PERSISTENT URETHRAL DIS- CHARGES DEPENDENT ON SUB-ACUTE OR CHRONIC SEMINAL VESICULITIS. BY EUGENE FULLER, M. D. New York. REPRINTED FROM THE JOURNAL OF CUTANEOUS AND GENITO-U RINARY DISEASES A FOR JUNE 1884. PERSISTENT URETHRAL DISCHARGES DEPENDENT ON SUB- ACUTE OR CHRONIC SEMINAL VESICULITIS.1 EUGENE FULLER, M.D., New York. FORMERLY oftener than at present it was customary in medical literature to find mention made of a class of urethral discharge which were so rebellious under all known and approved forms of treatment that the most effica- cious plan seemed to be to leave them alone to recover as best they could. Many such cases would finally get well of them- selves, but in the great majority of these instances the person afflicted would be positive that something or other which he had done generally in desperation had cured him. In a respectable percentage of these individuals the extra- ordinary alleged curative agency would be sexual or alcoholic excess or, and as very frequently happened, a combination of the two. Since the introduction of deep urethral instillations and of the electrical illumination of the urethra through the endoscope, permitting topical applications to be made, cases of so-called incurable urethral discharges have wonderfully dimin- ished ; but still a goodly number exist, as evidenced by the many chronic cases one sees, which have been the professional rounds without relief. I flatter myself that I have been able to cure, at least appar- ently, and as thoroughly as one can ever claim to cure a chronic urethral discharge, a certain number of these cases which at i Thesis presented for membership to the American Association of Genito-Urinary Surgeons at the May, 1894, Meeting, held in Washington. 2 Original Communication. my own and at the hands of others had resisted all the usual forms of treatment. In treating a number of them I was aided by the valuable advice and co-operation of Dr. Keyes, and it was from him originally that I obtained the ideas which I have endeavored to develop. A consideration and classification of these cases, their histories more or less minute according to the points of interest presented, together with some comments, are the ob- jects of this paper. During my earlier investigations with reference to vesicu- litis, usually undertaken in the cases of individuals who pre- sented symptoms indicating a disturbance of the sexual function (see article on Seminal Vesiculitis in the September, 1893, num- ber of The Journ. of Cutan. and Gen. Urin. Dis.) I was impressed with the fact that in a certain percentage there co-existed a urethral discharge oftentimes somewhat intermit- ent in character, generally scanty in amount, although occa- sionally profuse. Inquiry disclosed the fact that a number of these individuals had already sought treatment for these dis- charges almost invariably without success. As the vesicles in these cases presented the chief focus of disturbance all treatment was directed toward them, little or no attention being paid at the time to the discharge. As, how- ever, the vesicles got better it was observed that the discharge oftentimes also disappeared. These facts, together with the instances already alluded to, a number of which had come under my personal observation, where patients tiring of a tedi- ous and apparently futile treatment for a chronic discharge, had broken the rules laid down by their medical advisers, and indulged freely in sexual intercourse, resulting in the cure of their complaint, led me to investigate the condition of the semi- nal vesicles in all cases where a discharge had proved itself rebellious to the ordinary modes of treatment, even though there were apparently no co-existing sexual derangements. Within the last two years, during which time I have been actively investigating this subject, I have seen quite a number of cases which apparently were of the class under considera- tion, but in this article it has seemed best to notice only such of them as remained under my personal supervision for a con- siderable interval, and concerning the final outcome of which I am well acquainted, all transient cases and those simply seek- ing a diagnosis with instructions being discarded. The cases thus left for consideration number twenty-two. Of these, seven Persistent Urethral Discharges. 3 were evidently tubercular in character, and will be considered last of all by themselves, the fifteen representing simple inflam- matory conditions coming first. In most of these fifteen cases the origin of the inflammation was gonorrhoeal. In some of them that disease was the imme- diate cause of the vesiculitis, though commonly it was found to be the cause more or less remote. All but one of the fifteen acknowledged having had gonorrhoea at some time or other; although a number of those admitting a former clap did not themselves ascribe their existing trouble to that source. In twelve of the fifteen cases, as the result of treatment, all signs of discharge have disappeared, although in several of these twelve cases some signs of vesiculitis still exist, it having been observed that ordinarily the discharge ceases before com- plete resolution in the vesicles has taken place. On this ac- count some patients consider themselves cured when the discharge stops, and consequently become careless or neglectful of further treatment directed toward the final cure of the vesic- ulitis. Of the remaining three cases, all very chronic in char- acter, one is slowly but steadily improving, one is irregular in attendance, easily discouraged, and although somewhat better is not relieved, and one, an elderly gentlemen, with consider- able accompanying chronic prostatic hypertrophy, showed no signs of improvement after numerous treatments. During the active stage of treatment patients should be seen once in every five to seven days. The active stage of treatment lasts all the way from a month to six weeks, in the most favor- able cases to eight or nine months, and possibly longer in the severe and chronic ones. During the active stage of treatment in some cases where