CONTRIBUTORS TO VOLUME I. 
BARNEY, J. DELLINGER, M.D., F.A.C.S. 
BARRINGER, B. S., M.D., F.A.C.S. 
BUERGER, LEO, M.D., F.A.C.S. 
CORBUS, B. C., M.D., F.A.C.S. 
FOWLER, H. A.-, M.D., F.A.C.S. 
GARDNER, JAMES A., M.D., F.A.C.S. 
HICKEY, PRESTON M., M.D., F.A.C.S. 
HINMAN, FRANK, M.D., F.A.C.S. 
KEYES, EDWARD L„ M.D., Ph.D., F.A.C.S. 
LEWIS, BRANSFORD, M.D., F.A.C.S. 
OSGOOD, ALFRED T„ M.D., F.A.C.S. 
QUINBY, WILLIAM C., M.D., F.A.C.S. 
SANFORD, HENRY L., M.D., F.A.C.S. 
SMITH, GEORGE GILBERT, M.D., F.A.C.S. 
STEVENS, A. RAYMOND, M.D., F.A.C.S. 
WARREN, GEORGE W., M.D., F.A.C.S. 
YOUNG, HUGH HAMPTON, M.D. F.A.C.S. MODERN UROLOGY 
IN ORIGINAL CONTRIBUTIONS BY 
AMERICAN AUTHORS 
EDITED BY 
HUGH C.M.G., F.A.C.S. 
DEAN AND PROFESSOR OF SURGERY IN THE MEDICAL SCHOOL .OF THE UNIVERSITY OF 
MICHIGAN, ANN ARBOR, MICHIGAN 
VOLUME r 
GENERAL CONSIDERATIONS —DISEASES OF PENIS AND 
URETHRA-DISEASES OF SCROTUM AND TESTICLE- 
DISEASES OF PROSTATE AND SEMINAL VESICLES 
vSECOND EDITION, THOROUGHLY REVISED 
Illustrated with 398 Engravings and 11 plates 
LEA & FEBIGER 
PHILADELPHIA AND NEW YORK 
1924 COPYRIGHT 
LEA & FEBIGER 
1924 
PRINTED IN U. S. A. DEDICATED 
TO THE MEMORY OF 
ARTHUR TRACY CABOT 
TO WHOSE SKILL AND INTEGRITY AS A SURGEON 
AND TO WHOSE WISDOM, GENTLENESS AND FORCE OF CHARACTER 
I DESIRE TO EXPRESS MY DEBT OF GRATITUDE PREFACE TO THE SECOND EDITION. 
Tiie five years which have elapsed since the appearance of the 
first edition have brought no peace to those who would keep abreast 
of this department of surgery. Revision has become inevitable. It 
is to be regretted that changes have had to be made in the list of 
contributors, but death is no respector of persons. Walter J. Dodd 
has joined the long and still lengthening list of martyrs to the develop- 
ment of the science of roentgenology, and the sudden death of Paul 
Pilcher has deprived us of a sound and respected colleague. 
In order to avoid great increase in the size of the volumes it has 
been found necessary to omit the “ Historical Sketch of Genito- 
urinary Surgery in America,” by F. S. Watson. This has perhaps 
served its purpose in forming a background to the first edition, but 
nevertheless we, in company with many readers, shall miss this 
brilliant essay by its distinguished author. 
I wish to express my appreciation of the complete cooperation of 
my many colleagues in revising their chapters. 
Hugh Cabot. 
Ann Arbor, Mich., 1924. 
VII CONTENTS. 
SECTION I. 
CHAPTER I. 
THE CYSTOSCOPE AND ITS USE 17 
By Leo Buerger, M.A., M.D., F.A.C.S. 
CHAPTER II. 
METHODS OF DIAGNOSIS IN LESIONS OF THE URINARY TRACT 76 
By Bransford Lewis, M.D., F.A.C.S. 
CHAPTER III. 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT . 119 
By Preston M. Hickey, M.D.,. F.A.C.S. 
CHAPTER IV. 
SYPHILIS OF THE GENITO-URINARY ORGANS 138 
By B. C. Corbus, M.D., F.A.C.S. 
SECTION IF. 
THE PENIS AND URETHRA. 
CHAPTER V 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS ... 189 
By H. A. Fowler, M.D., F.A.C.S. 
CHAPTER VI. 
DISEASES OF THE PENIS 230 
By George W. Warren, M.D., F.A.C.S. 
IX X 
CONTENTS 
CHAPTER VII. 
GENITAL ULCERS 247 
By B. C. Corbus, M.D., F.A.C.S. 
CHAPTER VIII. 
INFECTIONS OF THE URETHRA AND PROSTATE OTHER THAN 
TUBERCULOSIS 306 
By B. S. Barringer, M.D., F.A.C.S. 
CHAPTER IX. 
DISEASES OF THE URETHRA IN THE FEMALE 366 
Alfred T. Osgood, M.D., F.A.C.S. 
CHAPTER X. 
STRICTURE OF THE URETHRA 414 
By Edward L. Keyes, M.D., F.A.C.S. 
SECTION III. 
DISEASES OF THE SCROTUM AND TESTICLE. 
CHAPTER XI. 
ANATOMY AND PHYSIOLOGY, MALFORMATIONS, INJURIES 
AND TORSION OF THE TESTICLE 447 
By George Gilbert Smith, M.D., F.A.C.S. 
CHAPTER XII. 
DISEASES OF THE SCROTUM 477 * 
By A. Raymond Stevens, M.D., F.A.C.S. 
CHAPTER XIII. ' 
HYDROCELE, HEMATOCELE, SPERMATOCELE AND VARICO- 
CELE 491 
By Henry L. Sanford, M.D., F.A.C.S. CONTENTS 
XI 
CHAPTER XIV. 
INFECTIONS OF THE TESTICLE 517 
By J. Dellinger Barney, M.D., F.A.C.S. 
CHAPTER XV. 
GENITAL TUBERCULOSIS 532 
By J. Dellinger Barney, M.D., F.A.C.S. 
CHAPTER XVI. 
TUMORS OF THE TESTICLE 580 
By Frank Hinman, A.B., M.D., F.A.C.S. 
SECTION IV. 
THE PROSTATE AND SEMINAL VESICLES. 
CHAPTER XVII. 
ANATOMY AND PHYSIOLOGY OF THE PROSTATE AND SEMINAL 
VESICLES 611 
By William C. Quinby, M.D., F.A.C.S. 
CHAPTER XVIII. . 
PROSTATIC OBSTRUCTIONS 623 
By James A. Gardner, M.D., F.A.C.S. 
CHAPTER XIX. 
CANCER OF THE PROSTATE 725 
By Hugh Hampton Young, M.D., F.A.C.S. 
CHAPTER XX. 
SARCOMA OF THE PROSTATE . ’ S02 
By Hugh Hampton Young, M.D., F.A.C.S. 
CHAPTER XXL 
CALCULUS DISEASE OF THE PROSTATE 806 
By Hugh Hampton Young, M.D., F.A.C.S. MODERN UROLOGY. 
SECTION I. 
CHAPTER I. 
THE CYSTOSCOPE AND ITS USE. 
By LEO BUERGER, M.A., M.D. 
OPTICAL CONSIDERATION. 
The interior of the bladder can be brought into view either with 
the cystoscope or with an endoscope. A cystoscope is a tube carrying 
a system of lenses (telescope) by virtue of which a field much larger 
than the lumen of the tube can be seen. An endoscope is a simple 
metal tube through which light can be thrown to allow of inspection 
by direct vision. 
Cystoscopes may be distinguished, according to the lens system 
employed, into two types: the direct, in which the plane of the field 
or view is perpendicular to the axis of the telescope or cystoscope, 
and the indirect or prismatic, in which the field is deflected 90 degrees. 
The Direct Cystoscope.—Through the work of Nitze, an optical 
system was developed, by means of which a comparatively large por- 
tion of the vesical interior can be visualized through a very small 
tube, the field of view being many times greater than that obtainable 
with the endoscope. Fig. 1 illustrates the actual field of vision (x.y) 
through an endoscopic tube, and that (a b) of a Nitze telescope, and 
shows how they are projected by the eye to X Y and A B respectively. 
Properties of the Nitze (Direct) Optical System.—Enclosed in a narrow 
tube there are three essential lenses: an objective lens or lenses, a 
middle or inverting lens and an ocular or eye-piece (Fig. 2). The 
chief physical properties of such a system are (1) amplification of 
the field of vision, the picture being in correct or upright position, 
and (2) magnification of objects as they approach the telescope, the 
focus being practically correct at all distances (universal focus). 
1. Amplification of the Field.—The objective is a lens of very short 
focal distance, which produces a minute, real and inverted image of a 
17 18 
THE CYSTOSCOPE AND ITS USE 
comparatively large field (Fig. 2, a b) at the distal end of the tube 
(Fig. 2, a B). This image, which is too small to be seen by the naked 
eye, is transplanted by the middle lens to the eye or ocular end of 
the telescope, where it can be enlarged by the ocular lens. The eye 
sees an enlarged virtual image, whose apparent size depends upon 
the diameter of the telescope and the magnifying power of the ocular 
(Fig. 2, A B). In short, a field much larger than the capacity of 
the tube is brought into view. 
Fig. 1.—Comparison of actual field inspected with a simple endoscopic tube (x y = X Y) 
and with a direct telescope (a b = A B). 
The illuminated disk that is seen when the objective of the tele- 
scope is held toward the sky may be called the “inner field,” or appar- 
ent or virtual image. The size of the true “outer field,” or object, 
varies with the distance of the objective lens from the plane upon 
which the telescope looks. The virtual capacity of such a system 
can be represented by a cone whose base is at infinity and whose 
apex is at the centre of the objective lens (Fig. 2, acb). 
Fig. 2.—Direct telescopic system, a b, outer field; A B inner field; angle a c b = 
visual angle aB = small inverted image produced by the objective lens. 
2. Magnification.—If such a telescope be held toward the sky and a 
small object be interposed, the following facts will be noticed: (1) that 
the illuminated disk or inner field remains the same; (2) That the size 
of the interposed object varies, becoming larger as it approaches the 
objective, and smaller as it recedes; (3) that when the object is made 
to approach closely but a small portion of it can be seen, and, con- 
versely, at greater distances more and more of it comes into view. OPTICAL CONSIDERATION 
19 
Fig. 3 will illustrate: Let 0 be a telescope, the objective lens of 
which produces an inverted image (a/3) of the field, ab (a a, bb in 
full-face view) and a cb the visual angle of the system. Given an 
ocular of such power that the size of the object (a b) and of the enlarged 
image or virtual image (A B) will be identical. In other words, let 
a b be situated at a point (/) where it appears as large as it really 
is (ab = A B). At 7/ only a portion {a' b') will be seen. This, how- 
ever, takes up the same space in the tube (a/3), and therefore will 
also be seen as large as A B; therefore a' b' is equal to A' B'. At 
III, a" b" = A" B"; at IV, a'" b'" = A'" B'". The virtual image 
{AB), or “inner field,” seen through the telescope always remains 
the same, but the size of the outer or actual field rapidly diminishes 
as it approaches the lens. A small field at a short distance is made 
to occupy the same amount of space in the virtual (inner) field as a 
large one, and is therefore enlarged. 
Fig. 3.—Diagrammatic explanation of the magnifying power of the telescope. 
This system (the direct, non-prismatic) is employed in all direct 
telescopic cystoscopes, such as the modifications of Brenner, Brown, 
Lewis and in Buerger's universal urethroscope. 
The Prismatic (Indirect) Optical System.—In order to bring the 
trigone of the bladder more readily into view a right-angled prism is 
placed in front of the objective. The prism’s silvered hypothenuse 
acts like a mirror, deflecting the whole field 90 degrees, and inverting 
the upper (north) and lower (south) parts of the picture, no change 
taking place as far as left and right are concerned (Figs. 4 and 5). 
This optical system was first used in the Nitze cystoscope (Figs. 5 
and 6). Resembling a metallic catheter, this consists of a shaft (Fig. 20 
THE CYSTOSCOPE AND ITS USE 
6, A-B), a beak (to the right of A, Fig. 6) and an ocular portion (to 
the left of B, Fig. 6). The shaft contains the optical system.* At 
the point A there is a window through which the rays from the object 
Fig. 4.—The effect of the right-angled prism in inverting the far (north) and near 
(south) points of the field. 
or field enter. The beak carries a detachable electric lamp for illum- 
ination of the bladder. Near the ocular is the apparatus for attach- 
Fig. 5.—Nitze cystoscope in longitudinal section viewing the arrow in the floor of the 
bladder, the picture seen by the eye being inverted. 
ing the electric coupling B. The current is transmitted through the 
shaft to the beak by way of an enclosed wire, the circuit being com- 
Fig. 6.—Nitze cystoscope, showing sheath with lamp, prism (A), contact (B), and fork 
coupling (C) for electric connection. 
pleted by the metal wall of the instrument itself. This instrument 
is known as the Nitze examining or observation cystoscope (Fig. 6). 
* Note that two lenses are employed in the objective instead of one as in our diagrams. 
The second lens tends to overcome spherical aberration. OPTICAL CONSIDERATION 
21 
The Oblique View (Indirect) Optical System.—F. T. Brown and 
Buerger have both described and employed special optical systems, 
whose central axis of vision is so directed as to form an obtuse angle 
with the longitudinal axis of the telescope. When the objective lens 
of such a system looks downward, the vista or visual cone is directed 
downward and forward. Hence the descriptive appelations oblique 
or oblique and forward vision types, are employed. Although a cer- 
tain degree of distortion is unavoidable in such lens combinations, 
there are occasionally special circumstances that warrant their use. 
The cystoscopist may well dispense with these instruments since 
they are but rarely required. 
Fig. 7.—The course of the rays from north and south points through the corrected lens 
system, showing four reversals of the arrow, the result being an upright picture. 
Correct Vision Systems.—To overcome the disturbing effects of 
the inversion of the picture E. R. Frank7 added a second or rectifying 
prism to the ocular. The most improved methods are those of Ringleb 
(used in some Continental instruments) and Buerger. In most of 
the American cystoscopes the system described by Buerger5 has been 
adopted. A modified Wappler prism (a hemispherical lens with one 
Fig. 8.—The course of the rays in the same telescope from east and west, showing 
three reversals through lenses, one reversal by the prism, the final result being non- 
inversion. 
plain side) is the objective, and six middle achromatic lenses and an 
ocular make up the rest of the system. The objective lens brings 
about one reversal of the picture, the middle lenses two additional 
reversals. In the sense of north and south (Fig. 7) the prism causes 
another inversion, so that we have a total of four reversals for the 
north and south points and three reversals for the east and west 
points (Fig. 8). This naturally results in the production of an image 
whose north and south poles are upright and correct, and whose 
east and west points are reversed. The interchange of these points 
is then brought about by a simple reversing prism of 90 degrees (Fig. 
8) that is placed in front of the ocular. This system gives a larger 22 
THE CYSTOSCOPE AND ITS USE 
field of vision and a great deal more light than is obtainable in any 
other telescopic system. 
Since a corrected or upright picture greatly facilitates cystoscopic 
work, the above optical system has been almost universally adopted 
in the United States. In all future descriptions, therefore, the use 
of this system will be understood. 
CYSTOSCOPES. 
Classification.—In addition to the grouping according to optical 
system employed—direct, indirect and oblique view—cystoscopes 
may be distinguished as examining (observation), catheterizing and 
operating instruments, according to their special function. 
The classification of cystoscopes into special varieties has, of late 
years, become confused by reason of the recent development of instru- 
ments of multiple function. The nomenclature may also suffer in 
clarity, since authors may describe these instruments according to 
territory of application, mode of use and therapeutic adaptability. 
Considerable diversity in the scope of these devices was attained by 
correct assemblages and adaptations of simple tubular, light-carrying 
tubular and telescopic apparatuses. While a division into telescopic 
(cystoscope) and non-telescopic (endoscope or urethroscope) did suffice 
formerly; the variety of instruments at our disposal today warrants 
additional classification. 
The terms endoscope and urethroscope have been heretofore used 
interchangeably. Since endoscopes are also being applied for visual- 
izing the mterior of cavities other than the urethra and bladder, it 
would seem preferable to discard this appelation as far as its appli- 
cation to the urinary tract is concerned, in order to avoid confusion. 
The simple urethroscope, therefore, would designate an endoscope for 
viewing the urethra, it being well understood that the modern addi- 
tion of a telescope in its complete assemblage has converted it into 
a device for viewing both urethra and bladder. 
We may then divide the instruments for viewing and working 
within the bladder and urethra according to the visual system 
employed, their function and the territory in which they may be 
utilized. With the extension of service of simple instruments, a 
sharp inclusion into one or another category has now become impos- 
sible. As an example may be cited the conversion of the simple endo- 
scopic tube into an instrument that serves also as an irrigating 
urethroscope and cystoscope. 
A useful division for purposes of orientation of the student is the 
following: 
I. Non-telescopic cystoscopes and endoscopes. 
(a) Simple endoscope or urethroscope (Kelly, Valentine, 
Swinburne, Luys, etc.). 
(b) A part (the tubular) of the Buerger universal urethro- 
or urethro-cystoscope. CYSTOSCOPES 
23 
(c) Elsner-Braasch water cystoscope; or a certain assemblage 
of parts of the Buerger universal urethroscope. 
II. Telescopic cystoscopes. 
A. Direct vision—Brown; a certain assemblage of parts of 
the Buerger universal urethro- or urethro-cystoscope; 
or the Geiringer urethroscope and Bransford Lewis. 
B. Indirect or prismatic type: 
(а) Observation (examining)—Nitze; Otis-Brown; obser- 
vation assemblage of the Buerger cystoscopes. 
(б) Catheterizing: Nitze-Albarran; and Buerger cysto- 
scopes. 
(c) Operating: Buerger operating and Bransford 
Lewis modification; also Buerger composite or 
universal cystoscope and special radium cysto- 
scope. 
Direct Cystoscopes.—This type had been used by Nitze for purposes 
of examination before he had improved the cystoscope through the 
addition of a prism. Brenner, by adding a catheter channel, was 
the first to employ this instrument for catheterization of the ureters. 
Fig. 9.—The beak of the Brown direct catheterizing cystoscope showing lamp, objective 
end of telescope and two catheters projecting. 
F. Tilden Brown improved this by separating the telescope from the 
sheath, the former carrying channels for two catheters for synchron- 
ous ureteral catheterization (Fig. 9). Later, Brown modified this 
instrument by cutting an additional fenestra into the concave aspect 
of the beak and by rearranging the lamp. This permitted of the 
introduction and the application of a telescope of the indirect type 
for ureteral catheterization. To this instrument he applied the name 
composite cystoscope. Bransford Lewis developed a similar instru- 
ment, calling it universal cystoscope. 
The field of vision of the cystoscope illustrated in Figs. 1, 2 and 3 
will be seen to encompass a cone whose apex is at the objective and 
whose base lies in planes perpendicular to the axis of the telescope. 
When introduced into the bladder, such a cystoscope would look 
directly at the posterior wall. For a thorough inspection of the 
bladder it has certain disadvantages which have resulted in its being 
gradually supplanted by the prismatic type of instrument. Thus, it 
is necessary to make wide excursions with the instrument to inspect 
the interior of the bladder. Although this is feasible without much 
distress to the patient in the female, it is almost impossible to make 24 
THE CYSTOSCOPE AND ITS USE 
adequate excursions in the case of the male. Fig. 10 illustrates the 
wide sweep that must be made with the shaft of the instrument in 
order to bring a considerable portion of the bladder interior into 
Fig. 10.—Wide excursion of the direct cystoscope in order to bring the posterior wall 
of the bladder into view with a direct cystoscope. 
view. The prismatic cystoscope is not open to this objection, since 
by rotation about its long axis (Fig. 11) an annular band, including 
roof, lateral walls and floor of the bladder can be seen. By an inward 
or outward movement along its long axis combined with rotation, 
almost the whole of the bladder interior can be inspected. 
Fig. 11.—Annular band around the whole bladder brought into view by rotation 
of the prismatic cystoscope on its long axis, very slight rotation bringing the fields 
I, II, and III into view. 
Another disadvantage of the direct system is the fact that only 
objects that lie in planes perpendicular to the long axis of the telescope 
escape the effects of distortion. Figs. 12, 13, 14 and 15 demonstrate CYSTOSCOPES 
25 
this fact, the hair-pin having a grotesque appearance when telescope 
and object are parallel. When the most important portion of the 
bladder is viewed, namely, the trigone and ureteric orifices, the ocular 
end of the instrument must be raised so as to depress the objective 
against the floor of the bladder (Fig. 44). Under these circumstances 
the plane of the trigone is almost parallel to that of the long axis of 
the instrument. The trigone and ureters, therefore, come but poorly 
Fig. 12 
Figs. 12, 13, 14 and 15.—Diagrammatic drawings demonstrating that only objects lying 
in planes perpendicular to the axis of the direct cystoscope suffer no distortion. 
Fig. 13 
Fig. 14 
Fig. 15 
into view. The prismatic telescope, however, gives a perfect picture 
of this region. 
The Prismatic or Indirect Cystoscope.—Here the eye of the observer 
may be regarded as transferred from the region of the ocular to the 
objective, where it looks in a direction perpendicular to the shaft of 
the instrument (Figs. 5 and 28). 
For a long time the prismatic cystoscopes were unpopular in the 
United States because of the difficulty in interpreting the inverted 26 
THE CYSTOSCOPE AND ITS USE 
picture and because of the cumbersome mechanical construction of 
the European Nitze type of instruments. Since the introduction of 
the corrected systems1 the advantages of the prismatic type have 
become evident to most all cystoscopists, so that the indirect system 
is most widely used today. 
The most generally useful examining cystoscopes are the Buerger, 
Otis-Nitze and Nitze (Eig. 16). The first will be described under 
Catheterizing Cystoscopes. 
Otis-Nitze Cystoscope.—The Nitze evacuating cystoscope for pur- 
poses of observation was improved by Otis and Brown by the use of a 
Wappler hemispherical lens and a change in the pattern of the beak. 
The Otis-Nitze consists of a sheath carrying a lamp, a fenestra through 
which the objective looks, two irrigating faucets at the ocular end, 
and an observation telescope. After removal of the telescope the 
sheath can be employed for irrigation of the bladder. Since the 
introduction of Buerger cystoscopes of small calibre, 21-22 Erench 
and 17-18 French, the Otis-Brown-Nitze type has almost fallen into 
complete disuse. 
Fig. 16.—Otis-Brown-Nitze cystoscope, 
Catherizing Cystoscopes.—In order to provide for the collection 
of urine from each kidney separately, the examining cystoscopes had 
to be modified so as to carry catheters that could be inserted into 
the ureteral orifices under the guidance of the eye. This was first 
accomplished by Nitze, then by Casper and Albarran. 
Two types were evolved, both finding favor among urologists: 
catheterizing cystoscopes with the direct and indirect optical sys- 
tems. The same disadvantages mentioned as impairing the utility 
of the direct examining cystoscope obtain with the catheterizing 
modification. Other mechanical and optical features, inherently 
possible in the prismatic types, and recently made practical, have 
now been generally appreciated, so that the indirect varieties have 
been almost universally adopted. We recommend the indirect cysto- 
scopes almost altogether except for those cystoscopists who, by reason 
of education, have been trained in the use of other forms. Even these 
urologists would do well to become so proficient with the indirect CYSTOSCOPES 
27 
instruments as to enable them to recognize the superiority of the 
latter. 
Of the less valuable and less frequently employed catheterizing 
instruments, we may mention: the simple endoscope (or urethro- 
scope) with light carrier (Valentine); the modified endoscope of Luys; 
the Kelly; the Elsner-Braasch cystoseope; the Buerger eystourethro- 
scope and universal urethrocystoscope. 
Direct Catheterizing Cystoscopes.—Brenner converted the direct cysto- 
scope into a catheterizing instrument in 1887 by placing a channel 
for one ureteral catheter below the telescope. 
F. Tilden Brown improved the Brenner cystoseope by separating 
the sheath and the telescope, the latter carrying the catheter bed or 
channels (Fig. 9). The sheath carries the lamp and provisions for 
electric contact, and is closed with an obturator before introduction 
into the bladder. 
Indirect Catheterizing Cystoscopes.—All instruments of this type are 
based upon the Nitze instrument, in which it was found necessary 
to add a mechanism for deflecting the catheters so that they would 
have the proper direction for insertion into the ureters. Albarran’s 
deflector, or finger, which could be elevated or depressed by a mech- 
anism situated at the ocular end of the instrument, is the most useful 
device of this kind, and, in somewhat modified form, is still in use 
today. This deflector, lid, finger, or elevator, is a small flattened 
plate secured by a hinge-joint at a point proximal to the objective 
lens, and, in such a manner, that the distal end of the lid may be 
raised and depressed. As the ureter catheters lie against the deflector, 
elevation of the latter brings about the desired angulation or change 
of direction of the catheter where it emerges from the sheath. 
The Nitze-Albar ran Cystoseope.-—In America, this instrument 
possesses merely historical interest. It is the Nitze observation 
instrument with provision for the introduction of one or two ureteral 
catheters that may be passed through a separate channel in the shaft 
of the instrument. Because of many mechanical disadvantages, this 
instrument has been discarded almost completely in the United 
States. 
Of the antequated types, those of Brenner, Brown, Nitze and Casper 
have been superseded almost altogether by the Albarran and Buerger 
cystoscopes. The former still finds favor on the Continent, the latter 
is almost universally employed in the United States. 
The Buerger Catheterizing Cystoseope.*—This instrument (Fig. 17) 
consists of four parts: the sheath, the obturator, the observation 
telescope and the catheterizing telescope. The sheath is circular on 
cross-section, bears a very short lamp at its end, and possesses a large 
fenestra or window behind the lamp. Its calibre is about 24 French. 
The obturator closes the working aperture perfectly. The observa- 
* One of the models is sold under the name of Brown-Buerger Cystoscope, because the 
sheath principle popularized in the United States by Brown was adopted. (This principle 
had been introduced by Nitze in his “Evacuation Cystoscope.”) 28 
THE CYSTOSCOPE AND ITS USE 
tion telescope is large, but does not completely fill the sheath, room 
being left for irrigation. The catheterizing telescope combines in 
one piece the optical apparatus, the mechanism for deflection and 
the catheter grooves or beds. At the objective end the catheters 
may be fastened by a clip; at the ocular end there are two catheter 
Fig. 17.—Buerger catheterizing cystoscope. 1, concave sheath; 2, convex sheath; 
2b, extra lamps; 3, observation or examining telescope; 4, obturator; 5, catheterizing 
telescope; 6, clip to hold catheters against telescope. 
channels through which the catheters emerge. These are provided 
with rubber tips or nipples that firmly grasp the catheters and prevent 
the escape of fluid from the bladder. A large deflector or catheter 
lift is implanted near the objective. 
This instrument presents the following advantages: The employ- CYSTOSCOPES 
29 
ment of a catheter for washing the bladder is unnecessary, the sheath 
serving this purpose; because of its small size, its round shape, the 
smoothness in the region of the beak and window, the introduction 
of this instrument is easy, and injury to the deep urethra is avoided; 
synchronous ureteral catheterization with two No. 6 French catheters 
is possible, and the telescope and sheath may be removed, leaving the 
catheters in the ureters; irrigation of the bladder may be very rapidly 
effected, through the sheath after removal of the telescope, or more 
slowly through the faucets, even while the process of catheterization 
is going on; the separation of the catheters in their grooves avoids 
friction between them, and a new catheter can be inserted at any time 
without removing the telescope; the relation of the lamp to the objec- 
tive lens gives the best illumination and prevents burning of the 
bladder wall; inasmuch as the catheter-bearing mechanism is sepa- 
rable from the sheath, and is not introduced until the bladder is 
cleaned, the likelihood of carrying infection into the ureters is reduced 
to the minimum; if the lens becomes soiled, the telescope may be 
removed without disturbing the sheath, or a larger observation tele- 
scope may be substituted. 
The typical sheath carries the lamp on the concave side of the 
instrument (Fig. 17, No. 1) and is called the concave type of sheath, 
the fenestra and lamp being on the same side. An additional sheath 
is provided (Fig. 17, No. 2), in which the convex portion of the beak 
encloses the lamp. This allows of very close approximation of instru- 
ment and bladder wall, and is applicable in contracted bladders, where 
distention of the bladder is impossible, when a very close view is 
essential, whenever work must be done at close range, and when 
the sphincter and posterior urethra are to be examined, particularly 
in prostatic adenoma (hypertrophy). 
The same instrument furnished in smaller size (21 French) has 
found popular favor, since it is apt to be better borne. It is indicated 
in irritable and sensitive individuals, often obviates the necessity of 
doing a meatotomy when the external meatus is abnormally small, 
and is advised whenever the patient’s urethra is small or is the seat 
of a stricture. 
A still smaller cystoscope built on similar lines, though somewhat 
elliptical on cross-section, is a single catheterizing instrument of 
17 French caliber. It is useful in the narrowed male urethra and in 
children. 
Modified Buerger Cystoscope.—For purposes of economy, it has 
been found feasible to unite into one sheath some of the advantageous 
qualities of both the convex and concave sheaths usually employed. 
In this instrument, the principles of the Buerger cystoscopes are con- 
served. The sheath, however, has been altered in such a manner 
that it has the appearance of a concave sheath, the light being carried 
in the concavity but not at the termination of the beak. Since the 
curve is but slight, it is possible to withdraw the instrument with the 
beak downward in the male urethra without causing pain or without 30 
THE CYSTOSCOPE AND ITS USE 
meeting any special obstruction, and thus to view the neck of the 
bladder and posterior urethra. For close vision, too, the length, 
angle and shape of the beak, make it applicable, even though abso- 
lute approximation cannot be obtained as with the convex sheath. 
Fig. 18 depicts this type of sheath. 
Fig. 18.—Concave sheath for close vision. 
Buerger Baby or Children Cystoscope.—A special single catheterizing 
instrument was devised for male infants and children as well as for 
female infants between the ages of twelve and twenty-four months. It 
differs from the author’s typical models in two essentials: (1) The 
catheter outlet forms a part of the sheath, projecting from the distal 
end; (2) there is no deflector, a saving in caliber being thereby possible. 
A small projection or hump is provided just beyond the point of 
emergence of the catheter, to give direction to the latter. A slightly 
larger instrument with deflector has also been devised. 
Combination Catheterizing and Operating Cystoscope.—This instru- 
ment that unites all of the useful features of the Buerger observation, 
catheterizing and operating features, will be described under the section 
on operative cystoscopy. 
Composite or Universal Cystoscope.—A number of workers have 
attempted to make the direct and indirect methods of procedure 
applicable in one sheath. For this purpose, the sheath is provided 
with two fenestra", one on the concave side of the lamp for the indirect 
telescope, the other at the convexity for the projection of the objec- 
tive of the direct telescope. Because of the larger size of the beak, 
the inadequacy of illumination for indirect vision, the weakness of 
the mechanism in the region of the beak, and many other mechanical 
disadvantages, such instruments are not recommended. F. Tilden 
Brown and Bransford Lewis have both devised instruments of this 
type. CYSTOSCOPES 
31 
Endoscopic Tubes.—These are simple tubes of varying diameters, 
and are called urethroscopes* when employed for inspection of the 
urethra. They are of two types, male and female. Gruenfeld intro- 
duced these in 1881 for use in the urethra, and both Pawlik and 
Howard Kelly, of Baltimore, demonstrated that, at least in the female, 
the ureters could be catheterized with comparative ease through a 
mere tube, into which light could be reflected from a forehead mirror 
from a lamp situated near the eye portion of the tube or from a small 
light carrier inserted into the tube itself. 
The Kelly Endoscope.—A simple tube (Fig. 19) provided with an 
obturator and handle is successfully used by many for ureteral cathe- 
terization in the female and also for inspection of the bladder. Light 
is thrown into the bladder with a forehead mirror. In certain modi- 
fied models of this instrument a small lamp is attached either to the 
eye end of the tube or carried inward on a small light carrier. The 
Kelly-Pawlik method is not recommended for observation cystoscopy, 
Fig. 19.—Kelly speculum or endoscope. 
since the field obtained is too limited. In the female, however, it 
has a sphere of usefulness for purposes of ureteral catheterization. 
The Luys Endoscope.—Luys employs a simple endoscopic tube for 
catheterization of the ureters even in the male, and has modified the 
instrument by the addition of a small magnifying lens in front of the 
eye end of the instrument and a small canal through which the urine 
can be aspirated and the field kept dry. 
The Elsner-Braasch Cystoscope.—'This is a modified endoscope con- 
sisting of a sheath carrying a beak and lamp, an obturator and a small 
glass window to close the eye end of the tube. When used in a water 
medium, a direct view is obtained without the intervention of any 
lenses, the observer looking through the window down the water-filled 
sheath. Ureteral catheters may be passed through special channels, 
no deflector being necessary, the technic being similar to that employed 
with the direct cystoscopes. Because of the restricted field of vision, 
* Described under Section on Urethroscopy. 32 
THE CYSTOSCOPE AND ITS USE 
the wide excursions necessary to bring the bladder interior into view, 
and the difficulty of finding the ureters, particularly in pathological 
bladders, the instrument will scarcely find general adoption. In the 
hands of a very few experts it may answer in the majority of cases. 
CYSTOSCOPIC ACCESSORIES. 
The Lighting Apparatus.—The source of electricity is preferably the 
street current, but a dry cell, storage or other battery may be employed. 
The requisite amount of current is obtainable through a controller* 
that can be attached to any universal lamp socket. Current should 
be turned on gradually until the outlines of the lamp filament become 
blurred and the light becomes white, the instrument being tested and 
the proper amount of current determined before its introduction into 
the bladder. Dry-cell batteries (single or six-cell pocket battery with 
rheostat) are often serviceable, though larger portable batteries con- 
taining twro to six cells wall last longer and give more satisfaction in 
an office not equipped with electric light, f 
Sterilization.—After cleansing with green soap and water, then 
alcohol, the cystoscope may be sterilized either in pure carbolic acid 
or in formaldehyde vapor. A carbolic acid sterilizer may be impro- 
vised by placing two large tubes or cylindrical vessels in a wooden 
stand, one containing carbolic acid and the other 95 per cent, alcohol. 
The cystoscope is plunged into carbolic acid for five minutes, then 
immersed in alcohol, and finally washed with sterile water. 
A in which there is provision for the development of 
formaldehyde vapor is even more reliable. This is developed by allow- 
ing a tablet of paraform to be vaporized over a lamp. The instruments 
should be kept in this vapor for several hours, preferably overnight, 
and must be rinsed off with sterile water before using. 
Cystoscopic Table.—A table suitable for cystoscopic work should per- 
mit the patient to be comfortably placed in the following positions: 
lithotomy position, the modified lithotomy position with legs hanging 
down; Trendelenburg and knee-chest position.§ 
Anesthesia.—Although an anesthetic may be dispensed with in many 
cases, it is a good plan to employ novocaine or alypin as a routine in 
males, and occasionally even in the female. A 2 and 4 per cent, 
solution of novocaine and lf-grain tablet of alypin or novocaine 
should be at hand. Lubrichondrin or Iv-Y, to which 4 per cent, 
novocaine or alypin has been added (Barringer), is employed by some. 
The following is a useful method of obtaining local anesthesia in 
the urethra of the male: After cleansing of the foreskin and meatus, 
the patient voids, and the urethra is irrigated with a 2 per cent, boric 
acid solution. The anterior urethra is then distended with a 2 to 4 
per cent, novocaine solution and closed with a penis clamp. After 
* The Wappler controller, No. 3, is one of the best instruments for this purpose, 
f See Wappler Catalogue. t Hospital Supply Company, New York. 
§ Buerger-Hyman table made by the Hospital Supply Company, was especially 
designed for this work; or the Buerger combined cystoscopic and radiographic table. CYSTOSCOPIC ACCESSORIES 
33 
five minutes have elapsed, about 15 c.c. of the novocaine solution are 
injected into the urethra in such a manner that the greater part of 
this solution enters the bladder, the urethra remaining distended for 
an additional five minutes. Some recommend the introduction of a 
tablet of alypin or novocaine (1| gr.) into the posterior urethra by 
means of a special tablet depositor (Bransford Lewis), or the injec- 
tion of a 4 per cent, alypin-lubrichondrin into the urethra for five 
minutes, the instrument being then anointed with the same prepa- 
ration. 
Suppositories containing 1 grain of codein or \ grain of the extract 
of belladonna with \ grain of the extract of opium may be adminis- 
tered in irritable patients an hour before the examination. In rare 
instances nitrous oxide gas anesthesia will be necessary. 
Solutions.—Since cystoscopy with telescopic instruments necessitates 
the distention of the bladder with a clear fluid, a warm 2 per cent, 
boric acid solution must be at hand. It is best employed in an irri- 
gator, but may also be injected with a 5 to 6 ounce syringe. 
Indigo-carmin (0.08) mixed and boiled in 15 to 20 c.c. of sterile 
normal salt solution may be injected into the buttocks, if selected 
as a functional test; a sterile solution prepared in ampoules may be 
injected intravenously and found superior to the intramuscular 
method, for the latter is apt to cause considerable pain; or phenol- 
sulphonephthalein (vial of 1 c.c.) is introduced either into one of 
the arm veins or under the skin. 
Ureteral Catheters.—The French silk-woven catheters are the best. 
They vary in size and in the shape of their tips or collecting ends. 
They may terminate in an olivary point with one or two lateral open- 
ings, in a whistle-shaped tip with lateral holes, in a single terminal 
opening without any lateral holes, or with a rounded, closed end 
with a lateral opening. The most serviceable are the olive-tip and 
the whistle-tip catheters; the former are preferred for routine work 
since they more easily surmount obstruction in the ureter; the latter 
have the advantage of giving a somewhat more copious flow. 
Although the No. 6 French catheter is recommended for routine 
use, it will be necessary occasionally to employ one of 4 or 5 French 
caliber. In pyelography where reflux of the injected argyrol or 
collargol must be prevented, or in estimating the total output of a 
kidney, or in order to collect thick purulent secretions, etc., a larger 
catheter from 7 to 12 French may be introduced through an operating 
cystoscope. * 
Lubricants.—A lubricant containing tragacanth put up in tubes has 
given us satisfaction. Four per cent, novocaine or 4 per cent, alypin 
may be added to the K-Y jelly to aid local anesthesia. Sterile glycerin 
or liquid petrolatum may also be employed. 
Syringes.—A complete outfit includes a 1-ounce (urethral) syringe 
with rubber tip for injection of novocaine solution; a small 5 to 10 c.c. 
* Buerger or Brown instruments. 34 
THE CYSTOSCOPE AND ITS USE 
syringe for washing the pelvis of the kidney, injecting fluid, oil or 
glycerin into the ureteral catheters and provided with a special coni- 
cal blunt needle to fit into any ureteral catheter; a small hypodermic 
syringe for injection of phenolsulphonephthalein; or the intravenous 
preparation of indigo-carmin, and a 5-ounce syringe for injecting 
fluid into the bladder when an irrigator is not at hand. 
Other Accessories.—Other accessories are rubber tips or nipples, 
with or without perforation to occlude the catheter outlets; clips to 
hold catheters in their beds in the telescope; cystoscope holder, espe- 
cially valuable in females to grasp the cystoscope and to hold two 
test-tubes for collecting specimens. 
Preparation for Cystoscopy.—Although a complete armamentarium 
for the use of the specialist includes a large number of instruments, 
a satisfactory set would include: (1) A Buerger cystoscope (com- 
plete);* (2) the 21 French calibre;f (3) the operating cystoscope;! (4) 
the operating cystourethroscope; § (5) the universal urethro- or 
cystourethroscope and (6) the Kelly endoscope or speculum.** 
Or to be economical, the first and third of these could be substituted 
by the Buerger combination catheterizing and operating cystoscope. 
The cystoscope selected for use, after sterilization, is laid out on 
a sterile towel and the lamp tested. Preparation of a male patient 
includes the cleansing of the external parts, the irrigation of the urethra 
with a 2 per cent, boric solution with a hand syringe, followed by the 
application of the local anesthetic. After ten minutes have elapsed 
the patient may be put in the position for cystoscopy. In the case 
of the female, after irrigation of the vagina and thorough cleansing 
of the external parts, a tablet of novocaine or alypin may be intro- 
duced into the urethra with forceps. A slightly modified lithotomy 
position will be found to answer in most cases, except for the Kelly 
and Luys methods, which require either the knee-chest posture or 
an exaggerated Trendelenburg. Some neurologists prefer to allow 
the separated thighs to recline with the patient in the horizontal 
position, the legs being flexed at right angles and the feet supported 
upon a rest attached to the legs of the examining table. 
The Introduction of the Instrument.—In the case of the female this 
requires no special comment, but in the male the technic is as follows: 
The operator standing in front of the patient holds the penis in the 
left hand, puts it on the stretch, everts the lips of the meatus, and is 
ready to pass the well-lubricated cystoscope through the urethra. 
The sheath with the obturator in place is allowed to slip into the 
urethra as far as the bulb, by its own weight whenever possible, until 
it meets the resistance of the bulbomembranous junction. Here it 
is allowed to rest for a second or more. The ocular end of the instru- 
ment is then depressed until a sensation of penetration begins to 
make itself manifest. A slight rotation of the beak from one side to 
* Manufactured by Wappler Electric Manufacturing Company, catalog, 
t Ibid., catalog. t Ibid. § Ibid. If Ibid. 
** Manufactured by instrument makers under name of Kelly speculum. CYSTOSCOPIC ACCESSORIES 
35 
the other may facilitate in this maneuver, and a finger of the left 
hand (which has now released the penis) may aid by pressing the 
beak of the cystoscope upward against the pubic arch. The instru- 
ment will then suddenly plunge through the posterior urethra and 
into the bladder, while the right hand continuously depresses the 
ocular end. The obturator is then removed, the urine collected in 
a sterile vessel, and the bladder is irrigated with a 2 per cent, boric 
solution from an irrigator until the return flow is perfectly clear. 
Either the observation or the catheterizing telescope is now inserted, 
locked in place, and the boric acid allowed to flow into the instrument 
through one of the lateral faucets until 150 to 200 c.c. have entered. 
Technic of Observation Cystoscopy.—Four motions of the cysto- 
scope must be mastered: motions of translation, rotation, a pendulum 
or rocking motion, and a motion of circumduction. 
Fig. 20.—Inspection of (A) antero-superior, (C) postero-superior, and (B) vertex, 
by motion of translation; in a similar manner the floor of the bladder (D) is brought 
into view. 
By the motion of translation we mean an inward and outward 
movement of the instrument (introduction and withdrawal). In 
Fig. 20 the positions A, B and C bring into view the greater portion 
of the antero-superior wall, vertex and postero-superior region. When 
associated with rotation around the long axis of the shaft, the lateral 
walls and floor also are visualized (Fig. 11). A motion of translation 
alone, when the beak is turned down, gives a survey of a band of the 
floor of the bladder, whose wridth depends upon the distance of the 
objective lens from the floor, it being remembered that the nearer 
the objective, the smaller the field. Complete rotation affords a view 
of an annular band extending around the wThole bladder. Therefore, 
the two motions of rotation and translation demonstrate practically 
the whole of the bladder except a small area of the posterior wall and 
the immediate neighborhood of the sphincter. 
The combined motions of introduction, withdrawal and rotation 
do not suffice, since the illumination is scarcely adequate at all dis- 36 
THE CYSTOSCOPE AND ITS USE 
tances, and since details will not be sufficiently magnified until the 
objective is brought nearer to the bladder wall. 
Therefore the rocking or pendulum motion is useful. By this we 
mean the elevation and depression or side-to-side movement of the 
ocular with consequent conjugate motions of the beak. These are 
appropriate to exhibit the posterior wall (Fig. 21), and the juxta- 
Fig. 21.—Rocking or pendulum motion to demonstrate the posterior wall, 
sphincteric portions of the anterior wall; for the purpose of magnify- 
ing objects, and for special conditions, as in cystocele, diverticula, 
adenoma of the prostate, etc. 
Motions of circumduction combine the rocking motion with rota- 
tion and offer the possibility of a more comprehensive view of larger 
objects, such as stones or tumors. 
The Routine of Inspection.—The following is a useful scheme: 
Fig. 22.—Air-bubbles seen with the beak turned upward when vertex is inspected. 
First: Obtain a superficial view of the superior wall with the beak 
turned up, introducing and withdrawing until the air bubble comes 
into view (Fig. 22). The air bubble occupies the highest point of 
the bladder, being air introduced into the bladder upon insertion of 
the sheath. Do not tarry in this examination, since the inspection 
of the floor of the bladder is most important and should be executed 
first. CYSTOSCOPIC ACCESSORIES 
37 
Second: Examine the floor (including trigone and ureteric orifices) 
after having rotated the instrument so that the beak looks down 
(Fig. 21). 
Third: Finding of the ureters. Carry the cystoscope well into 
the bladder (Fig. 23) and the field becomes dark, for the lamp has 
Fig. 24. — View obtained 
with the cystoscope as seen 
in Fig. 23. Upper part of 
field illuminated, lower por- 
tion dark. If cystoscope is 
pushed still farther in, the 
whole field may become dark. 
Fig. 23.—Finding of the ureters; first position. 
impinged against the posterior bladder wall, leaving the greater part 
of the field dark (Fig. 24); withdraw slightly and the retrotrigonal 
region appears. If the illumination is imperfect, you are probably 
too far from the floor, and the ocular must be raised. Continue 
Fig. 26. — View obtained 
with the cystoscope as in Fig. 
25; the interureteric bar runs 
across the field; above, the 
retrotrigonal region; below, 
the more vascular area of the 
trigone. The ureteral orifices 
lie outside of the field. 
Fig. 25.—Finding of ureters. Second position. 
The interureteric bar occupies the middle of the 
field. 
the recessive motion (withdrawal) until the interureteric bar or ridge, 
a fold running transversely between the ureters, comes into viewT 
(Figs. 25 and 26). This is distinguished by its marked vascularity, 
darker color and prominence in the male, although in the female the 
markings may be less distinctive. Even here, however, the change 38 
THE CYSTOSCOPE AND ITS USE 
in the color of the mucous membrane, fascicles of prominent vessels, 
running sagittally, will indicate its presence. Allow the bar to occupy 
the centre of the field and rotate about 20 degrees to either side and 
the ureters will come into view (Fig. 27). Examine the ureters care- 
fully, both with the instrument in the position of lateral rotation 
and also with the shaft carried into the line of the course of the 
ureter, a position which is obtained by bringing the beak toward the 
opposite side of the patient. By raising the ocular the details of 
the ureteric orifices will be brought distinctly into the field. Note 
the intermittent vermicular contractions of the ureteral orifices and the 
character of the efflux or urinary jet. 
Fourth: Study the trigone itself. 
Fig. 27.—Finding the ureters. Third position. I, cystoscope in the midline 'ooking 
at the interureteric bar; II, cystoscope turned to the patient’s right to see the right 
ureter; III, to the left to see the left ureter. 
Fifth: Proceed to the inspection of the superior wall by turning 
the break upward. 
Sixth: View the lateral walls by combining the motion of transla- 
tion with rotation, and with the cradle motion so as to bring the 
beak nearer to the wall. 
Seventh: Examine the posterior wTall with the beak down or up by 
a rocking motion (Fig. 21). 
Eighth: Inspect the sphincter by rotation after having drawn the 
objective into the urethrosphincteric margin, so that the prism lies 
partly within the urethra, partly within the bladder. 
Ninth: Remove the instrument with the light turned off, the tele- 
scope removed, and with the obturator reinserted. 
Elementary Principles of Observation Cystoscopy.—For a thorough 
comprehension of the field of view (outer field) of the indirect cysto- CYSTOSCOPIC ACCESSORIES 
39 
scope, certain elementary physical principles must be known: (1) We 
must study the relation of the inner field to the position of the cysto- 
scope; (2) the movements of this field induced by the motions of the 
instrument; (3) the problem of magnification; (4) the observation of 
the internal sphincteric region; and (5) the question of illumination. 
Relation of Field and Cystoscope.—It is necessary to remember that 
the eye of the observer is transferred to the objective of the cysto- 
scope and looks in a direction perpendicular to the shaft of the 
instrument. With the objective looking down upon the floor of the 
bladder the field is that of a swimmer headed in the same direction 
as the beak. The view obtained by the cystoscope as it is pushed 
inward is comparable to that of such a swimmer (Fig. 28). 
Fig. 28.—Viewing the floor of the bladder, far point (north) occupies the upper portion 
of the field, near point (tail of the arrow) the lower part of the field. 
When the anterior and superior walls are inspected the view is that 
of one swimming on his back and looking upward at the vertex of 
the bladder (Fig. 29). 
When the right wall is examined, the swimmer is treading water 
and looking to the patient’s right, so that a “far”* point will be on 
the examiner’s right; conversely, for the left wall, the swimmer looks 
to the left and the far points will be on his left. 
