larger sacs  show no such ten-
dency.  They are rather  inclined slowly to extend, causing peripros-
tatic abscess and urethro-rectal or urethro-perineal  fistulae,  often
complicated by calculi.
    Treatment.—On beginning  the treatment of chronic prostatitis the
patient should be informed that cure is slow and  difficult and is de-
pendent upon persistence in the use of appropriate therapeutic meas-
ures and faithful  observance of the laAvs of  health.   General direc-
tions are given  in regard to diet, exercise, and hours of  sleep.   The
urine is rendered bland and slightly antiseptic.  The bowels are prop-
erly regulated by enemata; erotic excitement is avoided.  Ordinary
sexual intercourse need not be forbidden.  It is undoubtedly true that
many cases of chronic prostatitis would be cured by  hygiene alone if
it included regular and  unemotional sexual  gratification.  Unfortu-
nately, the majority of these  patients are young,  unmarried adults,
and, even  if  the question of morals were set aside,  it would not be
possible for them to secure sexual relations  that  would meet their
requirements.  Hip-baths of  a temperature  and  duration governed
by the sensations of the  patient  are useful.  Rectal  lavage with hot
or cold normal saline solution should be used daily.   The use of the
cold jet by means of the  bidet is markedly beneficial in many cases.
   Urethral irrigations followed by massage, as described  in the treat-
ment of prostatic  abscess, are  serviceable even Avhen pus-collections
are not present, since this  treatment expresses the contents of the
prostatic glands and enables  the cleansing, slightly stimulating  fluid
used for irrigation to  act directly upon the diseased and congested
mucous membrane.  In a chronic  prostatitis kept up by pus-cavities
massage is  of special importance.
   Local applications to the prostatic urethra are generally indicated
for  the relief of the accompanying posterior urethritis.   These are
selected and applied in  accordance Avith the principles  already laid
doAvn, but  should be used cautiously, since reactionary swelling  may
entirely close the  urethral opening of a  chronic abscess, causing re-
tention of pus, extension of parenchymatous inflammation, and septic 
          INJURIES  AND DISEASES OF THE PROSTATE.       957

absorption.   If the reaction following the use of weak instillations is
unusually prolonged and severe they should be discontinued.
   Irritable  Prostate.—This is a  condition  characterized by  re-
peated rather sudden  and acute engorgements of the prostate, usually
dependent upon an abnormal condition of the urine, such as excessive
acidity.  It  is also due to chilling and other Avell-known causes of
pelvic congestion.   It is probable that it does not attack the perfectly
healthy prostate.  It  has  been so  often observed in gouty patients
that the manifestations of this  form of  irritability are in them called
prostatic gout.
   The symptoms are  those of the  first stage of acute  prostatitis.
There  develops often  in the night urgent, frequent, painful urination.
There  may  be steady or shooting pain  felt in the perineum, testicles,
or back.  On rectal examination the prostate is hypersensitive.  In
gouty patients the urine is extremely acid and contains an excess of
mucus.  The symptoms  attain their maximum severity during the
night, and the prostate remains sensitive for some time.  This condi-
tion of irritability may be the first step in the development of cystitis
or calculus-formation.
   Diagnosis.—An irritable prostate is distinguished from an inflamed
gland by rectal palpation  and examination of the urine.   Inflamma-
tion is ahvays accompanied  by the formation of pus and by marked
increase in the size of the prostate.   The diagnosis of prostatic gout
depends upon the constitutional  history of the  patient and examina-
tion of the urine.
    Treatment.—The irritable prostate is amenable to treatment directed
to the relief of congestion.  Acid or irritating  conditions of the urine
should be remedied, sexual excess, constipation, and the well-recog-
nized causes of pelvic congestion  should be avoided, and the prostatic
circulation should be strengthened by massage, hot rectal injections,
and the application of electricity.  In general the treatment applica-
ble to the early stages of acute prostatitis is serviceable for the relief
of acute attacks.  The medicinal treatment is directed to the equaliza-
tion of circulation and the general strengthening of the patient. Hyos-
cyamine and ergotine seem to have some value by their direct action
on local circulation, and may be given in the form of  suppository.

                TURERCULOSIS OF THE  PROSTATE.
   The prostate is nearly always affected in  genito-urinary tubercu-
losis, KrzyAvicki  noting  that of fifteen cases the gland shoAved lesions
in fourteen.  Tuberculosis  may be  primarily  in  the prostate  or
secondary to involvement of organs either adjacent or remote.  The 
968        GENITO-URINARY DISEASES AND SYPHILIS.

proportion of cases in which the disease is primary in the prostate is
not known, since there have been few opportunities offered  for post-
mortem  examination  until tuberculosis  has been  widely diffused.
There have, however, been a sufficient number to prove that the first
manifestation of the disease may appear in the prostate gland.  This
gland is particularly susceptible to infection of all  kinds, Weigert
having proved that it is involved in the majority of cases of pyaemia
and septicaemia.  Tubercle bacilli have been found in the apparently
healthy prostate.
   Tubercular prostatitis is commonest in the prime of life.   It is
often excited by posterior urethritis ; at least the histories of many of
these cases show that tubercular involvement followed gonorrhoea.
It is  evident that any of the causes of prostatic congestion may thus
predispose to the local development of tuberculosis.  The morbid
anatomy of tubercular prostatitis is that characteristic of tubercular
involvement in general,—i.e., exuberant granulation, central degenera-
tion, and caseation.  The tubercles are first lodged in  the Avails of the
glandular ducts, extending through a part or the Avhole of the gland,
and  ultimately either undergoing encapsulation or absorption, a rare
termination, or softening and breaking down, forming abscess-cavities.
   The prostate is usually enlarged  from  inflammatory congestion;
abscess-formation takes place slowly but surely.  Exceptionally the
lesions  develop  in the loAver outer portion of the gland  near  the
rectum ; usually  they are observed near the  urethra.  In  this  case
ulcers are formed which steadily extend.   Abscesses developing in
the substance of the gland, though occasionally sclerosing and healing,
commonly enlarge steadily, opening into the urethra,  the rectum, the
perineum, or even the hypogastrium, and forming multiple fistulous
tracts.   Tuberculosis of the prostate becomes generalized slowly.
   Symptoms.—The symptoms of tubercular infiltration of the prostate
are practically those of chronic prostatitis, and are probably dependent
upon involvement, or  at least secondary congestion,  of the prostatic
urethra.   The patient  complains of frequent, often urgent, urination,
and  a slight  continuous or intermittent, glairy, muco-purulent dis-
charge from the meatus.  Shreds are constant in the urine ; there may
be a discharge after defecation  or even after each act of urination  ;
sometimes one or two drops of blood are passed at the end of uri-
nation,  and  attacks  of acute or subacute prostatitis are  excited by
slight and apparently insufficient causes.  When the parenchymatous
or peripheral portion of the gland is involved there may be no symp-
toms for a long time, or the patient may note  slight pain during defe-
cation  and burning pain  afterwards.  In certain cases the disease 
          INJURIES AND DISEASES OF THE  PROSTATE.       969

appears to begin as an acute  parenchymatous prostatitis.  On the
subsidence of the  early inflammatory symptoms nodulation may be
felt.
   Diagnosis.—This is based on finding the tubercle  bacilli in "the
discharge milked from the prostate and subsequently voided with the
urine, on the detection of thickening, nodulation, or points of soften-
ing on rectal examination, and on the discovery of tubercular involve-
ment of the epididymis or the seminal vesicles.  The infiltration some-
times spreads Avide of the prostate, forming a large, irregular, diffuse
mass entirely obscuring the outlines of the prostate and vesicles.
   Prognosis.—This is extremely grave.   Spontaneous cure  by a
process of sclerosis, though possible, is rare.
    Treatment—The treatment should be directed towards improving
the general health of the patient, and is practically that appropriate to
pulmonary  consumption.    As a rule,  local  instrumentation  and
applications should be avoided, with the exception of instillations
of mercuric bichloride (1 to  6000).  These  may be  employed as
directed in  the  treatment of tubercular  cystitis, and are serviceable
only when the infiltration begins in the urethra or in  the ducts of the
glands.  Silver nitrate causes exacerbation of  suffering;  indeed, this
is so marked as to be of some diagnostic value.
    In conducting local treatment it  must be remembered that tuber-
 cular infiltration especially predisposes the involved portions of  the
prostate, and the bladder, which also often shows tubercular lesions,
to the invasion of the ordinary pus micro-organisms:  hence special
antiseptic precautions should be taken in the use of instruments.
    Direct operative treatment is indicated when the general condition
 of the patient is fairly satisfactory and it is evident  that the disease
is steadily progressing.  The simplest form of intervention consists
in parenchymatous injections of ten per cent, iodoform-glycerin emul-
sion, driven directly  into the prostatic  substance by a  long needle
introduced  through  the  perineum  and guided  by a  finger in the
rectum.   Each of these injections is followed  by some inflammatory
reaction.  In  other regions of the body they  have been so service-
able that there is reason to hope that injection of from ten to fifteen
drops  of the  emulsion every third  or fifth day may be followed by
sclerosis and cure of the tubercular  infiltrate.
   Incision is indicated when an abscess develops which  threatens to
form a fistula.  The prostate should  be fully exposed by the semilunar
incision in front of the anus, and all the diseased tissue should be
removed by the curette, the urethra not being  opened if it is possible
to avoid this.  The wound is treated by packing with iodoform gauze. 
970        GENITO-URINARY DISEASES AND SYPHILIS.

Abscesses  opening into the urethra are kept  clean  by irrigation.
Retention of urine is relieved by continuous catheterization or supra-
pubic drainage.

                ENLARGEMENT OF THE PROSTATE.
   Enlargement or hypertrophy of the  prostate consists in an over-
growth of the normal cellular constituents of the gland taking place
in the lobes or the isthmus or affecting the entire organ.   At the be-
ginning of the overgroAvth the change in form  is best expressed by
what Thompson calls an unnatural tendency to rotundity.  The gland
is increased in thickness rather than in other dimensions, the lateral
lobes encroaching to some extent upon the  urethral  lumen.  If the
enlargement is progressive it is likely to be somewhat irregular, certain
portions of the gland increasing more rapidly than others.  The poste-
rior isthmus, the so-called median lobe, is frequently affected, though
the bulk of the growth  may occupy one lateral  lobe,  or bosses may
project from both lobes and the isthmus, producing great distortion
of the urethra, diverting it from its normal course, and  sometimes
considerably lengthening it..  The growth is  most rapid in the lower
posterior isthmus (median lobe).
   Thompson classifies the common forms of enlargement as follows:
   a. Over-development of glandular and stromal tissues in nearly
their normal proportion,—true hypertrophy.   The organ is evenly
but not greatly enlarged, and the growth seldom causes symptoms of
importance.
   b. Increase in the  stromal tissue, chiefly the white fibres, and not
of the muscular elements.  This is the common form of enlargement,
and  may attain large  size.   It should be classed as a fibrous hyper-
plasia, since it shows no tendency to contraction.  It is not associated
Avith impaired blood-supply, and is not a process of degeneration in
pre-existing structures.
   c. In the third class the overgrowth of glandular tissue predomi-
nates over the stromal; this is rarely permanent, the glandular tis-
sue gradually disappearing and being replaced by a fibrous groAvth of
greater density.
   d. Simple tumor-formation,—a local hypertrophy commonly ob-
served.   (Fig. 244.)  These small tumors are found in almost every
case of hypertrophy of the  prostate, and  seem to be confined to
no particular portion.   They may extend  a considerable  distance
from the gland,  pushing the capsule ahead of them, and  may be
connected with the prostate by only a thin band of fibrous and glan-
dular tissue. Their form and direction  are of more importance than 
Fig. 244 A.
Bilateral hypertrophy of the prostate.  A thick rigid bar at the neck of the bladder
                     unites the two lateral lobes.  (Watson.) 
Fig. 245.
Hypertrophy of the median lobe of the prostate.  (Watson.) 
          INJURIES AND DISEASES  OF THE PROSTATE.       971

the absolute increase in size.   Thompson  thus  groups the enlarge-
ments in accordance with their position :

                             Fig. 244.
Separate tumors springing from the lateral lobes of the prostate.  (Watson.)
   1. General enlargement of the prostate;  that is, both lateral lobes
and median portion are equally increased in size.  (Fig. 244 A.)
   2. General enlargement,  most  marked  in the  median portion.
(Fig. 245.)
   3. General enlargement, most marked in the right lobe.
   4. General enlargement, the left lobe predominating.
   Under these headings are included a large number of minor varia-
tions.  Thus, but one lobe may be involved, or one lobe and the pos-
terior commissure.  (Fig. 246.)   The direction  of growth may be
toAvards the bladder, the urethra,  or the rectum.   The overgrowth
may be  limited to the posterior isthmus, which may form a project-
ing intra-urethral or intracystic  sessile or pedunculated mass (bar at
the neck  of the  bladder), which  may seriously interfere with uri-
nation.  Thompson  finds  that hypertrophy commonly involves the
lateral lobes and the median portion of the  prostate, and that the
overgrowth proceeds at about an equal  rate in each of these regions,
though in exceptional instances it becomes irregular, showing greater
activity in one portion,  commonly  the median.  The  anterior com-
missure  (isthmus) has only exceptionally been involved.
   As to the amount of overgroAvth, this varies between wide  limits.
The tumor may be little larger than normal, or may reach the size of 
972        GENITO-URINARY  DISEASES AND  SYPHILIS.

an orange.   Thompson reports a case in Avhich the growth was as
large as a full sized-cocoanut.
   Far more important than the position and size of the growth are
the alterations it  causes  in  the length, direction, and calibre of the

                               Fig. 246.
 Hypertrophy of the median and one lateral lobe of the prostate,  a, interureteral bar.  (Watson.)

prostatic urethra, and in the patulousness of the neck of the  bladder.
In consequence of the increase in thickness and the growth of the
lateral lobes, the transverse diameter of the urethra is lessened, and its
length is increased, in some cases by as much as three and  one-half
inches.  If the growth is  asymmetrical, the canal will  be deflected
from  its regular curve.  Thus, if the median portion enlarges more
rapidly than the lateral lobes  the  floor of the urethra is lifted up,
forming an abrupt projection, which effectually prevents the introduc-
tion of the ordinary silver catheter.  When one lateral  lobe  is devel-
oped  more than another there is lateral deviation, Avith the concavity
of the curve toAvards the most affected  side.  Thompson describes a
form  of deviation  due  to  overgrowth of the median  commissure. 
          INJURIES  AND DISEASES OF  THE PROSTATE.        973

There is formed a pyriform tumor, which projects into the vesical end
of the urethra, leaving a passage on either side.
   It is evident that  a comparatively slight projection at the vesical
neck will seriously interfere with the function  of  micturition.   This is
particularly the case in those tumors Avhich project from the median
portion of the gland.
   Watson found the chief obstruction to urination to be median en-
largement in nearly ninety per cent,  of the cases he collected.
   The posterior commissure  growing backAvard  into  the  bladder
may become pedicled, forming  a true  valve;  commonly it  is  sessile.
The lateral lobes may project backward about the vesical neck in the
form of multiple  tumors,  Avhich encroach  upon the vesical cavity and
lift the neck above the level of the base, forming  two vesical pouches,
one above  and in front, behind the pubis, the other below the pros-
tate  in the bas-fond.  The  lower pouch is usually caused by over-
growth of the posterior  commissure (median  lobe).   (Fig. 247.)   Be-

                              Fig. 247.
   Bladder and prostate cut through longitudinally in the median line,  a, lateral lobe; b, median
lobe; c, depression behind the middle lobe called the bas-fond; d, prostatic urethra; e, bladder-
wall. (Watson.)
tween the ureters  there  is normally an interureteral bar, made up
of muscular fibres, not distinguishable except  by dissection  in  the
normal bladder; this bar becomes greatly hypertrophied in enlarged
prostate because of the frequent straining efforts to expel  urine from
the region in Avhich it is apt to accumulate and cause  irritation. 
974       GENITO-URINARY DISEASES AND  SYPHILIS.

    The average weight of the normal prostate is  between four and
five drachms; should it weigh over six and a half drachms it may be
considered enlarged.   Thompson's and Messeris tables sIioav that the
healthy prostate does  not Aveigh  over six drachms; there are, hoAV-
ever,  many  prostates Avhich, even though  they weigh under six
drachms, yet show signs of hypertrophy in the shape of small tumors.
The enlargement  can be estimated  clinically by exploration  of the
urethra and rectal examination of the prostate.
    Prostatic  enlargement occurs, as a rule, in men Avho  have passed
the age of fifty-five.   There are  many exceptions in Avhich the gland
enlarges and causes obstruction  at a  much earlier age.  Mudd has
reported a case of prostatic hypertrophy in a negro only twenty-seven
years old.   On the  basis  of extensive tabulations it  is, however,
apparent that enlargement of the prostate begins only exceptionally
under the age of fifty or after that of  seventy.
    The time of life at which it makes its first appearance  must not be
confounded with the age at which residual  urine is observed, as the
growth may have  been present for years Avithout giving rise to this
particular, result.   Indeed, the prostate may attain very large  dimen-
sions without interfering with the function of urination.   It has been
estimated that  over eighty per cent, of old men with enlarged pros-
tates are free from serious urinary symptoms.
    A section  of an enlarged prostate gland shows  an irregular bulg-
ing, presenting  musculo-fibrous, spheroidal  projections, which can be
readily shelled  out from the  surrounding tissues.  These spheroidal
masses may become  pedunculated, projecting into the urethra or the
bladder; they have been compared by Thompson to  uterine fibro-
myomata.  The  little tumors are made  up  of  connective tissue,
smooth muscular tissue, and centrally of glandular elements.
    As to the  cause of prostatic overgrowth, no absolutely satisfactory
explanation has  yet  been given.   Thompson states that, far from
being usual in elderly men, it is an  exceptional  condition,  though
it is probable that there  is  a slight  tendency towards  overgrowth,
which  gives rise to no symptoms, but which occurs in one-third of
all  men  past sixty years  of age, and that appreciable enlargement
will be encountered in about one-eighth of the men of that age or
upward. The  probability of the enlargement being an exaggeration
of a physiological  process is suggested by the fact that small encap-
sulated  fibromyomatous tumors are found in otherwise  healthy and
unchanged prostates.
    As a working hypothesis the following explanation has  been sug-
gested (White): 
          INJURIES AND DISEASES  OF THE PROSTATE.       975

   The function of the testis, like that of the  ovary, is twofold,—the
reproduction of the species and the development and preservation of
the secondary sexual characteristics of the individual.  The need for
the exercise of the latter function ceases when full adult life is reached,
but it is possible that the activity of the testis and that of the ovary in
this respect do  not disappear coincidently, and that hypertrophies in
closely allied organs like the prostate and the uterus  are the result of
this misdirected energy.  This hypothesis would increase the analogy
between the  fibromyomata  of the uterus and the  adenofibromata
of the prostate, Avhich, from a  clinical stand-point, is  already very
striking, and is further strengthened by the  almost identical result of
castration in the tAvo conditions.
   The dependence of prostatic enlargement upon general atheroma
remains to be proved, though  it is undoubtedly true that these tAvo
elements are often associated and are common at the same period of
life.  There is a variety of overgrowth in which the prostate becomes
excessively hard, showing  little alteration in shape or size, but giving
rise to marked obstruction.  Such a condition as this may have for its
cause  a general sclerosis, though it is more probably due to fibroid
degeneration folloAving chronic inflammation.
   Symptoms.—The symptoms of enlarged  prostate are  mainly de-
pendent upon interference Avith the function of micturition: hence
it is possible when  the overgrowth occupies  such a position in the
gland as not to interfere with the  calibre of the urethra that it may
attain  large proportions before any symptoms are excited.  As soon
as the tumor groAvs in such a direction or reaches such size that the
urethral calibre is distinctly encroached upon, the  patient Avill notice
that—(1)  Micturition is unduly  frequent, this frequency  being  most
marked during the night or in  the early morning.  (2) There is some
delay in  starting the stream, and this  does  not Aoav with its wonted
force,  falling almost  directly from the penis without the customary
parabolic curve.  (3) There is a tendency to dribble on the  comple-
tion of the act of micturition.
   Provided  infection  does  not  take place,  with the development of
posterior  urethritis  and cystitis, these  may be the  only symptoms of
which the patient complains until the distention of the bladder reaches
such a point that incontinence of retention develops.   As  a rule, long
before this there is set up a certain amount  of urethritis and cystitis.
There are then added to  the  obstructive symptoms—i.e., frequency,
most marked at night, slowness  in starting  the  stream, loss of force,
and dribbling—the symptoms of inflammation, pain, and suppuration.
The pain may be manifest in  the form of a sensation of weight, of a 
976        GENITO-URINARY DISEASES  AND SYPHILIS.

weak and tired feeling, of an  ache Avhich may be steady or intermit-
tent, or sharp  or  dull pains  may be felt in the perineum, scrotum,
hypogastric region, groins,  inner surfaces  of  the  thighs,  back, and
testicles.  Later there are pains above the pubis and sharp, shooting
pains in  the  urethra behind the glans  penis.  Urination becomes
excessively frequent  and painful, is attended with violent straining,
and is suddenly and frequently interrupted; the stream  is small and
broken.  The urine becomes alkaline and offensive, is turbid with pus
and mucus, and there is often a muco-purulent urethral discharge.
   Frequency of  urination in cases with non-infected bladders is due
to residual urine.   This occupies the space  that should be taken up
by fresh secretion  from the kidneys, and hence causes the  bladder to
become distended sooner  than would be  the case normally.  The
amount of residual urine is proportionate to  the degree of obstruction,
and as  it increases in quantity it causes gradual distention  of  the
bladder-walls, with atrophy and degeneration of the vesical muscles,
nearly always  preceded  by hypertrophy incident to the efforts made
to overcome resistance.
   The frequency of urination is in the absence of inflammation pro-
portionate to the  degree of vesical distention.  This symptom is es-
pecially distressing because  it is most pronounced during the night,
in advanced cases  compelling  the  patient  to rise every  half-hour.
Nocturnal frequency has been ascribed to the more irritating  nature
of the urine  secreted at night  and to the  increase in the quantity
secreted.  This may be true in part, but it may be doubted if urination
is really much more frequent in  the night than in the day.   All night
disturbances make a much deeper impression than those by day, and
anxiety exaggerates  a few  disturbances into a constant series.   It
must be borne in mind that when the patient micturates once during
the night it is significant, and the gravity of  this significance increases
with the frequency of the act.
   Residual urine, and hence  frequent  urination,  are more marked
and  earlier symptoms  Avhen  there  is hypertrophy projecting back-
ward from the  median portion of the prostate.   Owing to the  altered
relation produced by the overgrowth  of  the neck of  the  bladder, a
pouch is formed about the  outlet.   In this a certain amount of urine
is contained which the atrophied and degenerated bladder-walls  are
unable to expel.  This pouch increases in size as the bladder becomes
distended, until a condition of chronic tension  is reached, character-
ized by an incontinence Avhich in prostatics is nearly ahvays indicative
of retention.
   Loss of force  in the stream is due in  part to atony and  degen- 
          INJURIES AND  DISEASES OF THE  PROSTATE.       977

eration of the bladder-muscles, in part to the urethral obstruction.
Slowness in starting micturition and dribbling on the completion of
the act are caused partly by the  atony, partly by reflex spasm of the
compressor urethrae muscle.
   Very exceptionally complete retention of  urine is an early symp-
tom  of hypertrophy.  It is then an  expression  of acute congestion
incident to excess, exposure to cold, etc.  In the later stage of the
affection  it is due to mechanical obstruction.  As a result of vesical
and renal retention there is always  polyuria, the urine being of Ioav
specific  gravity.   This  hypersecretion  of  urine is  one cause  of
frequency,  and this  fact should be  remembered in  estimating the
bladder-capacity and the significance of frequent urination.
   As the  disease progresses, in  consequence of severe straining,
hemorrhoids, rectal  prolapse, or  abdominal  hernia  may develop.
Ultimately, if the obstruction is untreated, there will be dilatation of
the ureters and kidney pelves, and in infected cases the development
of pyelonephritis and uraemic poisoning.
   Exceptionally there is bleeding.   This may  be severe and sponta-
neous, in Avhich case there is usually relief of symptoms.  It is  com-
monly due to instrumentation.  The  presence of albumen in the urine
does not necessarily indicate  involvement of the kidneys, since this
may be due to the constant straining and frequent micturition.  Cal-
culus not infrequently develops.
   It is evident that the symptoms of enlarged prostate are those of
obstruction  to  the passage of urine, to  which are ordinarily added
symptoms of inflammation. The obstructive symptoms are compara-
tively painless, and are slowly progressive ; they ultimately bring about
changes  in  the upper urinary tract, which  lead to gastro-intestinal
disturbance, uraemia, and  death.  Inflammation converts this slow,
painless disease into one that is extremely painful, is often rapid in
its course,  and is immediately threatening to  life.  From this con-
sideration the importance  of  strict cleanliness in dealing with cases
of enlarged  prostate is evident.
   Diagnosis.—In the presence of symptoms of prostatic obstruction
in a man over fifty-five years old,—i.e., a full-sized but feeble stream
started with difficulty, frequent  urination, most marked at night, and
a feeling  as though the bladder were  not  completely emptied,—a posi-
tive diagnosis may be made by direct examination.  The first step in
this direction consists in the introduction of a finger into the rectum.
   The  patient being  placed on his back, with the  thighs flexed
and separated, the index or middle  finger well lubricated is slowly
introduced through  the  sphincter, and an effort is made to feel the
                               62 
978        GENITO-URINARY DISEASES  AND SYPHILIS.

apex of the prostate.  As the finger is entered more deeply the lateral
dimensions of the gland are explored, and its density, the irregulari-
ties of its surface, finally the height to Avhich it reaches, are noted, the
finger being carried on until  the  soft bladder can be felt above the
upper border of the prostate.  It will be remembered that the normal
prostate is about the size of a horse-chestnut, is often distinctly cor-
date in shape, Avith the  base upAvard toAvards the bladder, is not very
sensitive to pressure, and can be clearly outlined by rectal palpation.
Above it the bladder-wall can be felt.
   In conducting  the examination  for  enlarged  prostate bimanual
palpation is serviceable, firm pressure  over  the  hypogastric region
forcing the bladder doAvnAvard and rendering its base more accessible
to the examining fingers, often enabling them to reach above the pos-
terior border of the gland and feel the normal bladder-Avail.  Finally,
by means of the free hand, a sound may be introduced into the blad-
der, and the thickness of the tissue lying betAveen the instrument and
the rectum may be accurately determined.
   The next  step in direct examination  consists in the  introduction
of urethral instruments.  This will enable the  surgeon  to determine
the extent to  Avhich the prostatic portion of  the canal has  been
lengthened, the presence of  lateral deviations, and sometimes the
general nature  of an obstruction placed at the neck of the bladder.
   For the purpose of determining the extent to Avhich the urethra is
lengthened, a soft  elbowed catheter is  employed.   Urethral length
varies  so greatly in individuals that  it is impossible to establish a
standard Avhich will apply to each case.   Perhaps, as a rule, it is safe
to conclude that if  the catheter has to be passed more than eight and
one-half inches to evacuate the urine from a bladder containing three
or four ounces, the prostate  is  enlarged.  A more accurate way of
arriving  at the length  of the prostatic urethra is to determine the
length of  the anterior urethra by passing an acorn-headed bougie to
the anterior layer of the  triangular ligament.   A catheter is then intro-
duced into the  bladder  containing but a few ounces, and when urine
begins to  Aoav the point on its shaft corresponding to the position of
the meatus is  marked.   When  the catheter is  withdrawn, measure-
ments  are taken from this point to the end of the eye.   Subtracting
the anterior  urethral  length  from the  total  length,  the  remainder
represents the  length of the  prostatic and  membranous portions of
the canal; three-quarters of  an inch can be alloAved for the mem-
branous  urethra.   Should  the prostatic  urethra be found over one
and  three-quarter inches long,  the diagnosis of enlargement of the
prostate is reasonably assured. 
INJURIES AND DISEASES OF THE PROSTATE.
979
   Metal instruments are employed to determine the presence of lat-
eral  deviations or growths about  the  neck  of  the bladder.   They
should never be grasped tightly when they are introduced.   Pressure
should be gentle, and so direct that the instrument may folloAv any
slight irregularities in the direction of the prostatic urethra.  It will
often happen  that before the instrument can  be  made to enter the
bladder the handle must be considerably lateralized, shoAving devia-
tion  of the urethra to one  side, or when the middle  portion of the
prostate is enlarged and  projects upward the handle may have to be
depressed much more than  is usually the case. *
   For the purpose of exploring the internal meatus and determining
whether or not a stone lies  in the bladder, an ordinary stone-searcher
may be employed, or an instrument Avith a  short, abruptly curved
beak.  This beak having been carried into the bladder is turned in all
directions, and a careful  exploration is made for stone,  since this is  a
frequent complication of prostatic enlargement.  After exploration of
the bladder is completed the instrument is Avithdrawn  until the beak
lies just Avithin the  internal vesical sphincter.  Then, by  turning  it
from side to side, not only  can the base of the bladder be explored,
but polypoid tumors, Avhich sometimes project about the neck of the
bladder, can be distinctly felt.  In case of a healthy bladder and pros-
tate, the rotation  of this sound Avhen its beak is still Avithin the neck
of the bladder is unattended  with resistance.   If there is marked
hypertrophy, and particularly if the middle portion  of the prostate is
affected, jutting back into the  bladder,  the beak of the instrument
cannot be rotated in this Avay, but will  encounter a resistance from
which it can be freed only by greatly depressing the  handle.  For the
purpose of determining  by  instrumentation Avhich lateral lobe is  en-
larged, Mercier, after having explored  the  bladder, withdraAvs  the
instrument,  keeping its  shaft as nearly horizontal  as  possible as it
traverses  the  prostatic  urethra.   The  shaft of  the bougie will be
deflected to the side  of  the greatest enlargement;  in  cases of sym-
metrical enlargement there will  be  no deflection.
   The patency of the urethra and the  encroachments upon its cali-
bre by prostatic outgrowths are best ascertained by  introducing solid
steel instruments, or silver or soft English catheters.   If these instru-
ments are arrested at a point more than seven inches from the meatus,
the obstruction is in the prostatic  urethra.  If an instrument Avith a
prostatic curve is arrested at the same point, but on  continued press-
ure passes on into the bladder, often with  a distinct jump, and if a
Mercier elboAved catheter goes in Avithout difficulty, the  obstruction is
probably one caused by  upAvard projection of  the urethral floor, and 
980        GENITOURINARY DISEASES AND SYPHILIS.

its distance from the meatus can be measured by the solid sounds.
If the moderately stiff Mercier catheter will not pass, but a very small
gum catheter or one of the rat-tail pattern enters, the urethra is prob-
ably deflected  to  one side or  the other.   If all instruments enter
readily, but the outward Aoav of urine is decidedly interfered with, the
obstruction is valvular.
   The amount of residual urine is determined by directing the
patient to-empty his bladder, and then introducing a soft catheter and
draAving off Avhat remains.   Normally no urine should Aoav through
this catheter, or at  most a few drops.  Measurements of the  urethral
length can advantageously be made during this portion of the  explo-
ration.
   The tonicity of  the bladder  is estimated  by the force Avith  Avhich
the  urine  is  propelled  through  the catheter.   The cystoscope  is
serviceable mainly  in demonstrating intravesical growths about the
bladder-neck, enabling the surgeon to determine the degree of cystitis,
and in affording a view of the ureteral orifices.  From observation of
the regularity and vigor with which they eject the urine an estima-
tion  as to the  functional activity of the kidneys may be made.  In
some cases it may be possible  to catheterize the ureter,  and thus to
determine  absolutely by examination of the  drawn  urine the  condi-
tion  of each  kidney and its  pelvis.  This is, hoAvever,  likely  to  be
difficult in cases of  enlarged prostate.
   The differential  diagnosis of obstruction from enlarged  prostate
must be made  from that due to stricture, to chronic posterior  ureth-
ritis, to calculus, to  bladder-tumors, to vesical atony, and to paralysis.
   In stricture there is a  small  stream which often has  considerable
force ; in prostatic obstruction  the stream may be large, but is with-
out its normal parabolic  curve.  Stricture, as a  rule, attacks  young
men, enlarged  prostates are  chiefly observed in old men.  Stricture
causes obstruction  to the  passage of instruments Avithin six  and a
half  inches of  the  meatus;  the obstruction of  enlarged  prostate  is
more than seven inches from the meatus.
   Chronic posterior urethritis  is commonly observed in young and
middle-aged  men, and is  often  a sequel  to gonorrhoea ; there is little
or no increase in the size of  the prostate, by either rectal or urethral
examination ; there is constantly a small quantity of pus in the urine,
and the force of the stream is not markedly diminished, although there
may be trouble in starting it and an imperfect cut-off.   There is no
residual urine.
   Vesical calculus is most painful and causes most marked frequency
of urination Avhen the patient is up and about, and the symptoms are 
          INJURIES AND  DISEASES OF  THE  PROSTATE.       981

markedly alleviated by rest in bed.   Rectal  examination and instru-
mental exploration of the bladder should at once establish the diag-
nosis, since a calculus can usually be  readily felt.
   Intravesical tumor  may closely  simulate  the symptomatology of
enlarged prostate.  Haematuria is, however, pronounced, and becomes
progressively more severe.   Rectal and cystoscopic examinations will
establish the diagnosis.
   The diagnosis of hypertrophied prostate from atony or paralysis
of the bladder  is dependent upon the history  of the case and  upon
exclusion of enlargement of the prostate by rectal examination.
   The clinical classification of cases of hypertrophy of the prostate
may be made from various stand-points.   The folloAving factors are,
however, most  Avorthy of mention  as having a direct bearing  upon
treatment.   They should be taken  into account in deciding upon the
management of any particular case.
   (1) The  predominant  character  of  the growth,  whether soft,
indicating  excess of glandular  and muscular elements, or hard, shoAV-
ing advanced fibroid  change.  The distinction can be made  more
simply and accurately by rectal  palpation than by any other method.
   (2) From a practical stand-point the seat of  the groAvth is of  chief
interest in relation  to  the changes in the bladder.  In a general Avay
it may be said that Avhen the enlargement affects chiefly the lateral
lobes the  urethra is narroAved and compressed, and the condition  is
analogous to that existing in organic urethral stricture.  The difficulty
in urination depends on  causes  purely obstructive and outside of the
bladder itself.  That organ undergoes,  therefore,  the usual  hyper-
trophy and thickening of  its muscular Avail Avith diminution of the size
of its cavity.  There is little or no residual urine.
   If, however, the growth is  median and  projects backAvard  into
and  beneath the neck of the  bladder, or if  the  lateral lobes are
elongated in the same direction, a dam is formed, behind Avhich  urine
accumulates.  The muscular tissue at the base  of the bladder, unable
to contract  properly,  atrophies and thins; a post-prostatic pouch
forms and increases.   Generally, vesical atony supervenes, and often
the expulsive poAver is completely lost, so that  in neglected cases the
only urine which escapes from the bladder is the overflow.
   These two conditions may be best differentiated during catheteriza-
tion.  In the former, when there are uncomplicated lateral enlarge-
ment and  vesical hypertrophy, the  catheter  goes in, possibly with
difficulty,  but  Avithout the  necessity  for  great  depression  of the
handle ; it does not go to an  unusual depth before reaching urine;
there is little or no residual  urine.  In the other variety the presence 
982        GENITO-URINARY  DISEASES AND SYPHILIS.

of the  median  obstruction is recognized by the difficulty, often  the
impossibility, of passing an ordinary instrument, and the necessity
for employing one of larger curve or with longer shaft, or of using
a Mercier or other catheter coude.   There is ahvays  some residual
urine, often to the amount of  many ounces.
   (3) A third and  not unimportant classification may be made on  the
basis of the presence or absence of general sclerosis.  If this condi-
tion is a factor in the case, rigid vessels, arcus senilis, polyuria, hya-
line casts, etc., will be associated Avith the evidence of vesical inability
due to rigidity of the bladder-Avails.   The prostatic enlargement will
usually be dense and distinctly fibroid.
   (4) Infection of the vesical mucosa with pyogenic organisms should
be mentioned as modifying materially any grouping of prostatic cases.
Indeed, it is almost of itself a sufficient basis  for classification, and if
we were compelled to  rely upon  one single  factor, it  might be said
with some  justice to take precedence of all others.
   While the above classification  cannot be regarded  as exhaustive,
and while  it must be  admitted that, as to  each of the  first three
groups,  cases will  be found which it will be  difficult  to  place, it is
believed that, on the whole, it will prove a distinct help in deciding
questions of treatment.