there is a tendency to an inflammatory re- action, it may be beneficial to suspend treatment for a month or six weeks. After resolution in the vesicles has been sufficiently estab- lished (i.e., after the muscular tonus has been restored) it is still well, as a precautionary measure, to examine these organs at least once a month for a period of from four to six months, in order to make certain that they do not tend to relapse into their former state, thus rendering a return of the discharge possible. The peculiar mode of treatment adopted in these cases, which consists of stripping the diseased vesicles of their contents by means of the fore-finger in the rectum, has been fully described in my article on seminal vesiculitis, reference to which has already been made. 4 Original Communication. As, however, some confusion seems still to exist in the pro- fessional mind regarding this point, it has seemed well at the present time to make further remarks on this subject. In the first place, there has been a tendency to confound this treat- ment with that of the so-called “prostatic massage,” which form of treatment has been advocated, off and on, for a number of years, in a rather random manner, by a few Continental writ- ers, chiefly Russian, for certain vague prostatic conditions, mainly neuralgias, such as may persist after the subsidence of inflammatory conditions, and in old men to reduce chronic pro- static hypertrophy, the object being to improve the circulation in the parts with the hope of promoting absorption. In a good percentage of cases where I have delegated this stripping of the vesicles to others, and in which, after an apparently sufficient interval, no improvement took place, I found that the attend- ing surgeon had not grasped the idea of stripping the vesicles, but had simply massaged the prostatic region. By so doing little or none of the inflammatory vesicular material was pressed out, but rather churned up, as it were. Consequently the vesic- ular contents instead of being reduced were more apt to be increased by reason of the disturbance produced, and thus oftentimes the condition of the patient was aggravated rather than relieved. In a number of these cases, with the consent of the attend- ing surgeon, I subsequently undertook the treatment with the result of speedily relieving the symptoms. In all such cases the patients remarked that my manipulations produced sensa- tions entirely different from those they had previously experi- enced during their former treatment. Then, again, a number of surgeons have declared to me that such treatment could be successfully executed only by those who happened to have a long fore-finger, and consequently an extensive reach. This is the same argument which one hears so often advanced against the short-armed man in the boxing match. Still, if the short-armed man has only the requisite skill, it is seen that he has no difficulty in reaching ail the vul- nerable parts of his long-armed antagonist. I take it that the fore-finger of most adults is long enough. In fact the real ob- stacle to success does not lie in the length of the fore-finger, but in the ability of the operator to overcome the natural resis- tance of the perineal muscles. When a case is first treated this muscular resistance is liable to be very marked. As, how- ever, the patient becomes by degrees accustomed to the manip- Persistent Urethral Discharges. 5 illations, and as the vesicular tenderness decreases, this element of muscular resistance diminishes. On this account it is al- ways well with a new case to be as gentle as possible in execut- ing treatment, otherwise what is simply a disagreeable sensa- tion may be looked upon as an ordeal. If a patient continues in this latter mental state the muscu- lar tension is always intensified and manipulations maybe very difficult. To overcome this muscular resistance, firm pressure with the closed fist minus the extended fore-finger against the perineum is necessary. In some thick-set, rigid individuals the perineal pressure required may be very considerable, since in such instances counter pressure on the hypogastrium with 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 where much resistance is encountered, I have found that the knee corresponding to the arm, used in manipulating, can be made to play an important auxiliary role in pushing against the elbow. In order to carry out this maneuver a chair is drawn up behind the patient as he stands with his body bent forward in what I have been accus- tomed to term the “leap frog” position, and ready for the treatment. Then the foot of the operator corresponding to the hand to be aided is placed in the chair, thus bringing the knee up to the level of the elbow. By this arrangement the muscles of the thigh and leg, as well 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 occasion- ally 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 fore-finger in the sigmoid flexure. Cases. I.—twenty-five years old, had gonorrhoea three years ago, and had never been well since. He complained of a relapsing urethral discharge, associated with a burning sensation along the urethra, and a pain above the pubes. After being very careful of himself for a time the discharge might disappear, though the painful sensation did not. Upon the least indiscre- tion, however, the discharge was liable to reappear. Since this trouble he had been sexually weak. He had tried all kinds of 6 Original Communication. internal remedies, anterior and deep injections, besides having had his anterior urethra extensively cut for alleged large-calibre stricture. All this treatment had failed to relieve him. In fact, he considered that the sounds used after the urethrotomy had made him worse than before the operation. Examination of the urine showed numerous urethral shreds and considerable free pus, chiefly, however, from the deep urethra, A large- sized blunt steel sound entered the bladder with no resistance and detected but little tenderness. Rectal feel showed both vesicles, especially the left, to be tender, indurated and dis- tended. Systematic strippings of the vesicles, associated with an occasional vesical lavage of corrosive sublimate in solutions of from 1-12000 to 1-10000 accomplished a cure in about two months, at the end of which time the gentleman married. This case would, I expect, have recovered without the asso- ciation of the lavage, but as it was one of my earlier ones, and as time was an object, it was thought better not to depend wholly upon the vesicular manipulation. II.