Induced Movements of the Field.—One of the most disturbing phe- 
nomena is the apparent movement of the interior of the bladder con- 
sequent upon motion of the cystoscope. The up-and-down motions 
* Far points in the antero-posterior direction are away from the cystoscopist, hence 
nearer the posterior wall. 40 
THE CYSTOSCOPE AND ITS USE 
that attend movements of translation are easily comprehended by 
keeping the positions of the swimmer in mind. But when the cysto- 
scope is rotated on its long axis, or when a rocking motion is carried 
out, the changes in the field are somewhat more confusing. 
On rotating the cystoscope with the beak down, toward the patient’s 
right (clockwise), the field will seem to travel in a similar direction. 
Thus, when the right ureter is being viewed the interureteric bar and 
right border of the trigone will be seen to rotate about the ureteric 
orifices as a centre, although this centre will travel toward the observer’s 
right.* 
Fig. 29.—Inversion of the field when the beak is turned upward; the near point occupies 
the upper portion of the field. 
With the cystoscope looking at the floor of the bladder (Fig. 30), 
depression of the ocular (cradle movement in a sagittal plane) imparts 
a downward motion to the object. This is tantamount to advancing 
the instrument, except that the details of the field will become smaller, 
and the illumination will become poorer (Figs. 31, 32 and 33). 
Magnification.—To produce enlargement the ocular must be moved 
so as to approximate objective and outer field. The ocular must go 
upward in viewing the floor, downward for the roof. Such rocking 
motions tend also to throw objects out of the field, depression of the 
beak toward the floor having the effect of withdrawing the instrument. 
Hence, to compensate, slight intrusion of the cystoscope is necessary. 
The Problem of the Sphincter.—Here, three disturbing factors are 
encountered; the proximity of lens and field, the great enlargement 
* The opposite motion will be conferred upon the field by rotation of the instrument 
to the left. CYSTOSCOPIC ACCESSORIES 
41 
and the difficulty of obtaining adequate illumination. The concave 
sheath is inferior to the convex here, since the lamp of the latter can 
be brought into better relation with the juxtasphincteric and urethro- 
sphincteric regions. The cystourethroscope gives the best picture 
here. 
Fig. 30.—-Induced movement of the field by depressing the ocular when a stone on the 
floor of the bladder is being inspected. 
The roof and sides of the internal sphincter normally present a con- 
cave line, that portion of the bladder occupying the concavity being 
darker because the illumination is inadequate (Fig. 34). The floor 
is somewhat convex. These concave and convex lines represent the 
margin of the sphincter in the direction of an approximately hori- 
zontal plane. Any abnormality in this plane, such as intravesical 
Fig. 31.—Stone is in the 
centre of the field. 
Fig. 32.—Stone has moved 
downward and is smaller. 
Fig. 33.—Stone is almost 
out of the field and is still 
smaller. 
intrusion due to prostatic adenoma (hypertrophy) will alter the con- 
cave to a convex line. In the vertical plane outgrowths are difficult 
to estimate, since they will have no other effect than one of magnifi- 
cation. 
Light.—The quality, intensity and position of the light will vary 
according to type of lamp, three forms being in use: With the lamp 
in the concave sheath, in the convex sheath, and in the cystourethro- 42 
THE CYSTOSCOPE AND ITS USE 
scope. The illumination varies also with the distance of the lamp 
from the field; and finally it will depend upon the relation of the 
lamp to the mucous membrane, being modified by the presence of 
tumors, foreign bodies (calculi, etc.), and the displacements produced 
by extravesical causes. 
Up to a certain point approximation enhances the intensity of the 
light, but when the lamp comes too close to the mucous membrane, 
illumination diminishes, particularly when the lamp is in contact 
with the mucous membrane. Then transillumination and shadow 
formation occur. 
When the cystoscope is too far back in the bladder (Fig. 23) the 
lamp becomes covered by mucous membrane and the light is shut 
off. A tumor may throw a shadow by obscuring the light, so also 
a calculus, as well as an enlarged uterus, a myoma, or a tumor out- 
side of the bladder. Prostatic adenoma (hypertrophy) leads to 
Fig. 34.—Diagrammatic drawing showing the view obtained at the sphincter, the roof, 
the floor, the right and left side being shown. 
the formation of a retroprostatic pouch and prevents the approxima- 
tion of the beak and mucous membrane so that light is diminished. 
So also do prolapse of the uterus and cystocele interfere with illum- 
ination. Some of these conditions can be overcome by compensat- 
ing movements of the instrument, by pressure over the abdominal 
wall, or by manipulation of the vaginal wall in the case of cystocele. 
URETERAL CATHETERIZATION. 
Technic with the Indirect Cystoscope.—The technic with the 
Buerger cystoscope will be described, since this is commonly employed.* 
In the majority of cases, synchronous ureteral catheterization is 
advised, since the collection of urine simultaneously from both kidneys 
is invaluable in determining the relative function of the two organs, 
aided by the use of such tests as the phenolsulphonephthalein and 
* In the United States. URETERAL CATHETERIZATION 
43 
indigo-carmin and the chemical microscopic and cultural examination 
of the separated specimens. 
The catheterizing telescope is armed with two No. 6 French ureteral 
catheters; the sheath, observation telescope, and obturator having 
Fig. 35.—Normal ureteral catheterization. First move. Cystoscope in normal 
position. 
been also prepared. After observation cystoscopy has been com- 
pleted, we proceed to the catheterization of the ureters as follows: 
1. The ureteral opening is found and the ocular end of the cysto- 
scope is brought slightly to the opposite side of the patient. By 
raising the shaft the ureteral slit is made to occupy a point just above 
the centre of the field. This position must be rigidly maintained 
during the next two steps. The ureter orifice should be about normal 
Fig. 36.—Cystoscopic view in first move: the ureter slightly above the centre of the 
field. 
in size, or but slightly enlarged, which can be expected at a distance 
of about three-quarters to one inch (Figs. 35 and 36). 
2. After the deflector has been slightly raised (just sufficient to 
prevent the catheter from hugging the lens) the catheter is pushed 44 
THE CYSTOSCOPE AND ITS USE 
forward almost 1 cm. beyond the limit of the field. Now the catheter 
appears enlarged, for it lies close to the prism (Figs. 37, 38 and 39). 
3. The deviation is gradually increased by raising the deflector, 
the movement of the catheter in the field being observed during the 
Fig. 37.—Normal ureteral catheterization. Second move. The tip of the catheter lies 
beyond the field. 
procedure. The tip of the catheter now comes into view, first appear- 
ing at the top of the field and gradually traveling downward, its 
size diminishing at the same time. When its tip is a short distance 
below the ureter, it is usually in the proper position; in reality it then 
Fig. 38.—Cystoscopic view. The 
catheter is being pushed across the 
field. 
Fig. 39.—Cystoscopic view: the 
catheter lies beyond the field; view 
seen in Fig. 37. 
lies in front (nearer the neck of the bladder), below and slightly to 
the inner side of the ureteral mouth (Figs. 40 and 41). 
4. By now raising the shaft of the instrument, and at the same 
time passing it farther into the bladder, the tip of the catheter is 45 
URETERAL CATHETERIZATION 
made to enter the mouth of the ureter. Therefore, the cystoscope 
and catheter, as a whole, travel toward the opening and not the 
catheter alone (Figs. 42 and 43). In the picture we see the ureter 
Fig. 40.—Normal ureteral catheterization. Third move. 
Catheter has received its full inclination. 
Fig. 41. — Cystoscopic 
view. The catheter tip 
lies just below the ureteral 
opening; view seen in Fig. 
40. 
descend to meet the catheter at about the middle of the field. When 
the catheter has engaged the ureteral opening, it is pushed a short 
distance forward, the deflector is depressed somewhat, and, by still 
Fig. 42.—Normal ureteral catheteri- 
zation. Fourth move. The tip of the 
catheter is made to enter the ureter. 
Fig. 43. — Cystoscopic view. 
Catheter has entered; view seen 
in Fig. 42.* 
further raising the ocular, the introduction of the catheter becomes 
easy. The lid (deflector) is now turned upward, the other ureter 
sought and the method repeated. 
* Note that through an error the ureteral orifice has been drawn too high in the field, 
since it must occupy a lower position than in Fig. 35 after the instrument has been 
pushed inward, Cf. with Figs. 29, 30, 31 and 32. 46 
THE CYSTOSCOPE AND ITS USE 
Although the above may be considered as a “normal” method, cer- 
tain variations in technic will be required in difficult or anomalous 
cases. Thus we may find it advantageous to change the amount of 
deflection or to retain the maximum deviation while pushing the 
catheter along the ureteral canal. If we see that the bladder wall 
is being raised considerably by the entering catheter, we know that 
the anterior wall of the ureter is being lifted up by the catheter. This 
occurs especially when stiff catheters are used and when the deflector 
has been turned down too far, for in both instances the catheter has 
a tendency to seek a higher level, one approaching the plane of the 
shaft of the instrument. To overcome this, three maneuvers are per- 
missible, either raising the ocular so as to bring the catheter more 
nearly in the direction of the uretheral canal or increasing the deflec- 
tion, or a combination of both. 
If carefully carried out, this procedure is far superior to that 
by which the catheter is “aimed” at the opening and pushed out 
Fig. 44.—Catheterization with the direct cystoscope. 
to meet it. It affords a more certain way of hitting the mark, 
avoiding scraping of the bottom of the bladder, and is easy of 
execution. * 
Technic with the Direct Cystoscope.—In our experience the direct 
method of catheterization is far inferior to the indirect. The direct 
cystoscope will almost never be found necessary for ureteral catheter- 
ization. 
After introduction of the instrument, the obturator is removed 
and the bladder irrigated. The telescope armed with two catheters 
is then introduced and boric acid solution allowed to enter. The 
trigone is then inspected, it being remembered that the instrument 
looks directly forward and that the intravesical portion of the instru- 
ment necessarily comes into contact with the trigone The latter, 
* For those'who catheterize at close range, particularly when the convex sheath is 
used, the method described need not be followed. URETERAL CATHETERIZATION 
47 
therefore, appears considerably enlarged and is distorted by virtue 
of the fact that the plane of the field lies in the axis of the instru- 
ment (Figs. 12 to 15). When the ureter is recognized, the ocular 
end of the instrument is raised somewhat and the catheter introduced 
into the direction of the canal (Fig. 44). The instrument is then 
turned to the opposite side, an attempt being made to follow the 
interureteric bar, and the other ureter recognized and catheterized. 
Right cornu (3) 
Base (l) 
Fig. 45.—The position of the Kelly endoscope in viewing the bladder. (After Kelly 
and Burnam.) 
Technic with the Elsner-Braasch Cystoscope (or Endoscope).*—In the 
hands of a few experts this method still finds application, but is not 
recommended for the average cystoscopist because the view is too 
limited; thorough inspection of the bladder is impossible; observa- 
tion cystoscopy necessitates wide excursion of the ocular end of the 
instrument; the procedure is much more painful and disagreeable 
than the indirect method; in difficult cases the finding of the ureters 
takes a great deal more time and is not as certain as with the indirect 
* For those who occasionally use this method, the Buerger universal cystourethro- 
scope will be found just as serviceable. 48 
THE CYSTOSCOPE AND ITS USE 
method; the acquisition of the requisite technic is painstaking and 
success with the method is relegated to a very few 
As for the technic, the instrument is introduced with the obturator 
removed, the bladder irrigated and the ocular end is closed with a 
glass window. Through an irrigating cock a continuous flow of boric 
acid solution bathes the telescopic tube and enters the bladder. The 
operator looks through the glass window, inspecting the trigone, and 
by a lateral motion brings the ureteric orifice into view. The catheter 
is then put into the corresponding catheter canal and introduced into 
the orifice under the guidance of the eye 
With the Kelly-Pawlik Endoscope.—A method for direct examination 
of the bladder first adopted by Kelly and Pawlik was described by 
H. A. Kelly as the serocystoscopic method9 (Fig. 45). In this method, 
distention of the bladder with air is induced by posture. A simple 
speculum or urethroscopic tube is introduced and located by with- 
drawing the speculum until the internal urethral orifice is seen. It is 
then carried in a short distance and pointed from 20 to 30 degrees to 
one or the other side, the base of the bladder being viewed. With 
the orifice in view a ureteral catheter provided with a stylet is held 
in the right hand for catheterization of the left ureter, in the left 
hand for entering into the right ureter. The stylet is then removed. 
If we wish to catheterize both ureters, the speculum is withdrawn, 
reinserted and the same maneuvers carried out for catheterization of 
the other ureter. 
Luys Method.—Luys recommends his modified endoscope or ure- 
throscope for catheterization of the ureter of the male, employing 
an exaggerated Trendelenburg posture. The bladder is kept dry by 
continuous suction through a special canal in the endoscope. This 
method will be found too difficult and uncertain for anyone but the 
expert. 
Fig. 46.—Buerger operating cystoscope with forceps of the recessive type in place. 
OPERATIVE CYSTOSCOPY. 
In this we include all those special diagnostic and therapeutic 
manipulations that can be carried out through a catheterizing cysto- 
scope or through an operative cystoscope. The Buerger and Lewis OPERATIVE CYSTOSCOPY 
49 
operating cystoscopes are the simplest, and used most widely in the 
United States. The Nitze and Ivuttner cystoscopes are employed on 
the Continent. 
The Buerger Operating Cystoscope.—The instrument resembles the 
catheterizing cystoscope, but its sheath is elliptical and its telescope 
provided with but a single outlet (Fig. 46). Concave and convex 
sheaths are provided and telescopes for giving either a right-angled 
view, an obliquely forward view, or a slightly retrograde view, 
depending upon the region to be attacked. The right-angled tele- 
scope will suffice for almost all cases. 
Fig. 47.—Buerger’s modified operating cystoscope. 
The Buerger Modified Operating or Radium Cystoscope (Fig. 47).— 
This instrument may be substituted for the operating cystoscope. 
It embodies similar features, except that it is provided with a deflector 
almost twice the usual length. This is manipulated by a mechanism 
that gives it such strength as to effectively deflect rigid spiral instru- 
ments, and also to allow of the treatment of lesions in otherwise 
WAPPLER ELECTRIC COMPANY. INC. 
Fig. 48.—Applicators for reception of steel and platinum needles; on the left, for two 
20 mg. needles; in the centre, for one 50 mg. needle, on the right, for one 20 mg. needle. 
inaccessible portions of the bladder. Tumors at the sphincter may 
be reached, and if the sphincter itself can be displaced, can be brought 
within reach of radium applicators (Fig. 48), or the operating instru- 
ments which will be described later on. 
The Buerger Combination Operating Cystoscope.—This instrument at 
first glance indistinguishable from the others, offers the possibility of 
introducing examining, catheterizing and operating telescopes into 50 
THE CYSTOSCOPE AND ITS USE 
the same specially designed sheath. As far as the requirements of 
observation and operating cystoscopy are concerned, it is identical 
with the catheterizing cystoscopy. For operating purposes it is 
usually adequate, although it carries slighly smaller operating devices. 
The Operating Instruments.—Two varieties are available, the recessive 
and non-recessive or scissors type. In the first the general assembly 
includes a shank carrying the special working ends or jaws (Fig. 49), 
a flexible spiral cannula and a handle. The distal extremity of the 
cannula is reinforced, serving for the closure of the jaws of the instru- 
ment. By means of a universal scissors type of handle the jaws are 
drawn into the cannula and thereby made to close (Fig. 50). In the 
Fig. 49.—Working ends, operating forceps and snare. 
second type of operating instrument the closure of the jaws is brought 
about by a scissors mechanism which obviates recession of the jaws 
as they shut (Fig. 51). Grasping, cutting, biting forceps and scissors 
for cutting the ureteral orifices are provided. 
The most useful forceps is one of the scissor type with cup-shaped 
(Rongeur) jaws. In Fig. 51 (to the right) such a forceps is depicted 
in somewhat less than natural size. A forceps with ovoid jaws (when 
closed) and almost twice as large, will be found useful by those who 
are adept in this work, for it will enable them not only to remove 
calculi from the bladder, but to excise adequate material for micro- 
scopic examination. 
Although the recessive type (Fig. 49) is widely employed in bron- 51 
OPERATIVE CYSTOSCOPY 
choscopic manipulations, it is recommended in urologic work only 
to those with wide experience because of the difficult technic that 
must be mastered. 
Fig. 50.—Operating forceps in telescope. 
A very useful and simple instrument is a snare, which comprises 
a spiral cannula whose distal end is capped with a solid metal knob 
containing two perforations for the emergence of the wire loop and 
Fig. 51.—Scissors type of operating forceps; cutting blade to left, Rongeur forceps to 
right. 
whose proximal end is fitted with a catheter channel which may be 
closed by a rubber tip. 
The forceps with scissor blades (Fig. 52) are especially adapted 
for cutting the upper lip of the ureteral orifice in the bladder. One 52 
THE CYSTOSCOPE AND ITS USE 
of its jaws is provided with a tiny knob, that catches the mucous 
membrane as the lower jaw enters the ureteral lumen. 
Besides, bougies for dilatation of the ureter, a special bougie through 
which the d’Arsonval current may be applied will be found useful. 
A No. 9 French silk ureteral catheter serves to insulate a wire con- 
ductor, the proximal end of which has a coupling for attachment to 
Fig. 52.—Scissor forceps. 
the high-frequency machine, the distal end being provided with a 
screw-thread. To the latter, metal olives of various sizes are attached 
in sizes from 6 to 16 French (Fig. 53). 
Fig. 53.—Dilating olives and bougie. 
The Technic of Operative Cystoscopy.—In the Buerger instrument 
it is possible to employ operative instruments of much greater size 
than the catheter outlet would seem to allow by a retrograde inser- 
tion of the working devices. All of the larger instruments must be 
introduced somewhat in advance of the telescope so that they may 
pass through the telescope alone, emerging through the fenestra 
before the telescope is locked home. OPERATIVE CYSTOSCOPY 
53 
1. Technic with the Recessive Type of Instrument.—The operating 
telescope is prepared as follows: The cannula provided with a rubber 
nipple is introduced into the telescope through the catheter outlet 
until its extremity lies about 1 cm. beyond the lens prism. A suit- 
able working end with its shank is now inserted in reverse fashion 
and the handle securely attached. 
After introduction of the sheath and thorough inspection with an 
observation telescope, fitted to the operating sheath, the operating 
telescope armed with the instrument selected is introduced as fol- 
lows: The working end with jaws closed enters in advance, and, 
if it is somewhat too large to escape at the fenestra in all possible 
positions, may be made to emerge by slight motions of rotation or 
with the aid of slight deflection of the lid. With the bladder filled, 
the lesion or foreign body is located. The cannula is pushed inward 
for the requisite distance, the jaws are opened, and by a combination 
of movement of the cystoscope and deflector the part to be attacked 
is readily seized. To overcome recession of the jaws the cystoscope 
or cannula must be pushed inward slighty as the jaws are made to 
close. Small bodies, tissue and tumors are easily extracted through 
the sheath, the telescope and operating device being removed together. 
In extracting larger bodies, such as a ureteral calculus or foreign 
bodies, the cystoscope is withdrawn first, the forceps following. 
If it is desired to replace the particular operating device just used 
with another, the telescope is withdrawn, the jaw with its shank 
removed and another inserted, the cannula and handle remaining 
undisturbed. 
2. Technic with the Scissors Type.—After being provided with a suit- 
able tip or nipple the operating instrument (forceps or scissors) is 
adapted to the sheath by being passed through the catheter outlet. 
Larger jawed instruments must be inserted in the manner described 
as suitable for the recessive instruments. The technic is the same as 
recounted above, except that it is unnecessary to move the cystoscope 
or cannula while the jaws close. It is best to open the jaws before 
deflection, since bending of the cannula interferes with easy working 
of the instrument. Whenever small devices are needed the scissors 
type is recommended; when larger forceps for removal of foreign 
bodies, as ureteral calculi, are required, the recessive type is preferable. 
The large ovoid-jawed forceps previously described must be made 
to enter the sheath of the cystoscope at least one-half inch in advance 
of the telescope. As it meets the obstruction afforded by the closed 
distal end of the sheath (marking the distal boundary of the fenestra) 
it may be dislodged so as to emerge through the window of the sheath, 
either by a slight elevation of the lid, a to-and-fro motion, or rotation 
of the spiral shank. Usually the elevation of the deflector and lock- 
ing of the cystoscope will suffice to cause the forceps to make its 
proper exit. 
Methods in Operative Cystoscopy.—The Diagnosis of Ureteral Cal- 
culi by Means of Wax-tipped Catheters.—This method of detecting a 54 
THE CYSTOSCOPE AND ITS USE 
calculus in the ureter through scratch marks left upon the surface of 
a wax-tipped catheter was first suggested by Kelly, of Baltimore. 
In females there will be no danger of producing adventitious scratch 
marks if the Kelly endoscope is used. In the male, when the direct 
cystoscope is employed, the following special technic must be observed: 
Either the catheterizing cystoscope or the operating cystoscope is 
selected, preferably the latter. A No. 5 French olive-tipped ureteral 
catheter* is prepared by dipping the tip into a mixture of equal parts 
of paraffin and beeswax. On withdrawal from the mixture a small 
fusiform mass of hardened wax remains. The following technicf is 
to be followed in the male. After irrigation of the bladder with a 
catheter, a sterile wax-tipped catheter is introduced through the 
urethra and made to coil up in the bladder. The sheath of the cysto- 
scope is then threaded over it and then the catheterizing telescope 
is inserted, the butt end of the catheter being passed in retrograde 
fashion through the catheter outlet. The bladder is then filled and, 
under the guidance of the eye, the redundant portion of the wax- 
tipped catheter is slowly withdrawn, care being taken that the wax 
portion does not come into contact with metal or with the deflector. 
Catheterization of the ureter and exploration of the same are then 
done. Finally, the instrument is withdrawn first, the catheter fol- 
lowing. A search for scratch marks is then made with a pocket 
lens. Hinman has recently described an ingenious rubber sheath 
which protects the wax-tipped catheter as it glides through the 
operating cystoscope.8 
In the female it will be found easiest to insert the wax-tipped bougie 
through the urethra, thread the sheath over it, and then follow with 
the catheterizing telescope. 
Or if the operating cystoscope be not at hand, the following technic 
is applicable: After introduction of the sheath the wax-tipped bougie 
protected with a rubber tube (which projects 1 cm. beyond the wax 
tip) is made to enter and manipulated until tube and bougie emerge 
through the fenestra. The bougie is then pushed a little farther 
into the bladder, the rubber tube withdrawn and the telescope in- 
serted. 
Special Catheterization.—The synchronous employment of three 
catheters or bougies is possible in the operating cystoscope, and 
useful in cases of reduplication of the ureters. A large catheter of 
the Garceau type may be useful in pyeloradiography and for drainage 
of a pyonephrotic kidney. This is a catheter whose widest portion is 
of a calibre of about 12 French and tapers gradually, terminating in 
conical fashion in a single aperture, the smallest diameter being 
about 5 or 6 French. It is useful also for the purpose of dilating the 
lower end of the ureter. Special catheters with bulbous enlargements 
* Long whalebone filiforms are useful but more rigid and less easily handled, 
t Since the introduction of the Buerger operating and combination cystoscopes, it is 
an easier procedure to guard the wax-tipped bougie with a rubber tube placed in the 
operating telescope. OPERATIVE CYSTOSCOPY 
55 
to prevent reflux can be introduced through the operating cystoscope, 
and are valuable in pyelography. 
High-frequency Treatment of Tumors.—This can be carried out 
through the catheterizing cystoscope, operating cystoscope or cysto- 
urethroscope. For the employment of this method of treatment 
which has been variously termed desiccation, fulguration, electro- 
coagulation, cauterization, intravesical cauterization, Beer made use 
of an insulated wire electrode which can pass through the cystoscope 
and be made to discharge the current from a high-frequency machine.* 
Although the exact nature of the effect of the electric sparks upon the 
tissues is not clearly understood, we may regard destruction of the 
tissues that ensues as equivalent to cauterization. Two types of 
current, the Oudin or monopolar, and the d’Arsonval or bipolar 
current, give almost identical results. This procedure is applicable 
only in benign growths, particularly to papillomata, and must not be 
carried out until the exact diagnosis has been made with the micro- 
scope. For this purpose a portion of the tumor should first be 
removed with the snare or with the punch forceps through the operat- 
ing cystoscope. Carcinomata do not respond, except perhaps for 
those small papillomata in which a change into carcinoma is just 
beginning to take place. When used through the cystourethroscope 
and operating cystoscope, special electrodes covered with silk and 
shellac insulation will be found more durable than the rubber-insulated 
wire first suggested. 
Perhaps the most useful electrode and one that we recommend 
altogether for routine fulguration is made of a No. 6 French ureteral 
catheter, cut down to an appropriate length and enclosing a wire 
conductor (Bugbee). At the distal end a metallic knob serves as 
the point for discharge of the current, and at the proximal end there 
is an insulated coupling for connection with the high-frequency 
machine. We advise that the d’Arsonval current be employed 
through this electrode. Various sizes may be obtained so as to 
meet the requirements of the smaller cystoscopes and the small 
operating cystourethroscope; and large electrodes may be intro- 
duced through the operating or combination cystoscope. 
Dilating the Ureters and Facilitating the Descent of Ureteral Calculi. 
—For strictures of the ureter, abnormally narrow ureteric orifices, 
occasional inflammatory conditions of the ureter due to calculus, 
and particularly for the purpose of expediting the descent of descend- 
ing ureteral calculi, the dilatation of the ureter may be practised. 
With the operating cystoscope, we begin with a small catheter or 
small bougie, No. 5 French or less, then insert a larger one, or two 
or more catheters or a large bougie. Somewhat more certain and 
effectual is the employment of graduated metal olives at the end of 
a bougie electrode, through which the d’Arsonval current may be 
applied.1 Detachable metal olives are screwed on the end of an 
* Standard Nos. 2 and 3 made by Wappler Electric Manufacturing Company. 56 
THE CYSTOSCOPE AND ITS USE 
insulated wire electrode. These can be introduced after the fashion 
of a ureteral catheter. With a large indifferent electrode over the 
lower abdomen, the second pole being the metal olive, a current of 
200 to 400 milliamperes is allowed to pass, while gentle pressure is 
exerted against the point of ureteral obstruction. Often the obstruc- 
tion gives way after a few seconds’ contact. The small olive (begin- 
ning with No. 5 or 6) is then removed, and a larger one inserted, the 
process being repeated until adequate dilatation has been produced. 
When using the larger olives, it is important that the olive protrude 
beyond the objective and enter the sheath first, or else introduction 
into the sheath will fail. In many cases of descending ureteral cal- 
culi a small stone will be made to pass shortly after dilatation by 
this procedure. This may be combined with the injection into the 
ureter of olive oil or glycerin and the employment of the current is 
not always essential. When the ureteric orifice is not too small, the 
procedure may be preceded by meatotomy of the ureter. 
The Removal of Foreign Bodies, Calculi and Phosphatic Encrustations. 
—The technic of the removal of foreign bodies with the operating 
cystoscope will depend upon their size, structure and shape. We must 
be guided in the selection of the type of forceps by these considera- 
tions. When the body is too large to pass through the sheath, which 
is often the case with descending ureteral and also vesical calculi, 
the forceps with body in its grasp is first pushed farther into the 
bladder beyond the beak. The cystoscope is then rotated so that 
its beak points upward,* and the cystoscope, forceps and body are 
removed simultaneously, the foreign body being the last to appear 
from the urinary meatus. For the removal of phosphatic encrus- 
tations in alkaline and ulcerative cystitis, the operating punch forceps 
or a special curettef will be found invaluable in clearing up an other- 
wise intractable cystitis. The sheath must remain in situ while the 
encrustations are removed piecemeal. 
Ureteral Meatotomy.—This may be necessary as a preliminary pro- 
cedure before dilatation of the ureter to facilitate the passage of a 
calculus; also in cases of congenital stenosis of the ureter. Special 
scissors are used to cut the upper ureteral lip. 
This is most often indicated to dislodge a calculus that has found 
its ultimate lodgement at the ureteral orifice and which cannot be 
made to escape by other means. When the upper lip seems avascu- 
lar the necessary incision is at once made with the scissor forceps; or, 
as a precautionary measure, the edges of the incision may be subse- 
quently fulgurated. If bleeding is to be expected, by reason of the 
turgescence of the mucous membrane, or distinctly visible, vessels 
traversing the operative field, a linear burn by fulguration may precede 
the meatotomy. 
* Rotation is unnecessary if a convex sheath is employed. 
t Constructed by the Wappler Elec. Mfg. Co. for the author according to designs of 
the latter. URETHROSCOPE AND URETHROSCOPY 
57 
Exploratory Excision (Intravesical Biopsy).—We are not infrequently 
confronted with alterations of the vesical mucous membrane, whose 
exact nature is doubtful. For the diagnosis of certain cases, excision 
of lesions followed by microscopic examination may be indicated. 
In the case of suspected carcinoma, the removal of adequate pieces, 
preferably from the periphery of the growth, is absolutely imperative. 
Some urologists take exception to the excising of pieces of carcinom- 
atous tissue in this way, believing that extension of the growth 
might be caused thereby. The author is of the opinion that very 
little or no danger is incurred, particularly if that wound produced 
be well cauterized with the fulguration method. In the cases of 
suspected renal tuberculosis when there are early changes, such as 
edema and polypoid protuberances in the neighborhood of one ure- 
teral orifice, excision of tissue from the ureteral lip will disclose miliary 
tubercles under the microscope. When tubercle bacilli are not found, 
we often can make a diagnosis in this way. 
Snaring of Papillomata.—Experience6 has shown that carcinoma must 
be ruled out in the case of all papillomata by means of histological 
examination. Whenever feasible, therefore, a large part of the 
growth should be removed with the intravesical snare. This can be 
readily accomplished when the tumor has attained sufficient size and 
lies in accessible portions of the bladder. In certain positions, such 
as the immediate neighborhood of the sphincter, the snare is not 
applicable. Here the removal of material, by means of the punch 
forceps through the operating cystoscope or operating cystourethro- 
scope, must be substituted. The snare is provided with a loop of 
No. 00 piano wire, which is developed by pushing out one and then 
the other of the wires. The tumor is encircled, the end of the cannula 
being carefully held against the pedicle lest the papilloma elude the 
grasp of the loop as it is being drawrn tight. Because of the peculiar 
villous nature of these growths, tumors of considerable size can be 
forced through the sheath of the operating cystoscope. 
Excision of Ulcers.—Callous ulcers of the bladder, particularly in 
females, and foci that are covered with phosphatic encrustations, 
when these cause an irritable bladder, should be treated with excision 
with the punch forceps. 
Operations on Ureterocele and Cystic Bodies.—When there is an anoma- 
lous or congenital stenosis of the ureteric orifices, or when there is a 
condition of cystic dilatation of the lower end of the ureter, incision 
with a special intravesical knife or with cystoscopic scissors, combined 
with the use of the punch forceps, may completely abolish the cause 
of the obstruction and make for drainage of the kidney.4 
URETHROSCOPE AND URETHROSCOPY. 
Urethroscopy deals with the inspection of the male and female 
urethra in their entirety. In the male we may arbitrarily divide the 
urethra for purposes of urethroscopy, into the anterior urethra, the 58 
THE CYSTOSCOPE AND ITS USE 
posterior urethra and the urethrovesical or spliincteric portion. In 
the female we may divide the canal into the urethra proper and the 
spliincteric or urethrovesical portion. 
The anterior urethra may be brought into view in two ways: directly 
with the urethroscope, also called endoscope, and indirectly with tele- 
scopic instruments. 
The posterior urethra may be viewed directly by endoscopes of the 
straight or curved variety, indirectly by means of a cystourethroscope. 
The sphincter or urethrovesical portion in the male may be poorly 
and inadequately viewed by means of simple endoscopes or urethro- 
scopes while with the author’s cystourethroscopes and universal 
urethroscopes excellent pictures may be obtained. 
THE URETHROSCOPE. 
The simplest and most useful instrument for viewing the anterior 
urethra is a tube into which light can be thrown either from without 
by means of a small electric lamp or from within by means of a light 
carrier introduced into the tube (Fig. 54). A small magnifying lens 
is invaluable to enlarge the picture. A set of tubes in sizes of 20, 22, 
24, 26, 28 and 30 French should be available, Nos. 24, 26 and 28 
being the most frequently used. Although this instrument will suffice 
for routine work in the anterior urethra, the cystourethroscope and 
universal urethroscope are now employed by many for a study of 
those finer details that may escape observation by direct vision. 
Technic of Urethroscopy.—The patient is placed either in the dorsal 
decubitus with the operator standing on his right or in a modified 
lithotomy position with the thighs horizontal, the legs vertical and 
the feet supported upon a rest, in which case the operator stands 
between the patient’s thighs. The former position will be found 
convenient for the inspection and treatment of the anterior urethra. 
The set of urethroscopes having been boiled, the lamp having been 
tested, the operator selects a tube of ample size, preferably 24, 26 or 
28 French. If the meatus is too small, meatotomy may be done. 
After cleansing the foreskin and meatus the left hand holds the penis, 
while the endoscope with the obturator in place, previously lubricated, 
is allowed to find its way into the urethra, until it is arrested at the 
bulbomembranous junction. The obturator is removed, the urethra 
and tube mopped dry by means of sterile cotton applicators, the light 
applied, the lens adjusted and the urethra is ready for view. The 
left hand continues to hold the penis while the right hand gradually 
withdraws the endoscope. 
In most cases local anesthesia is not recommended for simple 
observation urethroscopy, because it may produce anemia of the 
mucous membrane, and may wash away secretion whose source is 
to be determined. If painful operative procedures are to be done, 
a 2 per cent, or 4 per cent, novocaine solution is injected and allowed 
to remain in contact with the urethra for five minutes. THE URETHROSCOPE 
59 
Urethroscopic Picture.—The essential features of the urethroscopic 
view are the character of the central figure and of the mucous mem- 
brane. The central figure is that artificial termination of the urethral 
canal produced at the far end of the urethroscope. By virtue of the 
distending effect of the endoscope the urethral walls are symmetrically 
separated at the level of the end of the tube and present, in their 
gaping condition, a funnel whose outlet is made up of the centre of 
the urethral canal (the central figure) and whose walls are the mucous 
Fig. 54.—Urethroscope for viewing the anterior urethra: 1, obturator; 2, light carrier 
with small lens attached; 3, electric coupling and cable; 4, endoscopic tube. 
membrane immediately in view. The shape of the central figure 
will vary in different parts of the canal, being a vertical slit in the 
region of the glans, being punctiform in the penile urethra, and 
becoming a more or less transverse crevice farther down in the canal. 
The surface of the mucous membrane presents for consideration the 
longitudinal folds, longitudinal striae, the lacunae of Morgagni and the 
glands of Littre. 
The longitudinal folds, by virtue of their disposition, may be likened 60 
THE CYSTOSCOPE AND ITS USE 
to the spokes of a wheel and become considerably altered by patho- 
logical changes in the mucous membrane. 
The longitudinal striations are the consequence of vascular rami- 
fications, and are seen as red converging markings on a paler, yel- 
lowish-red background. The surface of the mucous membrane is 
smooth and shiny, any loss of brilliancy being evidence of patho- 
logical change. The lacunae of Morgagni are crypts situated on the 
superior roof of the penile urethra, and their orifices can be seen as 
minute depressions whose color does not vary from the surrounding 
mucous membrane in the normal state. The larger lacunae have 
orifices that are V-shaped, the point being turned toward the central 
figure. 
The glands of Littre are very numerous and hardly recognizable 
except when they have undergone pathological change. The Cowper’s 
glands are rarely visible in the floor of the bulbous urethra. 
The Pathological Anterior Urethra.—As a result of gonorrheal 
inflammation, two broad types of lesions in the mucous membrane 
may result, “soft infiltration” and “hard infiltration.” 
Soft Infiltration.—This is characterized by a turgid condition of the 
mucous membrane, histologically by infiltration of the submucosa 
with round cells and increased vascularization. This condition 
results or accompanies acute urethritis, also the earlier stages of 
chronic urethritis. The mucous membrane is hyperemic, inflamed, 
turgid and not unlike a group of hemorrhoids. The central figure is 
closed, the longitudinal striae disappear, and the longitudinal folds 
are effaced. 
The lacunae of Morgagni and glands of Littre are usually involved, 
their glandular secretions being increased. The mucosa in the imme- 
diate neighborhood is a deeper red and slightly swollen, and the 
excretory ducts of the Littre glands are more prominent than normal. 
Hard Infiltration.—This is distinguished by pallor of the mucosa, 
histologically by connective tissue proliferation, the end result of an 
exudative cellular inflammation. This corresponds to the condition 
of “stricture of large calibre” described by Otis. The urethroscopic 
tube meets with a certain resistance in its passage through such a 
urethra. The walls present a characteristic rigidity, having lost their 
normal suppleness. When the endoscope is withdrawn the central 
figure gapes and the eye may look down much farther than in the 
normal case. There is notable diminution in the coloring of the 
mucosa, pallor, a grayish-yellow color or even a wliitish-gray 
appearance. 
Lesions in the Lacunae of Morgagni and Littre’s Glands.—Two 
types of lesions must be recognized, the glandular form, or open 
lesion, and a dry or follicular form, the closed lesion. 
Glandular Open Lesions.—Here the orifices of the glands of Littre are 
enlarged and surrounded by an inflammatory zone. A drop of secre- 
tion, sometimes purulent, sometimes clear, may be seen emanating 
from the orifice. Similar changes are seen about the lacunae of THE URETHROSCOPE 
61 
Morgagni. Their orifices are crater-like, and mucoidal or purulent 
secretion escapes. 
The Dry or Follicular Form.—When the excretory duets are closed, the 
glands become shut off and secretion accumulates so as to form cystic 
bodies which may harbor the gonococcus. 
For the more rare lesion, such as ulceration, leukokeratosis, leuko- 
plakia, syphilitic lesions, chancroid, varices, new growths, papillomata, 
polyps, sarcoma, tuberculosis, etc., special works on urethroscopy 
should be consulted. 
Urethroscopy of the Posterior Urethra.—The posterior urethra 
can be brought into view in two ways: directly, through a straight 
or curved urethroscopic tube, and indirectly, through a cystourethro- 
scope carrying a telescopic lens system (Goldschmidt or Buerger or 
Geiringer). 
With Endoscopes.—Two types of instruments may be used for this 
purpose: The straight tube employed for inspecting the anterior 
urethra, or the curved tube with a beak as suggested by Lowenhardt 
and modified by Swinburne. These instruments were much in use 
before the development of the cystourethroscope, and, although they 
still have a sphere of usefulness in the hands of those who frequently 
make topical applications, they may be regarded as being so greatly 
inferior to the cystourethroscope and universal urethroscope that, 
in our experience, they need rarely be employed. 
A useful type is that in which the lamp is carried in a special groove 
and does not encroach upon the lumen of the tube. When it is desired 
to look into the bladder also by direct vision, the Buys endoscope is 
recommended since the field can be kept dry by aspiration. Some 
urologists find an attachment for air inflation of the urethra of value. 
Technic.—With the bladder empty and after the application of 
the local anesthetic, the patient is placed in either the lithotomy or 
modified lithotomy position, with the inclination of the Trendelen- 
burg posture if the Buys tube is employed. In the female the knee- 
chest position is preferred by many. After the patient has voided, 
the urethroscope is introduced, the urine aspirated either through a 
special aspirator or through the canal in the urethroscopic tube or 
mopped out with cotton applicators, the lamp applied, and inspec- 
tion is begun at the internal vesical sphincter. The urethroscope is 
withdrawn gradually, the posterior urethra being inspected as it 
prolapses into the lumen of the tube. It is difficult to avoid trau- 
matism in these manipulations. 
With Cystourethroscopes—Since the introduction of the telescopic 
variety of instrument for viewing the posterior urethra the direct 
method has been discarded by a large number of urologists. In our 
Gn 11 .opinion, a cystourethroscope is to be preferred both for routine 
examinations and for therapy, for the following reasons: It produces 
no trauma, may be easily introduced, and is very well borne by the 
patient; the view of the ureters, trigone, sphincteric and juxta-sphinc- 
teric regions and posterior urethra is immeasurably superior to that 62 
THE CYSTOSCOPE AND ITS USE 
obtained with any other system; by the use of a constant flow of 
irrigating fluid that dilates the posterior urethra the to-and-fro as 
well as the rotatory motions of the instrument are facilitated, trauma- 
tism is obviated, pain is dispelled, the urethra is unfolded and the 
thoroughness of inspection is enhanced; even the region of the neck 
of the bladder, almost inaccessible in a therapeutic sense through 
other instruments, can be attacked with ease; in the diagnosis of pros- 
tatic hypertrophy the cystourethroscope gives exact data obtainable 
with no other instrument. 
The Goldschmidt Instrument.—This is made up of a sheath with a 
large fenestra whose width corresponds to the diameter of the sheath, 
necessitating the cutting out of one-half of the circumference of the 
tube. A non-prismatic telescope is introduced, the source of illum- 
ination being situated either in the beak or in the roof of the sheath. 
Although a fairly good view of the urethra is obtained with this 
instrument, objects must necessarily suffer considerable distortion, 
owing to the fact that the part to be seen is parallel with the axis 
of the telescope. Then, too, the source of illumination takes up a 
portion of the field, disturbing the picture. Wossidlo has modified 
this instrument so that the view and accessibility of the parts for 
treatment are enhanced. 
The Buerger Cystourethroscope.—Two types of instrument are 
available, one for simple observation and another for special opera- 
tive work, the optical principle involved being the same in both. 
In the Buerger cystourethroscope a true picture of the interior of 
the posterior urethra is obtained by a special lens system, which 
produces scant augmentation in the size of near objects, and looks 
downward at right angles upon the field. 
The observation instrument (Fig. 55) consists of a sheath with a 
curved detachable beak, an obturator, and telescope. In the sheath 
there is a small fenestra, two irrigating cocks, and the source of illum- 
ination is a small lamp behind an obliquely set window, illumination 
coming from above. The telescope is provided with a single catheter 
outlet and deflector. 
Technic of Cystourethroscopy. *—The sheath with obturator in situ 
is introduced into the bladder, the obturator removed, and if the 
contents of the bladder are cloudy, irrigation is carried out through 
the sheath. Otherwise the telescope may be inserted at once, an 
irrigator attached to one of the lateral faucets, and a constant flow7 
of boric acid solution is allowed to pass through the sheath, being 
controlled with the finger of the left hand at the stopcock. The light 
is then turned on, the beak turned up, the lens looking downward. 
The trigone is first inspected; then the sphincteric margin is brought 
into view, the instrument being rotated on its long axis. The lw,frk’- 
ment is then gradually withdrawn and the posterior urethra exam- 
ined as far as the membranous urethra. The instrument is then 
* With the Buerger cystourethroscope. THE URETHROSCOPE 
63 
introduced again beyond the sphincter and the bladder emptied, if 
it is too full, either through the irrigating cock or by withdrawing 
the telescope. By rotation of the instrument the superior and lateral 
walls of the posterior urethra are now viewed. Finally, the men- 
branous urethra and bulb are examined, and upon withdrawing the 
instrument the left hand firmly grasps the penis, so that an inspection 
of the anterior urethra can also be carried out. 
In order to facilitate localization of the findings obtained with the 
cystourethroscope, it is expedient to divide up the posterior urethra 
in an arbitrary way, taking certain well-defined landmarks, such as 
the annulus urethralis, or margin of the internal sphincter of the 
bladder, and the colliculus seminalis, in determining the extent of 
each portion. The subdivisions that are most useful in practice 
are the following: 
Fig. 55.—Buerger observation cystourethroscope. 
The sphincter margin with superior (roof), inferior (floor) and 
lateral portions (sides); the pars prostatica (C) and the pars mem- 
branacea (B) (Fig. 56). 
We divide the prostatic urethra into: 
(1) Supramontane portion between the sphincter margin and 
verumontanum, with a roof, lateral walls (sides) and floor (U). (2) 
Montane portion with a roof, sides and floor (T). 
The floor of the supramontane portion shows the fossula prostatica 
(F P) and the floor of the montane portion contains the colliculus 
(verumontanum or urethral crest) and lateral sulci (sulci laterales). 
If we regard the complete ridge or verumontanum as the urethral 
crest (crista urethralis) it seems best, for topographical reasons, to 64 
THE CYSTOSCOPE AND ITS USE 
distinguish the following parts: Posteriorly (toward the bladder) 
there are usually a number of small bands that lie in the fossula 
prostatica and pass into the crista urethralis, namely, the posterior 
frenula. They belong both to the supramontane portion and to 
Fig. 56.—Diagrammatic subdivision of the posterior urethra, the membranous urethra, 
and bulb. 
the montane. The crista shows a posterior gradual inclination or 
declive (S), a central prominence, or summit, and the anterior distal 
slope, the acclive (R). We shall drop the term urethral crest and 
speak only of a verumontanum or colliculus showing a summit, acclive 
(anterior crista), and declive (posterior crista). The valleys on either 
side of the colliculus are the sulci laterales. 
Fig. 57.—Floor of the sphincter and supramontane urethra. 
The membranous urethra (B) receives the terminating fold of the 
acclive and also has a roof, side walls and floor. 
Normal Urethroscopic Picture (Posterior Urethra).—The Supramon- 
tane Region.—The markings of the floor are prolongations of those of THE URETHROSCOPE 
65 
the trigone. The floor descends toward the periphery and terminates 
in the fossula prostatica. The mucous membrane of this region is of 
a deeper red than that of the roof and sides of the sphincterie margin. 
As for the markings, we usually find longitudinal vessels which show a 
tendency to converge toward the periphery, taking their source from 
the sphincterie margin and passing toward the fossula prostatica 
(Fig. 57). 
The side walls and roof present nothing worthy of note. The 
supramontane region contains a proximal and a distal portion. The 
proximal part corresponds to the true internal sphincter. Distally, 
the floor of the pars supramontana contains the fossula prostatica, in 
which lie the posterior frenula, tiny ridges which pass backward from 
the foot of the deelive, diverging as they are traced backward toward 
the sphincter and varying both in number, in size and inclination. 
At the level of the fossula prostatica we begin to meet with the 
larger, plainly visible prostatic ducts, that hide in the depression 
between the posterior frenula and at the foot of the deelive. 
Fig. 58.—Normal type of colliculus 
(verumontanum), with large utricle. 
Fig. 59.—Normal colliculus, showing 
three vertical slits, the utricle in the 
centre and the ejaculatory ducts on 
either side. 
The Montane Region.—The verumontanum has a summit, a posterior 
portion or deelive, and an anterior portion or aceiive. The size of 
the verumontanum varies greatly. The general shape of the region, 
too, is subject to variation, insofar as it may sometimes show a deep 
concavity, and at other times seems to be almost filled by the veru- 
montanum. 
Types of verumontanum are illustrated in Figs. 58, 59 and 60. In 
most the orifice of the utricle can be distinctly seen. It takes a med- 
ian position not far from the summit, varying in general appearance, 
sometimes being punctiform, slit-like (Figs. 58 and 59), umbilicated, 
even of bizarre form. Commencing by a fine tapering extremity in 
the membranous urethra the urethral crest broadens in a triangular 
fashion as it ascends, becoming the acclive of the colliculus. In most 
cases the ejaculatory ducts can be made out as two symmetrically 
situated orifices somewhat below, distal and to either side of the 
utricle. They may be vertical slits or may resemble the prominent 
eyes of a frog when they occupy a more lateral position. 66 
THE CYSTOSCOPE AND ITS USE 
In the contracted state the color of the colliculus is a pale yellowish- 
red. A change in color takes place when, upon artificial irritation, 
traumatism, or psychical excitation, this body becomes congested. 
The Sulci Laterafes.—Their depth varies considerably in different 
cases. It is in these sulci that we find a number of prostatic ducts 
varying from two to six sometimes in the form of tiny slit-like openings, 
and more frequently having a punctate shape. The mucous mem- 
brane here is also of pale reddish-yellow and the vascular markings 
are in the form of irregular longitudinal streaks and tortuous delicate 
vessels. 
As for the side walls, these offer very little of interest. In most 
cases there is a fairly abrupt rise from the sulci, and in other cases 
there is a concavity which is of a somewhat deeper red than the floor. 
The Pars Membranacea.—As the instrument is withdrawn from the 
montane region with the fenestra turned downward the acclive can 
be followed by its tapering crest into the membranous urethra. The 
longitudinal markings are very distinct, as a ride, parallel or slightly 
converging vascular striations running distally on either side of the 
crest and gradually becoming lost in the floor of the membranous 
urethra. 
Fig. 60.—Normal colliculus, showing the 
utricle, the ejaculatory ducts, the declive 
above and the posterior frenula. 
Fig. 61.—Junction of the bulbous and 
pendulous urethra; the bulb is not 
properly illuminated. 
The delicate median ridge of the acclive, as it becomes lost in this 
portion of the urethra, often shows a striking pallor at its summit or 
middle, due partly to the pressure effect of the instrument and pos- 
sibly also to an avascular condition of the part. 