              TREATMENT OF  ENLARGED PROSTATE.
   The  treatment  of enlarged prostate  is hygienic,  medicinal, me-
chanical, and operative.
   Hygienic Treatment.—Careful attention to the  general health
of a patient suffering from prostatic enlargement is of cardinal im-
portance, since comparatively slight  disturbances, such as acute  at-
tacks of indigestion, exposure to cold, or excess in eating and drinking,
may, by adding  the element of acute congestion to  the  chronic  en-
gorgement of the prostate, bring on an attack of retention, which may
permanently cripple the bladder.   The diet must be  carefully regu-
lated, the needs and idiosyncrasies of each patient being considered.
In general,  sweets, pastries, exclusively nitrogenous diets, and highly
spiced foods should be avoided.  Alcohol may be taken in moderation,
well diluted, after  meals, though it should be allowed  only Avhen  the
general atonic condition of the patient indicates that it is likely to  be
useful;  in robust individuals its use should be prohibited.  Thompson
highly approves of cider in certain  cases.  This should be neither
sweet  nor  markedly  acid.   Milk,  buttermilk,  effervescing alkaline
mineral waters,  are all  serviceable.   Smoking in moderation, if it  has
been  a  habit, need not be interdicted.   Among the  articles of food 
INJURIES AND DISEASES OF  THE  PROSTATE.
983
Avhich  should be strictly forbidden are pork in all its forms, cheese,
raAV fruits, and sugars.  Most careful attention should be paid to the
condition  of  the  boAvels, and  regular evacuation  should be secured
daily by the use of  Vichy or Hunyadi Avater or enemata.
   Clothing  should be regulated in accordance  with the weather,
chilling of the surface being particularly avoided.  The acute conges-
tive attacks so common in the course of chronically enlarged  pros-
tate are especially apt to result from cold, Avet feet.  The skin should
be kept in good  condition by  daily cold  sponging followed by brisk
rubbing Avith a flesh-brush.  Moderate exercise in the air is always
serviceable;  in some cases horseback riding is attended  by no ill
effects ; in other cases the jolting markedly increases congestion, as is
evidenced by obstructive symptoms.   Walking, driving, the use of
gymnastic apparatus, calisthenic motions  employed regularly, are all
serviceable.
   The sleeping hours should be sufficient for rest, but long lying in
bed  should be discouraged.   Prostatic  patients  are always  better
when they are  up and  about.   When  the patient is much annoyed
by frequent urination at night, a hot bath before retiring will be found
serviceable.
   The most frequent and most potent causes of pelvic engorgement,
and hence of sudden increase in the obstructive symptoms due to en-
larged prostate, are—1. Retaining the urine for a considerable period
after the desire to urinate becomes urgent.  2. Chilling of the surface.
3. Sexual excitement.  4. Over-indulgence in eating and in the use of
alcohol.  5. Constipation.
   The therapeutic or rather prophylactic indications  are sufficiently
plain.
   Medicinal  Treatment.—Of the drugs which may be employed
with any hope  of benefit in cases of enlarged prostate but little can
be said.  No drug seems to have a specific influence  upon the pros-
tate, unless it is ergot, which is administered on the plausible theory
that  this gland, being possibly  the  analogue of the uterus, may re-
spond  in a similar manner to similar influences.  Ergot may be bene-
ficial where  hypertrophy of the muscular  elements, as shown by the
softness of the gland, predominates.  It  should be used  merely as
an auxiliary to  other treatment.   Salol and boric acid, in conjunction
with belladonna  and the  bromides, will often  be  serviceable in the
treatment  of the inflammatory complications of hypertrophied pros-
tate, notably  cystitis. Sodium  iodide  in doses of three grains, three
times a day, is  valuable as a means of retarding the development of
arterio-sclerosis, Avhich  so commonly  complicates prostatic  hyper- 
984        GENITO-URINARY DISEASES  AND SYPHILIS.

trophy, and hyoscine or hyoscyamine seems to exert a favorable influ-
ence on the function of micturition.
   Mechanical  Treatment.—(a)  Intermittent Dilatation.—A pa-
tient who presents  the  symptoms of a prostato-vesical  congestion of
the early stages of hypertrophy, Avho  is  disturbed once or twice at
night,  who has  an enlargement of moderate density, appreciable
through  the  rectum, but  not offering  much resistance to  the  intro-
duction of an ordinary catheter,  and Avho  has but little residual urine,
is likely to derive great benefit  from the  systematic  introduction of
full-sized steel sounds.  This treatment, and this alone, often relieves
existing symptoms, and prevents or, at least, delays the development
of further  trouble.   That it can have any true curative effect is un-
likely ; that it can even modify to any extent the continuous enlarge-
ment of the gland seems improbable ;  but that, either by producing a
local atrophy in the parts immediately surrounding the urethra, or by
simply stretching the canal itself and relieving local  congestion and
tumefaction, it mitigates the early symptoms,  lessens the vesical irri-
tability, diminishes  the amount of residual urine, and modifies favor-
ably the whole course of  the case, is beyond  all doubt.  The largest
steel sound Avhich the membranous urethra will permit to pass is in-
troduced every fifth day, and is allowed to remain in place for ten to
fifteen minutes, or longer if  the patient is  in bed.  Preliminary irriga-
tion of the urethra, careful sterilization of the  instrument, and gentle-
ness in its introduction render the treatment free from objection,  and
intelligent patients carry it on for themselves for years.
   (6) Catheterism  should  be  systematically  employed in cases in
Avhich the quantity  of residual urine is three or four ounces or more,
and in which the introduction of the instrument is easy and painless
and the urine is  sterile.  The  frequency should be proportionate to
the amount and character of the residual urine, a very good working
rule (if the urine is sterile) being to use the catheter once daily (pref-
erably at bedtime) for three ounces, twice for  six ounces, and then
once more for every additional tAvo ounces.  With sterile  urine it is
rarely necessary to catheterize oftener  than once in every four hours.
   The objections  to habitual  catheterism in  prostatics are—(1) the
risk of vesical infection ; (2) the production of  vesical atony.  These,
though serious, are not sufficient to contra-indicate the employment
of the method.  Infection may often, but not always, be avoided by
scrupulous and unflagging  care  as  to asepsis.  The  production of
vesical atony is  unavoidable, and this fact should be  regarded as
Aveighing in favor of operation in all cases where it comes up for con-
sideration. 
          INJURIES AND  DISEASES  OF THE PROSTATE.       985

   In the selection of  a catheter the softest and smallest  that  will
ansAver  the  purpose is usually  preferred.   This is  often absolutely
necessary in nervous  patients who  shrink  from  the least pain,  and
who dread the procedure and avoid it as long as possible.  It is  also
proper  in unintelligent and clumsy persons, Avho cannot be taught
the use of a solid instrument.   (See  section on  Retention  of  Urine
from Enlarged Prostate.)
   In all others in Avhom a silver catheter Avill pass without exciting
bleeding or undue  pain it should  be the  instrument of  choice,  and
should  be  left in situ for a feAV minutes  on each  introduction, the
point being AvithdraAvn just enough to avoid contact Avith the wall of
the empty bladder.
   The largest size  that the canal Avill admit should be used.  By this
means a certain amount of dilatation is  kept up, and the progress of
the case is favorably influenced.
   In those patients Avho do not present themselves until the intro-
duction of a metallic instrument has become impossible, the  choice of
a catheter lies betAveen the Mercier and the Neiaton, either of which
may be used in accordance Avith the comfort of the patient.
    (c) Rectal  Injections.—These may be hot or cold, as the patient
prefers, and may be of normal  saline solution Avhen ordinary Avater
congests and  irritates  the mucous membrane of the rectum.   The
stream  of water  should  be throAvn forcibly upAvard and forAvard di-
rectly against the prostate, and the  injecting-pipe should be provided
Avith openings through Avhich  the  liquid escapes at once without  dis-
tending the rectum.
    (d) Massage is useful, not so much because it causes shrinking of
the prostate as because of its tonic  effect upon the walls of the blood-
vessels,  thus  diminishing  congestion and rendering the circulation
more normal.  Sometimes it seems to irritate the  prostate;  in  this
case it  should be discontinued.   Massage is made with the  finger in-
troduced to the  loAver  extremity  of the  prostate  and pushed  up-
ward first vertically, then  laterally, from the central portion.  These
manipulations are  continued  from five to ten minutes, and may be
repeated daily.  They are most useful  when there is associated with
the enlarged prostate a chronic  inflammation.
    (e) Rapid  dilatation, or over-stretching of the prostatic urethra,
may be serviceable when enlargement of the lateral lobes causes  ob-
struction by narrowing the urethra  or rendering it tortuous.   The
slio-ht bruising of  the gland and the  moderate laceration of the mucous
membrane produced by over-stretching undoubtedly favor the devel-
opment of infectious  inflammation, but the risk is one which may be 
986        GENITO-URINARY DISEASES AND SYPHILIS

properly taken if the method lessens  obstruction, Avhich is the chief
cause of all the grave symptoms.   The operation may be said to be
indicated  in  those  cases  Avhere palliative  treatment has  failed  and
more radical measures are declined.   It has not been tried in a suffi-
cient number of cases to justify any belief in its permanent beneficial
effects.   The hope  of good resulting from it is based on the marked
amelioration of obstructive symptoms which sometimes folloAvs the use
of full-sized  steel sounds.   We believe that better  results will prob-
ably follow continuous catheterization, since this excites less inflam-
matory reaction and is more likely to  produce pressure atrophy.   If
the method of  over-distention is tried, it should be conducted under
ether, should be  carried to the furthest degree consistent with safety
(No. 44 French),  and should be followed by  continuous catheteriza-
tion combined with unirritating cleansing irrigations.
    Operative Treatment.—In patients Avith moderate obstruction
or  Avith a high grade of  compensatory hypertrophy, with a small
amount of residual urine which remains sterile, and in Avhom cath-
eterization is easy and painless, operation is not to be thought of.
    As a  rule,  however,  the introduction  of instruments gradually
becomes more  difficult.
    The indications  for operation are furnished by an approaching
break-down in catheter life,—that  is, Avhen instrumentation becomes
progressively more  frequent, difficult, and painful, and when the urine
shows fermentation changes characteristic of true cystitis.   It is at
this time that operation is most clearly indicated and that it promises
most.   The general health is practically unimpaired, and the kidneys
are in good condition.   Usually prostatics are not subjected to surgical
intervention until long past this  period, Avhen there is pronounced
infection of both the bladder and  the  kidneys, Avith the characteristic
toxaemia, a combination of sapraemia, septicaemia, and chronic uraemia.
    The operations  planned for the relief of urethral obstruction due
to enlarged  prostate are  (1) prostatotomy,  (2) prostatectomy, (3)  cas-
tration and vasectomy.
    Prostatotomy may be performed through the urethra or from
the perineum.
    Urethral prostatotomy, or division of  the bar at the neck of the
bladder (median  lobe), has received but little professional  endorse-
ment.  The operation is conducted either with a urethrotome specially
devised for the purpose or Avith the ingenious galvano-cautery planned
by Bettini.   In either case it is conducted  in the dark, and involves
great risk of hemorrhage and infection.  Where it has been attempted,
relief has been found to be but temporary.   In the successful cases 
INJURIES AND DISEASES OF THE PROSTATE.
987
Avhich have been reported it is probable that the apparently satisfac-
tory results noted Avere due rather to continuous catheterization than
to the prostatotomy, since this method of drainage has been generally
employed folloAving the urethral operation.
   It  is possible that  by means of a urethroscope  and a galvano-
cautery knife properly directed intra-urethral  prostatotomy or pros-
tatectomy may be  satisfactorily performed in cases of moderate but
obstructing enlargement of the median lobe, complicated by marked
irritability of the bladder from congestion of the mucous membrane
of the neck.   The  operation,  hoAvever,  must be regarded as both
uncertain and dangerous.
   Perineal prostatotomy may be of benefit  Avhen  combined Avith
prolonged drainage through the perineal wound.   This operation has
usually been performed for the relief of obstinate  cystitis in rigid and
contracted or in sacculated bladders rather than for the cure of pros-
tatic overgroAvth.
   The incision is  made into the urethra  at the apex  of the prostate,
the projection Avhich  causes  obstruction is divided Avith  a probe-
pointed bistoury, the channel is enlarged  by forcing a finger through
the urethra into the bladder, and a perineal drainage-tube the size of
the little finger is introduced and kept in place by a stitch.  This tube
is worn for some Aveeks.
   It  is probable that in addition to mechanical dilatation of the chan-
nel there is a certain amount of cicatricial  contraction  in the substance
of the gland Avhich reduces its bulk in the immediate vicinity of the
urethra and thus  diminishes its  obstructing power.   In a  certain
proportion of cases not only is there temporary amelioration of suffer-
ing, but  also  apparently permanent  relief.  The mortality is four
and five-tenths per cent.  It is  much higher than would  be the case
were operation performed at the very beginning of the changes which
denote that the catheter is no longer fulfilling its purpose.
   Prostatectomy may be performed  through the  perineum or
through an opening above the pubis.   The dense fibroid prostates are
not amenable to this treatment, since they cannot be enucleated.
   Perineal Prostatectomy.—When the perineal distance  is such that
the overgroAvth can be reached by the finger, and particularly Avhen
the hypertrophy is of  small size  and is limited to the  mid-prostatic
portion, or is pedunculated and acting like a ball-valve at the neck of
the bladder, a median perineal incision may be made as for perineal
prostatotomy, after Avhich the projecting  portion may be  seized with
the finger or  forceps or  caught with a wire or galvanic ecraseur and
removed.  The results have been remarkably good. 
988        GENITO-URINARY DISEASES  AND SYPHILIS.

   The chief objections to the method are that only in one-third or
one-fourth of the cases can the groAvth be reached by the finger, that
often Avhen accessible to the finger it cannot be satisfactorily dealt
Avith through the narroAved urethra, and  that vesical projections are
altogether beyond reach for accurate or careful manipulation.
   The modern development of this partial perineal prostatectomy is
removal of the entire gland through the perineum.   For the purpose of
pressing the prostate down into the perineal opening, and thus making
it accessible, a preliminary suprapubic cystotomy is required.  Nicoll
does not open the urethra, but  after introducing the fingers into  the
bladder from above, thus pressing the prostate Avell  into the perineal
opening and fixing it there, shells the  substance of this gland from its
capsule by means of a finger  or curette.   The four cases reported as
thus treated Avere all successful.
   Alexander has  slightly modified  this  operation.  The ordinary
suprapubic  cystotomy  having been performed,  making an opening
into  the anterior bladder-Avail large enough to admit tAvo fingers, the
patient is placed in  the lithotomy position, and  the  membranous
urethra is opened on a grooved staff by the customary median perineal
incision.   The staff is removed, iavo fingers of the left hand are passed
into  the bladder from above, pressing  the prostate doAvn, and Avith the
forefinger of the right hand the sheath of the prostate is torn through
at its apex close to the prostatic urethra, and the gland is shelled out
by blunt  dissection.   The lateral lobes  are first removed, then the
isthmus, if this forms an overgrowth.   The prostate is rendered more
accessible by seizing it with forceps and draAving it Avell doAvn into the
perineum.   The  hemorrhage is not severe.   The bladder is drained
through both the perineal and the suprapubic opening.
   Of eight patients  operated on, six recovered and  were able to
urinate.
   Suprapubic prostatectomy is usually the operation of choice, since
the seat of operation is readily accessible both to manipulation and
to inspection.   The operation is no more  dangerous than  when it is
performed through the  perineum, the mortality being  about  sixteen
and  six-tenths per cent, for both operations.
   In  suprapubic prostatectomy the  bladder is reached and  opened
as in suprapubic lithotomy.   Immediately preceding operation  the
bladder is thoroughly irrigated Avith saturated boric acid solution or
silver nitrate solution 1 to 1000, and  from eight  to twelve ounces of
the irrigating fluid  are left in this viscus.  When the  rectal bag is
introduced  it  should be distended Avith not more than eight ounces.
It is perhaps safer to dispense Avith this bag.   The prostatic catheter 
INJURIES AND DISEASES OF THE PROSTATE.
989
passed into the bladder is of service  in locating its  anterior Avail.
Incision is made directly in the  linea alba down to the symphysis,
and  the  bladder on  being opened  is held  in  place  by sutures  se-
curing it to the parietal  incision.  The patient  is then placed in  the
Trendelenburg position,  and the projecting and obstructing portions
of the prostate are palpated and inspected.   After  the first incision
hemorrhage is so free that examination by the eye, even though aided
by the electric light, is of little service.  Where there  is a peduncu-
lated middle lobe  the pedicle  may be  divided by curved scissors.
When this portion of the overgrowth is sessile, the partially encapsu-
lated tumors making up the greater part of its bulk may be shelled
out Avith the fingers  after opening the mucous membrane, although
sometimes the  curette  or the curetting  forceps may be  required.
When there is a collar-like projection about the entire vesical neck,
this  should be divided into tAvo halves by passing one blade of a pair
of scissors into  the urethral orifice and  cutting the portion above ;
this  procedure is repeated on  the floor of the urethra,  cutting  doAvn-
Avard in this  case, and  the projecting mass  is  enucleated Avith  the
fingers, aided by  scissors.  Enucleation,  when  it is  practicable, is
ahvays to be preferred to cutting.
   Hemorrhage, which is usually  free and  often alarming, may  be
controlled  by very  hot  water or by  packing.   The   most efficient
manner of packing for the control of hemorrhage is  that  suggested
by  Keyes.  It  is accomplished by a tampon  applied through   the
suprapubic opening and held firmly apposed to the bleeding surface
by a cord passed through a perineal opening or through  the urethra
and  secured at  its exit to a roll of gauze.  The tampon  is removed
at the end of twenty-four hours.  It is thus constructed :
   " The  tampon is made of  bichloride gauze. A square  of four
thicknesses of gauze is first cut, the length of each side being about
six  inches.  Upon  this  are placed  eight  thicknesses  of gauze,  cut
square, each  side measuring four inches,  and upon this eight other
thicknesses of gauze, also square, the sides  measuring three inches.
Centrally, upon the three-inch pad, a small white shirt-button  is tied
by stout silk ligature, transfixing the pad and tied upon the six-inch
square surface.  This central button also has a piece of silk attached
to it, running out freely in the  direction  aAvay from the three-inch
surface.  This is to facilitate extraction.   Each  of the  corners  of the
six-inch pad is  stoutly tied with a piece  of silk, and  the  silk from
each of these  four corners is  knotted  at its end into a double knot,
Avhile the silk running out backward from the  button  is tied with a
single knot, for  the  purpose of distinguishing Avhich is which Avhen 
990        GENITO-URINARY  DISEASES AND SYPHILIS.

making the extraction ;  although,  practically, it will be found  that
they must all be made taut and pulled upon all together in order to
effect removal Avith the greatest ease and facility.1'
   At the end of the operation the surgeon should ascertain that the
urethra is entirely patent by inserting the forefinger as far as the first
joint into the canal.   It must not be forgotten that the object of the
operation is to restore a low level channel through the prostate, and
is not simply the  excision of the overgroAvth.   (Belfield.)  When it is
evident  that  the  obstruction  has been removed,  the bladder  is
thoroughly irrigated Avith 1 to 1000 silver nitrate solution;  the supra-
pubic  opening is  tightly  sewed  about a full-sized  drainage-tube
(Guyon's).   Subsequent treatment is conducted by regular irrigations,
as in the case of ordinary suprapubic cystotomy.
   When it has  been necessary to remove a large amount of tissue,
thus leaving a  large  cavity, we believe it  advisable to introduce a
perineal drainage-tube, in this case making an effort to close the supra-
pubic opening into the bladder by immediate suture.
   The operation of suprapubic prostatectomy does not result in com-
plete cure even in the majority of successful cases, owing to the fact
that from previous constant distention and inflammatory degeneration
the  bladder-walls become so weak that they are  no longer  able to
expel the urine.   Even though the bladder does not regain its poAver,
there is sufficient increase in comfort resulting from  lessening of the
cystitis and from increased facility of catheterization to justify opera-
tion.
   Vignard  found  that of  thirty-seven operations  in six  only  was
the  function  of micturition  restored.  Belfield, of one hundred  and
thirty-three prostatectomies, reports complete  functional cure  in less
than twenty-five per cent.
   The best period for the  performance of this operation is  before
the development of marked chronic cystitis, Avhile some tone remains
in the vesical Avails and the bladder is neither  thinned and  dilated
nor rigid and contracted.  Under these circumstances, where a patient
reports  that he is disturbed at night with increasing frequency, that
he is obliged to use a catheter oftener, and not only with greater dis-
comfort but Avith  less relief  in  the interval, that the urine is occasion-
ally turbid and offensive, that he has recently had one or more attacks
of retention, and  that he is beginning  to lose flesh  and suffer from
symptoms of gastro-intestinal irritation, the indications for operative
interference are unmistakable, though  the operation of  choice is not
necessarily suprapubic prostatectomy.
   Castration and  Vasectomy.—Castration  for prostatic  hyper- 
          INJURIES AND DISEASES OF  THE  PROSTATE.       991

trophy, first advocated  (White) in 1893, has since been performed in
hundreds  of cases, and Avith results Avhich  establish  it as the safest
and most radical curative operation yet proposed.
   The apparent analogy betAveen uterine and  prostatic growths first
suggested  the  idea of castration as a possibly valuable  treatment for
prostatic hypertrophy.   This analogy may be briefly stated as follows :
   The prostatic vesicle  is the analogue of  the sinus genitalis in the
female,—the uterine and vaginal cavities; the  structure of the pros-
tate and that of the uterus are strikingly similar, and Avould be almost
identical if the tubular glands found in the inner walls of the uterus
were prolonged into its substance; the histology of its growths, from
small encapsulated tumors easily  shelled out,  or  polypoid growths
intimately connected Avith the uterus or the prostate, up to the  enor-
mous groAvths which far exceed the original bulk of  the organ  itself,
is identical; or there  may be in either case a general hypertrophic
enlargement affecting  the  Avhole  organ; lastly, these  disturbances
occur at about the same time in the  sexual life of the tAvo sexes,—
that is, during the  latter half of the reproductive period.  This ends
sooner in  the  female than in  the male, and accordingly Ave find the
groAvths appearing in the former at a someAvhat earlier age.
    This analogy is said by the embryologists to be Avithout foundation
as regards any true homology betAveen the  prostate  and the uterus.
The clinical resemblances betAveen the two forms of  overgrowth are,
hoAvever,  none the less  striking, and it  may  noAv be said that the
results of castration in such cases are  equally similar and remarkable
in each sex.
    Even though the prostate is not the absolute  homologue of the
uterus,  as it contains and encircles  the cavity which is said to be the
absolute homologue, the utricle, or prostatic vesicle, the relationship
between the two  is notably  close.   So, too,  although  the  uterine
growths begin as fibromyomata and the prostatic as adenomata or
adenofibromata, the difference  merely corresponds  Avith the differ-
ences in structure of the two organs, the prostate containing normally
more glandular tissue than the uterus.
   An experimental investigation on dogs (White, Kirby) proved con-
clusively that after castration the glandular tissue of the prostate first
atrophies and   disappears, this atrophy beginning within a few days.
   Soon after the  publication of  the  first  paper  on this subject,*
clinical  evidence as to the value of the treatment began to accumulate,
and in a short time was overwhelmingly favorable.
* Annals of Surgery, August, 1893. 
992        GENITO-URINARY DISEASES  AND SYPHILIS.

   In several cases autopsies have been made Avhich demonstrate the
exact nature of the  shrinkage, and show that  it is due to the same
sort  of atrophy, first of the glandular elements, then of the stroma,
that  Avas  originally  reported  as the invariable result of castration
of dogs.   Nearly all varieties of enlargement  are probably originally
adenomatous:  hence  such growths  Avould naturally  begin where
glandular tissue is most abundant.  This  is in the posterior com-
missure, the so-called median  lobe, enlargement of which,  from  its
position,  more effectually blocks the urethra than overgroAvth of any
other portion of the prostate.
   The indications  for castration are those for  any form of surgical
intervention,—i.e., beginning  break-down of catheter  life.  At this
time the patient is usually impotent: hence the removal of the testi-
cles  is not objectionable except for sentimental  reasons.  The oper-
ation is  further indicated  in  those  cases of  advanced bladder and
kidney disease combined Avith retention of urine in Avhich the general
condition is so unfavorable that any prolonged  operation is  likely to
be immediately fatal.
   Castration can  be performed  in  from  three  to five minutes, is
bloodless, and is attended with almost no shock.  Vasectomy can be
performed in even less time, and does not require the administration
of ether.
   As to the clinical results of castration, Wood reports one  hundred
and  forty-three cases of this operation, including in this  number those
collected by Cabot; one hundred and seventeen of these recovered
(eighty-tAvo per cent.); twenty-six  died (eighteen per cent.).  Of the
one  hundred  and  seventeen cases which recovered,  improvement
was  noted  in  one  hundred  and  ten (ninety-four per cent.); four
were not improved.   In sixty-three cases (fifty-three and eight-tenths
per cent.) it was noted  that the prostate was reduced in size.  Of
Wood's last series of cases (ninety-tAvo) the mortality  Avas  nine and
eight-tenths per cent.; rejecting two cases in which death Avas in no
way attributable to  the operation, and apparently Avas not hastened
by it, there is left a  legitimate mortality of seven and  six-tenths per
cent.
   One of the most surprising and satisfactory results of castration
has  been the return of power in the bladder  (sixty-six per cent.)
and  the   disappearance of cystitis.   It  is certain that Sir Henry
Thompson's assertion that the return of voluntary   power in the
bladder is  impossible  after  two years'  use  of the  catheter is not
correct.
   There is no conclusive method of determining in advance whether 
          INJURIES AND DISEASES OF THE  PROSTATE.       993

a particular bladder is hopelessly dilated and atonic or still possesses
the poAver of recuperation.   In many cases the evidence of continued
contractility will be unmistakable, but even after complete retention
with the AvithdraAval of urine exclusively by the catheter for years
there has been noted a satisfactory return of power in the detrusors,
in some instances amounting almost to perfect health.  Enough cases
have now been folloAved for a sufficient length of time to  warrant
belief in the permanence of the cure Avhen once effected (seventy-five
per cent.).
    The legitimate  average mortality  of the  cases operated on with a
reasonable expectation of cure is, as  has been  said, about seven per
cent., and Avill probably be  less  in  the  future.  If so, it will accord
with the  history of  every neAv operation in the matter of mortality.
A table  of  ninety-five cases of suprapubic prostatectomy shoAvs a
mortality of fwenty  per  cent, for  the whole number, but only fifteen
per cent, for the last half.   The mortality of the first half is  twenty-
five per cent.   Careful impartial study of the cases  of fatality folloAV-
ing castration  for enlarged prostate will  show that in the majority of
those as to Avhich details are  given there was little to  be hoped for from
palliative operations and less from the unaided efforts of nature, while
it seems highly probable that any other radical procedure would have
been at least  equally likely to result fatally.  Even the fatal  cases, it
is interesting to note, shoAved distinct improvement in the symptoms
or some shrinkage in the prostate before death.
   While there is little or no risk in the operation itself, if it is applied
in the future as Avidely as it has already been,—i.e., to patients of all
ages and all degrees of weakness, with uraemia  and  toxaemia,—it will
undoubtedly always have a considerable mortality.
   It is probable that the mortality of the operation will be found  to
have a very  direct  relation to a few factors, the  most important being
the presence or the absence of renal  infection and the history of long-
continued catheter life, or of a number of attacks of complete reten-
tion or of a very large amount of residual urine.  When these factors
are conjoined  the case is of  the most unfavorable type.  Differences
in the size, the density, and the shape of  the  prostatic overgroAvth will
probably be found to be minor factors in determining mortality, but
they have an important relation to the degree of improvement effected
by the operation and the rapidity with which it occurs.
   The  remote results of the operation cannot yet be determined.
Cases of death with precedent mental symptoms, described as mania,
acute mania, etc., are only such as every surgeon is familiar with in a
certain proportion of operations done upon aged persons, whose men-
                               63 
994        GENITO-URINARY  DISEASES AND SYPHILIS.

tal equilibrium is easily disturbed, and can  have no bearing upon the
question of later mental  changes as the result  of  castration.  With
greater accuracy Ave should probably classify the large  majority of
them as uraemia and some of the remainder as traumatic delirium.
Clinical evidence leads to the belief that  the  removal of the  testicles
from persons Avho have  reached full adult life, and  a fortiori from
very aged persons, has no effect upon the  mental functions or upon
the general physical characteristics.  Impotence will undoubtedly be
caused in  the  majority of cases, but even this  is not immediate or
inevitable.
   Castration.—The operation  of  castration has  been  described
already.  The patients on whom it is  performed for the relief of
enlarged prostates are old, feeble, vulnerable, and little fitted to react
from any prolonged surgical intervention.  Ether should be given to
the  first stage.  An assistant then grasps the scrotum from  behind,
pressing the testicle forward  and making the overlying skin tense.
The surgeon makes a three-inch incision, through which the testicle
is squeezed by the  pressure of  the  assistant's hand.  The gland is
grasped, pulled Avell forAvard, the ligament attaching  the base of  the
testicle and the epididymis to the scrotum behind is divided with  the
scissors or knife, the cord is pulled well doAvn,  transfixed, ligatured,
and  divided, the lumen of the vas is touched with  a crystal of pure
carbolic acid, and the parietal  Avound is  closed by tAvo or  three  silk
or horse-hair sutures, no drainage being  employed.  Not more than
two  or three blood-vessels need be secured, and both testicles should
be removed in less than five minutes. The wounds are dressed with
an abundance  of loosely crumpled sterile gauze, secured in place by
a crossed of the perineum bandage.
   Vasectomy has been proposed  and practised as a substitute  for
castration,  primarily with the idea  that division or  ligation of  the
vas causes atrophy and destruction of the  testicle, hence, ultimately,
the  same  effect produced  by castration.    This  reasoning is  not
founded on fact, since ligation  or division of the vas does  not neces-
sarily cause atrophy of the testicles.  There are no reported obser-
vations upon the effect of operation on the vasa deferentia of patients
suffering from  prostatic hypertrophy previous to 1895, but  a  series
of experiments on dogs  (White, Wood,  and  Kirby) had shown
("Annals of Surgery,"  July, 1895)  that  double ligature of the vas,
while not materially influencing the testicles, constantly caused  loss
of weight in the prostate, perceptible in ten days from the  time of
operation.   In  dogs kept for  fifty-two   days the  atrophic  changes
were unmistakable.   It is difficult to explain these results, Avhich 
INJURIES AND DISEASES OF  THE PROSTATE.
995
have been  corroborated by clinical  experience, except on the basis
of the influence  exerted on the  prostate through the medium of the
nervous system.
    The clinical evidence as to the value of  Arasectomy is as follows:
    Of forty-nine cases of ligature and vasectomy collected by A. C.
Wood, there Avere  six deaths, a mortality  of tAvelve per  cent.  The
practical results folloAving  this operation Avere legitimately those that
could have  been looked for from experiments on dogs.  With some
feAV exceptions, the  testicles did  not  atrophy, nor did  they show
signs of acute inflammation.  The  prostate, hoAvever, shoAved  the
same form  of shrinkage noted  after castration, though the atrophy
took  place  more sloAvly.  The results from vasectomy Avere some-
what better than those from ligation.
    The operation  possesses  the advantages of not requiring ether
for its  performance, of not exciting the  opposition of the  patient,
and of producing no appreciable deformity.  It is  easily and quickly
done, and does not cause shock.  The vas  is usually most accessible
through the posterior surface of the scrotum.  It is isolated from its
surrounding veins,  and is held in place  close beneath the skin, which
is stretched tightly over it  by the  tAvo hands  of an assistant,  the
thumbs and forefingers making firm  pressure and holding the  vas
aAvay from the other structures of the  cord.  The  skin overlying  the
vas  is then infiltrated by Schleich's solution of cocaine  and is  di-
vided ;  the  fibrous  tissue  overlying  the vas is  cut through, the  vas
itself is isolated and hooked out with a grooved director, is freed for
an  inch, and  a ligature applied above and beloAV, and the  portion
lying betAveen the  ligatures is removed.  The wound is closed by a
stitch, and the testicle is enveloped in sterile gauze and supported by
a crossed  of the perineum bandage.
    The conclusions which seem Avarranted by the arguments and
the facts set forth in the  foregoing pages are as follows :
    (1) The function of the testis, like that of the ovary, is twofold,—the
reproduction of the species, and the development and preservation of
the secondary sexual characteristics of the  individual.  The need  for
the exercise of the latter function ceases Avhen full adult life is reached,
but it is possible that the activity of the  testis and that  of the ovary in
this respect  do not  disappear coincidently,  and that hypertrophies in
closely allied organs like the prostate and the uterus are the result of
this misdirected energy.
   (2) The  theoretical objections which have been urged against the
operation  of double castration have  been fully negatived  by  clinical
experience, which shows that in a very large  proportion of cases 
996        GENITO-URINARY DISEASES AND  SYPHILIS.

(thus far in more than eighty per cent.) rapid atrophy of the prostatic
enlargement follows the operation, and that disappearance or great
lessening in degree of long-standing cystitis (fifty-two per cent.), more
or less  return of vesical contractility  (sixty-six per cent.), ameliora-
tion  of the most  troublesome symptoms (eighty-nine per cent.), and
a return to local  conditions not very far removed from normal (fifty
per cent.) may be expected in a considerable number of cases.
   (3)  In patients operated upon under  surgically favorable condi-
tions—i.e., before the actual  onset of uraemia, or,  better, before  the
kidneys have become disorganized by the two factors rarely absent in
advanced cases,—backward pressure and infection—there has been a
mortality of about seven per cent., Avhich will probably be decreased
as advancing  knoAvledge permits of a better selection of cases.   It is
important to note that even in the desperate cases AAdiich made up the
series of deaths in the first collection of cases a very large percentage
(seventy-five per  cent.) showed improvement of symptoms or shrink-
age of the prostate before they died.
   (4)  Comparison with other operative procedures seems to justify
the statement that, apart from the sentimental objections of aged per-
sons on the one  hand, and the real, entirely natural, and very strong
repugnance to the operation felt by younger patients, castration offers
a better prospect of permanent return to nearly normal  conditions
than does  any other method of treatment.   The  relatively greater
degree of improvement in successful  cases should  be considered, as
well as the mortality, in comparing the operation Avith the various
forms of prostatotomy  and prostatectomy.   So, too, should the  ab-
sence of any risk of permanent fistulae, peritoneal or suprapubic, the
ease and quickness Avith Avhich the operation can be  performed, and
the possibility of  avoiding altogether the use of anaesthetics, Avhich, in
these cases, are in themselves dangerous.
   (5) The evidence as  to unilateral  castration is at  present contra-
dictory, but there can be no doubt that in some cases it is folloAved by
unilateral atrophy of the prostate, and in  two cases, at least, it  has
resulted in a very marked  improvement of symptoms.   It is Avorthy
of further investigation.
   (6)  Experiments  on dogs have sIioavii in nearly every case in which
the vas  deferens was tied or divided on both sides that, without much
change in the testicles, there were beginning atrophy and considerable
loss  of weight of the prostate.   Operations  performed  on  man have
given similar results.  It is possible that the  inclusion or severance
of small but  important nerves  may  account  for  the  effect on  the
prostate. 
INJURIES AND DISEASES OF  THE  PROSTATE.       997
    (7) Ligation of the vascular constituents of the cord,  or of the
whole cord, produces atrophy of the prostate, but, at least  in experi-
ments on dogs, only after first causing disorganization of the testis.
    Complications of Enlargement of  the  Prostate.—It  has
been stated that practically all the symptoms  and dangers in  relation
to enlargement of the  prostate are due to the  urethral obstruction
occasioned by this enlargement, this obstruction causing first hyper-
trophy, then dilatation and  atrophy, of the  vesical Avails, and  ulti-
mately affecting the ureters, kidney pelves, and kidneys, predisposing
the entire genito-urinary  tract to infection.  In the absence of infec-
tion the changes brought about may be so gradual  that the patient
is not seriously inconvenienced until digestive disturbances and steady
deterioration in health indicate renal insufficiency due to degeneration
of the secreting substance of the kidneys.  With the development of
infection  are excited  characteristic functional disturbances, and  ulti-
mately symptoms  of sapraemia and septicaemia.
    The treatment  of  the complications of enlarged prostate  is dis-
cussed under  the headings  of Retention from  Enlarged Prostate,
Cystitis, and Pyelo-Nephritis.   Retention of urine is treated by inter-
mittent or continuous catheterization in the manner already described.
Cystitis is treated  by the  catheter.   If because of the sacculation of
the bladder or for other  reasons  symptoms become progressively
more severe in spite of the use of the continuous catheter,  an opera-
tion  is indicated.  When the  perineum  is not  too deep, perineal
drainage gives good results, since it is not  only palliative but in some
cases accomplishes cure of the prostatic condition.   When from  the
size of the enlargement, the severity of the cystitis, and the long con-
tinuance of the disease it is evident that perineal drainage can relieve
only Avhile the tube is left in place, and when a curative operation is
absolutely refused, suprapubic drainage is  indicated. This  operation
may be performed as described under the treatment of stone.   Hunter
McGuire has proposed and successfully practised  a modification of
this  operation.  He states that it is simple and the relief afforded
instantaneous.   The mortality is not more than three per cent.
   A rubber catheter is passed into the bladder, and the organ thor-
oughly irrigated with  a two per cent, solution of boric acid.  The
rectal bag is  then inserted,  and  distended  with not over fourteen
ounces of water.  Finally, four or five ounces of water are injected
into the bladder.  With a small scalpel an incision is made through
the  skin and superficial fascia in the median line, commencing about
two inches above the pubic bone, and extending down to the level of
its upper  border.   This  exposes the  recti  muscles, the  fibres  of 
998        GENITOURINARY DISEASES AND  SYPHILIS.

which are separated Avith  the  handle of a knife, and the Avound is
deepened to the transversalis fascia.   When this is incised the pre-
vesical fat is exposed.  The large veins are pushed aside, the friable
tissue  is scratched through, the back of  the  knife  is placed close
against the upper border of the pubis, and its point is pushed through
the wall of the bladder and made to cut upward  about half an inch.
The rectal bag is then evacuated and removed,  and a rubber catheter
is passed into the bladder and stitched to the skin at the margin of
the wound.   This operation takes only two or three minutes, and re-
quires no instrument other than a small knife.  The Avound is  dressed
by placing some gauze about the catheter, the free end  of Avhich is
inserted into a bottle to catch the urine.  No stitches  are employed,
nor is any effort made to approximate the surfaces of the cut.   In hvo
weeks only  a fistulous  tract will be left along the line occupied by the
catheter.  The patient is then allowed to get up, and  a silver plug or
stopper is placed in the opening.  This plug  should have a diameter
of about No. 20 F., and should be just long enough to enter the blad-
der.  It is designed to keep the opening patent, and to act as a stopper
in preventing dribbling of urine.  It should be worn  constantly, and
taken  out only when the patient wishes to micturate.  The plug is
kept in place by a belt  going about the hips and passing over the head
of the plug.  It is  prevented from slipping up  or down by a second
belt above,  which is supported by the hips, and by  perineal bands
which encircle the thighs.
    Patients thus operated on can retain their water without discom-
fort from three to six hours in the day, and from six to eight hours at
night.  Cystitis rapidly disappears, and often the prostate shrinks so
that the natural passage again becomes patulous.