—Twenty-nine years old; contracted gonorrhoea a year and a half before consulting me. During all this time he had had a very abundant purulent discharge and much free pus in the urine. In fact, at the time of the first consultation, the discharge was as free as one would expect to encounter in the acute sup- purative stage of the disease. Besides this, he had gonorrhoeal rheumatism, which had centered in the right knee. He had tried internal remedies together with anterior and deep injec- tions, all to no purpose. I examined his urethra carefully. There was no stricture and only moderate tenderness. There was nothing, indeed, to be discovered in the condition of the urethra to account for the excessive discharge. Rectal examination showed the left vesicle to be very much distended, it being about the size of a hen’s egg. The peri-vesicular tissues were indurated and inflamed, and the entire region was quite sensi- tive, a little pressure giving rise to much pain. On making such pressure, considerable fluctuation could be detected, and upwards of a drachm of purulent vesicular fluid containing many lifeless spermatozoa dripped from the meatus as the re- sult. This consultation took place in June, 1892. My opinion at the time was that extirpation of the purulent vesicle would probably be required in order to effect a cure, as the case seemed most aggravated. Still, I decided to make a trial of stripping the vesicle. At the end of a week the case reported again for examination. The vesicle at that time was not as tense as be- Persistent Urethral Discharges. 7 fore, and no disagreeable reaction had followed the first treat- ment. Feeling encouraged by these results, I sent the patient home with instructions to his medical attendant prescribing a continuance of the treatment. Early in September the patient returned and reported that he was no better. On examination the condition of the vesicle was found to be exactly as when first examined. On stripping the sac a great quantity of the purulent fluid was discharged. The patient told me that his regular attendant had never succeeded in squeezing out any- thing as the result of his manipulations. The consent of the medical gentleman in charge was then readily given me to con- tinue the treatment myself. After this the patient reported regularly once in a week to ten days. The intervals between treatment were a little too long, but were as frequent as the patient could arrange. Under this systematic treatment pro- gressive improvement ensued. In a little over two month’s time the discharge from the urethra ceased, and the urine be- came clear. The material pressed out from the vesicle lost its purulent character and became viscid and somewhat gelatinous. The vesicular tenderness and the peri-vesicular induration also gradually disappeared. The vesicle, however, still remained distended, with its muscular walls flabby. On this account it seemed very probable that a relajjse might occur should treat- ment be suspended. Accordingly, treatment was continued for about six months longer, although during this latter interval the visits did not average as frequent as at first, oftentimes the patient being seen but twice, and on one occasion but once dur- ing a month. At the end of this time the pouchy condition of the vesicle had disappeared, and the organ was able to empty itself as the result of seminal emissions. Since suspending treatment this case has reported occasionally in order to be assured that everything is all right. The vesicle is now per- forming its functions perfectly. It is normal to the feel, and nothing can be squeezed out of it. There has been no return of the urethral discharge, and the urine is perfectly clear. lll.—Thirty-five years of age, had never for any considerable interval since his first gonorrhoea, about six years ago, been free from a urethral discharge. Since his first gonorrhoea he reported having had numerous fresh attacks of the disease. As he had, apparently, been quite conservative in his sexual relations, it seemed probable that a number of these subsequent fresh attacks were simply exacerbations of the existing patho- logical condition. Latterly, also, added to his former com- 8 Original Communication. plaints, signs of sexual weakness had appeared. Before seeing me, both in this country and abroad he had consulted a number of eminent authorities, without any apparent benefit. The urine in this case showed a number of urethral shreds and some free pus, Nothing in the urethra was found to account for these symptoms. Sounds, anterior and deep injections, and in fact all the ordinary urethral methods had been tried without avail. Both vesicles were found tender and somewhat distended. They were not, however, indurated, and their walls were not thickened. Considerable material appeared in the urine as the result of vesicular stripping, but it contained comparatively little pus. This case had the appearance of being a very favor- able one for the treatment, and so it proved. Great relief was experienced after the first few strippings. The discharge dis- appeared and the urine became clear The patient being thor- oughly satisfied with his condition, soon became irregular in attendance, and then stopped further treatment before I was satisfied that the vesicles were wholly well. As, however, the condition of the vesicles was not bad to start with, the limited treatment they received may have been suffi- cient to guard against relapse. IY.