The Bulbous Urethra.—The pars bulbosa may be so large that when 
distended with fluid its distance from the fenestra and lamp is con- 
siderable and illumination becomes diminished. The floor presents 
a corrugated appearance with occasional transverse folds. The roof 
and the sides do not present these plicae. A useful and interesting 
distal landmark is afforded by the junction of the bulbous and penile 
urethra (Fig. 61). The transverse margin with the illuminated 
mucous membrane below presents the beginning of the penile urethra. 
On either side the folded lateral wall and part of the floor of the bul- 
bous urethra are seen, and the central upper dark region represents 
the poorly illuminated distended bulb. THE URETHROSCOPE 
67 
The Sphincter Margin.—Three parts may be considered: the vesical 
part, which also belongs to the realm of the right-angled and retro- 
grade cystoscope; the true margin, or ring; and the urethral portion. 
Owing to anatomical conditions, it is impossible, in the male, to 
obtain a satisfactory view of a small zone adjoining the roof of the 
sphincter (the juxtasphincteric part of the bladder roof). The 
sphincteric margin, however, can be perfectly seen throughout. Our 
inability to depress the ocular of the instrument sufficiently makes 
it impossible to approximate the window of the instrument near 
enough to obtain a proper view of an area adjoining the roof of the 
sphincter. At the sides, however, this is easier, particularly if we 
allow the bladder to collapse. In examining the inferior aspect of 
the vesical portion of the sphincter, we encounter no difficulty, for 
the transition from trigone to floor of the vesical sphincter is a grad- 
ual one, and there is no sudden drop or sudden concavity, such as 
is characteristic for the roof and sides. In the female, these obstacles 
do not obtain, the urethra being short and the instrument having 
perfect freedom of motion. In the picture of the floor (Fig. 57), 
there is an upper portion which is relatively dark and represents the 
poorly illuminated bladder. Below this is the beginning of the floor 
of the pars supramontana with its slightly convex margin, the internal 
orifice or floor of the sphincteric margin. The color of this part is 
a fairly deep red admixed with yellow, and the vascular markings 
run in a longitudinal direction, with a tendency to converge toward 
the urethra. In the picture of the sides of the sphincter we note the 
absence of vascular markings and a relative pallor as compared with 
the floor. A slight concavity is the rule. The sides are usually 
counterparts (Fig. 62), but the roof of the sphincteric margin often 
represents a more acute angle. 
Pathological Lesions.—Just a bare mention of some important 
lesions can be made here. A more complete description may be 
sought in special monographs.2 
Sphincteric or Urethrovesical Lesions.—Cystitis colli, lesions of gon- 
orrheal urethrocystitis, edema, leukoplakia, urethritis cystica (Fig. 
63), cystitis proliferans, papillomata, anomalies, early incisure and 
lobe formation, indicating hypertrophy of the prostate, the tabs 
following healed proliferative processes—all these can be distinctly 
made out. 
The mpramontane region is the favorite site of urethritis prolifer- 
ans, which is characterized by hypertrophy of the mucous membrane, 
bulbous knobs, thickenings resembling small cysts. Widely dilated 
crypts occur as a sequel of gonorrhea. 
In urethritis chronica cystica the formation of cysts or edematous 
bodies is common, and these may involve any portion of the supra- 
montane or montane urethra. The cystic changes may be so exten- 
sive as to involve the whole of the fossula, even converting the veru- 
montanum into a cystic or edematous mass (Fig. 64). 
In the montane region the lesions of the verumontanum are impor- 68 
THE CYSTOSCOPE AND ITS USE 
tant: hyperemia, swelling, distortion, excrescences, enlargement, a 
velvety appearance, absence of vascular markings, disappearance of 
the openings of the ejaculatory ducts, while the utricle remains 
visible, etc. As a result of posterior urethritis, the mucous mem- 
brane of the verumontanum loses its smoothness, often developing 
cockscomb-like vegetations. Intense changes with conversion of 
the summit of the verumontanum into a deep crater (Fig. 65) and 
other distortions result from the rupture of abscesses. 
Fig. 62.—Right margin of the 
sphincter. 
Fig. 63.—Cystic changes at the right 
margin of the sphincter. 
In our experience, enlargement, hyperemia and inflammation of the 
colliculus are not as frequent as one would suppose from the writings 
of those who have relied upon direct endoscopic examination. 
As a result of repeated instrumentation, traumatism or chronic 
urethritis, the verumontanum suffers marked alterations. A number 
of knob-like masses may be all that is left of it; peculiar bands may 
divide it into irregular portions, or it may almost completely dis- 
appear through atrophy. 
Fig. 64.—Cystic changes in the 
verumontanum. 
Fig. 65.—Atrophy of the verumon- 
tanum with crater formation due to 
rupture of an abscess. 
Dee]) scars in the montane (Fig. 66) and supramontane urethra are 
the sequels of instrumentation, perforation, and rupture of prostatic 
abscesses, traumatism and operations for stricture. Papillomata are 
not uncommon, particularly near the summit of the colliculus, and 
polyps of the lateral walls and membranous urethra are not rare. THE URETHROSCOPE 
69 
In the membranous and bulbous urethra strictures of large calibre 
with their transverse bands and ridges are frequently demonstrable. 
Stricture usually forms shelf-like projections in the floor, sometimes 
extending over either lateral wall, with white crow’s foot-like lateral 
offshoots. 
Fig. 66.—A deep scar and large crypt 
in the right sulcus lateralis and distor- 
tion of the colliculus. 
Fig. 67.—Floor of the sphincter in 
so-called lateral lobe hypertrophy 
(prostatic adenoma). 
In prostatic hypertrophy the cystourethroscope will demonstrate the 
very earliest submucous adenoma formations. The outline of the 
sphincter will present either an intrusion at the site of the submucous 
adenoma, or a distinct incisure, often at the floor, roof or sides of the 
sphincter. Such clefts indicate the convergence of two contiguous 
adenomata or “lobes.” As a rule, in cases of so-called “lateral 
lobe hypertrophy” the normal convex line at the floor of the sphincter 
is replaced by two distinct rounded bodies (Fig. 67). These can be 
traced into the supramontane urethra where they look like two large 
Fig. 68.—Lateral lobe hypertrophy 
in the supramontane region viewed with 
the cystourethroscope. 
Fig. 69.—Lateral lobe hypertrophy 
view just above the verumontanum; 
the latter is small. 
vocal chords, separated by a deep cleft (Fig. 68). Even the termina- 
tion of these lobes in the membrano-montane region can be found, 
and the verumontanum will appear much reduced in size (Fig. 69). 
A middle lobe may be combined with the lateral or may be present 
alone. Its presence is easily recognized at the floor of the sphincter. 70 
THE CYSTOSCOPE AND ITS USE 
OPERATIVE URETHROSCOPY. 
This includes all therapeutic procedures that are applicable through 
either a urethroscope or cystourethroscope. 
In the Anterior Urethra.—Very few instruments will suffice to do all 
the necessary therapeutic work in the anterior urethra. Cotton 
applicators, preferably on wooden handles, a fine probe, an electro- 
lytic needle, a high-frequency applicator and an operative punch 
and alligator forceps should be available. 
The lacunae of Morgagni and glands of Littre may be destroyed 
either with the electrolytic needle or with the high-frequency elec- 
trode, the aim being to burn through the inner wall of the lacunae 
or glands, so as to leave a wide avenue of communication with the 
urethral lumen, or to completely destroy the glands. Under special 
circumstances a small Kollmann knife may be of value in incising 
closed inflammatory foci.10 
In the Posterior Urethra.—The straight urethroscope, the Swinburne, 
the Goldschmidt, Wossidlo, or the Buerger instruments may be 
employed. 
Through urethroscopes (endoscopes), the following manipulations 
have been suggested: The application of silver nitrate in the strengths 
of 5, 10, 15 and 20 per cent, to lesions in the posterior urethra; caut- 
erization of polypi and papillomata with galvanocautery or the high- 
frequency current; incision of cysts or closed suppurative foci with 
a knife; the injection of the utricle with silver solutions through a 
special cannula; and the removal of foreign bodies with forceps. All 
of these procedures can be carried out by experts, but will be found 
difficult of execution through mere endoscopes. Practically all neces- 
sary manipulations can be more easily learned and more precisely 
executed with the operating cystourethroscope. 
Operating Cystourethroscopes.*—These are of two types: The indi- 
rect (prismatic) and direct (non-prismatic). The former is repre- 
sented by the Buerger observation and operating cystourethroscopes, 
the latter by the universal urethro- or urethrocystoscope. The gen- 
eral construction (Fig. 70) of the indirect type is the same as that 
of the observation cystourethroscope, except that the fenestra and 
the catheter outlet are larger, both being ample for the insertion of 
operating devices. The lamp is arranged to give adequate illumina- 
tion in the bladder as well as in the urethra. Synchronous 
catheterization of the ureters is possible, either through the operating 
telescope or through a special telescopef provided with two smaller 
outlets, and a fin to separate the catheters. 
Technic and Application.—With the operating punch forceps the 
following therapeutic and diagnostic procedures are possible: (1) 
The removal of excrescences, inflammatory hypertrophies and inflam- 
matory polypi at the vesical sphincter and in the urethra; (2) the 
* Buerger Operating Cystourethroscope, Wappler Elec. Mfg. Co., and Buerger 
Universal Cystourethroscope. 
t This may be obtained by special order from the Wappler Elec. Mfg. Co. OPERATIVE URETHROSCOPY 
71 
ablation of polypi and papillomata in the urethra of the male (this 
can be carried out in a few seconds and will be found much easier 
technically than through a straight tube); (3) the removal of pieces 
of tissue for diagnosis; (4) the opening of the superior wall of the 
utricle when this harbors inflammatory exudate, the injection of 
silver solutions being less efficacious; (5) the application of the high- 
frequency current through a special electrode* (the d’Arsonval current 
is preferred). 
One of the most useful fields for the application of the operating 
cystourethroscope is in the treatment of papillomata at the sphinc- 
teric margin and for the diagnostic removal of pieces of tumor in 
this region. The application of medicaments to the posterior urethra 
Fig. 70.—Buerger’s operating cystourethroscope. This instrument has recently been 
constructed according to Buerger’s specifications of a calibre equivalent to 21 French, a 
useful instrument in case of stricture and prostatic adenoma. 
through the operating cystourethroscope is carried out as follows: 
After the lesion is recognized the sheath is firmly held with the left 
hand in the position in which the lesion was found, while the tele- 
scope is removed and the fluid aspirated or mopped out of the sheath. 
Then the medicated applicator is introduced. 
Buerger’s Universal Cystourethroscope.—This instrument employs 
the Goldschmidt-Nitze type of direct non-prismatic telescope in a 
specially designed endoscopic tube, and is so constructed that by 
interchange of its parts it is available either as a cystourethroscope 
for the anterior urethra, an air-inflating or aero-urethroscope, a 
* Bugbee electrode, Wappler Elec. Mfg. Co. 72 
THE CYSTOSCOPE AND ITS USE 
posterior urethroscope or cystourethroscope of the irrigating type, 
a Kelly cystoscope, an Elsner-Braasch eystoscope, and a direct 
catheterizing cystoscope and operating cystoscope. It consists of 
a straight endoscopic tube (Fig. 71), an obturator for the anterior 
urethra, a curved obturator for the posterior urethra and bladder, 
a light-carrying tube, a telescope, and magnifying window. The 
endoscopic tube carries a large catheter outlet for the introduction 
of operating devices, applicators, catheters, etc., and permits of the 
introduction of either of the two obturators and also the light-carry- 
ing tube. Either the direct non-prismatic telescope or the magnifying 
window fit into the ocular end of the light-carrying tube. 
In Buerger’s latest model (Fig. 72), provisions are made for the 
insertion of a special lamp to permit of extensive bladder investiga- 
tion, and the catheter outlet is attached to the telescope. The shaft 
is so constructed as to permit of the employment of several sizes of 
tubes, serving thus as an endoscope of variable dimensions. 
Fig. 71.—Buerger’s universal urethroscope with Philip’s filiform bougie for treatment 
of strictures of the urethra. 
Special Diagnostic Application.—Paralytic Conditions of the Sphinc- 
ter.—Indirect and direct cystonrethroscopes are both valuable in a 
study of conditions of relaxation of the sphincteric region, the direct 
telescopic method giving possibly more information than the indirect, 
in that we have at our disposal a means of estimating the functional 
activity of the sphincter. When the function of the sphincter is partly 
in abeyance, when it is relaxed, as it were, it is possible to dilate it 
much more easily than in the normal by means of the irrigating 
fluid. The examining instrument acquires greater ease of motion 
in the urethra, and can often be pushed backward and forward with- 
out causing bleeding and without meeting any resistance at the 
sphincter. This circumstance alone may be regarded as indicative 
of sphincteric relaxation. 
We may distinguish between the mild or early stages of sphincteric 
relaxation, or the well-developed stage, in which the floor of the 
sphincter has lost its tone completely, and retracts so that the inter- 
nal sphincteric orifice opens in a funnel-shaped fashion into the 
bladder. OPERATIVE URETHROSCOPY 
73 
Not only is the direct type of cystourethroscope of great value 
in cases of mild relaxation of the sphincteric region, when it can be 
definitely shown to have acquired greater ease of motion, in a to-and- 
Fig. 72.—Second model of author’s universal cystourethroscope. From above down- 
ward, endoscopic tube and mandrin for introduction into bladder; endoscopic light 
carrier and ocular fenestra; light carrier for bladder illumination; and direct telescope. 
Fig. 73.—The picture obtained with the direct cystourethroscope in a case of relax- 
ation of the sphincter; a, floor of sphincter b-c, show the recession of the floor of the 
sphincter. 
fro sense, but particularly is it valuable, when it shows that the floor 
of the sphincter has definitely retracted, as shown in a case from 
which Fig. 73 wras drawn. Here we see in Fig. 73, c, d, that the floor 74 
THE CYSTOSCOPE AND ITS USE 
of the sphincter is dark a good distance from the field of vision, 
undoubtedly relaxed. Whereas much more of the lateral aspect of 
the sphincter comes into view than in the normal cases. The relaxa- 
tion in the region just behind the verumontanum is also seen (Fig. 
73 b). 
Where the paralytic condition of the sphincter is well developed, 
the cystourethroscope of the indirect type may give valuable informa- 
tion, as seen in Fig. 74. 
Fig. 74.—On the left, the views obtained with the indirect cystourethroscope in a 
case of the paralysis of the sphincteric reunion; on the right a sagittal section of the nor- 
mal and paralytic sphincter and bladder. 
Technic.—The sheath fitted with the curved obturator for the 
bladder and posterior urethra or the short obturator for the anterior 
urethra is introduced, and when the bladder and posterior urethra 
are to be inspected the obturator is removed, the bladder emptied 
and irrigated through the sheath. The light-carrying tube and tele- 
scope are then locked into place, and the irrigating fluid is allowed 
to flow. The trigone and ureters come into view and the ureters 
may be catheterized according to the direct method. The instru- 
ment is withdrawn, the trigone, the sphincteric region, the supra- 
montane, montane, membranous, bulbous and penile urethra are 
inspected, a sort of periscopic view being obtained of the neck of 
the bladder and urethra. This instrument will be found particularly 
useful in the recognition and treatment of filiform strictures of the 
urethra. OPERA TIVE URETHROSCOP Y 
75 
Urethroscopy in the Female.—The Kelly type of endoscope answers 
for work in the urethra itself. For the juxtasphincteric margin, how- 
ever, the operating cystourethroscope is to be preferred. 
Selection of Cystoscopes, Urethroscopes and Cystourethroscopes.—In 
the vast majority of cases, the Buerger cystoscope with two sheaths 
will suffice for observation and ureteral catheterization. A No. 18 
French single catheterizing and a 21 French Buerger catheterizing 
cystoscope are useful when small calibre is desirable. In children a 
small Nitze or Otis-Nitze (10 or 12 French) for observation, a single 
catheterizing (17 or 18 French), and Buerger’s smallest 15 French 
single catheterizing have their sphere of application. 
In special cases, such as contracted bladder, in prostatic hyper- 
trophy for study of the sphincteric region, and when the posterior 
urethra, too, must be attacked, the operating cystourethroscope is 
to be used. It combines the possibility of operative work with syn- 
chronous ureteral catheterization either through its operating telescope 
or through a special telescope carrying a fin and two catheter outlets. 
Whenever we desire to combine ureteral catheterization with any 
endovesical operative procedure, an operating cystoscope, or the 
combination operating cystoscope should be selected. 
For inspection of the anterior urethra the straight tubes (Valentine, 
Squier, Buys or Young) are admirable. For the posterior urethra 
the Lowenhardt, Swinburne, or Luys find adherents. The cysto- 
urethroscope is best in our opinion. In treating the posterior urethra 
the two types of Buerger operating cystourethroscope are recom- 
mended. For Buerger’s method of treating filiform strictures of the 
urethra the direct non-prismatic universal cystourethroscope should 
be employed. 
1. Buerger: Am. Jour. Surg., April, 1913. 
2. Buerger: Am. Jour. Urol., January, 1911; loc. cit., January, 1912. 
3. Buerger: Ann. Surg., February, 1909. 
4. Buerger: Med. Rec., June 21, 1913. 
5. Buerger: New York Med. Jour., April 1, 1911; Am. Jour. Uro]., September, 1911. 
6. Buerger: Surg., Gyn. and Obst., August, 1915. 
7. Frank: Med. Klinik, 1907, No. 12. 
8. Hinman: Jour. Am. Med. Assn., June 26, 1915. 
9. Kelly: Johns Hopkins Hosp. Bull., 1893, iv, 101; Am. Jour. Obst., xxix, 1. 
10. Oberlander-Kollmann: Die chronische Gonorrhoe der mannlichen Harnrohre, 
Leipzig, 1910. 
BIBLIOGRAPHY. CHAPTER II. 
METHODS OF DIAGNOSIS IN LESIONS OF THE URINARY 
TRACT. 
By BRANSFORD LEWIS, M.D. 
Introduction.—The following general remarks on genito-urinary 
diagnosis may be looked on by some as an innovation not sanctioned by 
custom, and one hardly appropriate to a scientific treatise for urologists. 
But when it is understood that they are written for the advancement of 
the scientific aspects of urology—to bring up and straighten out the 
irregular marching lines where they are hesitant and lagging; when it 
is understood that they are written from the stand-point of the earnest 
student of facts and causes; and that the conscientious hope exists 
that they may throw some light on the vital and glaring question, why 
so many failures in genito-urinary diagnosis continue to appear, not- 
withstanding that this is an era of ample instrumental equipment and 
well-organized technic for the successful practice of urology—it is 
hoped that these remarks may seem timely and appropriate. But 
especially is it desired that they may be received in the spirit in which 
they are tendered, as having the sincere purpose of being serviceable 
and practically beneficial to all concerned—to patient, specialist, and 
practitioner. 
In further explanation, it might be said that the writer esteems 
diagnosis as the most important, by far, of all the subjects of urology; 
and he believes that anything that contributes to a better under- 
standing of its general principles, its successes or its failures, should 
promote the interests of urology from its foundation up. 
SOME VITAL TRUTHS REGARDING GENITO-URINARY DIAGNOSIS. 
Diagnosis in urology has experienced mutations and phases of evolu- 
tion just as have other departments of medicine and surgery. 
While in ancient times Hippocrates and Cornelius Celsus pursued 
logical though primitive methods in reckoning diagnoses and applying 
their deductions to the treatment of urinary retention, stone, and other 
genito-urinary affections, it remained for the later period of medi- 
evalism to witness the most extreme exploitation of the urine as an 
index of disease. Guiteras1 relates that at this period (about the 
fifteenth century) examination of the urine was resorted to not only 
by the regular practitioner and the university graduate, but also by 
the school of quacks, known as uromancers or uroscopists. These 
76 VITAL TRUTHS REGARDING GENITO-URINARY DIAGNOSIS 
77 
quacks would gravely inspect urine passed into glass flasks and imme- 
diately guess the illness and temperament of the patient, and then base 
a miraculous cure thereon. While the modern trend is hardly so 
materialistic as this, it is, nevertheless, a fact that there have been 
marked changes in that direction in methods of investigation for devel- 
oping diagnoses, even during the last quarter-century. Previous to 
that time investigators of greatest acumen had, perforce, to resort to 
and rely on the evidences then attainable in genito-urinary diseases, 
which consisted mainly of symptomatology plus the external evidences 
observable and an examination of the urine. Under the stress of neces- 
sity urologists became most skilful in refined analysis of symptoms, 
weighing at its full value every deviation from the normal either as 
detected by them or as related by the patient; the art of deduction 
doubtless reached its ultimate degree of perfection in the hands of 
Iticord, of Fournier, Guyon, Sir Henry Thompson, and Ultzmann. 
The contributions of Guyon fairly scintillate with logic and acumen as 
they relate the diagnostic estimate to be placed on the symptoms of 
urinary tuberculosis, urinary lithiasis, “ painful cystitis,” etc. But the 
trouble came when there were no symptoms to analyze; when there 
were kidneys destroyed by stone and never a backache; when there 
was pus in urine and little to indicate its source; hematuria and no 
index of its causation or its point of origin. The difficulties of the situa- 
tion were enhanced by reason of the fact that the genito-urinary organs, 
hidden more or less in the body, were inaccessible to the means of 
research then available; and reliance was limited to the examination 
of the only factor that was at hand, namely, the urinary excretion. 
There can be no doubt that accurate and comprehensive diagnosis 
has been the most influential factor in the establishment of urology 
on the scientific and satisfactory plane on which it rests today. It was 
the turning of the patient inside out, so to speak, and the plain demon- 
stration of the cause and nature of his complaints by means of the 
various instruments of diagnostic precision, that lias accomplished the 
miracle of evident progress; that has developed urology from venere- 
ology; that has won this field from the domain of obscurity and empiri- 
cism to one of science and accomplishment. 
Nevertheless, while urology as a specialty has progressed in the man- 
ner and extent mentioned, it cannot be said that the general profession 
has kept pace with its progress. The chief basis for this remark lies in 
the countless number of genito-urinary patients who suffer needlessly 
from month to month and year to year—ten, twenty or more years, 
often—while under the care of practitioners who go no further in efforts 
at relief than to supply various “ favorite prescriptions” for urinary 
symptoms or complaints. Instead of giving undivided attention to 
efforts at learning the source and causation of a hematuria, they 
supply drugs and measures for stopping the bleeding, which is the 
worst object that could be accomplished by them at that time. Instead 
of learning the origin and nature of an infection, they are industriously 
and empirically supplying “internal antiseptics,” vaccines, or urinary 78 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
soothing syrups, that palliate, perhaps, but incidentally postpone the 
day of definite diagnosis and effectual relief. The patient may, indeed, 
have cause for self-gratulation if he is not incidentally conducted, mean- 
time, from a benign into a malignant period of growth in the bladder, 
passing from a condition amenable to treatment into one beyond relief 
or hope. When he is finally referred for the examination that has been 
long deferred or ignored, he is found to be beyond all human aid save 
that of palliating his progress to the grave. The failure of relief in an 
infinite number of such cases is due, not to obscurity of the disease or 
difficulty in diagnosis, but to the fact that no effort to attain a real 
diagnosis is systematically or methodically made or even advised. The 
precious time is spent on so-called treatment, and a wonderful oppor- 
tunity is wasted. If members of the profession could collectively 
realize the truth and import of these facts they could better appreciate 
the incalculable importance of genito-urinary diagnosis as compared 
with immature and ill-based therapy, and would oftener refrain from 
the reversed action alluded to. 
It is believed that so great is the importance of this matter that an 
awakening and reformation of the profession in this respect would not 
only redound to its benefit in scientific progress, but would markedly 
subtract from the sum total of human misery as well as add materially 
to the span of human life. 
There is one thought in this connection that cannot be suppressed or 
overlooked: Whenever a practitioner of medicine, either general or 
special, undertakes the care of a patient, he assumes responsibilities 
that he cannot avoid; he takes on the moral obligation to supply or to 
have supplied to that patient all means and mechanisms at the disposal 
of the profession that are necessary for securing the relief desired, and 
this whether the practitioner is himself capable of using them or not. 
Lack of familiarity with the use of the x-ray machine, or failure to 
possess one, does not excuse him for depriving his patient of the advan- 
tages of such a machine when needed. The same reasoning applies to 
the ophthalmoscope, or the cystoscope or any other of the parapher- 
nalia so useful and often so essential in modern medicine and 
surgery. 
Another broad fact of importance in this connection is that no prac- 
titioner who undertakes the care of such cases has the right to disclaim 
knowledge of the appliances used in the various specialties, and on that 
account justify himself for emitting the false doctrine that “nothing 
else can be done” in a given case. No one, in the author’s humble 
opinion, has the right to make any such ex-cathedra statement, and 
many a poor patient has, doubtless, been assisted to his grave on account 
of it. A better, truer, and more serviceable axiom would be: Some- 
thing can always he done. And, it might be further remarked, mainly 
through diagnosis. 
As to the causes of backwardness and inadequacy in genito-urinary 
diagnosis, it is probable that a part of the difficulty lies in the fact that 
the methods and technic of genito-urinary examinations, being of VITAL TRUTHS REGARDING GENITO-URINARY DIAGNOSIS 
79 
comparatively recent development, are not yet familiar to the pro- 
fession at large, or that they assume formidable proportions in the 
perspective of infrequent use or lack of practical experience. 
As a matter of fact, for most genito-urinary diseases the demands of 
serviceable diagnosis are easily met and may be carried out by anyone 
who possesses a logical mind and a reasonable acquaintance with labora- 
tory technic. This remark, of course, does not apply to the more re- 
fined and difficult steps of investigation, such as those of endoscopy, 
cystoscopy, etc. But for the ordinary investigation the greatest lapse 
seems to be in the lack of a formulated plan for pursuing the examina- 
tion. 
Relative Value of Symptoms and of Physical Examination for 
Diagnosis.—There should be no denial of the value of a well-rounded 
and carefully studied history of a genito-urinary case. Symptoms are 
often typical and characteristic of certain maladies, and lead to ready 
deductions that prove correct on applying the steps of investigation 
without which no genito-urinary diagnosis should ever receive con- 
sideration. But in many instances urinary symptoms are not typical, 
are not regular, do not conform to what would be expected of them or 
harmonize with the actual pathological conditions as later demonstrated 
by postmortem examination or otherwise. In many such cases the 
symptoms are unconventional and misleading. In renal cases, for in- 
stance, pain may arise apparently from the healthier of two diseased 
kidneys; or, indeed, acute and severe pain may be thus transposed 
from a totally diseased to a healthy kidney of the opposite side. If 
symptoms were to be accredited in such cases without the test of search- 
ing physical examination, it would readily lead to disastrous conse- 
quences. In fact, it has led to disastrous consequences in actual 
experience. These are facts well-known to all practitioners of experi- 
ence in urology. 
Method in the Quest for Diagnosis.—A certain prescribed plan of 
investigation should be carried out in every case of chronic urinary 
disorder, and all the steps should be included up to the point at which 
the diagnosis is not only made but completed. 
In a given case of urethritis, for instance, it is necessary to learn, not 
only the nature of the infection—as to whether gonococcal or not—but 
also whether the posterior urethra is involved*, and the prostate, and 
seminal vesicles, and all other parts of the body subject to such microbie 
invasion. The omission of either one of these features of diagnosis 
would be as serious an oversight as the omission of the other. To find 
gonococci in a urethral discharge and then treat the anterior urethra 
only, failing to recognize and treat the infected posterior urethra as 
well, would be like putting a splint on one of two broken legs and 
neglecting the other. That very tendency of many to ignore the post- 
urethral infection has probably been the most prolific source of failure 
in the treatment of gonorrheas, as was pointed out by the author as 
early as 1893;2 and, similarly, with the diagnosis of prostatic obstruc- 
tion, certain factors are absolutely essential to a serviceable diagnosis 80 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
and nothing short of them all will suffice. They must include definite 
information as to whether: 
1. The prostate is hypertrophied or atrophied? 
2. Whether there is obstruction to urination? 
3. If so, the relative amount of obstruction? 
4. The form, physical characteristics and nature of the obstruction? 
5. The physical condition and functional activity of the allied organs 
(especially heart and kidneys). 
To illustrate why it is necessary to learn all of these individual 
features in prostatic obstruction, it may be mentioned that no one could 
determine the proper measures for relieving such a case without first 
learning the several points of diagnosis mentioned and then acting on 
that precise information. And if, for instance, he learned the correct 
answers to the first four of these diagnostic points, operated skilfully 
but ignored investigation of the fifth point (with reference to the con- 
dition and functional activity of the allied organs), it might very readily 
prove to be another case of “successful operation, but the patient 
died;” because renal involvement with unrecognized suppression of 
urine, uremia and death may follow on the heels of the “successful” 
operation, a result that should readily be avoided by attention in diag- 
nosis to the point under discussion, together with appropriate prepara- 
tory treatment. Hence it is evident that diagnosis, to be efficient, must 
be not only analytical but comprehensive and inclusive. 
But to show that in the given instance of prostatic obstruction it is 
within the ability of any practitioner of ordinary skill to acquire the 
information desired in the five diagnostic points, it may be mentioned 
that the first point is determined by rectal palpation, the finger detect- 
ing whether the prostate is unduly large, unduly small, or of approxi- 
mately normal size. The second point is determined by the passing 
of a soft-rubber catheter into the bladder directly after the patient has 
finished voluntary urination, which shows whether there is residual 
urine or not; and the quantity of residuum thus obtained is the answer 
to the third point. The fourth point is not so easily settled, but, never- 
theless, should be settled in every case that has been proved by the 
steps above mentioned to be the subject of prostatic obstruction. It is 
most advantageously accomplished by means of the cystoscope, and 
especially the retrospective lens of the cystoscope, showing the confor- 
mation and character, etc., of the vesical neck and prostate. The fifth 
point is determined by examination of the urine and physical examina- 
tion of the heart, together with the application of such functional tests 
as are appropriate. 
It is therefore apparent that if carried out methodically and judi- 
ciously, the essential requirements for a working diagnosis of such a 
case, with the exception of one point only (cystoscopy), are within the 
ability of every practitioner of even ordinary skill and experience; and 
nothing has been demanded in the technic that was either unreasonable 
or ultra-scientific. As to the cystoscopy, every town of self-respecting 
ambition now possesses a cystoseopist of sufficient ability to resolve 
that question. PLAN OF INVESTIGATION 
81 
Hence the difficulties have proved, when fairly attacked, neither 
insurmountable nor appalling. Which may be said to be true, also, of 
diagnostic endeavors with reference to other diseases of the urinary 
organs. Difficulties melt down and disappear in the face of method 
and system, and repeated endeavor brings success. 
PLAN OF INVESTIGATION. 
So much depends on method and system in developing genito-urinary 
diagnosis that some definite plan should always be followed. The field 
of investigation being more or less limited, it is feasible, therefore, for 
those following this work as a specialty to formulate and have printed 
in the history book a series of questions relating to the several genito- 
urinary organs or diseases, with a blank for the response, which may be 
filled by an affirmative or negative sign for reply. This markedly 
shortens the time and labor in getting and recording the history. Cur- 
rent and additional events, treatments, reactions, and responses may be 
recorded on cards that are indexed and filed after the usual card-index 
filing system. Intricate and time-consuming bookkeeping may be 
avoided in this manner and all necessary records continued and kept 
indefinitely—and always available. 
The diagnosis should be based on the following three kinds of evidence: 
1. History and symptoms of the case. 
2. Physical examination of the patient. 
3. Examination of the secretions and excretions, pathological and 
physiological, of the organs in question; and of the blood (complement- 
fixation tests). 
I. History of the Case.—-The questioning should cover the family 
history, the previous personal history, and the history of the existing 
complaint. In the family history information that would have a bear- 
ing on hereditary influences and stigmata should be learned. The bale- 
ful effect of inherited syphilis is discovered with surprising frequency 
when definite search is made for it. This is especially true now that 
the Wassermann blood-test has come into frequent use. The writer 
has found syphilis to be the underlying factor in a number of instances 
in which there had been obstruction at the vesical neck from childhood 
to manhood.3 
While a positive history of hereditary syphilis might be of great 
significance, one should not place too much reliance on a failure to 
acknowledge such a history if there is reason to suspect the contrary. 
It is like the Wassermann blood test in this respect; while the positive 
test is of great import, the negative is of relatively little significance 
and must not weigh heavily in the final estimate. Neurologic, neurotic, 
and other tendencies should be inquired into as related to family 
traits. 
Previous Personal History.—In both chronic and acute affections of 
the urinary tract antecedent infections frequently have a dominant 
influence, and failure to discover them in developing the history may 82 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
seriously handicap one’s understanding of the case. Chronic and 
recurrent urethral discharges often are only exacerbations of uncured 
but apparently inactive urethritis; subacute vesiculitis may persist for 
years after active urethral discharge has ceased to be an outward sign 
of trouble. The insidious evidences of urethral stricture come on when 
the patient has but a dim remembrance of his former infection. Even 
at the risk of a seeming insistence the questioner should tactfully learn 
about all such “accidents” and conditions of the patient’s former 
life. 
Habits and customs have a bearing that is unrealized by individuals, 
sometimes; such as habitual postponement of the act of urination until 
long after the desire has been felt, either from occupational causes or 
undue modesty. Permanent damage to the bladder, ureters, and kid- 
neys is occasionally the price of such heedless practices. 
Habits of eating and drinking may have a bearing on obscure cases. 
Evidences of rheumatism, tuberculosis, defective metabolism, dyscra- 
sise, loss of weight or strength, should be developed in the history. 
Focal points of irritation and infection at distant parts of the body 
are now recognized as having a preeminent bearing on the urinary 
tract, notably the kidneys in connection with nephritis. 
Special inquiry should be made about pain; frequency or urgency 
in urination; changes in the urine; changes in the stream. 
Undoubtedly pain, though irksome, is a great conservator of the 
human kind. It is unfortunate that a larger proportion of genito- 
urinary maladies are not ushered in with pain. A larger proportion 
of sufferers would thereby be impelled earlier to seek medical assistance. 
Many accept even a bloody urine complacently for a long time just 
because there is no pain accompanying this portentous sign. A patient 
who possessed a growing hypernephroma held a letter of introduction 
from a physician to the writer for over six years before finally presenting 
it; there was pronounced hematuria all of that time. 
Pain may be primary or secondary in the genito-urinary organs. 
Originating in a diseased or strictured urethra, the irritation may be 
reflected into the rectum, presenting the whole complaint, so far as the 
patient knows it, at that point. Or ascarides vermicularis may display 
their vicious effect by reflected irritation from the rectum into the ure- 
thra, producing inordinate frequency or troublesome difficulty in urina- 
tion. Therefore, although one must learn what he can about pain, in 
getting the history, he must refrain from making deductions concerning 
it until physical examination is able to set him right. 
Pain in the back is ordinarily ascribed by the laity to “ kidney dis- 
ease,” and on so slight a piece of evidence do they often take cures and 
courses of treatment at the spas of repute. The profession is well 
aware that pain in the back seldom has such a significance, but the pro- 
fession is not so well aware of the fact that an actual renal pain is often 
transposed from one kidney into the region of its fellow; and it often 
requires the more exact findings of physical examination to establish 
the real origin of the complaint. PH YSICA L EX A MINA TION 
83 
The pain of prostatic inflammation is frequently reflected into the 
glans penis; that of the ureter into the cord and testis; that of the 
vesicles into the back, the rectum, or the testis. 
Frequency and urgency in urination are standard indications of 
irritation of the posterior urethra, not of the bladder. Inflammation of 
the posterior urethra is in itself a source of irritation and arouses the 
undue desire to urinate; hence undue frequency results. A healthy 
person should urinate from three to four times in twenty-four hours, 
and should not have to get up in the night for that purpose. It is 
practicable, therefore, to draw a fairly distinct line between normal and 
abnormal frequency of urination. 
Undue frequency in the daytime usually means an irritative or 
inflammatory causation, such as posturethritis or vesical stone; whereas, 
nocturnal frequency is more likely to indicate an obstructive causation 
(prostatic obstruction). 
Changes in the Urine.—The changes in the urine most liable to impress 
themselves on the attention of the patient relate to the appearance of 
blood, of pus, or of precipitated urates or phosphates. Information 
based on the time of appearance of any of these may be of great im- 
portance, as showing whether an infection or disease is of recent or 
remote origin. Patients have been able to establish that the clouding 
of their urine, for instance in an obstructive condition in an adult, had 
existed since childhood, which would at once eliminate ordinary pros- 
tatic hypertrophy or gonorrheal infection as the originators of the 
trouble and give the investigator quite a different view-point from the 
one that might be forming. The most effective use that can be made 
of information that the urine is bloody is immediately to start the train 
of real diagnostic endeavor—to put into motion the arrangements for 
systematic examination of the whole urinary tract and not only trace 
the blood to its origin, but also to learn the reason for its appearance 
in the urine. Until both of those objects are accomplished no effort should 
be made to stop the bleeding, unless it is of menacing proportions. In the 
presence, then, of hematuria, the first duty of the practitioner is one of 
diagnosis, not of treatment. 
Changes in the Urinary Stream.—Much significance has been attached 
by some to the description of changes in the stream as given by patients, 
but in view of the lack of information or observation powers in many 
patients, and their proneness to see the same things differently, the 
writer has seldom found their impressions in this regard to be of much 
service. Some patients with a normal stream complain that it has been 
twisted latterly; and others with well-defined obstruction from stricture 
or congenitally narrow meatus, say that they have never had any 
impediment in urination. It is hardly justifiable to place reliance in 
such an insecure basis. If, however, the investigator himself has the 
opportunity to observe the stream, its description may be worth while 
in the record. 
II. Physical Examination.—Nowhere in medicine or surgery do 
method and system count for more than they do in pursuing the 84 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
physical examination of genito-urinary cases, hi any times this will 
save the investigator from overlooking conditions that have a vital 
bearing; conditions that, without method and system, would assuredly 
go undiscovered. On a number of occasions the writer has seen crystal- 
clear urine passed by patients which might have led to the inference 
that there could be no such thing as gonorrheal infection present; yet 
massage of the vesicles made directly afterward has brought out pus 
and gonococci, leading to a vastly different conclusion and furnishing 
the required revelation for diagnosis and proper treatment. 
Physical Examination.—Following the taking of the history the uro- 
logic patient should be conducted through certain prescribed steps of 
physical examination, and without regard to whether diagnoses have 
been made of his case before or not. The only exception to this rule 
should be that in which the infectiousness or acuteness of the trouble 
indicate a postponement of instrumentation until a period in which it 
will not in itself cause injury or extension of infection. 
Physical examination in genito-urinary cases may be divided into 
general and local. The local examination naturally takes precedence 
over the general from the nature of the conditions. 
The steps of local examination may be subdivided into (a) those 
preceding instrumentation, and (b) those including instrumentation. 
Local Examination.—(a) Steps Preceding Instrumentation.—1. In- 
spection.—Obtain good exposure of the external genitals for complete 
inspection: Coat and vest oft* and clothing widely open. Inspect the 
external genitals, including especially the prepuce and urethral meatus 
for pathological secretions. If present, make smears on three glass 
slides for microscopic investigation: one for methylene-blue stain, one 
for Gram stain, and a third for reserve. 
2. Have the patient urinate into two clean, clear glasses, for inspec- 
tion and chemical and microscopic examination:* 
Microscopic and Chemical Examination.—1. Centrifugalize the two 
glasses of urine for microscopic and chemical examination. The first 
portion is better for detecting infecting organisms, pus that is sparse, 
red blood cells, etc.; while the second part is preferable for chemical 
examination and study of the condition of the kidneys, as indicated by 
the urine: Albumin, casts, red blood cells, urates, phosphates, specific 
gravity, etc. 
2. Palpation.-—Prostatic and vesicular palpation and massage. 
While the urine is undergoing sedimentation step No. 2 may be carried 
out. With the patient well exposed, bending forward over a chair, the 
hand of the operator protected with a finger cot or rubber glove, lubri- 
cated preferably with one of the iceland moss or gum tragacanth 
* If from the interview a suspicion of urinary tuberculosis is aroused, a specimen 
should be taken, by catheter only, at a subsequent time or at least after completion of 
the several steps now being described. Urine passed voluntarily should never be used 
for tubercle bacillus investigation (except for guinea-pig inoculation) because of the likeli- 
hood of confusion with the smegma bacillus. The only safe method is to exclude the 
smegma organisms by aseptic catheterization, either in males or females. INSTRUMENTATION 
85 
preparations, palpation of prostate and seminal vesicles is carefully 
executed; after which gentle massage of these organs is also carried out. 
At the same time a sterile butter platter or saucer is held under the 
penis and catches the drops of secretion expelled by the massage. This 
also furnishes material of value for microscopic examination, both in 
the stained and unstained (“fresh”) condition. Gonococci that were 
undiscoverable in the urinary specimens may be plainly evident in the 
massage specimens, and if such proves to be the case, one can readily 
understand wdiy it is worth while to be persistent and searching in such 
examinations. 
There may have been no discharge at the meatus, in a given case; 
there may be nothing of importance (pus, organisms) found in the sedi- 
mented urine passed after the inspection, and there may be no dripping 
into the butter platter on massage; and yet means are still available 
for gathering, at this time, gonococci-laden secretion from prostate or 
vesicles. With this object in view, following the massage and before 
any instrumentation is undertaken, the patient is directed to pass 
water again, this time into a third glass; and even though he urinated 
only a short while previously and he now passes but a few drops of 
urine, that amount suffices; for it brings out with it the massage effect 
(pus, mucus, leukocytes, organisms, spermatozoa, etc.) that up to that 
time had been retained in the posterior urethra by mere lack of sufficient 
volume to flow out. It has now been washed out by the additional 
drops of urine, and is at our disposal for examination just as if it had 
been obtained in the more usual way. If the patient proves unable to 
pass the additional urine into the third glass, we have still another mode 
of obtaining the desired massage effect: without a catheter, inject two 
or three ounces of warm distilled water into the bladder and allow the 
patient to pass it into the third glass. It is then sedimented and ex- 
amined as previously described. 
Microscopic Examination.—See Examination of the ITine. 
Instrumentation.—(a) Of the urethra; (6) of the bladder; (c) of the 
ureters and kidney pelves. 
Instrumental Examination of the Urethra.—This step is for 
chronic cases, not for acute. It should be conducted without pain or 
disturbance to the patient, leaving with him not even an unpleasant 
memory; and yet sad experiences with instrumentations may keep 
patients away from needed medical service for years at a time, so 
painful and shocking sometimes are they. 
Local Anesthesia.—Fifteen to twenty minims of 5 per cent, alypin 
solution properly used at this time are worth their weight in gold— 
giving contentment to the patient and blessings to the doctor. A 
rubber-tipped anterior urethral syringe is used to inject the solution 
into the urethra, a cushion of air following the fluid serving to distend 
the urethra and diffuse the solution as far as desired. The cushion is 
made by injecting the air with the same syringe (Fig. 75). The early 
burning effect is soon replaced by effective local anesthesia, whereupon 
bulb sounds (the largest possible size first, smaller ones next) are passed 86 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
as far as the cut-off muscle, to learn if there are strictures in the anterior 
urethra; or an air-inflation urethroscope of Mark is used for the same 
Fig. 75.—Anesthetizing the anterior urethra. 
Fig. 76,—Anesthetizing tne posterior urethra: Depositor dropping 
alypin tablets in prostatic urethra. 
purpose, disclosing at the same time any erosions, granulations, cicatri- 
cial deposits, etc., of chronic urethral processes. A full-sized urethral INSTR U ME NT A TION 
87 
steel sound may be used for determining the permeability of the poste- 
rior urethra; or it may be replaced by use of the posterior endoscope of 
McCarthy or Buerger, which give a distinct view of the verumontanum 
and its varying pathological conditions. Lastly, the steps of ordinary 
instrumentation are completed, in cases in which urinary obstruction or 
retention is suspected, by the passage into the bladder of a soft-rubber 
catheter for determining the amount, if any, of residual urine left after 
the voluntary urination of a few minutes before. 
(Note.—A dram or two of urine thus found would be negligible; 
whereas, 40 ounces would mean severe obstruction, and the several 
points for diagnosis previously mentioned (page 80) would then have 
to be solved.) 
Tubercle Bacilli.—If there is reason to suspect urinary tuberculosis, 
this is the stage at which investigation with this in view should be 
pursued. 
In certain cases the bacilli of tuberculosis are numerous and easily 
found in the urine; in other cases they are scarce and are then demon- 
strated microscopically only with difficulty. An expedient that serves 
for their easier detection, to which attention was called by Bryson, is 
that of utilizing for examination the small amount of urine (a dram or 
two) that may be drawn by catheter shortly after the patient has uri- 
nated voluntarily. It is supposed that this serves to collect the bacilli 
which have settled in the bas-fond, remaining and accumulating there 
in spite of successive urinations. 
The custom of catheterizing after voluntary urination may, then, 
have a double object: The determination of residuum, and the detec- 
tion of tubercle bacilli. The importance of this is reenforced by reason 
of the belief, long held by the writer, that voluntarily passed urine 
should never be used for searching for tubercle bacilli. The chance of 
finding the acid-fast smegma bacilli in such urine is too great and of 
differentiating them from tubercle bacilli too precarious to place reliance 
on such a measure. The only means that affords reliability, both in 
men and women, is to draw the urine by aseptic catheterization, avoid- 
ing the possibility of including smegma bacilli in the specimen. 
The writer has personal knowledge of several instances in which 
failure to carry out such precautions led to erroneous diagnoses and 
disastrous consequences, reliance having been placed on the accuracy 
of the bacteriologists’ unsupported reports. 
Summary.—The steps thus presented may seem from description 
elaborate and ponderous; but they are much more so in description 
than in practice, and take much longer in the telling than in the execu- 
tion. One might readily elaborate a more complicated plan of investi- 
gation, but the writer believes the one submitted to be simple, definite, 
and practicable; and no one who endeavors to do good work in this 
department can afford to minimize or ignore them. Nor should the 
sequence of the steps be reversed. The passing of any instrument 
before the voluntary urination or the massage would, from traumatism, 
superinduce the presence of blood and other cellular elements in the 88 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
urine that might wholly change and disguise the actual conditions pre- 
vailing and lead to erroneous conclusions. 
Instrumentation of the Bladder.—Sounds; stone-searchers. 
From time immemorial reliance has been placed on sounds, bougies, and 
stone-searchers for detecting foreign bodies, tumors and other patho- 
logical entities within the bladder. The sharp contact of a metal sound 
or searcher with a stone in the bladder elicits a click that is distinctive 
and of definite value for diagnosis when attained. But in a large pro- 
portion of cases in which vesical stone is present the click is not ob- 
tained. The stone may be coated with soft, sticky mucus that softens 
or prevents the expected contact; or it may be ensconced in a pocket 
under an overhanging prostate (Fig. 77), or in a diverticulum, prevent- 
ing the approach of the searcher within striking distance of the stone. 
Positive evidence only is of value with this method. But many a 
surgeon and patient, relying on its negative evidence, have been soothed 
into false security against the presence of stone and have failed utterly 
Fig. 77.—Enlarged prostate rendering stones inaccessible to sound, but evident to 
retrospective universal cystoscope. 
in their efforts at diagnosis. A diagnostic appliance or method to be 
efficient must be reliable; one that gives a large proportion of failures 
is not reliable and should be replaced by others affording reliability. 
Cystoscopy.—Cystoscopy outweighs all other methods and measures 
for diagnosis of affections of the bladder and upper urinary tract. It is 
analytical, comprehensive, and convincing. 
A discussion of cystoscopes and cystoscopic methods is presented 
elsewhere, but it is deemed appropriate to consider the logic and pro- 
priety of cystoscopy here. 
Indications for Cystoscopy.—The indications for cystoscopy in con- 
nection with disturbances of the upper urinary tract are many; the 
contra-indications are few. 
Cystoscopy should be performed in practically all cases of chronic 
urinary disturbance in which no definite contra-indication is present. 
It is often the case that an existing seminal vesiculitis or prostatitis 
appears quite sufficient to account for the persistence of an infection, INSTRUMENTATION 
89 
and treatment is expended solely on them without result, until finally, 
discouraged by lack of success and merely as an experimental measure, 
cystoscopy and ureteral catheterization are carried out, whereupon a 
flood of light is unexpectedly thrown on the case. It is found that the 
infection involves one or both pelves of the kidney as well, and that 
explanation might never have been attained without the cystoscopy 
and catheterization. 
Hematuria, pyuria, microbic infection, when demonstrable as coming 
from the upper or middle urinary tract, symptomatology that is in- 
veterate or is apparently referable to the kidneys or ureters, no matter 
of what character, demand cystoscopy with insistence that should never 
be denied. The definite indication in many of these is for diagnosis 
first, not treatment; and cystoscopy, together with ureteral catheteri- 
zation and radiography, are the means above all others for meeting that 
indication. Therefore, with chronic or obscure or unsatisfactory con- 
ditions of the urinary tract, it is advisable not to be too punctilious in 
awaiting the positive indications for cystoscopy, but rather to withhold 
it only in the face of definite contra-indications opposing it. 