                  ATROPHY OF THE PROSTATE.
   In exhausting diseases accompanied by general Avasting of the en-
tire body marked atrophy of the prostate may occur.  Thus, Thomp-
son noted one case in Avhich the gland weighed  less than one drachm.
Extreme old age is usually accompanied by wasting of the prostate;
mechanical  pressure, as from  extravesical tumor or prolonged dis-
tention of the bladder, may produce the same effect.   The gland may
also be partly or completely destroyed by abscess-formation folloAved
by cicatricial contraction  and by sclerosis secondary  to  chronic in-
flammation.  In certain  cases  the prostate is congenitally atrophied,
this condition being generally  associated with other  malformations.
Castration, especially if performed in early life,  is ahvays folloAved by
prostatic atrophy, and  masturbation, if begun early, and if excessive 
INJURIES AND  DISEASES OF THE PROSTATE.
999
and long continued, may result in a similar condition.   Symptoms of
atrophy are practically Avanting.
   The diagnosis is founded upon rectal examination.
   Treatment is unavailing.

                       PROSTATIC  CALCULI.
   Thompson has shoAvn that the corpora amylacea are so constantly
found in the prostate  that their  presence can scarcely be considered
abnormal.  In youth these bodies are usually  microscopic  in size.
Later in life they become larger,  so that they are readily seen by the
naked eye.  The name corpora amylacea is given to them because
they exhibit a  granular nucleus, probably made up of degenerated epi-
thelial cells and inspissated mucus, about Avhich are formed concentric
layers composed of an  albuminoid  substance the nature of which is
not rightly understood, and presenting the microscopic appearance of
starch cells.
   When the corpora amylacea are small they occasion no symptoms;
as they groAv larger they act as foreign bodies, exciting inflammation,
and  have deposited in and upon them the salts of lime, calculi being
thus formed.   The calculi may lie separately, each in  its own pouch,
or many of them may be placed in a common pouch, often adherent
to one another.  In color they  are broAvn  or black,  with a  smooth
polished surface, exhibiting facets when a number of calculi are placed
together in a  single pocket.   They are made up of calcium phos-
phate, calcium  carbonate, and  organic  matter, and  are  commonly
found beloAV the urethra, particularly in the region of the verumon-
tanum.   If by ulceration the cavity in which they lie  opens  into the
urethra, and the urine has access to them, its salts  will be deposited
upon them, causing rapid groAvth, abscess-formation,  and  ulceration,
usually in the  direction of the urethra, sometimes backward towards
the bladder, or into the rectum or the perineum.
   Prostatic calculi may originate in the substance of the gland as
just  described, may come from the bladder or the urethra, or may be
deposited from the urine in suppurating prostatic pouches.
   Symptoms.—Until prostatic calculi of glandular formation open into
the urethra, symptoms  are usually wanting, the condition not being
generally recognized until it is shoAvn by post-mortem  examination or
operation performed for some other pathological condition.  When
the calculi begin to grow from deposition of urinary salts, the symp-
toms of posterior urethritis or of chronic prostatitis develop.
   Diagnosis is founded on rectal palpation and urethral examination.
These  calculi, if of considerable size, can  generally  be  felt  by  the 
1000       GENITO-URINARY DISEASES  AND SYPHILIS.

finger  introduced into the rectum.   A  metal catheter will give  a
grating sound as it is introduced into the  prostatic  urethra; urethro-
scopic  examination Avill bring the concretions directly into vieAv.
    Treatment.—It is sometimes possible  to remove calculi from  a
suppurating prostate by the straight or slightly curved urethral forceps.
We have removed ten  from  one patient in this  manner, and  the
patient has  remained perfectly well.  A perineal urethrotomy affords
the safest and best route for thorough removal of  these concretions.
The median perineal  incision gives enough room.   Exceptionally,
when it is necessary to make a careful exploration of the entire pros-
tate, the semilunar incision in front of the anus is required, the anus
Avith its sphincter and  the  rectum being carried backAvard, the pros-
tate exposed, and the calculi freed and removed through the incision.
For the very small calculi Avhich pass  spontaneously no treatment is
necessary other  than avoidance of all  causes of prostatic congestion,
as constipation and alcoholic or sexual excess.  When in consequence
of  prostatic calculi there  are harassing  pains, undue frequency of
urination, retention of urine, or cystitis, Ave believe that surgical inter-
vention is imperatively indicated.

             MALIGNANT TUMORS OF  THE PROSTATE.
    Cancer,  under Avhich heading are considered both carcinoma and
sarcoma, when  it occurs as a primary tumor,  is usually observed
before the  tenth and  after the fiftieth  year of life.  The majority of
the tumors  are carcinomatous.  Sarcoma is rare, though Barth holds
that there is some misconception on this point.
    Malignant groAvth  exhibits a characteristic tendency to infiltrate
surrounding parts.  There is said  to be no other tissue or organ from
Avhich there are such Avide-spread  metastases as  from encephaloid
of the prostate.  The  morbid anatomy of the early stages of the dis-
ease is obscure, since opportunities for  post-mortem examination are
not  afforded until all parts of the  normal structure of the prostate
have disappeared.  The disease may be at first circumscribed or may
begin as a general  infiltration.   The entire gland is shortly involved,
and the infiltration rapidly spreads beyond the limits of the proper
capsule to the seminal vesicles, rectum, and ureters, and  forms sec-
ondary deposits in the  neighboring glands.   By pressure upon the iliac
vessels these cancerous  glands may cause thrombosis and cedema of
the loAver limbs.
    Symptoms.—In the early stage of cancer of the prostate there are
obstruction of the prostatic urethra,—i.e., urination becomes painful
and somewhat difficult,—haematuria, Avhich may be extremely severe, 
          INJURIES AND  DISEASES OF  THE  PROSTATE.      1Q01

and pain  felt  in the scrotum, in the hypogastric region, or along the
inner  surface of the thighs or near the rectum.  Complete retention
of urine develops  rapidly,  and there is often great  rectal tenesmus.
Hemorrhage is an  almost  constant  symptom, and may occur at the
beginning  or at a  late period of the  disease; it may be profuse or
scanty.  The bleeding is generally intermittent and terminal.
   Diagnosis.—This is made by digital examination  through the rec-
tum.  In  the  earlier stages,  Avhen  the tumor is still confined by the
prostatic capsule, it may be  difficult to distinguish  it  from prostatic
enlargement.  It increases rapidly, causes  a chronic, hard, nodular
groAvth, quickly invades neighboring glands, and produces cachexia.
   The prognosis  is bad.   In children the disease runs a very  rapid
course, terminating in three or four months;  in adults it terminates
in from one to four years.
    Treatment  is directed toAvards  relief  of the retention of urine,
the alleviation of  the accompanying cystitis,  and mitigation of the
pain.   Retention of urine should be relieved by intermittent or con-
tinuous catheterization.  Should this cause severe  bleeding, supra-
pubic incision and drainage are indicated.  The cystitis is best treated
by suprapubic drainage  and antiseptic irrigations.  The pain is con-
trolled by opium and morphine administered by the rectum or hypo-
dermically.   Suprapubic extirpation  has  been  frequently  attempted,
but by the time diagnosis  can be thoroughly formulated the disease
is already so Avide-spread that complete removal is impossible.
    Cysts  of the Prostate.—Cysts of the prostate are either hyda-
tid or retention.  The hydatid cysts are so extremely rare that symp-
tomatology based  on  clinical experience can scarcely be  formulated.
The symptoms Avould  naturally be dependent on interference with
micturition or defecation, and pain.
   The detection   of a  fluctuating,  non-inflammatory  tumor Avould
lead to a diagnosis.
   Retention  cysts are frequently associated Avith hypertrophied  pros-
tates, but  in any case are rare.  Usually they are due to obstruction
of the prostatic  follicles.   Exceptionally the  cyst  may  be due to
narrowing or  obliteration of the opening of the utricle.   In this case
interference with micturition might readily occur.  Englisch found five
examples  of this affection  out of  seventy post-mortem examinations
of newly born children.
   The treatment is puncture through the perineum, evacuation, and
drainage. 
                    CHAPTER  XXVIII.

                  SEXUAL weakness  and sterility.

   The term impotence implies a lack of ability to perforin the sexual
act.  It is not necessarily associated with sterility, nor is a sterile per-
son necessarily impotent.   Thus, patients whose ejaculations are pre-
mature and whose erections are feeble  or wanting, though  unable to
have sexual  relations, may discharge  semen  swarming Avith living
spermatozoa; while those  Avho are particularly vigorous  in sexual
congress may have no  emissions, or  may emit fluid entirely devoid of
living spermatozoa.
   Impotence in the male  may be due to congenital or acquired de-
formity or to feebleness or deficiency in erection.
   Mechanism of Erection.—In the ordinary condition  of the penis
the muscular fibres lining  the trabeculae are  in a condition of tonic
contraction: hence the spaces are obliterated.  Moreover, the arteries
are so  contracted  that no  more blood  is furnished than  is sufficient
for the nourishment of the parts: hence circulation is carried on as
in other parts of the body.  When  the impulse  is sent out from the
erection centre the arteries dilate and the muscular structure  of the
erectile tissue relaxes: hence there are  provided  an increased blood-
supply and spaces for its accumulation.   At the same time, as a result
of muscular contraction,  the  veins carrying  the  return blood are
pressed upon and congestion is thus increased.   As a  result the erec-
tile tissue becomes turgid, and  this in  itself adds to the tendency to
engorgement, since the  fibrous investment of the  penis  is put upon
the stretch, and thus the venous return is materially interfered with.
As the penis becomes tense and  rigid  it is mechanically carried up-
ward to an elevation of  about forty-five degrees  by the action of the
suspensory ligament, though both the  erector penis and the accele-
rator urinae,  by draAving dowmvard and backAvard upon the organ
behind the position of  this ligament,  assist in maintaining this position.
Erection is finally completed by the active participation of the perineal
group  of muscles.  The erector penis, the accelerator urinae, the trans-
versa perinei, and the compressor urethrae by tonic contraction with
clonic  accentuations, materially increase the venous  congestion.
   With  all  the factors described  in  harmonious  action,  the  penis
     1002 
SEXUAL WEAKNESS AND STERILITY.          1Q03
becomes fully erect; its  hardness is dependent upon the amount of
engorgement and the  density of its fibrous  investment;  the spongy
body and the glans are never as hard as the cavernous bodies.
   As  the  result of sexual  excitement coincident Avith erection, the
testicles are drawn close  to the abdomen by contraction of the dartos
and of the  muscular fibres of the cord.  It is probable that the sper-
matozoa which fill the epididymis are rapidly carried by the peristaltic
action of the muscular coat of this tube and of the vas to the ampulla,
from Avhich dilatation, the ejaculatory duct being patulous, sperma-
tozoa are driven into the prostatic urethra.   In the mean time, as a
result of the active congestion,  the mucous glands and follicles of the
urethra have been secreting a clear, slightly alkaline, viscid mucus, the
possible purpose of Avhich may be the neutralization of any acid urine
Avhich  may remain in contact Avith this tube.  At the time of orgasm
the muscles of  the  prostate vigorously  contract as the compressor
urethrae  muscle becomes relaxed: thus  not only the spermatozoa
and the contents of the seminal vesicles,  but also the prostatic secre-
tion, are driven forAvard into the bulbous urethra,  being prevented
from going back into  the bladder by the congestion of the erectile
tissue of the verumontanum and also  probably by contraction of the
internal sphincter of the bladder.   Once in the bulbous urethra, the
semen is driven  forAvard by contraction of the whole perineal group,
aided by the muscular fibres of the urethra.
   The semen is a composite  fluid, made up of the secretion of the
testicles, seminal vesicles, prostate glands, Cowper's glands, and the
urethral crypts and follicles.  It is a gray fluid, becoming gelatinous on
ejaculation.  If  alloAved  to  stand  it becomes thin, and there settles
from it an opaque deposit,  made up of spermatozoa, over Avhich lies
a layer of  about equal  thickness of gray, translucent liquid.  The
characteristic  odor of semen is  probably given to it by the  prostatic
secretion.   It  resembles that of a raAV potato.  Spermatozoa at the
time of ejaculation and  for about twenty-four  hours  afterwards, if
evaporation is  prevented,  should be  in active motion.  When the
semen is deposited in the female genital tract, spermatozoa live for
many days.   After  standing for tAvo  or three  days, healthy semen
deposits  the  spermatic  crystals.   The  amount discharged  at one
orgasm is from  one  to tAvo drachms, though this quantity is subject
to marked  variations.
   The nerve-centres for erection and  ejaculation are situated in the
lumbar cord,  the fibres passing  outward  from the erector centre
being termed  nervi erigentes.
   The erector centre  may  be  stimulated by reflexes from the geni- 
1004       GENITO-URINARY DISEASES  AND SYPHILIS.

talia or from regions  associated by nerve anastomosis, by the  direct
action of the  brain,  or by injuries or diseases  of the  spinal cord.
Familiar examples of erection from  reflex action are afforded by the
morning priapism incident to a full bladder; by the  continued erec-
tion sometimes associated Avith prostatic calculus or Avith inflammation
of the posterior urethra; and  by the tendency  to local congestion
exhibited with balanoposthitis.  The effect  of sights, sounds, odors,
or mental conceptions upon  the erector centre is too Avell knoAvn to
require comment.   After fracture of the lower dorsal  spines priapism
may last for Aveeks.
    Before  considering the question of impotence it is Avell to  knoAv
what  constitutes an average  amount of sexual strength.  A man be-
tween his  twentieth  and  fiftieth year, Avho has  no  drain upon his
system, such  as is required  by unusual  business anxieties,  or such
as results from grief,  disappointment, etc., should be able to have in-
tercourse about tAvice a  week  without  experiencing any sense of
fatigue  or  exhaustion.  Idiosyncrasy, surroundings, or habits of life
may so affect  the  individual  that a much more moderate indulgence
Avould be  hurtful.  Thus  those of lowered  vitality  from excessive
Avork, deficient food, or organic or functional diseases  may find indul-
gence to the extent above given highly injurious or even impossible,
Avhile the vigorous, full-blooded man, whose  life is spent mainly in
the open air, may far exceed this limit.  The gauge as to the healthful
limit of intercourse should be the sensations experienced  afterwards.
These should be rather of increased poAver, both physical and mental,
than of exhaustion.
    Erections may take place  shortly after birth.  The poAver usually
departs about the sixty-fifth year, though it is often  retained ten or
fifteen years longer; it may be lost as early  as the fiftieth year.
    From  a clinical stand-point  impotence  may be classified as  fol-
lows : (1) organic  impotence;  (2)  psychical  impotence;  (3) atonic
impotence.
    Organic impotence implies the existence of appreciable lesions
which interfere Avith  function.   These may involve the spinal cord,
producing  sclerotic changes either in the  lumbar centres or in their
afferent or efferent nerve-fibres.  Thus, in  lumbar ataxia, in syphilis
of the cord, and  in some  cases of  myelitis, impotence is sometimes
an early symptom of the nerve-affection.   This is comparatively rare.
    The majority of cases  of  organic impotence depend upon malfor-
mation of the  external genitals.  This malformation may affect the
penis, the testicles, both these organs, or the surrounding parts.  The
penis  may be  absent, may be rudimental, may be deformed, may be 
SEXUAL WEAKNESS AND  STERILITY.
1005
 hypertrophied, may  be multiple.  If the organ  is absent or  exists
 simply as a rudiment, cure is hopeless.   If the mechanical  impedi-
 ment to coitus is dependent upon the small size of a penis AArhich is
 normal in other respects, the case  is not beyond help, since it  has
 been shown in several instances that use has been quickly followed
 by an increase in groAvth.   Thus, Wilson observed a man of  tAventy-
 six years Avhose penis before marriage was not larger than that of an
 eight-year-old child.  Two years after marriage this organ had reached
 its normal size.   In the treatment of impotence in patients Avith organs
 perfectly formed but markedly undersized, the application of a suction
 apparatus may be beneficial.   This  consists of a cylinder Avhich is
 fitted over the penis  and from Avhich the air can  be exhausted; as a
 result there is venous congestion, with temporary increase in the  size
 of the organ.   It is stated that this increase Avill become permanent
 if the treatment is continued a sufficient length of time.
    The abnormal size of the  organ may be an impediment to coitus,
 but  only relatively so.   Sometimes the penis is congenitally adherent
 to the scrotum, or is fixed  to the  groin  or the  belly as the result
 of cicatricial contraction.  Here plastic operations will be necessary,
 according to the special indications of the case.
    Hypospadia is a frequent cause of impotence, since the doAvmvard
 curve of the organ is so greatly exaggerated during erection that intro-
 mission is  impossible.   Wounds and lacerations of the  floor of  the
 urethra, sometimes internal urethrotomy, will produce the same incur-
 vation.   The  distortion  of hypospadia  may be remedied by the free
 division of the restraining band, usually a rudiment of the  spongy
 body; the distortion  occurring later in life and incident to  cicatricial
 contracture, either from  lacerated Avounds or from urethrotomy, may
 be improved by inunctions of mercurial  ointment, massage, excision
 of the cicatrix, and  restoration of  the penis to its  proper position
 by various plastic  operations, or, as advised by Gross, the removal
 of a wedge-shaped piece  from the corpora cavernosa, folloAved  by
 suturing of the raAV surfaces.  Even if this last operation straightens
 the penis, it is likely to  interfere with erection, since the portions of
 the cavernous bodies in front  of the section may remain flaccid while
 the rest of the organ  is  rigid.
   Fibrous  or cartilaginous indurations of either the sheath of the
 penis or the erectile  tissue materially interfere with coitus, not only
 because of the distortion which ahvays becomes manifest on erection,
 but because the  erectile tissue anterior to this point of induration
 remains  entirely  flaccid.   These indurations are irregular in  their
distribution, and are common in the rheumatic and the gouty. 
1006       GENITO-URINARY DISEASES AND  SYPHILIS.

   Deeper fibrous indurations, also interfering Avith function, not un-
frequently develop after gonorrhoea, and in some cases syphilis seems
to be a factor in the growth of these lesions.  When they appear  in
the form  of gummata  their  specific  origin is sufficiently  obvious.
Calcification sometimes takes place.
   The treatment of this condition is unsatisfactory.  Gummata can
be made to resolve under specific treatment.  The hard nodulations
and indurated  plaques Avhich are observed in  gonorrhoea or in gout,
or Avhich come Avithout obvious cause, are extremely obstinate.   Mas-
sage and inunctions of mercury should  be employed, together with
pressure, Avhich is best applied  by means  of a thin rubber  bandage.
The prognosis as to cure must always be extremely guarded.
   Aneurismal dilatations of the  corpora cavernosa, whether con-
genital or traumatic, may mechanically prevent coitus.  Relief is here
obtained by the application of firm rubber bandages or supports.
   Varix of the dorsal vein of the penis, though it may attain large
dimensions, rarely produces functional disturbance.  If it does, ex-
cision is the proper remedy.  A similar condition of the lymph-vessels
may be cured  by excision, or by the  less radical means of passing
a seton through the vessel.  A  tight fraenum should be remedied by
incision.
   Tumors or swellings  about the genitalia may mechanically inter-
fere with  function.  Thus,  elephantiasis of the  scrotum, enormous
oedema  of  the prepuce, huge scrotal hernias  and  immensely pro-
tuberant bellies, large scrotal  tumors, muscular contractures, hydro-
celes,  all may render coitus well-nigh impossible.
   Malformations and diseases of the testicles may also produce im-
potence.   Such deformity is not necessarily attended with  any mal-
formation  of the penis, though this is the rule.
   In anorchidism—that is, congenital  absence  of  the testicles—
impotence is complete.   Cryptorchids (those AAmose testicles  have not
descended) are usually  sterile, but  not impotent.  Removal of both
testicles is  ultimately followed by impotence, but this may not come
on for some years.
   Disorganization of the testicular structure  either from inflamma-
tion or  from tumor-groAvths is  also folloAved by the loss of  sexual
poAver.  If the inflammation is  confined to the epididymis,  however,
as in  the  case  of  epididymitis, the  glandular  structure of the testes
remaining  intact,  sterility follows,  but there  is  no loss  of  sexual
strength.  Syphilis, tubercle, sarcoma, carcinoma, even though they
involve  but one testicle, are sometimes associated with  impotence.
The chronic congestion and sIoav atrophy incident to pronounced 
SEXUAL WEAKNESS AND  STERILITY.         1QQ7
varicocele are  not infrequently folloAved by  impotence  long before
gross changes in the testicle have been noted.
   Psychical  Impotence.—In this  form of Aveakness the  sexual
organs  are  normally formed,  and erection is  possible, but  is  not
properly under the control of the will.   At times such patients have
vigorous erections.  These occur in  the morning and on  compara-
tively slight  provocation.   Under  certain circumstances,  and usually
at times Avhen this failure  is most mortifying,  erections fail utterly,
or, at most,  are so feeble as to be of no service.   This form of impo-
tence not infrequently attacks the neAvly married, avIio fancy that they
suffer from some form of sexual Aveakness incident to early self-abuse.
It is sometimes due to  a mental impression  produced by  failure on
the first attempt, such failure being attributable at times to fright, to
disgust, or to other emotions.
    Treatment.—The treatment of these cases of psychical impotence
should  be  one calculated  to  make  a strong  impression  upon the
patient's mind.  He must be examined Avith the utmost thoroughness
both locally and generally.  All causes of local  irritation  must be re-
moved  and  every effort made to improve  his  general health; he
should be assured that his Aveakness is merely temporary and that cure
Avill  certainly result.  Such  patients have  generally read pernicious
literature, and have usually consulted charlatans: hence they need to
be disabused of the teaching that masturbation indulged in moderately
and for a short time invariably produces disastrous results.
   In addition to the general hygienic directions, including  regulation
of the  diet, attention to the  boAvels,  and exercise,  some  medicine
should be given to these patients, and this  should be one appropriate
to their general condition,  or, if the health is perfect, one which has a
tendency to act as  an  excitant on the spinal centres.   Perhaps the
best prescription is the folloAving:
                    R Strychninae sulph., gr. ^;
                      Phosphori, gr. ^;
                      Damianae ext., gr. iii ;
                    M. et ft. pil. no. i.
                    S.—One pill three times a day.
   Under some  circumstances moderate  stimulation by  means of
Burgundy or champagne may be  beneficial, since the patient is often
entirely cured  after one successful effort.   Absolutely forbidding in-
tercourse acts  at  times as an excellent  stimulus.  Patients suffering
from  this form of impotence should be especially cautioned against
trials of their poAvers with prostitutes, since  the circumstances of these
trials are little  conducive to a normal degree of  sexual excitement. 
1008       GENITO-URINARY DISEASES AND  SYPHILIS.

   The term relative impotence implies lack of ability to perform the
sexual act Avith certain partners, Avhile with others full strength  may
be preserved.  No rule can be  laid doAvn for the  management of
such cases.   Each must be conducted in  accordance Avith its merits,
the physician ahvays  throAving his influence on the side of morality.
Much can  sometimes be  done by strong mental impression, usually
accentuated by the administration of drugs.  In many cases impotence
upon the part of the man is due  to the frigidity of the woman,  Avho
does not realize the profound effect of her attitude.  Perhaps the  best
plan in these cases is to advise the man to shun the society of other
Avomen, to live  well, work little, exercise much.
   Atonic Impotence.—Under this heading are included those cases
of partial or complete impotence which are due to a Aveakened condi-
tion  of the lumbar centres.   When these  centres are in their normal
condition, erection should be vigorous, and coitus should be continued
for from three to five minutes before ejaculation, and after ejaculation
there should not  be  immediate  subsidence  of erection.  In many
healthy young men the erection can be maintained until bvo emissions
have taken place.
   In  atonic impotence (1) erections may be  vigorous, but ejacula-
tions may be premature, occurring on contact or even before, folloAved
by immediate subsidence of  erection; (2) erections  may be weak or
may be entirely \vanting.
   The atonic condition of the lumbar centres may be  dependent on
certain  general conditions, such as anaemia, diabetes, uraemia, choke-
mia, and  rheumatism.  Sometimes temporary impotence is one of
the first signs of post-diphtheritic paralysis.  Wasting  diseases, such
as consumption, are usually accompanied  by this form of atonic im-
potence.  Many drugs if taken until  their toxic effects are produced
occasion failure of sexual poAver.   Thus, organic lead-poisoning,  car-
bonic acid gas,  carbon bisulphide, antimony, and particularly alcohol,
tobacco, and opium,  may cause complete loss of both poAver  and
desire.  Impotence resulting from the excessive use of tobacco and
alcohol often long outlasts the other bad effects after  the habit has
been  stopped.   Certain  persons exhibit an  idiosyncrasy  toAvards
tobacco, which, when taken in  such moderation as to produce no
constitutional  effect, may  destroy both sexual desire  and power.
It is  alleged that the cigarette is particularly potent in  producing this
result.
   According to Trousseau, coffee has marked  anaphrodisiac effects,
and may produce complete impotence.  This observation is  certainly
not in accord  Avith the  experience of  the majority of surgeons,  at 
SEXUAL WEAKNESS AND STERILITY.          1Q09
least so far as the moderate use of the drug is concerned.   If taken
in enormous quantities it may of course produce this result, but rather
because  of the  general nervous  break-down  than because of any
special action on  the  sexual centres.  Certain drugs given in phys-
iological  doses will produce a marked  lessening of  sexual power.
The bromides are particularly depressing;  cocaine is also alleged to
have  this  effect,  and  morphine  in  certain  individuals  is markedly
sedative to the sexual centres.
    In accordance  with the degree of impotence the  condition is said
to be either irritative or paralytic.
    In the irritative form the erections are either perfect or imperfect.
The emissions are ahvays premature, quickly followed by subsidence
of erection.  The  sexual desire is strong.
    In  the  paralytic form  erections  are  absent or  feeble, desire is
Avanting; during orgasm the semen drops from the flaccid penis, with
little or no pleasurable sensation.
    Of these two forms the irritative is the more common.  The cause
is in the great majority of cases a diseased condition of the prostatic
urethra,  the mucous  membrane being  exceedingly hyperaemic, or
chronically inflamed, keeping the  centres for erection and ejaculation
in a constant state of reflex excitability.   This condition  of the pros-
tatic urethra may  depend upon—(1)  gonorrhoeal inflammation and its
sequel,  stricture;  (2)  excessive  venery;  (3) prolonged  ungratified
sexual excitement;  (4)  strongly  acid or irritating conditions of the
urine.   Of all these causes, gonorrhoeal  inflammation and its sequel
stricture are the most  frequent.  In most  cases of acute gonorrhoea
the prostatic urethra is involved to a very  slight degree, and  the  dis-
ease, at least in this part of  the tube, undergoes complete resolution.
In a certain percentage of cases, however, the disease becomes firmly
lodged in  the  prostatic follicles,  utricle, ejaculatory ducts,  seminal
vesicles, or ampullae of the vasa, manifesting  itself only  by an occa-
sional  apparently  causeless outbreak in the form  of  an acute attack.
As a consequence  of the continued  irritation, the mucous membrane
of the prostatic urethra undergoes catarrhal alterations, and the sen-
sory nerve filaments so rich in this part of the tube are involved and
reflexly excite the centres for erection and  ejaculation.  This inflam-
matory and hypersesthetic condition of the posterior urethra is  still
further aggravated by the formation  of a stricture.
   Atonic impotence from sexual  excess  is most frequently observed
among masturbators, if this  habit can properly be classed as "sexual."
In the recently married sexual excess is by no  means  uncommon,
but shortly regulates itself.   Occasionally it  is continued for a  long 
1010       GENITO-URINARY DISEASES AND SYPHILIS.

time, and then doubtless Avorks permanent harm: first, by producing
a hyperaesthetic  condition of the posterior urethra, and consequently
one of the forms of impotence ; next, by ultimately producing certain
fibroid changes in the cord.
   Masturbation  as a  cause of impotence is generally given prom-
inence Avhich  is  not deserved.  This is a habit Avhich practically all
boys have had at one time.  The popular belief as to the injury which
even a slight indulgence in it may cause leads those Avho subsequently
have sexual trouble to refer this back to self-abuse.   Even Avhen the
habit  is  continued  for years  during  the period  of  youth and early
manhood it is often followed by  no  appreciable  ill effects:  at least
such is the testimony of large  numbers of medical students.  It is,
however, undoubtedly true  that in certain instances, aside from  the
rooted conviction of the patient,  irritative  and paralytic forms of
impotence  can be referred  directly to excessive masturbation.  The
physique and  morale of a  masturbator are  popularly considered as
almost pathognomonic.  Thus,  such  patients are supposed  to have
muddy, pimpled complexions ; a cold, moist surface ; holloAv, sunken,
blinking,  shifting, watery eyes;  lustreless hair; a timid, constrained
manner; stooping shoulders; a tendency to swalloAv frequently, par-
ticularly  on  being  embarrassed;  weak knees ;  a  shambling gait;
shrunken sexual organs, and a solitary disposition, Avith incapacity for
any intellectual effort.
   This description no doubt applies  to certain aggravated cases.   It
may, hoAvever, be observed  in neurotics Avho are not addicted to  the
habit, and  an  extreme degree of masturbation may coexist with  the
appearance and manners of  perfect health.
   Atonic impotence from prolonged  and ungratified sexual desire is
usually observed in men of neurotic  temperament, particularly those
coming from the rural districts, who, from the circumstances of their
life, are exposed  to  sexual  excitement,  and who, either from moral
reasons or for lack of opportunity, do  not  indulge  in sexual inter-
course.  Many  of  these  cases  can properly  be classed  as  mastur-
bators, since the sexual centres finally become so irritable that orgasm
occurs on the  slightest  provocation, and an  opportunity for such pro-
vocation  is so  constantly afforded that exhaustion follows.
   The irritability often becomes so marked that the slightest mechan-
ical frictions or jarrings, such as come from riding on horseback or in
a jolting  wagon,  occasion emissions.
   In  these cases the condition of sexual neurasthenia is unusually
Avell marked.
   Since the ordinary lesion of atonic impotence, Avhatever its remote 
SEXUAL WEAKNESS AND  STERILITY.          IQH
 cause may be, is a hyperaesthetic condition of the prostatic urethra, it
 is not unreasonable to suppose that the irritation incident to abnormal
 conditions of the urine may excite a  prostatic hyperaemia,  resulting
 in the derangement of the sexual centres.  That this is the cause of
 impotence associated Avith certain  abnormal  conditions of the urine
' cannot be positively asserted, since it is possible that the general con-
 dition Avhich occasions the abnormal  urine may also operate on  the
 centre presiding over erection.   Thus, in complete impotence a careful
 examination of the prostatic urethra may fail to sIioav the slightest sign
 of abnormal prostatic  condition.  In  cases of oxaluria, however,  the
 return of sexual  strength is  often  coincident Avith the disappearance
 of calcium oxalate in the urine.   The irritating effect of acid urine on
 the prostatic urethra is sIioavii by the persistent priapism Avhich some-
 times accompanies acute attacks of gout, in Avhich there  is found a
 heavy deposit of  uric acid.
     Genito-Urinary Neuroses.—Atonic impotence is characterized  by
 certain local and general symptoms, Avhich Ultzmann has admirably
 described under the general heading of genito-urinary neuroses.   He
 states that the symptoms incident to a hyperaemic or chronically in-
 flamed condition of the prostatic urethra are almost identical Avith
 those obser\red in the female as the result of endometritis.   Both the
 uterus and the prostate are richly supplied with nerves.   In men the
 bladder and seminal vesicles  and prostate receive filaments from the
 vesical plexus, Avhich, in turn, is made up of anastomosing branches
 from the  hypogastric branch of the sympathetic, together Avith branches
 from the sacral ganglia and  from the pudendal  plexus of the sacral
 nerves.   This nerve-supply sufficiently explains Avhy irritation of the
 prostatic urethra should excite such reflexes as pain passing down the
 inner surface of  the thighs or referred to the hip, the anus, the hypo-
 gastric region, or the small of the back.
    The general symptoms are those of neurasthenia.   Loss of mental
 power, vertigo, headaches, shortness  of breath,  indigestion, palpita-
 tion, colic, cough, emaciation, Avandering neuralgic pains, nervousness,
 and excitability,—these and  many other symptoms of which'neuras-
 thenic females complain  are duplicated  in the male suffering  from
 atonic impotence.
    The  urine in these cases is  often abundant and of Ioav specific
 gravity.   Sometimes there is a transient glycosuria.  In some cases
 the urine is alkaline when it  is passed, owing to the presence of car-
 bonates.   On heating,  the earthy phosphates are  precipitated.  Indi-
 can is observed particularly in those  given to sexual excess.  Tran-
 sient albuminuria is sometimes  noted.  Calcium oxalate frequently 
1012      GENITO-URINARY  DISEASES AND SYPHILIS.

appears in great excess.   The amorphous crystalline salts of lime and
magnesia are also to be found,  together with a few spermatozoa.
    The  neuroses of  the  sexual  centre may be  either sensory or
motor.
    The sensory  neuroses present an almost infinite variety.  The
usual symptoms  complained of are a sensation  as though fluid Avas
trickling through the urethra;  a tickling and burning  feeling at the
meatus; neuralgic, aching, or burning pains referred to the testicles,
anus, inner surface  of the thighs, hypogastric region,  small of the
back, or any of the  regions  innervated  by branches communicating
with  the  hypogastric and sacral plexuses; pain in the  testicles and
burning in the meatus after ejaculation ;  and extreme sensitiveness to
the passage of instruments.   In aggravated cases the urethra becomes
anaesthetic, and the penis feels  cold, is shrivelled, and is sometimes so
non-sensitive that even  applications of an electric brush occasion no
pain.
    The motor neuroses of the  urinary and  genital  systems may take
the form of over-action  or of paralysis.   Vesical irritability is some-
times manifested by paroxysmal dribbling or even complete stoppage
of the urine, occasioned either by a lack of contraction of the smooth
muscular fibres  or by spasm of the compressor  urethrae.   So-called
stuttering urine may be due to  the same cause.  When the detrusors
of the bladder are involved in over-action there is difficulty in retain-
ing Avater.  Urination is  frequent and urgent, and is usually not asso-
ciated with pain, but sometimes there is marked tenesmus.   Paralysis
of the sphincters or  detrusors  is extremely rare; in the one case it
Avould occasion  dribbling  of the  urine  and in the other retention.
The motor neuroses of  the  sexual system may be manifest in the
form  of priapism, or of partial or complete impotence, often associated
Avith involuntary seminal emissions and spermatorrhoea.  Priapism is
observed only in the early stages of acute involvement of the prostatic
urethra;  impotence  is common  in chronically inflamed conditions.
The frequent  pollutions  complicating it are due to spasm  of  the de-
trusors of the seminal vesicles  and the vasa deferentia.  Spermator-
rhoea or dribbling of  the  semen Avithout the  sensation of  an orgasm is
due,to paresis of the muscular fibres of the ejaculatory ducts.
    The secretory neuroses of the genital system are manifested in the
form  of polyspermia, or  ejaculation of abnormal  quantity  of semen;
aspermia, or absence of semen; or prostatorrhoea,  a discharge made
up of the secretions of the prostatic glands, the glands of CoAvper, and
the urethral crypts and follicles.
    The  Diagnosis of Atonic Impotence.—A  careful  history Avill often 
SEXUAL WEAKNESS AND  STERILITY.          1Q13
 indicate whether impotence is due to psychological  influence, to or-
 ganic changes, or to exhaustion of the lumbar centres.  Examination
 should be made not only of the sexual organs but also of the heart,
 of the  lungs, and of the system at large.   Examination of the urine
 should never be omitted ; the total quantity in the hventy-four hours,
 the specific gravity, the reaction, the  deposit,  the presence or absence
 of abnormal  constituents, must all  be carefully noted.  Microscopic
 search  Avill  determine Avhether or not pus is to be found.   The source
 of this pus must  be discovered in  the  method described when con-
 sidering the treatment of posterior urethritis.  The anus  should be
 explored carefully, since lesions in  this region  may  excite reflexes
 Avhich are referred to the genital tract.
    Finally,  the sexual organs must be  carefully examined ;  the testi-
 cles are palpated,  and their size, position, consistence, sensitiveness,
 and the presence or absence of swellings and new groAvths are noted.
 The penis  is similarly examined, its circumference behind the glans
 recorded, and the urethra carefully palpated  for indurations along its
 track.   The prepuce is subjected to careful scrutiny, the meatus is in-
 spected, and finally the urethra is explored exactly as in searching for
 strictures.  In many of these cases spasmodic contraction of the com-
 pressor urethrae muscle is particularly marked.   A full-sized sound
 passed  to the membranous urethra and kept gently pressed against its
 anterior opening will finally  slip through, not with a jump, but rather
 as though an attempt Avere being made to pass it through a tight, flex-
 ible tube Avithout previously  lubricating it.   Sometimes it seems to be
 draAvn in Avith a SAvalloAving  motion.   During the introduction of the
 instrument  not only should the points of resistance to its entrance be
 noted, but also areas of unusual tenderness.  The posterior urethra
 is extremely sensitive; in cases of the  paralytic  type, hoAvever,  the
 passage of a sound is absolutely painless.
   If the meatus is so narroAved that  it will not  admit  a full-sized
 sound  it should be cut.  Urethroscopic examination is rarely neces-
 sary in these  cases, at  least until the  failure of ordinary treatment
 suggests the possibility of some unusual pathological condition, such
 as polypoid groAvth.
   An  examination thus conducted  will shoAv a hyperaemic  or  in-
 flammatory condition of the posterior urethra, either associated with
 stricture or  other obstructive lesion, or simply remaining as the result
 of repeated  prolonged congestion or previous  acute inflammation.
   The prognosis  of atonic  impotence is  good, except in the most
advanced cases.  When strictures or  granular patches in the anterior
urethra are the exciting causes, the  cure of these conditions by ap- 
1014       GENITO-URINARY DISEASES AND SYPHILIS.