—Thirty years old, consulted me for a urethral discharge which had been so profuse for the preceding six months as to saturate several clothes daily. For over a year before the pres- ent profuse discharge commenced, there had been more or less gleet, which had become quite troublesome after alcoholic excess. There was an early history of several gonorrhoeas which had, apparently, occasioned only temporary inconveni- ence. The peculiarity of the present muco-purulent discharge was that, although very profuse, it was not accompanied by any urethral pain or vesical disturbance ; in fact, the patient stated that he felt perfectly well in every way, the presence of the discharge being his only discomfort. There was considerable free pus in both the first and second flow of urine. Numerous anterior injections had been tried, many of which would hold in check the anterior discharge so long as employed, but as soon as discontinued the discharge would reappear. On com- mencing to treat this patient I tried deep urethral instillations of nitrate of silver. The discharge and most of the free pus in the urine would disappear for about twenty-four hours after each of these treatments, at the end of which time there would be a sudden relapse to former conditions. Persistent Urethral Discharges. 9 Examination of the urethra showed an absence of lesions sufficient to account for the discharge. Attention was then called to the vesicles, although, as has been stated, there were no subjective symptoms pointing to those organs. The left vesi- cle was found to be much distended and rather tender. There was, however, but little peri-vesicular infiltration. A large amount of purulent vesicular fluid was squeezed out. This case was treated continuously by stripping the vesicle once in five to seven days for six weeks. There was then marked improve- ment in the volume of the discharge and also in the condition of the vesicle. At this time, however, the vesicle began to be- come tender to the touch and the strippings, which had latterly caused no discomfort, became somewhat painful. The material squeezed out, which had lost its purulent character, began again to show free pus. In fact, I found that my treatment had been a little too vigorous. After seeing him a few more times and stripping gently, as the vesicle still remained tender, though not much distended, the patient was sent off, and the treatment discontinued for the time being. He went away on a three months’ trip. At the end of that time he reported for exami- nation. He stated that he was well and had been wholly free from all discharge for the last two months, ever since, in fact, the soreness, occasioned by the strippings, had disappeared. Latterly he had been drinking and knocking about with women, no disagreeable after-effects resulting. Rectal exami- nation showed the vesicles to be normal. In this case the local treatment, although efficacious, had been a little too severe. Y.—Twenty-seven years old, came complaining of a urethral discharge associated with frequent and painful urination. At the end of each urinary act it was customary for a drop or two of blood to appear at the meatus. He also suffered much pain on the occurence of a seminal emission. These disagreeable symptoms had persisted for two years as the result of a gon- orrhoea. In the meantime the patient had been treated at the hands of numerous eminent medical men without relief. His meatus had been cut, large sounds passed, deep and anterior injections used, and topical applications through the endoscope applied, all with the result of aggravating rather than improv- ing the existing state of affairs. Endoscopic examination did show a beefy-looking, granular spot in the deep urethra. Rec- tal feel showed both vesicles to be tender, distended and in- flamed. Much material, associated with pus and blood, was 10 Original Communication. squeezed from them. It was thought best to leave the granular spot in the deep urethra alone, and to treat simply the vesicles by the usual method, once in every five to seven days. During the first six weeks of treatment, though the vesicular feel was constantly improving, the patient, made sceptical perhaps by his former experiences, did not admit that he was any better, aside from the fact that painful sensations at the time of seminal emissions had disappeared. Shortly after this time the discharge, the blood and the frequent painful urinations all disappeared. Then the patient became enthusiastic, and wanted to call him- self cured. Treatment was continued, however, for some time, until the condition of the vesicles became quite satisfactory to the feel. Since the discharge stopped, now six months ago, the patient has considered himself perfectly well, and he has been well as far as his urinary apparatus is concerned. It has been difficult in this case to impress on the patient the import- ance of having the vesiculitis entirely cured before abandoning treatment. On this account there may be some future trouble in store for him. VI.—Fifty-seven years old, came with a slight, relapsing urethral discharge together with numerous shreds and some free pus from the deep urethra. He has had this trouble con- tinuously for six years. In early life he had had gonorrhoea a number of times. About six years ago, as the result of exces- sive sexual intercourse, a slight discharge appeared. The elec- trolysis craze was then in full swing in this country, and the doctor consulted at that time diagnosed a stricture, and advo- cated its cure by electricity. This agent was applied twice with disastrous results. The patient was then, for the first, seen by Dr. Keyes and myself. He remained under our treat- ment for some time. He was very much relieved of his dis- tressing symptoms due to the electricity, but not cured. He then sought advice abroad, without benefit. He refused peri- neal drainage. In the Fall of 1893, meeting the patient and learning that he still suffered from his old complaint, I re- quested him to call for further examination. On making this examination chronic suppuration was discovered in connection with both seminal vesicles. These sacs were also enlarged and their walls much thickened. Besides this, marked hypertrophy of the prostate had taken place during the six years since I had examined him. The deep urethra, though but moderately strictured, seemed inelastic and unyielding. Within the last few years his sexual power had greatly diminished. Although Persistent Urethral Discharges. 