Contra-indications to Cystoscopy.—Acute inflammatory conditions of 
the urinary tract, together with exacerbations of chronic inflamma- 
tions, form contra-indications for cystoscopy. This does not apply to 
anuria from renal or ureteral stone, which sometimes is relieved by 
ureteral catheterization. The same measure has been known to start 
up urinary secretion, for a time at least, in anuria from nephritis; so 
that cystoscopy need not be feared in these conditions where there is 
reason to apply it. 
Urinary tuberculosis has by some been considered a dangerous field 
for cystoscopy. It would more properly be termed a dangerous field with- 
out cystoscopy. The outcome of neglected urinary tuberculosis is not 
only unpromising but almost assuredly fatal. Urinary tuberculosis 
in the earlier periods means infection of one kidney only so far as the 
urinary tract is concerned. In other words, the discovery of the nature 
and location of the infection—clearly the province of the cystoscope— 
is the vital, pivotal step to be taken at a time when such a discovery is 
of service—at a time when it may lead directly to removal of the origi- 
nating focus of infection from the body and reclamation to health of the 
patient. No means other than the cystoscope can compare with it in 
the performing of this function. 
On the other hand, experience with thousands of cases of urinary 
tuberculosis, in the hands of many operators, has failed to show that 
cystoscopy is injurious. Such patients are usually inordinately tender 
and demand the liberal use of local anesthetics, but they recover from 
the transient effects of instrumentation quite satisfactorily. Some ob- 
structive phases of urinary tuberculosis are even improved by instru- 
mentation and local medication. 
Prostatism.—It is well known that prostatics may go for long periods 
with considerable obstruction and no infection until some form of 
instrumentation is undertaken; and whether this be done with or with- 90 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
out careful aseptic precautions it is liable to precipitate the long-deferred 
urinary infection and bring about conditions more painful and irritative 
than any that previously existed. Yet the claim that a prostatic should 
never be instrumented because of these facts would hardly receive 
general support. Like catheterization, cystoscopy is one of the disa- 
greeable necessities, temporarily objectionable, perhaps, but having the 
ultimate object of permanent relief and restoration. 
As mentioned previously, prostatic obstruction is of such multi- 
farious production that it cannot be adequately coped with except on a 
basis of accurate diagnosis. 
Contracture, hypertrophy, cyst formation, all may produce obstruc- 
tion, but do so in different ways; and it requires cystoscopic inspection 
to differentiate between them. 
It is as illogical to expect to accomplish this object without cystoscopy 
as it would be to expect to determine the amount of obstruction present 
without using a catheter. And the use of either is as liable to be fol- 
lowed by infection as the other. But their use paves the way to re- 
covery and is therefore amply justified. 
Uretliral stricture, prostatic inflammation, or abscess and other 
obstructive conditions militate against or interfere with the use of the 
cystoscope; but under such circumstances they themselves are the con- 
ditions demanding attention, and there is seldom any need for cystos- 
copy in connection with them. But if such a need were found, the 
obstructing factors could be attended to first, opening the channel 
for the introduction of the cystoscope. A narrow meatus should be 
incised for the same purpose when necessary. It must be remembered, 
too, that there are small-calibered cystoscopes on the market (No. 17 or 
18, French) which, though sacrificing certain features of the larger 
instruments, are advantageous for such exceptional conditions. 
Urine Segregation.—The separation of the urines of the two kidneys 
by means of segregators for a time was held in favor by some, but 
further experience with such instruments has proved that they are 
quite unreliable for diagnostic service in that they give false returns 
and lead to erroneous conclusions. In working with them the oper- 
ator is working in the dark and must take for granted that such 
exacting conditions are fulfilled as that of obtaining an effective water- 
shed between the ureteral orifices, and that each tube of the instrument 
is draining from its respective side and from this side only. That the 
instrument is unreliable was proved by Kiimmel,2 who found that in a 
case in which he had previously removed one kidney, the only urine 
that flowed came from the side on which the nephrectomy had been 
done. 
Aside from its incompetence for diagnosis, the segregator suffers 
when compared from the therapeutic stand-point with cystoscopy and 
ureteral catheterization. It offers no possibility of sounding ureters or 
of administering irrigations to kidney pelves. 
Ureteral Catheterization.—Ureteral catheterization is so closely 
associated with cystoscopy that what has been said may well refer, for URETERAL CATHETERIZATION 
91 
the most part, to this procedure also. But when, by cystoscopy, the 
pathological condition is clearly demonstrated to be in the bladder, 
such as a tumor, stone, simple ulcer, etc., and there are no indica- 
tions of further trouble above, ureteral catheterization may be deemed 
unnecessary. 
Some authors place much reliance on meatoscopy as a guide to con- 
ditions in the upper tract. They watch the urine as it issues in jets 
from the ureteral orifices, and inspect the orifices themselves, alleging 
that reliable evidence may thus be obtained as to the presence of pus 
or blood in the respective urines or pathological conditions in the 
ureters. It is but another instance of positive evidence being valuable 
and negative evidence worthless, or worse. 
If the ureteral orifice displays ulceration or the funnel-shaped de- 
pression characterizing tuberculous ureteral contraction, the evidence 
is of value; but it is established that many kidneys are tuberculous 
without the corresponding ureteral orifice showing any deviation from 
the normal. And to await the ureteral demonstration would be 
indefinitely postponing required action and seriously endangering the 
chances of the patient. 
As to the other claim, if it is impossible to say whether there are pus 
or blood cells in a glass of fairly clear urine without examining by the 
microscope, one can readily appreciate how much greater the difficulty 
of making the determination by macroscopic observation of urine while 
it is being ejected from ureteral orifices. The claim is preposterous 
except for pathological conditions that are very pronounced. There 
would be no objection to the claim did it not incline to mislead 
inexperienced cystoscopists who may not realize the fallacies of the 
situation. 
It is advisable, therefore, not to forego the many advantages of 
ureteral catheterization on too slight provocation. Many pathological 
conditions of the ureter are not discoverable by meatoscopy. Ureteral 
strictures, kinks or dilatations may betray no evidence at the meatus of 
their existence. 
Wax-tip Bougies.—The wax-tip bougies of Kelly have been tested 
by wide usage in the profession but have not found favor to the extent 
that exists with their illustrious author. That is probably explainable 
by the difference in the form of cystoscopes used. Kelly has never 
given up the use of his very simple pattern of cystoscopic specula, which 
he uses with women in the knee-chest position. This permits the use 
of the wax-tip bougies with more or less freedom from danger of con- 
tact with the instruments, thereby producing a false scratch. Most 
practitioners now use one of the several forms of lens cystoscopes on 
the market. With these it is difficult or impossible to prevent the 
scratching of the tip by the cystoscope itself, and thus casting doubt 
and confusion on the findings. 
Obstructions in Ureteral Catheterization— Obstruction to the passage 
of a ureteral catheter may occur either in a healthy or a diseased ureter. 
The axis of the channel may be such that the catheter impinges against 92 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
the wall and hangs there until dislodged by a twist or movement that 
enables the catheter to follow the curve of the channel, when it may 
pass easily. In other instances the presence of the catheter excites 
spasmodic contraction for a time of the muscles of the ureter, which 
clamping down on the catheter effectually oppose its passage until the 
spasm is relieved, when the catheter passes promptly and without 
further difficulty. Obstructed ureteral catheterization, therefore, 
does not always point to a pathological condition. In many instances 
in which catheters were obstructed by spasm of the ureter or angu- 
lation or fold in the ureter, the writer has found such obstruction to 
disappear immediately on changing from an indirect telescope to a di- 
rect one, or vice versa. This exchange of telescopes directs the cath- 
eter into the ureter at a different angle and often secures immediate 
and easy passage for the catheter that has been hanging fixed at a 
certain point in the ureter. It is therefore of advantage to have both 
forms of catheterizing telescope at hand for such emergencies, such 
as is embodied in the author’s universal and operating cystoscope. 
Organic pathological conditions, such as narrow ureteral meatus or 
stricture of the ureter, impacted calculus, kink, or an anomalous vessel 
crossing the ureter, may obstruct the passage of a ureteral catheter, 
and when met with must be differentiated by the various methods dis- 
cussed. Through the influence of a strictured ureter it often happens 
that from the resulting or coincident pelvic infection mncopus plugs 
cause colics, persisting pain, and backward pressure by coming in 
contact with and plugging up the narrowed orifice of such a constriction. 
The author has seen prolonged invalidism result therefrom, relieved 
promptly and permanently by widening the contraction to physiological 
proportions. 
Lack of Drainage after Ureteral Catheterization.—It occasionally 
happens that after an especially irksome and difficult essay at cathe- 
terization success is finally attained and the fruits of victory are natu- 
rally expected, but none appear. In other words, the urine does not 
flow through the catheters, notwithstanding their introduction well up 
to the kidney pelves. Such a disappointing failure may result from 
any one of several causes. The catheter itself may be stopped up, or 
it may be too high in the pelvis, thus failing to locate the eye of the 
catheter where it can draw the contents by siphonage or otherwise. 
A little mucopus plug caught in the eye of the catheter may close the 
outlet and defeat drainage for the time being. Another prolific cause 
for lack of drainage is the temporary discontinuance of renal activity 
in the presence of catheters in the ureters, one or both. The resulting 
“shock” to the kidneys seems to superinduce a temporary anuria or 
oliguria. The drinking of a glass of water usually restores activity 
and the expected drainage. The injection of a few drops of warm 
sterile water by means of a ureteral syringe will usually clear the 
catheter of a mucopus plug and start drainage. This is better than 
aspiration, except when the obstructing agent is thick pus. RADIOGRAPHY IN GENITO-URINARY DIAGNOSIS 
93 
RADIOGRAPHY. ITS POSITION IN GENITO-URINARY DIAGNOSIS. 
Value of Radiography.—In connection with cystoscopy and ureteral 
catheterization, radiography is invaluable for genito-urinary diagnosis. 
It has helped tremendously to bring urinary diagnosis to its present 
satisfactory state. But it must not be considered as all-sufficient or 
free from liability to err. It indulges in errors both of commission and 
of omission. Its shadows must be attested and controlled lest they 
betray us into diagnosing stones that are not present, and its occasional 
failure to delineate a shadow where one ought to be is one of its lament- 
able shortcomings. 
Nevertheless, when these failings are met and controlled by appro- 
priate action, radiography becomes the wheel-horse of service men- 
tioned. 
The corollary to the above is that radiography in urology should not 
be relied on without the control of cystoscopy and possibly ureteral 
catheterization. It may also be admitted that for diagnosis of stone 
in the upper tract, cystoscopy and ureteral catheterization should not 
be relied on without the control of radiography. In other words, they 
are mutually interdependent and should be utilized together. It is 
mere waste of time to speculate on which is the more important of the 
two. 
Radiography in Diseases of the Middle Urinary Tract.—For diseases 
of this part of the tract, radiography is less important, though not 
without marked value in certain conditions. It serves in the 
detection of stone in the prostate. With oxygen gas distending the 
bladder Kelly has taken good negatives, showing the size and con- 
formation of enlarged prostates. Used with 12 per cent, iodide of 
sodium distention of the bladder, radiography dilineates diverticula 
of that organ, and showrs the shape and size of the bladder to advantage. 
The size of a vesical tumor is often made appreciable by the same 
means, but without the use of the collargol. Kelly used bismuth 
suspension in tragacanth, and later, a suspension of argentide, for this 
purpose. Information regarding the size, number, and location of 
vesical stones and foreign bodies is afforded. 
Radiography in Diseases of the Upper Urinary Tract.—It is 
especially in this part of the tract that the supreme advantages of 
radiography are made manifest. It is found to be most serviceable 
and reliable when used in connection with such control appliances as 
radiograph catheters (opaque to roentgen rays), ureteral sounds, or 
the injection of 15 to 25 per cent, solution of sodium iodide or sodium 
bromide solutions (ureteropyelography). While certain precautions 
are required to avoid accident or injury to the kidneys in this work, 
it may be said that these are easily carried out, and, with them in 
effect, the procedures are safe. 
Dangers of Pyelography.—There are certain elements of danger in 
injecting the renal pelves with collargol solution in that it has been 
showm that even under very moderate pressure the solution passes up 
the urinary tubules and permeates the kidney tissues to make infarcts 94 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
and infiltrations that have proved highly injurious or even fatal. 
But no such danger pertains to the use of the metallic solutions, 
sodium iodide or bromide, which have practically superseded the 
others. Pyelography should not be applied in a case in which drain- 
age from the pelvis is seriously interfered with unless provision is 
made for prompt artificial evacuation (drainage by ureteral catheter, 
for instance). The injection should be made, not with a piston- 
syringe, which may prove too forcible in its effect, but by a simple 
hydrostatic apparatus such as that of Thomas. 
The necessity for using radiograph catheters is brought about by 
the fact that calcified glands or phleboliths in the abdomen or pelvis 
often give shadows to roentgen rays that resemble those of ureteral 
stones, and it is desirable to provide some method of differentiating 
between them. The opaque catheter in the ureter shows the exact 
line of the ureter, a shadow widely separated from that line is at once 
recognized as having no relation to the ureter or ureteral stone. A 
shadow in the line of the catheter shadow is differentiated by filling 
the ureter with sodium iodide solution and then making the exposure 
(Braasch). If it is an ureteral stone shadow a distinct difference in 
the calibre of the ureter above and below the shadow is seen; the 
ureter is relatively dilated above the site of the stone. Whereas, if it is 
only a phlebolith shadow, there is no difference in the ureteral calibre 
above and below the shadow, as indicated by the pyelogram. Another 
means of differentiation is that of stereoscopic radiogram, also with 
the opaque bougie in the ureter (Kelly). The stereoscopic view 
removes the shadow from the plane of the ureter, either forward or 
backward, showing it is not in the ureter. It is safe not to put too 
much faith in the ability of the radiologist to make the differentiation 
by the characteristics of the shadow itself. This has proved fallacious 
in many instances. Nevertheless, certain characteristic differences 
in shadows have been noted, as pointed out by Fenwick. Shadows 
that are clean cut, round and grouped near the outer or ischial portion 
of the open pelvic space in a roentgen-ray picture are likely to be 
those of phleboliths, while the ureteral stone shadows are inclined 
to be oval, with the long axis in the line of the ureter, and located 
near the median line of the body. 
Author’s Sign for the Differentiation of Ureteral Stone.—That dupli- 
cate exposures on the same plate do not always correctly resolve 
the question is shown in Fig. 78. Here a shadow resembling that of 
stone appears in apposition with the radiograph catheter, yet later 
investigation showed it to be a phlebolith in line with the catheter 
and not a stone. For positive differentiation the author* has utilized 
and described the following procedure: After obtaining a radiogram 
such as shown in Fig. 79, in which the shadow apparently lies in con- 
tact with the catheter, remove the catheter and replace it with a 
metal ureteral forceps or dilator. If the shadow be from stone it 
* A New Sign in the Diagnosis of Ureteral Stone, Jour. Urol., June, 1922, p. 487. RADIOGRAPHY IN GENITO-URINARY DIAGNOSIS 
95 
Fig. 78.—Two exposures in succession on same plate at differing angles. 1, Shadow 
almost in contact with catheter; 2, shadow behind the catheter. Failing to determine 
question of stone in left ureter. 
Fig. 79.—Stone-shadow in contact 
with ureteral catheter. 
Fig. 80.—Same case as Fig. 79. Stone- 
shadow in contact with ureteral forceps. 96 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
will necessarily be in contact with the forceps, as shown in Fig. 80, 
since both shadow and forceps are contained within the ureter. But 
if the shadow be from phlebolith, the differentiation is at once made 
evident by the removal of the shadow from the ureteral line, as indi- 
cated by the forceps. The latter is within the ureter but the shadow 
is definitely separated from it: therefore proving to be phlebolith, as 
shown in Figs. 81 and 82. 
Fig. 81.—Mrs. S., shadow in contact with ureteral radiograph catheter, simulating 
ureteral stone. 
The explanation is that the softer radiograph catheter follows the 
natural and greater curve of the ureter, which happens to be in the 
line of the shadow; while the forceps, being more rigid, straightens 
out the ureter and removes it from the path of the shadow. This 
method has proved successful in the author’s hands on several occasions 
in which it seemed impossible to make the differentiation in any other 
way. RADIOGRAPHY IN GENITO-URINARY DIAGNOSIS 
97 
Capacity of the Kidney Pelvis.—The question is important for differ- 
entiation between a normal pelvis, a dilated one, and hydronephrosis 
or pyonephrosis. Injecting fluid through a ureteral catheter to the 
point of exciting pain, Kelly allows 8 c.c. capacity as the normal maxi- 
mum; whereas Braasch considers 15 c.c. as compatible with physio- 
logical capacity. 
Fig. 82.—Mrs. S., ureteral forceps three inches up the ureter and removing the ureter 
from the shadow of a phlebolith, previously in contact with a ureteral catheter. 
Indications for Radiography of the Upper Urinary Tract.-—Radiography 
and pyelography are applicable to cases in which there is ground for 
suspecting stone, stricture, kink, obstruction of any sort, or dilata- 
tion at any point in the ureter; or duplicated ureter; hydronephrosis 
or pyonephrosis; calculus, benign or malignant tumor, tuberculosis or 
abscess formation in connection with the kidney. Modern radiograms 
made with “soft” tubes are capable of showing shadows of abscess 
pockets, tuberculous and like conditions, that are of much service when 
correctly interpreted. 
Interpretation of Radiograms.—It must not be thought that this is an 
easy matter or one requiring only indifferent ability. Much experience 
and refined judgment are really necessary; and these must be backed 
with the repeated testings and the various methods of control 
available. 98 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
Preparation of the Patient.—In anticipation of radiography the patient 
should be prepared so as to eliminate extraneous factors as much as 
possible. The bowels should be emptied, including flatus, by a brisk 
cathartic; and a light diet should be observed for a day or two before- 
hand, when permissible. 
Technic and Mode of X-ray Examination.—This will be considered 
elsewhere. It may be remarked, however, that, as with ureteral cathe- 
terization, if one is guided solely by the symptoms and takes a radio- 
gram only on the side complained of, one is liable to overlook evidence of 
great value that may exist on the opposite side. Unless the opposite 
side has been definitely excluded by ureteral catheterization as a source 
of trouble, it is advisable to take both the kidney and ureter of that 
side—always remembering that a shadow without the control of the 
radiograph catheter merely indicates the taking of another radiogram 
with such a catheter in place. 
Kelly suggests that it is well to take a verifying plate a day or two 
following the positive finding or before a contemplated operation for 
stone; not only for verification but also for indicating a change in the 
position of a stone. 
Stereoscopic Radiography.—This refinement of a-ray photography 
serves to place the shadow of a stone or foreign body with reference to 
the horizontal planes of the body. Used in connection with a radio- 
graph catheter in the ureter it gives an attractive elucidation of con- 
ditions not otherwise rendered. 
FUNCTIONAL TESTS. 
The integrity of the kidneys is universally recognized as being of 
great moment in its bearing on the risk involved by a given surgical 
operation. But this risk relates not so much to the anatom icopatho- 
logical condition of the kidneys as to their functional activity. Conse- 
quently, while the information obtained by chemical and microscopic 
tests of urine is valuable, it is not the kind of information that is most 
useful in the case at hand. The pathological condition does not always 
parallel the functional activity. Some kidneys badly degenerated give 
urine that shows good excretion by reason of adequate compensation; 
while others apparently little involved may give urine very inferior in 
quantity and quality. Individuals with albumin and casts in their 
urine have been known to live for many years without apparent progress 
in the renal condition or decrease in the kidney activity. But the 
menace comes when the function is inefficient—even in the face of a 
sufficient quantity of urine and of fair quality. So insignificant an 
operation as a urethral catheterization may disturb the equilibrium 
that has existed, and be followed by suppression of urine and death. 
Such sequences have occurred even where the volume and quality of 
urine seemed to be satisfactory. 
Variability of Renal Function.—This is marked in both health 
and disease; and depends on many influences. A glass of beer in a FUNCTIONAL TESTS 
99 
healthy person may double or quadruple the urinary output in the 
space of a few minutes. Functional activity that is lessened through 
disease may be restored by removal of the disease (acute nephritis) or 
its cause (a prostatic obstruction). Therefore the estimate should 
include not only the actual renal activity but also the potential capa- 
bilities of the kidneys under better or worse conditions—for instance, 
in the face of an operation, especially a nephrectomy. 
With the exception of hippuric acid the kidneys do not manufacture 
any of the waste products that issue from them. They simply extract 
them from the blood. It is the measure of this faculty of extraction 
that is desired. If the renal function is adequate, the waste products 
are excreted sufficiently and the blood is kept in its proper and healthy 
condition. If kidney activity is below the requirements of the 
individual, such products accumulate unduly in the blood or tissues 
of the body with more or less noxious consequences to the individual 
—autotoxemia, uremia, acidosis. 
To determine whether this function is being properly attended to, 
it would seem proper to investigate either (a) the state of the blood, 
with reference to retention of waste products in it, or (b) the product 
of the kidneys (the urine), with reference to completeness of excretion. 
These tests would resolve themselves, then, into (a) tests of retention 
and (b) tests of excretion. 
Certain of the tests of retention (cryoscopy of the blood, electrical 
conductivity) have so far not proved their efficiency or reliability; 
but the nitrogen content of the blood has been found by some (Widal, 
Folin, Ovisannikova) to have much prognostic significance. When 
the blood urea rises to 1 or 2 gm. per 100 c.c. of blood, the prognosis is 
considered a grave one; if above 3 gm. impending uremia and disso- 
lution are expected. The normal limits are from 20 to 40 mg. The 
amount of non-protein nitrogen retained in the blood is an index 
of renal function very similar to that of blood urea and about equally 
as valuable. The physiological limits for non-protein nitrogen are 
from 30 to 50 mgm. per 100 c.c. of blood. The presence of 1 gm. 
is of serious portent and must be corrected before a serious operation 
could be undertaken. 
The tests of excretion have found favor because of their greater 
convenience and reliability. Apparently realizing the supreme value 
that would attach to the finding of an efficient test of this kind, students 
of the subject have submitted many different tests during the past 
decade. They have aimed at measuring the rapidity and completeness 
with which in a given case the test drugs were eliminated through the 
kidneys, and the relative activity of the two kidneys as tested sepa- 
rately; this, mainly to learn whether, if the diseased kidney were oper- 
ated on or removed, the remaining one could fulfill the requirements of 
elimination and sustain life. 
Endeavors at gauging functional activity or insufficiency by measur- 
ing the amount of the physiological waste products of the urine have 
proved unreliable. The chlorides, the phosphates, uric acid, the urates. 100 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
urea, the total solids, etc., vary so much in health and the variations 
depend on such multifarious causes that they cannot be interpreted as 
having any relationship to operative risk or renal potentiality. The 
same thing may be said for the total quantity of urine. While it is 
of material value and definitely advisable to make use of these (urea, 
total solids, total quantity of urine, etc.) there yet remains something 
to be desired for determining functional activity. 
For reckoning permeability, the following products have been found 
of most service: Phloridzin, methylene blue, indigo-carmin, phenol- 
sulphonephthalein (reduced for convenience to “phthalein”). 
Phloridzin.—The discovery by von Mehring that phloridzin renders 
the kidney very permeable to sugar led to its use as a test of renal func- 
tional activity, and it seemed at first to promise much in this respect; 
but it was found that occasionally there was no elimination of sugar at 
all in perfectly healthy kidneys, while in others with only slight deteri- 
oration the test would apparently indicate serious degeneration. It 
has therefore not held the position at first hoped for it. 
The manner of using the phloridzin test is as follows: An injection of 
0.01 to 0.05 gm. of the drug in aqueous solution is made subcutane- 
ously, intramuscularly or intravenously, the solution being freshly 
prepared and slightly alkalinized with bicarbonate of soda, which 
favors complete solution. After ten minutes the urine is tested every 
minute with Fehling’s solution until the appearance of the sugar is 
indicated in the usual way. Fifteen- or thirty-minute estimates of the 
output are then recorded. The sugar should make its appearance in 
from ten to fifteen minutes with normal conditions; reaches its maxi- 
mum in one hour and gradually disappears in from two to three hours, 
with a total excretion in that time of 1 or 2 gm. (Geraghty and 
Ilowntree). 
Indigo-carmin, methylene blue, and other anilin dyes have been 
praised in this light. The first is used by intramuscular injection of 
4 c.c. of a 4 per cent, solution freshly prepared in sterile distilled water 
at room temperature (warmed before using). In about nine to twelve 
minutes after the injection is made, a greenish-blue tinge appears in 
the urine, with normal kidneys, and continues until about 25 per 
cent, of the injected drug has returned through the kidneys. But 
only 10 to 12 per cent, returns in an hour, and it continues showing 
for the next day or two. 
B. A. Thomas9 puts much faith in this test, but in addition to 
marking the promptitude of its appearance after injection, he seeks, 
as he terms it, the index of elimination of the drug; that is, he divides 
the quantity of indigo-carmin eliminated during the first hour by the 
quantity excreted during the third hour after injection. He found that 
the index for normal individuals in a series of cases averaged 5.1. If 
the amount eliminated during the third hour equals or exceeds that 
excreted the first hour, the patient’s kidney function contra-indicates 
serious operative intervention. 
The conclusions are based on the theory that disease of the renal FUNCTIONAL TESTS 
101 
parenchyma delays the onset of elimination and diminishes the early 
output as well, while the duration of excretion is prolonged; it there- 
fore seemed to the author that the relative excretion for the first and 
third hours was of greater value than the mere quantitative output for 
the first two hours. Thomas considers this to be the safest guide to 
renal functionation of all the tests that have been proposed. 
Methylene blue has been held in much the same esteem by its spon- 
sors, Kutner and Casper, and later Achard. But by others it is rated 
of inferior merit. Investigation showed that in certain forms of nephri- 
tis there was none of the expected delay in the appearance of the green 
tint (normally nine to twelve minutes) after injection nor any inter- 
ference with the rapidity of its excretion; while in some normal cases 
the drug did not appear in the urine at all after the injection. Its 
unreliability condemned it. 
Methylene blue is given by intra-muscular injection, fifteen minims 
of a 5 per cent, aqueous solution being used. Fifty per cent, of the 
drug comes back in the urine; the remainder is supposed to be con- 
verted in the body. The blue-green color should make its appearance 
in the urine within twenty to thirty minutes after injection, and may 
continue to show for one or two days thereafter. In some cases of 
nephritis it has been observed as persisting for fifteen days. In inter- 
stitial nephritis its initial appearance may be delayed for five or six 
hours, whereas in parenchymatous nephritis there may be no marked 
delay (Albarran; Bond; Ilinman). 
These instances serve to indicate the difficulty of finding a functional 
renal test that furnishes accuracy, reliability and innocuousness. 
Nevertheless one closely approaching the fulfillment of these exacting 
requirements has been found. 
Phenolsulphonephthalein. This agent (“ phthalein,” for conveni- 
ence) possesses certain properties and reactions, as described by Ger- 
aghty and Rowntree (1910-1912), that make it more nearly ideal than 
anything heretofore proposed. It is innocuous, even in large doses. 
It is secreted entirely by the kidneys and, in health, with punctilious 
uniformity, both as to time of appearance and rate of excretion. And 
this rapidity is so great that within two hours after it has made its 
appearance in the urine (beginning ten minutes after injection) from 
60 to 85 per cent, of the drug passes out in the urine. This fact is 
doubly valuable, both for an estimate of the total function of the two 
kidneys, and for determining the relative functioning power of the 
two organs. 
The rapidity of elimination shows variations dependent on the 
method and location of introduction of the dose. The response is 
slowest and least certain after subcutaneous injection; more prompt 
with intramuscular injection and most prompt with intravenous use. 
It is therefore advisable to use either the intramuscular or intra- 
venous. The latter is particularly useful in connection with ureteral 
catheter drainage, the test being completed in fifteen minutes and 102 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
permitting a shorter retention of the catheters in the sensitive 
ureters. 
While it is practicable to determine the promptitude of appearance 
of phthalein in the urine after injection, it is not essential, and this 
is not nearly so important as the measurement of the amount of the 
drug excreted in the first and the second hour taken separately. After 
intramuscular use, the time of appearance is from five to ten minutes; 
the output for the first hour from 40 to 60 per cent.; for the second 
hour, 20 to 25 per cent, (making from 60 to 85 per cent, for the two 
hours). When administered intravenously in connection with ureteral 
catheterization, it appears in from two to eight minutes. The collection 
of urine for the fifteen-minute or half-hour period should begin with the 
appearance of color in either urine. To make the drug visible, a few 
drops of sodium hydrate solution are placed in the test-tubes or vessels 
intended for receiving the urine drainage. Then, at the moment when 
excretion begins, a pinkish tinge appears, merging into a definite 
Bordeaux red by the additional flow. 
In order that there may be no inhibition of urinary secretion from the 
presence of the ureteral catheters, it is advisable to have the patient 
drink one or two glasses of water before the beginning of the test. 
Schmidt and Ixretchmer7 advise the collection of urine for three 
successive hours, believing that the excretion for each of three hours of 
the same amounts of phthalein indicates that the kidneys are working 
at top speed all the time because they are badly damaged. 
Relative Functional Activity.—Where the quantity of urine, merely, is 
measured and the collection is made for ten minutes only, there may 
be a marked difference in the amount excreted by two healthy kidneys. 
But if the time of collection be prolonged for an hour or two, or per- 
haps if repeated at another time, this discrepancy is made up and the 
account balanced. 
Excretion of phthalein, however, does not depend on the quantity 
of fluid excreted, whether large or small, and its relative findings are 
positive indications of functional activity, whether taken at long or 
short intervals. This, indeed, is one of the vital advantages of the 
test, making it both useful and reliable. 
Technic of Applying the Phthalein Test.—Intramuscular.—Ampules 
containing about 20 minims of standard solution of Phenolsulphone- 
phthalein are supplied by Hynson & Westcott, of Baltimore, Md. 
Exactly one cubic centimeter is injected by hypodermic syringe deeply 
into the gluteus or any muscle of the lumbar region, the time of injec- 
tion being noted. A soft-rubber catheter in the bladder drains the 
urine as it enters that organ from the kidneys. The drainage is caught 
in a white enamel vessel containing a few drops of sodium hydrate 
solution, which renders the phthalein visible on the instant of its 
arrival in the vessel. The appearance of the pink color marks the 
beginning of the first hour of the quantitative phthalein estimate. The 
catheter is withdrawn and is reinserted an hour from that time for 
obtaining the first hour’s specimen. Sixty minutes later the second EXAMINATION OF URINE 
103 
hour’s specimen is obtained in the same way (unless the patient can be 
depended on for completely emptying his bladder by voluntary urina- 
tion, default of which vitiates the result). The phthalein percentage 
of the two hours’ excretion is then determined by adding to each speci- 
men respectively enough water to make 1000 c.c.; placing a few cubic 
centimeters of this diluted specimen in the cup of the colorimeter of 
DuBoseq, which by comparison with a standard solution at once gives 
the required percentage. The same is then done with the diluted 
specimen from the second hour’s excretion and its reading recorded. 
When ureteral catheterization is employed for determining the relative 
functional activity of the two kidneys, the intravenous method should 
be used and the time lessened as previously suggested. Fifteen minutes 
(one-fourth of an hour) is the customary period used, and its result 
is multiplied by four for the full hour. This represents the output 
of each kidney, which, added together, gives the output of both kid- 
neys. In the first fifteen minutes a normal kidney should put out half 
of about 30, or 15 per cent. (G. G. Smith). If one kidney is diseased 
and putting out less than the normal (less than 15 per cent.), the other 
may be compensating and putting out more than 15 per cent. Hence 
the value of making the comparative functional test by ureteral cath- 
eterization. 
In women the average output is slightly lower than in men. 
In summing up, it may be said that no one test should be relied on 
as all-sufficient, but that a working combination of two or three should 
be utilized. The daily output of urine-urea and solids, the quantity 
of urine, together with phthalein estimate, repeated as necessary, should 
be prominent among the factors determining the question of operation 
and prognosis. 
According to Cabot, the stability of renal functionation, established 
by successive tests, is of greater moment than a high functional per- 
centage. Patients who under strains of exercise, changes of diets or 
alterations in quantity of water vary markedly in their renal output 
are less favorably considered than those having a lower index which is 
well maintained under these influences. 
Relative Value of Tests of Excretion and of Retention.—Both of these 
tests are essential in estimating the activity and completeness of renal 
functionating and it is idle to speculate on which is the more valuable. 
Both should be used where either is needed, in order that every 
means of determining the safety of a contemplated operation be 
applied. Further, they afford valuable information for prognosis, 
even in the absence of a question of operative safety. 
EXAMINATION OF THE URINE. 
While the conventional steps of urine examination will not be con- 
sidered here, it may be profitable to express some thoughts on the 
subject that clinical experience has indicated as of frequent and prac- 
tical importance, % 104 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
Examination of the urine may be of incalculable serivce in tracing 
the location and nature of a genito-urinary affection. But it must be 
made understandingly and not in the stilted, routine fashion ordinarily 
carried out. Many think that if they have learned whether a patient’s 
urine contains albumin or not their full obligation in that direction 
has been discharged. As a matter of fact, such a return may offer no 
enlightenment on the case, one way or another. Aside from the evidence 
on renal functional capability, considered elsewhere, the pertinent 
questions to be answered are, what pathological elements does the 
urine contain; and from whence do they come? Eminently practical 
questions, both, and answerable by definite methods of investigation. 
Volumes have been written in the endeavor to make the source of 
urinary disturbance recognizable by means of the particular shape or 
other characteristics of epithelia formed in the urine; that caudate 
epithelia mean pyelitis, etc. To the mind of the writer this is mere 
waste of time; and illusory. More exact methods are those which trace 
the epithelia or pus cells or other pathological findings to their source 
by the definite means of cystoscopy, ureteral catheterization and radi- 
ography. Mark Twain said that when he dined at a boarding house he 
always called for hash because he wanted to know what he was eating. 
In this work one wants to know one’s evidence, putting doubt and 
speculation as far behind as possible. One should never assume an 
ability to name the contents of urine by viewing it macroscopically; 
yet this assumption is practised habitually by some. Many a speci- 
men of urine looks limpid clear and innocent, yet contains blood 
cells, pus corpuscles or tubercle bacilli; and these spell pathology. 
Cloudy Urine.—The clouding of urine, apparent to the naked eye as 
viewed in the urine glasses, may come from the admixture in it of 
precipitated urates or phosphates, of spermatozoa, pus cells, blood 
cells, epithelia, bacteria, parasites of various sorts, foreign material 
(dirt), and crystalline formations. 
It should be the first object of the investigator to learn the cause of 
the clouding. This is accomplished to best advantage by means of the 
microscope after sedimentation. 
To propose a sequence, then, of steps of urinary examination, it is 
well to begin with the double-glass urine specimens that have been 
passed voluntarily by the patient and described on page 84. In inflam- 
matory conditions the second portion is usually the clearer of the two 
and the one less influenced by disturbances in the anterior urethra. In 
passing outward, the first part of the urine carries not only the materials 
it has collected in the bladder and upper urinary tract, but has added to 
it products from the urethra; hence its greater cloudiness. Exceptions 
to this occur when, in the final contractions of the vesical and post- 
urethral muscles, blood is squeezed from an acutely inflamed vesical 
neck; or incidental to the same act, there is the passage of spermatozoa 
from the seminal vesicles into the second part of the urine. Then the 
second part is bloodier or cloudier, as the case may be, than the 
first. EXAMINATION OF URINE 
105 
If the clouding be due to precipitated phosphates it may be cleared 
by the addition of a few drops of acetic acid; if due to precipitated 
urates, warming the specimen over a Bunsen burner will cause them 
to redissolve. But if these simple measures do not at once succeed in 
clearing the urine, resort must be had to the more definite plan of 
seeing what is causing the clouding; and this should be done while the 
specimen is fresh and unchanged by decomposition or bacterial in- 
vasion. It is to be accomplished by microscopic demonstration, to 
which no chemical test or other method is comparable in accuracy or 
completeness. The specimen of urine is sedimented by centrifuge; the 
sediment is placed unstained (“fresh specimen”) under the micro- 
scope, enabling the investigator to see whether motile bacteria, pus 
cells, crystals, blood cells or what not produce the clouding. Stain- 
ing of the same sediment brings bacteria, when sparse, into more 
prominent view, and permits their differentiation; so that it should 
be the next step of the investigation. Naturally the staining must 
accord with the requirements of bacteriology and must be varied accord- 
ing to the kind of organisms suspected to be present; but methylene 
blue is a convenient and serviceable stain to begin with. If, in a sus- 
pected gonorrheal case, this dye demonstrates diplococci that appear 
to be gonococci, they must invariably be attested by means of the 
Gram stain. If the fuchsin stain appears to demonstrate tubercle 
bacilli they must be proved to be such by measures that leave no room 
for doubt. These include methods of acquiring the urine specimen that 
at the same time exclude the possibility of contamination with smegma 
bacilli, and may include inoculation tests, as well. The question of 
differentiating between tubercle and smegma bacilli by processes of 
staining alone has been discussed elsewhere (page 87) with the conclu- 
sion that no such possibility should be entertained. In both sexes the 
urine for tubercle bacilli demonstration should be obtained by cathe- 
terization and after careful cleansing of the external genitals. With 
bid few exceptions it may be said that the finding of tubercle bacilli in the 
urine means tuberculosis of one or both kidneys. That truth, the deter- 
mination of which has been within-the past decade, has been of immeas- 
urable service to sufferers from urinary tuberculosis—leading the 
surgeon to disregard, as of secondary import, the tuberculous implica- 
tion of the bladder and go straight to the source of trouble, one or the 
other kidney; remove it and reclaim the patient to health and the 
enjoyment of living. 
It is true that tubercle bacilli have been found in the urine of patients 
who had no renal involvement, but were tuberculous elsewhere, the 
bacilli apparently having been filtered through the sound kidneys after 
being conveyed by the blood from the original focus. But the dis- 
covery of tubercle bacilli under such circumstances is so rare that it 
should be viewed more as a pathological curiosity than a reality to 
be reckoned with in the clinic. Practically, then, tubercle bacilli in 
the urine means renal tuberculosis—especially if associated with 
pus in the urine. The next question is, which kidney? As mentioned 106 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
elsewhere (page 91), ureteric meatoscopy through the cystoscope, 
though relied on by many, should be supplanted by the surer method 
of ureteral catheterization, by which means is learned not only which 
kidney is to blame for the tuberculous infection, but also the con- 
dition of health and functional activity of the other organ. The 
answer to both of these questions is absolutely demanded in a com- 
plete diagnosis. 
The Absence of Tubercle Bacilli.—The inability to find tubercle 
bacilli in a suspected urine should not at once lead to false hopes of their 
absence and to what may later prove an erroneous diagnosis of non- 
tubereulous infection. While latter-day methods have increased the 
ability to find the bacilli when present, it must be remembered that 
even with active and severe renal tuberculosis there are periods in 
which the bacilli do not appear in the urine. They seem to be pent up 
for the time being in the suppurating pockets, to escape periodically 
in the so-called showers of the organisms, easily demonstrable then in 
countless numbers. The necessary deduction is that in a suspected 
case a failure to find tubercle bacilli should count for nothing and should 
be followed by many repetitions, if necessary, of the search. 
Guinea-pig Inoculation.—A measure that often proves successful in 
the face of failure by direct microscopic investigation is that of inocu- 
lating a guinea-pig (or two) with the sediment of suspected tuberculous 
urine. Too few to be detected by the microscope, the bacilli are 
numerous enough to respond positively to this more refined method and 
develop tuberculosis in the animal, showing within two to four weeks. 
But this also is not absolutely reliable as to negative evidence, since 
it is established that failure to inoculate has happened with urine that 
later was proved to be tuberculous by postmortem demonstration. 
A failure of this sort may be due to the fact that the attempted inocula- 
tion is made during a quiescent period, between showers of bacillary 
excretion, or to some other cause. At any rate, because of the unre- 
liability of the various phases of negative evidence, one is reduced 
occasionally to make a diagnosis instinctively, so to speak: Feeling, 
from the several aspects of the case, that it is tuberculous at bottom, 
even though the ultimate proof, demonstration of the presence of the 
tubercle bacillus, be lacking. 
Tuberculin Tests.—Tuberculin tests may be used in cases of suspected 
urinary or genital tuberculosis, and occupy the same position as when 
the focus of infection is located elsewhere in the body. Its positive 
reactions are similar, consisting of the well-recognized chill or chilliness, 
temperature, aching sensations; and in urinary infection, local reaction 
of various sorts: Increased pain during urination, increased frequency, 
occasionally hematuria or increase in a hematuria already present. 
Radiography can be of assistance only in the late stages of a renal 
tuberculosis when it demonstrates the shadows of caseous masses in a 
badly damaged kidney. When this condition is reached, the diagnosis 
has doubtless already been made by other methods. EXAMINATION OF URINE 
107 
Examination of Urine Drawn by Ureteral Catheters.—It is not 
always practicable or desirable to draw a considerable quantity of 
urine for examination after ureteral catheterization. Both the time of 
the surgeon and the safety of the patient militate against this. Fortu- 
nately, it is not necessary. Two or three drams of urine are usually 
sufficient for practical purposes. The separated urines should be put 
through the same processes of examination as have been applied to 
the other specimens. Albumin due to the presence of the catheter 
in the ureter will nearly always be found, and is therefore a negligible 
element. Sometimes casts appear for the same reason. Blood cells 
often are present from the same cause. But as these may all have been 
absent in the specimens previously examined, they are recognized as 
having no significance. If there are sufficient blood cells present to 
interfere with steps of the examination, they may be at'once dissolved 
and eliminated by adding a few drops of acetic acid to the specimen, or, 
better, a drop of the acid to the sediment on a slide. This also clears 
up the pus corpuscles and leaves their multinuclei plainly discernible 
as compared with leukocytes, white blood cells, etc. Round epithelia 
are usually present in abundance in the specimens acquired by ureteral 
catheterization, and do not always indicate pathological conditions, 
especially if unaccompanied by pus, bacteria or other evidence of dis- 
ease. Specific gravity of small quantities of urine is obtained by using 
gravity beads in small test-tubes; but this, also, is of lesser import, 
influenced as it is by many accompanying conditions, excitation or 
inhibition of renal excretion from instrumentation. 
Aside from the determination of the relative functional activity of 
the two kidneys (discussed elsewhere), the chief objects to be attained 
in examining ureteral catheterized specimens are: Learning whether 
pus or bacteria (including tubercle bacilli) are present, and making the 
differential recognition of the organisms found; learning the exact 
source of bleeding which is present before the catheterization; compar- 
ing the relative activity of the two kidneys with regard to quantity of 
urine secreted in a given time. (For insuring against error in this, 
precautions must be taken with reference to leakage on one side or the 
other alongside the catheter into the bladder, instead of draining 
through the catheter); and relative functional activity. 
Complement Fixation Test,—In inflammatory conditions of the 
urinary tract, when intracellular groups of diplococci are found by 
methylene blue or other of the anilin dyes and they are decolorized in 
the Gram stain, the diagnosis of gonococcus infection is fixed irrefutably. 
But if in the face of symptoms and history simulating those of gonor- 
rhea, or if there is a question of recovery from gonorrhea and none of the 
organisms can be found, the question as to whether the gonococcal 
element prevails may be a momentous one, yet difficult of solution. 
The tests of irritation (beer, nitrate injection, use of urethra] sounds) 
may all fail and leave the investigator in the dark. Cultural methods 
are not alwyays satisfactory or available. To meet this dilemma the 
complement-fixation blood test was devised by Muller and Oppenheim 108 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
in 1906, the efficacy of which was confirmed by Schwarz and McNeil8 
whose contribution on the subject was highly appreciated by the 
profession. Others investigated the efficiency and reliability of this 
test and reports of Swinburne, Schmidt, Gardner and Clowes, Gradwohl 
and others gave strong support to the favorable estimate early placed 
on it. 
The test is somewhat analogous to the Wassermann test. It is based 
on the fact that microorganisms, when mixed with their homologous 
antisera, are capable of rendering complement inactive or fixed, as 
shown by the absence of hemolysis when sensitized erythrocytes are 
added to the mixture. The antibody is produced in the patient by the 
gonococci, and the antigen is a preparation of the gonococci. The 
fixation of complement is a result of the specific interaction between 
the two. For details of preparation and use, see the papers by the 
authors alluded to {Trans. Am. Urolog. Assn., 1911-1912). The test is 
now available in practically all modern laboratories, and should be 
used whenever the other modes of diagnosticating suspected gonococcal 
infection prove unsatisfactory or uncertain, 
Wassermann Tests: Blood and Spinal Fluid.—That the Wassermann 
blood and spinal fluid tests have great practical value in assisting in the 
solution of obscure cases of urinary obstruction and other chronic 
genito-urinary disturbances, is becoming widely recognized. These 
tests should be applied without hesitation in all cases, young or old, 
whose etiology is not traced or understood. The writer has found 
syphilis to be the basic and controlling factor in a number of cases of 
prostatic obstruction, urinary retention and vesical atony—cases in 
which there had never been the slightest suspicion of such infection, 
although it had evidently been present for years. Even hereditary 
syphilis has been observed in the same light, causing chronic and severe 
urinary obstruction from infancy to adolescence, the patient meantime 
being put through a number of operative measures and treatments that 
served only to aggravate his This topic is discussed at 
greater length in a paper by the writer, “Studies in Obscure Forms of 
Prostatic Obstruction and Vesical Atony.”3 
The chronic retention of urine from locomotor ataxia is but a similar 
manifestation of syphilis and its late effects on the spinal cord. The 
modus operandi of the production of retention in these and similar 
cases has been expressed by the writer4 as follows: The normal filling 
and emptying of the bladder is accomplished by a well-balanced 
relationship between the detrusor and sphincteric muscular systems of 
the bladder. If there is incoordination or loss of balance between 
these two systems, there is derangement of the function of urination. 
If the sphincteric function be weakened or abolished, there is leakage 
or incontinence; if the sphincteric energy be excessive, as compared 
with detrusive power, there is retention. Sphincteric energy is rela- 
tively stronger when the detrusors are weakened from any cause. In 
atony, for instance, while the sphincters may not actually have gained 
any strength through the establishment of that condition, they offer DIAGNOSIS OF OBSTRUCTION IN THE URINARY TRACT 
109 
sufficient resistance to the now weakened detrusors to interfere with the 
discharge of their function; a certain amount of urine is left over after 
each urination. The insertion of a catheter removes the effect of the 
sphincters, opens the outlet and restores the original balance between 
the two opposing systems. The detrusors demonstrate their remaining, 
though weakened, power and readily empty the bladder. 
It is incumbent on the diagnostician to differentiate between these 
conditions, and also to trace the cause of the disturbances described. 
CARDIOVASCULAR EXAMINATION. 
As suggested under a previous heading, an examination of the allied 
organs, the kidneys and cardiovascular system, is of the utmost 
importance in its bearing on the outcome of a contemplated major 
surgical operation; and may have much to do with success or failure 
in non-operative plans of treatment in certain affections, especially 
of the kidneys. Cardiac functionating is intimately associated with 
renal activity and competence. Nothing shows this more plainly than 
the success that frequently follows the prescribing of efficient heart 
tonics in the presence of lagging kidneys. The heart grows energetic, 
circulation becomes better, the kidneys respond with more and better 
urine and improvement becomes manifest in every respect. 
In determining the condition and efficiency of the heart and vascular 
system, besides the methods of examination regularly employed, the 
blood-pressure should be accurately taken. Some operators consider 
this to be as important as the urinary findings as a gauge on the physical 
condition and powers of resistance to the shock of operation. A press- 
ure unduly high or low may "well be considered as directly suggestive of 
the propriety of postponing a contemplated operation until such time 
as various corrective measures may bring about a more favorable 
condition. 
DIAGNOSIS OF OBSTRUCTIONS IN THE URINARY TRACT. 
Obstructions in the urinary tract must be diagnosed with reference 
to (a) location; (b) form and nature; and (c) severity. They occur at 
any point between the preputial orifice, and the urinary tubules of the 
kidneys. There are definite and well-conceived methods of attaining 
the above-mentioned objects in diagnosis. 
Urethral Obstructions.-—Obstructions located at the preputial or 
external meatal orifice are patent to observation and require no com- 
ment other than a gentle expression of regret that physicians do not 
always make even the cursory inspection of these parts that would 
locate the source of trouble, which is often on that account severe and 
unnecessarily prolonged. In children kidneys have been destroyed 
through backward pressure from so simple a cause as a narrow meatus 
or a tight prepuce. The tissues surrounding a narrow meatus gradually 110 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
merge into a dense fibrous ring, producing, through backward pressure, 
insidious but disastrous effects on the organs above. Invalidism and a 
shortened life may be the consequence. 