propriate means is followed  by the disappearance of the symptoms
of impotence.
   When the symptoms  are due to the persistence of a posterior
urethritis, local applications are curative.  When impotence is caused
by impaired  health, the outlook is  favorable, provided  the  general
condition  can  be improved.  Even though  erections  are  entirely
absent at times when they  are most desired, or  are of such short
duration as to be of no practical service, if the  patient has volup-
tuous dreams with erection,  and  particularly if he has an occasional
morning erection, the chances of ultimate cure are good.  The prog-
nosis is bad only in such cases as have no erection at any time, the
semen dribbling without pleasurable sensations, and the penis being
cold, shrivelled, and non-sensithre.
    Treatment.—The treatment of atonic impotence must be both gen-
eral and local.  The daily life of the patient should be carefully regu-
lated.   The hours of sleep, the diet, the amount and kind of exercise,
should  all  be prescribed.  The boAvels should  be kept  regular, and
general treatment should be  instituted  Avhen this is  required  to
combat the pathological conditions  of the urine.   During treatment
the patient must  be particularly  cautioned  against venereal  excite-
ment of any kind, whether  from reading, conversation,  or  associa-
tions, and against testing the efficacy of his treatment by an occasional
trial of  strength.
   All  sources of reflex  irritation must be  removed.   Fissures  or
hemorrhoids in the rectum,  phimosis, or  narrow  meatus should re-
ceive prompt  surgical  treatment.   Some  cases of impotence have
been cured by the removal  of a hemorrhoidal mass, by the slitting
of the meatus, or by treatment directed to the destruction of lumbri-
coids or ascarides.   Even a moderate degree of varicocele should  be
remedied either by a suspensory bandage or  by operation.
   If in the  course  of treatment the thoughts are in spite of every
effort turned  to  sexual topics, the  patient  should be instructed  to
counteract this tendency in its very beginning by vigorous and pro-
longed exercise and cold baths.
   The local treatment has  for  its  end the  restoration of the entire
urethra to a normal condition.   Strictures must be cured by section
or dilatation, granular patches healed by applications through the en-
doscope, and hyperaesthetic and inflammatory conditions of the pos-
terior urethra treated by irrigation, instillations, and the passage of
full-sized cold steel sounds, or by the use of the psychrophore.
   The sound should be  introduced every  third or fourth  day and
should  be  of full normal calibre.   When the  urethra is extremely 
SEXUAL WEAKNESS AND STERILITY.          1Q15
hyperaesthetic,  injections  of cocaine, first into the anterior urethra,
then into the posterior part of the  canal by means of an  instillator,
will render instrumentation comparatively painless.
   When there are distinct evidences of congestion  or inflammation
in the posterior urethra, in addition to the sound, irrigation and instil-
lation will usually  be necessary  before  cure  can be accomplished.
Irrigation is  conveniently  practised by means  of a short  urethral
nozzle  and bag, or a soft rubber catheter, which  is attached to the
pipe of a fountain syringe.   (See treatment of acute  urethritis.)
   The solutions Avhich have given the best clinical  results are silver
nitrate  1 : 6000 to  1 : 500 :  corrosive  mercuric chloride  1 : 10,000 ;
potassium permanganate  1 : 10,000 to 1 : 1000;  zinc  permanganate
1: 6000 to 1: 3000 ; zinc sulpho-carbolate  1 :  3000 to 1:1000 ; fluid
extract of hydrastis, hvo to six per cent.
   The term instillation as used in genito-urinary surgery denotes the
local application of a feAv  drops of a medicinal solution by means of a
syringe.  (See  treatment  of chronic posterior  urethritis.)   The instil-
lator is practically never used for  applications  to the  anterior urethra,
the endoscope  enabling the  surgeon to conduct such treatment with
very much greater accuracy.   In diseases of the posterior urethra,
hoAvever, it is a most valuable  means of treatment.  The instrument
is introduced till its tip is grasped by the compressor urethrae muscle ;
the injection is then made, and, provided a sufficient quantity is used,
will Aoav back  into  the bladder.   It never Aoavs forAvard into the an-
terior  urethra,  OAving to  the sphincter-like action of the compressor
urethrae muscle.   It is important that such escape should  not take
place anteriorly, since the solutions commonly  employed are so strong
that they Avould probably excite acute anterior urethritis.   The quan-
tity to  be injected  each  time varies betAveen ten and  thirty drops,
depending upon the strength of the solution employed;  the stronger
the medication the  feAver  the  number of drops.  If the prostatic
urethra alone is to be treated, instillations should  be made when the
bladder is partly filled.   If it is  important  to influence the internal
sphincter and  the  neck of the  bladder, instillations  should be made
on an empty bladder.
   The following are the solutions  most employed in this plan  of
treatment: silver nitrate,  from one to ten per cent., particularly for
gonorrhoeal  cases;  copper sulphate, ten per cent.;  zinc sulpho-car-
bolate, ten per cent.;  iodine, carbolic acid, and boro-glyceride, equal
parts    It is  well to begin  Avith  a  Aveak injection and increase  the
strength from  day  to day.   Thus, Avhen it  is decided  to  use silver
nitrate  the usual strength should be one per cent.; ten drops of this 
1016       GENITO-URINARY  DISEASES AND SYPHILIS.
are throAvn in, and the patient  required to report in three or four
days.  A similar quantity of a two per cent, solution is then used, and
the strength of the solution is gradually increased until ten  per cent.
is reached.  Zinc and copper are employed Avhen silver nitrate cannot
be  used.   In  extremely obstinate cases an occasional application of
carbolic acid and iodine Avill prove serviceable.  The immediate effect
of the instillation is to produce burning pain in the perineum and an
almost irresistible desire to urinate.  This subsides in from  fifteen to
thirty minutes ; after Avhich for one to hvo days the patient Avill  suffer
from frequency of urination, some urgency, and pain after the act.  In
case too strong solutions  have been employed there Avill be marked
tenesmus,  passage  of blood, particularly toAvards  the end  of mictu-
rition,  constant  pain,  and sometimes fever.   If the  instillation has
been alloAved  to escape into the anterior urethra there will be  a free
purulent discharge, simulating  that of gonorrhoea.   In many cases it
will be found impossible to use solutions of more than one-half the
strength Avhich has been given as the maximum.
    When inflammation is absent, or after it has been cured, if hyper-
aesthesia still persists, this is best combated  by the  prolonged applica-
tion of cold.  The passage of a cold  sound accomplishes this end in
an imperfect Avay, since the metal is soon heated.  The psychrophore
(Fig. 248) will, hoAvever, permit of a continuous cold application for as
long a period  as is desired.   This instrument is made in the form of
a hollow sound, through the curved  extremity of  which a stream of

                              Fig. 248.
                            Psychrophore.

Avater of the desired temperature constantly flows.   It is so devised
that the  sheath of the instrument Avhich passes through the anterior
urethra is not kept cold by the liquid, which Aoavs through pipes con-
tained in the sheath, but separated from its Avails by air-spaces.  It
is only in the terminal three inches that the water is  alloAved to come
immediately in contact Avith the Avails of the instrument. 
SEXUAL WEAKNESS AND STERILITY.          1017
   The psychrophore should be as large as the normal calibre of the
urethra.  It is introduced until its curved portion occupies the mem-
branous and prostatic urethrae ; then a current of Avater of the desired
temperature is allowed to pass sloAvly through it, thus maintaining the
chamber at its end at about the temperature of the Avater.  In cases
of hyperaesthesia attended by the irritative form of  atonic impotence,
cold water  is most sen-iceable.  The temperature of this  should  be
betAveen 40° and 50° F., and the treatment should be kept up for from
five to ten minutes every second or third day.   In the paralytic form
of atonic impotence hot water from 106° to 110° F. should be chosen.
   Heat or cold may be applied through the  rectum in the  form
of injections,  or a  rubber  bag introduced within  the grasp of the
sphincter.
   Rectal injections  are so planned that the solution of choice (sodium
chloride solution, seven-tenths per cent.) is thrown upAvard in a forcible
stream against the prostate, and is alloAved to escape immediately with-
out distending the bowel.  This end is readily accomplished  by the
instrument pictured  in Fig.  55.  The selection of  heat  or cold will
depend upon the type of disease and the sensations of the patient.
At least a quart  of solution  should be  used  daily.   Dry heat or cold
through the rectum is readily applied by means of a modified Barnes's
bag  inserted into the rectum and distended  Avith either  hot or cold
Avater.  This method of  treatment is to be commended,  since it adds
to the beneficial effects of temperature those incident to pressure.
   When by the means already described urethral hyperaesthesia has
been entirely subdued and yet impotence still persists, other methods
of treatment must  be employed to restore  power  to the Aveakened
centres and also to the muscles concerned in erection and ejaculation.
Full doses of strychnine are advisable in these cases, and particularly
strychnine  in  combination  with  phosphorus  and damiana.  Massage
and general electricity are useful.
   The needle spray applied once a day to the external genitalia at
the time of the  morning bath  is tonic and  stimulating.   The water
should be driven forcibly against the inner surfaces of the thighs, the
hypogastric  region,  the  buttocks, and  the small of the back, and
should be alternately as hot as can be borne and as cold as possible.
The applications should be continued for from two to five minutes.
   Electricity  is  one of the most valuable means of stimulating the
sexual centres.  Both the galvanic and  the faradic current seem to be
of value.  It is employed not only as a general nerve tonic, but also as
a means of directly exercising the perineal muscles concerned in erec-
tion    The current should be first applied to  the spine, and then used 
1018       GENITO-URINARY  DISEASES AND SYPHILIS.

locally.   The positive pole is placed over the lumbar region ; the other
is  carried to the perineum, the  anus, the hypogastric region, or the
prostatic urethra, and  swept over the external genitalia, the buttocks,
and the inner surface of the thighs.
   The rectal electrode is senuceable in cases of imperfect erection
and loss of poAver of ejaculation; it is  particularly valuable because
by means of a sloAvly interrupted  current it exercises the  entire
perineal  group of muscles.   The important part these muscles play
in erection has been shoAvn already, and restoration of their vigor by
the use of electricity is often followed by complete recovery of sexual
strength.  The application should.last from fifteen to tAventy minutes
and be repeated daily for several Aveeks  or months.
   The urethral electrode allows the current to be applied directly to
the prostatic urethra.   Both galvanic and  faradic  currents  are em-
ployed, the  gauge as to strength usually being the sensation  of the
patient.  An electrode properly placed and conveying a sloAvly in-
terrupted current  strongly  exercises the  sphincter of the  bladder,
the compressor urethrae, and the unstriped fibres of  the prostate,
probably including those of the ejaculatory ducts : hence in cases of
spermatorrhoea this treatment  is particularly serviceable.  When the
galvanic current is employed it should  never be of such strength as
to occasion electrolytic action.
   In  some cases which do not  yield to other treatment, a complete
course of hydrotherapy,  including,  as  it  does,  change  of air,  sur-
roundings, and occupation, is sometimes advisable, or, in place of this,
prolonged out-door but not solitary life.
   Two of the symptoms of atonic impotence are so conspicuous as
to deserve separate consideration: these are prostatorrhoea,—that is,
intermittent discharge  of prostatic fluid  from the urethra,—and sper-
matorrhoea, or involuntary loss of semen.
   Prostatorrhoea is characterized by  a discharge during defecation,
after urination, and at times of sexual excitement, of  a white-of-egg-
like substance from the urinary  meatus.  This same  substance may
be caused to  Aoav  from the meatus by pressure  upon  the prostate
through the rectum.  Microscopic examination of the discharge sIioavs
that it is made up of leucocytes, cylindrical epithelium, and concentric
amyloid concretions;  Bottcher's  sperm crystals and casts of the pros-
tatic  ducts, closely resembling  renal  casts, are also  found. Blood is
rarely present.
   Prostatorrhoea  is dependent  on a chronic catarrhal condition of
the prostatic urethra, involving  the  ducts and follicles.   Gonorrhoea
and prolonged ungratified or  unnaturally gratified sexual excitement 
              SEXUAL WEAKNESS AND STERILITY.          1019

most often  produce this catarrhal condition.   On examination of the
prostate per rectum it Avill not usually be found materially increased
in size, although occasionally the  nodular outline indicative of follicu-
lar  prostatites  can be  felt.  The most  prominent  symptoms of this
condition are—(1) A marked condition of sexual neurosis, perhaps a
reflex  from the  catarrhal  region,  usually  aggravated  because the
patient believes that the discharge is semen and that thus his strength
is draining  from him.  (2) A discharge  at stool and after urination
of viscid prostatic mucus.   The hypersecretion is  going on steadily,
but, OAving  to the tonic contraction of the compressor urethrae muscle,
cannot pass forAvard until the resistance  of the muscle is overcome by
the pressure of hardened masses of faeces, or by the reflex required
by the act of micturition.   In some aggravated cases the compressor
urethrae  muscle becomes so Aveak that the  discharge will  flow for-
Avard almost constantly.   If many spermatozoa are found  in the dis-
charge, the case must be regarded as one of spermatorrhoea.  (3) Fre-
quency and some urgency in urination, tickling or aching sensations
in the prostatic urethra, and reflex pains in the back, rectum, hypo-
gastrium, and doAvn the  inner surface of the thighs.   (4) Partial or
complete impotence.  Exceptionally, beyond  the prostatic discharge,
there are no symptoms.
    The  prognosis of  prostatorrhoea  is usually good.  Even  Avhen
habitual  masturbation  causes  prostatorrhoea, the  prognosis is  fairly
good, provided the paralytic form of impotence has not been reached
and the patient has some  strength of will on Avhich to build.
    Treatment.—The treatment is especially that directed to the cure
of congestion or inflammations of the posterior urethra.  When  a de-
pressed condition of the  system or irritating urine seems to be the
cause of prostatorrhoea, corrections of these  departures from health
may be followed by prompt cure.
    It is  particularly important that the bowels  should be kept  open.
Magnesium sulphate or Hunyadi Avater in the morning will accom-
plish  this;   fluid extract of cascara, twenty drops three  times a day,
is useful.   Both exercise  and  diet must  be  carefully regulated.
Horseback   or  bicycle  riding should  be forbidden in  cases of fol-
licular prostatitis, or in those Avhose symptoms after a trial are  made
distinctly worse.  Often  these exercises provide  a species of  mas-
sage for the  prostate which acts most beneficially upon  it.  The
prostatic mucous membrane seems to be particularly sensitive to the
effect of chilling: hence patients suffering from prostatorrhcea  must
be carefully protected against Avet feet, draughts, and other causes of
cold. 
1020      GENITO-URINARY  DISEASES AND SYPHILIS.

    When there is pus in the discharge or in the shreds found in the
urine, the treatment is that appropriate to posterior urethritis.
    The medical treatment is of minor importance, but should none
the  less receive attention.  When the  inflammation is one  of long
standing, stimulants  may be required.  Here  oil of  sandal Avood in
ten-minim doses three times a  day, taken  one  hour after meals, Avill
be  of great help.   Cubebs, copaiba, turpentine, and  cantharides, the
latter in small doses, are  all  useful.  When the bladder is irritable,
belladonna, fifteen drops of  the tincture three times a day, is bene-
ficial.   When the urethra is especially hyperaesthetic, and  particu-
larly in cases of marked sexual neurasthenia, potassium bromide,
administered in hventy-grain doses three times a day,  may quiet the
nervous symptoms.   As a rule, tonics, compound syrup of hypophos-
phites  in  teaspoonful doses,  emulsion  of cod-liver oil Avith iodide of
iron, and iron and nux vomica, should be recommended.  We have
found  hyoscine and  hyoscyamine  sulphate particularly efficacious in
the non-inflammatory forms  of prostatorrhoea.
    It is upon  local  treatment, however, that most reliance must be
placed.  This consists in  the use of steel sounds, the psychrophore,
the prostatic dilator, the rectal  bag, the rectal douche, irrigations, and
instillations.
    Instillations in these cases  should  be more astringent than in an
ordinary inflammatory case: thus, fluid  extract of hydrastis or pure
zinc sulphate, twenty grains to the ounce, may be employed.  Soluble
prostatic bougies are prescribed only Avhen it is impossible  for the
patient to see his physician.   Under these  circumstances instruction
may be given  as to  the  proper  method of inserting these bougies.
The latter may be ordered in accordance with the indications, using
the strongest and  most  astringent in  the oldest cases.   Among the
most useful bougies is one containing the following:

                      Zinc sulphate, gr.  ii;
                      Carbolic acid, tt\ji;
                      Fluid extract of hydrastis, n\,xv.

    The prostatic dilator  (see Fig. 52) is  sometimes of sendee.  It
probably accomplishes its good effect  by mechanically emptying the
inflamed follicles and thus allowing the  instillation, which  should
immediately folloAv the stretching, to reach to the deeper parts of the
diseased mucous membrane; the solutions of choice  and the method
of instrumentation have been given.   (See Chronic Posterior Ureth-
ritis.)  Stretching by means  of the dilator should be carried  as high
as No.  36  of the  French  scale and not higher than No. 44.  Full 
SEXUAL WEAKNESS AND STERILITY.          1021
dilatation  of the prostatic urethra by means  of  ordinary  sounds is
impossible, since an instrument of sufficient  size to overstretch  the
membranous urethra fits loosely in the wider prostatic portion of  the
tube.
   Blisters applied to the perineum  and the hypogastric region have
been  Avarmly  commended.   If used, the  blistered area should  be
small, the application of the vesicant being  frequently repeated.
   Electricity  is sometimes a useful agent in prostatorrhoea. The
galvanic current is most popular, one pole being applied to the lumbar
region, the other to the prostatic urethra.
   Usually it  is best  strictly to interdict intercourse ; though Avhen
prostatorrhoea occurs in married men as the result of  long-continued
excess it  is wise  for a time to  allow  of moderate indulgence, since
otherAvise the  local  congestion  incident  to  prolonged excitement
Avithout gratification might  counteract the effect of treatment. The
advisability of alloAving  moderate intercourse must  be determined
by the immediate effect; thus, if the discharge is increased, and par-
ticularly if the patient feels  exhausted and  suffers from lumbar pains,
intercourse must be forbidden.
   Under proper treatment recovery may result in from one to three
months, though  in some cases  a much longer period of time is  re-
quired.   Certain  cases  are  aggravated  by local treatment.   Under
these circumstances it is adAisable to make a complete change of  life
and surroundings.  An active open-air life will sometimes be folloAved
by ultimate cure.
   Involuntary Seminal  Emissions.—These  may be due to erotic
dreams, or may be occasioned by a local  hyperaesthesia so marked
that stimuli too feeble to produce any effect in health become suffi-
cient  to excite ejaculation.   The involuntary  emission may occur at
night  or in the day, and the semen  may escape  intermittently in  the
form of pollutions or  as an  almost constant flow.
   Nocturnal Pollutions.—In continent men it is entirely compatible
with health to have nocturnal pollutions as frequently as once a week.
When during the  waking hours there has been prolonged   sexual
excitement, these pollutions may occur much more frequently, two or
three  times a week, and  yet indicate  no abnormal local or  general
condition.  It is, however, by no means rare  to  find  continent men
in perfect health  who have no pollution  for weeks or months at a
time; it is especially  in those Avho are kept constantly occupied both
in mind and  in body that  this  is observed.  After prolonged exer-
tion either mental or  physical, it is  not uncommon for two or three
emissions to occur in a single night.   The pollutions may be unat- 
1022       GENITO-URINARY DISEASES AND SYPHILIS.

tended by voluptuous dreams, and may occur Avith the penis flaccid.
It  is possible  for the variations  just named  to be  found Avithin the
limits of perfect health.
   The gauge as to Avhether the  loss can be  considered indicative of
either local or general weakness is the condition of the patient.  If
aside  from imaginary sufferings  these  pollutions  are folloAved by
weakness,  backache,  and mental  depression, if  they  are habitually
frequent, and particularly if they are associated Avith sexual Aveakness
or impotence, they must  be regarded as an index  of disordered  func-
tion.   At  first nocturnal  pollutions, even though  they occur with
extreme  frequency, are usually associated with full sexual strength;
later, as the excitability of  the ejaculatory centre  becomes weakened,
there  is  usually developed a more or less profound form of sexual
weakness.
   Diurnal pollutions indicate  a degree of  sexual Aveakness much
more marked than do even excessive seminal losses occurring during
sleep.  In  these cases the  slightest psychical or  physical stimulus is
often  sufficient to  excite emission.    The presence of women,  the
jarring of a wagon,  manipulations necessary for cleaning the fore-
skin, or even  examination  of the skin surface around the genitalia,
may occasion pollutions.  The  erections are usually  imperfect,  the
voluptuous sensations are  blunted,  and immediately  after emission
there is subsidence  of the erection.
   Spermatorrhea.—This  condition is characterized by oozing out of
the semen Avithout erection or pleasurable sensation. It is occasioned
by erotic thoughts,  or by light mechanical stimuli,  or  may occur in-
dependently of these causes, the semen escaping with the urine or
during defecation as in prostatorrhoea.
   Spermatorrhoea in the sense of a constant Aoav of semen from the
urethra is  extremely rare.   It is occasionally observed in vigorous
men much given to sexual excess who become  suddenly continent.
In these  cases a \vhitish  discharge is obsenred, Avhich on examination
is  found to be swarming Avith spermatozoa.  In  such  cases sperma-
torrhoea  is  unassociated with impotence,  and there is  often but a
moderate degree of sexual  hypochondriasis.  Slight and intermittent
spermatorrhoea is comparatively common in  chronic posterior ureth-
ritis, even  Avhen there is  no appreciable functional weakness.
   A typical sufferer from  spermatorrhoea represents the most aggra-
vated  form of impotence.   Both desire and power of erection are
usually  lost, and  voluptuous sensations are  excited  only  by  the
strongest stimuli.
   The diagnosis of spermatorrhoea must be founded on microscopic 
              SEXUAL  WEAKNESS AND STERILITY.          1023

examination.  A feAv spermatozoa in a mucous discharge are probably
accidental, and do not necessarily indicate any pathological condition.
If great numbers  are constantly present in the urine and  in the dis-
charge occurring after defecation or urination, it may be assumed that
there is a condition of true spermatorrhoea.
   The differential diagnosis from  prostatorrhoea is not particularly
important except  from  a prognostic stand-point, since  the treatment
of aggravated forms of  the tAvo affections is very much  the same.
    Treatment.—The treatment of  involuntary seminal emissions  is
that appropriate to atonic impotence, since both these  conditions are
symptomatic of an irritable condition of the lumbar centres.
   The treatment  of nocturnal pollutions must be conducted  upon
rational principles.  First, it must be determined Avhether such pollu-
tions indicate an abnormality.  Usually the patients applying for the
relief of this condition  have seminal losses  not more frequently than
is consistent Avith  perfect health.   When  the  loss is  excessive, or
even Avhen  it is strictly confined Avithin normal  limits,  if the patient
is markedly hypochondriacal, a vigorous treatment should be  insti-
tuted.  General hygienic directions are given; the patient is particu-
larly cautioned against  sexual excitement.  By means  of a saline or
other mild  laxative the boAvels are opened at night before  retiring.
The bed should be hard, the covering  light; sleeping  in  the  dorsal
decubitus should  be avoided by tying a towel around the Avaist with
a  knot over the  spine.  An alarm-clock is  set to ring about  four
hours after the time of going to bed, the patient  then rising  and
passing Avater.  Before going to bed, light calisthenics to the  point
of  perspiration,  cool   sponge  bath, and brisk  rubbing  down are
advisable.
    When in spite of these precautions erections and emissions  occur,
an anti-pollution ring may be Avorn.   This is designed  to fit comfort-
ably about the penis Avhen the organ is in its flaccid condition ; Avhen
it becomes erect a number of sharp teeth dig into the skin, and  by the
pain  they  excite wake  the patient.  All sources of reflex irritation
must be sought  for and removed.   Medication  directed to subduing
the irritability of the lumbar centres is  sometimes most serviceable.
Potassium bromide, from thirty to ninety grains at bedtime, is tempo-
rarily useful.  Atropine, one three-hundredth of a grain three times
a  day,  or  twice  this quantity given at  bedtime; hyoscine, one two-
hundredth of a grain;  hyoscyamine sulphate, one one-hundred-and-
fiftieth  of a  grain;  lupuline, one-tAventieth of a grain  three times a
day ; and monobromate of camphor, five grains three times a day, are
all serviceable :  hyoscyamine is almost a specific. 
1024       GENITO-URINARY  DISEASES  AND SYPHILIS.

   The treatment  of  diurnal  pollutions  is conducted on the same
general principles as that of atonic impotence, except that,  as  this
symptom  usually  denotes an  advanced  catarrhal alteration of  the
prostatic urethra, strong applications to this portion of the canal are
usually necessary.   In addition to the various instillations the solid
stick of silver nitrate may be used advantageously.  The  hot rectal
douches, the needle spray, electricity, and  the  treatment appropriate
to nocturnal pollutions are applicable in these cases.
   In  cases of seminal incontinence (spermatorrhoea) the treatment
should be directed  towards restoring tone to the  paretic vessels  and
revitalizing the exhausted lumbar centres.  Of the drugs  employed,
strychnine, one-twentieth of a  grain four times a day;  damiana,  five
grains  three times a day ;  phosphorus, one-hundredth of a grain three
times a day; fluid extract of ergot, a teaspoonful three times a day;  and
arsenous acid, one-fortieth of a grain three times a day, are valuable.
Electricity is  particularly serviceable.  The psychrophore, hot rectal
douches, strong posterior applications, particularly the solid  stick of
silver nitrate, or instillations of pure iodine or of iodine and  carbolic
acid mixed, will give the best results.
   Many cases of sexual Aveakness are made Avorse by treatment.   If
after one  thorough  trial of methods Avhich careful examination  has
shoAvn  most likely  to be successful there is no  improvement, local
treatment, in the absejice of local lesions, should be abandoned, the
physician  devoting  his whole  attention  to the improvement of the
general health of the patient.
   Impotence in the Female.—Impotence in  the  female, in  the
sense of inability to accomplish the sexual  act under normal  and
laAvful  conditions, may be classified under the following  headings:
(1) intromission of the male organ is impossible; (2) intromission is
possible, but either excites pain or fails to cause orgasm.
   Intromission of the male organ  may  be prevented by congenital
or acquired obstruction, or by obliteration of the vulva and vagina.
The  congenital anomalies  may appear in the form of  absence of the
vagina, extreme narroAving,  division into two parts,  each too small
to alloAV of intromission,  or opening in abnormal positions, as, for
instance, into the rectum.  The vulva may  be obstructed by adhe-
sions, by hypertrophy  of the labia or clitoris, or by a rigid or imper-
forate  hymen.   Acquired  obstruction may depend upon cicatricial
contraction, inflammatory swelling, neAv groAvths,  hypertrophy of the
parts.
   The treatment of impotence dependent upon  congenital  absence
of the  vulva or vagina is of little avail.   In cases of narroAving, con- 
SEXUAL WEAKNESS AND STERILITY.         1Q25
tinuous dilatation may bring about cure.  A rigid  or imperforate
hymen, adherent labia, or mechanical obstructions, as from swellings
or tumors, can be remedied only by surgical operation.
   Intromission may be mechanically possible, but may be  resisted
or entirely prevented because of the pain occasioned by the attempt.
Thus, acute inflammations about the vulva, vagina, uterus, or ovaries
Avill  render sexual approach  extremely painful;  urethral caruncles,
urethritis, fissures of the neck of the bladder, hemorrhoids or  rectal
fissures, ulcers  and displacement of the Avomb, inflammation of the
Fallopian tubes, and disease or prolapse of the  ovaries, are frequently
observed as causes of this condition.
   Usually, on  account of the pain,  the perineal muscles  become
spasmodically contracted and intromission is impossible. Sometimes
this  spasm does  not  occur  until entrance is accomplished, in Avhich
case the  male organ  may  be so  tightly  imprisoned that  release is
accomplished only Avhen the muscles of the  female are relaxed by
ether.   It is customary to class vaginismus among the pure neuroses.
A careful  search will, hoAvever, in almost every case reveal an in-
flammatory area from which the reflex starts.   In  most of these cases
the origin of the reflexes is to be found in fissures in the neck of the
bladder;  urethral caruncle  and urethritis are also  frequent causes of
vaginismus.  As a very rare exception the  only pathological condition
to be detected is an apparently causeless hyperaesthesia of the vaginal
mucous membrane.
   The treatment  of  vaginismus  depends for successful issue  upon
the  skill  and thoroughness Avith which local  examination is made.
An exhaustive search should be made  for  the source of the reflexes.
In the  absence  of any cause  discoverable by palpation or inspection
of the  genitalia, a  thorough endoscopic examination of the  bladder
must be made.
   The cure  of vaginismus depends  upon the cure  of its  exciting
causes.  Where, as is usually the case, there are found several abnor-
mal  conditions, each of which may possibly be responsible,  such as
extensive fissure in ano, chronic endometritis, and granular urethritis
near the neck of the bladder, all these abnormal conditions should be
remedied.
   In the absence of any local pathological condition, vaginal douches
of hot one per cent, soda solution, folloAved by the application of ten
per cent, cocaine solution to the vulva  and the lower portion of the
vagina, may render introitus comparatively painless.  These patients,
belonging  as  they  do to  a neurotic  type, should receive treatment
appropriate to their general condition. 
1026       GENITO-URINARY DISEASES AND SYPHILIS.

                           STERILITY.
   Sterility in the male  is that condition in which there is loss of
procreative power.   This necessarily implies absence of living sper-
matozoa, since these are  the  elements essential to impregnation.  It
must  be remembered that sterility does not imply failure of poAver
in sexual congress.
   Comparatively recent  investigations have  shown  that failure to
bear children  on the part of married women is due in a certain pro-
portion of  cases to sterility of the husband.   The definite percentage
cannot be given, since the whole subject is somewhat obscure.  Thus,
it is well known that a marriage may remain barren, but that each
partner of this marriage, after other sexual relations, may become a
parent.  The  percentage  of  sterile husbands in  childless marriages
has been variously calculated at from five to tAventy.
   The composition  and physical  qualities  of normal semen have
been  already  described.   The total  quantity and the number of
spermatozoa are markedly diminished by sexual  excess and Avasting
diseases.   Sterility may be manifest by—
   (1) Aspermia, entire absence of semen.
   (2) Oligospermia, diminution in the quantity of semen.
   (3) Azoospermia, absence of  spermatozoa.
   Aspermia is a condition in Avhich no seminal fluid is ejaculated,
though the act of coitus may be performed normally in other respects.
Aspermia may be due to imperfect coordination  of the muscles of
ejaculation; sometimes it is an expression of sexual Aveakness.  In
this case, though there is no  escape of semen during orgasm, it may
subsequently drop from the end of  the flaccid penis.
   More rarely there may be seminal emissions only during sleep, pro-
longed and repeated efforts utterly failing to produce emission during
or after coitus.   In this  case incoordination probably involves the
muscles which  force the seminal  fluid into the prostatic urethra
and  the dilatation of the bulb, or failure in emission may be  due to
sensory paralysis.
   As a modification of  this form of aspermia, patients are seen in
whom ejaculation sometimes takes place during coitus and sometimes
cannot be excited.
   The common cause of aspermia is  obliteration or obstruction of
some portion  of the urethra.  This obstruction may be congenital or
acquired.  The acquired form may be due to traumatism or inflam-
mation.  When inflammation has attacked and destroyed  the greater
portion of the secreting  substance  of the prostate, and has blocked
the ejaculatory ducts, after orgasm there will be a discharge of tAvo or 
              SEXUAL WEAKNESS AND STERILITY.          1027

three viscid drops, representing the secretion of Cowper's glands and
the urethral  crypts and follicles.   Tubercular infiltration, malignant
degeneration, the pressure of tumors, tight  stricture, or the blocking
of the passage by a prostatic or cystic calculus may produce aspermia.
Injury to the common ejaculatory ducts, without  involvement of the
prostate, will cause diminution in the quantity of semen secreted and
absence of spermatozoa, but not aspermia, since the prostatic secre-
tion is ejaculated and presents  at  least the gross  physical attributes
of normal  semen.
    The term false aspermia, or malemission, is sometimes employed
to designate  that condition in which  semen is discharged into the
urethra but does not reach the meatus, either  passing back into the
bladder to be voided Avith the urine or exuding  drop by drop from
the urethra after  coitus has been completed.  This is commonly due
to stricture, Avhich may be of such  calibre as not to interfere with the
function of micturition when the circulation of the parts is in its ordi-
nary condition, but which so encroaches upon the urethral calibre as
the result of  congestion incident to erection that the  passage is prac-
tically obliterated.  Another form of malemission  is the condition in
Avhich the  semen is not properly ejaculated into  the vagina because
of  some defect in the urethra, such as  hypospadia, epispadia, or
urethral fistulae.   Such a patient  is neither sterile nor impotent, yet
he is incapable of impregnation.
    Oligospermia, or a diminution in the  quantity of  semen  ejacu-
lated, may be due to deficiency in quantity or absence of any of the
constituent parts of this  fluid.   Thus, in  bilateral  epididymitis the
spermatozoa  are  absent and the quantity of the semen  is diminished.
In cicatrization following  suppurative prostatitis the  secretion of the
prostate will  be deficient.
    Oligozoospermia indicates a condition in which the  semen  ejacu-
lated contains feAv spermatozoa.
    Deficiency in the quantity of the semen may be due to general
weakness,  debilitating disease,  sexual  neurasthenia, sexual  excesses,
masturbation, or  any of the various inflammatory or infiltrating affec-
tions Avhich obliterate the ducts of the glands the  secretion  of Avhich
goes to make up  the semen.
   Azoospermia,  or absence of spermatozoa in the semen, may  be due
to failure of the testes to  produce spermatozoa, or to mechanical ob-
struction in some portion  of the passage by  which  spermatozoa reach
the urethra.  The testicles fail  to secrete  spermatozoa  when there is
bilateral retention, atrophy, or malignant,  syphilitic, or tubercular
degeneration.  Even  unilateral affections of the testicles frequently 
1028       GENITO-URINARY DISEASES  AND SYPHILIS.

cause azoospermia.  Absence of both testicles, either  congenital or
from accident or surgical operation, necessarily produces a condition
of azoospermia.
   The ordinary cause is bilateral gonorrhoeal epididymitis.   This is
followed by azoospermia in a fairly large percentage of  cases,  though
not in the majority of those carefully treated.  Obstruction of the
vasa, either congenital, as from absence or occlusion, or acquired, as
from traumatism or malignant or tubercular degeneration, or block-
ing of the common ejaculatory ducts, will prevent spermatozoa  from
reaching the urethra.  Carefully conducted post-mortem examinations
have  shoAvn  that bilateral  blocking of the ejaculatory ducts  as the
result of chronic gonorrhoeal posterior urethritis is more common than
has been supposed.  This condition will not produce aspermia, since
it  simply prevents  the secretions  of  the seminal vesicles and the
contents of the  ampullae of the vasa from being discharged into the
urethra.   Sexual excess produces temporary azoospermia.
   It is to be remembered that the  semen  discharged by those suffer-
ing from azoospermia may be normal in odor, consistence, and primary
gelatinification.  On standing the white deposit is thinner;  on  micro-
scopic  examination the absence of  spermatozoa is at once detected.
This semen deposits the spermatic (Bottcher) crystals very  rapidly.
   Treatment.—Sterility dependent  upon  absence or imperfect devel-
opment of any portion of the secreting or excreting apparatus is hope-
less.  When  it  is due to gonorrhoeal epididymitis of comparatively
recent origin  the treatment  described under the head of gonorrhoeal
epididymitis may produce almost complete resolution.   In case the
induration persists for ten to twelve months, further resolving treat-
ment is hopeless.  We believe on theoretical considerations alone that
it is worth while under these circumstances to divide the vas obliquely,
—splitting its lumen from the point of  section upward a quarter of an
inch,—open the  head of  the epididymis,  and secure the  vas in this
opening by catgut sutures.
   When the  sterility is dependent upon blocking  of the common
ejaculatory duct, no  treatment  has been  suggested which promises
favorable results.  Sterility  dependent upon stricture is cured by full
dilatation of the urethra.   If due to muscular incoordination, tonic or
stimulant treatment directed to  the general nervous condition may
be beneficial.   That form of sterility Avhich is apparently  dependent
upon chronic  suppuration of the prostatic urethra, ejaculatory ducts,
seminal vesicles, and ampullae of the vasa  is best treated by massage,
combined with unirritating antiseptic urethral irrigations.
   Alterations in the color of  the semen have  been occasionally 
SEXUAL WEAKNESS AND  STERILITY.          1Q29
observed.   It  may be red from admixture with  blood due to inflam-
mation or intense congestion of the vesicles, vasa, or prostatic urethra.
Unless the  bleeding has been recent, the  color will be a dirty choco-
late.   A large quantity of pus mixed with the  semen  may give it a
yelloAvish or greenish tint.   Indigo  is sometimes found as a coloring
matter, and is said  to impart a reddish color to the fluid much like
that due to admixture Avith blood. 
CHAPTER  XXIX.
                      PSYCHOPATHIA sexualis.