11 this case seemed most unpromising, a course of vesicular strip- pings were given. No benefit, however, being experienced ex- cept, possibly, in the way of increasing slightly the sexual ca- pacity, treatment was abandoned. Formerly, before the vesi- cles had been examined, my opinion had been that a perineal section and drainage would have cured this patient. I now think that such an operation would have proved a disappoint- ment to all concerned. VII.—Thirty-five years of age, had a gonorrhoea in 1889, and had not been well since. This statement was made early in September, 1898. During 1890 and 1891 he suffered much from a relapsing discharge associated sometimes with blood. At this period also his urinations were frequent and urgent. In the urine, besides free pus, there were large clumpy shreds from the deep urethra, with oftentimes some adhering blood clots. Numerous urethral treatments were tried without benefit, and in 1892 he submitted to perineal section and drainage. From this operation he received considerable benefit. The bloody element disappeared and only a slight gleety discharge re- mained. His urinations were, however, still quite frequent and urgent. He had pain in the perineum, and he experienced lit- tle satisfaction or relief from sexual intercourse. In Septem- ber, 1893, the seminal vesicles having been found to be distended and inflamed, stripping was tried, and much firm gelatinous material pressed out. This course was continued at frequent intervals for two months, and then more infrequently for three months longer. Under this treatment the discharge soon wholly disappeared together with the perineal pain, the urinations be- came normal as regards frequency and urgency, and his sexual sensations were again natural. In all probability in this in- stance much discomfort together with the perineal section might have been avoided had the value of vesicular strippings been known two years or more before. Still there is much sat- isfaction in making a final cure in such a case. Vlll.—Thirty-three years old, came for consultation on ac- count of a soreness of the deep urethra associated at times with a slight, sticky discharge. The urine was clear at the time of the first consultation and there was just then no discharge. He had been troubled with these symptoms for the past year. Several years before he had had a gonorrhoea, and when quite young he had over-indulged himself sexually. He had already been treated thoroughly by means of deep urethral instilla- tions, and by sounds without apparent benefit. The surgeon 12 Original Communication. under whose charge this case had been had discovered a granu- lar condition of the deep urethra and by the means just men- tioned had with good apparent reason hoped to relieve the symptoms complained of. On investigation, finding no definite urethral lesion, but some derangement of the sexual function, an examination of the vesicles was made, which disclosed a marked amount of trouble. Both sacs were much distended and thickened. On pressure fully two drachms of gelatinous material was squeezed out. There was no marked tenderness. This case has been under treatment for nine months, and is still taking treatment. During all this time the discharge has never reap- peared, and for several months past there have been no dis- agreeable sensations. The distension and thickening of the vesicles have in great measure also disappeared. This case has been peculiar. From the mildness of the symptoms and from the absence of any severe antecedent inflammation one would at first have been led to believe that but little disturbance of the vesicles existed, a large proportion of which might have been merely functional, and that appropriate treatment would result in a speedy cure. Instead of this, however, the course of treatment has been slow and tedious, and the pathological condition of the sacs most aggravated. IX.—Thirty-four years old ; had gonorrhoea six years ago. Since that time he has never been free from a urethral dis- charge. During the early stages of the gonorrhoea he had a double epididymitis, which affection showed a great tend- ency for several years to relapse in connection with the left testicle. In search of relief this patient had visited many surgeons of reputation. All kinds of injections and applications, both anterior and deep, had been used; in- ternal urethrotomy followed by large-sized sounds had been tried, all to no purpose. On examination I found the vesicles the real seat of his trouble. Both of them were very much distended and thickened. In answer to my ques- tions I learned that although he could accomplish sexual intercourse, yet little pleasure was experienced, and the ejacu- lation was very feeble. I undertook the treatment of the vesi- cles in this case, without great expectations, and made no promises. As the result of six months’ treatment the patient is decidedly better than he has been for a long time. His gen- eral feelings are better as well as his sensations experienced during coitus. His discharge has diminished, but has not dis- appeared. The vesicles to the feel are improved. They are Persistent Urethral Discharges. 13 not as distended, the walls are not as thickened, and the amount of fluid to be pressed out is considerably less. The patient desires a continuance of the treatment. The pathological con- dition of the vesicles in this case seems to resemble closely that of Case YIIL X.