Obstruction of the urethra at any point offers little difficulty of 
detection. Suspicious symptoms or history should lead to direct 
examination of the urethra by bulb sounds, which, the larger sizes 
being used first, will demonstrate the “hitch” of a stricture, its size 
and extent; or the obstructive presence, and possibly the grating feel 
of a foreign body. 
The bulb sounds are useful for the anterior urethra, but the large 
size conical steel sounds are preferable for the posterior part of the 
canal. A tight stricture at this point will obstruct a steel sound with- 
out the objectionable grasping of the bulbs. E. G. Mark6 expresses his 
belief that one of the most satisfactory methods of diagnosticating 
urethral stricture is that by means of the aero-urethroscope. This gives 
a plain and clean-cut view of the constricted area, as W'ell as of the 
adjacent healthier portion. Such a view also leads to more definite 
indications as to the treatment, it is claimed. 
Obstruction at the Vesical Neck.—The demonstration of obstruction 
located at the vesical neck rather than at some point in the urethra is 
made in the following way: In a given case the symptoms of which 
point to obstruction somewhere, the patient is instructed to pass his 
urine (all that he can) by voluntary effort; after which a soft-rubber 
catheter is passed if possible into the bladder. This immediately 
shows whether or not residual urine has been left over after the volun- 
tary urination. Five, ten or twenty ounces residual urine thus obtained 
is clear evidence of marked obstruction; and also that the obstruction is 
located at the neck. So marked an obstruction as this (5 to 20 ounces 
residuum) if in the form of a urethral stricture, would stop the passage of 
a soft catheter before it arrives at the neck; whereas, prostatic obstruc- 
tion, in the first place, does not make itself evident to a catheter until 
the depth of the vesical neck is reached; and, in the second, prostatic 
obstruction is usually surmounted by a soft-rubber catheter of good 
size and quality. In brief, therefore, the drawing off, by means of 
a good sized rubber catheter (No. 18), of a pronounced amount of residual 
urine after voluntary urination indicates obstruction at the neck. If, 
on the other hand, the progress of the soft catheter is suddenly stopped 
before reaching the vesical neck, we know the obstruction is urethral; 
and in all probability is either a stricture or a manifestation of the 
obstructing influence of the cut-off muscle (compressor urethrae). The 
differentiation between these is made by means of the bulb and conical 
steel sounds. The muscle offers obstruction to the bulbs but not to 
the steel sounds. Pronounced stricture offers obstruction to both. By 
these tests, then, is learned (a) whether there is obstruction; (b) the 
severity of the obstruction; and (c) its location. 
If the obstruction is thus found to be located at the neck, the problem 
resolves itself into the determination of the remainder of the diagnostic 
points previously described, namely, the form, character and other DIAGNOSIS OF OBSTRUCTION IN THE URINARY TRACT 
111 
physical characteristics of the obstructing factor at the neck; and the 
determination of the condition, functional activity, etc., of the allied 
organs, the heart and kidneys. 
From the view-point of obstruction, the vesical neck is undoubtedly 
the most interesting part of the urinary tract. While many forms 
of obstruction here met with are readily differentiated under the plans 
of examination already described, there are many others in which the 
cause is not easily determined. It may be obscure and may never be 
identified. The patient then is either classed as incurable or joins the 
host of “ journeymen patients” who go unrelieved through the hands of 
physicians, thence to quacks, to osteopaths, “scientists” and down the 
line of fakery. 
With its importance and far-reaching influence in mind the writer, 
in discussing this subject at length elsewhere,3 expressed himself as 
follows: “The causation of urinary obstruction should always be 
found in one of two factors, namely, (a) physical obstruction of 
some kind or (b) disturbance of the nervous mechanism controlling 
urination (tabes, spinal or cerebral lesions, etc.). There is no such 
thing as ‘unaccountable5 atony or urinary retention; such a term 
represents incomplete diagnosis. The most frequent and important 
of the obscure, unrecognized causes of obstruction are: (a) Ill-defined 
contracture at the vesical neck demonstrable sometimes only by 
palpation through the opened bladder or urethra; (6) unrecognized 
syphilis, acquired or hereditary, affecting the spinal centres. Such con- 
ditions are by no means confined to adult life, and should be looked for 
at any age, from infancy up; diagnosed and treated in accordance with 
the refined diagnosis always demanded in cases of urinary obstruction. 
A final, but too late recognition is but poor solace for a lifetime of 
suffering due to delinquencies in diagnosis.” 
Causes of Obstruction at the Vesical Neck.—The causes of obstruction 
at this point are multifarious. They include disturbances both local 
and general or internal, primary or secondary, congenital or acquired, 
and are capable of being subdivided as to etiology as follows: 
Local causes: 
1. Prostatic overgrowths (adenoma); 
2. Contracture; 
3. Cyst formation; 
4. Abscess; 
5. Congestion or Inflammation; 
6. Neoplasm, benign or malignant; 
7. Calculus; 
8. Foreign body; 
. 9. Valve formation in prostatic urethra; 
10. Cyst or tumor of verumontanum; 
11. Inflammation of seminal vesicles; 
12. Infection (colon bacilluria of little girls); 
13. Hemorrhage (clot formation). 112 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
Internal or systemic causes: 
1. Cerebral (meningitis, hemorrhage); 
2. Spinal (paresis, tabes, spinal syphilis); 
3. Habit (deferred urination of teachers and others); 
4. Fatigue (Peyer); 
5. Neurotic (hysteria, nymphomania); 
6. Psychic (fixed idea); 
7. Reflex (secondary to irritations originating elsewhere; post- 
operative; shock). 
8. Toxic (alcoholism, diabetic coma; acidosis, effect of drugs). 
The number and variety of causes of obstruction at the vesical neck 
afford no excuse for not making the required recognition and differ- 
entiation. Indeed, these must be made in order to choose an appro- 
priate treatment. Aside from an intelligent study of symptoms and 
signs, the cystoscope and posterior urethroscope afford the greatest 
assistance in arriving at diagnostic conclusions. These instruments are 
not interchangeable. A lens appropriate for the close-vision work of 
urethroscopy is inefficient and inappropriate for cystoscopy; and the 
relatively long distance focus of the cystoscope lens is inappropriate 
for intra-urethral vision. For discussion of diagnostic instruments see 
page 87. 
Obstruction in the Bladder.—Obstruction and urinary retention 
sometimes occur from causes located within the bladder itself; such 
as foreign bodies, stones, tumors, etc.; or diverticula, whose lack of 
muscular equipment prevents them from contracting and emptying 
their contents into the bladder cavity. Cystoscopy is the chief agency 
for determining the diagnosis in such cases, although much may be 
done with radiography, using collargol or silver iodide solutions for 
distending the bladder. Deviations from normal size and form are 
thus to be recognized. 
Obstruction in the Ureter.—Ureteral stricture is not as rare a. 
condition as its lack of recognition in general would indicate. Occur- 
ring independently, or in connection with ureteral stone, the symptoms 
of both are often intertwined. Mucopus plugs passing down a ureter 
and becoming impacted in a strictured area act like stones and are 
followed by similar consequences of distention, pain, colic, chills or 
fever and infection. The effects resemble those of stone colic so closely 
that the differentiation is often made only with difficulty and with the 
aid of ureteral catheterization and radiography. A catheter is usually 
obstructed or stopped in its passage up the ureter on coming in contact 
with a stricture; and is frequently, though not always, obstructed by 
the presence of ureteral stone. But the progress of a catheter may be 
stopped from too great angulation of the ureter channel or from spasm 
of the ureteric muscles, to be overcome in both instances by appropriate 
measures: Changing the course or direction of the catheter, in the 
first, and making steady pressure with the catheter and awaiting 
relaxation of the spasm, in the second, will usually overcome the 
obstacle. A ureteral band, pressure from an anomalous vessel or SYMPTOMATOLOGY IN GENITO-URINARY DISEASES 
113 
adhesions, are other causes of ureteral obstruction whose differentia- 
tion is assisted by catheterization and pyelography. The efficiency 
of these measures in diagnosis has gradually lessened the utility and 
necessity of the old stock reliance, exploratory operation, in surgery of 
the upper urinary tract. Time was when surgeons opened the bladder 
to see whether or not the prostate was enlarged, but such a pro- 
cedure would hardly be countenanced now except in the presence of 
very complicated conditions. 
Obstruction in the Renal Pelvis.—This is produced by stone forma- 
tion, constriction from stricture, adhesions, kink, anomalous vessel, or 
malignant growth, and sometimes from plugging of the outlet by 
the products of inflammation, crystalline sedimentation, or hemor- 
rhage. 
The typical characteristic distress-signal of Nature indicating any of 
these conditions is pain, intense, repeated, horrid; described by some 
as possessing all the tortures conceivable. Where the stone forms in 
the kidney tissue, especially in the cortical portion, the pain is less 
insistent ; indeed, it may be insignificant or even absent throughout the 
progress of destruction of the organ. But this well-established fact 
should not justify a failure to trace and find the offending stone, no 
matter how insidious its development nor retired its situation. Investi- 
gation along the lines of comprehensive physical examination should 
divulge the secrets of all cases and evoke relief before the period when 
decreptitude and participation of the opposite kidney preclude chances 
of reclamation. 
Pathological evidences of obstruction in the pelvis consist in hydro- 
nephrosis, pyonephrosis, thinned, sacculated and destroyed kidneys, the 
latter being sometimes nothing but a thin-walled sack, incapable of 
excreting real urine, but perhaps carrying on a process of filtration 
of thin, worthless fluid incapable of performing the renal scavenger 
service required for life and health. 
SYMPTOMATOLOGY IN GENITO-URINARY DISEASES. 
The writer has always considered the extended discussion of urologic 
symptomatology as detrimental to the attainment of correct and useful 
diagnosis, rather than the contrary. Such symptomatology is inexact 
and often illusory, as has been previously shown, and cannot be given 
much credence even by the initiated. How much less reliance, then, 
can be placed on it by those who are doing general practice and do not 
possess experience in this special work that would keep them out of 
the pitfalls ever present. The symptoms under such circumstances 
assume more the character of will-o’-the-wisps, leading practitioner and 
patient on and on from one erroneous assumption to another, the while 
postponing the day of definite reckoning, exact diagnosis and correct 
treatment until the arrival of the unhappy time when everyone realizes 
that it is too late; that opportunity has fled from the poor sufferer, 
leaving in its wake only the miserable duty of palliation until death 114 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
relieves. The betrayal has been made through the guile of plausible 
but illusory symptoms. 
Used in their proper light, however, urinary symptoms are valuable 
and serviceable for paving the way to recovery. They should be 
received as pointing the way, not to diagnosis, but to appropriate 
methods and steps of physical examination, on which must rest the 
development of the diagnosis. This is a real situation in urology 
and is met with every day of the year, the country over. Its considera- 
tion, therefore, and its reiteration are worth while. Whatever is 
said of symptomatology, in this or any other review, should be said 
with those thoughts ever in mind. 
Symptoms of Urethral Affections in the Male.—The anatomico- 
physiological division of the male urethra into anterior and posterior 
portions markedly influences the symptomatology of this tract. Be- 
tween the placid progress of an anterior urethritis and the urgent and 
impetuous invasion of the posterior urethra there is a wide difference. 
Frequency and urgency of urination usually mark the transition; and 
inspection of the urines confirms the suspicion: The two (or three) 
glasses are found to be cloudy, instead of the clouding being confined 
to the first glass, as has been the case up to that time. 
With subsidence in the intensity of the posterior inflammation there 
is usually decrease in the unwonted frequency until often, even with 
persistence of a low-grade inflammation and moderate infection there 
may be no greater frequency than normal. Also, under the same 
circumstances, there may be no purulent discharge at the external 
meatus; and if one were guided by symptoms alone, he might pro- 
nounce such a patient well and permit him to resume intercourse though 
he were as infectious as during the more active stages. 
In the misconception that undue frequency of urination means 
cystitis, the irritative symptoms of posterior urethral infection are 
often ascribed to the bladder. As a matter of fact, the sensation of 
desire to urinate arises in the posterior urethra, and excessive frequency 
is an indication of irritation of the posterior urethral membrane. Were 
the bladder mucosa the seat of the sensation, desire to urinate would be 
aroused practically all of the time, as the bladder nearly always contains 
some urine—even shortly after urination, when it is refilling. 
Vesical Symptoms.—Pain deep in the pubic region and a disagreeable 
feeling of fulness are often present with cystitis. In connection with 
the presence of a stone in the bladder there is described by the patient 
the sudden interruption of the urinary stream and, after a pause, the 
resumption of the flow. These are the most characteristic symptoms 
pointing to disturbances within the bladder. But they are not to be 
relied on for differentiation, even with the addition of blood in the 
urine, as the same conditions and interruptions may be brought about 
by the presence of a pedunculated tumor in the bladder, intermittently 
plugging the outlet and interrupting the stream as does the stone. 
Prostatic and Seminal Vesicular Symptoms.—A symptom almost con- 
stantly attendant on prostatic inflammation, either from abscess forma- SYMPTOMATOLOGY IN GENITO-URINARY DISEASES 
115 
non or in connection with acute retention from hypertrophy, is pain in 
the glans penis. Complaint of such pain, in the absence of apparent 
disturbance of the glans, should arouse suspicion of prostatic disturbance 
and lead to the rectal palpation that should determine the question. 
Active irritation in the vesicles often produces an uncomfortable “ bear- 
ing-down” feeling in the perineum with a sensation of fulness there; or, 
the pain may be transmitted down the spermatic cord into the testicle 
of the side affected. Chills or elevation of temperature in connection 
with any of these conditions depend on the acuteness and intensity of 
the process, and may or may not be present. 
A sign of atonicity of the ejaculatory ducts is given in the recurrent 
escape with urination of spermatozoa from the seminal vesicles. Sig- 
nificant evidence of this appears in the two-glass urine test: In this 
case the second glass is cloudier than the first, an exception to the rule 
as already mentioned. The clouding, on microscopic examination, 
is found to be from numbers of spermatozoa. 
Ureteral Symptoms.—Ureteritis sometimes presents symptoms, some- 
times not. If present, they may show as a fixed or intermittent pain 
in the line of the ureter, extending downward into the scrotum and testis 
of the corresponding side; to which may be added an irritation reflected 
into the posterior urethra that evokes frequency of urination or even 
strangury. Tenderness in the line of the ureter is also characteristic of 
ureteritis. This is accentuated when one comes to catheterize that 
ureter through the cystoscope; and further confirmation is obtained in 
the contents of the urine drawn from that side: pus, bacteria, epithelia 
and blood cells. 
Ureteral Stone.—By blocking the ureter and damming the urine back 
into the kidney, and also by arousing spasmodic contractions of the 
ureteral muscles, ureteral stone often becomes one of the most painful 
conditions affecting the human body; and such attacks may recur at 
irregular intervals for many years, subjecting the patient to the mortal 
dread, as well as the realization of their horrors. When the stone is 
smooth and oval, and leaves room for the passage of urine beside it, 
there may be no more than an occasional dull ache in the vicinity of its 
location; and this, notwithstanding that the kidney above it may be 
undergoing damage and gradual destruction through infective and 
insidious back-pressure influences. Nausea and vomiting often occur 
in connection with such ureteral crises. 
Renal Pelvic Symptoms.—Chronic backache that has, by the laity, 
been ascribed to “kidney disease” is more closely and typically con- 
nected with pyelitis than with nephritis, of the chronic form. The 
amount and intensity of pain caused by a stone in the pelvis depends 
largely on whether it falls into the ureteropelvic outlet and blocks the 
escape of urine. But even aside from that it may be said that a stone 
moving about in a pelvis and thereby irritating it arouses much more 
pain than does the stone that grows while fixed immovably in the 
cortex, even though the destructive effect may be as great with the 
latter. Many cases have been observed in which kidneys had been 116 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
utterly destroyed—found so at postmortem examination—without any 
complaint of backache having been made during life. 
Probably the most typical sign of severe pyelitis is the persistent 
loading of the urine with pus, continuing perhaps over many years. 
The very absence of other symptoms in the presence of excessive 
pyuria is in itself sufficient to cause a suspicion of pyelitis and call for the 
cystoscopy and ureteral catheterization that are needed to solve the 
question. Of course the determination of pyelitis by such means is 
only one step in the procedure, and the cause of the pyelitis is also to 
be learned: Whether from stone, tumor or infection; and if the latter, 
what kind (colon bacillary, tuberculous, gonococcal, etc.). It is sur- 
prising how long such pelvic suppuration may go on without making 
marked inroads on the general health of the patient. A patient of the 
writer showed urine that by bulk was almost a third pus on settling, 
and declared that the same thing had been going on for twenty years; 
and without apparent detriment to his general health. 
Movable and displaced kidneys produce symptoms of pain and 
systemic reaction, nausea and vomiting harmonizing with the occur- 
rence of displacement and obstruction to circulation and urine escape 
incidental thereto. Such attacks are called Dietl’s crises, a term given 
in recognition of their graphic description and explanation in 1864, by 
Dietl. 
Genital Symptoms.—Symptoms of pain connected with diseases of 
testis or scrotum are sufficiently localized to disclose their identity, 
with certain exceptions. The writer recalls an instance in which a bed- 
ridden patient was crying out with plaints of pain in the back and could 
give no clue to the cause until an extended search disclosed the existence 
of acute swelling and inflammation of one testicle, of which the patient 
was not aware until it was shown to him. It showed where the reflexes 
of testicular pain might be looked for: Up the cord and into the back. 
Disturbances of the cord tend to reflect pain in the same direction. 
Urologic Symptomatology in Women.—Urethral Symptoms.—In 
women the short urethra is undivided by a cut-off muscle, and the 
symptomatology presents no such variations according to location of in- 
volvement as are found in the male. The female urethra, nevertheless, 
is the source of much suffering and intensely painful symptomatology, 
which, curiously enough, is nearly always ascribed to the bladder by the 
sufferers. Designated as “cystitis,” such urethral irritations, inflam- 
mations and contractures go for years, often with no better treatment 
than some internal medicine and perhaps an occasional washing of the 
bladder—an organ that is merely an innocent bystander in multitudes 
of such instances. 
The symptoms complained of, then, are undue frequency and urgency 
of urination, often painful urination, accompanied with straining or 
incomplete emptying of the bladder; and all with or without clouding 
or infection of the urine. Some patients show crystal-clear urine yet 
complain strenuously from adolescence to middle life. Some relate that 
the same conditions have prevailed since childhood. Others give the 
birth of their first child as the date of beginning; while still others note SYMPTOMATOLOGY IN GENITO-URINARY DISEASES 
117 
the close and suspicious relationship between marriage and the begin- 
ning of their “bladder trouble.” At any rate, like the poor, it seems 
ever present with them. A recent patient of the writer was certain 
that she had had the same symptomatology for years; yet 
she became well within a month after appropriate treatment, based on a 
correct diagnosis, had been applied. In this case the urethra only was 
involved, in the form of a narrow stricture at the meatus, causing 
obstruction and urethritis behind it.* 
In these conditions, as well as in those in which the female vesical 
neck is particularly involved, the symptomatic expression is chiefly 
frequency of urination and an inability to retard urination wdien once 
the desire is felt. It occurs in the young, the middle-aged and the 
old. Vesical symptoms, pain and aching feelings often originate from 
disturbances in the uterus or malpositions of that organ, causing it to 
impinge on or distort the bladder. Cystoscopically, one may often see 
the dome-shaped body of the fundus uteri as it encroaches on the 
bladder cavity. 
The symptomatology of the remaining urinary organs of women 
do not differ materially from that described for men, and requires no 
further special mention. 
Hematuria, pyuria, bacteriuria when sufficiently pronounced are evi- 
dent to the naked eye, and on being thus observed should always impel 
the practitioner to make or have made the definite investigation that 
should disclose their source and causation. Under no circumstances 
short of actual danger from loss of blood should an endeavor be made by 
medicines, etc., to check hematuria until opportunity is had for cysto- 
scopic diagnosis of the source and causation of the bleeding. It is of 
greatest importance to have the cystoscopy done while the bleeding is 
going on. When it stops, the urine may be as clear as crystal and give 
no tangible evidence of whence came the alarming hematuria of a few 
days previously. To bring about a temporary clearing of the urine of 
blood is no real accomplishment and postpones the making of a definite 
diagnosis; so that the more successful the practitioner is in that 
endeavor, the more he is liable to injure the prospects of his patient. 
To depend on the color of the blood as indicating whether it has 
come from bladder, ureters or kidneys, is fallacious in the extreme and 
should not be entertained for a moment. The crucial test is the use 
of cystoscopy and ureteral catheterization, with possibly the addition 
of radiography. 
Phosphaturia, oxaluria, uric acid excess and other like conditions 
are indicative of disturbances of metabolism. Their irritating influ- 
ences sometimes excite an irritation of the urethra that may become 
quite an active urethritis, not easily controlled unless the causation is 
recognized and is eliminated at the source. The writer has seen cases 
in the males that, excepting for the absence of gonococci in the dis- 
charge, closely resembled gonorrheal urethritis. These are among the 
* See also " Urothro-trigonitis in Women,” by the author; Urologic and Cutaneous 
Review, November, 1920, p. 632. 118 
METHODS OF DIAGNOSIS IN LESIONS OF URINARY TRACT 
so-called “simple urethritis” cases. The diagnosis is arrived at by 
examination of the urine and identifying the causal element therein. 
Physical Examination of Women.—The patient should be cautioned 
against taking a douche or urinating shortly before undergoing exami- 
nation—something that prospective patients are prone to do. Such 
action only washes out the inflammatory products and disguises the 
real situation. If the woman is being examined because of a suspicion of 
gonococcal infection, inspection of the external genitals should be the 
first step, a little pressure with the finger being made under the meatus 
to express any urethral discharge that may be present. If none is 
found, the meatus may be cleaned with moist cotton and the patient 
requested to urinate in a sterile vessel, both for macroscopic and micro- 
scopic examination. Such a urine specimen will contain vaginal epi- 
thelia in abundance; and if urethritis be present, evidence of it will be 
shown in the pus and other inflammatory products, possibly with 
gonococci, attained by sedimentation and staining. If it is desired to 
examine for tubercle bacilli, the specimen for this purpose should be 
drawn by catheter directly from the bladder. 
Continuing the physical examination, a vaginal speculum is intro- 
duced and the cervix is inspected. Some of its secretion may be mopped 
up with a small cotton swab and transferred to glass slides for staining. 
It is scarcely worth while to take secretion from the vaginal wall, as the 
bacteria are naturally so numerous in the vagina that no particular 
forms can be identified in this way. The cervical canal and uterine 
cavity may be sounded by the uterine probe, for information as to 
depth and conformation. The remainder of the physical examination 
is to be made by bimanual palpation, with the patient on the back and 
legs and thighs flexed to the degree of affording most relaxation to the 
abdominal muscles. 
Bimanual palpation gives information not only as to the size, shape, 
mobility and position of the uterus, but often gives valuable informa- 
tion regarding the bladder and ureters: As to whether they are thick- 
ened, tender, severely inflamed, etc.; and sometimes a ureteral stone 
may be felt in the lower part of the ureter. 
Bimanual palpation of the kidneys should be made with the patient 
in three successive positions: Lying down, semireclining and standing 
up. These changes give opportunity of detecting the mobility of loose 
kidneys as well as outlining the shape and size of the organs, and elicit- 
ing any tenderness that may be present. 
BIBLIOGRAPHY. 
1. Guiteras: Urology, vol. i. 
2. Kummel: Trans. 32d Congress of German Surg. Soc. 
3. Bransford Lewis: Ann. Surg., March, 1915. 
4. Lewis: Keen’s Surg., iv, 300. 
5. Lewis: Trans. Am. Assn, of Genito-Urin. Surg., 1893. 
6. Lewis and Mark: Cystoscopy and Urethroscopy, 1915. 
7. Schmidt and Kretchmer: Trans. Am. Urol. Assn., 1911, p. 233. 
8. Schwarz and McNeil: Am. Jour. Med. Sci., May, 1911. 
9. Thomas: Jour. Am. Med. Assn., November 28, 1914. CHAPTER III. 
ROENTGEN-IIAY EXAMINATION OF THE URINARY 
TRACT. 
By PRESTON M. HICKEY, M.D. 
A roentgen-ray examination of the genito-urinary tract is made 
either with the use of the fluoroscope or by making a roentgen-ray 
plate or film. 
Fluoroscopic examination has many limitations, and as the informa- 
tion which it gives is usually meagre, it is not often employed. It is 
true that one can often see on the fluoroscopic screen very distinctly 
calculi of moderate size when the amount of lime salt which the 
calculus contains is considerable. However, if one does not see any 
definite shadows on the screen it is never right to return a negative 
report. Small urinary calculi are not usually distinguishable on the 
screen, which is especially true if the patient’s weight is above the 
average. The screen is often useful in the differential diagnosis 
between renal and biliary shadows. 
A roentgen-ray plate or roentgenogram of the urinary tract is 
to be always regarded as a record of density of the part examined. 
As the roentgen-ray waves pass through the different tissues they 
register upon the sensitized plate a faithful record of the comparative 
atomic weight of all the elements traversed. Inasmuch as the gastro- 
intestinal tract overlies portions of the kidney, and ureter, it follows 
that substances in the intestinal track will also register their densities 
upon the photographic film. Accordingly, before the patient presents 
himself for examination, the intestinal track should be emptied as 
completely as possible. On this account, a thorough preparation of 
the patient is to be considered an essential part of the technic of the 
examination. 
However, it must be borne in mind that a partial preparation of 
the patient with incomplete catharsis may fill portions of the intestinal 
tract with gas. When gas is present in the intestines it gives rise to 
confusing shadows, owing to its low density; this may make the plates 
very difficult of interpretation. 
Preparation of the Patient.—In order to empty the intestinal tract 
it is necessary first, that the intake of food for a number of hours before 
the examination should be minimized, and second, that laxatives 
should be given to empty the tract. In the selection of these laxa- 
tives one should choose drugs which do not produce a considerable 
quantity of water in the intestines. If the plate is made with con- 
119 120 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
siderable water in the intestines the resulting interpretation becomes 
quite difficult. Accordingly, saline laxatives should be avoided. 
Pills or tablets containing metallic salts are also objectionable because 
if they are not dissolved in the stomach they may pass on into the 
intestines, and if present at the time of the examination may cause 
shadows which will be quite confusing. Compound cathartic pills 
which have not dissolved often give rise to shadows which on super- 
ficial examination may be mistaken for a calculus. Moderate 
repeated doses of compound licorice powder act in a method which 
Fig. 83.—Illustrating position of patient when taking plate of kidney. Notice that 
the shoulders and legs are elevated and that the back is flat on plate. Patient’s arm 
elevated to show plate. Should be at the side when plate is taken. 
is preferable to the inorganic laxatives. Castor oil in dosage suffi- 
cient to produce free catharsis is probably the most generally used 
purgative for this purpose. If the first dose is not sufficient to pro- 
duce an adequate emptying of the intestinal tract, the dose should 
be repeated before the examination is made. Castor oil should be 
followed by a cleansing enema (a tablespoon of turpentine to a quart 
of water is usually sufficient). A proper emptying of the intestinal 
tract usually requires from thirty-six to forty-eight hours and unless 
this preparation can be thoroughly carried out, it is much better not 
to give the patient disturbing laxatives, as the intestinal tract partly TECHNIC 
121 
filled with gas presents so many confusing shadows that a positive or 
negative diagnosis cannot be authoritively given. 
The roentgen-ray examination should be conducted, preferably, 
in the morning after the patient has fasted over night. If the stomach 
is filled with food there will be so much more tissue to be traversed 
by the waves of the roentgen ray and the plates will be less clear. 
Examination of the patient immediately succeeding an attack of 
renal colic is usually most unfavorable for good roentgen-ray work. 
If the patient has such severe pain that it is necessary to give him 
morphine, it will be found that the intestinal stasis will predispose 
Fig. 84.—Position of tube when plate of bladder and lower portion of ureter is taken. 
the patient to an accumulation of gas, which confuses the plates. 
Also if abdominal tenderness is present, compression cannot be satis- 
factorily resorted to with a consequent loss of diagnostic accuracy. 
If possible, it is much better to wait until the patient has recovered 
from the immediate effects of his severe pain and prepare him 
thoroughly before the examination is made. 
Technic.—The electrical equipment used in generating the roentgen 
rays should be sufficiently powerful to permit of an adequate exposure 
in a few seconds. If the patient breathes during the time of exposure 
the movement of the kidneys will so blur their outline that the examin- 
ation cannot be considered satisfactory. The average patient without 122 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
training will find it difficult to hold his breath for more than ten or 
twelve seconds. It is preferable that the exposure should not last 
longer than five or six seconds. In heavy patients, and especially 
those with a thick abdominal wall, the roentgenologist finds it dif- 
ficult to make an adequate exposure in a sufficiently short time. 1 he 
use of double-coated films, sandwiched between two intensifying 
screens, is a great help. They serve to reduce the time of exposure 
very materially, and thus produce clearer plates. Another advantage 
in the employment of intensifying screens is that as the exposures 
are short they may be repeated with less risk of producing roentgen- 
Fig. 85.—Patient sent in for examination of spine. Old Pott’s disease. Plate 
reveals stone in kidney. This plate shows the great importance of not only examining 
spine in such cases, but also the renal area. It is also wise to examine spine when 
making renal examination, as not infrequently pathological processes may be revealed 
in the spine. 
ray dermatitis. The screens used should always be free of surface 
markings and defects. In heavy patients there are always produced 
a considerable number of scattered rays, which tend to fog the plate 
and to reduce the contrast of the shadows. The problem of minimiz- 
ing scattered radiation during exposure is one which, unless satisfactorily 
dealt with, constitutes a very definite handicap. Fortunately the 
recent perfection of the Potter-Bucky diaphragm has resulted in a 
marked improvement in the quality of plates. This diaphragm 
abolishes 80 per cent, of the scattered radiations produced in the 
patient’s body. Its use has been of the greatest advantage in pro- TECHNIC 
123 
ducing clear, contrasting films even in comparatively fleshy individuals. 
It is an advantage also to employ a small area, selecting suitable 
diaphragms to aid in the minimizing of scattered radiations. If 
the Potter-Bucky diaphragm is used, the examination can be com- 
menced with two films, one exposed so that it embraces the kidney 
area with the ureteral tract down to the brim of the pelvis, and the 
other film showing the lower ureter region with the bladder. As it is 
a self-evident fact that no operative procedure should be based on 
evidence gained from a single plate or film, it becomes the duty of the 
Fig. 86.—Ureteral calculi—one at vesical orifice and one just above the bladder. 
roentgenologist to cover each area twice so that the facts obtained 
by an examination of one film may be compared with data from 
another exposure. 
These two sets of exposures may be made according to the technic 
for producing stereoscopic effect and in this way we shall have two 
records of the kidney density taken at slightly different angles; these 
when viewed in the roentgen-ray stereoscope will be a great aid in the 
interpretation of suspicious shadows. In these exposures the stereo- 
scopic shift should preferably be made in the vertical direction. If 124 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
spinal pathology is present the stereoscopic examination will make 
it more evident and perhaps bring to light conditions which may 
simulate the symptoms of kidney pathology. In these examinations 
the patient lies upon his back with the holder containing the film 
directly underneath. The patient’s clothing over and underneath 
the area examined should be removed so that there may be no question 
of buttons or other substances which might cause confusing shadows. 
The patient’s back should always be inspected for moles, warts, or 
other abnormalities of the skin. An inconspicuous mole upon the 
back has been known to have given rise to a shadow which was misin- 
Fig. 87.—Same case eighteen hours later. Very important, as this case shows, the 
great necessity of making the examination as near the time of operation as possible, as 
the stones may change their position. 
terpreted. The patient should be made as comfortable as possible 
with pillows under the head and shoulders, and with the thighs flexed 
in order to relieve abdominal tension. The purpose of relieving the 
abdominal tension is to permit of as much compression of the abdominal 
wall as possible. This serves two purposes—first, to reduce the 
antero-posterior thickness of the body, and second, to immobilize the 
visceral organs. Compression may be obtained by a firm canvas 
band stretched from side to side, which, when tightened, tends to 
flatten the abdominal wall. This pressure aids the patient in the 
holding of his breath and also inhibits him from taking a long breath 
during the time of the examination. A rubber bag or a pad of cotton TECHNIC 
125 
may also be used to indent the patient’s abdomen. When a rubber 
bag is chosen it should be made of seamless rubber so as not to cause 
irregular streaking of the plate. The patient’s back should be as 
flat as possible so that the kidney area may come as close as possible 
to the plate; this is necessary inasmuch as the nearer the kidney is 
brought to the plate the sharper will be the outline of the kidney 
shadow. If the patient’s symptoms point strongly to vesical calculus, 
one exposure should be made with the plate under the buttocks and 
another made with the patient lying on his face with the plate placed 
Fig. 88.—Crescentic shaped shadow in the right kidney area proved, by the introduction 
of the opaque catheter, to be in the pelvis of the kidney. 
directly under the bladder area. The plates should be properly 
labelled by small lead letters at the time they are made, the letter 
“L” being placed upon the left side, and the letter “It” upon the 
right side. It is better to use the double check of two letters than 
simply to depend upon a single letter for the identification of the sides 
of the plate. 
The essential part of the art of making a good roentgen-ray exami- 
nation of the kidney tract lies in the choice of the quality of the rays 
employed. If too penetrating a ray is employed the resulting plates 
will be flat without sufficient contrast to give definitive shadows. 126 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
If too little penetration is used the resulting plates are under-exposed 
and the detail will be consequently lacking. It becomes necessary 
therefore to employ a ray of such quality that as contrasty plates as 
possible may be secured. The ability to choose the proper wave 
length to bring about the best results can only be acquired by experience 
and by keeping an accurate data of all exposures so that the plates 
may be carefully compared. 
It has been definitely shown that during quiet respiration the kid- 
ney has an excursion of at least one-half inch. On forced inspiration 
Fig. 89.—Indefinite but suspicious shadow found in the area of the left kidney. This 
shadow warranted the making of a subsequent plate. See Fig. 90 which produced a 
more characteristic shadow of calculus. The indefiniteness of the shadow shown in the 
first plate is due to the patient breathing during the exposure. 
and expiration, the excursion of the kidney may measure one and a half 
inches. Accordingly, the most careful attention should be paid to 
the immobilization of the kidney during exposure The patient must 
hold his breath very precisely. If necessary one or two dummy 
exposures can be made before the actual plates are exposed so that 
the patient may learn what is expected of him. When dealing with 
patients who, either by deafness or by reason of their speaking a 
foreign language, do not comprehend what is required, an assistant 
may close the patient’s mouth with one hand and hold the patient’s TECHNIC 
127 
nose with the other. In this way the diaphragm can often be kept 
quiet and clear plates obtained. 
If it is impossible to make a cystoscopic examination the outline 
of bladder tumors can sometimes be demonstrated in the following 
method: The bladder may be filled with an opaque solution such as 
a 15 per cent, solution of iodide of soda or bromide of soda, which 
will give a shadow that shows the bladder outline. If on account 
of a new growth being present the bladder is not completely filled, 
the shadow will show the irregularity of outline, which very often is 
quite diagnostic. The same procedure may be resorted to for the 
demonstration of vesical calculi, the patient being allowed to evacuate 
the opaque medium, immediately after which a plate is made. Fre- 
Fig. 90.—Shadow found in the area of the left kidney, which has the characteristic 
outline of a calculus in the renal pelvis. This is made from the same patient as the plate 
shown in Fig. 89 and illustrates the necessity of the patient holding his breath during 
the time of exposure. 
quently enough of the opaque fluid will adhere to the calculus to aid 
in its identification. The same method can also be used for the 
demonstration of diverticula of the bladder. 
There has recently been introduced by Carelli a method of inject- 
ing air with a long needle into the tissues around about the kidney. 
The introduction of air in this fashion has been called perirenal 
emphysema. When successfully used it affords plates of surprising 
excellence. If the technic of this performance is properly carried 
out it is probable that there is very little danger. However, its use 
will probably be reserved for the detailed study of kidney tumors or 
other obscure renal pathology. If the roentgenologist did not have 
at his disposal the modern methods of minimizing scattered radiations, 
it is very probable that perirenal emphysema would be more generally 128 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
employed. As it is, the number of cases where it seems necessary 
is comparatively few. 
Quality of the Negative.—The exposed film should be developed 
with a developer compounded to produce the maximum contrast. 
If the view-box in which the negative is to be examined is provided 
with a very strong light, development can proceed further so as to 
produce a greater density than if the finished plate is to be looked at 
with a feeble illumination. The utmost care in the dark-room technic 
should be exercised to prevent artifacts on the film. These artifacts 
may occur from improper flowing of the film and from accidental 
scratches; finger-marked abrasions are always annoying and confusing. 
Fig. 91.—Large phlebolith adherent to the ureter causing symptoms. 
(Case of Dr. Lincoln Dodge.) 
It is best to reserve the careful examination of the plate until after 
it is allowed to dry. The wet negative may be immediately examined, 
so that if on hasty inspection it seems to be of a poor quality, an 
immediate attempt may be made to secure a better exposure. After 
the negative is properly washed and dried it should be carefully 
inspected to determine if it has the technical excellence which entitles 
it to diagnostic importance. It should be clearly stated in the final 
report whether the examiner is dissatisfied with the quality of the 
negative so that the surgeon when he receives his report may attach 
to it the proper importance. If the negatives are thin, show insuf- 
ficient preparation, or show evidence of movement of the patient QUALITY OF THE NEGATIVE 
129 
during examination, they should not be regarded as giving as much 
diagnostic data as if they were of the proper technical quality. A 
satisfactory plate of the kidney area should show the outline of both 
Fig. 92.—Ureteral catheter with injected pelvis. The opaque fluid has blotted out 
the shadow of the stone; hence the inference that the suspicious shadow found on the 
first examination is in the pelvis of the kidney. 
Fig. 93.—Two shadows lying in the shadow of the right kidney. These shadows 
are so well rounded that they at once suggest that they are not renal calculi. I hey also 
are not of uniform density, as the original plate shows that the centres are less dense than 
the periphery. (See Fig. 94). 130 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
the right and the left kidney, the structure of the eleventh and twelfth 
ribs and the outline of the great muscles of the back. Detail in the 
Fig. 94.—Same case as Fig. 93. The use of abdominal pressure has shifted the posi- 
tion of the shadows. Stereoscopic plates, after the introduction of the opaque catheter, 
shows that both of these shadows have their origin outside of the kidney. 
Fig. 95.—Small stone in the pelvis of the right kidney. Note the characteristic cres- 
centic shape of the stone and the juxtaposition of the shadow of the stone and the opaque 
catheter. QUALITY OF THE NEGATIVE 
131 
spine should be sufficient to show the structure of the transverse 
processes. If the transverse processes are not clearly outlined one 
should not expect that the plate will demonstrate small calculi in the 
ureter. Bladder plates will usually show the outlines of the bladder 
unless the patient is very fleshy. If the bladder is distended at the 
time of the examination, the outline of the bladder will be plainly 
seen. If the outlines of the kidney do not show satisfactorily upon 
the plates a second examination should be made, if possible, to secure 
a good outline of each kidney. Inasmuch as the fatty capsule of the 
kidney is a tissue which by its shadow outlines the kidney, it follows 
that patients who are well-nourished oftentimes show a better kidney 
Fig. 96.—Pyelogram showing dilated pelvis of the kidney. 
contour than exceedingly thin patients. The examination of the 
films is best conducted in a darkened room, with the films properly 
illuminated by a light box in which the quantity of light can be easily 
regulated. Frequently very small stones of low atomic weight will 
show better by looking at them with an oblique light than by directly 
transmitted light. The white light from a north window is also very 
advantageous. In examining the plates the length and angle of the 
twelfth rib should be carefully noted. If the twelfth rib is very 
short, the operating surgeon in his incision may mistake the eleventh 
rib for the twelfth; the roentgen-ray plates should give clear data 
upon this important subject. In studying a kidney plate mention 
should be made of the visibility of the right and left kidney and of 132 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
their size, shape and position. It will be found as a rule that the 
left kidney will show more distinctly than the right kidney. Satis- 
factory plates will often show the lower border of the liver; as the 
shadow of the liver superimposes on the shadow of the right kidney, 
the right kidney outline will not be quite as clear as that of the left 
side. If there are any shadows within the kidney areas they should 
be carefully discussed and described as to their relative position. 
When these shadows are found in the area of the pelvis of the kidney, 
they are very often quite characteristic. It is important to remember 
the possible sources of shadows which may be mistaken for calculi. 
Fig. 97.—Opaque catheter introduced into a diverticulum of the bladder within 
which the catheter coils upon itself. This plate is made from the same patient as shown 
in Fig. 98, where the diverticulum was filled by a roentgen-ray-opaque solution, iodide 
of sodium. 
About the most important of these and the most frequently met are 
those caused by calcified glands. Shadows of calcified mesenteric 
glands are often typical in shape and hence do not cause confusion. 
However, some of them simulate very closely the outline of a kidney 
stone. In a good plate of the kidney, the kidney stone should be 
sharp in outline, whereas the shadow cast by a lime-containing gland 
is usually dim in its outline and does not show the definite, uniform 
density of a true calculus. If the observer is in doubt, better plates 
can be made. These plates should be made with a small cone making 
deep pressure immediately over the area in question. If the shadow 
is caused by a stone in the kidney, the relative position of the calculus QUALITY OF THE NEGATIVE 
133 
shadow will not change with regard to the outline of the kidney, 
whereas if the shadow is caused by a gland with calcium content it 
can be made to change its relative position by pressure applied at 
different angles. Gall stones have been confused with kidney calculi 
and vice versa. However, if plates are made in the postero-anterior 
position and also in the antero-posterior position it will usually be 
found that the gall stone will show more clearly with the plates made 
with the patient lying upon his abdomen, while the kidney shadow 
will show better with the patient lying upon his back. If the shadow 
is of considerable size frequently a fluoroscopic examination will show, 
with the patient lying on his side, whether the shadow is nearer the 
anterior surface or the posterior surface. Multiple gall stones do 
not usually cause shadows which can be confused with kidney stone 
shadows. Frequently the tip end of one of the transverse processes 
Fig. 98.—Diverticulum of the bladder demonstrated by the injection of sodium iodide 
solution. 
may present an extra amount of lime so that at first glance it may 
simulate a ureteral calculus. However, this is not liable to appear 
in clear, satisfactory plates. If the patient has not been properly 
prepared and there is some gas in the colon, the haustra of the colon 
may cause confusing shadows as outlined against a background of 
lessened density produced by gas. However, these shadows are 
usually multiple and of a contour and density wThich serves to identify 
them. In case of doubt the examination can be repeated after a 
more thorough preparation of the patient. The most confusing 
shadows are those caused by phleboliths. These, however, are 
usually multiple in number, fairly circular in shape, and usually lie 
below a line drawn from one tuberosity of the ischium to the other 
tuberosity. A ureteral calculus is usually oval in shape in contra- 
distinction to the circular shape of the phlebolith. However, a 
ureteral calculus may be so placed in the ureter that it will give a 134 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
round shadow on account of the end pointing toward the target 
of the roentgen-ray tube so that the long axis of the calculus corre- 
sponds to the central ray with which the plate is made. Prostatic 
calculi are usually recognized as small, multiple dots; these are usually 
just above or within the upper edge of the symphysis pubis. As 
their density is rather slight they may escape a superficial observation. 
If one kidney is sharply outlined and persistent reexamination fails 
to show the outline of the other kidney, a perirenal abscess may be 
suspected. If multiple exostoses are shown on the spine indicating 
Fig. 99.—Large prostatic calculus, weighing 60 grams. 
a hypertrophic type of spinal arthritis the focus of infection may be 
suspected to be in a pus kidney. If suspicious shadows are seen super- 
imposed on the shadow of either sacro-iliac joint, examination may 
be repeated with the rays directed at different angles or stereoscopic 
plates may be made of the suspicious area, so as to determine whether 
the extra density is within the bone or within the pelvis. If small 
shadows multiple in number, and with rather irregular outline are 
found in the kidney area, the patient may be suspected of having a 
renal tuberculosis. These shadows may be caused either by calci- QUALITY OF THE NEGATIVE 
135 
fication of old scars within the kidneys or by small caseating areas. 
It will sometimes be found that a caseous area filled with putty-like 
material will cast a very definite shadow upon the plate. 
On account of the fact that it is impossible to bring the urinary 
tract immediately next to the plate, it will happen that very small 
calculi on account of scattered radiation may escape observation. 
These, however, may be classed under the heading of non-surgical 
importance. The roentgenologist should embrace every opportunity 
to roentgen-ray kidneys which have been removed either by surgical 
operation or by autopsy. This will familiarize him with the appear- 
ance of renal pathology which can be demonstrated upon the roentgen- 
ray plate. In this wray basic facts can be established which become 
of the utmost value in plate interpretation. 
Fig. 100.—Perirenal emphysema. Note the sharp differentiation of the kidney by 
the background formed by the air injected into the perirenal tissues. (Print furnished 
by Dr. Imboden.) 
The question arises as to the reliability of a roentgen-ray exami- 
nation in making a positive or negative diagnosis or urinary calculi. 
The writer has corresponded with a number of leading roentgenologists 
asking them what they considered to be a fair estimate of their per- 
centage of error. The replies received indicated that a roentgen- 
ologist of experience should not have a greater percentage of error 
than from 5 to 10 per cent. Most of the replies indicated that the 
greater percentage of error occurred in the examination of vesical 
calculi. Fortunately for the benefit of the patient the physician can 
resort to cystoscopic examinations. If this is impossible and the oper- 136 
ROENTGEN-RAY EXAMINATION OF THE URINARY TRACT 
ative procedure is to be based upon the roentgen-ray findings, the 
bladder can be injected with a small amount of air introduced through 
a sterile rubber catheter. The presence of air within the bladder will 
outline the size and shape of the bladder, and furnish a contrasting 
background which will usually display vesical calculi with great 
distinctness. 
It may be well to discuss for a moment the causes of failure of the 
roentgen ray to properly demonstrate urinary calculi. Perhaps the 
most frequent cause of failure is excessive corpulence of the patient. 
This, however, is not as important a factor as formerly, since now, 
with the use of the modern diaphragm, scattered radiation can be 
minimized. The second cause of failure might be given as insuf- 
ficient or incomplete preparation of the patient. Outside of making 
use of an unsuitable quality of ray, there is no other factor which 
contributes more to failure. If the patient has been poorly prepared 
and shows considerable gas in the bowels at time of the examination, 
the plates should not have too much diagnostic importance attached 
to them. The third cause of failure is sometimes seen in an extreme 
lordosis, so that the kidney area cannot be approached sufficiently 
near to the plate to get good kidney contrast. The fourth cause of 
failure is the fact that some calculi have a chemical composition of 
such a nature that their atomic weight is low and consequently the 
resulting shadow is of slight density. Fortunately, however, most 
calculi show the presence of some lime salt and can be demonstrated 
in the average patient with careful technic. Probably the most 
important cause of failure is a poor technic, which results in the pro- 
duction of plates of poor quality. The roentgenologist should never 
be satisfied to make a negative diagnosis unless the plates approach 
a technical excellence which warrants such a confidence. The clinician 
in the examination of the case usually avails himself of the opportunity 
to see the patient several times and perhaps to rely not on a single, 
but on several examinations of the urine. It is only fair therefore 
to accord to the roentgenologist the opportunity to repeat his exami- 
nation, so that he may finally be satisfied with the type of plate 
obtained. 
In considering whether a given shadow in the kidney area is a 
veritable calculus, the knowledge afforded by plates made after the 
introduction of the opaque catheter affords often decisive evidence. 
Plates of the kidney, after the opaque catheter has been introduced, 
should always be stereoscopic, so as to determine the special relation- 
ship of the catheter to the shadow under consideration. The same 
procedure may be necessary to form a final conclusion as to the position 
of shadows seen in the lower pelvis. On this account, in hospital 
services, where a large number of kidney examinations are made, a 
close relationship between the cystoscopic room and the roentgen- 
ray department should be established. For the comfort of the patient 
it is much better to have a suitable roentgen-ray apparatus located 
in the cystoscopic examining room. QUALITY OF THE NEGATIVE 
137 
For the accurate study of suspected tumors in the kidney region 
resort may be had to the pneumo-peritoneum method. In employ- 
ing this method it is necessary to make the plates with the patient 
in such a position that part of the injected gas may form a back- 
ground for the kidney. This may be secured by plates made with 
the patient upon his side, so that the gas will float up around the 
uppermost kidney or, more essentially, plates should be made with 
the patient lying upon his abdomen, so that the injected gas may be 
around each kidney area. It would be necessary in every case where 
pneumo-peritoneum is resorted to, to make an individual study of the 
best position to display the pathology in question. An individual 
technic is here far more valuable than a routine procedure. CHAPTER IV. 
SYPHILIS OF THE GENITO-URINARY ORGANS. 
By B. C. CORBUS, M.D. 
The Spirochseta pallida may invade the urethra in either the primary, 
secondary, or tertiary periods, and provoke lesions which on account 
of their site, form, and evolution may produce a variety of more or less 
obscure symptoms. 