   The various forms of perversion or aberration of the sexual instinct
are, as a rule, associated  with symptoms which belong to the domain
of the neurologist or the  alienist.  But some of them have a physical
basis which demands attention from the genito-urinary specialist, who
is, at any rate, apt to be first consulted in many such cases.  Moreover,
the distinction between a pure neurosis and one dependent upon lesions
often requires the judgment of  an expert, based upon a thorough  ex-
amination of the genital tract.  It seems proper, therefore, to present
a brief summary of the chief varieties, and to give at  least a resume of
the general  principles which  should  apply  in  dealing  with  these
patients.  The works of  Krafft-Ebing and  Schrenck-Notzing  are  the
most valuable of recent  contributions to this subject, and  have been
used freely in the preparation of this chapter.
   An accurate and entirely scientific classification of these phenom-
ena is at present impossible, but a provisional  one may be employed,
which will aid in the systematic study of the subject.
   Nearly all the known varieties of sexual perversion will fall under
one or other of the following headings:
   A.  Sexual Hyperesthesia.
        1. Onanism.
            ( Satyriasis.
            \ Nymphomania.
   B.  Sexual Anesthesia.
        Impotence.   (See Chapter XXVIII.)
   C. Sexual Paresthesia.
        1. Heterosexual  perversion,—algolagnia.   Perverse activity
             of the sexual impulse.
        2. Inversion  of  the  sexual feeling (contrary sexual  feeling;
             homosexuality, etc.).
   Sexnal hyperaesthesia, when  not dependent  on affections of
the cord  or on cervical  disease, is  usually associated Avith hyper-
aesthesia of the  deep urethra.   This in its turn may be caused by
masturbation when practised in great  excess, by urethral stricture,
by sexual intemperance (which  term should include both excessive
     1030 
PSYCHOPATHIA SEXUALIS.
1031
intercourse and prolonged abstinence), by departure from the normal
or physiological  in  the  performance of the act of copulation (as, for
example, the practice of Avithdrawal for the prevention of conception),
and  in various  other ways.   Certain  drugs produce it,  cantharides
being the best known.
   Onanism is the most wide-spread  of these causes, a  majority of
males having at  some time in their lives practised it.  Much difference
of opinion prevails even in the profession as to its exact importance
as a cause of cerebral or spinal disease.
   Its alleged consequences are used by quacks to foster the miseries
of the sexual hypochondriac, who, having almost always been a mas-
turbator to some extent during his  youth, is easily led to believe that
he has thus done himself serious injury.  It is thought, hoAvever, by
many practitioners that, apart from the question of morality, the effect
of the act itself on the  nervous system is injurious.  Von Schrenck-
Notzing, in reply to the argument that the single act of masturbation
is no more harmful than that of normal coitus, says that masturbation
has  a much  more intense  psychical  effect  than sexual  intercourse,
as the content of ideas  in every onanistic act must overcome reality,
and thus a much  more intense strain  of the imagination is neces-
sary.  He  adds, hoAvever, that " masturbation moderately practised
exercises on a  good  constitution no  direct destroying effect,  but it
changes, when it is long indulged  in,  the character, the imagination,
and the whole mental existence in a way that is unmistakable and, so
to speak, necessary.  These evil effects  of onanism seem to us to be
greater than those lesser disturbances  which seldom affect materially
the general health."
    A long list of local disorders following excesses in onanism is to be
found in the  abundant  literature of the  subject.   Lowenfeld (quoted
by Schrenck-Notzing) says that in the  male the most  frequent results
are " excessive pollutions (day and  night), spermatorrhoea, premature
ejaculation in attempt at coitus, hyperaesthesia of the genital centres,
spinal neurasthenia, congestion of  the prostate, inflammation of the
urethra, hyperaemia and swelling of the  mucous membranes, and in-
tense  sensitiveness  of  the  glans.  In young children, besides, there
may readily occur vesical tenesmus, wetting of the bed, spasm of the
compressor urethrae, and urinary incontinence."   Further results are
urethritis,  prostatorrhoea,  spermatorrhoea,  and  impotence.  As sec-
ondary results of the neurosis of the lumbar portion of the cord  he
mentions "general  neurasthenia, tachycardia, pains in  the eyelids,
spasm  of  the lids, photophobia, or  subjective  sensations of light,
diminution of the acuity of central  vision, neurasthenic asthenopia." 
1032       GENITO-URINARY DISEASES AND SYPHILIS.

   In the female masturbation is said  to produce  neurasthenic dis-
turbances,  such as  hysterical  attacks,  paralyses (vesical paralysis),
vesical tenesmus and spasm, ovarian neuralgia, Aveakness of the legs,
and  spinal  irritation.   Among  alleged  local disturbances  may be
mentioned hyperaemia  of the labia minora  and the vaginal  orifice,
desquamation of the vaginal epithelium, fluor albus, cervical catarrh,
intense hyperaesthesia,  pruritus vulvae, hypertrophy of the  clitoris,
and irritable conditions  of the uterus and adnexa.   Schrenck-Notzing
says that " a condition that has thus far been too  little studied, and
Avhich in  its significance is one of  the  most important and frequent
results  of  masturbation in the female, is  a form of impotence  in
which the orgasm  no longer occurs during the sexual act, even when
it is performed with several men, but in many cases may be induced
post coitum by masturbation."
   It is not possible here  to go into this subject with detail, but it
seems to us that in both sexes the act of masturbation, while unques-
tionably exercising a prejudicial influence on the general character on
account of the sense of wrong-doing almost invariably accompanying
it  and  the atmosphere  of secrecy and  deceit which necessarily sur-
rounds it, cannot in normal individuals  be accredited with more than
a very small proportion of  the evils said to  folloAv in its wake.
   In  neuropathic  children or  adolescents, the  inheritors  of de-
praved nervous systems  or of vicious impulses,  it is  no doubt far
more injurious, but even  in them it is open to question whether it is
a  cause or a symptom of  the associated nervous phenomena.  An
exhaustive investigation Avas made by one of  the Avriters some years
ago  into  its relation to hereditary nervous  and  mental disease  as
seen  among criminals.   The result shoAved  that  the men who had
become onanists  in  a  criminal  population  of  eight  hundred  Avere
classified either as the subjects of  mental or physical disease at the
time  of their  admission to prison  or as  hereditarily predisposed  to
such disease  in the proportion of eighty-five per  cent.   Among the
remainder of the  eight hundred only fifty-eight per cent, were  so
classified.   So, too, it was found that fifty-six per cent, of the mas-
turbators had been guilty of one or another of the so-called " crimes
of the passions,"—as distinguished from crimes against  property,—
wdiile a review of the  records for fifty years showed that only thir-
teen  per cent, of  the whole number of convicts had been convicted
for crimes of this character.   The  evidence, therefore, goes to shoAv
that  masturbation in great excess is itself  a symptom rather than a
cause of the various nervous phenomena attributed to it.
    As  to the ordinary  form of masturbation, so common as almost 
PSYCHOPATHIA SEXUALIS.
1033
to be called physiological, the views of Sir James Paget seem to us to
be Avholly correct.  He said twenty-five years ago that he believed
" you may teach  positively that masturbation does neither more nor
less harm than sexual intercourse practised  with the same frequency
with  the  same conditions  of  general health and age and  circum-
stance.   Practised  frequently by the very young,—that is,  at  any
time  before  or at the beginning of puberty,—masturbation  is very
likely  to  produce  exhaustion, effeminacy, over-sensitiveness,  and
nervousness, just as equally frequent  copulation at  the same age
Avould probably  produce them.  Or, practised every day, or many
times in one day, at any age,  either masturbation  or copulation  is
likely to produce similar mischiefs or greater.   And the mischiefs are
especially likely or  nearly sure  to happen,  and to be  greatest, if the
excesses are practised by those who, by inheritance or circumstances,
are liable to any nervous disease,  to  ' spinal irritation,'  epilepsy,
insanity, or any other neurosis.  But the mischiefs are  due to the
quantity, not to the method, of the excesses; and the quantity is to
be estimated in relation to age and the power of the nervous system.
He has seen as numerous and as great evils consequent on excessive
sexual intercourse  as on excessive masturbation ;  but he  has  not
seen or heard anything to make him  believe that occasional  mastur-
bation has any other effects on one who practises it than has occa-
sional sexual intercourse, or anything justifying the dread with which
sexual hypochondriacs regard the having occasionally practised it."
    Treatment of  Onanism in Children.—In  the  absence of inherited
neuropathy, onanism in very young  children is usually an automatic
act, resulting from some  persistent local irritation.
   Phimosis, balanitis, vesical calculus, and urethral polyp are com-
mon  causes  of sexual excitation in male children,  producing  the
custom of handling or pulling at the penis, which  after a time results
in a fully formed onanistic habit.
   Masturbation  in young female children is far less common than in
males.  Eczema and pruritus vulvae, seat-Avorms, and other causes of
irritation about the  genitals or the anus are the most  common etio-
logical factors.
   In both sexes irritation from diapers or from tightly  fitting clothing
may favor the continuance of the habit.
   Obviously the treatment of such cases is to be directed towards
the removal of the cause.   Circumcision should  be performed,  re-
gardless of the condition of the foreskin, in all children avIio have
this habit.
   Even if it is not very  long or tightly adherent, its removal lessens 
1034       GENITO-URINARY DISEASES  AND SYPHILIS.

the sensitiveness of the  region of the glans and  the  fraenum.  The
psychical  effect  of the operation itself, if the  child is three or four
years of age or older, has a powerful deterrent influence.   Of course
vesical  calculi should be  removed, eczema cured, and  the other
pathological conditions mentioned  should receive appropriate treat-
ment.
   Intelligent  parents can be of great assistance in breaking up the
habit.   The individual management of the child must be determined
by his peculiarities of disposition and temperament.  With  some chil-
dren, even while they are very young, a few words of caution or advice
are effectual.  With  others  some form of  punishment is required.
Occasionally it may be necessary to apply a vesicant to the genitals,
so as to leave a denuded spot which will be painful enough  to prevent
handling of the  part.
   Attention should be paid to the condition of the urine.  An excess
of uric  acid, oxaluria, a very acid or concentrated urine, may furnish
the necessary  stimulus to the performance of the act.
   The diet, especially the evening meal, should be light and simple.
Constipation  should be  carefully avoided.  An enema of  cold water
at bedtime, followed  by the insertion of a  Avhite  wheat gluten sup-
pository into the rectum, will often be found of advantage.
   Open-air  exercise to the  point of fatigue is indicated in the
majority of cases.  Drugs  should be avoided.
    Treatment of Onanism in Adolescents and Adults.—In all  cases of
persistent  masturbation, at whatever age, the same general line of
treatment  as that outlined above  should be followed. The condi-
tions that are  provocative of the act in young children may cause its
continuance after puberty.   In males  circumcision is especially to be
recommended, the patient being told that the operation is necessitated
by his previous  indulgence in the vice, and that it will prove curative.
Cold bathing, a simple natural life, a plain diet, plenty of exercise, and
avoidance of social  and, of course, of sexual excitements, are the main
points to be observed as to the hygiene of such patients.
   The use of full-sized cold steel  sounds  introduced twice weekly,
and  left in the urethra for from ten to fifteen minutes, instillations of
fifteen to twenty drops of a one per cent, silver nitrate solution into
the prostatic urethra, and counter-irritation to the perineum, are the
chief therapeutic measures.
   As to the  general advice to be given such patients in regard  to
their sexual relations, while we agree with those Avho think  it improper
to advise  fornication, and  believe it is almost equally inadvisable  to
recommend marriage as a mode of treatment, yet Ave must dissent 
PSYCHOPATHIA SEXUALIS.
1035
from the opinions Avhich have been expressed by many of the  most
distinguished men in the profession as to the harmlessness of enforced
chastity.  Sexual abstinence, when entirely voluntary and spontane-
ous, and practised Avithout thought or mental struggle on the part of
the patient, is doubtless harmless.   But it seems to us equally beyond
doubt that the continence which is the result of fear of wrong-doing
or of dread  of social disgrace or of physical disease, and Avhich  is at-
tended Avith continued sexual excitation and constant hyperaemia of
the genital  organs, is  harmful.   We believe that every-day clinical
facts abundantly demonstrate the truth of this assertion, if they are
studied without prejudice or preconceived theory.   It does not folloAv
that a remedy can be  suggested.   It is highly probable that the evils
which  certainly result  from continence in some individual cases are
far less than those which would result from promulgation of the doc-
trine that " the idea of complete health includes complete and regular
satisfaction of all the  needs of man, and that is  the  goal  for Avhich
hygiene must strive, and not seek  to stifle  one of the most important
functions of the organism, like the sexual  instinct.  The recommen-
dation voluntarily to destroy any function like the idea of love is a
subject for  the  fanatic,  but directly  opposed  to  hygiene."  (Tar-
noAvsky.)
    Von Schrenck-Notzing, writing of prostitution, says, " The limita-
tion of the  evil to a  minimum, which seems  to every one of any
knoAvledge of the  subject both  desirable and  attainable,  with any
prospect of relative success, can only be brought about through an
inner reform of society ; through correct education of the young and
ignorant; and through an increase of facility of marriage and amelio-
ration  of conditions of life.  'For the more undeveloped  an  indi-
vidual is, the more reckless he is in the  gratification of his desires.'
We should  institute a real sexual education, and lead  the matured
sexual instinct by  means of the preservation of rational indulgence
into paths devoid of danger; we should make needful concession to
the natural impulse;  and thus public vice,  with its  results, the un-
limited spread of venereal diseases  and  the increasing number of
crimes  against morality, would  be greatly  diminished  and become
more and more confined to the step-children of nature (those subject
to congenital viciousness).  But, more than all, the foundation would
be  removed upon which rest masturbation  and the development of
the sexual instinct in perverse directions."
    Continuing, he  adds, u The strength and intensity of the sexual
instinct, like moral  and physical individuality, are too various to make
it necessary to give a general  application to the foregoing statements. 
1036       GENITO-URINARY DISEASES  AND SYPHILIS.

Such a misunderstanding might  become a welcome license and cloak
for  all possible  expression of vice, and it would open  the  door to
sensuality.  While  one, thanks to the inherent  peculiarities of his
organization, can easily practise abstinence, another is led to onan-
ism, and,  as a result of it, is utterly ruined if he  has no opportunity
for  natural sexual indulgence."
    We  believe,  as we have already  said, that the patients " utterly
ruined" by onanism are very few, but it must be admitted that  even
in the cases in Avhich it is a symptom rather  than a cause of disease
normal  sexual relations are greatly to be desired for the patient.
    In the present constitution of society individuals must suffer.   We
cannot follow either in theory or in practice  the  further teaching of
Notzing, Avho says, "The chaste youth  should exercise sexual  absti-
nence as  long as he  is able to restrain the instinct without injury to
his  health.  Should he be in danger, OAving to increasing strength of
his  sexual impulse,  of onanism, of  falling a  victim  to  satyriasis or
perverse sexual  indulgence, then it becomes  the duty of his teacher
and his physician to cause indulgence in  coitus, and also to acquaint
the neophyte with precautionary measures which will guard against
excesses, infection, and the procreation of illegitimate offspring, which,
under certain  circumstances,—e.g., with contrary sexuality,—may be
hereditarily tainted.   Individual sexual capabilities should  determine
the frequency of sexual indulgence.   It is impossible to fix a normal
standard."
    We  do not  believe that  it is customary  in this  country to  give
advice of this character, and we think the  resultant evils, if this should
become a common professional practice,  would far ouhveigh the ad-
vantages,  but we must reiterate  that  the  contrary teaching as to the
invariable harmlessness and even benefit of sexual continence is un-
scientific, and is  opposed to many easily observed clinical phenomena.
    Satyriasis and Nymphomania.—In these cases the  sexual de-
sire is so overpowering that its gratification becomes the one dominant
thought and purpose of the patient's life.  The condition may be spas-
modic Avith  remissions, or, in bad cases,  may be  almost continuous.
It is favored by  any form of genital irritation, but the  essential factor
is some cerebral disturbance or degeneration which results in a dimi-
nution or  abolition  of the will-power.  Magnan locates these lesions
in the sensory regions of the cortex Avhich lie  behind the central  con-
volutions, where, according  to this author, "  the  zone of the desires
and instincts lies, and which are influenced quasi-automatically by the
genito-spinal centre as soon as the forebrain for any reason ceases to
act." 
PSYCHOPATHIA SEXUALIS.
1037
   It  may in some cases be a reversion to ancestral instincts.  In
many of the  lower animals during the rutting season the sexual im-
pulse becomes so powerful as to dominate all other desires and habits
and render the  individual insensible  to  dangers ordinarily carefully
avoided.
   Women are said to be more subject to this form of sexual perver-
sion  than are men.  Whether this is true  or not, there  can be no
doubt that, since women have less sexual need than men, a predom-
inating  sexual desire  in  them should arouse  more early a suspicion
of its having  some pathological significance.
   Krafft-Ebing  says  that " the  central origin  of  sexual excitement
is of frequent occurrence in  persons  having a neurotic taint or hys-
teria, and in conditions of psychical exaltation.  Here, where the cor-
tex and the psycho-sexual centre are in a condition of hyperaesthesia
(abnormal excitability of the imagination, increased ease of associa-
tion), not only visual  and tactile  impressions, but also  auditory and
olfactory sensations, may be sufficient to call up lascivious concepts."
   Magnan (op. cit.) reports  the case of a young Avoman who had an
increasing sexual desire from puberty, and satisfied it by masturba-
tion.  Gradually she greAV to become  sexually excited at the sight of
any man pleasing to her, and, since she Avas  unable to control herself,
she Avould sometimes  shut herself up in a room until the storm had
passed.   At last she gave herself up to men of her choice, that she
might get rest from her tormenting  desire; but  neither  coitus nor
masturbation brought relief,  and she went to an asylum.
   The case is  added of a  mother of five children, who, in  despair
about her inordinate  sexual impulse, attempted  suicide, and then
sought  an asylum.   There  her  condition improved,  but  she never
trusted  herself to leave it.
   It is obvious  that in such patients the sexual symptoms are only
part of  a general disease, probably cerebral in almost every instance.
   They are  acute manifestations of a more  or less chronic degenera-
tive process, which later will nearly ahvays show itself by some form
of paresis or paralysis, or by mania or dementia.
   Krafft-Ebing  says,  " There are also cases  that, not Avithout reason,
might be called chronic satyriasis  or nymphomania.  To these belong
the men who, for the  most part as a result of abusus veneris, or more
particularly of masturbation, suffer with neurasthenia sexualis, and at
the same time have intense libido sexualis.   The  imagination, as in
acute cases, is in a state of  excitement and  the mind  full of obscene
images  so that the  most elevated ideas are besmirched with the most
cynical'  images and thoughts.  The thought and desire of such men are 
1038       GENITO-URINARY  DISEASES AND SYPHILIS.

solely directed to the sexual sphere ; and since their flesh is weak, led
on by their fancy, they come to indulge in the grossest perversions of
the sexual act.  Analogous cases in  women may be called chronic
nymphomania.   They naturally lead to prostitution."
   In all  these  cases the genito-urinary surgeon  may be of use in
removing  every source of peripheral irritation, an  important element
of treatment, as it  renders more easy  a restoration of the balance
betAveen desire and will-power.
   Sexual Anaesthesia.—The ordinary forms of impotence, or in-
ability to perform the sexual act, in the  male are among the manifes-
tations of  sexual anaesthesia, and are described in Chapter XXVIII.
   The corresponding forms of impotence in women are less frequent,
so far as  the profession has any reliable knowledge of the subject.
The most  common variety is said to be that in which failure of the
female to  secure orgasm during the sexual act is owing to  premature
ejaculation on the part of the male,—premature, that is, in relation to
the woman's requirements. This appears to be due in a large propor-
tion of cases to a degree of sexual coldness which is not overcome by
the ordinary mechanical excitation of  the parts, and may result from
either physical or psychical conditions.
   Among the  former is  to  be  noted disproportion between the
genital organs of the two individuals, as in cases of abnormally small
development  on the part of the male or of unusually large and re-
laxed genitalia on that of the female.   Exhaustion of the sexual centre
from long-continued uterine or ovarian irritation, neurasthenia, and
vaginismus should  also  be mentioned. Emotional conditions are
among the chief psychical causes of  impotence  in the female,—the
fear of pregnancy, or of disease, or of discovery, when the intercourse
is illegitimate; the  lack of affection,  or of some of the sentimental
concomitants of  the act, when it is performed maritally.
   It is obvious  that in the management of these cases the tact and
intimate personal  knowledge  of  the  regular medical attendant are
likely to be of far more use than any surgical or gynaecological pro-
cedures, Avhich  must be limited to the removal of obvious sources
of irritation and  of  any mechanical impediments to intercourse.
   The foregoing conditions  barely fall within the limits of sexual
psychopathy, but there are more marked examples  of sexual anaesthe-
sia in both sexes in which the  absence of sexual  instinct seems to be
absolute and to depend upon central causes.
   Krafft-Ebing  says that these functionally sexless individuals are
seldom  seen, and  are, indeed, always persons having degenerative
defects, and in whom other functional  cerebral disturbances, states of 
PSYCHOPATHIA SEXUALIS.
1039
psychical  degeneration, and  even anatomical signs of degeneration,
are observed.   With such patients there is even less opportunity for
treatment, which should in any event be directed by the neurologist
or alienist.
    Sexual  Paraesthesia.—In all its forms this condition involves a
perversion of the sexual ideas  with  relation to  the individual.   The
perversion may be—1, heterosexual, with abnormal and distorted
activity of the sexual impulse,  or, 2, homosexual.
    1. Algolagnia  (algos,  pain;  lagnos,  lust).—In the  heterosexual
varieties of the disease—i.e., those  in which an  inclination to inter-
course with the  opposite  sex exists—the  perversion may take  the
form of associating acts of cruelty and violence Avith the  act of coitus.
When such acts  are directed by the patient against another person
the disease is known as sadism (active algolagnia).  This is not infre-
quent, especially Avith males.   It is explained on the theory that  the
two emotions of lust and anger  both throAv the psychomotor sphere
into a state of extreme excitation,  causing an  impulse to react in
every possible  Avay  on the  object  that  supplies the stimulus.   In
neuropathic individuals this  impulse  becomes uncontrollable  and
leads to mutilation or murder.  The  disease is more frequent in males
because to them belongs the aggressive rdle in sexual life, and their
sexual relations have  ahvays involved the overcoming of obstacles.
In the presence of pathological conditions this aggressiveness,  usually
physiological, becomes uncontrollable and leads to various monstrous
and unnatural crimes.
    The Whitechapel murderer is in  all probability an example of the
most extreme form of  sadism.  A minor form is illustrated by one of
Tarnowsky's cases.    The patient Avas  a physician of neuropathic
constitution reacting badly to alcohol.  Under ordinary circumstances
capable of normal coitus, as soon as he indulged  in wine he found
that his increased desire Avas no longer satisfied by simple coitus.  In
this condition he was compelled to prick the nates puellae or to make
stabs with the  lancet, to see  blood and feel the entrance of the blade
into the living body,  in order to  have  ejaculation and experience
complete satiety of his lust.
    Cases  exemplifying a great variety of forms  of sadism have been
published in detail, but it is  probable that they differ  only in  degree
from  those  in  which  the abnormal impulse is satisfied by biting,
scratching or light flagellation  to those in which  the patient becomes
a veritable  monster,  sucking  the blood or eating  the  flesh  of his

  C  Masochism (passive algolagnia) is the converse of sadism.  The 
1040       GENITO-URINARY DISEASES AND SYPHILIS.

abnormality manifests itself  in a desire  to suffer and  be subjected
to violence and cruelty.  It might be expected that for similar physi-
ological reasons  to  those  Avhich  explain  the  greater  frequency of
sadism in males,  masochism  would be found far more  frequently in
females, whose normal instincts lead towards sexual subjugation and
submission.  But except in very rare instances the restraints of cus-
tom and of modesty have been sufficient to prevent  Avomen from
giving noticeable  expression to this form  of sexual perversion, Avhich
probably often constitutes an unobserved stage  of mental disorder
shoAvn later in other ways.
    In men masochism is  frequent, large  numbers of  cases  having
been reported in great detail.   It is usually  less serious in its conse-
quences than is sadism.
    u In masochism there is also a gradation of the acts from the most
repulsive and monstrous to the silliest, in accordance Avith the degree
of intensity of the perverse instinct, and the power of  the remnants
of moral and  aesthetic motives that oppose  it.   The ultimate conse-
quences of masochism, however, are opposed by the instinct of self-
preservation, and therefore murder and serious injury, Avhich may be
committed in sadistic excitement, have  here,  as  far as  known, no
passive equivalent in reality;  but the perverse desires of masochistic
individuals may,  in imagination, attain these  extreme consequences."
(Krafft-Ebing.)
    For example Ave may cite  the case of a middle-aged man, married,
and the father of a  family, who had always led a normal sexual life,
but who came of a very nervous family.   In his  early youth he Avas
poAverfully excited sexually at the sight of a woman slaughtering an
animal with a knife.   From that  time, for many years, he revelled in
the lustfully colored  idea of being stabbed and cut and even killed by
women with knives.  Later, after the beginning of normal sexual
intercourse, these ideas  lost  completely their perverse stimulus for
him.
    Rousseau appears to have been  a masochist, and, according to
Lombroso, Baudelaire belonged in the same class.
    2. Homosexuality, or contrary sexual instinct, is a form of sexual
paraesthesia which is among those most commonly observed.  A large
number of varieties have been noted and classified, but  the symptom
common to all of them is the existence  of sexual desires  and in-
stincts exactly opposite to those  characteristic of the sex to which the
patient belongs.   The cause of this perversion is unknoAvn.  It is prob-
ably associated Avith some inherited central  degeneration in  the vast
majority of cases, though those in which definite external influences 
PSYCHOPATHIA SEXUALIS.
1041
were observable have  been classed as "acquired  homosexuality,"
Avhile those in which the perverse instinct appeared spontaneously at
or about puberty have been called " congenital."
    " In so-called  contrary sexual instinct there  are  degrees of  the
phenomenon which quite correspond with the degrees of predisposi-
tion of the individuals.   Thus, in  the milder cases, there is simple
hermaphroditism;  in more  pronounced  cases,  only homosexual
feeling and instinct,  but limited to the vita sexualis;  in  still  more
complete cases,  the whole psychical personality, and even the bodily
sensations, are transformed to correspond Avith the sexual perversion ;
and in the  complete cases the  physical form  is correspondingly
altered."   (Krafft-Ebing.)
    In  accordance Avith  this classification the same author describes
the following varieties of the disease :
    1. Psychical Hermaphroditism.—The characteristic mark of this
degree of inversion of the sexual instinct is that, by the side of  the
pronounced sexual  instinct and desire for the  same  sex,  a desire
towards the opposite sex is present;  but the latter is much weaker
and is manifested  episodically only,  while the homosexuality is
primary, and in time and intensity forms the most striking feature of
the vita sexualis.
    It is thought that such individuals,  on account of neurasthenia, of
masturbation, or of  unfavorable  experiences in  sexual intercourse
with persons  of the opposite  sex  (lack  of pleasure,  Aveakness  of
erection, premature ejaculation, infection, etc.), may have the homo-
sexual  instinct  strengthened,  and  after  satisfying the impulse  by
passive or mutual onanism  with a person  of the same sex, or  by
coitus inter femora, may pass into the second group.
    2. Urnings.—In  distinction from the preceding group of psycho-
sexual hermaphrodites there are here, ab origine, sexual desires and
inclinations for persons of the same sex exclusively; but, in contrast
with the following group, the  anomaly is limited to the vita sexualis,
and does not more  deeply  and seriously affect  the  character and
mental personality.   (Krafft-Ebing.)
    The patients belonging in this class have a disgust for coitus  Avith
persons of the  opposite sex.  Their  affections  are apt to be emo-
tional  and passionate;  they present  all the  phases of sentimental
attachment to  persons  of their own  sex that  are  seen in normal
individuals  only behveen males  and females.   They are  usually
unable to have  intercourse  successfully in a normal manner, partly
because the act of coitus is  inhibited  by their  emotional  condition.
In men of this class mutual masturbation  and often pederasty afford
                               66 
1042       GENITO-URINARY DISEASES AND  SYPHILIS.

sexual gratification ; in women, mutual masturbation in one form or
another.
   3. Effemination and Viraginity.—In this  class not only the sexual
instincts but all the feelings and inclinations are reversed.   The men
are females in habits, sentiments, and character; the women, males.
In such cases heterosexual love is looked upon as incomprehensible,
and sexual intercourse with a person of the opposite sex as impossible.
In homosexual intercourse the man always feels himself, in the act,
as a woman; the woman, as a man.  The means of indulgence, in
the case of a  man, where there is irritable weakness  of the ejacu-
lation centre, are simply succubus,  or passive coitus  inter femora ; in
other cases passive  masturbation, or ejaculatio  viri  dilecti in ore
proprio.  Many have  a desire for  passive pederasty ; occasionally a
desire  for  active  pederasty occurs.  The  sexual satisfaction of the
female probably consists of amor lesbicus, or active masturbation.
   4. Androgyny and Gynandry.—In  this most extreme variety  of
homosexuality not  only are the character and the  feelings  sexually
reversed,  but  also  the form, the features, and  the  voice, so that the
individual  approaches the opposite  sex anthropologically and in more
than a psychical and psychosexual way.  This anthropological  form
of the cerebral anomaly apparently represents  a very high degree of
degeneration ; but  that this  variation is entirely different  from the
teratological manifestation of hermaphroditism, in  an  anatomical
sense, is clearly shown by the fact that thus  far in the domain of
contrary sexuality no transitions to hermaphroditic malformation of
the genitals have  been  observed.  The  genitals  of these persons
always  prove  to  be fully  differentiated sexually, though not  infre-
quently there  are present  anatomical signs of degeneration (epispa-
diasis, etc.), in the sense of arrests  of development  in organs that are
otherwise well differentiated.  (Krafft-Ebing.)
   It is impossible in this book to  pursue this  interesting though
repulsive  subject further.  The Avorks so freely quoted in the above
outline of sexual psychopathy contain many suggestions  as to therapy.
The most important  of   these relate  to  the prophylaxis  of  such
troubles by early  recognition of  the  neuropathic  constitution, the
prevention of  onanism, and the encouragement of normal or hetero-
sexual impulses even in early youth by regulating the sports and the
companions of children.   Hypnotic  suggestion is  being extensively
tried  in adult  cases,  but  no  estimate  of  its value can as yet be
reached. 
INDEX.
Abdominal  retention  of  tes-
  ticle, 867, 870.
Abnormal substances in urine,
  621, 645.    .' .
Abortion in syphilis, 341,  451,
  454, 456, 480, 535.
Abortive gonorrhoea, 99, 109.
  treatment   of  gonorrhoea,
       104, 117, 122, 99.
    of syphilis, 486.
Abscess, follicular, in chan-
       croid, 280.
    in gonorrhoea, 166.
  from hypodermic injection
    of mercury, 511.
  in gonorrhoeal epididymitis,
    179.
  of  kidney,  S10, 814,  817,
    818, 825.
  of seminal vesicles,  950.
  of  space  of  Retzius,  660,
    963.
  of testicles, 889, 894.
  perinephric, 820, 826.
  periprostatic, 964, 966.
  periurethral, in gonorrhoea,
    166.
  prevesical, 660.
  prostatic, acute, 961,  962,
       963, 964.
    chronic, 965.
    tubercular, 968, 969.
Absence of bladder, 543.  See
  Anomalies.
Acetonuria, 621.
Acid  urine,  crystaUine sedi-
  ment of, 640.
Acne  in iodism, 504.
  papulosum, 348.
  syphilitic, 343, 354,  460.
Actinomycosis in  perinephri-
  tis, 819.
Acupuncture   in   hydrocele,
  924.
Acute urethritis, anterior, 93,
       97, 103.
    posterior,  100, 120.  See
       Urethritis.
Adenitis, chancroidal,  294.
  gonorrhoeal, 165.
  syphilitic, 434.
Adenocystoma  of   kidney,
  848.
Adenoma of kidney, 842.
Adherent penis, 5.
Adhesions of prepuce,  6.
Aero-urethroscope, 82.
Albumen, tests for, 624, 634.
Albuminuria,  622,  628,  634,
    636, 674, 683.
  from  amyloid degeneration
    of  kidneys  in   syphilis,
    438, 439.
  from gonorrhoeal urethritis,
    101.
  from   hydrargyrism,   501,
    502.
  from syphilis, 340.
  from   syphilitic  hepatitis,
    437.
Albumosuria, 625.
Algolagnia, 1030, 1039.
Alimentary canal, syphilis of,
  382.
Alkaline  urine in   calculus,
      616, 642, 683.
    sediment in, 642.
Alopecia, syphilitic,  339, 369,
  462.
Alteration of blood in syphilis,
    333, 536.
  of color of urine, 615.
  of reaction of urine, 616.
  of specific gravity  of urine,
    615.
  of stream in urination, 562.
  quantitative, of urine,  614,
    616.
Ammoniacal urine in cystitis,
  646.
Ammonia in urine,  619,  635,
  642.
Ammonium urates in alkaline
  urine, 642.
Amor lesbicus, 1042.
Amorphism of  the   teeth in
  hereditary syphilis, 469.
Amputation of penis, 42.
Amyloid casts in urine, 639.
  degeneration of the liver in
      syphilis, 437, 438.
    of kidney, 808,  812,  818,
      820, 843, 845.
    with syphilis of kidney,
      440, 441.
Analgesia, syphilitic, 341.
Anal   region,   extra-genital
  chancres, 325.
Anastomosis  of ureters,  734,
  744, 745.
Androgyny, 747,  762,   788,
  1042.
Aneurism in syphilitic arteri-
     tis, 432, 433.
  aortic in pyonephrosis, 812.
Angina, syphilitic, 339, 372.
Angioma of  bladder, 723.
Angiosarcoma of kidney, 844.
Annulus migrans,  differential
  diagnosis  from   syphilitic
  glossitis, 378.
Anomalies of bladder, 543.
  of kidney, 767.
  of penis, 4.
  of prepuce, 6.
  of scrotum, 857.
  of seminal vesicles, 947.
  of   spermatic   cord,   863,
     938.
  of testicles, '863.
  of ureters, 742.
  of urethra, 49.
  of   vasa  deferentia,   863,
     938.
Anorchism, 864, 1006, 1028.
Anosmia from syphilitic rhini-
  tis, 414.
Anterior urethritis, acute, 93,
       97, 103, 117, 142,  319,
       372,   948.    See  Ure-
       thritis.
     chronic, 127, 141.
Antipollution ring, 1023.
Antiseptic    applications   in
       chancroid, 286.
     in chronic urethritis, 137. ■
  precautions in treatment of
       cystitis, 588, 654, 666.
     in treatment of diseases
       of  the  bladder,   588,
       654, 577, 596, 666, 678,
       683, 684, 693, 706, 718.
    in treatment of hydrocele,
       920, 923.
    in treatment of stricture,
       220, 221.
    in treatment of urethra,
       267.
  solutions  in  treatment of
    bladder,  654.
Antitoxin of syphilis, 527.
Anuria, 615,  755,  803.
Anus, syphilis of, 383.
Aphthae, differential diagnosis
  from  mucous   syphilides,
  375.
Apoplexy in cerebral syphilis,
  396.
                 1043 
1044
INDEX.
Appendages of the skin, syphi-
  litic affections of, 339, 369,
  462.
Applicators for urethroscopy,
  83.
Arachnitis in hereditary syph-
  ilis, 480.
Arachnoid,  syphilomata   of,
  389.
Ardor urinae in  gonorrhoea,
  95.
Aromatic series in urine, 616,
  617, 620.
Arteritis, syphilitic, 432, 387,
  391.
Arthralgia, syphilitic, 426.
  in  hereditary  syphilis  of
    joints, 474.
Arthritis, gonorrhoeal, 190.
  syphilitic, 427, 428.
Ascites in syphilitic hepatitis,
  437.
Aspermia, 1026, 208, 1012.
Aspiration in bladder diseases,
    579, 586.
  in haematocele, 933, 935.
  in hydrocele,  909, 914, 921,
    923, 928.
  in kidney diseases, 811, 812,
    833.
Asymmetry of skull in heredi-
  tary syphilis,  471.
Ataxia, locomotor, in syphilis,
  401.
Atonic impotence, 1008, 1014.
Atresia of  urethra, 49.
Atrophia neonatorum in  he-
  reditary syphilis, 458.
Atrophic  syphilitic  rhinitis,
  412.
Atrophy of bladder, 551.
  of  kidney, 748,  750,  756,
    767, 780, 793, 826, 828.
  of optic nerve  in syphilis,
    407.
  of prostate, 998.
  of seminal vesicles, 948.
  of testicles, 866,  877,  879,
    882, 885, 886, 888,  897,
    898, 915, 933,  935, 938,
    942, 943, 945.
  of ureters, 749.
Axial  rotation  of  spermatic
  cord, 876.
Azoospermia, 1027.