—Thirty-six years old ; had gonorrhoea twelve years ago. Seven years ago being troubled with a relapsing discharge, he was treated by electrolysis. Since that time the relapsing dis- charge, although diminished in amount, and of less frequent recurrence, still persisted, associated with a perineal pain after erection. His erections although frequent always failed him on attempting coitus. In this case both vesicles, especially the left, were found distended and moderately thickened, no ure- thral disease being discovered. After a moderate amount of treatment all feelings of discomfort disappeared, and there being no more signs of discharge, the patient became irregular in attendance before thorough restoration in the vesicles had taken place. In the future this case may need some further treatment, though at present well, as far as subjective symptoms are concerned. Xl.—Twenty-two years old; had gonorrhoea over two years ago. One year ago, being troubled by a thick glairy discharge which followed straining at stool or any sexual excitement, he sought relief at my hands. The left vesicle was found to be much distended. After six weeks’ treatment some inflammatory symp- toms resulting, partial suspension of the strippings for a month was deemed prudent, at the end of which time active treatment was resumed for two months. At that time the patient, being much improved in all respects, had to leave the city. Six months afterwards he reported, stating that he was well of all discharge, and had been so since shortly after leaving the city. Examination showed the condition of the vesicles to be satis- factory. There was, however, a suspicious hardness and unevenness to the feel of the prostate that made me suspect that later on tubercular evidences might manifest themselves. Xll.—Twenty-seven years old; came seeking relief for a chronic urethral discharge which he had had for four years. This discharge had its beginning in a gonorrhoea which was complicated with an epididymitis in connection with both testicles. There was no pain and no disturbance of micturition in connection with the discharge, which was muco-purulent and very profuse, so much so, indeed, as frequently to saturate a handkerchief in a few hours. His sexual powers were very much 14 Original Communication. weakened, though oftentimes the sensations were aggravated. He had no stricture. Anterior and deep injections besides large- sized sounds had been used without any benefit. In fact, he had come to the conclusion that all local treatment up to date had aggravated rather than relieved his condition. Examination of the vesicles showed them both to be very flabby and distended. The walls were moderately thickened. The sacs were not tender to the feel. Pressure ejected a large amount of fluid, fully half an ounce running out of the penis. In this vesicular material there were a few dead spermatozoa, which showed that the double epididymitis had not succeeded in entirely blocking both spermatic cords. The prognosis of this case as the result of the first examination did not seem to me very favorable, owing to the lack of sensation in the vesicles and to their very distended condition, which seemed to indicate a great lack of muscular tone. At the end of five or six treatments this patient was called away on business, although at the time he felt that the treatment was improving his condition. About five months afterward I was informed by letter that the improvement fol- lowing the strippings still persisted, and that as soon as busi- ness would allow he would report again for further treatment. I feel that the discharge in this case could be entirely cured by a continuance of the manipulations. Whether the tone of the vesicles could be wholly restored is somewhat doubtful; still, youth in this case is a very favorable feature, and if great regu- larity of life could be combined with it I think there might be a perfect recovery. Xlll.—Twenty-three years old ; married a year ago ; sought relief for a sticky discharge which kept the meatus at all times wet. He had never had gonorrhoea. He had noticed the discharge for some months, and recently there had been associated a drag- ging sensation in the testicles. His occupation was sedentary. There was a history of sexual excess’ since marriage. A short time previously a doctor had given him a deep urethral injection of nitrate of silver. This had apparently aggravated the exist- ing symptoms. Examination showed the vesicles to be extremely tender and very moderately congested. A fair amount of gelatinous material was squeezed out. The first treatment gave much relief, and after four succeeding visits the patient was discharged cured. In this case tonics and proper directions concerning exercise and sexual moderation were most important in the after-treatment, otherwise a relapse might be expected. XIV.—Thirty-eight years old; complained of a discharge Persistent Urethral Discharges. 15 from the urethra of six weeks’ duration coming on ten days after exposure. The discharge had never been accompanied by painful sensations. In earlier life he had had gonorrhoea. Numerous injections were tried, and the discharge diminished. The anterior urethra being somewhat granular and moderately strictured, sounds were used, and the strictures thoroughly dilated. As a result of this treatment the urethra appeared to be in a healthy condition. Still, the morning drop continued. The vesicles were then examined, though there were no special symptoms pointing in that direction, aside from the persistence of the discharge, and a history of considerable sexual indul- gence. The sacs were found to be tender and slightly dis- tended, but not thickened. As the result of stripping a fair amount of transparent gelatinous fluid was pressed out. A few strippings sufficed to dissipate all the remaining evidences of discharge. The patient now reports, ten months after the ces- sation of treatment, that he has continued perfectly well. XV.