In 1897 appeared the first review of syphilis of the urethra, by 
Faitout,5 followed later (1898) by the thesis of Bellet,22 and stiil 
later (1905) by the general review of “Syphilis of the Urethra,” by 
Simionescu.15 More recently (1908) the thesis of Rougier,14 “Tertiary 
Syphilis of the Urethra,” followed by the general review of “Syphilis of 
the Urethra,” by Tanton/6 have added materially to our knowledge of 
these conditions. 
Primary Syphilis.—1. Frequency.-—Fournier8 reports that out of 414 
indurated chancres, 32 occurring at the meatus, 17 were deep and could 
easily have escaped notice. In women urethral chancre is much more 
infrequent than in men. According to Fournier,7 the order of frequency 
in women is as follows: Entrance to the vagina, region of the clitoris, 
uterine neck, and urethra. 
2. Location.—Urethral chancre is located either at the meatus 
(chancre of the meatus) or more deeply in the interior of the urethral 
canal (endo-urethral chancre). 
A. Chancre of the Meatus.—Chancre of the meatus may make 
its appearance in the following ways: 
1. Round chancre embraces all of the free extremity of the canal. 
This form presents itself under the aspect of a small rose-colored circle, 
hemming in the meatus and leaving the urethra projecting like a beak 
on the surface of the glans. 
2. Left or right hemilateral chancre occupies the corresponding lip 
of the meatus; it appears under the form of a projecting nodule which 
provokes a deformation of the meatus by retraction of the correspond- 
ing lip or side on which the chancre is located. 
3. Superior or inferior commissural chancre occurs in the form of a 
crescent, the corners of which descend or ascend more or less on either 
of the two lips of the meatus or on both. 
These three types of chancre during the course of their evolution 
may lose the primitive characteristics which differentiate them from 
each other, particularly when phagedena is a complication. 
SYPHILIS OF THE URETHRA. 
138 SYPHILIS OF THE URETHRA 
139 
Symptoms. — Syphilitic chancre of the meatus may be of either 
erosive or ulcerative type. Induration is marked and often diffuses 
toward neighboring structures. 
When the chancre is situated exactly on the meatus, whether or not 
it extends itself into the canal, the orifice presents itself as swollen, 
deformed, red and gaping, bleeding on pressure and offering to the 
touch a sharply circumscribed, indurated area. 
In women, syphilitic chancre of the meatus usually has its site at the 
inferior angle of the orifice. Simionescu15 cites an observation where 
the chancre, primarily located at the meatus, sank into the urethra up 
to the vesical neck. 
B. Endo-urethral Chancre.—While endo-urethral chancre is not 
common, it is far from uncommon. Occurring in the fossa navicularis 
portion of the urethra, as it does, many times it is unrecognized. Often 
it is so near the meatus that it can be seen by forcibly separating the 
borders of the urethral orifice. 1 >u Castel4 observed one situated 2 
cm. behind the fossa navicularis. Fasoli6 cites one situated 2f cm. 
from the meatus on the inferior wall of the urethra. 
Endo-urethral chancre occurs in the following ways: 
1. From a chancre at the meatus, extending by continuity. The 
endo-urethral chancre of the anterior portion of the urethra is only an 
extension of the chancre of the meatus. 
2. Sometimes, in patients afflicted with gonorrhea, the mucous mem- 
brane in the fossa navicularis becomes eroded* producing an atrium of 
entrance for the spirochetes. 
3. It is possible, but highly improbable, that infection may take place 
by the passage of sounds into the urethra. Such things have been 
reported, but in this day of asepsis and antisepsis, it is almost beyond 
belief. 
Symptoms.—The three principal symptoms are: 
1. Pain. 
2. Discharge. 
3. Induration. 
1. Fain.—This is slight, always accompanies micturition and occurs 
in the majority of cases toward the end of urination; this is due to the 
expansion and contraction of the base of the lesion. 
2. Discharge. — This is the first symptom noticed by the patient 
and causes him to consult a physician. In every case a discharge is the 
initial symptom. It begins slowly after variable periods of incubation. 
In the beginning it is seldom accompanied by pain at the time of mic- 
turition; it is very watery at first, later slightly seropurulent, easily 
becoming blood-tinged, especially if the urethra is palpated roughly. 
At times the discharge is thick and purulent, but this is always a sign 
of mixed infection. 
3. Induration.—This is perceptible only by palpating the glans from 
behind and in front; the chancre is situated in the substance of the 
urethra, following an anterior-posterior direction, and, as a consequence, 
is lamellate in form. Often in the fossa navicularis the induration 140 
SYPHILIS OF THE GENITO-URINARY ORGANS 
manifests itself as a mass of cartilaginous consistency and of variable 
dimensions. 
In women the endo-urethral chancre is situated in the anterior part 
of the canal; in order to locate the induration, the index finger of the 
left hand is introduced into the vagina in contact with the suburethral 
region, while the right index finger examines the meatus from before 
backward. Sometimes this forms a veritable indurated cylinder, a peri- 
urethral muff, around the canal. At other times it is limited to the 
inferior segment of the canal and to the lateral surfaces. 
Syphilitic chancre of the urethra is accompanied by indolent inguinal 
adenitis, the same as any other chancre situated on the penis; at times 
the dorsal lymphatic vessels appear as an indurated cord. 
Diagnosis.—Chancre of the meatus should not be difficult of diagnosis 
from the character of the induration, appearance, and lastly and most 
important, from the microscopic examination of the secretion for 
Spirochaeta pallida. 
In endo-urethral chancre, most patients present themselves on 
account of a discharge; this should be immediately examined for 
gonococci, as this is the most frequent condition that produces a “ure- 
thral running.” Failure to find any organism either of a specific or 
non-specific variety should arouse suspicion. 
Chancre of the meatus may be confounded with simple chancroid 
of the meatus, on account of induration caused by the irritating effect 
of the urine; however, in chancroid there is more discharge and extreme 
pain, and the lesion may be covered by a membrane with a dirty, moth- 
eaten appearance. 
Superficial erosions due to gonorrhea may simulate chancre of the 
meatus, or both may exist together. 
Herpetic eruptions are multiple, the borders are polycyclic, and, 
if recent (vesicle stage), clear serum can be expressed from the 
lesion. 
Syphilitic chancre of the meatus may be confounded with epithelioma 
of the glans; here an error in diagnosis might lead to unnecessary 
operation. The epithelioma may be accompanied by infiltration and 
adenopathy, the same as a chancre. 
In women the error may be still more easy, as the periphery of the 
meatus is the place of election of urethral epithelioma; cancerous 
induration is more extended, but less hard and less resistant than the 
syphilitic induration. The adenopathy is less tardy in the neoplasm, 
and the neoplasm does not tend toward cicatrization. 
However, in all cases a careful history should be noted, together with 
a complete physical and careful microscopic examination. In examin- 
ing for Spirochseta pallida there is no better way of obtaining the 
material than by capillary attraction, as illustrated on page 257, under 
Genital Ulcers. 
Complications.—The evolution of urethral chancre is slower than that 
of other syphilitic chancres; this is due, in a measure, to the constant 
passage of urine and secondary infection, with poor drainage. SYPHILIS OF THE URETHRA 
141 
Ulceration.—Often in the male and female, syphilitic chancres of the 
meatus may form extensive ulcerations, the edges become uneven, the 
base grayish, and a pseudomembrane may form, giving the condition, 
as a whole, a formidable appearance. 
Phagedena.—Occasionally, in practice, more especially in dispensary 
work, chancre of the meatus isseen complicated by phagedena. This 
condition, occurring in endo-urethral lesions, is not so common. When 
occurring at the meatus, it may form extensive cavities, extending 
deeply; it may even decapitate the glans penis or enlarge the meatus 
considerably. Extensive mutilation may later cause complete closure 
of the orifice, calling for surgical interference. 
Stricture.—Chancre of the meatus or endo-urethral chancre may at 
times cause stricture. Two varieties may occur: 
1. A diminution of the caliber due to the syphilomatous neoplasm. 
2. True cicatricial stenosis. 
The first variety occurs at the time of the specific induration and is 
of little importance; the stenosis disappears with the reabsorption of 
the induration. 
The second variety follows ulcerated or phagedenic chancres, espe- 
cially of the meatus and fossa navicularis. These strictures follow 
the general law of cicatricial strictures. They develop with great 
rapidity and offer great resistance to dilatation. 
Secondary Syphilis. — Urethral Mucous Syphilides. — Numerous 
French authors recognize the possible existence of a specific secondary 
urethritis. It is characterized by a more or less viscous, transparent, 
slightly opalescent discharge, rarely creamy or purulent. This is scarcely 
perceptible during the day, but is always present in the morning, 
after the urine has been held all night. Inflammatory symptoms are 
absent. Microscopic examination without the dark-field condenser 
shows nothing characteristic; mucus and epithelial cells predominate. 
However, the Spirochseta pallida may be found if the proper appa- 
ratus is used. Antisyphilitic treatment rapidly clears up the con- 
dition. 
It is this secondary specific urethritis that is the means of contagion 
through the semen, which, during this period, in its passage through the 
urethra at the time of ejaculation becomes saturated with the urethral 
discharge and the spirochetes that it contains, thus acting as a carrier 
of the infection. 
An interesting case of Rochon is cited by Tanton,1;the details of 
which are as follows: A woman presented on the abdomen excoriations 
caused by her corset; the syphilitic husband, afraid of having syphilitic 
children, had the habit of ejaculating on the abdomen. A gigantic 
chancre developed at the site of the excoriations. The author con- 
cluded that urethral mucous syphilides existed. 
Tertiary Syphilis.—In 1901 Fournier8 reported nineteen cases of 
tertiary syphilis of the urethra; Mauriac,11 Gaucher,10 Renault,12 and 
Rougier14 have observed and reported cases; recently Drs. I)ey and 
Kirby-Smith3 in this country have reported two interesting cases. 142 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Time of Appearance.—Often they are late, making their appearance 
eight, ten, or even fifteen to twenty years after the primary symp- 
toms. 
Modes of Invasion.—1. Primary.—These lesions make their appear- 
ance by way of the canal. 
2. Secondary.-—These lesions appear in the canal from an extension 
by continuity. 
In the case of primary localization these lesions may appear under 
two forms. 
(а) Primary ulceration. 
(б) Syphilitic gumma. 
The latter is the most common form and may be presented under two 
clinical aspects: 
1. Circumscribed infiltration. 
2. Diffuse infiltration. 
Circumscribed infiltration appears as a small gummatous tumor, 
often resembling a small tumor or core, forming a slightly rounded or 
hemispherical projecture. 
In the diffuse infiltration the gumma grows on the surface, infil- 
trating the tissues to a variable extent, often appearing as a sheet-like 
induration. 
Both of these forms may contract the canal, causing symptoms of 
obstruction in a greater or less degree. However, these forms often 
undergo softening and ulceration, thereby eliminating, for the time 
being, obstructive symptoms. Hemorrhage following such a condition 
may be severe. 
These gummata may break down and ulcerate in either one of two 
ways: toward the urethral canal or on the under surface. If the 
gumma breaks down on the surface which is in connection with the 
urethral canal, it often forms internal blind fistake which act as 
reservoirs and collect urine during the act of micturition. Later, these 
foci may be the starting-points of urinary infiltration and abscess. 
Symptoms.—Tertiary syphilitic lesions of the urethra have the fol- 
lowing characteristics: 
1. Insidious invasion, indolent, often remaining for a long time 
unnoticed. 
2. Slow evolution: It is necessary for these lesions to attain compara- 
tively large proportions before the patient seeks surgical advice. 
3. The local reaction is generally insignificant or absent. There is no 
inguinal adenopathy. 
In general, these lesions do not pass the balanitic region, for which 
they seem to have a specially marked predilection. 
Cylindroid Syphiloma of the Urethra.—Cylindroid syphiloma is a 
gummatous infiltration, regular, cylindric, occurs in a segment of the 
canal and may lead to stricture. It occurs under two forms: 
(a) Sclerotic. 
(b) Sclerogummatous. 
The sclerotic form is rare, severe, and resistant to treatment. SYPHILIS OF THE URETHRA 
143 
The sclerogummatous form is benign and yields rapidly to specific 
treatment; the gummata disappear, the islands alone persisting. This 
Fig. 101.—Extensive gummatous destruction of the glans penis involving the urethra. 
Date of primary infection three years. Wassermann positive. Neglected treatment. 
One arsphenamine injection made in May, 1911. (Author’s case.) 
Fig. 102.—Beginning gumma of the glans penis involving the urethra. Previous treat- 
ment none. Wassermann positive. (Author’s case.) 
condition may exist at the same time as other gummatous lesions of the 
canal, from which it seems only a prolongation. 144 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Complications following Tertiary Urethral Syphilis.Phagedena.— 
Phagedenism, according to Fournier, is the most serious and gravest 
complication that can occur. lie says that one should be impressed 
with the fact that genital phagedenism occurs as a complication in 
tertiary syphilitic lesions more frequently than in simple chancres. 
Here phagedena of the urethra may destroy not only the meatus, 
but also may extend extensively into the glans portion of the urethra. 
This is particularly noticeable interiorly where gummata are most 
often encountered. From this extensive destruction hypospadias of 
the glans portion may occur to a greater or less degree. 
Fistula.—As a result of this extensive destruction, fistulas are very 
frequent. They may be in the following locations: fistulas of the 
balanopreputial groove, of the fossa navicularis, or of the body of the 
penis, causing destruction of the penile portion of the urethra to a 
greater or less extent. 
Albarran1 says: “It is probable that certain fistulas are veritable 
urinary abscesses with secondary infection, the microorganisms gaining 
entrance into the lesions through the canal, thus acting as a great open 
portal for entrance into peri-urethral tissue.” 
Stricture.—Strictures may be of two kinds, false or pseudostrictures, 
and true strictures. 
False strictures occur during the formation of the gumma and, once 
they ulcerate or dissolve, empty their contents either into the urethra 
or externally, and the stricture disappears. 
True or cicatricial occur secondary to ulcerated urethral 
gummata or following phagedenic ulceration, or as a sequel to cylin- 
droid syphiloma. 
The site of the obstruction depends on the form of syphiloma from 
which it is derived. It is most frequently found at the meatus or in 
the balanitic region. 
The diagnosis of this form of stricture must be made on the particular 
history of the patient. Diagnosis may be considered under the follow- 
ing headings: Wassermann reaction, microscopic examination of the 
discharge, and a careful physical examination. 
The Wassermann reaction here, as in other forms of tertiary syphilis, 
if performed by a careful serologist, should be positive in 100 per cent. 
The urethral discharge is very characteristic. The diagnosis is made 
by exclusion. If one cannot find any predominating organism, one 
should be suspicious and a careful search continued until the diagnosis 
is positive. 
Erosive and gangrenous balanitis may produce destructive symptoms 
at times, greatly simulating a broken-down gumma; however, micro- 
scopic examination will rapidly settle the question. 
Epithelioma, while comparatively rare, must be thought of. Glan- 
dular enlargement, however, occurs early. Gummata here, as elsewhere, 
grow very slowly and ulcerate only after some time. They are only 
slightly painful, and, as a rule, are attended by no constitutional 
symptoms; however, both gumma and neoplasm have the common SYPHILIS OF THE PROSTATE 
145 
characteristic of being indurated. The cancerous discharge is purulent, 
foul-smelling, often streaked with blood and the pain at micturition is 
severe. If the urethra is explored with a sound or bougie there is 
abundant bleeding. Often the sound will bring away particles of the 
tumor. These should be microscopically examined immediately. 
Neoplasmic induration often adheres to the deeper parts, ulcerates the 
skin and produces fistula surrounded by neoplasmic offshoots. 
In the neoplasm the edges of the ulceration are projective, thick and 
resistant; the surface bleeds easily, with a characteristic fetid discharge. 
In syphilitic gumma there is no adherence to subjacent parts, the 
base is unequal, and if seen early, there often exists a yellowish adherent 
scab with central necrosis. The base is indurated but not painful; 
secretion is not marked. The W'assermann reaction is always negative 
in epithelioma, and a biopsy will rapidly clear up the diagnosis. 
Occasionally urinary abscess may be mistaken for gumma. Here 
the history either of traumatism or of previous stricture should be 
sufficient to make the picture plain. 
Prognosis.—The prognosis of primary lesions, whether occurring at 
the meatus or endo-urethrally, depends on a prompt diagnosis. If 
treatment is begun early, before there is any secondary infection and 
destruction, these lesions cause no further symptoms. 
However, in tertiary syphiloma the prognosis varies according to the 
character of the lesion. In simple, uncomplicated cases, ulcerations 
scar over rapidly and gummata dissolve. But if there is great destruc- 
tion of tissue, with resulting strictures, treatment may be prolonged 
and unsatisfactory. 
Treatment.—In chancre of the meatus and endo-urethral chancre the 
treatment is the same as described under primary lesions elsewhere. 
(See Chapter VII, p. 263, under Genital Ulcers.) 
In tertiary lesions of the urethra the treatment is the same as that 
described under Tertiary Lesions of the Bladder. 
For the treatment of stricture following tertiary lesions of the meatus 
and urethra the reader is referred to the chapter on Strictures. 
The small number of reports in the literature up to the present 
would seem to indicate that syphilis of the prostate is extremely rare. 
Cnlike the bladder, infections in the prostate only manifest themselves 
in the destructive lesions of tertiary syphilis. 
W hen we stop to consider that syphilitic infection can occur in any 
part of the human organism, it is only natural to suppose that now and 
again it would involve the prostate. Consequently, if we hope to 
recognize this condition in the future, it will be necessary to carefully 
examine all cases that are at all atypical for prostatic involvement. 
Recently Thompson has reviewed the literature on syphilis of the 
prostate. His report dates from 1836 to 1920 inclusive and contains 
reports from the following authors: Rattier,65 1836; Ricord,66 1851; 
SYPHILIS OF THE PROSTATE. 146 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Reliquet,67 1885; Wroczynski,68 1894; Grosglik,69 1 897; Ilochon,70 1897 
Drobniy,17 1906; Kudintseff,71 1908, 2 cases; Power,72 1908; Divaris,73 
1908; Desnos,74 1910, 2 cases; Jungano,75 1910; Cook,76 1912; Rush,15 
1913; Wright,19 1914; Ulrich,77 1915; Ravogli,78 1916, 2 cases; Por- 
tillo,79 1917; Warthin,80 1918; Thompson,81 1916. 
Of the 24 cases reported, 12, or 50 per cent, are not accepted. There- 
fore, we certainly are fair in assuming that syphilis of the prostate 
is a most rare condition. 
A study of the symptoms in these cases shows that it is extremely 
difficult to make a differential diagnosis of syphilis of the prostate 
from infections that occur in the prostate, and hypertrophy of the 
prostate, as there is nothing pathognomonic either by cystoscopy 
or rectal examination that will aid us in diagnosing this condition. 
It is only in the presence of a positive Wassermann reaction and the 
subsidence of symptoms under specific treatment that we can venture 
jto make a diagnosis of syphilis of the prostate. 
SYPHILIS OF THE BLADDER. 
By syphilis of the bladder is meant only those diseases which involve 
the bladder mucous membrane itself. All those affections which ex- 
tend from the surrounding tissues to the bladder, whether they come 
from syphilis of the rectum in man or syphilis of the uterus and vagina 
in woman, are not considered. 
Syphilitic lesions of the bladder are at present scarcely known and 
most of the works on urology and syphilology fail to make mention of 
the subject. 
However, observations are being published and numerous articles 
have appeared in the foreign literature describing the clinical picture in 
detail, so that now that attention has been brought to this subject, it 
is highly probable that numerous cases will be reported in the future. 
The history of this affection is divided into three distinct periods: 
In the first period there is almost complete obscurity. There is 
cited only an occasional observation of autopsy findings in syphilitics, 
dying on account of their urinary lesions, ulcers, perforations and 
tumors, which were discovered on opening the bladders. This extends 
down to the year 1872, at which time Tarnowsky41 reported a case which 
is described later on in this chapter. 
In the second period are related some clinical observations, the 
diagnosis being based solely on the result of treatment; some of these 
observations lack accuracy. 
However, a sign of our advance in understanding this condition is 
the fact that the cases published during the second period were all 
diagnosed in life and many of the patients recovered under specific 
treatment. 
I n the third period diagnosis was made by the cystoscope, with the 
addition, many times, of the Wassermann reaction. SYPHILIS OF THE BLADDER 
147 
During this period 9 cases of syphilis of the urinary bladder were 
reported; all diagnoses were made at the autopsy table. Of these 9 
cases, 5 were undoubtedly gummata and 4 were secondary lesions. Fol- 
lowing is a brief history of the vesical findings, arranged in chronological 
order: 
Morgagni,33 in 1767, at the autopsy of a patient who presented scars 
on the surface of the penis and syphilitic lesions of the tongue and 
epiglottis, found a bladder hollowed out by ulcerations, and made the 
diagnosis of syphilis of the bladder. This observation is especially of 
historic interest, but on authority is doubtful. 
Follin,24 in 1849, found in a woman with destructive lesions of the 
bony and soft palate and syphilitic lesions of the liver, the vesical 
mucous coat covered with twelve small tumors about the size of lentils, 
making slight projections, in appearance similar to vulvar syphilitic 
papules. 
Ricord,40 in 1851, reports 2 cases: The first of a patient, aged 
fifty-two years, without special antecedent history, who for two months 
presented a urethral discharge, which was very abundant, persisting, 
and a little painful, At the end of fifteen days a right epididymitis 
appeared, with hydrocele; a month afterward the discharge was still very 
abundant and tinged with blood; the hydrocele had disappeared; the 
epididymis was still indurated. Soon a left epididymitis with hydro- 
cele manifested itself. Then, in spite of the cure of the lesions, the 
discharge persisted, the general condition was aggravated, and death 
followed four months after the beginning of the infection. At the 
autopsy the membranous and prostatic portions of the urethra were 
hollowed out by deep ulcers, presenting the character of primary 
phagedena. The prostate was in part destroyed. In the bladder there 
existed several round ulcerations, with borders cut into peaks. On the 
left side the seminal vesicle, the vas deferens, and even the testicle, 
showed abscesses. On the right side these organs were normal. 
The next observation dealt with a young man, aged eighteen years, 
who some days after a suspicious coitus had contracted a chancre of the 
frenum which spread from place to place, encroaching on the meatus. 
A little later an abundant discharge appeared, with painful urination. 
A phimosis formed, the constriction of which was removed by incision, 
but the edges of the wound ulcerated and the ulceration encroached on 
the glans and destroyed it almost completely. During three months 
the discharge persisted, with pain and incontinence of urine; death 
followed from marasmus. There was found at the autopsy an ulcera- 
tion of the meatus which had encroached on the urethra, and a second 
ulceration much elongated on the surface of the membranous urethra 
and in the prostatic region. The vesical neck was in part destroyed. 
The vesical cavity was filled with elevated tumors, reposing on an 
ulcerated mucous coat; the vesical wall was hypertrophied. 
Virchow,44 in 1852, at autopsy found ulcerations of the bladder and 
urethra in a woman, aged fifty-four years, who for fifteen years pre- 
First Period, from 1767 to 1872. 148 
SYPHILIS OF THE GENITO-URINARY ORGANS 
sented periosteal pains and syphilitic ozena, with destruction of the 
nose and pharynx, and who, during the first month, had had incon- 
tinence of urine. 
A idal, of Cassis,43 in 1853, reported the case of a patient, aged 
twenty-six years, who had had a chancre three years previously, and 
who, having presented urinary troubles, urethral discharge, abdom- 
inal pains, hematuria after micturition, and retention of urine, suc- 
cumbed to a generalized peritonitis. At the autopsy there existed 
a vesico-peritoneal fistula. The vesical mucosa presented an elevated 
ulceration with edges cut into peaks, rounded, with a vascular 
periphery surrounded with disseminated plaques. 
Tarnowsky,41 in 1872, reports the case of a child, aged four years, 
infected by its foster-mother. The diagnosis of syphilis not having 
been made at the beginning, and the child having been treated for 
eczema, entered the hospital in a deplorable condition. The body was 
covered with oozing and ecchymotic papules. The mouth and throat 
were covered with ulcerations and mucous plaques separated by deep 
fissures. The general condition was not favorable. The respiration was 
difficult and anorexia complete. This child was subjected to mercurial 
treatment, baths and rubbings. 
Four days after its entrance to the hospital it was noticed that at 
each micturition the child was extremely agitated and experienced pains 
in the genital region. On examination it was found that the prepuce 
was very much tumefied and inflamed, that the urethra was indurated 
and painful; puncture of the preputial sac allowed a purulent greenish- 
yellow liquid to escape. The patient died the twelfth day after his 
entrance to the hospital. At the autopsy the mucous coat of the 
urethra and, in part, that of the bladder were covered with superficial 
syphilitic ulcerations. The pharynx and throat were sprinkled with 
ulcerated papules; the liver was syphilitic. 
Fenwick,23* in 1879, reported the case of a twenty-three-year-old 
man who was admitted to the London Hospital for a stab wound; he 
died of the injury. Autopsy showed, beside this injury, a hard chancre 
of the penis and adenitis of the inguinal and lumbar glands. Elevated 
spots were seen on the mucous membrane of the bladder, which looked 
like condylomata. 
Neumann,36 f in 1899, reported a case of gumma of the bladder 
observed by him in a forty-four-year-old working woman, who pre- 
sented in the bladder numerous round whitish nodules the size of a 
millet-seed, some of them isolated and some in groups. 
Second Period, from 1872 to 1900. 
Morris,34 in 1897, reported the case of a woman who had bladder 
hemorrhage for months; she had lost thirty pounds in weight. Morris 
* These authors’ cases, while appearing in publications as cited, belong to the first 
period, 1767 to 1872. 
t Ibid. SYPHILIS OF THE BLADDER 
149 
made a cystoscopic examination, but reports nothing definite; specific 
treatment caused a rapid subsidence of symptoms. 
Griwzow,27 in 1899, presented observations on two patients attended 
by urinary troubles of a doubtful nature; the diagnosis of syphilitic 
cystitis was admitted, because of the action of the mercurial treat- 
ment, which was instituted for the specific lesions in other organs. 
In the first case, a woman, aged forty-two years, syphilitic for ten 
years, presented urinary troubles, pain and intermittent retention of 
urine. The diagnosis of chronic catarrh of the bladder had been made, 
but the mercurial treatment instituted for three years gave no results. 
At this time, on palpation, a compact, rounded tumor could be felt 
below the pubis, also palpable by the vagina; the diagnosis was not 
definite. At the same time the particular symptoms, pain in the region 
of the liver, with palpable hepatic nodes, diarrhea and vomiting, caused 
a diagnosis of gumma of the liver to be made, and in several months the 
mercurial treatment caused not only the hepatic symptoms to disappear 
but the vesical condition and the subpubic tumor as well. 
The second observation by Griwzow is that of a man, aged thirty 
years, who had contracted syphilis six years before. The vesical symp- 
toms and the pain on micturition, which he had for two years, per- 
sisted in spite of all local treatment. A perforation of the bony palate 
had appeared. Mercurial treatment was given, which brought about a 
cure not only of the soft palate, but also the disappearance of the 
vesical pains. 
Griwzow had in these 2 cases discovered accidentally the specific 
nature of the vesical lesions. 
Chezelitzer,22 in 1901, presented a case similar to that of Griwzow. 
He treated a patient, afflicted with vesical pains and retention of urine 
for a long time, for catarrhal cystitis and prostatitis. He did not obtain 
any result, when, one day, he found the presence of syphilitic lesions of 
the testicle and psoriasis of the palms of the hands. Mercurial treat- 
ment brought about the cure of the testicular lesions and the disappear- 
ance of the vesical phenomena, which, indeed, seemed to have been of 
syphilitic nature. 
Margoulies,30 in 1902, reported a case of vesical phenomena, hema- 
turia, incessant desire to urinate, diminution of vesical capacity, in a 
man, aged fifty-five years, a tabetic, who besides had a nephritis 
(albumin and edema). Margoulies made the diagnosis of syphilitic 
cystitis, and mercurial treatment caused the vesical symptoms to 
disappear. Unfortunately cystoscopic examination had not been made 
before treatment, and when made, it showed only a bladder rich in 
trabeculae, which occurs often in tabetics. 
Towbien,42 in 1904, reported a case, probably a gumma, the record 
of which, however, is incomplete. 150 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Third Period, from 1900 to 1916. 
The rapid progress made, coincident with the development of the 
cystoscope, in the diagnosis of vesical lesions is particularly noticeable 
during this period; while the first authentic reports of Matzenauer31 
appeared in 1900, others were still using the older therapeutic diag- 
nostic test and reporting their cases (Chezelitzer, Margoulies and 
Towbien). 
It is interesting to note how, in the first years of the second decade 
(1872 to 1900), the syphilitic nature of the bladder infection was only 
occasionally discovered, and how later physicians came to consider 
the possibility of bladder syphilis more and more, and how, at last, 
Matzenauer,31 in 1900, opened the modern period by publishing the 
first case of syphilitic ulcerations of the bladder, as observed by means 
of the cystoscope. Since then the serum reaction of Wassermann has 
been added as strong supporting evidence in diagnosis. 
Syphilitic lesions of the bladder may be of two kinds: 
1. Secondary. 
2. Tertiary. 
Secondary Bladder Syphilis.—In 1893 Neumann called attention 
to the fact that secondary lesions of the bladder were undoubtedly not 
so rare as was previously thought. 
Ernest Frank, in 1909, presented at the Congress of Urology in Berlin 
a number of plates of cystoscopic examinations of secondary lesions of 
the bladder before, during, and after treatment. In all he reported 5 
cases that had never been published before. Unfortunately I have not 
been able to find a description of Frank’s cases. 
Paul Asch,20 in 1911, reported the case of a woman, aged twenty-eight 
years, who presented all the signs of an acute cystitis which several 
doctors had diagnosed as gonorrhea. At the time of examination the 
patient urinated during the day every half-hour and at night every ten 
minutes. There was persistent and severe strangury, accompanied by 
terminal hematuria. Tuberculosis having been excluded by inoculation 
and microscopic tests, a cystoscopic examination was made which showed 
the following picture: The whole of the bladder mucous membrane was 
very much swollen and red, and scattered over it at irregular intervals 
were hard, superficial, round, and oval defects in the mucous membrane, 
with small undermined edges and whitish bases. They looked like 
syphilitic patches such as are found in the mouth in the secondary 
stages of syphilis. Examination of the inguinal glands showed them to 
be large, hard, and painless on both sides. The patient now admitted 
that one year and three months before, she had had a small ulcer on the 
left labium that had recovered under local treatment, and had not been 
followed by any other symptoms. 
Mercury inunctions were ordered. During the first week of the 
treatment the symptoms seemed rather to increase, which was probably 
the result of irritation from the cystoscopic examination, but may also 
have been a reaction from the treatment itself. At the end of the PLATE I 
FIG. 1 
FIG. 2 
Secondary Syphilis of the Bladder Mucous Membrane as 
described by Peresehiwkin. 
Fig. 1 shows the vessels of the mucous coat strongly injected, with some 
edema around the internal sphincter. All over the mucous membrane, 
especially on the base, are ulcerations of various forms and dimensions, 
some flat, others with infiltrated edges. 
Fig. 2 shows complete disappearance after mercurial treatment. SYPHILIS OF THE BLADDER 
151 
second week the symptoms began to improve. The urine cleared up, 
the general condition improved and in the fourth week the picture was 
very different. The patient had increased fourteen pounds in weight; 
she could retain her urine two to three hours in the day, and only had 
to get up once during the night. The urine was almost clear, contain- 
ing only a few red blood cells and leukocytes. The cystoscope, at the 
end of the fourth week, showed the mucous membrane only a little 
reddened, with small white flecks of mucus. In the sixth week the 
bladder was completely normal, so that treatment could be given up. 
A year later the patient came for examination, and bladder and urine 
were both normal. 
This case is undoubtedly one of those rare ones, not previously 
reported in the literature, of secondary syphilitic disease of the bladder 
corresponding to the patches in the mouth and sexual organs. 
Pereschiwkin,37 in 1911, published 3 cases of “ papulous exanthema 
of the vesical mucous coat;” all these patients showed lesions on 
the skin and mucous surfaces, together with vesical symptoms. 
In the first patient the cystoscopic examination showed a normal 
vesical mucous coat with the exception of the base of the bladder, wdiich 
was edematous and hyperemic. On the periphery of the left ureter one 
saw several ulcerations with edges elevated and infiltrated. The base 
was very red, the ureteral orifices were normal. 
In the second there existed in the region of the summit of the 
bladder seven small ulcerations with infiltrated edges. 
In the third patient the vessels of the mucous coat were strongly 
injected and the vesical sphincter was edematous; on all the mucous 
coat, especially at the base of the bladder, there existed small areas of 
ulcerations of variable forms and dimensions, some with edges infil- 
trated, others with flat edges. The ureteral orifices were a little edema- 
tous. Mercurial treatment brought about a rapid disappearance of the 
symptoms. (Plate I, Figs. 1 and 2.) 
Michailoff,32 in 1912, published a case of a woman, aged thirty-nine 
years, who complained of bladder pain radiating into the hips; hema- 
turia was periodic over a period of five years. Gradually the hematuria 
increased in amount and frequency. There were no pains during the 
hematuria, and the temperature was normal. The details of the cysto- 
scopic picture were as follows: On the lateral and superior wall of the 
bladder, characteristic rows of vesicles covered by yellowish-gray 
crusts were visible; each vesicle was surrounded with small areas 
of the color of red raspberries which sharply contrasted with the 
normal coloring of the neighboring mucous coat. Here and there 
injected vessels were seen, the rows of circles, which were surrounded 
by little “coronas,” looking like the papules which we are accus- 
tomed to see on the epidermis. Later on, at a second cystoscopic ex- 
amination, catheterization showed that the hemorrhage came from the 
left kidney. In secondary affections of the bladder and upper urinary 
tract hemorrhage has never been observed. It is possible that the 
hemorrhage came from the renal papilla or from minute bloodvessels. 152 
SYPHILIS OF THE GENITO-URINARY ORGANS 
It resembled that form of hemorrhage that is spoken of as “essential 
hematuria.” The diagnosis in this case was based entirely on the 
cystoscopic examination, afterward confirmed by the Wassermann 
reaction, with prompt disappearance of local and general symptoms 
as a result of specific therapeusis. 
Mucharinsky,35 in 1912, reported the case of a patient who a year 
before had had a hard chancre; later roseola and treatment. There 
were no objective signs of syphilis; glands not palpable; no urethral 
discharge; there was painful urination by day and night; a catheter had 
been used for two weeks. Cystoscopic examination showed diffuse 
bluish-red hyperemia of the neck of the bladder and trigone; middle 
lobe of the prostate protruded considerably into the bladder; bladder 
tense; on the mucous membrane flakes of mucus; on the fundus of 
the bladder an ulcer the size of a copper coin, with jagged, strongly 
hyperemic edges; on the base of the nicer a blood clot. Complete 
healing took place under specific treatment. This case belongs to 
the secondary erythemata of the bladder with ulcer formation. 
The author has had the opportunity to examine cystoscopically one 
case of secondary syphilis in a young man with a diffuse macular erup- 
tion, without any bladder symptoms. The mucous membrane was 
diffusely hyperemic; the vessels were injected, with numerous islands 
of mucus adherent throughout. Urine from both kidneys showed a 
large number of leukocytes, but no organisms. 
Tertiary Bladder Syphilis.—Matzenauer,31 in 1900, heretofore men- 
tioned as the first to publish a case of syphilitic lesion of the bladder 
ascertained by the cystoscope, describes a case of a girl, aged twenty- 
two, a syphilitic for four years, whose vesical neck was covered with 
papilloma-like projections resembling villosities; the rest of the mucous 
coat of the bladder was normal. On the superior wall of the urethra a 
superficial ulceration existed, with edges cut into peaks, reaching the 
internal orifice. Matzenauer made a diagnosis of gummata of the 
urethra and bladder. 
MacGowan,29 in 1901, reported a case of a patient, syphilitic for ten 
years, who presented urinary troubles and, in particular, vesical pains, 
with frequent desire to urinate and with retention of urine. The local 
treatment brought no amelioration; he made a cystoscopic examina- 
tion. He found on the posterior part of the vesical mucous coat 
numerous papilloma-like projections and behind the right ureteral 
orifice several concentric ulcerations, with hard edges, infiltrated, the 
syphilitic nature of which could not be doubted. 
While syphilis of the bladder is not so frequent in this country as it is 
abroad, and as a consequence not so easily diagnosed, MacGowan 
deserves credit for his pioneer report of a case diagnosed by means of 
the cystoscope. 
Graff,26 in 1906, mentions a case in a fifty-six-year-old man, who, 
thirty-five years before, had had a gonorrhea and small ulcers on the 
penis, and who was admitted to the hospital because of repeated 
hemorrhages from the bladder. For some months there had been pain SYPHILIS OF THE BLADDER 
153 
in the perineum and limbs, extending sometimes to the glans penis. 
Urination was difficult. Both testicles showed a moderate doughy 
swelling, but no pain. Catherization was rendered difficult by a con- 
tracted external urethral orifice. Cystoscopy could not be performed 
on account of the bladder hemorrhage. The urine was bloody and 
purulent. No tubercle or other bacilli could be demonstrated in the 
urine. The general condition improved under irrigation of the blad- 
der with weak silver nitrate solution and the hemorrhage and other 
symptoms decreased, so that the patient thought of leaving the 
hospital; cystoscopy was not possible and it showed, at the summit 
of the bladder, a tumor-like new growth with a defect in the centre 
and papillary proliferation of the edges, so that papilloma was sug- 
gested, or several small papillomata. 
Suprapubic cystotomy was performed. At the summit of the bladder 
there was an ulcer extending into the muscular layer, from the base of 
which white particles could easily be removed. The ulcer was cauter- 
ized, the bladder closed by suture, with drainage through a catheter. 
The wound healed uneventfully. After opening the bladder, the nature 
of the tumor could be better recognized. In connection with the swell- 
ing of the testicle, it suggested syphilis. Syphilis had been thought of 
before, but the history alone did not give sufficient grounds for it. The 
diagnosis of gumma of the bladder and bilateral gummatous orchitis 
was confirmed by the results of the antisyphilitic treatment, which was 
now begun. Six weeks after the operation the patient was discharged, 
completely cured. 
The excised piece consisted chiefly of necrotic cell masses and bladder 
epithelium, which did not show any tumor-like degeneration. 
Le Fur,23 in 1902, reported the case of a patient who had never had 
gonorrhea, but eight years before had had syphilis, which was treated 
very irregularly. Two years before hematuria had appeared, which 
lasted throughout the act of urination. This occurred several times at 
irregular intervals, but without pain and without any other bladder 
symptoms. A few months before a more severe hematuria than usual 
had appeared, which caused urinary retention by the formation of clots 
in the bladder. The aspiration of these clots stopped the hemorrhage, 
but it must have been profuse, for the patient’s mucous membrane was 
very pale. The urine was turbid, contained numerous red blood cells 
and leukocytes, but no bacteria. The capacity of the bladder was good. 
The prostate was very hard and irregular, and in the right lobe a 
large, hard nodule could be felt. The author suspected, therefore, 
that the hemorrhage was caused by chronic prostatitis and began 
treatment for that. As this treatment had no effect he made a cysto- 
scopic examination. 
He found a group of three ulcers in the region of the trigone, one of 
which was of some depth, had fissured edges and a gray base. From 
these findings he suspected an infection of the bladder from the dis- 
eased prostate and irrigated the bladder with a solution of silver nitrate. 
Since the urine remained turbid even after this treatment, and as 154 
SYPHILIS OF THE GENITO-URINARY ORGANS 
syphilitic patches developed in the pharynx, the author concluded 
that syphilis was the cause of the bladder disease, and antisyphilitic 
treatment brought about complete recovery in a short time. The 
urine became clear and free of blood, the prostate soft and the nodules 
disappeared. Cystoscopy showed white scars in place of the ulcers 
in the bladder. 
Margoulies, in 1912, reported the case of a woman, aged forty-one 
years, who presented intermittent hematuria, with pains in the left 
hypochondriac region, radiating toward the bladder, with frequent 
desire to urinate; cystoscopic examination showed a little behind and 
to the left of the left ureteral orifice a neoplasm formed of three tumors, 
each the size of a bean; these three excrescences were very close to each 
other and the sides turned toward the summit of the bladder were 
covered with a visible membrane; all around the mucous coat was 
hyperemic. Having made the diagnosis of cancer of the bladder, 
Margoulies, in proposing ablation, noticed that the patient bore on her 
legs whitish scars and had in her previous history a miscarriage. He 
had her take potassium iodide. To his great surprise it produced a 
rapid amelioration, and a month later the vesical tumors had disap- 
peared, leaving on the mucous coat little insignificant scars. 
Von Engelmann,45 in 1911, reported the following 3 cases: 
His first case was in a sixty-year-old woman who had had bladder 
hemorrhages for six months, without any other bladder symptoms. 
Cystoscopic examination showed, above the right ureter, a tumor 
about 3 cm. long, with ulcerated surface covered with a purulent mem • 
brane, and, in places, encrustation. The author thought the tumor 
was a carcinoma and proposed an operation; then he found that the 
patient had acquired syphilis twenty years before and ordered mercury 
treatment. The ulcerations healed rapidly and the entire tumor disap- 
peared in a few weeks. 
The second case was that of a man, aged forty-six years, who had 
suffered from hematuria at times during the preceding three months. 
He had had syphilis fifteen years before and a mercury and potassium 
iodide treatment. A year before paralysis of the left leg had developed, 
which disappeared after mercurial treatment. The urine was turbid, 
and at the end of urination there was slight pain. Cystoscopic ex- 
amination showed, beneath the opening of the right ureter, a round, 
prominent tumor about the size of a hazel-nut, with surface partly 
ulcerated and covered with purulent membrane and with papillary 
characteristics in places. At that time there were no other syphilitic 
symptoms. The author made a diagnosis of gumma of the bladder 
and advised antisyphilitic treatment. Cystoscopic examination, after 
thirty mercurial inunctions, showed that the tumor had disappeared 
and there was a red spot in place of it. No local treatment had been 
given. 
The third case was that of a woman, aged forty-seven years, who had 
had paralysis of both legs for a year. She had had painful urination 
for a month. There was a history of three abortions twenty years SYPHILIS OF THE BLADDER 
155 
before. Examination showed syphilitic myelitis, ulcerated papules of 
the labia majora, swelling of the inguinal glands, paresis of the detru- 
sor vesicse and also of the extremities. The urine was turbid, con- 
tained much pus, streptococci and Gram-positive diplococci; tubercle 
bacilli could not be demonstrated. Cystoscopy showed reddening of 
the bladder, and in the region of the opening of the left ureter, com- 
pletely surrounding it, a large ulcer covered with encrustations which 
projected into the bladder. Similar encrusted ulcers were found in 
the summit and on the lateral and anterior wall. They were all of 
different sizes, up to 5 cm. The encrustations could hardly be sepa- 
rated with the catheter; when separated hemorrhages occurred. The 
surfaces of the ulcers were papillary in appearance. 
Antisyphilitic treatment, combined with bladder irrigations, brought 
slow but progressive improvement in all the symptoms. The paresis 
disappeared and cystoscopic examinations, repeated at regular inter- 
vals, showed progressive improvement of the cystitis as well as of the 
ulcers. The encrustations gradually came off and were discharged 
with the irrigations. After two months the bladder mucous membrane 
was normal. In some places, where the larger ulcers had been, there 
were white scars on the mucous membrane, a sign that they had not 
been superficial erosions, but deep ulcers. 
Asch says that we will probably not err in saying that the ulcers and 
encrustations in von Engelmann’s third case were only indirectly caused 
by syphilis. 
Asch,21 in 1911, reported the case of a man, aged forty-five years, 
who had suffered for three months from bloody urine; no other symp- 
toms. General condition good. Previous treatment had not affected 
the disease. Suddenly a hemorrhage appeared without explainable 
cause. Its duration from the beginning to the end of urination, and 
the failure of previous methods of treatment, caused Asch to suspect a 
tumor. The lack of other symptoms indicated that it was probably 
in the summit of the bladder. Cystoscopic examination showed 
papillae the size of a hazel-nut about 0.5 cm. externally from the open- 
ing of the left ureter, and directly above, partially covered by the 
papillae, an ulcer about 1 cm. in diameter with hard, infiltrated edges 
and grayish-yellow purulent masses covering its base. This ulcer 
aroused a suspicion of syphilis. The patient admitted that he had had 
syphilis about twenty years previously, and that he had hardly been 
treated at all. Bacterial examination of the urine showed that there 
were no gonococci or tubercle bacilli. 
This shows that syphilis may produce papillomata which are very 
similar to the ordinary papillomata in appearance. 
Asch reports a second case of a man, aged thirty-five years, who, for 
three months, had had severe bladder hemorrhages and, for six weeks, 
painful desire to urinate. The urine had recently become turbid and 
contained many leukocytes and a considerable number of red cells. 
There was an ulcer on the right thigh which had persisted for five 
months, and which had had all the characteristics of a gummatous ulcer, 156 
SYPHILIS OF THE GEN 1TO-URINARY ORGANS 
Twenty years before the patient had had a hard chancre which was 
only superficially treated, but no other symptoms until the gummatous 
ulcer developed. Cystoscopic examination showed a large gumma- 
tous ulcer in the fundus. It was 2 or 3 cm. in diameter, had edges very 
much infiltrated and projected 1 cm. into the bladder. The base of 
the ulcer was yellowish and projected above the mucous membrane. 
There was no doubt of the diagnosis. The patient received an intra- 
venous injection of arsphenamine, 0.5 gm.; the result was excellent. 
After four days the gummata of the thigh and the bladder had com- 
pletely disappeared. Cystoscopy showed a normal bladder. 
Picot,39 in 1912, gives the details of one case of vesical syphilis in a 
patient, aged fifty-three years, who denied all venereal disease. The 
patient began to have urinary symptoms eight years previously, 
apparently without cause; at the end of two years he was operated on 
for vesical calculi. One day, a year afterward, cystitis increased and 
brown masses appeared in the urine; later most of the urine passed 
through the rectum. Cystoscopy showed the left ureteral orifice 
round, large, and gaping. A little below this orifice the vesical wall 
was thickened and sclerotic. Large projections were visible, intersected 
by longitudinal furrows on which finer ones branched. This aspect 
recalls that of a parquetted floor. The right ureteral orifice was 
elongated transversely. The bladder mucous coat which surrounded 
it was pale. This pallor contrasted with the deep coloration of the 
region of the trigone. Above and below the ureteral orifice, almost 
touching it, were found small irregular plaques of a clearer red, sur- 
rounded by a sort of halo. The edges were irregular, and a little 
polycyclic. It was above this region that the more characteristic ele- 
ments were discovered. At this point the vesical wall was covered 
by numerous ulcerations of some depth; they were very variable 
as to dimensions and some were confluent. Their border was 
irregular and polycyclic, the base was red at the periphery, paler at 
the centre. These elements had the aspect of ulcerous syphilides. 
The posterior part of the bladder on the right side presented the same 
parquetted aspect as that which has been described of the left ureter. 
In the midst of the projections, in a cavity, a fistula was found. It was 
an irregular orifice, the borders of which were cut into peaks. It 
appeared to be about 0.25 cm. in diameter. Below this orifice, floating 
in the liquid were two blackish bodies (debris of fecal matter). 
The summit of the bladder was occupied by small tuberculous 
masses, some of which were massed together, others isolated, slightly 
ulcerated at their apices. At the left posterior part of the bladder, 
at a point where the preceding formations were found there was a 
large varicose vessel, emerging into the bladder like a temporal arterio- 
sclerosis. Papulo-ulcerative elements in a fistula, the edges of which 
are cut into peaks, suggest syphilis. The patient denied having 
contracted a chancre, but the Wassermann reaction was found to be 
positive. 
It. Picker,38 in 1913, reported the case of a solitary gumma of the 157 
SYPHILIS OF THE BLADDER 
bladder in which he maintains that the diagnosis is the earliest on 
record for this class of cases. The Wassermann examination was 
negative. This, however, was before the ulcer had broken down. 
There wras no hemorrhage. The clear urine and the normal adnexa 
pointed to the localization of the condition in the bladder. Complete 
healing took place under specific treatment. 
Cystoscopy showed the vault thoroughly smooth and pale yellow. 
Both ureteral folds wTere clearly defined throughout their whole course. 
The openings of the ureters appeared at the end of the ureteral folds 
in the form of small, papillse-like protuberances. The stream of urine 
from both sides was strong. At the posterior end of the trigone, the 
mucous membrane appeared entirely normal and smooth, while on the 
internal side of the right ureteral fold, there wras a cystoscopic picture 
of a prominence about the size of a quarter of a dollar, w hich was sur- 
rounded by a narrow but livid red border which gradually passed over 
into the normal neighboring mucous membrane. The surface of the 
prominence itself appeared yellowish, tinged with red, and was demar- 
cated from the livid border by a margin formed of five segments coming 
together at an obtuse angle. In the middle of this formation there 
was a depression covered with a thick whitish eschar about the size 
of a five-cent piece. The entire formation was like a pansy in shape. 