Bacteria in infection of kid-
    neys, 805.
  in urine, 566,  636, 638, 640,
    646, 648, 662.
Bacteriuria, table  for differen-
  tial  diagnosis  from  acute
  urethritis, 142.
Balanic hypospadia, 53, 54.
Balanitis and balanoposthitis,
      32, 33, 35, 8, 28, 280.
    gonorrhoea,  98, 155, 161,
      163, 164.
Ballottement renal in tumors
  of kidney, 846.
Bartholinitis  in  gonorrhoea,
  149.
Baths in treatment of syphilis.
  518.
Bicycle-riding and diseases of
  prostate, 960.
Bigelow's evacuator, 686.
  lithotrite, 684.
Bilirubin  crystals  in  acid
  urine, 641.
Biniodide of mercury in treat-
  ment of syphilis, 505.
Bladder, 539,  644.
  abscess, prevesical, 660.
  absence, 544.
  acute inflammation, 571.
  anatomy, 539.
  anomalies, 543.
  aspiration, 579,  586.
  atrophy, 551.
  calculus, 672.  See Calculus.
  catheterization,   577,  588,
      568, 570,  573, 591, 603,
      610, 613,  659.
    continuous,  581, 586, 603,
      613, 688,  709, 711, 712.
  congestion,  564, 571,  599,
    645, 655.
  contusion, 607.
  cystitis, 644, 662.  See Cys-
    titis.
  cystoscopy,  716.  See  Cys-
    toscopy.
  cystotomy,  683, 697,  706.
    See Cystotomy.
  drainage, 703, 709, 659, 668,
    688.
  exstrophy, 544, 60, 710.
  fistulas, 669, 706, 712, 761.
  foreign bodies, 712.
  haematuria,  598. See Haema-
    turia.
  hernia, 544* 551, 712.
  hypertrophy,    550,    567,
    829.
  injuries, 539, 604.
  instillations, 596, 657, 667,
    709.
  instruments, 588, 654.
    care of, 577, 596, 666.
  irrigations,  657, 658,  709,
    711.
  malformations, 543.
  multiple, 544.
  paresis, 568.
  pouches with  prostatic  en-
    largement, 973, 976, 981.
  rupture, 592, 608, 688, 696,
    707, 711.
  stone, 672.  See Calculus.
  symptomatology, 553.
    frequency of  urination,
      559, 649.
    haematuria,    598.   See
      Haematuria.
    incontinence of urine, 592.
    pain, 553, 613, 649, 676,
      677, 681.
    retention  of  urine,  563,
         644,  646, 656.  See
         Retention.
      incomplete, 587, 591.
    suppression of urine, 563,
      682, 696, 737.
Bladder, syphilis, 442.
  traumatism,   retention  of
    urine, 592.
  tuberculosis,  662.
    bacillus, 636, 638,  646.
       662.
    diagnosis,    665;   cysto-
       scopic, 721.
    etiology, 662.
    instillations, 658, 667.
    pathological    anatomy,
       664.
    symptoms, 664, 602.
    treatment, 666, 604, 667.
  tumors, 723.  /See Tumors of
    Bladder.
  Wood's  operation  for  ex-
    strophy, 546, 549.
  wounds, 604.
Blebs  in  hereditary  bullous
  syphilides, 460.
Blepharitis in hereditary syph-
  ilis, 464.
Blocking of ureters, 812.
  of urethra, 572.
  of vesical neck, 572,  676.
Blood, alterations of, in syph-
    ilis, 333.
  in  sediment  of urine,  633,
    616,  640.    See  Hama-
    turia.
Blue  mass  in   treatment of
  syphilis, 506.
Bottcher  crystals, 1003,1028.
Bonaduce  on  protective  se-
  rum in treatment  of  syphi-
  lis,  527.
Bones, syphilitic involvement
  of,  34i, 420, 470, 480, 534.
Borovski on hot baths in treat-
  ment of syphilis, 521.
Bougies a boule, 210.
  filiform, 219.
Brain, hereditary syphilis of,
  475.
" Breaking a chordee,"  26, 69,
  96,197.
Breast, syphilis of, 324,  449.
Bright's disease and syphilitic
  nephritis, 440.
Bronchial catarrh in syphilis,
  418.
Broncho-pneumonia in heredi-
  tary syphilis, 478.
Bubo.  See Lymphadenitis.
Buller's shield in gonorrhoeal
  conjunctivitis,  189.
Bullous  syphilide, 363, 460,
  480.
Bursitis, syphilitic, 429.

Calcification of penis, 26.
Calcium   carbonate  in  acid
       urine, 641.
    in renal calculi, 792, 793.
  in urine, 619, 641, 642, 673.
  oxalate in acid urine, 641.
  soaps in acid urine, 642.
  sulphate in acid urine, 641.
Calculus of bladder, 672,  553,
  554, 558, 562, 572, 598,  601,
  620, 627, 641, 642, 645, 671. 
INDEX.
1045
Calculus of bladder, bimanual
      palpation, 677, 703.
    classification, 672.
    cystitis, 645, 675,677, 681,
      683, 690, 693, 703, 707,
      709.
    cystoscopy, 677, 680, 716,
      717, 719, 721.
    cystotomy, 683, 697, 706,
      711, 714.
    diagnosis, 677, 980.
    etiology, 674.
    evacuating   instruments,
      680, 685, 687, 689, 692.
    litholapaxy, 683, 684, 694.
      in children, 691, 697.
      perineal, 689.
    lithotomy,  697,  683, 690,
         691,  693,   711,  714.
         See Cystotomy.
      in children, 707.
    lithotrites,  680, 692, 699.
      (Bigelow's), 684.
      (Chismore's), 689.
    lithotrity, 684, 687.
    podalgia as symptom, 676.
    prognosis, 681.
    prophylaxis, 682.
    prostatic     enlargement.
      See  Prostatic  enlarge-
      ment.
    rectal prolapsus, 675, 677.
    recurrent, 690, 691, 701.
    sterility as  a result  of
      operation, 692, 704.
    stone-searchers, 678, 679,
      979.
    suprapubic   auscultation,
         679, 688.
      lithotomy, 706,683, 688,
         692, 693, 694, 702.
    symptoms, 675, 682.
    treatment,  683, 697.
  of kidneys, 792, 755,  757,
    758, 808, 828, 830, 831.
  of prostate, 999, 963,  964.
  of ureters, 755, 748, 751, 760.
  of urethra, 79, 88.
Cancer and adenopathy, 434.
  of bladder, 723, 725.
  of Cowper's glands, 266.
    diagnosis from chancre of
        cervix uteri, 317.
      from  gummatous glos-
        sitis, 379.
      from  gummatous mas-
        titis, 450.
      from  gummatous proc-
        titis, 384.
      from gummatous  syphi-
        lides, 367.
      from  syphilitic   laryn-
        gitis (table), 417.
      from syphilitic orchitis,
        445.
      from  syphilitic   leuco-
        plakia, 377.
      from  tubercular  syphi-
        lides, 363.
 of kidneys, 842, 845,  847.
 of  liver,  and gummatous
    hepatitis, 438.
 Cancer of prostate, 1000.
   of scrotum, 863.
   of spermatic cord,  940.
   of  testicles, 899,  445,  869,
     870.
   of urethra, 265.
 Capillary drainage  in supra-
   pubic lithotomy, 709.
 Carbo-hydrates in urine, 629.
 Carbonates  in urine, 618,  635,
     642, 673.
   of alkaline earths  in alka-
     line urine, 642.
 Carcinoma.  See Cancer.
 Care of urethral instruments,
   220,  267.
 Caries in  syphilis, 420, 421.
   in cerebral syphilis, 386.
 Casper's  catheterizing  cysto-
   scope, 750.
 Castration,  906, 874, 896,  902,
     934, 935, 940, 998.
   for  prostatic  enlargement,
     990, 994, 995.
 Casts  in  sediment  of  urine,
   639.
 Catarrhal gonorrhoea, 98.
 Cathcart's siphon drainage in
   suprapubic lithotomy, 709.
 Catheter en  chemise   in  lith-
     otomy, 699, 701, 703.
   fever, 252.
 Catheterization in  treatment
           of bladder diseases,
           577, 588,  568,  570,
           573, 591, 603,  610,
           613, 659.
         continuous,  581,  586,
           603, 613,  688,  709,
           711, 712.
   in treatment  of  prostatic
     enlargement,  978,  979,
     981, 984, 986.
   in  treatment  of  prostatic
    wounds, 959.
   in  treatment of   ureteral
     disease, 750, 751, 756, 760,
       761, 762.
   retrograde, in treatment of
    stricture, 245.
   ureteral,  in  treatment  of
    kidneys,  802,  804,  816,
    833, 839.
Catheterizing cystoscope, 717.
Cauterization  in   chancroid,
   288, 290.
Cavum Retzii, abscess,  660,
       963.
    hydatid cysts, 739.
    inflammation, 708.
Cellulitis from hypodermic in-
    jection of mercury, 511.
   in hereditary pustular syph-
    ilide, 460.
Cephalalgia in cerebral syph-
    ilis, 341, 391, 476.
  parasyphilitic, 395.
  prodromal, 394.
Cerebral syphilis, 386, 475.
    differential diagnosis from
      tubercular  meningitis,
      476.
 Cervix uteri, concealed genital
   chancres, 317.
 Chancre, 304, 486, 529.
   extragenital, 306, 320.
     anal region, 325.
     breast, 324, 449.
     ear, 410.
     extremities, 325;  digital
       chancres, 325.
     eye, 404.
     head and face, 320.
     lip, 321.
       differential    diagnosis
         from  labial epitheli-
         oma (table), 322.
     nose, 411.
     tongue, 323, 324.
     tonsils and fauces, 324.
     vaccination, 327.
   genital, 307, 317, 447, 448.
     complications, 309, 313.
       balanitis, 33, 312,  164.
       chancroidal  inflamma-
         tion, 309, 310.
       condylomata, 310.
       lymphatic involvement,
         328.
       papillary growth, 310.
       phagedaena  and  gan-
         grene, 310.
       simple   inflammation,
         309.
     diagnosis, 311.
       differential,  313.
         chancroid, and herpes
           (table), 314.
         subpreputial,    and
           non-syphilitic sub-
           preputial   ulcera-
           tion (table), 316.
         urethral, and  gonor-
           rhoea (table), 319.
   immunity, Colles's, 299, 325,
       453, 454, 455, 527.
     Profeta's, 299,  455, 527.
   induration,   305,  309,  311,
     312.
   lymphatic involvement, 328.
       differential    diagnosis
         (table), 330.
       treatment, 330.
   mixed, 308, 309,  313.
   prognosis, 327.
   pseudo-, 300.
   relapsing, 299, 313.
   synonymes, 305.
   treatment, 486.
    local, 529.
Chancroid, 273.
  auto-inoculation, 275,  279,
    280.
   cause, 273.
  cauterization, 288.
  clinical aspects, 276.
  complications, 280.
    balanitis, 163, 280.
    balanoposthitis,   33,  35,
      280.
    chancre, 279,  309,  310,
      314.
    gangrene and phagedaena,
      292. 
1046
INDEX.
Chancroid,     complications,
      lymphadenitis, 294.
    lymphangitis, 294.
    phimosis, 17, 291.
  description, 277.
  diagnosis, differential, 279.
    between chancroid,  chan-
      cre, and herpes (table),
      314.
    urethral chancre, 319.
  dressings, 287,  288.
  frequency, 275.
  inoculability, 274.
  localization, 275.
  ointments, antiseptic,  288.
  pathology, 276.
  symptoms, 278.
  treatment, 286, 16.
    antiseptic    applications,
      286.
    cauterization, 288.
    complications, 291.
    operation, 289.
Chancroidal   balanitis,  163,
    280.
  balanoposthitis, 33, 35, 280.
  bubo, 166.
Chicken-breasted forehead  of
      hereditary syphilis, 471.
    thorax   of   hereditary
      syphilis, 471.
Chimney-sweepers'    cancer,
  863.
Chismore's lithotrite and evac-
  uator, 689, 694.
Chlorides in urine, 616.
Cholesterine crystals in alka-
  line urine, 643.
Choluria, 631.
Choroiditis, 407,  465.
Choroido-retinitis, 407, 408.
Chronic   urethritis,  anterior,
      127, 141.
    posterior, 131,  141.  See
      Urethritis.
Chylous" hydrocele, 925.
Chyluria, 616, 633.
Cicatricial cystitis, 660.
Ciliary body,  syphilis of, 407.
Circulatory system,   syphilis
  of,  431.
Circumcision, 9.
  complications,  12.
  recurrence of phimosis, 14,
    18.
  Schleich's method  of percu-
    taneous filtration, 14.
Civiale's urethrotome, 236.
Club-foot occurring  with  ex-
  strophy of the bladder, 545.
Cock's operation in  urethrot-
  omy,  238.
Colles's immunity from syph-
  ilis, 299, 325, 527, 453, 454,
  455.
Colloid  cysts of kidney, 849.
Color of urine, alterations  in,
  615.
Colpeurynter as cause of rectal
  rupture, 707, 711.
Concealed  genital   chancres,
  317, 447, 448.
Conceptional syphilis, 454.
Concretions,   spermatocystio,
  954.
Condylomata in syphilis, 342,
    533.
  of penis, 33, 39.
Confrontation in treatment of
  syphilis, 311, 488, 490.
Congenital   hydrocele,  910,
    920, 921.
  hydronephrosis, 828.
  phimosis, 7.
  stricture, 50.
Congestion  of  bladder,  564,
  571, 599, 645, 655.
Conjunctiva,  chancre  of, 320,
  327.
Conjunctivitis,   gonorrhoeal,
    108, 186, 190.
  syphiiitic, 404.
Constitutional syphilis, 332.
    anus, 340.
    appendages of the skin :
       alopecia, 339, 369, 462.
       onychia, 340, 369,462.
       paronychia, 370.
       perionychia, 340.
    arteries, 432.
    bladder, 442.
    bones, 420.
    brain, 386, 394, 475.
    breast, 449.
    circulatory system, 431.
       arteries, 432.
       heart, 431.
       veins, 433.
    ear, 410, 463, 465.
    encephalon, 475.
    epididymis, 442, 341, 479,
       898.
    eye, 404.
       hereditary syphilis, 464,
        478.
       iris, 405, 465.
        treatment, 406.
       ocular muscles, paraly-
        sis, 409, 478.
       optic nerve, 408,  409,
        465.
       retina, 408, 464, 465.
    heart, 431.
    intestines,   340,    382,
       479.
    joints, 341, 426, 474.
       arthralgia, 426, 474.
       arthrosis  in  hereditary
        syphilis, 474.
       bursitis, 429.
    kidneys, 440, 479.
    larynx, 415, 463.
    liver, 435, 478.
    lungs, 417, 464, 478.
    lymphatic  system,  328,
       333, 433, 474.
    mammary gland,  449.
    mouth, 339, 372, 376, 380,
        463,481.
       local treatment, 532.
    mucous  membrane,  339,
       371, 463, 532.
    muscles, 429.
    nails, 340, 369, 462.
Constitutional  syphilis, nasal
      cavities, 411, 463.
    nervous system, 335, 340,
        402, 386, 391,  475.
      spinal cord, 399, 477.
    nose,   411,   425,    463.
      481.
    oesophagus, 340, 382.
    ovaries, 448.
    palate, 380, 463, 481.
    pancreas, 439, 479.
    penis, 448, 372.
    pharynx, 381, 463, 481.
    prostate, 447.
    rectum, 340, 383.
    respiratory   tract,  411,
      464, 478.
    scrotum, 863.
    seminal vesicles, 447.
    skin  (syphilides),   336,
        341, 449.
      hereditary syphilis, 458,
        480.
      local  treatment, 531.
    spinal cord, 399, 477.
    spleen, 439,  478.
    stomach, 340, 382.
    symptoms, 332.
    teeth, 466.
    testicles,  442, 443,  479,
        898.
      differential  diagnosis,
             from encephaloid
             carcinoma,  and
             tubercular orchi-
             tis (table), 445.
          from enchondroma,
             446.
          from    lymphade-
             noma, 446.
      epididymitis and  epi-
        didymo-orchitis, 341,
        442,  479, 889,  890,
        898.
      fungus, 444, 447, 890.
    tongue, 376, 463, 372.
      differential   diagnosis
          from   carcinoma,
             379.
          from    tubercular
             glossitis, 378.
      tertiary  lesions, 377.
    tonsils,  382.
    treatment, 483. See Treat-
      ment of Syphilis.
    ureters, 442.
    urethra, 447.
    uro-genital  system,  440,
      479.
    uterus, 449.
    vagina, 449.
    vasa  deferentia, 447.
    veins, 433.
    vulva, 449.
Contagion in syphilis, 301.
Continuous treatment of syph-
  ilis, 493.
Contusion of bladder, 607.
  of kidneys, 778, 825.
  of penis, 24.
  of prostate, 958.
  of scrotum, 857. 
INDEX.
1047
Contusion  of  spermatic cord,
    938.
  of testicle, 878.
  of urethra,  69.
Copaiba  rash, diagnosis from
    erythematous   syphilide,
    344.
  urticaria in  gonorrhoea, 111.
Cornea, syphilitic affections of,
  405.
Corpora amylacea of prostate,
  999.
Coryza in hereditary syphilis,
  463,481.
Cowperitis  and  gonorrhoea,
  168.
Cowper's  glands,  cancer  of,
      266.
    cysts of, 266.
Cranium, syphilis of, 424.
    hereditary, 470, 471.
Croupous cystitis, 647.
Cruro-scrotal  retention of  tes-
  ticle, 867, 873.
Crushing forceps  in perineal
  litholapaxy, 690.
Cryptorchism, 867, 1006.
Crystalline sediment  of acid
  urine, 640.
Cutaneous affections  of scro-
  tum.  85S.
Cyclitis in hereditary  syphi-
  lis, 464.
Cystinuria, 632, 642.
  calculi, 673, 792,  793.
Cystitis, 644,  662.
  acute, 645,  651, 655.
  catarrhal, 647.
  catheterization, 577, 659.
  chronic, 647, 651, 656.
  classification, 644.
  cystoscopy, 716, 721.
  cystotomy,  683, 697, 706.
  diagnosis, 650.
  drainage, 659, 668, 688,  703,
     709.
  etiology, 644.
  gangrenous, 648.
  instillations, 657, 667.
  interstitial, 647.
  irrigation, 657,  658.
  membranous, 647.
  prevesical abscess, 660,  707,
     712.
  prognosis, 651.
  symptoms,  648.
    fever, 650.
    frequent  urination,  559,
       649.
    haematuria, 598, 650,  602,
       627, 633, 637, 664.
    muscular spasm, 650.
    pain, 553, 649.
    pyuria, 648, 635, 638, 665,
       666.
  treatment,  652.
Cystoma of testicle. 903.
Cystoscopes, 716, 750.
  catheterizing, 717.
  irrigating, 717.
  Leiter, 716.
  operating, 717.
Cystoscopes, use of, 718, 721.
Cystoscopic diagnosis, 720.
Cystoscopy,  716,  721,  602,
  606, 607, 611, 651,  666, 670,
  677, 680, 717, 719.
Cystotomy, 697, 683,  691, 693,
    706, 711.
  perinea], 697, 705.
    bilateral,  704.
    lateral, 697.
    median, 704, 960, 63.
    medio-bilateral, 705.
  suprapubic, 706, 695, 730.
    complications,  707, 708,
       711.
    drainage, 709, 997.
    sequelae, 711.
Cysts of bladder,'7:>7.
  of Cowper's glands, 266.
  of kidney, 848.
  of penis, 38.
  of prostate, 1001.
  of scrotum, 863.
  of testicle, 904.

Dactylitis, syphilitic, 425, 473.
Dactylius  aculeatus  in kid-
  neys, 851.
Decortication in haematocele,
  934, 935.
Deformities of scrotum, 857.
Dental erosion of hereditary
  syphilis, 467.
Dermatitis in hydrargyrism,
     501.
  in inunctions, 508, 511, 536.
  in iodism, 503.
Dermoid cysts of bladder, 738,
       739.
     of testicle, 904.
Diabetes  as a complication of
     balanitis, 35.
  insipidus and syphilis, 441.
Diacetic acid in urine, 632.
Diarrhoea and  colic  in sys-
  tematic treatment  of syphi-
  lis, 495.
Digital chancres, 325.
Dilatation  in  treatment  of
  prostatic enlargement, 984,
  985.
Diphtheritic cystitis, 647.
Diphtheroid papule in syphi-
  lis, 373, 375.
Direct infection  of  syphilis,
  453.
Discharge in acute gonorrhoea,
  94, 101.
Dislocation of penis, 27.
Distoma haematobium in haem-
       aturia, 627,  637.
     in kidneys, 851.
Disturbed   cerebration   in
  hereditary syphilis, 476.
Diverticula of urethra, 51, 54,
  262.
Division of ureters, 734, 743.
Divulsion in stricture, 247.
Dolbeau's  operation  in epi-
  spadia, 61.
Double penis, 5.
  urethra, 948.
Drainage, perineal, 703.
  suprapubic, 709, 997.
Dressings in acute gonorrhoea,
    108.
  in chancroid, 287.
  in circumcision, 11, 17, 18.
Dribbling of urine in prostatic
      enlargement,  975, 977.
    in stricture, 200, 207.
Duplay's operation, 57.
Dupuytren's lithotome  cachg,
  705.
Dura mater, gummata of. 389,
  424.

Ear, syphilis of, 410, 463, 465.
Eburnation  in  syphilis   of
  bones, 420, 421, 422, 424.
Echinococcus  cysts in urine,
    637.
  of kidney, 849.
Ecthyma and chancre, differ-
    ential diagnosis, 320.
  syphilitic, 343, 356, 460.
Ectopy, 866, 867,  871,  873.
Eczema and syphilides, differ-
    ential diagnosis, 351, 352,
    355.
  in hydrargyrism,  501.
  in inunctions, 508.
  in iodism, 504.
  of penis, 28.
  of scrotum, 28, 859.
  rubrum, 501.
Effemination, 1042.
Ejaculatory  ducts,  anatomy,
      856, 947.
    obstruction, 950, 951, 953,
      954, 961, 1027,  1028.
Electric baths in treatment of
  syphilis, 522.
Electricity  in treatment   of
  impotence, 1017, 1021.
Electrode, urethral, 596.
Electrolysis in stricture, 247.
Elephantiasis   of  penis,  38,
    861.
  of scrotum,  861, 887.
Elimination of mercury,  502,
  503, 519,  523.
Emboli, pulmonary,  from hy-
  podermic injection of mer-
  cury,  510, 512.
Emphysema of scrotum, 858.
Encephalalgia, syphilitic, 392.
Encephalitis from  exostoses  of
  cranium, 425.
Enchondroma   distinguished
      from gummatous  teno-
      synovitis, 431.
    from  syphilitic orchitis,
      446.
  of bladder, 725.
  of scrotum,  863.
  of testicle, 903.
Encysted  haematocele of sper-
      matic cord,  936.
    of testis, 935.
  hydrocele  of   epididymis,
      910, 920, 925, 926.
    of  spermatic  cord, 911,
      930, 939. 
1048
INDEX.
Encysted hydrocele of testis,
  910, 920, 925, 928.
Endarteritis, 432.
  in  cerebral  syphilis,  388,
    390, 432, 475.
Endocarditis, syphilitic, 431.
Endometritis,    gonorrhoeal,
    153.
  syphilitic,  449.
Endoscope, 82, 87, 130.
Endothelioma of kidney,  844.
Enlarged prostate,  573,  970.
  See Prostatic Enlargement.
Enuresis, 592.
Epididymis,  anatomy of,  855.
  hydrocele  of, 910, 920, 925,
    926.
  parenchymatous   haemato-
    cele of, 935.
  syphilis of, 341, 442, 479.
Epididymitis,  883,  887,  891,
    895, 908, 1027.
  and   vesiculitis,  950,  951,
    954.
  gonorrhoeal,  176, 443,  444,
    880,  883,  884, 895, 909,
    941, 1028.
  sequel of litholapaxy, 697.
  syphilitic,  341,442,479, 889,
    890, 898.
  tubercular, 891,  443,  479,
    881, 889, 940, 954,  969.
  urethral, 883.
Epididymo-orchitis, 883.
    complicating acute infec-
      tious diseases, 884.
    from strain,  880.
    syphilitic, 442, 479,  889,
      890, 898.
    tubercular, 892, 893,  898.
Epilepsy and cerebral  syphi-
    lis, 397,  476.
  and neuralgia of testis, 937.
Epileptic   incontinence   of
    urine, 593.
  symptoms of hereditary cer-
    ebral syphilis, 476, 477.
Episcleritis, syphilitic, 405.
Epispadia, 59, 544, 1027.
  treatment,  61.
Epithelial cysts of bladder,
    737.
  tumors of kidney, 842.
Epithelioma  and gummatous
    syphilides, 367, 368.
  labial, differential diagnosis
    from    labial    chancre
    (table), 322.
  of penis, 39, 42, 43, 44.
  of scrotum, 863.
  of tongue,  differential diag-
    nosis,  from  gummatous
    glossitis       (Fournier's
    table), 379.
Epithelium   in  urine,   637,
  639.
Erasion in treatment of tuber-
  culosis of testicle, 896.
Erectile  tissue of  penis, in-
  flammation of, 30.
Erection and orgasm, mechan-
  ics of, 1002.
Erysipelas   with  ulcerating
  syphilides, 534.
Erythema  in  hydrargyrism,
     501.
  in iodism, 504.
  in  syphilis,  337, 338, 339,
     342, 343, 415.
  intertrigo of scrotum, 858.
Erythematous syphilides, 343,
  372, 459, 531.
Essential oxaluria, 620.
Eunuchism  from  anorchism,
  864.
Evacuating  instruments  in
  treatment of  calculus  of
  bladder, 680, 685, 687, 689,
  692.
Examination  of  urine,  614.
  See Urine.
Excision  in hydrocele,  919,
     921, 928, 931.
  in stricture, 246.
  of chancre, 487.
  of seminal vesicles, 955.
  of spermatic cord, 944.
Exostoses in syphilis of tibia,
     425, 472.
  of cranial bones in syphilis,
     425.
Exstrophy of bladder, 60, 544,
  710.
Extragenital  chancre,   306,
  320.
Extravasation of urine in dis-
       eases  of  bladder,  543,
       606.
     in diseases of ureters, 743,
       744.
     in   periurethral  abscess
       from  gonorrhoea,  167,
       168.
     in  stricture of  urethra,
       213.
Eye, chancre of, 320, 327.
  gonorrhoeal  conjunctivitis,
     186, 190.
  syphilis, 404, 464, 341, 389,
     396, 403, 478.
Fatty hydrocele,  925.
  tumors of scrotum, 863.
Fauces, chancre of, 324.
Fehling's  test  for  sugar  in
  urine, 620, 630, 631.
Fever,  catheter,  urethral,  or
    urinary,  252,  696,  705,
    737.
  in cystitis, 650.
  syphilitic, 334.
Fibrinuria, 626, 727.
Fibroma of bladder, 725.
  of kidney, 844.
  of scrotum,  863.
  of testicle, 904, 937.
Filaria sanguinis hominis, 600,
  633, 638, 861, 911, 925.
Filiform bougies, 219, 231.
Filtration,  percutaneous,  in
  circumcision, 14.
Fistula from prostatic abscess,
    963, 964, 965.
Fistula from prostatic wounds,
     959.
   from stricture, 203, 205, 241.
   of bladder, 669, 706, 712,
     761.
   of kidney,  841, 761, 803,
     813, 827, 834.
   of testicle, in  tuberculosis,
     893, 894.
   of ureters,  761, 748, 760.
   of urethra, 256, 964, 1027.
   urinary, in gonorrhoea, 167.
     168.
Floating kidney, 769, 622,831.
Foetal structures in hydrocele,
   926.
Folds, valvular, of urethra, 50.
Folliculitis in gonorrhoea, 147,
     166,318.
   ulcerating,     distinguished
     from  chancre of  cervix
     uteri,  317.
Foreign bodies in bladder, 712.
     in  urethra, 76.
Fracture of penis, 26, 69, 197.
Fraenum, shortness of, 19.
Frequency of  urination,  96,
       100, 200, 206,  559, 649,
       675, 727, 796,  837, 838,
       894, 895, 962,  965, 972,
       973, 975.
     Fenwick's tables for, 559,
       560.
Fungus of testicle, 890, 444,
   447, 898, 900.
Funicular  hydrocele, 930, 939.
Funiculitis, 938.
Fused kidney, 768, 769.

Gabbett's staining method for
   tubercle  bacillus, 636.
Gangrene of penis, 25, 27, 28,
     29, 33, 34, 40.
   of scrotum, 858, 860.
   of spermatic cord, 938, 945.
   of testicle,  869, 877,  888,
     889, 890, 938, 945.
Gangrenous cystitis, 648.
Garson-Petersen  method  for
   distention  of  bladder  and
   rectum, 706.
Gastritis, syphilitic, 382.
Gastro-enteritis,    syphilitic,
   382.
Genital  chancres, 307,  447,
     448.
   tuberculosis, 891, 892, 893,
     896.
Genito-urinary   neuroses  of
   atonic impotence, 1011.
Gentian  violet   solution  in
   gonorrhoea, 92.
Germinal syphilis, 451.
Gerster's urethrotome, 237.
Glandular  hypospadia, 53, 54.
   urethra,  formation  of,  in
         epispadia, 63.
      in hypospadia, 55.
Gleet, 123, 200, 208, 950.
Globulin in urine, 625, 640.
Glomerulo-nephritis,    syphi-
  litic, 441. 
Glossitis, syphilitic, 376.
Glycosuria, 629.
Goldberg on  albuminuria  and
  haematuria, 634.
Gonococcus, 89, 92.
Gonorrhoea, 89. See Urethritis.
  abortive, 99, 109.
  acute, of male urethra,  93.
    children, males, 155.
      females, 158.
    complications,  98,   103,
      161.
    diagnosis, differential, 142.
      from  urethral chancre,
        318, 319.
    internal  medication, 109,
      115.
    pathology, 103.
    prognosis, 97, 103.
    symptoms, 94, 100.
    treatment, 103.
      abortive, 104, 122.
        Janet's method, 117.
      systematic, 106.
  catarrhal,  or  subacute,  98,
    109.
  chronio, of male urethra, 123.
        diagnosis, 128,  132,
          141.
        symptoms, 127, 131.
        treatment, 129,  133.
          summary, 139.
  complications, 161, 98.
    abscess, follicular, 166.
      in epididymitis, 179.
      periurethral, 167.
    adenitis, 165.
    balanitis, 161,  163, 164,
      98, 155.
    balanoposthitis,   161,  98,
      155.
    bubo, 165.
    cowperitis, 168.
    cystitis, 183, 646,  662.
    epididymitis,  176,  443,
        444,  880, 883, 884,
        895,  909, 941, 1028.
      treatment, 180.
    folliculitis, 147, 166, 318.
    funiculitis, 178, 939.
    lymphadenitis     (bubo),
      165.
    lymphangitis, 164.
    nephritis, 185.
    paraphimosis, 164.
    phimosis, 162.
    phlebitis, dorsal, 165.
    prostatitis, 170,  573, 697,
      963, 968.
    pyelitis, 185.
    rheumatism,  190.
    ureteritis, 185, 748.
    vesiculitis, 174, 948, 955.
 etiology, 89.
 eye, 186.
 epididymitis, 176, 177, 178,
    179, 443,  444, 880, 883,
    884, 895,  909.
 gonococcus, 89, 92, 186, 636,
    646, 806.  See  Gonococ-
    cus.
 in children, 155.
          INDEX.


Gonorrhoea, injections in acute
     urethritis, 104, 109, 111.
   instillations in chronic ure-
     thritis, 134,  657, 667.
   in women, 144.
   irrigation  of urethra, 116,
     122, 131, 133.
   irritative  or  abortive,  99,
     109.
   ointments  in  chronic ure-
     thritis, 137.
   periarthritis, 191.
   rectum, 159.
   retention of urine, 571, 591.
   sicca, 93.
   strictures of urethra, 193.
   subacute or catarrhal,  98,
     109.
   suppositories in chronic ure-
     thritis, 138.
   symptoms, acute, 94, 100.
     chronic, 127, 131.
   tenosynovitis,  191.
Gonorrhoeal vulvo-vaginitis in
   children, 158.
Gorgets  in  litholapaxy, 690,
   699, 702.
Gouty diathesis  in  constitu-
     tional treatment of syphi-
     lis, 491, 518.
   orchitis, 887.
   urethritis and epididymitis,
     883, 884, 887.
Gravel, 792, 675, 682, 796, 799,
   800.
Gray oil, 513.
Gross's urethrotome, 236.
Gummata, differential diagno-
     sis from  chancroids, 280.
     See Syphilides, and  Con-
     stitutional Syphilis.
   of hereditary syphilis, 461,
     470,  475, 477, 478, 479,
     535.
Gummatous arthritis, 427,428.
   bursitis, 429.
   dactylitis,  425.
   endarteritis, 432.
   glossitis, 377.
   hepatitis,  436,  437,  438,
    478.
   iritis, 406, 407.
   laryngitis, 416.
  mastitis, 450.
   myocarditis, 431.
  myositis, 430.
  nephritis, 441.
  orchitis, 444, 447, 898.
  osteomyelitis, 421.
  ostitis, 421.
  pancreatitis, 439.
  periostitis,  421.
    of cranium, 424.
  pulmonitis, 418.
  rhinitis, 412.
  scleritis, 405.
  splenitis, 439.
  synovitis, 427, 428.
  syphilides,   363,  374, 377
    387,461.
  tenosynovitis, 430.
  vulvitis, 449.
                        1049

 Gunshot wounds  in  lumbar
       region, 600.
     of bladder, 605, 606.
     of kidneys, 786, 787, 788.
     of penis, 26.
     of testicles, 882.
 Gynandry, 1042.

 Haematocele,  931,  869,  878,
   900, 901, 915.
 Haematoidin  crystals in  acid
   urine, 641.
 Haematoma, 931.
 Haematoporphyrin  in  urine,
   616, 621.
 Haematuria in diseases of blad-
         der, 598.
       calculus, 676, 677, 681.
       cystitis, 645, 650.
       cystoscopic   diagnosis
         of,  721, 723.
       examination of   urine
         in, 627, 633, 637.
       tuberculosis, 727,  663,
         664.
       tumors, 600, 601,  728,
         729.
       wounds, 605.
     of kidneys, 627.
       calculus, 796, 675, 756,
         797, 804.
       contusion, 780, 781, 782,
         784.
       tuberculosis, 837, 838.
       tumors, 845, 846,  847.
       wounds, 787, 600.
     of prostate, 977, 1000.
     of ureters, 743, 751,  756,
       758.
   in tubercular epididymo-or-
     chitis, 894, 895.
   in urethritis, 101, 142.
 Haemoglobinuria, 628.
 Headaches in cerebral syphilis,
     391, 394, 398.
   syphilitic  neuralgias, 335,
     341.
 Head  and face,  chancres of,
   320.
 Heart, syphilis of, 431.
 Heat in treatment of syphilis,
   518, 521.
Hemorrhagic  vaginalitis, 932.
Hepatitis, syphilitic, 435, 478.
Hereditary syphilis, 457.
    of appendages of the skin,
       462.
    of bones,  470.
    of brain, 475, 386.
    of ear, 465, 410.
    of eye, 464, 409.
    of joints,  474.
    of lymphatic glands, 474.
    of mucous membrane, 463.
    of  nerve   centres   and
      nerves, 475.
    of spinal cord, 477, 399.
    of skin, 458.
    of teeth, 466.
    of testicles, 479.
    of  viscera, 478.
    treatment of, 534. 
1050
INDEX.
Heredity, syphilitic, 451, 489,
  535.
Hermaphroditism,   psychical,
  1041.
Hernia of bladder,  551, 544,
    712.
  testis, 890.
Herpes, differential  diagnosis
        from balanitis, 35, 36.
       from chancre, 3i4.
       from chancre of cervix
        uteri, 317.
       from  chancroid,  314,
        277, 280.
       from multiple herpeti-
        form  chancre,  308,
        312.
       from  pseudo-chancre,
        300.
  progenitalis, 35, 28, 32, 33.
Heterosexual perversion, 1030,
  1039.
Hippuric  acid  in acid  urine,
  641.
Homosexuality, 1030, 1040.
Horny growths of penis, 41.
Hot baths  in  treatment  of
  syphilis, 518.
Hutchinson teeth, 468, 481.
Hyaline casts in  urine, 639.
Hyalitis,  syphilitic,  408.
Hydatid  cysts   in  space  of
       Retzius, 739.
     of bladder, 739.
     of kidney, 849.
Hydrargyrism, 500,  519.
Hydrarthrosis  in syphilis  of
  joints, 426, 427.
Hydrocele, 908, 858, 869, 875,
     883,  885,  893,  895, 897,
     900,  902, 179.
  acute, 908.
     of spermatic cord, 929, 938
  chronic, 909, 910.
  chylous, 925.
  complications,  911.
  congenital, 910, 920,  921.
  encysted, of epididymis, 910,
       920, 925, 926.
     of spermatic  cord, 911,
       930, 939.
     of testis, 910, 920, 925,928.
  excision  of,  919,  921, 928,
     931.
  fatty, 925.
  funicular, 930, 938.
  incision and  drainage, 918,
     920,  923, 924, 925, 930.
  infantile, 910,  923.
  inguinal, 910,  924.
  injection  treatment,  917,
     920,  923, 928.
  light test, 909, 914, 928, 930.
  milky,  925.
  multilocular, 921,926, 930.
  spermatic cord,  911, 929,
     930,  938.
  tapping, 916, 928, 930.
  translucency,  909, 914, 928,
     930..
  tunica  vaginalis  testis, 910,
     911.
Hydrocephalus  in  hereditary
  syphilis, 471,  475, 480.
Hydronephrosis, 828, 742, 750.
  acquired, 829.
  gonorrhoeal, 185.
Hydrops articuli in syphilitic
  arthritis, 427.
Hygienic treatment of syphilis,
  491.
Hyperkeratosis   and   scaly
  patches, 375.
Hyperostosis from  syphilis of
  cranial bones, 425.
Hypertrophic syphilitic  rhi-
      nitis, 411.
    synovitis, 427.
Hypertrophy of bladder, 550,
    567, 829.
  of foreskin in balanoposthi-
    tis, 33.
  of kidney, 767.
  of penis, 5.
  of prostate,  970, 573, 722.
    .See  Prostatic   Enlarge-
    ment.
  of testicle, 863, 866.
Hypodermic injections of mer-
  cury in treatment of syph-
  ilis, 509, 514,  488, 498, 537.
Hypospadia,  51,   857,  1005,
    1027.