—Twenty-seven years old ; had had numerous attacks of gonorrhoea. Three years ago, being troubled with difficult and frequent micturition associated with anterior and deep urethral inflammation, a strictured condition of the urethra was discov- ered, especially marked at the bulbo-membraneous junction. Anterior urethrotomy was performed, and the deeper stricture, which proved to be soft, was treated successfully by gradual di- lation. By this treatment the patient was entirely relieved for a year and a half. At that time as the result of alcoholic and sexual excess, there apparently being no fresh contagion, a pos- terior urethritis associated with left-sided epididymitis, devel- oped. After the testicle had fully recovered the posterior urethritis persisting, sounds and deep injections, which had proved themselv'es to be so efficacious formerly, were employed. At this time, however, instead of relieving the symptoms, they only served to aggravate them. On making an examination of the vesicles, the left one was found to be distended, infiltrated and very tender, much purulent material being squeezed out. All urethral treatment was suspended, and a few gentle vesicu- lar strippings were given, followed by an improvement in the symptoms. Then all local treatment was suspended for six weeks, there being danger of stirring up an acute vesiculitis. At the end of this time examination showed such improvement to have taken place that nature was left to complete the cure, which she speedily did, aided by the observance of regular modes of life. 16 Original Communication. Tubercular Involvement of the Vesicles. XVI.—Twenty- seven years old ; had gonorrhoea followed for more than a year by a persistent discharge. The patient was tall, thin and stru- mous. He never took much exercise, and spent little time out of doors. Examination of the urethra showed it to be granular and somewhat strictured. These conditions yielded to treat- ment, but a considerable mucous discharge still persisting, the vesicles were examined. These sacs were found to be slightly tender and somewhat thickened, a fair amount of fluid being squeezed out. After stripping the vesicles a few times the dis- charge stopped, and the patient disappeared satisfied with his condition. The feel of the vesicles, however, as the result of the few treatments, had not improved. In about three months the patient reappeared, stating that after free sexual indulgence the discharge had reappeared. The vesicles at this time, although not tender, were much more thickened than when first observed, the infiltration extending into the peri-vesicular tissues. The prostate also seemed firm and somewhat enlarged. The condition being considered tubercular no further local treatment was deemed advisable at the time, cod liver oil and hygienic measures being prescribed. A short time afterward the tubercular process extended to the left epididymitis, involv- ing it in a characteristic manner. This patient when last seen was improving slowly under general treatment, X VII.—Twenty-three years old; came complaining of a dis- charge due to a gonorrhoea which had persisted for a year and a half in spite of judicious measures directed toward the urethra. The urethra at that time being apparently sound, attention was directed toward the vesicles, the left one of which was found to be somewhat tender, infiltrated and distended. The patient was strumous and ansemic. Cod liver oil was pre- scribed and vesicular strippings attempted- After a few of these local treatments the discharge greatly diminished. As, however, the indurated condition of the vesicle seemed to be increasing it was thought best to stop all further local treat- ment, and to rely wholly on general anti-tubercular measures. As a result after a few months examination showed the dis- charge to have disappeared and the vesicle to be almost normal to the feel, a little thickening only persisting. XVIII.—Thirty years old ; sought treatment for a urethral discharge which had resisted various applications and injec- tions. He had previously had gonorrhoea. The exact cause of the present discharge was not from his history clear. He was Persistent Urethral Discharges. 17 tubercular in appearance and bad had trouble with one lung. The urine contained some free pus. The discharge was evi- dently more in connection with the posterior than the anterior urethra. The vesicles were found to be distended and somewhat thickened, considerable fluid being pressed out. A few very gentle strippings served to stop the discharge and to improve his local sensations without adding to the imflammatory infil- tration of the part, which was evidently tubercular. Since then the patient has married and his general health seems to be improving. There are at present no local symptoms. XlX.—Thirty years old; sought treatment for a slight ure- thral discharge and frequent seminal emissions. He was tall and thin. Had had lung trouble, for which he had gone to Col- orado, where he had improved, although since coming East again he had lost flesh quite rapidly and felt generally weak. He had never had gonorrhoea. Examination of the vesicles showed them to be somewhat thickened and a little distended. A few gentle strippings served to relieve his symptoms. The vesicles, however, becoming more tender and seeming to resent the manipulations, the patient was sent to the Adirondacks, where he continued to improve. XX. —Thirty-three years old; came for a slight discharge appearing three days after excessive intercourse. Had had gonorrhoea several years before. The present trouble was chiefly confined to the deep urethra, and was evidently not a fresh infection. The vesicles were examined and seemed nor- mal. The patient was thin and anaemic, with a tubercular his- tory. A few light deep injections were given. The deep urethra was very tender, and the injections, instead of proving beneficial, served only to aggravate matters, and that form of treatment was abandoned, internal remedies alone being relied on. After a few weeks’ interval the vesicles and prostate, on further examination, were found to be lumpy and infiltrated, though hot especially tender. Cod liver oil, together with hygienic measures, were now prescribed, all further attempts at local treatment being abandoned. The patient then began steadily to improve and in two months the prostatic and most of the vesicular induration had disappeared, a slight serous discharge persisting. The patient is now in the South, with good pros- pects of recovery. XXI. —Forty-two years old; came with a profuse purulent discharge. This was his third attack. He had been treated by injections and was getting worse. There was much frequency 18 Original Communication. in urination, associated with pain. He had chordee. In early life he had had tubercular hip joint disease with extensive sup- puration. Rectal examination showed the vesicles, especially the right, to be much inflamed and infiltrated, a considerable amount of bloody vesicular fluid being pressed out. Shortly afterward the inflammation extending, the right epididymis became acutely inflamed, suppuration finally resulting. During this acute attack the patient was put to bed and general pal- liative treatment employed. By the time the epididymis had been drained and cured the discharge from the urethra had dis- appeared and the urine had become clear. Examination of the vesicles at this time also showed resolution in that quarter. XXII.