Healing took place under specific treatment. 
Gayet and Favre,25 in 1914, reported under this heading 3 cases. 
The first had the following history: 
A tabetic, aged sixty-six years, wdiose urinary symptoms began 
fifteen months previously with a pollakiuria, most frequent at night, 
gradually growing worse; repeated attempts at cystoscopy were not 
successful. Later, however, the followdng picture was visible. On 
December 9, 1913, the patient continued to bleed; ureteral orifices 
clearly visible. Medium prostatic projection; at its site an ulcer with 
irregular contour. Twro other ulcerations were found on the upper 
side of the left ureteral orifice, in the form of papules, covered over 
wdth a greenish-wdiite exudation. This suggested the specific nature of 
the lesion and the patient wTho had been until then treated by washings 
only, was subjected to weekly injections of calomel and potassium 
iodide. The Wassermann was positive at this time. After the first 
week of treatment, the hematuria ceased, not to reappear, but 
incontinence persisted. January 17, 1914, after six months of treat- 
ment, cystoscopy showred a little vesicular vascularization, especially 
in the prostatic region, but there the preexisting ulceration was no 
longer to be seen. The neighboring ulcerations of the left ureter 
were in process of cicatrization; there was a sort of gray edematous 
covering. 
They conclude as follows: “An old syphilitic, tabetic, attended with 
chronic retention, writh ordinary cystitis, had suddenly a hemorrhage; 
the hemorrhage repeated itself in capricious manner, without provoca- 
tion, recalling the hemorrhage of neoplasms. It persisted until the 
day when mercurial treatment wras begun and then disappeared 158 
SYPHILIS OF THE GENITO-URINARY ORGANS 
rapidly. The cystoscopy, which at this time was not clear, gave the 
impression that there were ulcerations of specific nature. In ten weeks, 
under the influence of mercury, iodides, and finally neoarsphenamine, 
these ulcerations completely scarred over. 
“The only objection which could be made to the diagnosis of vesi- 
cal syphilis is that it might have been a question of ulcerous cystitis, 
occurring by ordinary infection in a tabetic bladder during retention, 
or the result of trophic lesions of medullary origin.” 
Gayet and Favre’s second case is that of a patient, aged fifty years, 
who denied venereal history. Seven years previously there was per- 
foration at the junction of the hard and soft palate. The patient 
suddenly had very intense hematuria, accompanied by pains at 
micturition and with pollakiuria; these functional symptoms dimin- 
ished soon; the hematuria was pronounced from the moment of 
entrance to the hospital and did not quiet down under the influence 
of rest. The first cystoscopy was not satisfactory on account of the 
hemorrhage. Arsphenamine treatment was instituted. Later cysto- 
scopic examination showed the following (five days after the first 
injection and one month after the patient’s entrance): The base of 
the bladder was red, the remainder of the mucous coat less red, but 
there existed numerous papillomata around the neck and the general 
aspect of a cerebral convolution still persisted, but with ridges and 
folds less pronounced. Later, the patient, who had quit the service, 
returned for a cystoscopy. She had not had the least trouble or the 
least hematuria since the last examination. Her bladder was entirely 
normal, except at the boundary of the neck, where several ridges 
still persisted, with the mucous coat a little irritated. 
The third case was that of a woman, aged thirty-five years. Eleven 
years previously she had had a chancre on the lip; fifteen days before 
her admittance to the hospital she suddenly, without premonitory 
symptoms, began to urinate blood. The first hematuria was of termi- 
nal character and accompanied by pain with the last drops. There was 
pollakiuria, especially on standing. Cystoscopy showed the bladder 
white throughout; the ureteral orifices presented nothing abnormal. 
The trigone was, on the other hand, somber red, with a median pro- 
jection recalling a prostatic lobe. The periphery of the neck was red, 
the folds much affected. No ulcerations were seen. Vaginal examina- 
tion was negative. Simple rubbings brought about complete cure. 
Schapira,82 in 1915, reported the case of a man, aged forty-six years, 
who contracted a chancre seventeen years prior to examination, for 
which he was treated for two years and discharged as cured. Fifteen 
years later a rash appeared on the chest and hands which was diag- 
nosed as syphilis. The Wassermann was positive and the patient 
received five intravenous injections of arsphenamine, which caused 
the rash to disappear and the Wassermann to become negative. At 
the time of examination the patient had been complaining of pain 
about the pubes for four or five months with urination every fifteen 
minutes during the day. About a week prior to examination the SYPHILIS OF THE BLADDER 
159 
patient began to suffer from frequency of urination at night and 
tenesmus. He had lost 30 pounds and was very anemic. The urine 
contained pus cells and bladder epithelium. Rectal examination 
of the prostate and seminal glands was negative. The cystoscope 
revealed the bladder slightly congested, very trabeculated but with 
normal ureteral openings. The trigone was very congested and a 
circular ulcerated patch with infiltrated edges and ragged base about 
the size of a quarter of a dollar on the left side of the left ureter. 
Another, similar, but smaller, ulceration was found a little to the 
right of the first one, and a white, glistening tumor covered by mucous 
membrane a little way from the left ureteral orifice. Although the 
Wassermann was negative a diagnosis of syphilis of the bladder was 
made and a week following an injection of arsphenamine; the Wasser- 
mann was strongly positive. Under mercury and potassium iodide 
and local treatment the bladder symptoms disappeared, the cysto- 
scopic picture becoming normal, and the Wassermann negative. 
Pedersen,83 in 1916, reported the following two cases: 
Case I.—A man, aged seventy-one years, who had contracted 
syphilis fifty years previously with only “mouth medication” for one 
month, had suffered so-called “liver attacks” ten years later which 
were finally cured ten years prior to examination by six weeks of 
intensive treatment. At this time appeared the first bladder symp- 
toms which consisted of painful and frequent urination and later on 
hematuria. At the time of examination he had suffered for about 
five years with sudden profuse hematuria and intermittent retention 
from time to time. Cystoscopy was difficult but a growth which 
was thought to be a malignant neoplasm was observed. Cystotomy 
was protested until antisyphilitic treatment had been tried. This 
was forced in the hospital but with only partial success. However, 
at the end of a month cystoscopy was successful and a “fleshy” or 
compact growth with a few moderate villous formations and an 
unusual amount of necrosis was observed. Nine months later under 
more or less continuous antisyphilitic treatment the bladder con- 
dition was much improved. 
Case II.—A woman, aged forty-four years, who twenty-five years 
previously had borne a child which presented, soon after birth, an 
eruption diagnosticated as congenital syphilis, which was successfully 
treated. Seven years previous to examination the patient developed 
frequent and painful urination which was succeeded by hematuria 
with clots. After being variously treated with little success a diag- 
nosis of syphilis of the bladder was made and the condition improved 
under intramuscular injections. Five months later, at the time of 
examination, she was complaining of frequent urination (every fifteen 
minutes during the day and every half hour at night), the urine being 
turbid and slightly blood stained. Cystoscopy revealed thickening 
of the mucous membrane with here and there sharply defined congestion 
set with ulcers to which mucous-like pellicles were adherent. Near 
the left ureteral mouth a ridge, its fine edge marked by a linear ulcer, 160 
SYPHILIS OF THE GEN1TO-URINARY ORGANS 
curved upward across the vault of the bladder. Under intramuscular 
injections she improved rapidly and within ten days she was retaining 
her urine three hours. 
Nilson,84 in 1916, reports the following: A man, aged forty-four 
years, who denied syphilis but admitted a gonorrheal infection four 
years previously, and gave a history of ulceration of the nose, which 
had not healed readily, following intimate contact with a person who 
had been treated for syphilis. The patient had had recurring 
hematuria for five years with no objective symptoms. At the time 
of observation nothing abnormal was found, upon physical exami- 
nation but a slight hardening of one epididymis. The urine was 
light colored, turbid, alkaline, but without albumin or red cells. 
Three tests for tubercle bacilli were negative. Cystoscopy revealed 
numerous ulcerations in the bladder and cicatricial changes which 
suggested tertiary syphilis. The patient failed to complete the course 
of treatment advised, and although normal conditions in the bladder 
were soon restored he succumbed three years later to aneurysm of 
the aorta. 
Gouvea,85 in 1916, reports the following two cases: 
Case I.—A woman, aged fifty years, who gave no history of syphilis, 
and although married had never had any children, presented the 
symptoms of a tumor of the bladder. She was bedridden and urinated 
every half hour, the urine being mixed with blood. The cystoscope 
revealed a healthy bladder, slightly hyperemic, except just below the 
outside of the left ureter there was a large globular tumor highly 
vascular, but without any ulcerations. The Wassermann test was 
negative, but the strange appearance of the tumor led to a diagnosis 
of gumma of the bladder. Specific treatment was begun and the 
patient gradually improved until three months later the cystoscope 
showed the bladder to be perfectly sound. 
Case II.—A man, aged thirty-four years, who had suffered from a 
slight gonorrhea four months previously, and during treatment a 
small ulceration on the lip, which healed quickly under neoarsphena- 
mine had complained of a profuse hematuria for several days, pre- 
ceded by severe pain in the left kidney. At the time of examination 
the urine was normal, but the cystoscope revealed a series of scattered 
papules around the left ureteral orifice, which was rather congested. 
All of the bladder symptoms, including the hematuria, yielded to 
antisyphilitic treatment. 
Baker,88 in 1917, presented the following two cases: 
Case I.—A woman, aged nineteen years, who denied all venereal 
diseases, but who admitted sexual indiscretion, complained of pains 
in the bladder and frequent and painful urination. There was no 
hematuria, although the urine was cloudy at times. On examination 
the patient was found to be well nourished and of good color with 
negative chest and abdomen and a little tenderness over the bladder. 
The lymph glands were not enlarged. Urine obtained with a catheter 
was clear with no pus cells, but contained a few red cells, and squamous SYPHILIS OF THE BLADDER 
161 
epithelium. Cystoscopy was attempted, but owing to the pain was 
not completed. Later under anesthesia cystoscopy was performed, 
and revealed the vesical mucosa deep red in color, smooth and glisten- 
ing, normal bloodvessels and normal ureteral orifices. The left 
anterior-lateral portion was covered with a livid mucous membrane, 
but with no ulcerations. The bladder was treated locally and some 
days later a soft red spot was noticed on the labium majora and 
syphilis was suspected. Antisyphilitic treatment was proposed and 
the bladder symptoms entirely disappeared after several months. 
Case II.—A woman, aged twenty-two years, with no history of 
venereal disease, but admitted frequent exposure, had complained of 
symptoms of severe chronic cystitis but with no hematuria for five 
years. A diagnosis of syphilis of the bladder was made upon a sug- 
gestive syphilitic eruption on the labia, irritable condition of the 
bladder, deep hyperemia of the vesical mucosa, a strong Wasser- 
mann reaction and marked improvement upon treatment. 
Fowler,87 in 1917, mentions a case in a boy, aged nineteen years, 
with no syphilitic history, who complained of frequent and painful 
urination and passing of small blood clots for the past three months. 
Upon examination the patient was found to be healthy looking, chest 
and abdomen negative, external genitalia normal. The urine was uni- 
formly turbid, giving a slight cloud of albumin. As the inguinal, 
axillary and epitrochlear glands were enlarged, syphilis was suspected 
and the Wassermann was found positive. Cystoscopy revealed a 
marked cystitis, the vesical mucosa being obscured, and a small 
ulcer by the side of the right ureter, which was bleeding. The appear- 
ance of the ulcer was suggesitve of tuberculosis, but all tests were 
negative. Arsphenamine was administered as a therapeutic test 
and the following day the patient noted a definite decrease in urination 
and improvement was continuous and rapid. Under further ars- 
phenamine and mercury, three months later the patient was normal. 
Although there was no syphilitic history in this case, the improve- 
ment of the bladder condition was so marked under antisyphilitic 
treatment, it was undoubtedly one of syphilis of the bladder. 
Denslow,88 in 1918, reports the case of a man, aged twenty-three 
years, who had a history of “chancroid” two years previously, who 
had had two negative Wassermann reactions and gonorrhea for one 
year, complained of frequent urination (every half hour) followed by 
mucus discharge at the end of the act. Cystoscopy revealed some 
papillomatous masses at the vesical margin, some protruding into the 
prostatic urethra. The bladder mucosa was intensely congested 
and bled easily. Suprapubic cystotomy was performed and the 
mucosa was found studded, especially at the base, with condyloma- 
like nodules, some being as much as \ an inch long. The bladder was 
curetted, with a sharp curette and as many of the nodules destroyed 
as possible. Sections of the latter were made and diagnosed as syphi- 
litic condyloma and the Wassermann was then found strongly posi- 
tive. Under mixed treatment improvement was rapid and in three 
months perfectly normal conditions obtained. 162 
SYPHILIS OF THE GENITO-URINARY ORGANS 
This case was undoubtedly syphilis of the bladder and was the 
first one to be recorded in which the diagnosis was made microscopically 
from sections of the lesion removed at operation. 
Wallace,89 in 1918, reports the following eight cases (the largest 
number of any contributor): 
Case I.—A man, aged twenty-seven years, for whom no syphilitic 
history is recorded, and who was the father of two healthy children, 
had complained of severe pain over the kidney and bladder three 
years previously. These attacks lasted off and on for six months, 
during which time he lost weight. He received some treatment 
which improved his condition but did not cure it. At the time of 
examination there was straining and tenesmus, frequent, painful 
and bloody urination with passing of lumps of mucus. Cystoscopy, 
under anesthesia revealed the prostate enlarged and a villous growth 
on the right side near the internal sphincter and another one near 
the right ureteral orifice. Antisyphilitic treatment was administered 
and the growth completely disappeared. 
Case II.—A woman, aged forty-three years, who had had one mis- 
carriage, one child who died at birth and one healthy child aged 
sixteen years, with no venereal history, complained of painful, fre- 
quent and bloody urination. The urine showed a small amount of 
albumin and a number of granular casts. Cystoscopy revealed both 
ureteral orifices thickened, a number of papules and ulcers on the 
internal sphincter and several in the urethra. The trigone was 
thickened, showing small nodes and three distinct ulcers irregular 
in outline. The condition resembled tuberculosis, but the Wasser- 
mann was positive and the lesions cleared up under specific treatment. 
Case III.—A man, whose age is not recorded and who denied 
venereal diseases, was suffering with terminal hematuria. Upon 
examination, his physical condition was below normal. He was 
nervous and apprehensive. The cystoscope revealed an ulcerated 
and nodular trigonitis, thickened and reddened condition of the 
bladder, also a distinct ulcer and a few small nodes at the internal 
sphincter. The Wassermann was positive and the condition cleared up 
under specific treatment. A later anamnesis developed the fact that 
the patient’s father had contracted syphilis twenty-eight or thirty 
years ago and Wallace considered this to be a case of congenital syphilis. 
Case IV.—A woman, aged thirty years, with a negative venereal 
history, who had been in poor health for eleven years, during which 
time she had been operated upon, presumably for kidney disease, 
had also complained of bladder symptoms more or less during that 
time. At the time of examination the patient showed tenderness 
over the bladder. The cystoscope revealed a highly inflamed mucosa, 
two ulcers at the right of the ureteral orifice, four ulcers on the trigone 
and the left ureteral orifice thickened with several small ulcers. The 
internal sphincter contained papules and four or five ulcers which 
bled. The Wassermann was positive and under antisyphilitic treat- 
ment the patient became apparently well. SYPHILIS OF THE BLADDER 
163 
Case V.—A woman, aged twenty-eight years, married, with one 
child aged five years, with no venereal history was referred to Wallace 
for cystitis. Cystoscopy revealed papules and ulcers on the trigones 
a group of small ulcers above the right ureteral orifice and the neck 
of the bladder was inflamed with a few ulcers and small papules. 
Attempted figuration was without success, while the bladder washings 
did not give relief. At this time the Wassermann was found positive. 
The local treatment was discontinued and the condition healed under 
antisyphilitic therapy. 
Case VI.—A man, aged forty years, with no venereal history, who 
had had a suprapubic cystotomy for a growth of the bladder three 
years previously, had suffered from frequent and painful urination 
for three months. The cystoscope revealed a reddened bladder, 
ulceration over the base and trigonal regions, with a white deposit 
covering same. The Wassermann was positive and two injections of 
arsphenamine and other antisyphilitic treatment caused great improve- 
ment. 
Case VII.—A man, aged twenty-nine years, with no children, who 
had had gonorrhea twelve years previously, but with no other venereal 
history, was operated upon two years previously for stone in the 
bladder. At this time no stone was found but a tumor (papilloma) 
was removed. Cystoscopy revealed ulceration and a villous growth 
on the neck of the bladder extending down on the trigone. The 
Wassermann was positive. The growth and bladder cleared under 
intensive treatment. 
Case VIII.—A man, aged twenty-nine years, who had had gonor- 
rhea fourteen years previously and a second attack recently, com- 
plained of difficult and frequent urination, much straining and some 
pain over the bladder when full. Examination revealed a large, 
soft, tender prostate and stricture of the membranous urethra. The 
stricture was treated for two weeks when cystoscopy was performed, 
which showed reddened and thickened bladder walls and a distinct 
gumma the size of a dime near the left ureteral orifice. The Wasser- 
mann was positive. The result of the treatment in this case is not 
recorded. 
Cole,90 in 1918, reports the case of a woman, aged thirty-four years, 
who had had syphilis twelve years previously for which she was 
treated and had suffered no symptoms of lues since. She had also 
had gonorrhea twice, ten and eight years prior to examination. The 
bladder trouble started six years previously with pain on urination 
and frequency; while two years later a partial acute retention with 
gross hematuria occurred. At the time of examination there were 
at times pain in the bladder region with burning on urination and 
every four or five weeks she suffered tenesmus with hematuria. The 
Wassermann was double plus. The urine was acid, contained albumin 
and many pus cells. Under bladder irrigation and autogenous vaccine 
there was slight improvement. Three months later the cystoscope 
revealed a severe trigonitis with edema and a large crescentic ulcer 164 
SYPHILIS OF THE GENITO-URINARY ORGANS 
with a necrotic base and covered with pus near the right ureteral 
opening and another ulcer with indurated edges near the left ureteral 
opening. 
There was decided improvement of the bladder symptoms under 
arsphenamine and mercury. Three months later cystoscopy revealed 
only a white scar at the site of the large ulcer and no evidence of 
the smaller. For three years after there had been no return of the 
bladder symptoms. 
Hesse,91 in 1918, reports the case of a woman, aged twenty-four 
years, who denied venereal disease, but who gave a tuberculous 
family history, complained of painful urination and gradually became 
aggravated up to severe and frequent urinary tenesmus. The urine 
contained a considerable amount of pus and at times there were 
blood cells, but no tubercle bacilli. The cystoscope revealed peculiar, 
reddish-brown, circular papules in the fungus of the bladder, which 
were suggestive of syphilis. The diagnosis confirmed by a careful 
anamnesis, the positive outcome of the Wassermann reaction and 
the recovery Under antisyphilitic treatment. 
Thompson,92 in 1920, presented the following case: A man, aged 
twenty-five years, who had developed an ulcerated papule of the 
glans penis three months previously and two weeks following a 
suspicious intercourse, was seen four days after a typical roseola, which 
was distributed over the trunk, legs and arms, had appeared. He 
had received no treatment but local cauterization of the chancre. 
At the time of examination, in addition to the roseola, there was a 
generalized superficial adenitis and several syphilomycodermata on 
the pharynx and the inner aspects of the cheeks were observed. The 
spleen was palpable two fingerbreadths below the costal margin. 
The patient looked ill and his temperature was 101° F. He com- 
plained of frequent and bloody urination with slight pain, which had 
begun two days previously. The Wassermann was strongly positive 
and the urine showed many red blood cells, leukocytes and some 
bladder epithelium. Cystoscopy, under local anesthesia, revealed 
the mucous membrane of the bladder congested and hyperemic, 
particularly in the region of the trigone, while in the region of each 
ureteral orifice were a number of ulcerating papules 2 and 3 mm. 
in diameter with slightly elevated borders, which appeared like the 
ordinary ulcerating papular syphilomycoderm or mucous patch of 
the mouth. At this time the urine was examined by the dark field 
for Spirochseta pallida, but none was found. The patient was given 
0.3 gm. of arsphenamine intravenously and 1 gr. of mercury salicylate 
intramuscularly. In twenty-four hours the hematuria had ceased 
and the frequency of urination had decreased, while in four weeks, 
following four injections each of arsphenamine and mercury salicylate 
all symptoms and outward manifestations had disappeared and the 
cystoscope revealed a normal bladder. 
Pedro Cifuentes,93 reports the case of a man, aged forty-five years, 
who had contracted syphilis twenty years previously. During the SYPHILIS OF THE BLADDER 
165 
last two years he had experienced crises of burning pain upon micturi- 
tion, followed by symptoms of cystitis, turbid urine, hematuria, finally 
with expulsion of mucus and coagula-symptoms which had yielded 
to no medical treatment. Examination with the cystoscope showed 
an intense vascularization of the mucosa, of a dark red color, especially 
in the trigone, with some ecchymotic zones. On the anterior face 
to the left was a petechial zone with an ulceration in the centre and 
a similar lesion behind the left ureteral orifice. In the centre of the 
trigone the mucosa had a granular appearance. These symptoms 
taken in connection with the patient’s history suggested syphilis. 
Wassermann reaction was frankly positive. Treatment with ben- 
zoate of mercury, 2 cgm. daily, given intramuscularly, brought prompt 
results. After two weeks the lesions had entirely disappeared. This 
form of syphilis is quite infrequent. 
E. E. Chocholka, reports the following case: A woman, aged thirty- 
six years, who for some weeks had suffered from painful micturition. 
Cystoscopic examination showed that the mucosa was covered with 
yellowish papules, surrounded by a bright red zone, which were most 
common around the ureteral orifices. This special localization being 
suggestive of tuberculosis, urine was injected in a guinea-pig, and 
von Pirquet’s test was made. Both gave negative results. Various 
bacteria were found in the urine. It was then ascertained that the 
patient had had a syphilitic exanthem eighteen months previously. 
The Wassermann was positive. Neoarsphenamine was administered, 
on the following day the red zones surrounding the papules had begun 
to fade. Treatment was continued with mercury ointment. After 
a months’ treatment the papules had completely disappeared, as 
well as the symptoms of dysuria. 
The author, with Dr. W. C. Danforth95 as collaborator, reports a 
case of a young woman, aged twenty-five years, who entered the 
hospital in December, 1919, complaining of pain over the lower 
abdomen, painful and frequent urination, loss of weight; 22 pounds 
in the last two months. 
Previous History.—The patient had measles, chickenpox, and scarlet 
fever when a child; Neisserian infection three years ago; criminal 
abortion in December, followed by evacuation of uterus. She states 
that she had fever for four days after this. Menstrual history began 
at fourteen years, the periods were four to five weeks apart, and 
always painful until recently, the flow was scant, and very irregular 
during past three months. 
Family History.—The patient has three brothers, one sister; the 
father and mother are living and well. 
Present Illness.—Since abortion in September last, the patient has 
not gained strength or regained her appetite and has lost about 15 
pounds in weight. Two months ago she began to be troubled by 
frequent urination and pain on voiding. The pain was of a sharp 
and burning character and would subside in the intervals between 
voiding. She would void every hour or so during the day and would 166 
SYPHILIS OF THE GENITO-URINARY ORGANS 
get up from four to five times at night. She has suffered from 
abdominal pain, which is not localized in any particular spot, but 
which seems more pronounced over the right iliac region and slight 
tenderness over bladder area. The pain is not continuous and not 
very acute. She tires very easily. 
Physical examination shows an anemic, slender, young woman, 
distinctly under weight, with no abnormalities. The chest is negative; 
the abdomen flat, symmetrical, slender; the liver and spleen not 
palpable; and there is slight tenderness in both lower quadrants; no 
palpable masses. 
Urinary examination on admission showed a specific gravity of 
1008, serum-albumin present and a very marked pyuria. Examination 
of urine for tubercle bacillus was repeatedly negative. Smears for 
gonococci were negative. The Wassermann, made three days after 
admission, was slightly positive. A second Wassermann done two 
days later was negative. 
Vaginally the anterior wall of the vesico-vaginal septum was found 
to be very distinctly infiltrated, indurated, and immovable, pre- 
senting an irregular surface. Cystoscopy showed the entire bladder 
floor to be occupied by an infiltrating growth with many small peaked 
projections, of papillomatous character, together with larger, rounded 
masses, the upper portions of which showed a translucency indicating 
edema. Neither ureteral orifice could be distinguished. The lateral 
portion of the bladder appeared approximately normal, there being 
only the evidence of a mild cystitis. 
Cystoscopy was repeated, at which time we both examined the 
patient. We were in doubt whether we were dealing with a malig- 
nant growth or syphilis. The cystoscopic findings were very distinctly 
suggestive of malignancy, against which spoke the youth of the patient 
and the evident possibility of the presence of a specific infection. 
Extensive induration in the vesico-vaginal septum would speak for 
syphilis. On the other hand, syphilis of the bladder is a very rare 
finding. 
We decided to do a cystotomy, which was carried out by both of us, 
on December 23. On opening the bladder its fundus and anterior 
wall were thick, almost 1 cm. in thickness, stiff, and of a pearly-gray 
color on cross section. The cavity of the bladder was smaller than 
normal, and its base was occupied by a growth which, on direct 
inspection, did not appear definitely malignant. 
It was then decided to place the patient upon active specific treat- 
ment and she was given arsphenamine intravenously nine times. She 
immediately began to improve, and cystoscopy, after the wound had 
nearly closed, showed a marked regression of the growth at the base 
of the bladder, the distinguishing characteristics of which, however, 
were still plainly evident. 
Figs. 1 and 2, Plate II show the growth as it appeared at this time. 
Two weeks later the bladder was still further improved, as is shown 
in Figs. 1 and 2, Plate III. She was discharged from the hospital, PLATE II 
FIG. l 
FIG. 2 
Vegetating Syphiloma of the Bladder. (Author’s Case.) 
Fig. 1, Cystoseopie view of right portion of bladder looking toward the 
trigone and showing vegetating syphiloma. The points of the papillse are 
arranged in peaks and have a silvery-gray color. 
Fig. 2. Cystoseopie view of left portion of bladder, same ease, looking 
toward the trigone. PLATE III 
FIG. 1 
FIG. 2 
Vegetating Syphiloma of the Bladder. (Author’s Case.) 
Fig. i. Cystoseopie view of right portion of bladder looking toward the 
trigone and showing vegetating syphiloma of the bladder two weeks after 
continuous treatment. Ureteral opening plainly visible in erater-like mass. 
Fig. 2. Cystoseopie view of left portion of bladder looking toward the 
trigone. SYPHILIS OF THE BLADDER 
167 
February 17, at which time the cystotomy wound was entirely healed, 
the patient’s general condition was very greatly improved, and she 
was gaining rapidly in weight. 
Pathology.—The pathology of vesical syphilitic lesions is the same 
as that found in syphiloma in other parts of the body. 
Symptoms.—Secondary Syphilis.—Age.-—It generally occurs in 
early adult life. 
During the period of secondary eruption, if the infection is severe, 
there frequently occurs a diffuse syphilitic cystitis. 
If one stops to consider that during the period of secondary invasion 
the spirochetes localize in every organ of the human body, it is not sur- 
prising that at times there should be vesical lesions during this period; 
however, in the majority of cases, they are overshadowed by the general 
infection and rapidly lose their identity once specific treatment is 
instituted. 
In the more severe infections there are all the symptoms of acute 
and chronic inflammation of the bladder, i. e., pyuria, pollakiuria, 
pain, and tenesmus. It must not be forgotten that secondary lesions, 
no matter where located, are not destructive, and as a consequence the 
accompanying symptomatology may be insignificant, compared with 
that of gumma. 
During this period secondary symptoms, such as mucous plaques, 
condylomata and secondary skin eruptions are common. 
Cystoscopic Examination.—During this period the vesical mucosa 
often shows an increased vascularization, or more or less congestion. 
Scattered diffusely over the mucosa are little islands of mucus. In 
the more severe forms the exact duplicate of the mucous patch may 
occur; this may be multiple and become so extensive as to form distinct 
ulcers. There is also a form of vegetating syphiloderm which through- 
out the literature has been described as “gumma of the bladder,” 
except by Denslow. In our case herein reported, the diagnosis of 
condyloma was made independently of Denslow’s report which we 
did not see until later. 
It may easily be conceived that the changes which occur in a papule 
on the skin on a moist surface may occur on the moist mucous surface 
of the bladder. This may occur at any time after the primary invasion. 
According to Thompson, this moist, papular syphiloderm may occur 
thirty years after a primary lesion, when no treatment has been given. 
The bladder offers a warm, moist bed for the growth and develop- 
ment of the spirochsetes. Its thin mucous membrane may be regarded 
as resembling quite closely the tissue about the anus, so far as the 
conditions which it offers for the growth of the organism. The moist 
papular syphiloderm, instead of becoming flat occasionally becomes 
warty and papillomatous. Several lesions may coalesce and a large 
cauliflower mass may develop, which we may term a vegetating 
syphiloma of the bladder. 
As studied with the cystoscope, these tumors simulate a papilloma 168 
SYPHILIS OF THE GENITO-URINARY ORGANS 
so closely that it is impossible at tirrles to differentiate between them. 
In many of the cases reported, these growths are referred to as gumma, 
as few observers believed them identical with condyloma which 
occurs upon the skin. It was with a view of stimulating further 
study of this lesion that the accompanying pictures were made. 
In passing a cystoscope over this hypertrophied papillomatous 
mass, one is impressed with the similarity to bullous edema. How- 
ever, by carrying the cystoscope to the border of the mass, the growth 
in uniform palisades can be differentiated from the normal bladder. 
The mass is freely movable. So far as the surface portion of the 
growth is concerned, the papillae rise and fall under the slightest 
pressure from the distal end of the cystoscope. The points of the 
papillae are arranged in peaks and are of a silver-gray color due to 
their distention, which causes them to be translucent under the 
cystoscopic light. Looking across this mass through a McCarthy 
cysto-urethroscope, the papillae look a little more yellow from the 
retained serum under the mucous membrane. Seen later and after 
continuous treatment, the round and oval papillae show as delicate, 
pearly, translucent fingers, resembling stalactites. The cysto-urethro- 
scopic picture may be compared to looking over the uneven surface 
of a lake, the peaks of the waves representing the papillae, perfectly 
transparent at their apices and so soft and delicate that they may 
easily be pushed over with the instrument. In the case here reported, 
induration at the base was marked and could easily be felt through 
the vaginal walls. 
The histopathology of the vegetating syphiloderm has been dis- 
cribed by Dennie as follows: 
When sectioned, the lesion is seen to consist of two parts, an upper, 
dense, finely striated portion, about 4 mm. thick and a lower narrowed 
core. Microscopically the former shows many slender epithelial 
fingers connected above by thin bridges and below penetrating the 
corium. 
Tertiary Syphilis.—Age — Gumma of the bladder occurs especially 
in middle life, thirty-five to fifty years of age, but may occur earlier 
or later. 
1. Pains are variable, intermittent or continued, or radiating at 
times, increased on deep pressure, little marked if the lesions lie on 
the base of the bladder; much more marked at the time of micturition 
if they lie at the vesical neck. 
2. Hematuria is the most constant and important symptom. There 
may be a terminal hematuria, intermittent hematuria, or a constant 
hematuria, lasting from the beginning to the end of urination. This 
may be scant or profuse, repeating at irregular intervals, often acting 
in a peculiar manner, capricious at times, as in hemorrhages due to 
neoplasms. 
3. Pollakiuria is a frequent symptom; the urine almost always 
contains a large quantity of red cells and leukocytes; rarely have any 
organisms been found. SYPHILIS OF THE BLADDER 
169 
As a rule the general physical condition is little affected. 
Cystoscopic Examination.—'Tertiary syphilis manifests itself on the 
vesical mucous coat in the form of ulcerations. 
The diagnosis of ulcerations is not difficult; they may be rounded, 
more or less extended, isolated or multiple; they make projections 
into the vesical cavity, the edges are infiltrated, and the base is gener- 
ally covered with a yellow purulent mass. 
It must not be forgotten that syphilis of the bladder may have its 
course quite independent of other syphilitic manifestations. The 
most varied forms will be observed, from simple hyperemia of the 
mucous membrane to extended breaking down of gummatous tissue. 
Diagnosis.—Secondary and Tertiary Syphilis.—Syphilis may affect 
the bladder as well as any other part of the body, but there is no such 
thing as chancre of the bladder. Syphilitic affections of the bladder 
that produce severe destructive symptoms belong to the tertiary period. 
Syphilitic ulceration of the bladder mucous membrane may be 
solitary or appear at the same time with syphilis of the skin and other 
mucous membranes. 
During the secondary stage of the disease on the mucous membrane 
of the bladder may be found a general or localized eruption, which 
may be in the form of ulcerous processes resembling mucous patches. 
Gumma of the bladder simulates the ulcerative form of papillary 
carcinoma. This is especially manifest when they are both broken 
down and covered with mucus. As these tumors may occur during 
the later periods of life, the time when malignancy generally occurs, a 
differential diagnosis is important. One should consider the age of 
the patient, the history, and the possibility of specific infection. 
These ulcers may extend deep and lead to perforation of the bladder, 
peritoneum or to vesico-vaginal fistuke. 
In this connection, it should not be forgotten that carcinoma may 
coexist with lues and the presence of a positive Wassermann reaction 
therefore is not necessarily conclusive. 
Simple solitary ulcers should arouse suspicion of syphilis, especially 
if tuberculosis can be excluded by bacteriological examination. 
Syphilitic ulcers can be distinguished from ordinary or tuberculous 
ulcers by the infiltrated edges which project more or less into the 
ulcer cavity. 
Vegetating syphiloma generally causes symptoms of new growth 
and hemorrhages which are not influenced by rest or other treat- 
ment. Hemorrhages from gumma may last from the beginning to 
the end of urination, while hemorrhages in ulcers of the bladder, even 
if syphilitic are terminal. 
Ulcers are more apt to cause pyuria than gumma. 
The number, size and location of the lesions greatly influence the 
accompanying symptomatology. 
In concluding a diagnosis of any ulcerating lesion of the bladder 
of doubtful origin, the solitary ulcer of Fenwick and the elusive ulcer 
of Hunner must be considered. 170 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Treatment.—It must not be forgotten that vesical syphilis, whether 
secondary or tertiary, is only an incident in the course of a general 
syphilitic infection and that after the vesical lesions are healed, every 
effort known to modern medicine should be made to safeguard the 
patient from a relapse in other organs. 
The Wassermann reaction offers the best and most efficient guide 
in the management of syphilitic cases. Unfortunately, the tendency 
is to give too little treatment and to stop when the first negative 
reaction is reached. 
Under the new therapy (arsphenamine and mercury) all cases that 
come under observation should be treated at least nine months after 
the negative goal is reached, giving during this period 150 rubbings 
of mercury and at least 2 intravenous injections of arsphenamine. 
It must be distinctly understood that treatment should be continued 
vigorously during the “negative phase,” in order to secure permanent 
results. 
Arsphenamine given every week or ten days for 4 or 5 doses 
then every month, with mercury rubbings, controlled by biological 
examinations, constitute the best method of treating the patient. 
It should be borne in mind that dilatory and haphazard treatment, 
while healing the lesions, often produces both an arsphenamine- and 
mercury-fast spirochete which when localized in other regions (spinal 
fluid) may never be dislodged. 
Spinal fluid examinations, while appearing superfluous, are as much 
indicated here as in other forms of visceral syphilis, and a physician 
with the patient’s best interests at heart should certainly insist on 
making them. 
Spinal Cord Affections Simulating Bladder Disease.—Besides these 
secondary and tertiary syphilitic diseases of the bladder there are 
considerable number of cases that come under observation on account 
of spinal cord disease (progressive paralysis and tabes). 
THE TABETIC BLADDER FROM THE STANDPOINT OF THE 
UROLOGIST. 
The primary consideration in this class of cases is the earliest possible 
recognition of any urinary changes which may occur in syphilitic 
involvement of the nervous system prior to the development of obvious 
tabetic or ataxic symptoms. The major problem, however, involves 
an accurate diagnosis in those cases in which the specific tabetic 
process has become apparently dormant, while the urinary abnormality 
persists or gradually increases in severity. 
The secondary pathologic changes in the urinary tract depend on 
the extent and character of nerve destruction involved in the paralytic 
process. Our most recent knowledge of the innervation of the 
apparatus for urine explusion comes from de Lisi and Colombino. 
According to these authors, the bladder receives a triple system of 
nerves. The most important group proceeding from the sympathetic STANDARD SVIM1ILIS TECHNIQUE XUMBKK 
CSS6 No _ _ LATE PRIMARY ) Spirochaeta Positive _ NcHT16 
S Y PHILIS I Blood Wasser. P ositive 
BLOOD WASSERMANN: Date Finding ... . 
When giving reaction state whether none - mild -moderate-or severe Regulate Arsphenamine dose to weight of patient. l*decigram for each 30 lbs. of body weight 
, ARSPHENAMINE ONCE WEEKLY FOR 6 WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction 
1st Week 2nd Week 3rd week 4th Week 5th Week 6th Week 
FOUR WEEKS OF MERCURY-HAVE PATIENT CAlL ARSPHENAMINE ONCE WEEKLY FOR 4 WEEKS 
WEEKLY FOR OBSERVATION 
• I— “1 - — I Date I Dose |Date |Dose Date Dose Date [Dose 
Date Date Date,; Date 
Reaction Reaction Reaction Reaction 
7th Week 8th Week 9th Week IOtm Wfek 11th week 12th week 13th week 14th week 
FOUR WEEKS OF MERCURY RUBS ARSPHENAMINE ONCE WEEKLY FOR 3 WEEKS/ 
Date Date Date Dale Date Dose Date Dose Date Dose 
___________ ___________ __________ Reaction Reaction Reaction 
15th week 16th week 17th week 18th week —— 
19th week 20th week 21st week 
FOUR WEEKS OF MERCURY RUBS ARSPHENAMINE ONCE WEEKLY FOR 2 WEEKS 
Date Date Date [Date Date Dose Date Dose 
Reaction Reaction 
22nd week 23rd week 24th week 25th week * _ 
26th week 27th week 
FOUR WEEKS OF MERCURY RUBS ONE INJECTION ARSPHENAMINE 
' I Date Date Date I Date Date Dose 
I Reaction 
28th week 29th week 30th week 31st week 
32nd Wt £K 
BLOOD WASSERMANN: Date Finding . SPINAL FLUID WASSERMANN: Date Finding 
' If Blood Wassermann is positive treat as latent syphilis (card. 5.) If Spinal Fluid Wassermann is positive treat as Neuro-syphilis (card 7.) If Blood Wassermann is Negative 
and Spinal Fluid is Negative apply discharge technique. DISCHARGE TECHNIQUE: Negative Blood Wassermann every four months for one year after treatment has stopped 
Jhis system was developed by Dr. 8. C. Corbus. Chicago. Published by physicians’ record Co., Chicago ulioois Sotmi Hve>’n» l eaan<> Chifaan 
171 STANDARD SYPHILIS TECHNIQUE NUMBER G — PAGE 1. 
tedtudv ! Skin lesions 
TERTIARY Bone lesions 
CVPHII ic ' Mucous membrane 
Cjacp Wr> l Vascular Syphilis Mqrnp 
1NU -..irirrm . Blood Wassermann positive INdlUC 
Spinal Fluid Wassermann negative 
BLOOD WASSERMANN: Date Finding SPINAL FLUID WASSERMANN Date Finding 
If Spinal Fluid is positive case should be treated as Neuro-syphilis. When giving reaction state whether —none—mild—moderate—or severe. Regulate Arsphenamine dose to 
weight of patient, 1 decigram for each 30 lbs. of body weight. 
POTASSIUM IODIDE FOR 4 WEEKS — 50 GRAINS DAILY—PATIENT SHOULD CALL ONCE WEEKLY FOR OBSERVATION 
Date Dose Date Dose Date Dose Date Dose 
1st Week 2nd Week 3rd Week 4th Week 
ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 8 WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction Reaction Reaction 
5th Week 6th Week 7th Week Qth Week 9th Week ioth Week 11th week 12th week 
POTASSIUM IODIDE FOR 4 WEEKS —50 GRAINS DAILY-PATIENT SHOULD CALL ONCE WEEKLY FOR OBSERVATION. 
Date Dose Date Dose Date Dose Date Dose 
23th week 14th week ,15th week 16th week 
ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 8 WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction Reaction Reaction 
17th WEEK 18th WEEK 19TH WEEK 20TH WEEK 21STWEEK 22NDWEEK 23RD WEEK 24TH WEEK 
MERCURY RUBS FOR 8 WEEKS-HAVE PATIENT RETURN ONCE WEEKLY FOR OBSERVATION 
Date Date Date jDate Date Date Date Date 
25th WEEK 26th WEEK 27th WEEK 28th WEEK 29th WEEK 30th WEEK 3IST WEEK 32nd WEEK 
BLOOD WASSERMANN: Date Finding SPINAL FLUID WASSERMANN: Date Finding 
If Blood Wassermann is positive repeat above course from beginning. In that case use form on back of this sheet. If Blood Wassermann is negative repeat above course 
substituting mercury rubs for the course of potassium iodide then apply discharge technique. 
DISCHARGE TECHNIQUE: Negative Blood Wassermann every four months for one year after treatment has stopped. 
•This system was developed by Dr 8 C Corbus. Chicago* Published by Physicians' record Co., Chicago Illinois Socia1 Hygiene league, OiiraRo 
172 STANDARD SYPHILIS TECHNIQUE NUMBER 6—PAGE 2., 
TERTIARY j BonelesTons 
svpuli Mucous membrane 
s,rmus lVascular Syphilis 
Blood V/assermann positive 
Spinal Fluid Wassermann negative 
BLOOD WASSERMANN:Date ...Finding 
If Spinal Fluid is positive case should be treated as Neuro-syphilis (card 7.) If Blood Wassermann is positive and Spinal Fluid Wassermann negative follow the treatment here 
outlined which is the same as for Late Secondary. When giving reaction state whether—none—mild—moderate—or severe. Regulate Arsphenamine dose to 
weight of patient, 1 decigram for each 30 lbs. of. body weight. 
POTASSIUM IODIDE FOR 4 WEEKS 50 GRAINS DAILY PATIENT SHOULD CALL ONCE WEEKLY FOR OBSERVATION 
Date Dose Date Dose Date Dose Date Dose 
1st Week 2nd Week 3rd Week 4th Week 
ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 8 WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction Reaction Reaction 
5th Week 6th WesSk 7th Week 8th Week 9th Week 10th Week 11th week 12th week 
POTASSIUM IODIDE FOR 4 WEEKS 50 GRAINS DAILY-PATIENT SHOULD CALL ONCE WEEKLY FOR OBSERVATION. 
Date Dose Date Dose Date Dose Date Dose 
13th week 14th week 15th week 16th week 
i II I I L 
ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 8 WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction Reaction Reaction 
17TH WEEK 18th WEEK 19TH WEEK 2CTH WEEK 21 ST WEEK 22ND WEEK 23RDWEEK 24TH WEEK 
MERCURY RUBS FOR 8 WEEKS-HAVE PATIENT RETURN ONCE WEEKLY FOR OBSERVATION. 
Date Date Date Date Date Date Date Date 
L J 
25TH WEEK 26th WEEK 27TH WEEK 28TH WEEK 29TH WEEK 30TH WEEK 31ST WEEK 32NDWEEK 
BLOOD WASSERMANN: Date Finding....... SPINAL FLUID WASSERMANN: Date Finding . 
If Blood Wassermann is positive repeat above course frotn beginning. If Blood Wassermann is negative repeat above course substituting mercury rubs for the course of 
potassium iodide then apply discharge technique. DISCHARGE TECHNIQUE: Negative Blood Wassermann every four months for one year after treatment has stopped. 
This system was developed by Dr. B. C. Corbus. Chicago. Published by physicians’ Recoro co., Chicago Illinois Sociat Hygiene 5 eague, Chicfgo. 
173 174 
SYPHILIS OF THE GENITO-URINARY ORGANS 
system by wyay of the second, third and fourth lateral lumbar ganglia, 
the mesenteric ganglia, the hypogastric nerves and the hypogastric 
plexus; secondly, by way of the pelvic nerves of the autonomous sacral 
group. The third system of nerves provides for the external sphincter 
of the urethra and the perineal muscles which are auxiliary to the 
explusion of urine. The latter are represented by the pudendal and 
belong to the sacral plexus, and therefore to the cerebrospinal system. 
This system is not usually affected, except in the most advanced stages 
of the disease. 
From a study of the innervation, it is seen that any attempt to 
correlate the neuropathology of bladder disturbances is extremely 
difficult. Repeated usage of the terms preclinical or “preataxic” 
and clinical or “ataxic,” has classified the disease into these two stages. 
It is the former which most concerns the urologist as a diagnostic 
problem, since the alterations of bladder function are most difficult 
of interpretation in the earliest stages of nerve-fiber involvement. 
A recent study of the very earliest changes which might occur in 
individuals with active cerebrospinal syphilis but without definite 
tabetic symptoms is given as follows: 
Early Urinary Changes in Patients with Active Cerebro- 
spinal Syphilis, but without Tabetic Symptoms. 
Number 
Patients 
Condition. 
of cases. 
examined. 
Positive blood Wassermann reaction 
. . 38 
50 
Positive spinal fluid Wassermann reaction . 
. . 50 
50 
Hyperactive patellar reflex 
. . 8 
50 
Patellar reflex absent 
. . 0 
50 
Romberg sign 
. . 0 
50 
Argyll-Robertson pupil 
. . 5 
45 
Babinski sign 
. . 0 
34 
Frequency of urination 
. . 7 
50 
Difficulty in starting stream 
. . 4 
50 
Occasional dysuria 
. . 3 
50 
Nocturnal incontinence of urine .... 
. . 2 
50 
Residual urine 
. . 14 
50 
Relaxed rectal sphincter 
. . 3 
50 
Of the 8 patients with hyperactive knee-jerks, 4 complained of 
some frequency of urination and 3 of occasional dysuria. None of 
these patients had any residual urine when tested by catheter. No 
pathologic condition of the urinary tract was demonstrable, apart 
from bladder irritability. The urinalysis was normal in all. 
Of the 14 patients with residual urine, 3 had relaxed rectal sphincters, 
2 had nocturnal incontinence, and 4 had Argyll-Robertson pupils. 
The smallest amount of residual urine was 60 c.c. and the largest 
180 c.c. This was tested on two or more occasions. Pyuria was 
present in 4 of these cases. In none of these patients wTas there 
sufficient urinary distress to cause them to seek medical advice 
except in the 2 cases of nocturnal incontinence. All were under active 
syphilitic management. In the preataxic stage, there may be definite 
bladder symptoms, such as frequency and dysuria, with or without 
urine retention. 175 
THE TABETIC BLADDER 
The patellar reflexes may be absent, but, on the contrary these may 
be normal or exaggerated. During this period, the blood Wasser- 
mann reaction may or may not be positive, while the spinal-fluid 
Wassermann reaction is invariably positive unless the patient has 
previously had prolonged syphilitic treatment. The presence of an 
Argvll-Robertson pupil, or Babinski sign, together with a relaxed 
rectal sphincter, should always suggest cerebrospinal syphilis. In 
concluding a diagnosis, greater stress should be placed on the spinal- 
fluid analysis than on the cystoscopic picture, unless the patient has 
previously had intensive antisyphilitic treatment. 
As a means of comparison of the clinical picture which may be 
presented in more advanced cases, the findings in 20 patients wTith 
definite ataxic symptoms is given. 
Findings in 20 Patients with Definite Ataxic Symptoms. 
Condition. 
Number of 
patients 
Positive blood Wassermann reaction 
12 
Positive spinal fluid Wassermann reaction .... 
20 
Hyperactive patellar reflex 
2 
Patellar reflex absent or sluggish 
12 
Positive Romberg sign 
12 
Argyll-Robertson pupil 
16 
Frequency of urination 
4 
Infrequency of urination 
6 
Difficulty in starting stream 
3 
Dysuria 
4 
Incontinence 
7 
Loss of sexual power 
13 
Crises (gastric or vesical) 
3 
Hematuria 
1 
Uremia 
0 
Pyuria 
7 
Prostatitis 
3 
Relaxed rectal sphincter 
6 
Residual urine 
18 
Diagnosis.—The accurate diagnosis of tabetic involvement of the 
urinary bladder requires a definite routine method of procedure. 