Ichthyosis and syphilitic glos-
  sitis, 378.
Immunity from syphilis, 299.
    Colles's law, 299, 325, 453,
      454, 455,  527.
    Profeta's law,  299, 455,
      527.
Impetigo, syphilitic, 342, 354,
  460.
Implantation of ureters, 734,
  744, 747,  762, 788.
Impotence,  1002, 1030, 1038.
  atonic, 1008.
  female, 1024.
  gonorrhoea, 173,  1006, 1009,
    1018.
  instillation, 134,  136, 1015,
    1020, 657, 667.
  irrigation  of urethra,  122,
    1015.
  irritative, 1009.
  organic,  1004.
  paralytic,  1009,  1017, 1018.
  pollutions,  diurnal,  1010,
       1022, 1024.
    nocturnal,   1021,  1023,
       101.
  prostatorrhoea,  1012, 1018,
    1031, 626.
  psychical, 1007.
  psychrophore, 1014, 1016.
  rectal injections, 1017.
  relative, 1008.
  seminal  emissions, involun-
    tary, 1021.
  spermatorrhoea,  1022, 1024,
     1012,  1018, 1019, 1031.
  treatment, 1005, 1007, 1014,
    1019,   1023,   1025,  562,
    864.
Impotence,  urine  in  atonic,
    1011, 1020.
  vaginismus, 1025.
Incision   and   drainage   in
    treatment  of  hydrocele,
    918,  920,  923,  924, 925,
    930.
  for excision of rectum, Zuck-
    erkandl,   Von   Dittel,
    Kraske, 954, 955.
  in treatment of haematocele,
    934.
  in  treatment of tubercular
    prostatitis, 969.
Inclusion  cysts  of  bladder,
  739.
Incomplete  retention of urine,
  587, 591.
Incontinence of urine from en-
       larged prostate,  976.
    from wounds  of prostate,
       959.
    in children, 593.
    in renal tuberculosis, 837.
    in  stricture  of urethra,
       207.
    in vesical disease, 592.
Incoordination   of   bladder
  muscles, 568.
Indican in urine, 617.
Indigo crystals  in  alkaline
    urine, 643.
  in calculi, 673.
  in semen, 1029.
Indurated papule of syphilis,
  309.
Induration  of chancre, 305.
Infantile hydrocele, 910, 923.
Infection as a  cause of  pros-
    tatitis,  960, 962, 965, 968.
  in wounds of prostate, 958,
    959.
  of kidneys by micro-organ-
    isms, 805,  652, 737, 982,
    986.
Influenza orchitis, 888.
Infusions, vegetable, in treat-
  ment of syphilis, 526.
Inguinal hydrocele, 910, 924.
  retention of  testicle, 867,
    869, 871.
Injection treatment of hydro-
  cele, 917, 920, 923, 928.
Injections  in  acute   gonor-
     rhoea,  104, 109, 111, 115,
     122.
  in  gonorrhoeal  vulvo-vagi-
     nitis, 159.
  in   gonorrhoeal  prostatitis,
     173.
  in   tubercular   prostatitis,
     969.
  of mercury,  hypodermic, in
       treatment  of syphilis,
       509,  514.
    intravenous, in treatment
       of syphilis, 522.
  rectal, in impotence, 1017.
    in prostatic enlargement,
       985.
Injuries  of   bladder.    See
  Wounds,  and Contusions. 
INDEX.
1051
Instillations  in chronic  ure-
    thritis, 134, 136.
  in diseases of bladder, 596,
    657, 667, 709.
  in treatment of  impotence,
    1015, 1020.
  in  tubercular   prostatitis,
    969.
Intermittent   hydronephrosis,
    831.
  pyuria in calculus of ureters,
      757.
    in  kidney-diseases,  811,
      815, 816.
Interrupted treatment of syph-
  ilis, 493.
Interstitial cystitis, 647.
Intestines, syphilis of, 383, 479.
Intratesticular   haematocele,
  935,
Intravenous injections of mer-
  cury  in treatment  of syph-
  ilis, 522.
Inunctions of mercury in treat-
  ment of syphilis, 506, 496,
  497, 536.
Inversion  of  sexual  feeling,
    1030, 1040.
  of testicle, 875.
Iodides  in  systematic  treat-
  ment of syphilis, 498, 523.
Iodism, 500, 503, 525.
Irido-cyclitis, 407.
Iritis, gonorrhoeal,  190.
  papulosa, 406.
  syphilitic, 341, 405.
Irregular syphilis,  333.
Irrigating bag in  gonorrhoea,
    116.
  cystoscope,  717,  722.
Irrigation in vaginitis, 155.
  in vulvitis,  149.
  of  bladder, 657, 658, 709,
    711.
  of  rectum   in   gonorrhoeal
    prostatitis, 173.
  of  urethra   for  impotence,
      1015.
    for prostatic abscess, 964.
    in  acute  gonorrhoea, 116,
      120, 122.
    in  acute  posterior ure-
      thritis,  122.
    in chronic urethritis, 131,
      133.
Irritable prostate, 967.
  testicle, 937.
Irritative impotence,  1009.
Ischaemia in cerebral syphilis,
  390, 433.

Janet's  method of irrigation
  in acute gonorrhoea, 117.
Jaundice   from   hereditary
  syphilis, 478.
Joints, syphilitic involvement
  of, 341, 426,  474.

Kalashnikoff  on heat  in  the
  treatment of syphilis, 521.
Keratitis  in hereditary syphi-
  lis, 464, 481.
Keratitis,   interstitial   and
  punctate, in syphilis, 405.
Keratosis pilaris  and  syphi-
  lides, 348.
Kidney, 764.
  abscess, 810, 814, 817, 818,
    825.
  absence, 767, 742.
  adenomata, 842.
  amyloid degeneration, 808,
    812, 818, 820, 843, 845.
  anatomy, surgical, 764.
  anomalies, 767.
  anuria, in calculus, 803.
  aspiration in hydronephro-
       sis, 833.
    in pyonephrosis, 812.
  atrophy, 748, 750, 756, 767,
    780, 793, 826, 828.
  calculi, 792, 808, 828, 830,
    831, 755, 757, 758.
  carcinomata, 842.
  colic  as a symptom of calcu-
       lus, 796,  799, 800, 804,
       823,  672, 675, 755, 756,
       757.
    as  a symptom  of  renal
       tuberculosis, 836.
  contusion, 778,  825.
  cystoscope in diagnosis, 723.
  cysts, 848.
  epithelial tumors, 842.
  extirpation, 748.
  fibromata, 844.
  fistulae, 841, 761, 803, 813,
    827, 834.
  fixation of movable, 775.
  floating, 769,  622, 831.
  fused, 768, 769.
  gravel, 792, 675, 682, 796,
    799, 800.
  gunshot wounds,  786, 787,
    788.
  haematuria, 627.
    in calculus, 796, 797, 804,
       675, 756.
    in  contusion,  780,  781,
       782, 784.
    in tuberculosis, 837, 838.
    in tumors, 845, 846, 847.
    in wounds,  787, 600.
  hydronephrosis,  828,  742,
    750, 829.
  infection  of, 805, 545, 652,
    737.
  injuries, 778.
  intermittent  pyuria,   811,
    815, 816.
  involvement of, in cystitis,
      652.
    in  retention   of  urine,
      567.
  leucomyomata, 844.
  lipomata, 844.
  lipomyomata,  844.
  malignant  growths,  842,
    845, 851, 798.
  movable kidney, 769, 831.
  nephralgia, 797.
  nephrectomy,  778, 785, 788,
    789, 813, S17, 826, 834,
    840, 847, 849,  749.
Kidney, nephritis,  805, 809,
     817,  849,  615,  622, 623,
     629, 886.
   nephrolithotomy  for  calcu-
     lus, 801.
   nephrorrhaphy, 774, 775.
   nephrotomy,  801, 802, 813,
     817,  818,  834,  840, 749,
     760.
   pain  in  renal  calculus,
     795.
   parasites, 849.
   perinephric   abscess,  812,
     819, 836.
   perinephritis, 818.
   pyelitis, 806, 807, 825, 798.
   pyelonephritis,   813,  808,
     809, 681, 682, 697, 729.
   pyonephrosis, 808, 810, 817,
     825, 726, 756, 759.
   pyuria,  809,  810, 811, 815,
     818, 825, 837, 838.
   reflexes  of  renal calculus,
     795.
   rhabdomyomata, 845.
   rupture, 779, 782, 783.
   sanguineous effusions, peri-
     nephric, 781.
   sarcomata, 844.
   solitary, 767, 769.
   suppurative diseases, 805.
   suprarenal capsules, 851.
     tumors, 844, 846.
   surgical, 809, 814.
   syphilis, 440, 479.
   tuberculosis,  834, 601, 662,
     663,  796, 798,  816, 822,
     842, 847, 851.
   tumors,  842, 601, 783, 824,
     830, 851.
   wounds, 786, 805.
Kraske's incision for  excision
   of rectum, 954, 955.
Kreatinin  in urine,  620.

Labyrinth of ear, in syphilis,
   410.
Lacerated   wounds  of penis,
       26.
     of urethra, 69.
Lachrymal apparatus,  syphilis
   of, 404.
Lafayette  emulsion  in  acute
   gonorrhoea, 110.
Laparotomy and  wounds of
     ureters, 746, 747, 748.
   exploratory, for calculus of
     ureters, 757.
Larynx, syphilis of,  415.
Leiter cystoscope, 717.
Leucin in acid urine, 641.
Leucocytosis  in  diseases of
  kidneys, 439, 818, 822, 824,
  825.
Leucomyomata of kidney, 844.
Leucorrhoea, vaginal, and gon-
  orrhoea of the eye, 186.
Leucoplakia, syphilitic, differ-
  ential diagnosis from non-
  specific, 375.
Lichen  and  papular syphi-
  lides, 342, 348. 
1052
INDEX.
Ligation of vas in treatment
    of prostatic enlargement,
    994, 995, 997.
  subcutaneous, in varicocele,
    943.
Light test in diagnosis of hy-
  drocele, 909, 914, 928, 930.
Lip, chancre of, 321.
Lipoma of kidney, 844.
  of spermatic cord, 939.
Lipuria, 632, 637.
Lithium iodide in treatment
  of syphilis,  526.
Litholapaxy, 684.
  children, 691, 697.
  complications, 694.
  contraindications, 693.
  evacuating     instruments,
    685, 687,  692.
  lithotrites, 682,  684, 692.
  operation, 686, 688,  693.
  preparation for, 683, 693.
  sequelae, 696.
Lithotome cach6, Dupuytren's,
  705.
Lithotomy, 697, 683, 691, 693,
  706,711. See Cystotomy.
Lithotrites, 684, 689, 692, 699,
  680.
Lithotrity, 687.
Liver,  syphilis of,  435, 478,
  480.
Local infection in  cystitis, 645,
    653.
  treatment of syphilis,  529.
Locomotor ataxia in syphilis,
  401, 409.
Loose  bodies  in tunica vagi-
  nalis testis, 936.
Lungs, syphilis of, 417, 478,
  480.
Lupus, differential diagnosis
    from  tubercular   syphi-
    lides (table), 362, 462.
  of nasal passages, diagnosis
    from hereditary syphilis,
    463.
Luxation of testicle, 876.
Lymphadenitis (bubo), balan-
    itic, 33.
  chancrous, 328, 329.
  chancroidal, 278, 283.
  gonorrhoeal,  165.
  inflammatory, 33, 98.
    differential diagnosis (ta-
       ble), 330.
  syphilitic, 333, 433.
    hereditary, 474.
Lymphadenoma  and  syphi-
    litic sarcocele, 446.
  of bladder,  725.
  of testicle, 904.
Lymphangioma of penis, 38.
Lymphangitis, chancrous, 328.
    differential diagnosis be-
       tween   syphilitic and
       simple   inflammatory
       lymphangitis   (table),
       330.
  chancroidal, 283.
     treatment, 294.
  gonorrhoeal, 164.
Lymphangitis,   gonorrhoeal,
    differential diagnosis from
    lymphangitis   of  hard
    chancre, 164.
  inflammatory, 30, 96, 98.
    differential diagnosis, 330.
Lymphatic   enlargement   in
    constitutional    syphilis,
    333, 433, 474.
  involvement in chancre, 328.
    in syphilitic glossitis, 379.
  vessels of bladder, 726.
Lymphomata, syphilitic, 434.

Magnesia in urine, 619,  642.
Magnesium  soaps   in   acid
  urine, 642.
Maisonneuve's    urethrotome,
  235.
Malarial orchitis, 887.
Malemission of semen,  1027,
  208.
Malformation.  See Anomalies.
Malignant  degeneration   of
    testicles,  869,  870, 875,
    889, 890, 857.
  growths.  See  Tumors.
  syphilis, 332.
  tumors  of   bladder,   722,
       723.
    of kidneys, 842, 845, 851,
       798.
    of penis, 38, 42.
    of prostate, 1000.
    of seminal vesicles,  956.
    of testicles, 934, 935.
    of ureters, 762.
Malposition of bladder, 543.
Mammary gland, syphilis of,
  449.
Manipulation for chronic ve-
  siculitis, 951.
Marasmus, syphilitic,  303.
Marriage and varicocele, 942.
  of syphilitics, 455, 489, 535.
Masochism, 1039.
Mastitis, syphilitic,  449.
Masturbation,  1030,  1031, 4,
  16, 197, 219, 560, 676, 941,
  960,  965,  998, 1007,  1010,
  1019, 1027, 1031,  1033.
Maternal descent of syphilis,
  451, 480.
McDade's formula, 526.
Meatotomy, 50, 81, 129,  234.
Megalopenis, 5.
Melanin in  urine, 632.
Membranous cystitis, 647.
Meningitis  from  syphilis of
    cranium, 424, 425.
  from syphilitic rhinitis,  413.
  syphilitic, 389, 400.
  tubercular,  diagnosis   from
    hereditary cerebral  syph-
    ilis, 476.
Menstrual   disturbances   in
  syphilis, 341.
Mercier's instrument for  re-
  moving foreign body from
  bladder, 714.
Mercurial ointment in inunc-
  tions, 507.
Mercurial soaps in treatment
    of syphilis, 509.
  teeth of hereditary syphilis,
    466.
Mercuric baths, 516.
Mercury  in treatment of syph-
        ilis,   abortive  treat-
        ment, 489.
       methods of giving, 504,
        489, 493, 494.
       toxic effects, 500, 519.
  plasters, 509.
Mesonephron,  765, 769,  772,
  778.
Metritis, gonorrhoeal, 151.
  syphilitic, 449.
Microcephalus in  hereditary
  syphilis, 471.
Microdontism  of  hereditary
  syphilis, 469.
Micropenis, 4.
Migration of  testicle, anoma-
  lies of, 866.
Milky hydrocele, 925.
Misplaced testicle, 866, 868.
Mixed chancre, 308, 309, 313.
  heredity of  syphilis, 452.
  treatment  of syphilis,  498,
    506.
Modified expectant treatment
  of syphilis,  493.
Molluscum   contagiosum  of
  scrotum, 860.
Monorchism, 864.
Movable kidney,  769, 831.
    fixation of, 775.
Mucin, 626.
Mucous patch, 339,  342, 343,
       346, 372, 375,  459, 463,
       532.
    diagnosis, 347, 351, 375.
    ear, 410.
    local  treatment,  376, 531,
       516.
    mammary glands, 449.
    palate, 380.
    tongue, 376,  463.
    urethra, 339.
       differential  diagnosis,
         319.
Multilocular   hydrocele,  921,
  926, 930.
Mumps  complicated by  or-
  chitis, 885.
Muscles of bladder,  incoordi-
    nation of, 568.
  syphilis of,  429.
Myelosyphilis, 399, 401.
Myocarditis,  syphilitic, 431.
Myoma of bladder, 725, 738.
  of spermatic cord,  940.
  of testicle, 905.
Myositis, syphilitic,  377, 384,
  429.
Myxcedema, 865.
Myxoma of bladder,  724.
  of testicle,  905, 937.

Nasal cavities,  syphilis  of,
  411, 425.
Necrosis in gummata of  cra-
  nium,  424,  425. 
INDEX.
1053
Necrosis in gummata of verte-
    brae, 425.
  in hereditary syphilide  of
    palate and  nasal bones,'
    463.
  in syphilis of  bones,  420,
    421, 422.
  in syphilitic  rhinitis,  412,
    413, 425.
Neisser's gonococci, 186.
Neoplasms.   See Tumors.
Nephralgia, 797.
Nephrectomy,  778,  785,  788,
  789, 813, 817, 826, 834, 840,
  847, 849, 749.
Nephritis,  805,  809, 817, 849,
    615, 622, 623, 629, 886.
  gonorrhoeal, 185.
  syphilitic,  440,  479,  501,
    514, 515.
Nephrolithotomy for  calculus,
  801.
Nephrorrhaphy, 774, 775.
Nephrotomy, 801,  802,  813,
  817, 818, 834, 840, 749, 760,
Nerves, syphilis of, 402.
Neuralgia of testicles, 937.
  syphilitic,  335, 340, 391,402,
    475.
Neuralgic herpes of penis, 37.
Neurasthenia in parasyphilitic
    cephalalgia, 395.
  sexual, 1011, 1031, 173.
    and varicocele, 942, 943.
    and vesiculitis, 950.
Neuritis, optic, syphilitic, 408.
  syphilitic,  335, 340, 391, 403.
Neurotic types in constitutional
  treatment  of syphilis,  492.
Nocturnal   pollutions,  1021,
  1023, 101.
Nodules, gummatous, of mam-
  mary gland, 450.
Normal constituents of urine,
  quantitative alterations  of,
  616.
Nose, bones  of,  in hereditary
    syphilis, 470, 471.
  syphilis of, 411, 425.
Nucleo-albumen in urine, 626.
Nylander's test for sugar  in
  urine, 630.
Nymphomania, 1030, 1036.

Occlusion of preputial orifice,
  7.
Oculo-motor  nerve,  paralysis
         of,  409.
      in  hereditary syphilis,
         478.
Q3dema in gummata  of hard
    and soft  palate,  380, 381.
  in gummata of larynx, 416.
  in gummatous glossitis, 378.
  in rupture  of urethra, 74.
  of glottis in hereditary syph-
    ilis of larynx, 464.
  of larynx  in   iodism,  503,
    504.
  of penis, 23, 24,4,12,13,20,
    21, 31.
  of scrotum, 858.
Oesophagus, syphilis of, 382.
Ointment-carrier (Tommasoli)
  in chronic urethritis, 137.
Ointments, antiseptic, in chan-
    croid, 288.
  in chronic urethritis, 137.
Olfactory nerves in syphilitic
  rhinitis, 414.
Oligospermia, 1027.
Oligozoospermia, 1027.
Oliguria, 614, 815,  818.
Omental hernia and  haemato-
       cele,  933.
    and lipoma of spermatic
       cord, 939.
    and varicocele, 941, 942.
Onanism,  1030, 1031.    See
  Masturbation.
Onychia, syphilitic, 340, 369,
  462.
Oophoritis,  gonorrhoeal, 152.
Opaline  plaques in  syphilis,
  374,  375, 377.  See Scaly
  Patches.
Operating cystoscope,  717.
Ophthalmia, gonorrhoeal, 186,
  190.
Ophthalmoplegia,  syphilitic,
  409.
Opium in systematic treatment
  of syphilis, 496.
Optic  nerve, atrophy of,  in
    syphilis, 409.
  neuritis, syphilitic, 408, 465.
Orchidopexy, 871, 872.
Orchi-epididymitis, 876, 888.
Orchitis, 869,  874, 884,  888,
    891, 898, 908, 934.
  syphilitic, 443, 479, 898.
    differential diagnosis be-
       tween, and  carcinoma
       and tubercular  orchitis,
       445.
Organic impotence, 1004.
Orgasm, 1003.
Ostalgia in cerebral syphilis,
  392.
Osteochondritis in  hereditary
  syphilis, 470, 480, 481.
Osteocopic pains in syphilitic
  neuralgia, 335.
Osteoma, gummatous,  391.
  of scrotum, 863.
  of testicle, 905.
Osteomyelitis, syphilitic,  421,
       470, 473.
    of phalanges, 426, 473.
Osteoperiostitis,    syphilitic,
       420, 421, 472.
    differential diagnosis  be-
       tween specific and non-
       specific (table), 472.
Osteophytes   in   hereditary
    syphilis of joints, 474.
  in syphilis of bones,  421,
       422.
  in syphilitic synovitis, 427.
Osteosyphilosis  of  cranium,
    424.
  of vertebral foramina, 425.
Ostitis  in  syphilis of bones,
Ostitis in syphilis of cranium,
     424.
  in syphilitic rhinitis, 412.
Otis's  dilating  urethrotome,
  237.
Otitis   media  in  hereditary
  syphilis, 410, 465.
Ovaries, syphilis of, 448.
Oxalate calculi of kidney, 792,
  793, 800.
Oxaluria, 620,  798, 1011.
Ozaena, syphilitic, 463.

Pachymeningitis,  syphilitic,
     389.
  with   gummata  of   dura
     mater, 424.
Pain  in  diseases  of  urinary
     tract, 553, 613, 649.
  in neuralgia of testicle, 937.
  in renal calculus, 795, 675.
  in varicocele, 942.
  in vesical calculus, 676, 677,
     681,  727, 729.
  in vesiculitis, 948, 949.
Palate, syphilis of, 380, 463.
Palisade worm in kidneys, 851.
Palpation, bimanual,  for cal-
     culus of the bladder, 677,
     703.
  for enlarged prostate, 978.
  for foreign bodies in urethra,
     77.
  for urethral calculi,  81.
  in  chronic   anterior  ure-
     thritis, 128.
  in diseases of ureters, 749,
     750, 751, 756, 762.
  rectal,  949,  953, 954,  962,
     967, 977.
Palsies  of  external   ocular
  muscles in syphilis,  409.
Pancreas, syphilis of, 439, 479.
Papilloma in urethritis, 124.
  of bladder, 721, 722, 724.
  of penis, 38.
  of ureters, 763.
  syphilitic,  310, 346.
Papular syphilides, diagnosis,
       347, 351, 375.
     of mucous membrane, 372,
       375, 463, 532.
     of skin, 342, 344, 370, 372,
       449, 459, 480, 516, 531.
Papule, indurated, of chancre,
  309.
Papulo-squamous   syphilide,
  348, 351, 374, 375, 377, 459,
  532.
Paralysis  from osteosyphilosis
     of vertebral foramina, 425.
  in syphilis,  341,  390, 396,
     397,  403,  409,  475, 477,
    478.
  of bladder in enlarged pros-
    tate, 981.
Paralytic   impotence, 1009,
  1017, 1018.
Parametritis, syphilitic, 449.
Paraphimosis, 19.
  as complication of acute ure-
    thritis, 98. 
1054
INDEX.
Paraphimosis as complication
      of balanoposthitis, 17.
    of chancre, 17.
    of chancroid, 282.
    of gonorrhoea, 98, 164.
  treatment, 20.
Parasites in urine, 627, 637.
  of kidney, 849.
Parasyphilitic     cephalalgia,
  391, 395.
Paravesical tumors, 738.
Parenchymatous syphilitic iri-
  tis, 406.
Paresis in cerebral syphilis,
    390, 396, 397, 475.
  in syphilis of nerves, 403.
  of muscles of bladder, 568.
Paronychia, syphilitic, 370.
Parotiditis  and orchitis,   885,
  886.
Parrot's nodes  in hereditary
  syphilis  of skull, 471.
Patent urachus, 549.
Paternal heredity of syphilis,
  451, 480.
Pathogenic bacteria in urine,
  636, 638, 662.
Pederasty, 1041.
Pediculi with syphilis, 337.
Pediculosis of scrotum, 860.
Pemphigus in bullous syphi-
    lide, 460, 461, 480.
  in hereditary syphilis, 458.
  in mucous syphilide, 463.
Penis, 1.
  abscess of, 29.
  adherent, 5.
  amputation, 42, 44.
  angioma, 38.
  anomalies, 4.
  benign tumors, 37.
  calcification, 26.
  chronic   inflammation  of
    erectile tissue, 30.
  concealed, 4.
  condylomata, 33, 39.
  contusion, 24.
  cysts, 38.
  dislocation, 27.
  eczema,  28.
  elephantiasis, 38, 861.
  emphysema in contusion of,
    25.
  epithelioma, 39, 42.
  erythema, syphilitic, 372.
  fibroma, 38.
  fracture,  26, 69.
  fraenum, shortness of, 19.
  gangrene, 25, 27, 28, 29, 33,
    34, 40.
  gunshot wounds, 26.
  herpes progenitalis, 28, 32,
    33, 35.
  horny growths, 41.
  hypertrophy,  5.
    of foreskin, 33.
  inflammatory lymphangitis,
    30.
  injuries, 24.
  lymphadenitis,  33.
  lymphangioma, 38.
  lymphangitis, 30, 96.
Penis, lymphangitis, rare form
    of, 31.
  malignant tumors, 38, 42.
  oedema, 4, 12, 13,  20, 21, 23,
    24, 31.
  osseous growth, 30.
  papilloma, 38.
  paraphimosis, 19.
  penitis, 29.
  phimosis,  7.
  phlebitis,  31.
  posthitis,  32.
  priapism, 1002, 1004, 1012.
  swelling from foreign bodies
    in urethra, 77.
  syphilis, 447.
  torsion, 5.
  tumors, 37.
  varicose veins, 32.
  venereal warts, 38, 39.
  wounds, 25.
Penitis, 29.
Pentastoma  denticulatum  in
  kidneys, 851.
Peptonuria, 625,  626.
Percutaneous filtration in cir-
  cumcision, 14.
Periadenitis,  syphilitic  and
  tubercular, 434.
Periarteritis, syphilitic, 432.
Periarthritis  in   gonorrhoea,
  191.
Pericarditis, syphilitic, 431.
Perichondritis   in  syphilitic
  rhinitis, 412, 413.
Pericystitis, 660,  645, 647, 681,
  697.
Perihepatitis, syphilitic, 435,
  436, 437.
Perimetritis, gonorrhoeal, 152.
  syphilitic, 449.
Perineal cystotomy, 697.
  hypospadia, 54.
  incision in prostatitis, 964.
  litholapaxy, 689.
  lithotomy,  697,  693,  694,
    705.
  opening,   in   examination,
    681.
  prostatectomy, 987.
  prostatotomy, 987.
  urethrotomy,    238,   245,
    959.
Perinephric abscess, 812, 819,
    836.
  sanguineous effusions, 781.
Perinephritis, 818.
Perionychia, syphilitic, 340.
Periorchitis   haemorrhagica,
  932.
Periosteal nodes, local treat-
  ment of, in syphilis, 534.
Periostitis  in  syphilis,  420,
  470.
Periprostatitis, 961,  962, 864.
Peritonitis in gonorrhoeal epi-
    didymitis, 179.
  in   gonorrhoeal vesiculitis,
    176.
  symptoms, in  acute seminal
    vesiculitis, 948.
Petersen's colpeurynter, 706.
Phagedaena,  chancrous, 310,
     313, 327.
  chancroidal, 282, 292.
  penile, 25, 27, 28, 29, 33, 34,
     40.
  syphilitic,  362, 367,  378,
     382, 434, 449, 462, 504.
  traumatic, 72.
Phalanges, syphilis of, 425.
Pharynx, syphilis of, 381, 463.
Phimosis, 7.
  complications,  7,  98,  156,
       162, 281, 316.
     balanitis, 8, 32.
     balanoposthitis, 8,32.
     chancre, 164, 488.
       dift'erentiai   diagnosis
         (table), 316.
     chancroid,  17, 162,  163,
       281.
     gangrene, 29.
     gonorrhoea, 162,  163, 282.
       in children, 156.
     secondary  and   tertiary
       syphilis,  164.
     venereal warts, 39.
  recurrence, 14, 18.
  treatment, 8.
Phlebitis, 31.
  differential  diagnosis from
     gonorrhoeal lymphangitis,
     165.
  septic,  from  prostatic ab-
     scess, 958, 959, 963.
  syphilitic, 433.
Phosphatic  calculi,  672,  683,
  792, 793.
Phosphaturia, 618, 642.
  table for differential diag-
     nosis  from   acute  ure-
     thritis, 142.
Pia mater, syphilis of, 389.
Pigmentary syphilide, 358.
Piperazin  in  prophylaxis of
  vesical calculus, 682.
P16iade   ganglionnaire   in
  chancre, 329.
Pleuritis in syphilis, 340.
Pneumonia,    catarrhal,  in
  syphilis, 418.
Pneumo-pyothorax, 823.
Podalgia as symptom  of caU
  cuius, 676.
Pollutions, diurnal, 1010,1022,
     1024.
  nocturnal, 1021, 1023, 101.
Polyarticular syphilitic syn-
  ovitis, 426.
Polymorphism  in syphilitic
     rhinitis, 411.
  of secondary syphilides, 338.
Polyorchism, 864.
Polypi in urethritis,  128, 130
Polypus forceps, 730, 731.
Polyspermia, 1012.
Polyuria, 614,  809,  815, 837,
  838, 977.
Post-conceptional    syphilis,
  452.
Posterior urethritis.   See Ure-
       thritis.
     acute, 100, 120. 
INDEX.
1055
Posterior  urethritis, chronic,
  131, 141.
Posthitis, 32.
Potassium in urine,  618.
Pott's  disease, syphilitic, 425.
Pouches of urethra,  51, 54, 79,
       262.
    diagnosis  by cystoscopy,
       723.
Prepuce, 6.
  anomalies, 6.
  chancre, table for differential
    diagnosis  between  sub-
    preputial  chancre  and
    non-syphilitic  subprepu-
    tial ulceration, 316.
  mucous patch, 346.
  narrowing of orifice, 7.
  paraphimosis,  19.
  phimosis, 7.
  redundant,  in epispadia, 61.
  syphilides, gummatous, 367.
    papular, 346.
Prevesical abscess,  660, 707,
  712.
Priapism, 1002, 1004, 1012.
Primary  lesion  of  syphilis,
  304.
Prodromal  cephalalgia,  391,
  394, 398.
Profeta's  immunity, 299, 455,
  527.
Prolapse  of rectum  from cal-
    culus of bladder, 675, 677.
    from enlarged   prostate,
       977.
  of ureter, 753.
Prophylactic   treatment   of
  syphilis, 483.
Prostate, 957.
  abscess, acute, 963, 964, 961,
       962.
    chronic, 965.
    periprostatic, 964, 966.
    tubercular, 968, 969.
  atrophy, 998, 965.
  bicycle-riding, 960.
  calculi, 999.
    irritable prostate, 967.
    prostatic abscess, 963, 964.
       enlargement,  681, 690,
         694, 702, 708.
  cancer, 1000.
  contusions, 958.
  corpora amylacea, 999.
  cysts, 1001.
  enlargement, 970.  See Pros-
    tatic enlargement.
  gonorrhoeal   prostatitis, 170,
    963, 573,  697, 968.
  gout, 967.
  hemorrhage from wounds of,
    958, 960.
  hypertrophy of,  970.   See
    Prostatic  Enlargement.
  infection,  958, 960, 962, 965,
    968.
  irritable, 967.
  periprostatitis, 961, 962, 964.
  phlebitis,  septic, from pros-
    tatic  abscess,   963,  958,
    959.
Prostate, prostatectomy, 987.
  prostatic dilator, 139, 1020.
  prostatitis, 170, 960.
  prostato-cystitis, 604.
  prostatorrhoea,  1018,  1012,
    1031, 173, 626.
  prostatotomy, 986.
  rectal palpation, 977.
  tuberculosis, 967, 940, 954.
  tumors, malignant, 1000.
    prostatic     hypertrophy,
      970, 974, 975.
  vesical  diseases, 573, 603.
    pouches, 973, 976, 981.
  wounds, 958.
Prostatic   enlargement,  970,
      573, 722.
    castration,  990, 994, 995,
      906.
    catheterization, 978, 979,
      981, 984, 986.
    classification, clinical, 981.
    complications, 997.
    diagnosis, 977.
      differential, 980.
    drainage, suprapubic, 997,
      688, 709.
    etiology,  974.
    exploration, 979.
    infection  of  vesical mu-
      cosa, 982, 986.
    instruments, 978.
    ligation  of vas, 994, 995,
      997.
    massage,  985.
    median enlargement, 972,
      973, 976, 981.
    obstruction,   differential
    operation, 984.
    prostatectomy, 987.
    prostatotomy, 986.
    rectal injections, 985.
      palpation, 977.
    retention  of urine, 573,
         975, 976.
      treatment, 576.
    suprapubic drainage, 997,
         688, 709.
      puncture, 579, 543.
    treatment, 982.
      hygienic, 982.
      mechanical, 984.
      medicinal, 983.
      operative, 986.
      vasectomy, 994, 992.
    vesical pouches, 973, 976,
      981.
  gout,  967.
Prostato-cystitis, 604.
Prostatorrhoea,  1018,   1012,
  1031,  173, 626.
Prostatotomy, 986.
Prurigo with syphilis,  337.
Pruritus of scrotum, 859.
Pseudo-chancres, 300.
Pseudo-hydronephrosis, 743.
Psoriasis, syphilitic, 342, 351,
  374, 375,459, 516, 532.
Psychical impotence, 1007.
Psychopathia sexualis, 1030.
    algolagnia, 1030, 1039.
Psychopathia  sexualis, amor
       lesbicus, 1042.
     androgyny, 1042.
     effemination, 1042.
     gynandry, 1042.
     hermaphroditism, psychi-
       cal, 1041.
     heterosexual   perversion,
       1030, 1039.
     homosexuality,     1030,
       1040.
     inversion  of  sexual  feel-
       ing,  1030, 1040.
     masochism, 1039.
     masturbation, 1030, 1031.
       See Masturbation.
     nymphomania, 1030,1036.
     onanism, 1030, 1031.  See
       Masturbation.
     pederasty, 1041.
     sadism, 1039.
     satyriasis, 1030, 1036.
     sexual anaesthesia, 1030,
         1038, 1002.
       hyperaesthesia, 1030.
       paraesthesia, 1030,1039.
     urnings, 1041.
     viraginity, 1042.
Psychrophore, 1014, 1016.
Ptomaines in urine, 620.
Ptyalism in systematic treat-
   ment  of  syphilis, 495,  496,
   497, 502, 518.
Pulmonary abscess from peri-
     nephritis,  821, 823,  826,
     765.
   emboli from hypodermic in-
     jection of mercury, 510.
Pulmonitis,  gummatous,  418,
   480.
Puncture,  suprapubic,  579,
   543.
Purpura in iodism, 504.
Purulent ophthalmia in gonor-
   rhoea, 186.
Pustular syphilides,  342, 352,
   460, 480, 533.
Pyaemia in  gonorrhoeal arthri-
   tis, 191.
Pyelitis, 798, 806, 807, 825.
   and gonorrhoea, 185.
Pyelonephritis, 808, 809, 813.
   from enlarged prostate, 977.
   in exstrophy of bladder, 545,
     548.
   in vesical disease, 681,  682,
     697, 729.
Pyogenic albumosuria, 625.
Pyonephrosis,  808,  810,  817,
   825, 726, 756, 759.
Pyuria, 635, 638, 640.
   in calculus of  ureters,  755,
     757.
   in cystitis, 648, 665, 666.
   in cystoscopy, 721, 723.
   in diseases of kidneys, 809,
     810,  811,  815,  818, 825,
     837, 838.