—Thirty-four years old; came for a discharge two months old, which appeared directly after an excess of cham- pagne and sexual intercourse. He had had gonorrhoea years before. His urethra had been examined for stricture with neg- ative results. His present discharge had not until recently caused him any pain or inconvenience aside from its presence. Shortly before coming for consultation he had made a trial of sexual intercourse. The act had caused him considerable pain and had aggravated his condition. He had received no benefit from injections. Rectal examination showed both the vesicles to be inflamed, nodular, and somewhat distended. A few gen- tle trials of vesicular strippings were made, but had to be abandoned as the parts became more nodular and infiltrated. Whiskey in stated amounts and cod liver oil were then pre- scribed, together with hygienic measures, all local treatment being stopped. The patient, who before had been anaemic and somewhat wasted, speedily improved, both locally and gener- ally. Now, at the end of three months, the vesicles although a little distended, have lost their nodular infiltrated feel and the discharge, which persists very moderately, has no longer its purulent characteristics, but has become watery. It is quite possible that readers of this article after consid- ering the cases reported, in which the urethral discharge was seemingly dependent on the associated vesiculitis, may infer that such a discharge is one of the cardinal symptoms to be looked for in diagnosticating this disease. This idea is to be discouraged, not only because it is very inaccurate, since in a great many cases of vesiculitis there is no discharge, but also because it might lead those who are inclined to be superficial and to jump at conclusions to neglect the study of the urethra, the common seat of the lesion causing a discharge, together Persistent Urethral Discharges. 19 with other possible sources. We have all seen illustrated this tendency to jump at conclusions in this same matter of persist- ent urethral discharges as the result of Dr. Otis’s writings on stricture of large calibre. These ideas, good in themselves, and valuable in the right place, were so perverted that it became the routine practice with many to cut freely the anterior urethra, not only in all cases where there was a chronic dis- charge, but also oftentimes even for pus in the urine, no at- tempt apparently having been made to trace the source of the pus, which in a number of cases I have in mind was of pelvic origin. I wish also to impress on the professional mind the fre- quency of tubercular inflammation of the vesicles, and to warn all in these cases to exercise the greatest care in attempting digital rectal treatment, lest the condition of the patient be aggravated rather than palliated. The practiced finger will soon learn to detect this condition either at the first examina- tion or very shortly after commencing a course of strippings as the result of the inflammatory reaction produced by the man- ipulations. The following conclusions are drawn: Ist. Seminal vesiculitis is the cause of chronic urethral dis- charges in a certain percentage of cases. 2d. In about one-third of these cases the seminal vesiculitis is tubercular in character. 3d. It is most important to differentiate between the simple inflammatory and the tubercular cases, owing to the difference in prognosis and treatment. 4th. In the simple inflammatory cases the prognosis is good unless the subject is of an advanced age, the duration of the treatment depending largely on the chronicity of the case. sth. The treatment employed in these simple cases consists of stripping the vesicles, thereby squeezing out into the urethra their inflammatory contents by means of the fore-fin- ger introduced into the rectum. This treatment should be employed once in five to seven days, a long interval being al- lowed to elapse between treatments should signs of acute in- flammation appear as a result of the manipulations. 6th. The duration of the treatment may be all the way from a month or six weeks in subacute cases to many months and possibly a year in very chronic ones. 7th. At the commencement of treatment the parts are usu- ally very tender, indurated and distended. If the case pro- Original Communication. gresses favorably all these elements gradually diminish and finally disappear as resolution takes place. The discharge cus- tomarily wholly disappears before a cure in the vesicles is attained. Bth. In tubercular cases the tenderness in connection with the vesicles is not liable to be so great as, and the induration more than, in simple inflammations. In this form of inflam- mation the parts resent the manipulations, unless, indeed, they be most gentle, and even then it is a question if this form of treatment is beneficial. If the tubercular condition is not diag- nosed at first the manner in which the vesicles, when so in- volved, resent the ordinary manipulations by becoming more tender and indurated, thus aggravating the urethral symptoms, speedily renders the correct diagnosis apparent. 9th. Many of these tubercular cases become quiescent under internal medication and hygienic measures. 109 East Thirty-/ourth Street, New York.