Quantitative alterations in the
  normal constituents of urine,
  616. 
1056
INDEX.
Rarefying ostitis, 421, 471.
Reaction  of urine, alterations
  in, 616.
Rectal  injections  in  impo-
      tence, 1017.
     in prostatic enlargement,
      985.
  irrigator   in   gonorrhoeal
     prostatitis, 173.
  palpation,  949,  953,  954,
     962, 967,  977.
  prolapse,  from  calculus  of
      the bladder, 675, 677.
     from enlarged  prostate,
      977.
Rectum, gonorrhoea of, 159.
  rupture of, in  lithotomy,
     707, 711.
  syphilis of, 383.
Recurrent calculus,  690, 691,
     701.
  herpes of penis, 37.
Reflexes  of  renal   calculus,
  795.
Relapsing chancre, 296, 313.
Relative impotence, 1008.
Renal albuminuria, 622, 623.
  calculi, 792, 808,  828, 830,
     831,  755, 757, 758.
  colic,  796,  799, 800,  804,
     823,  836,  672, 675,  755,
     756, 757.
  cysts, 848.
  fistulae, 841, 761,  803, 813,
     827,  834.
  haematuria, in calculus, 796,
       797, 804, 675,  756.
     in  contusion, 780,  781,
       782, 784.
     in tuberculosis, 837,  838.
     in tumors, 845, 846, 847.
     in wounds, 787,  600.
  tuberculosis, 834,  601, 662,
     663,  796, 798, 816,  822,
     842, 847, 851.
  tumors, 842, 601,  783, 824,
     830, 851.
Residual  cysts of bladder, 738.
Respiratory tract, syphilis of,
  411.
Retention of testicle, 867.
  of urine,  563.
     catheterization,  568, 570,
         573,  577, 588, 591.
       permanent, 581, 586.
     from blocking of urethra,
       or vesical neck, 572.
     from congestion of blad-
       der, 571, 645,  655.
     from  paresis,   or  inco-
       ordination  of bladder-
       muscles, 568.
     from rupture of urethra,
       71, 96, 592.
     from stricture,  207,  564,
       567,591.
     in  calculus  of   bladder,
       681,  690.
     in   calculus  of  ureters,
       755, 758.
     in   cancer  of  prostate,
       1001.
Retention  of  urine,  incom- I
      plete, 587, 591.
    in cystitis, 644, 646, 656.
    in prostatic  enlargement,
      573,  591,   975,  976,
      174.
    in  prostatitis,  174,  962,
      963.
    suprapubic puncture, 579,
      543.
    treatment, 568, 569, 571,
      573, 576, 588, 591.
Retinitis, syphilitic, 408, 464,
  465.
Retractor in circumcision, 17.
Retzius,  space of, abscess  in
      pericystitis, 660.
    abscess in prostatitis, 963.
    hydatid cysts, 739.
    inflammation, as  compli-
      cation  of   suprapubic
      cystotomy, 708.
Rhabdomyomata  of  kidney,
  845.
Rheumatic diathesis in consti-
  tutional treatment of syph-
  ilis, 491.
Rheumatism, gonorrhoeal, 190.
Rhinitis, syphilitic, 411.
Rickets, differential diagnosis
  from   osseous   lesions   of
  hereditary syphilis  (table),
  472.
Roberts's test for sugar, 631.
Roseola  in syphilis, 337, 342,
  343, 354, 459.
Routine method  in treatment
         of syphilis, 494.
      of hereditary syphilis,
         536.
Roux's  method for differential
  diagnosis of gonorrhoea, 92.
Rubidium iodide in treatment
  of  syphilis, 526.
Rupia, •  syphilitic,  343,  357,
  363.
Rupture of bladder, 608, 592.
    from lithotrite, 68$, 696.
  of  kidney, 779, 782, 783.
  oV rectum from  colpeurynter
    in  suprapubic  lithotomy,
    707, 711.
  of  ureters, 743.
  of  urethra, 69,  96, 592, 686.
    treatment, 73.
Russian clap, 96.

Sabre-shaped  tibia  of heredi-
  tary syphilis, 471.
Sacculation of bladder in cal-
  culus, 694, 703.
Saddle-back nose in syphilis,
  413.
Sadism,  1039.
Salicylate of mercury in treat-
  ment of syphilis. 505, 513.
Salivation, 494, 495, 496, 501,
  502, 514.
Salpingitis, gonorrhoeal, 152.
Sanguineous  effusions,  peri-
  nephric, 781.
Sarcocele, syphilitic, 443.
Sarcocele, syphilitic,  differen-
  tial diagnosis  from carcino-
  matous and  tubercular  or-
  chitis (table), 445.
Sarcoma   and   gummatous
    syphilides, differential di-
    agnosis,  368.
  of bladder, 723, 725.
  of kidney, 844.
  of spermatic cord, 940.
  of testicle, 869, 870, 903.
  of ureters, 762.
Satyriasis, 1030, 1036.
Scaly patches in syphilis, 348,
  351, 374, 375, 377, 459, 532.
Scarlatinal orchitis, 888.
Schleich's  method  of  percu-
  taneous filtration in circum-
  cision, 14.
Sciatica, syphilitic, 402.
Scleritis, syphilitic, 405.
Sclerosis, syphilitic, of brain,
       387, 389.
    of spinal cord, 399, 477.
Sclerous endarteritis,  syphi-
    litic, 432.
  glossitis, syphilitic, 377.
Scrotum, 852.
  cancer, 863.
  contusions, 857.
  eczema, 859.
  elephantiasis, 861, 887.
  eruptions,  858.
  fatty tumors, 863.
  fibromata,  863.
  gangrene,  860, 858.
  haematoma and haematocele,
    931.
  molluscum    contagiosum,
    860.
  oedema, 858.
  pediculosis, 860.
  pruritus, 859.
  sebaceous  cysts, 860.
  steatomata, 860.
  syphilis, 863.
  tumors, 863.
  wounds, 857.
Sediments in urine, 633.   See
  Urine.
Self-retaining catheter in re-
  tention of  urine, 582.
Semen, 1003, 1028.
Seminal emissions,  1021.
  incontinence, 1022, 1024.
  transmission  of   syphilis,
    451.
  vesicles, 945, 174.
    anatomy, 856,  945.
    anomalies, 947.
    concretions,  spermatocya-
       tic, 954.
    cystic swelling, 953.
    ejaculatory ducts, obstruc-
       tions  of,  950,  951, 953,
       954, 961,1027, 1028.
    injuries, 948.
    rectal palpation, 949, 953,
       954.
    spermatocystitis, 948.
    tumors,  malignant, 956.
    wounds, 948. 
INDEX.
1057
Seminal vesiculitis, 948.
    abscess from, 950.
    acute, 948.
    chronic, 950.
    epididymitis  and,  950,
       951, 954.
    gonorrhoeal, 174, 948, 955.
    pain  in, 948, 949.
    peritonitis and, 948.
    prostatitis and, 949, 961.
    syphilitic, 447.
    tubercular, 954, 969.
       excision  in, 955.
Serous cyclitis in syphilis, 406,
    407.
   iritis in syphilis, 406, 407.
Serpiginous   pustular  syphi-
    lide,  358, 359.
   tubercular  syphilide,  362,
    462.
Serum-albumen, 622, 628.
Serum  treatment of  syphilis,
   526.
Sexual anaesthesia, 1030, 1038.
   hyperaesthesia, 1030.
   neurasthenia,  1011, 1031.
     and  gonorrhoeal  prosta-
       titis, 173.
     and varicocele, 942, 943.
     and vesiculitis, 950.
   paraesthesia, 1030, 1039.
   weakness, 1002.
 " Silvery  spot"  in  syphilis,
   308.
 Siphon  drainage in   supra-
   pubic lithotomy, 709.
 Skin,  syphilitic eruptions of,
   336, 341, 449, 458, 462, 480,
   531.  jS"ee Constitutional, and
   Hereditary Syphilis.
 Skull  in  hereditary  syphilis,
   470, 471.
 Smegma, 888.
   bacilli  in urine,  638,  837,
     838.
Snuffles of hereditary syphilis,
   463.
Sodium in urine, 618.
Solitary kidney, 767,  769.
Sore throat, syphilitic, 372.
Sounds in treatment  of stric-
   ture, 220, 223, 230.
Space of Retzius,  abscess  in
         pericystitis, 660.
       in prostatitis, 963.
     hydatid cysts,  739.
     inflammation,  as   com-
       plication of suprapubic
       cystotomy, 708.
Spasm of urethra, 48, 211.
Specific  gravity  of  urine,
   615.
Spermatic cord, 938.
    anatomy,  856.
    anomalies,  938, 863.
    carcinoma, 940.
    contusions, 938.
    funiculitis, 938.
       gonorrhoea],  939,  178,
         180.
    gangrene, 938, 945.
    haematocele, 635.
Spermatic   cord,  hydrocele,
         911,  929,  939.
      funicular, 930.
    inflammation, 938.
    lipoma, 939.
    myoma, 940.
    sarcoma, 940.
    syphilis of vasa deferen-
      tia,  447.
    torsion, 876.
    tuberculosis, 939, 940.
    tumors, 939.
    varicocele,  940, 937.
      excision in, 944.
      ligation,  subcutaneous,
         in, 943.
      pain in,  942.
    vasectomy, 992, 994.
    veins of spermatic plexus,
       940, 941.
    wounds, 938.
Spermatocystio    concretions,
   954.
Spermatocystitis,   948.    See
    Seminal Aresiculitis.
   gonorrhoeal, 174, 948, 955.
   syphilitic, 447.
   tubercular,  954, 969.
Spermatorrhoea, 1022,  1012,
   1018,  1019, 1024, 1031.
Spermatozoa in urine, 640.
Spina bifida with exstrophy of
   the bladder, 545.
Spinal  cord,  syphilis of, 399,
   477.
Spiroptera hominis in kidney,
   851.
Spleen,  syphilis of, 439, 478,
   480.
Split clitoris, with exstrophy
   of  the bladder, 544.
Steatomata of scrotum,  860.
Steel sounds  in treatment of
   stricture, 220.
Sterility, 1026.
   from anorchism,  864.
   from  gonorrhoea, 179, 1028.
   from hydrocele, 910.
   from injury of seminal ves-
    icles,  948, 954.
   from operation for calculus,
    692, 704.
   from  tuberculosis, 954.
Sterilization of  instruments  in
       treatment of  stricture,
       220, 267.
    in  treatment of retention
       of urine, 589.
Stomach, syphilis of, 383.
Stomatitis  from  hypodermic
   injection of mercury,  512.
Stone of  bladder,  672.  See
    Calculus of Bladder.
   of  kidneys,  792, 808, 828,
    830, 831,  755, 757, 758.
   of  ureters,  755,  748, 751,
    760.
   of  urethra,  79.
Stone-searchers,   678,   679,
   979.
Stream  in urination, alteration
   of,  562.
             67
Stricture,  changes  in   the
      urethra, 203.
    essential lesion, 204.
  classification, 193.
  diagnosis, 210, 980.
  extravasation of urine, 213.
  female urethra, 249, 148.
  gleet, 200, 208.
  interference   with  coition,
    208, 1027.
  location, 201.
  of ejaculatory ducts, 950.
  of  ureters,  750,  751,  760,
    743, 744, 747,  749.
  of urethra, 193.
    care of instruments, 220,
       267, 588.
  organic, 195, 250.
  prognosis, 217.
  symptoms, 206.
  traumatic, 197, 202.
  treatment, 219.
    cleansing urethra, 221.
    dilatation,     continuous,
         232.
       gradual, 219.
    divulsion,  247.
    electrolysis, 247.
    excision, 246.
    meatotomy, 234, 129.
    over-distention  of   the
       urethra, 247.
    summary of 248.
    urethrotomy,   232.    See
       Urethrotomy.
  urethrotomes, 235, 236, 237.
Strictures  of  small  calibre,
  229.
Strongylus  gigas  in  kidney,
  851.
" Stuttering  urination,"  563,
  1012.
Sublimate  instillations in tu-
  bercular cystitis, 658, 667.
Succinimide of  mercury  in
  treatment  of syphilis,  505,
  511.
Suction  apparatus  in  impo-
  tence, 1005.
Sugar in urine, 629.
       tests for, 630, 631.
Sulphur in urine, 617.
Superficial cystitis, 647.
Suppositories in chronic ureth-
    ritis, 138.
  in vaginitis,  155.
Suppression of urine in gonor-
    rhoeal ureteritis and  ne-
    phritis, 185.
  in renal calculus, 797.
  in ureteral stricture, 750.
  in vesical diseases, 563, 682,
    696, 737.
Suprapubic  auscultation,  679,
    688.
  cystotomy (lithotomy),  706,
    683, 688,  692, 693,  694,
    695, 702, 730.
  drainage,  709, 997.
  prostatectomy, 988, 993.
  puncture  in  retention  of
    urine, 579, 543. 
1058
INDEX.
Suprarenal capsules,  851.
  tumors, 844, 846.
Surgical  kidney,  809,  814,
  217.
Suspensory  bandages in  gon-
  orrhoeal epididymitis, 180.
Suture  (Czerny-Lembert)  in
  closing wounds of bladder,
  612.
Syme's  operation in  urethrot-
  omy,  238.
Symptomatology  of  diseases
  of the urinary tract,  553.
Synechiae in syphilis of eye,
  406, 407.
Synorchism, 863, 866.
Synovitis,  syphilitic,   426,
  427.
Syphilides  of  mucous  mem-
    brane,   339,   371,  463,
    532.
  of skin, 336, 341,  449, 458,
    462, 480, 531.  See Consti-
    tutional, and  Hereditary
    syphilis.
Syphilis,  298,  304, 332, 451,
    457, 483.
  chancre, 304.  See Chancre.
    treatment, 486, 529.
  conceptional, 454.
  constitutional,  332.    See
    Constitutional syphilis.
  contagion, 300.
  etiology, 298.
  hereditary, 457.  See Hered-
    itary syphilis.
  heredity,  451.
  immunity, 299.
  impotence, 1006.
  incubation,   primary,  304,
      311, 312.
    secondary, 331.
  infection, 453.
  insontium, 306.
  lymphatic involvement, 328,
    333, 474.
  periods, 303,  298.
    intermediate, 303.
  primary lesion, 304.
  pseudo-chancres, 300.
  reinfection, 299.
  symptoms, secondary, 332.
    tertiary, 303.
  syphilophobia,   491,  492,
    517.
  tertiary,  332.   See  Consti-
    tutional syphilis.
  treatment, 483.
  types, 302.
Syphilitic heredity, 451.
  tooth, 466.
Syphilophobia, 491, 492, 517.
Systematic treatment of syph-
  ilis, 494.

Tabes  dorsalis and  syphilis,
  401, 477.
Tampon  for  hemorrhage  in
  prostatectomy, 989.
Tannate of mercury  in treat-
  ment of syphilis,  505, 511,
  513.
Tapping in  treatment of hy-
  drocele, 916, 928, 930.
Tarsitis, syphilitic, 404.
Teeth, hereditary syphilis of,
    466.
  in  constitutional treatment
    of   syphilis,   492,  496,
    501.
Teevan's urethrotome, 235.
Tendinous sheaths, syphilis of,
  341.
Tenesmus  in  gonorrhoea  of
    rectum, 159.
  in stricture, 207.
  in urethritis,  96, 101, 121,
    132.
Tenosynovitis,    gonorrhoeal,
    191.
  syphilitic,  430.
Teratomata of testicle, 904.
Tertiary syphilis, 332.
Testicles, 863, 852,  938.
  abdominal  retention, 867,
    870.
  abscess, 889, 894.
  anomalies,  863.
  anorchism, 864, 1006, 1028.
  atrophy, 866,  877, 879,  882,
    885, 886, 888, 897,  898,
    915, 933, 935, 938, 942,
    943, 945.
  azoospermia, 1027.
  blood-cysts and neuralgia of
    testicles, 937.
  cancer, 899, 445,  869, 870.
  castration,  906,  874, 896,
    902, 934, 935, 994, 998.
  contusion,  878.
  cruro-scrotal retention, 867,
    873.
  cryptorchism, 867,  1006.
  cystoma, 903.
  dermoid cysts, 904.
  ectopy, 866, 867,  871, 873.
  enchondroma, 903.
  epididymitis,  883, 887, 891,
    895, 908.   /See Epididy-
    mitis.
  epididymo-orchitis, 883,884.
  fibroma, 904, 937.
  fistulae, in tuberculosis, 893,
    894.
  fungus, 890, 444, 447, 898,
    900.
  gangrene, 869, 877, 888, 889,
    890, 938, 945.
  gonorrhoeal   epididymitis,
    176, 443, 444, 880, 883,
    884, 895, 909, 941, 1028.
  gouty, 887.
  gunshot wounds,  882.
  haematocele, 931, 869, 878,
    900,901,915. See Haema-
    tocele.
  hernia and neuralgia, 937.
  hydrocele,  908,  179,  858,
    869, 875, 883, 885, 893,
    895, 897, 900, 902.  See
    Hydrocele.
  hypertrophy,  863, 866.
  inflammation, 883, 869, 874.
  influenza orchitis, 888.
Testicles,  inguinal retention.
    867, 869, 871.
  inversion, 875.
  irritable, 937.
  loose bodies in tunica vagi-
    nalis, 936.
  luxation, 876.
  lymphadenoma, 904.
  malarial orchitis, 887.
  malignant    degeneration,
    899,  869,  445, 857,  870,
    875, 889, 890.
  migration, anomalies of, 866.
  misplaced, 866, 868.
    complications of, 868, 874.
    inflammation of, 869,  874.
  monorchism,  864.
  mumps orchitis, 885.
  myoma, 905,  937.
  myxoma, 905.
  neuralgia, 937.
  orchidopexy, 871, 872.
  orchi-epididymitis, 876, 888.
  orchitis, 869, 874, 884,  888,
    891, 898, 908, 934.
  osteoma, 905.
  polyorchism,  864.
  retention, 867.
  sarcoma, 903, 869, 870.
  scarlatina orchitis, 888.
  small-pox orchitis, 888.
  synorchism, 863, 866.
  syphilis, 341,  442, 479,  889,
    890, 898.
  teratomata, 904.
  tonsillitis and orchitis, 887.
  torsion, 876.
    of undescended, 875.
  traumatic orchitis, 878,  888,
    901, 852.
  tuberculosis,  891, 445,  479,
    881, 889, 890, 937, 940.
  tumors, 899,  869, 445,  889,
    915, 928, 934, 935, 939.
  tunica vaginalis testis, loose
    bodies in, 936.
  typhoid orchitis, 887.
  urethral epididymitis, 883.
  varicocele and neuralgia of,
    937.
  wounds, 882.
Test of  the two beakers in
  chronic urethritis, 141.
Tests for albumen, 624,  634.
  for sugar, 629, 620.
Thermal springs in treatment
  of syphilis, 517.
Thiersch's method in  epispa-
    dia, 62.
  solution in cystitis, 654.
Thompson's forceps for tumors
  of bladder, 730, 731.
  stone-searcher, 678, 679.
Throat,  erythematous  syphi-
  lide of,  372.
Thrombosis, syphilitic, 433.
  hypodermic   injection   of
    mercury, 522.
Tibia,  syphilis  of, 425,  470,
  471, 472.
Tinea  circinata  and   syphi-
  lides,  351. 
INDEX.
1059
Tissue in urine, 637.
Tolerance of iodides in treat-
  ment of syphilis, 500, 525.
Tommasoli  on  serum  treat-
    ment of syphilis, 528.
  ointment-carrier, 137.
Tongue,  syphilis of,  323, 372,
  376, 463.
Tonsiilitis and orchitis, 887.
Tonsils,   syphilis   of,  324,
  382.
Torsion of penis, 5.
  of spermatic cord,  876.
  of testicle, 875, 876.
Toxic effects of iodine in treat-
       ment of  syphilis, 500,
       503,  525.
    of mercury  in  treatment
       of syphilis, 500, 519.
Toxins in urine, 620.
Translucency in diagnosis of
  hydrocele,  909,  914,  928,
  930.
Traumatic  orchitis,  878, 888,
  901, 852.
Traumatism of bladder in  re-
  tention of urine, 592.
Treatment of  syphilis, 483.
    abortive,  486.
    constitutional, 491.
       continuous, 493.
       elimination   of   mer-
         cury,  523,  502, 503,
         519.
       interrupted, 493.
      modified    expectant,
         493.
    heat, 521.
    hereditary syphilis, 534.
    hydrargyrism,  500,  502,
         519.
      acute, 496, 501, 519.
      chronic, 501.
    iodides, 498, 523, 537.
    iodism, 503, 504, 525.
    local, 529.
      chancre, 529.
      condylomata, 533.
      gummata, 534.
      mucous patch, 532.
      periosteal nodes, 534.
      pustular  and  pustulo-
         squamous syphilides,
         533.
      syphilides, 531.
      tubercular  syphilides,
         534.
    mercuric baths, 516.
    mercury, methods of giv-
         ing,  504,  536,  489,
         493, 494.
      baths, 516.
      hypodermic      injec-
        tions, 509, 537,  488,
        498.
      intravenous  injection,
        522.
      inunction,   506,   536,
        497.
      mouth  administration,
        504, 537, 494.
      vaporization, 515.
 Treatment of syphilis, mixed,
       498.
     prophylactic, 483.
     serum, 526.
     syphilides, 531.
     systematic, 494.
 Tubercle-bacilli  in diseases of
       bladder, 636,  638, 646,
       662.
     in diseases of kidney, 835,
       837, 838,  851.
     in diseases of testicle, 891,
       895.
     in pyuria, 636, 638.
 Tubercle of brain  and  gum-
   mata, 387.
 Tubercular adenitis,  differen-
     tial diagnosis from syphi-
     litic adenitis, 434.
   bacillus, 636, 638, 646, 662.
   cystitis, 721, 646, 658, 662.
   epididymitis,  891, 881, 889,
       940, 954,  969.
     differential diagnosis from
       syphilitic epididymitis,
       443, 479.
   epididymo-orchitis,     892,
     893, 895, 898.
   fungus,  differential diagno-
     sis from syphilitic fungus,
     447.
   funiculitis, 939, 940.
   glossitis and syphilitic glos-
     sitis, 378.
   laryngitis, differential diag-
     nosis  from  syphilitic  la-
     ryngitis (table), 416, 417.
   meningitis, differential diag-
     nosis from hereditary cer-
     ebral syphilis, 476.
   nephritis, 834, 796, 798, 816,
     822, 842,  847, 851,  601,
     662, 663.
   orchitis, 891.
     differential diagnosis from
     syphilitic   orchitis,  and
     carcinoma  of    testicle
     (table), 445.
   ostitis, differential  diagno-
     sis from syphilitic  ostitis
     (table), 423, 424.
   prostatitis, 967, 940, 954.
   spermatocystitis, 954, 969.
   synovitis, differential diag-
     nosis from  syphilitic syno-
     vitis, 428.
   syphilide, 359, 461.
   ureteritis, 762, 748,  761.
   urethritis, 264.
Tumors and gummatous syph-
     ilide, 368,  379.
   in  hereditary  syphilis  of
     skull, 471.
  of bladder, 723.
   of kidney,  842, 601,  783,
      824, 830, 851.
  of penis, 37.  .
  of prostate, 1000.
    in prostatic enlargement,
      970, 974, 975.
  of scrotum, 863.
  of seminal vesicles, 956.    |
 Tumors of spermatic cord,939.
   of  testicles, 899,  445,  869,
      889,  915, 928,  934,  935,
      939.
   of ureters, 762.
 Tunica vaginalis testis, haema-
          tocele, 931, 932.
        hydrocele, 910,  911.
        loose bodies in,  936.
 Tunnelled  catheter in  stric-
   ture, 220.
 Typhoid orchitis, 887.
 Tyrosin in acid urine,  641.

 Ulcerating syphilide in heredi-
   tary  syphilis,  differential
   diagnosis from lupus, 462.
 Ultzmann's injection in acute
   gonorrhoea, 114.
 Unilateral castration  for en-
   larged prostate, 996.
 Urachus, patent, 549.
 Uraemia  in  gonorrhoeal pyeli-
        tis, 186.
     pyelonephritis, 815.
 Urates, 640, 642, 675.
   in calculi, 672, 792.
 Ureteral  catheterization,  750,
     751,  756,  760,  761,  762,
     802, 804, 816, 833, 839.
   colic, 796.
 Ureteritis, 748.
   gonorrhoeal, 185, 748.
 Ureteroplasty, 746, 747.
 Ureterotomy, 750, 754.
 Ureters, 740.
   anastomosis, 734,  744,  745,
     747, 762, 788.
   anomalies, 742.
   atrophy, 749.
   calculus, 755, 748, 751,  760.
   catheterization,  750,   751,
     756, 760,  761,  762,  802,
     804, 816, 833, 839.
   colic, 796.
   division, 734, 743.
   drainage, 747, 760.
   fistula, 760, 761, 748.
   haematuria, 743,  751,  756,
     758.
   multiple, 742.
   palpation,  749, 750,   751,
     756, 762.
   prolapse, 763.
   pyuria, 757.
   retention of urine, 755,  758.
   rupture, 743.
   stricture, 750, 751, 760,  743,
     744, 747, 749.
   syphilis, 442.
   transplantation,  in  exstro-
     phy,  548.
   tuberculosis, 762, 748, 751.
   tumors, 762.
   ureteritis, 748.
   ureteroplasty, 746, 747.
   ureterotomy, 750, 754.
   valve  formation,  operation
     for, 742.
   wounds, 743.
Urethra, 46.
   anatomy, 46, 208. 
1060
INDEX.
Urethra, appearance,  by ure-
    throscopy, 85.
  atresia, 49.
  blocking, sudden, 572.
  calculi, 79.
  cancer, 265.
  catarrh,  126.
  chancre,  concealed,   318,
    319.
  diverticula, 51, 54, 262.
  epispadia, 59.
  fever,  251.
  fistula, 256, 1027.
  foreign bodies, 76.
  gangrene in rupture of, 72.
  hemorrhage  in  rupture  of,
    71, 72.
  hypospadia,  51,  857,  1005,
    1027.
  inflammations of,  93.   See
    Urethritis.
  instillations, 134.
 ' instruments,  care of,  220,
    267, 588, 654, 666.
  irrigation in acute  gonor-
       rhoea, 116.
    in acute posterior urethri-
       tis,  122.
    in chronic prostatitis, 966.
    in chronic urethritis, 131,
       133.
  malformations, 49.
  meatotomy, 50, 81,129, 234.
  obstruction, 49.
  pouches, 51, 54, 262.
    with calculi, 79.
  rupture, 69, 96, 592.
  spasm of compressor urethrae
    muscle, 48, 211.
  strictures,  50,   193.    See
       Stricture of urethra.
    of  female  urethra,  148,
       249.
  syphilides,    erythematous,
    372.
  syphilis, 447.
  tuberculosis, 264.
  urethritis, 79, 87, 93, 97,  99,
       100, 103, 120, 122.
    chronic, 97, 123.
    in women,  146.
  urethroscopy, 82.
  urethrotomes, 235.
  urethrotomy, 50, 68, 82.
    in stricture, 232, 216, 229.
  valvular folds, 50.
  vegetations, 263.
  wounds, 68.
Urethral catarrh, 126.
  epididymitis, 883.
  fever, 252, 696, 705, 737.
  insufficiency (Guyon), 598.
  irrigations.  See Urethra.
  prostatotomy, 986.
  syringe, 111.
Urethritis,  89.   See Gonor-
    rhoea.
  acute, 93, 97, 100, 103.
    anterior, 93, 97, 103.
       symptoms, 94, 96, 97.
       treatment,    103,  117,
         122.
Urethritis,  acute,   complica-
      tions, 98, 103, 161.
    differential      diagnosis
      (Finger), 142.
    in women, 146.
    posterior, 100,  120.
    prognosis, 97, 103.
    treatment,  resumi,  115,
      122.
  catarrhal, or subacute, 98.
  chronic, 123, 141.
    anterior,  127.
      treatment, 129, 139.
    in women, 146.
    posterior, 131,  141, 960.
      diagnosis, 132.
      treatment,   133,   139,
           657,  667,  1015,
           1020.
         summary, 139.
    urorrhoea, 126.
  classification, 93.
  complications, 161.
  flushings, 106, 116, 121, 122.
  in children, 156.
  injections,  104,   109,  111,
    115, 122.
  instillations in chronic pos-
    terior urethritis, 134, 657,
    1015, 1020.
  internal  medication,  109,
    115.
  irrigation  in acute gonor-
      rhoea, 116, 120, 122.
    in  acute posterior  ure-
      thritis, 122,  658, 1015.
    in chronic urethritis, 131,
      133.
  non-specific, 99.
  ointments, 137.
  stricture, 193.  See Stricture
      of  Urethra.
    of female urethra, 249.
  suppositories, 138.
  symptoms,  acute, 94, 100.
    chronic, 127, 131.
  treatment, acute, 122.
    chronic, 139.
Urethro-cystitis, 142.
Urethro-penile fistula, 261.
Urethro-perineal fistula, 966.
Urethro-perineo-scrotal fistula,
  259.
Urethro-rectal fistula, 256, 966.
Urethro-vulvo-vaginitis, 157.
Urethroscopy, 82.
  appearance of urethra, 85.
Urethrotomes, 235, 236, 237.
Urethrotomy, 232,  216, 229.
  combined internal  and ex-
    ternal, 241.
  external perineal, 238.
       Cock's  operation, 244.
      drainage, 245.
      general indications for,
         240.
      retrograde  catheteriza-
         tion, 245.
      section, without guide,
         242.
       Syme's operation, with
         guide, 238.
Urethrotomy,  external  peri ■
    neal, AVheelhouse's opera-
    tion, 242.
  internal, 233.
    from  before   backward
      operation, 235.
    from behind forward oper-
      ation, 236.
    indications for  the oper-
      ation, 234.
    urethrotomes, 235.
  in treatment of wounds  of
    prostate, 959.
Uric  acid   calculi,  672, 682,
      695, 792, 793.
    in  alteration of  normal
      constituents  of  urine,
      619, 641.
Urinals in exstrophy, 546.
Urinary fever,  252, 696, 705,
  737.
Urination, alteration of stream,
    562.
  frequency of, 559, 649.  Sec
    Frequency of urination.
  in  prostatic  enlargement,
    972, 973, 975.
Urine, 614.
  abnormal  condition  of,  in
      cystitis,  645.
    substances in, 621,  645.
  acetonuria, 621.
  acid urine, crystalline sedi-
    ment, 640.
  albumen,  tests   for,  624,
    634.
  albuminuria, 622, 628, 634,
    636.
  albumosuria, 625.
  alkaline sediment, 642, 616.
  alterations in color, 615.
    in quantity, 614.
    in reaction, 616.
    in specific gravity, 615.
    quantitative, of   normal
      constituents,  616.
  anuria, 615,  755,  803.
  bacteria, 636, 638, 640, 646,
    648, 662, 566.
  blood   in  sediment,  633,
    640.
  casts  in sediment, 639.
  choluria,  631.
  chyluria, 633.
  color,  615.
  crystalline sediment, 640.
  cystinuria, 632, 642.
  enuresis, 592.
  examination of, 614.
  extravasation.    *S"ee  Ex-
    travasation.
  epithelium in sediment, 637,
    639.
  Fehling's test for sugar, 630,
    631, 620.
  fibrinuria, 626.
  frequency of urination.  See
    Frequency of urination.
  Gabbett's  staining   method
    for tubercle bacillus, 636.
  globulin,  625, 640.
  glycosuria, 629. 
INDEX.
1061
Urine, Guyon's table  for  in-
    continence, 593.
  haematoporphyrinuria, 621.
  haematuria,  627,  633, 637.
    See Haematuria.
  haemoglobinuria, 628.
  hyaline casts, 639.
  lipuria, 632.
  normal constituents,  quan-
    titative alterations, 616.
  Nylander's  test for  sugar,
    630.
  oliguria, 614.
  oxaluria, 620.
  parasites, 637.
  peptonuria,  625, 626.
  phosphaturia, 618, 642.
  polyuria, 614.
  pus as sediment,  635, 637,
    638, 640.
  pyuria,  616, 635,  637, 638,
    640.   See Pyuria.
  quantity,  614.
  reaction, 616.
  Roberts's  test  for  sugar,
     631.
  sediments in, 633.
    bacteria, 638, 640, 662.
     blood, 633, 640,  616.
     epithelium, 637, 639.
     parasites, 637.
     pus,  616, 635,  636, 638,
       640.
     spermatozoa, 640.
     tissue, 637.
   specific gravity, 615.
   sugar, tests for, 629, 620.
   tests for  albumen in,  624,
       634.
     for sugar, 629, 620.
   tubercle bacilli in pus, 636,
     638.
   urates, 640, 642, 672.
   urea,  619.
   uric acid, 619,  641.
 Urnings, 1041.
 Urobilin in urine, 616,  621.
 Uro-genital   system,  syphilis
  of, 440.
 Urorrhoea, 126.
 Urticaria with syphilis, 337.
 Uterus, syphilis of, 449.
Vaccination chancre, 327.
Vagina, syphilis of, 448.
A'aginalitis, haemorrhagic,932.
Vaginismus   in   impotence,
  1025.
Vaginitis, 372.
  gonorrhoeal, 153.
  urethro-vulvo-,  in  children,
     157.
Valve formation, operation for,
  in  obstruction   of  ureter,
  742.
Aralvular folds of urethra, 50.
Vaporization  of  mercury in
  treatment of syphilis, 515.
Varicella and vesicular syphi-
  lide, 352.
Varicocele,  940, 937.
Varicose veins of  penis, 32.
Variola, diagnosis from pustu-
  lar syphilide, 354.
Varioloid and vesicular syphi-
  lide, 352.
Vasa deferentia, 855.
     anomalies, 938, 863.
     syphilis,  447.
Vasectomy, 992, 994.
A'egetating papules in syphilis,
  347, 373.
A'egetations, urethral, 263.
Veins of   spermatic  plexus,
     940, 941.
  syphilis of, 433.
Venereal warts, 38, 124.
" Verole nerveuse," 399.
Verrucae of penis, 38.
     with chancre, 310.
     with  chronic  urethritis,
       124.
Vertebrae, syphilis of, 425.
Vesical.  See Bladder.
   calculus, 672.   See Calculus
     of bladder.
   fistula, 669, 706, 712, 761.
   haematuria, 598.  See Haem-
     aturia.
   neck, sudden  blocking of,
     572,  676.
   pouches, with  prostatic en-
     largement, 973, 976, 981.
   tumors, 723.  See Tumors of
     bladder.
THE  END.
Vesicular syphilide, 351, 460.
Vesiculitis.  See  Seminal ves-
    icles.
  acute,  948.
  chronic, 950.
  gonorrhoeal, 174, 948, 955.
  tubercular, 954, 969.
Viraginity, 1042.
Viscera,   syphilitic  involve-
  ment of, 340, 382, 478.
Von Dittel's incision for  ex-
  cision of rectum, 954, 955.
Vulva, syphilis of, 448.
Vulvitis, gonorrhoeal, 149.
Vulvo-vaginitis,     catarrhal,
      157.
    gonorrhoeal, 157, 158.


AVeiss's lithotrite, 684.
Wheelhouse's   operation   in
  perineal section  for  stric-
  ture, 242.
Whip-snap action as cause of
  epididymo-orchitis, 881.
White pneumonia in heredi-
  tary syphilis, 478.
White's   capsules  for   acute
    gonorrhoea, 110.
  operation for hypertrophied
    prostate, 990.
Wood's   operation   for   ex-
  strophy, 546, 549.
Wounds  of bladder, 604.
  of kidney, 786, 805.
  of penis, 25.
  of prostate, 958.
  of scrotum, 857.
  of seminal vesicles, 948.
  of spermatic cord, 938.
  of testicle, 882.
  of ureters, 743.
  of urethra,  68.
Xanthin bases  in  acid  urine,
    642.
  in urine, 620, 642.
    calculus, 673,  792, 793.


Zittmann's decoction in treat-
  ment of syphilis, 506.
Printed by J. B. Lippincott Company, Phi 
 
 
 
 
-%•,  Aavaan ivnouvn     3NOta3w jo Aavaan ivnouvn
                                   o
                                   Q.
NATIONAL LIBRARY OF MEDICINE
3nidio3w jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE
jNOiaaw jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE
3NOI03W jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE
3NOia3w jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY  OF MEDICINE
SNiDiasw jo  Aavaan tvnouvn     snioichw jo Aavaan tvnouvn
            5   Xx<8£^  Q  ^tfeSfcTxX   ^
            o.     >" /3 y1   ui   ^T J3< ^    9-

NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NiDia3w jo Aavaan tvnouvn     3nidio3w jo Aavaan tvnouvn
NATIONAL LIBRARY  OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NOIQ3W jo Aavaan tvnouvn     bnoiosw jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NOia3w jo Aavaan tvnouvn     snidiqsw jo Aavaan  tvnouvn
NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY  OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NOIQ3W jo Aavaan tvnouvn    3noio3w jo Aavaan tvnouvn     snoiqsw jo Aavaan tvnouvn 
NATIONAL LIBRARY OF MEDICINE 
		Z&aU£-	
			
			
			
			J ^ttK*-TcS
			jfijfir: 'vip
j,-V>- ■> 'A
  ZjUWA

WJ 100 W585g
40311080R
NLH  D5ED1E35  h
NATIONAL LIBRARY OF MEDICINE
!wi»BVW**«
5a
$
or.*.*;


NLM052012356