Following the usual careful clinical history and physical examination, 
urinalyses and renal function tests should be made. Because of the 
existence of residual urine in these cases, it is not advisable to per- 
form the standard dye-excretion tests unless routine catheterization 
of the bladder has previously been in vogue. Estimations of the 
urea nitrogen content in the blood will give a more accurate, and 
entirely safe means of ascertaining the renal function. Palpation 
and percussion of the lower urinary tract and estimation of the residual 
urine under strict asepsis will reveal the local condition. 
It must be emphasized again that, regardless of the blood-Wasser- 
mann reaction, spinal puncture must be performed and a careful 
cell count and Wassermann test made with the spinal fluid. 
Lastly, cystoscopic examination, cystograms or other roentgen- 
ological tests should be made in the more limited number of cases 
in which these procedures are indicated. 176 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Cystoscopic Findings.—The cystoscopic picture will vary with the 
extent, duration and severity of the destruction of innervation to 
the bladder itself, the bladder sphincter and the posterior urethra. 
It will also depend upon the presence or absence of urinary infection 
and possibly anatomical abnormalities in these regions. 
There is a definite relaxation of the internal vesical sphincter and, 
although the external sphincter may be spastic, the urethra is usually 
much more tolerant to the examination. This relaxation evidences 
itself by more or less obliteration of the normal outline of the bladder 
neck and encroaching prostatic lobes, and distorts the visual picture 
by a funnel-shaped continuity of the bladder outlet and prostatic 
Fig. 103.—Cystoscope in erroneous position, resulting in diagnosis of median bar 
obstruction. The hypertrophy of the trigone and interureteric muscle, with complete 
relaxation of the internal sphincter, obliterates the identity of the outline of the neck 
of the bladder. The interpretation is especially difficult in the presence of severe bladder 
infection with ulceration. 
urethra terminating at the external vesical sphincter. The entire 
posterior urethra can thus be as easily examined with the ordinary 
cystoscope (preferably a posterior sheath lens system) as the bladder 
itself. 
The floor of the bladder, consisting mainly of the trigone, is elevated 
and the interureteric bar is markedly elevated and often greatly 
hypertrophied. There is frequently a very deep pocket behind this 
muscular ridge bringing about an unusually deep has fonde. Care 
must be taken in the orientation of this picture as even a skilled 
cystoscopist might erroneously consider this a “median bar” obstruc- 
tion. (See Fig. 103.) THE TABETIC BLADDER 
177 
At the sides, the trigone tapers off into pronounced areas of muscular 
hypertrophy with relaxation of the bladder wall between. This 
trabeculization results in the formation of saccules or deeper pockets 
between the prominent muscle bundles. 
It has been stated that the trabeculation has a predilection for the 
lateral fornices of the bladder. At any event, it is undoubtedly more 
patchy in distribution than the usually more generalized trabecu- 
lation following a long-standing obstruction at the vesical outlet. 
The ureteral orifices usually show but slight changes although in 
later stages of the tabetic process they may appear markedly relaxed 
and gaping with a resultant sluggishness of urine efflux. 
Fig. 104.—Median bar obstruction as the true cause of urinary retention in an active 
case of tabes. 
It must be carefully borne in mind that even in individuals with 
definite cerebrospinal syphilis or even an apparent tabes the urinary 
symptoms may be due to a mechanical obstruction. The conditions 
most often overlooked in these cases are “ median bar” obstruction, 
median lobe prostatic hypertrophy, contracture of the vesical neck 
due to a scleratic process in the prostate, and hypertrophy of the tri- 
gone. (Figs 104 and 105.) 
Prognosis.—The prognosis will depend upon the extent of irreparable 
nervous destruction by the syphilitic process. The general condition of 
the patient, the extent of cardiovascular involvement, the amount of 
residual urine, the presence or absence of urinary infection, and the tena- 
city of both patient and physician to adhere to a long, painstaking pro- 
gram of carefully executed specific treatment are the important factors. 178 
SYPHILIS OF THE GENITO-URINARY ORGANS 
The premise that uremia is responsible for the complicating symp- 
toms, or even death, in tabetic involvement of the urinary tract is 
not necessarily supported by the facts. The urea-nitrogen esti- 
mation of the blood in a limited number of tabetics with appreciable 
amounts of residual urine is usually within normal limits. In rare 
instances, only does it compare with the nitrogenous retention that 
accompanies a like quantity of urine retained by mechanical obstruc- 
tion. It seems more plausible to believe that the pains and asso- 
ciated toxic condition of these patients are due to a long standing 
syphilitic process and not uremia. 
Fig. 105.—Hypertrophy of the trigone, with distortion of the bladder neck and floor. 
Contraction of the muscle of Bell on the left exerts upward traction on the internal 
vesical sphincter, causing incompetence of the sphincter, resulting in nocturnal inconti- 
nence. 
Treatment.—Treatment is either systemic or local, or both. In 
the uncomplicated cases of tabetic bladder, treatment should be 
systemic and not local. The same precautions should be taken in 
catheterizing a tabetic bladder as in catheterizing a “spinal injury 
bladder.” The less instrumentation and local manipulation the 
better. The forms of treatment that have been the most satisfactory 
have been: Intensive Intravenous neoarsphenamine injections fol- 
lowed by spinal drainage, continued with mercury injections or 
inunctions; or the spinal drainage without lumbar puncture by the 
hypertonic saline method. This latter method may ultimately SYPHILIS OF THE KIDNEY 
179 
prove to be superior to all other methods of introducing arsenic into 
the subarachnoid space. 
Local Treatment.—Forced fluids during the day and urinary anti- 
septics are valuable in the earlier cases. It is best to avoid all local 
manipulation of the urinary tract if possible. 
In badly infected cases, with dysuria and frequency, interval 
catheterization and lavage of the bladder may allay the symptoms. 
Occasionally, they aggravate them. If a considerable quantity of 
residual urine is present, which is causing nocturnal incontinence and 
bed-wetting, the best course to pursue is to pass a catheter, institute 
lavage and then empty the bladder when the patient is retiring. 
This may control the incontinence. 
In the most debilitated patients, marked improvement may be 
attained by putting them to bed and inserting an indwelling urethral 
catheter through which the bladder is lavaged three times daily. Sub- 
sequently, interval catheterization will be resorted to. 
In the uncomplicated “tabetic bladder” cases, even when a residual 
urine of from 900 to 1000 c.c. is present and the blood-urea-nitrogen 
is normal, the bladder should be undisturbed. Treatment in this 
class of cases should be limited to systemic management. Local 
treatment must only be instituted to combat imperative compli- 
cations. 
The cystoscope is a most valuable aid in differentiating a paralytic 
condition from a mechanical obstruction. It should be used only 
after a thorough routine has been followed. The possibilities of error 
in interpretation of the cystoscopic picture must be borne in mind. 
Syphilis of the ureter is rare. A case has been described by Hadden, 
as mentioned by Osier and Gibson. 
While involvement of the ureter has been observed in conjunction 
with bladder syphilis, it is impossible to recognize this condition alone 
except at autopsy. 
Essential Hematuria.—While a great deal of speculation has been 
brought forward in regard to the etiological factors in essential hema- 
turia, few have considered the possibility here of secondary ulcers 
or gummatous formation, and it might be well in this class of cases 
to thoroughly eliminate this form of infection before ascribing some 
doubtful etiology. 
SYPHILIS OF THE URETER. 
SYPHILIS OF THE KIDNEY. 
Syphilitic nephritis manifests itself in the following forms: 
1. Acute parenchymatous syphilitic nephritis. 
2. Chronic interstitial nephritis. 
3. Amyloid kidney. 
4. Gummatous kidney. 180 
SYPHILIS OF THE GENITO-URINARY ORGANS 
Under this heading will be considered only those forms of syphilitic 
infection in which the symptoms and pathology can be actually 
attributed to the Spirochaita pallida, the first and the fourth. 
Acute Parenchymatous Syphilitic Nephritis.—Synonyms.—Acute 
early syphilitic nephritis; nephritis syphilitica prsecox. 
The first to acknowledge syphilitic kidney diseases was Bayer.47 
He wrote as follows: “I have seen cases in which the influence of con- 
stitutional venereal diseases seemed so striking that I did not hesitate 
to attribute, at least to a great extent, the development of kidney 
diseases to the venereal cachexia.” 
The first description of kidney syphilis was given by Virchow.63 
lie observed that simple nephritis is often found in syphilitics, but 
that does not justify considering them specific, because they have no 
characteristic signs. 
Guiol50 published the first report of syphilitic albuminuria and 
Perodu57 the first description of early acute syphilitic nephritis. 
Karvonen52 and Neumann55 are among the writers on the subject. 
More recently, Bauer,46 Habetin, Erich Hoffmann,51 Osthelder,56 
Welz,64 Tach,62 Moritz53 and Damask49 have written communications, 
while the excellent monograph of Munk54 ranks as an authority on the 
subject. 
Owing to the fact that the causative agent in syphilis was so long 
misunderstood, few realize that during the period of secondary localiza- 
tion (secondary eruption), the spirochetes are actually present in every 
organ of the human body to a greater or less extent, and the fact that 
syphilis may cause disease of the internal organs during the eruption 
of the first exanthem or even for some time before, is recognized possibly 
by syphilologists alone. 
Hoffmann has shown that transmissible spirochetes circulate in the 
blood three weeks before the outbreak of the eruption. 
For a long time there has been a great deal of doubt concerning the 
specific nature of the nephritis appearing in the early stage. Sena- 
tor,59 60 an expert himself on kidney diseases, did not admit the real 
nature of this condition in 1902. 
We are astonished to find that today a great number of cases of 
disease of the heart, bloodvessels, liver, kidney and joints in syphilitics 
are due to the Spiroclneta pallida, yet more surprising is the number of 
syphilitics who do not know that they are affected. It has only been 
in the last ten years that the syphilitic etiology in many cases of aortic 
aneurysm has been recognized. 
In Munk’s clinic, among 260 cases of visceral syphilis writh a strongly 
positive Wassermann, 38 per cent, of the men and 84 per cent, of the 
women did not know that they had the infection. 
Notwithstanding the advance in our know-ledge of visceral syphilis, 
the subject has been more clearly understood only since the introduction 
of the Wassermann reaction in practice. 
Etiology.—This form of nephritis is a hematogenous injury, not a 
tissue process, and it is caused by the presence of the Spirochseta pallida. SYPHILIS OF THE KIDNEY 
181 
By most authors, therefore, syphilitic nephritis, as well as nephritis 
caused by scarlet fever and other infectious diseases, is attributed to a 
toxic cause. The idea that the continued administration of mercury in 
syphilitics causes a nephritis has long been held. 
The question of whether the kidney injury in these cases is due to 
syphilis or to mercury is decided at once by the lipoid findings in the 
urine, reference to which will be made later. In the nephritis caused by 
mercury there is never lipoid degeneration, therefore no lipoid casts are 
found in the urine. 
Naturally there are all sorts of transitional forms, from very severe 
cases of nephritis to slight and quickly passing albuminurias, which 
many syphilographers, especially the French, maintain are very fre- 
quent, but according to Hoffmann, are rare in Germany. 
Since the discovery of the Spirochseta pallida we are in a position 
to test its relation to the kidney. In these investigations it has been 
frequently found in the kidneys of congenitally syphilitic children. 
They have been reported as having been found in the urine in cases of 
acquired syphilis. 
Recent syphilis can generally be demonstrated by the clinical symp- 
toms; however, these may be so masked by severe edema that they 
are not apparent. It is more difficult to palpate the glands, and even 
the eruption is not so easy to recognize on an edematous skin. There- 
fore it is particularly important to make a diagnosis either by finding 
the spirochetes in the urine or by the Wassermann reaction. 
From Hoffmann’s experience in determining the syphilitic etiology in 
a given case, and from the recent advances in syphilology, he formu- 
lated the following signs as an indication of early syphilitic nephritis: 
1. The demonstration of recent syphilis by clinical symptoms, finding 
the Spirochseta pallida in primary or secondary lesions, and a positive 
Wassermann reaction. 
2. Characteristic signs in the urine, such as enormous albumin con- 
tents, and the finding of the Spirochseta pallida in the sediment of the 
urine removed by catheterization. 
3. The influence of specific treatment, which is almost always evident 
if mercury and salvarsan are correctly used. 
According to Hoffmann, acute syphilitic nephritis may develop in 
two ways: either gradually, without any specific symptoms, so that it 
may be overlooked unless the urine is examined, or in a more or less 
stormy fashion, with marked edema and fluid in the body cavities. 
However, most patients seek the physician’s advice on account of 
general edema and weakness; this gradually progresses and anemia 
may be marked. 
The principal and most characteristic symptom is the anemic appear- 
ance of the patient, with a more or less severe edema; the patients 
complain of a great weariness and weakness; sometimes there is 
difficulty in breathing; headaches are not very frequent; vomiting, as 
a rule, appears late, as well as other uremic symptoms. 
As long as there is no complication, fever rarely goes higher than 38° 182 
SYPHILIS OF THE GENITO-URINARY ORGANS 
to ,38.5° C.; chills are not present. The only symptom that the patient 
complains of is that on urinating he notices a small amount of urine. 
Urinary Findings.—These are especially characteristic. The vol- 
ume varies from 300 to 1200 c.c.; the color is normal yellow, reaction 
acid, specific gravity very high; albumin contents generally high, up to 
28 per 1000. Microscopically, examination of the urinary sediment 
shows a small number of red cells, fairly numerous white cells, many 
epithelial, and a few hyaline, waxy and granular casts, but most of them 
lipoid casts. Under the polarizing microscope, in fresh specimens the 
whole field may be strewn with double refracting drops, some of them 
in crystalline form and some of them cylindrical. 
Recently, Stengel and Austin,61 in this country, have examined the 
urine with a polarizing microscope fifty-eight times in 46 cases. Of 
the 46 cases, 23 showed nephritis with an abundance of albumin and 
casts in the urine. Of these 23 cases, 6 had positive Wassermanns; 
3 had strong presumptive evidence of syphilis, but not positive Wasser- 
mann. Fourteen had not the slightest evidence of syphilis. The 6 
cases with the positive Wassermann all showed lipoids in the urine, 
whereas, in the 14 non-syphilitic cases only 5 showed lipoids in the urine. 
Pathology.—According to Munk, the pathological anatomy of this 
form of syphilitic kidney, at the height of the disease, corresponds to 
the co-called large white kidney, which name has been given it on 
account of its macroscopic appearance. The color is really not white, 
but a grayish yellow, due to the lipoid contents and the cloudy swelling 
of the cortical substance. 
The kidney for the most part is flaccid and soft. On the surface 
of the kidney it is possible to see, at times, individual groups of 
convoluted tubules appearing as yellow flecks standing out from the 
remaining grayish-yellow turbid ground substance. 
On cross-section the cortical substance seems increased in breadth 
and so swollen that it stands out over the medullary substance. The 
medullary rays may be recognized as gray, watery stripes, often com- 
pletely transparent and gelatinous, while the cortical pyramids appear 
turbid, intersected by bright yellow stripes and flecks which are the 
convoluted tubules which have undergone fatty degeneration. The 
vessels are not well filled, while the vasa recta of the medullary 
substance are, so that there is a sharp contrast in the coloring of 
the two substances. Plate IV gives a picture of a frozen section of 
such a kidney colored with Sudan hamalaun. The lipoids are colored 
yellowish red; we see the convoluted tubules chiefly attacked by the 
lipoid degeneration. Besides the lipoid degeneration, some parts of the 
convoluted tubules show a somewhat indistinct appearance. These 
are in a state of cloudy swelling. The glomeruli, are, on the contrary, 
completely intact. The nucleus stains well and the interstitial tissue does 
not show any changes which indicate inflammatory processes, either 
cellular infiltration or productive proliferation. We have, therefore, 
an organ which has undergone a purely degenerative change. The 
cloudy swelling itself is a degenerative stage which may pass over into PLATE IV 
Acute Parenchymatous Syphilitic Nephritis. (Munk.) SYPHILIS OF THE KIDNEY 
183 
fatty or lipoid degeneration. A noteworthy fact is the rapid appear- 
ance of primary lipoid degeneration of the kidney epithelium, without 
any further degenerative or later inflammatory changes. 
Clinically, this type of syphilitic kidney is an acute nephritis, but from 
the point of view of pathological anatomy, it is a degenerative, non- 
inflammatory change of the organ of a chronic character, and can be 
set in a group by itself as a form of degenerative kidney disease peculiar 
to syphilis (Munk). 
Symptoms.—The leading symptoms of nephritis following infectious 
diseases are: marked anemia and a considerable degree of dropsy, 
which is a dropsy of the body cavities rather than a general anasarca, 
as in syphilis. Headache and rise of temperature are only exceptionally 
observed in uncomplicated cases. Marked uremia is unusual if there 
is not a considerable degree of stasis; the liver and spleen are involved 
only moderately, if at all. Murmurs may be demonstrated in the heart 
from time to time, but they are generally due to anemia. Accentua- 
tion of the second aortic sound is rare, at least in the beginning, and 
at that time there are no signs of increased blood-pressure. 
The symptoms of nephritis may appear in a few months, or not until 
some years after the infection. The Wassermann reaction may be 
strongly positive or only weakly positive. However, a positive Wasser- 
mann reaction is not sufficient to decide the question whether in a given 
case we have a syphilitic nephritis or merely nephritis in a syphilitic 
patient, but it fills the gap in the history of patients who do not know 
that they have the disease, and it increases the number of demon- 
strable syphilitic cases in which the nephritis is observed. 
Urinary Findings.—These are of the greatest importance. The 
daily amount is small, sometimes as little as 300 c.c. The urine is 
turbid, yellow or brown in color and macroscopically only rarely shows 
blood. The reaction is always acid, specific gravity high, sediment 
abundant. Its chief constituents are double refracting lipoid sub- 
stances which are sometimes free in individual droplets or clumped 
together, or they may appear as fine droplets in the numerous epithelial 
cells, but a more characteristic formation is that of large opaque casts. 
Pure hyaline and granular casts are found, but they are rare. There 
are also considerable numbers of leukocytes, the mononuclear form 
predominating. 
It is true that lipoid substances occur in the urinary sediment in 
secondary contracted kidney, but not in such amount as in parenchy- 
matous syphilitic kidney, and the albumin contents also are lower. 
Munk says that greater difficulties lie in differentiating this form of 
kidney from large white amyloid kidney. The urinary findings are 
quite similar, but the amyloid kidney is distinguished by the fact that 
in addition to lipoids it has relatively numerous single refracting fat 
elements. These two forms of disease are different also in the time of 
their appearance. While amyloid kidney generally develops slowly, 
still it leads to severe clinical symptoms; syphilitic disease appears 
early with very severe symptoms, especially marked dropsy. Within 184 
SYPHILIS OF THE GENITO-URINARY ORGANS 
ten days after the first appearance of albumin in the urine, the condition 
may become threatening. 
Munk hopes that this form of acute parenchymatous degenerative 
kidney will be more often recognized in the future, since it can be recog- 
nized only by means of examination of the sediment by the polarizing 
microscope. 
Unfortunately, most cases that come to the medical clinics have 
severe symptoms, and as a consequence this makes the number of cases 
appear relatively small, but there is no doubt that there are a large 
number of cases with mild symptoms that are observed and treated by 
syphilographers. 
Differential Diagnosis.—Differential diagnosis can be made between 
acute parenchymatous syphilitic nephritis and nephritis resulting from 
other infectious diseases. 
Prognosis.-—In most cases, with proper treatment and care, the 
patients recover from the first stage, even when there has been high- 
grade edema and weakness of threatening character. The edema may last 
two or three weeks, or may disappear earlier, sometimes very rapidly. 
The quantity of urine increases, the formed constituents in the urine 
decrease, but the albumin contents remain rather high. As soon as 
the edema disappears completely, the patient usually regains his 
strength and appetite and normal conditions return. The headaches 
gradually pass away. The amount of urine may vary for awhile in the 
formed elements; especially lipoids may be observed from time to 
time, but it is the high albumin contents that may persist for months 
afterward, rising and falling indefinitely. 
The relatively benign course of acute parenchymatous syphditic 
nephritis is surprising, and like all other forms of syphilitic infection, 
the prognosis depends on the prompt diagnosis, for the longer the 
kidneys remain jammed with spirochetes with their attending sys- 
temic symptoms, the more difficult will it be to bring about permanent 
resolution. 
According to Munk’s views, a fatal outcome in the acute stage is very 
rare in spite of the severe symptoms, such as dropsy, anemia, weakness, 
and so forth. 
Hoffmann says: “The prognosis of early acute syphilitic nephritis, 
which was good before, has become even better since the introduction 
of arsphenamine.” 
We have two powerful remedies, both without danger if properly 
used. In the majority of cases the albuminuria is completely over- 
come. Death is rare and when it occurs is perhaps due to improper 
treatment. The quick cure is due to the double action of arsphena- 
mine and mercury against the spirochetes through the blood and 
urinary tubules. 
Treatment.—In every case of syphilis which is presented for examina- 
tion and treatment a careful urinalysis should be made, and if later on 
an albuminuria presents itself, its etiology will not be so obscure. If a 
patient comes for treatment at the height of his disease, it is generally SYPHILIS OP THE KIDNEY 
185 
extreme dropsy and oliguria that demand attention. As this condi- 
tion is caused by the presence of the Spirochseta pallida within the 
substance of the kidney, as soon as specific remedies can be applied 
(arsphenamine and mercury), the condition should improve. Unfortu- 
nately, diuretics do harm; the chemical irritation caused by them 
causes the degenerated epithelium to be discharged suddenly and in 
large quantities. Such a considerable desquamation of kidney 
elements is not without danger for future restoration of the kidney. 
Diuretics, if used at all, should be of the mildest form; diuresis should 
be taken care of in a compensatory manner by free saline catharsis. 
Whenever the anasarca has advanced to a considerable degree, skin- 
drainage may be resorted to. 
As soon as possible small doses of neoarsphenamine should be given. 
It is perhaps best not to give over 0.2 gm. or 0.3 gm. at a dose, and, 
as soon as the dropsy has disappeared, rubbings may be combined. 
Hoffmann gives arsphenamine the preference in nephritis. It 
does not cause irritation of the kidneys, except in very rare cases. 
Some authors hold that it is sufficient to cure. 
The dietetic management in this class of cases deserves some little 
attention. Eggs, milk and carbohydrates are used as an exclusive diet 
in the beginning. Munk recommends some form of malt extract to 
be added to the milk, and, on account of the severe anemia, iron is 
given as soon as the intestinal tract will stand it. Meat should not be 
withheld long. 
The use of baths and hot packs is contra-indicated in this form of 
nephritis, because the advantage to be gained from them is not in 
proportion to the bad effects they have in increasing the general 
weakness. 
The general specific treatment for the syphilitic condition must, of 
course, be carried on, regularly controlled by the Wassermann reaction. 
Conclusions.—Munk’s conclusions are the following: 
In the clinical diagnosis of nephritis more attention must be paid 
than heretofore to the different degenerative processes in the kidney. 
The examination of the urine may give valuable information on 
this point. 
The demonstration of fat and fat-formed elements in the urine points 
to a fatty degeneration of the organ in the different forms of cachexia. 
The presence of a greater or less amount of fat-formed elements shows 
the destruction of kidney parenchyma in acute forms of nephritis. 
The demonstration by means of the polarization microscope of 
double refracting lipoids in the sediment of the urine is a reliable 
criterion for differential diagnosis between acute inflammatory and 
chronic degenerative kidney diseases. 
Gumma of the kidney is rarely recognized except at autopsy. 
It was Arnold Beer48 who gave the first description of gumma of the 
GUMMA OF THE KIDNEY. 186 
SYPHILIS OF THE GENITO-URINARY ORGANS 
kidney. Gummatous disease of the kidney generally appears in the 
form of circumscribed miliary nodules varying in size from that of a 
grain of millet to that of a hazel-nut, which, as a rule, are limited to one 
kidney. They generally occur in the cortical substance, extending at 
times more or less deeply into the medullary substance, even as deep 
as the papillae. Occasionally a single gumma occurs, but usually they 
are multiple. 
On section these gummata show a peripheral part which is gray 
and transparent. They may be either soft or hard, with a necrotic 
centre consisting of caseous masses undergoing fatty degeneration. 
The periphery consists of tissue which is rich in cells and vascular tissue. 
In this tissue, or sometimes surrounded by it, there are atrophied 
urinary tubules, together with shrunken Malpighian bodies. 
When these gummata have evacuated their contents, they may be 
resorbed by the lymphatics of the kidneys, and, when superficial, leave 
in their places cicatrices with corresponding deformities. 
Symptoms.—As in gummata elsewhere, gummata of the kidney 
manifest themselves from seven to twenty years after the chancre first 
appears. The evolution of the gumma is slow and insidious and only 
exceptionally gives symptoms which permit of a diagnosis during life. 
In some cases, however, gummata that open into the pelvis of the 
kidney may soften and discharge their contents into the urine. As 
soon as this elimination of the contents occurs, the urine again be- 
comes macroscopically clear, the condition remaining undiagnosed, 
thus leaving the true cause unsuspected. 
Gummatous kidney, when greatly enlarged, may simulate a malignant 
tumor. In such instances, even in the absence of positive symptoms 
of syphilis, a Wassermann reaction may clear up a doubtful diagnosis. 
The possibility of a tuberculous kidney should be constantly kept 
in mind. 
Prognosis.—Unless the attending interstitial nephritis is advanced, 
the prognosis is good. 
BIBLIOGRAPHY. 
1. Albarran: Sem. med., 1894, xiv, 489. 
2. Bellet, Charles: Contribution k 1’etude du chancre syphilitique de l’urfethre, 
These de Paris, 1898. 
3. Dcy, W. P., and Kirby Smith, J. L.: Southern Med. Jour., 1913, vi, 21. 
4. Du Castel: Jour. d. pract., 1894. 
5. Faitout, P.: Gaz. d. hop., 1897, lxx, 1045. 
6. Fasoli: Ann. d. mal. d. org. gen. ur., 1900, xviii, 954. 
7. Fournier, Alfred: Logons sur la syphilis tertiaire, Paris, 1899. 
8. Fournier, Alfred: Traite de la syphilis, Paris, 1898-1901. 
• 9. Gaucher and Druelle: Bull. soc. frang. de dermat. et syph., 1909, xx, 122. 
10. Gaucher and Rostaine: Ann. de dermat. et syph., 1904, xxxv, 149. 
11. Mauriac: Syphilis tertiaire et hereditaire, Paris, 1890. 
12. Renault, Alex.: Ann. de dermat. et syph., 1903, xxxiv, 932. 
13. Renault, Alex.: Bull. Soc. frang. de dermat. et syph., 1905, xvi, 215. 
14. Rougier: La syphilis tertiaire de l’urethre, These, Paris, 1908-1909. 
15. Simionescu, F.: La syphilis de l’urethre, Geneve, 1905-. 
16. Tanton, J.: Progr&3 m6d., 1910, xxvi, 607, 619. BIBLIOGRAPHY 
187 
17. Drobniy, B. A.: Syphilis of the Prostate Gland, med. Obzr. Mosk., 1906, lxv, 
455. 
18. Rush, J. O.: Gumma of the Prostate and Bladder, Med. Roc., New York, 1913, 
lxxxiv, 1028. 
19. Wright, F. R.: Syphilis of the Prostate, Report of a Case, Urol, and Cutan. 
Rev., 1914, xviii, 84. 
20. Asch, Paul: Ztschr. f. Urol., 1911, v, 504. 
21. Asch: Loc. cit. 
22. Chezelitzer: Zentralbl. f. d. Krankh. d. Harn- u. Sexualorgane, 1901, p. 6. 
23. Fenwick: Casper’s Handbuch der Cystoskopie, Leipzig, 1898. 
24. Follin: Soc. de biol., April, 1849; Gaz. med. de Paris, 1849, p. 492. 
25. Gayet, G., and Favre: Jour, d’urol., 1914, vi, 35. 
26. Graff, Karl: Beitrag zur Kenntnis der Blasensyphilis. Diss., Freiburg, 1906; 
also reported by Kraske, Chirurgenkongress, 1904. 
27. Griwzow: Monatsber. f. Krankh. d. Harn- und Sexualorgane, 1899, p. 449. 
28. Le Fur: Ann. d. mal. d. org. g6n.-Ur., 1902, xx, 1519. 
29. MacGowan, G.: Jour. Cut. and Gen.-Ur. Dis., 1901, xix, 326. 
30. Margoulifes: Ann. d. mal. d. org. Gen.-Ur., 1902, p. 384. 
31. Matzenauer: Arch. f. Dermat. u. Syph., 1900, p. 112. 
32. Miehailoff, N. A.: Ztschr. f. Urol., 1912, vi, 215. 
33. Morgagni: De sedibus et causis morborum per anatomen indagatis. Lovanni, 
1767. Cited by Proksch, J. K. Yierteljahrschr. f. Dermat. u. Syph., 1879, p. 555. 
34. Morris: Indiana Med. Jour., 1897-98, xvi, 5. 
35. Mucharinsky, M. A.: Ztschr. f. Urol., 1912, vi, 376. 
36. Neumann, Isidor: Syphilis. Nothnagel’s spezieller Pathologie and Therapie, vol. 
xxiii, 2d ed. Wien, 1899, p. 683. 
37. Pereschiwkin, N.: Ztschr. f. Urol., 1911, v, 732. 
38. Picker, R.: Ztschr. f. Urol., 1913, vii, 192. 
39. Picot, G.: Jour, d’urol. med. et chir., 1912, ii, 693. 
40. Ricord, Philippe: Traite complet des maladies veneriennes, Paris, 1851. 
41. Tarnowsky: Vortrage iiber venerische Krankheiten, Berlin, 1872, p. 199. 
42. Towbien: Yrach. Gaz., 1904, No. 9. Ref. Monatsber. f. Urol., 1904, p. 494. 
43. Vidal (de Cassis): Traite des maladies veneriennes, Paris, 1853, p. 169. 
44. Virchow: Verhandl. der physikalisch-medizinischen Gesellsch. zu Wurzburg, 1852, 
iii, 366. 
45. Von Engelmann, G.: Fol. urol., 1911, p. 472. 
46. Bauer, Richard, and Habetin, Paul: Wien. klin. Wchnschr., 1913, xxvi, 1101. 
47. Bayer: Traite des maladies des reins, Paris, 1840. 
48. Beer, A.: Die Eingeweide Syphilis, Tubingen, 1867. 
49. Damask: Mitt. d. Gesellsch. f. inn. Med. u. Kinderheilk. in Wien, 1912, xi, 119. 
50. Guiol, V. F.: Sur l’albuminurie syphilitique, These, Paris, 1867. 
51. Hoffmann, Erich: Deutsch. med. Wchnschr., 1913, xxxix, 353. 
52. Karvonen, J.: Die Nierensyphilis, Berlin, 1901. 
53. Moritz, Alfred: Beitrag zur Kenntnis der Nierensyphilis. Diss., Heidelberg, 1912. 
54. Munk, Fritz: Zeitschr. f. klin. Med., 1913, lxxviii, 24. 
55. Neumann, Isidor: Syphilis. Nothnagel’s spez. Path. u. Therap., Wien, 1896, 
xxiii, 436. 
56. Osthelder, F.: Vereinsbl. d. pfalz. Aerzte, 1913, xxix, 200. 
57. Perodu: De l’albuminurie dans la periode secondairo, de la syphilis, Mem. et 
compt. rend, de la Soc. d. sc. med. de Lyon, 1867, vi, 88, 196. 
58. Power and Murphy: System of Syphilis, London, 1901, iii, 79. 
59. Senator: Ueber die acut-infectiosen Erkrankungsformen der constitutionellen 
Syphilis, Berl. klin. Wchnschr., 1902, xxxix, 482. 
60. Senator: Erkrankungen der Nieren. Nothnagel’s spez. Path. u. Therap., Wien, 
1896, xix. 
61. Stengel and Austin: Am. Jour. Med. Sc., 1915, cxlix, 12. 
62. Tach, Jean: A propos de deux observations de nephrite precoce chez des sypliili- 
tiques, Th&se, Bordeaux, 1913. 
63. Virchow: Virchows Arch., 1858, xv, 217. 
64. W’elz, A.: Deutsch. med. Wchnschr., 1913, xxxix, 1201. 
65. Rattier, J. H.: Bull. gen. de therap. (etc.) 1836, xi, 164. 
66. Ricord, P.: Traite complet des maladies veneriennes, Paris, 1851, planche VIII. 
67. Reliquet, E.: Oeuvres completes de Dr. E. Reliquet, Paris, 1895, iii, 87. 
68. Wroczynski, C.: Cases of Late Syphilis, Medycyna, Warsawa, 1894, xxii, 820. 
69. Grosglik, S.: Gumma der Prostata, Wien. med. Presse, 1897, xxxviii, 74 and 102. 188 
SYPHILIS OF THE GENITO-URIN ARY ORGANS 
70. Rochon: Syphilis do la prostate, Med. mod., Paris, 1897, viii, 244. Abstracted 
in Ann. d. mal. d. org. genito-urin., Paris, 1897, xv, 658. 
71. Kudinsteff, S. V.: Syphilis of the Prostate Gland, Prakt. Vrach, S.-Petersb., 
1908, vii, 855. 
72. Power, D.: System of Syphilis, London, 1908, ii, 142. 
73. Divaris: Syphilis of the Prostate Simulating Tuberculosis, Cited by Power, 
Ibid. 
74. Desnos, M.: Syphilis de la prostate, Assn. Franc, d’urol. Proc.-verb., Paris, 
1910, xiv, 699. 
75. Jungano: Cited by Desnos, ibid. 
76. Cook, A. H.: Syphilis of the Prostate, Interstate Med. Jour., 1912, xix, p. 980. 
77. Ulrich, J.: Un caso de siflis de la prostata, Rev. d. 1. Assn. Med. Argent., 1915, 
xxiii, 504. 
78. Ravogoli, A.: Syphilis of the Prostate, Urol, and Cutan. Rev., 1916, xx, 125. 
79. Portillo: La Sifilis de la Prostata, Su diagnostico diferencial con las adenomas el 
cancro y otros tumors, Rev. espan. de urol. y. dermat., Madrid, 1917, xix, 620. 
80. Warthin, A. S.: The New Pathology of Syphilis, Am. Jour. Syph., 1918, ii, 425. 
81. Thompson, L.: Syphilis of the Bladder, Am. Jour. Syph., 1920, iv, p. 50. 
82. Schapira, S. W.: Gummatous Ulcerations of the Bladder—A Case Report, Am. 
Jour. Urol., 1915, xi, 283. 
83. Pedersen, J.: Syphilis of the Bladder, Med. Rec., New York, 1916, lxxxix, 235. 
84. Nilson, G.: Syphilis of the Bladder, Hygiea, Stockholm, 1916, lxxviii, 540. 
85. Gouvea, J.: Syphilis Vesical, Tribuna med., Rio de Jan., 1916, xxii, 173. 
86. Baker, T.: Syphilis of the Bladder; Report of a Case and a Review of the Litera- 
ture, Surg., Gynec. and Obst., 1917, xxiv, 187. 
87. Fowler, H. A.: Syphilis of the Bladder, Jour. Am. Med. Assn., 1917, Ixix, 1399. 
88. Denslow, F. M.: Report of a Case of Syphilis of the Bladder, ibid., 1918, lxx, 154. 
89. Wallace, W. J.: Symptoms and Diagnosis of Syphilis of the Bladder—Case 
Reports, Jour. Oklahoma Med. Assn., 1918, xi, 186 and 296. 
90. Cole, F. H.: Syphilis of the Bladder, Urol, and Cutan. Rev., 1918, xxii, 480. 
91. Hesse: Lues papulosa vesicse, Derm. Ztschr., xxv, Part 3, Abst. in Cor. Bl. f. 
schweiz. Aerzte, 1918, xlviii, 1146. 
92. Thompson, Loyd: Syphilis, Lea & Febiger, Philadelphia and New York,. 1916, 
p. 290. 
93. Cifuentes, Pedro: Rev. espan. de urol. y dermat., Madrid, May, 1921, xxiii, 274. 
94. Chocholka, E. F.: Jour, d’urol., Paris, November, 1921, xii, 353. 
95. Danforth, W. C. and Corbus, B. C.: Surg., Gynec. and Obst., 1920, xxxi, 219-226. 
96. Plaggemeyer, H. W.: Shell Fractures of the Spine, with Observations on Kidney 
and Bladder Function, Jour. Am. Med. Assn., November 22, 1919, lxxiii, 1599. 
97. Walker, J. T.: The Bladder in Gunshot and Other Injuries of the Spinal Cord, 
Lancet, February 3, 1917, i, 173. 
98. De Lisi, Lionello and Colombino, Silvio: General Study of the Innervation of 
the Bladder, S. Lattes & Co., Genoa, 1920. 
99. Koll, I. S.: Study of Twenty-five Tabetic Bladders, Surg., Gynec. and Obst., 
1915, xx, 176. 
100. Caulk, J. R., Greditzer, H. G., and Barnes, F. M.: Urologic Findings in Diseases 
of the Central Nervous System, Jour. Am. Med. Assn., November 22, 1919, lxxiii, 1594. 
101. Young, H. H., and Wesson, M. B.: The Anatomy and Surgery of the Trigone, 
Arch. Surg., July, 1921, i, 37. 
102. Corbus, B. C., O’Conor, V. J., Lincoln, M. C., and Gardner, S. M.: Spinal 
Drainage without Lumbar Puncture, Jour. Am. Med. Assn., January 28, 1922, lxxviii, 
264. 
103. Corbus, B. C. and O’Conor, V. J.: The Tabetic Bladder from the Standpoint 
of the Urologist, Jour. Am. Med. Assn., November 18, 1922, lxxix, 1750. SECTION II. 
THE PENIS AND URETHRA. 
CHAPTER V. 
ANATOMY, ANOMALIES AND INJURIES OE THE PENIS. 
By H. A. FOWLER, M.D. 
ANATOMY OF THE PENIS. 
The penis is the male organ of copulation. It is also concerned with 
urination. It therefore has a double function: genital and urinary. 
Its anatomical structure is peculiarly adapted to subserve these two 
functions. It is composed chiefly of erectile tissue separated into 
three parallel, cylindrical segments, by tough fibro-elastic investments. 
The two larger segments, the corpora cave'rnosa, lie side by side on the 
dorsal surface and make up the main bulk of the organ. In the groove 
on their under or ventral surface is placed the third or smaller segment, 
the corpus spongiosum, which surrounds the urethra and expands 
distally to form the free end of the penis. These three bodies are bound 
together by a common sheath of dense fibro-elastic tissue, called Buck’s 
fascia, and the whole covered by integument and subcutaneous layers. 
The size of the penis varies greatly in different individuals and bears no 
constant relation to general physical development. A large robust man 
may have a small penis, while a small undersized man may present an 
organ of unusual proportions. The average length of the penis, when 
it is flaccid, is from three to four inches; when erect, from five to seven 
inches. Its circumference is about three inches. 
Corpora Cavernosa.—The corpora cavernosa, composed of erectile 
tissue, are closely united in the greater part of their extent. They arise, 
one on each side, in the form of a dense, flattened, tendinous attachment 
from the ascending ramus of the ischium. They converge rapidly and 
meet just in front of the arch of the symphysis pubis. These two 
extremities form the root of the penis, and are called the crura penis. 
The anterior extremities are separated slightly and terminate in 
rounded, blunt ends which fit into corresponding depressions on the 
under surface of the glans penis. The average length of the corpus 
cavernosum is six inches; its diameter one-half inch. 
189 190 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
They are invested by a dense fibro-elastic sheath or tunica albuginea. 
This sheath, according to Henle, is 2 mm. thick when the penis is flaccid, 
ampulla 
of vas 
deferens 
seminal 
vesicle 
membranous 
urethra 
prostate 
, bulbourethra 
gland 
r\ corpus 
s caver- 
nosum of 
penis 
(crus penis) 
hemispheres of bulb '' 
of urethra 
corpus cavernosum 
of urethra 
mucous1 
folds 
■;* urethral 
J lacunae 
glans penis > 
valve of navicular fossa' 
Fig. 106.—The male urethra with the corpora cavernosa of the penis, the bulbo-urethral 
glands, and the prostate. (Sabotta.) 
external orifice of urethra 
'fossa navicular is 
and only 0.25 mm. thick during erection. It is, however, remarkably 
tough and strong, being capable of supporting the entire weight of the ANATOMY OF THE PENIS 
191 
body. It consists of two layers: an outer, of longitudinal fibers com- 
mon to both bodies; an inner, of circular fibers surrounding each body 
separately and forming a median partition, the septum pectiniforme. 
This septum is incomplete; numerous perforations allow free inter- 
communication between the two corpora, thus ensuring symmetrical 
distention during erection. 
While this sheath is very strong it is also very elastic, due to the 
predominance of elastic tissue. This allows for the great variation in 
size during repose and erection. There are no muscle fibers in the 
tunica albuginea. The angle between the rounded, anterior extremities 
of the cavernous bodies is filled with a dense fibrous expansion which 
projects forward into the glans in the form of a central stalk called the 
anterior ligament of the corpora cavernosa. 
The inner layer of the tunica albuginea gives off numerous fibrous 
septa, some thick and lamellated, others fine and filament-like, which 
anastomose freely and divide the inclosed space into innumerable 
irregular spaces or areolse. These trabecula contain unstriped muscle 
fibers in addition to connective tissue and elastic fibers, and form the 
supporting framework for the bloodvessels. The areola spaces thus 
formed communicate freely with each other and with those of the 
opposite body through the medium of the septum. They are lined by 
endothelial cells and represent dilated capillaries, communicating with 
the afferent artery on the one hand and the efferent veins on the other. 
There is no direct vascular communication between the corpora caver- 
nosa and the corpus spongiosum or glans. 
Corpus Spongiosum.—This is composed of erectile tissue similar 
in structure to the corpora cavernosa. It presents a central shaft and 
two expansions, one at either extremity. The posterior dilated ex- 
tremity, called the bulb, lies in-front of the triangular ligament in the 
angle formed by the converging crura. The anterior extremity is 
expanded into a cone-shaped body, the glans penis, which caps the 
corpora cavernosa. The glans presents at its posterior border a flange- 
like expansion, the corona glandis. Behind this is a deep sulcus, the 
coronary sulcus or neck of the penis. The urethra perforates the corpus 
spongiosum axially, terminating in a slit-like opening at the tip of the 
glans, the meatus urinarius. Within the bulb the urethra is not cen- 
trally placed, but lies nearer the dorsal surface, hence a greater thick- 
ness of spongy tissue covers the lower or ventral aspect of the urethra 
at this level. In the glans these relations are reversed, there is little or 
no erectile tissue below or ventral to the urethra. The fibro-elastic 
sheath surrounding the corpus spongiosum is separate and distinct 
from the fibrous investments of the cavernous bodies, which permits the 
easy dissection of the former from the latter. 
The glans is usually described in the text-books of anatomy as the 
expanded extremity of the corpus spongiosum, hence anatomically and 
morphologically a part of this body. The studies of Retterer (1892) 
upon the development of the penis in embryos and in the human fetus 
of different ages led him to quite different conclusions. According to 192 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
this author the spongy body surrounded by its fibrous elastic sheath 
accompanies the urethra as far as the meatus, but does not present any 
expansion at its anterior extremity. The central or axial portion of the 
glans is formed, therefore, of the anterior extremities of the corpora 
cavernosa and the corpus spongiosum. This is surrounded by a per- 
ipheral layer, much like a muff, particularly well developed dorsally, 
which represents the cutaneous and fibrous coverings of the penis at this 
point. Within this layer the terminal branches of the dorsal arteries 
and nerves of the penis end. At a later stage of development this per- 
ipheral layer takes on the structure of true erectile tissue and forms the 
peripheral portion of the glans in the adult. Free anastomosis takes 
place between the spongy body and the peripheral layer of the glans, 
while the vascular connections with the cavernous bodies are small and 
insignificant. 
Coverings of the Penis.—The coverings of the penis are disposed 
in four layers. From without these are: (1) skin; (2) dartos; (3) 
areolar tissue; (4) fascia of the penis. The skin covering the penis 
differs from the general body integument in its freedom from fat, the 
absence of smooth muscle fibers, the rudimentary character of its 
sebaceous glands, and the absence of hair except at or near the base. 
It is remarkably mobile, and after puberty is pigmented, resembling 
the skin of the scrotum. Extending beyond the glans it folds back on 
itself, forming a hood-like covering of the glans, called the prepuce. 
The inner scmimucous layer of this duplicature is closely adherent to 
the neck of the penis and passes forward intimately covering the glans, 
to meet the mucous membrane of the urethra at the meatus. A tri- 
angular fold, the frenum, attaches the prepuce to the glans just below 
the meatus. Tearing or rupture of the frenum is often accompanied 
by severe hemorrhage from the frenal artery, which is controlled only 
by ligature. This artery must also be tied whenever the frenum is 
severed during circumcision. The two layers forming the prepuce are 
separate and distinct, thus permitting obliteration of the preputial 
sac and uncovering of the glans by retraction of the skin. Numerous 
glands on the inner layer of the prepuce, particularly about the frenum 
and coronary sulcus, secrete a white cheesy material, smegma, with a 
characteristic offensive odor. 
Immediately beneath the skin is a layer composed of smooth muscle 
fibers continuous with the dartos of the scrotum. The fibers run for 
the most part longitudinally, others have an oblique direction. This 
layer extends forward to the preputial orifice, and follows the inner 
layer of the prepuce as far as the neck of the penis. These fibers, by 
their contraction, are supposed to assist in erection by producing stasis 
in the superficial veins. 
Beneath the dartos is a layer df loose areolar tissue rich in elastic 
fibers. Within this layer run the superficial vessels and nerves. It 
is to this layer that the skin owes its extreme mobility. Its loose 
texture favors the excessive accumulation of fluids seen in massive 
edema of the penis. ANATOMY OF THE PENIS 
193 
The sheath of the penis, already referred to as Buck’s fascia, is com- 
posed almost exclusively of elastic tissue. It forms the common sheath 
of the erectile bodies to which it intimately adheres. It is attached 
posteriorly to a triangular bundle of fibers, the suspensory ligament of 
the penis, which surrounds the penis and is inserted into the symphysis 
pubis, and to the superficial perineal fascia. Anteriorly it is inserted 
into the base of the glans. It is this disposition of Buck’s fascia which 
protects the cavernous bodies from invasion in ulcerative lesions of the 
glans, and also by confining periurethral inflammation and cellulitis within 
its limits for a long time protects the glans from involvement. 
Muscles.—The paired muscles of the penis are the ischiocavernosus, 
or erector penis, and the bulbocavernosus or accelerator urime. The 
ischiocavernosus arises from the tuberosities of the ischium, and running 
obliquely forward and upward is inserted into the lateral fascial 
covering of the corpora cavernosa. By their contraction they compress 
the cavernous bodies and thus aid in erection. The bulbocavernosus 
arises from the central tendon of the perineum, and passing forward 
and inward completely surrounds the bulb. By its forcible contrac- 
tion the fluid, urine and semen, which collects in the bulbous urethra, 
is expelled, thus assisting in the muscular effort concerned in ejaculation 
and in expelling the last drop of urine. Both muscles are innervated 
by branches of the internal pudic nerve and receive their blood supply 
from the branches of the internal pudic artery. 
Vessels.—The dorsal arteries of the penis, terminal branches of the 
internal pudics, pierce the suspensory ligament, and running along the 
dorsal surface beneath the fascia of the penis (Buck’s fascia), on either 
side of the deep dorsal vein, terminate in anastomosing branches about 
the corona glandis. These two arteries supply the coverings of the 
penis and give off branches to the corpora cavernosa. External to the 
dorsal arteries and the dorsal nerves courses the external pudic branch 
of the common femoral artery. This also supplies the integuments of 
the penis. The artery to the bulb, a branch of the internal pudic 
artery, pierces the anterior layer of the triangular ligament close beside 
the urethra and enters the bulb. It supplies the erectile tissue of the 
corpus spongiosum. The artery of the crus, also a branch of the 
internal pudic, pierces the anterior layer of the triangular ligament 
close to the ramus of the pubis and enters the crus. They furnish the 
main blood supply to the corpora cavernosa. In detaching the crura 
from the bone in the operation for the complete removal of the penis, 
the close proximity of these arteries to the bone may give rise to diffi- 
culty in controlling hemorrhage. It will be noted that the arteries 
of the penis supplying the erectile tissue and the envelopes are all 
branches of the internal pudic, except the small external pudic branches 
of the common iliac, which supply blood to the envelopes only. 
Veins.—The veins of the penis are divided into a superficial and a 
deep venous network. The superficial veins situated in the subcutane- 
ous tissue and collecting the blood from the integument unite to form 
the superficial dorsal vein of the penis. This passes back to the root 194 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
of the penis, anastomoses with the venous network of the abdominal 
wall and empties into the saphenous vein. The deep veins comprising 
the branches from the erectile tissue, and situated beneath the fascia 
of the penis, unite to form the deep dorsal vein of the penis. This 
vein forms the main venous trunk of the penis and, passing back, 
between the two layers of the triangular ligament, bifurcates and 
empties into the prostaticovesical plexus or plexus of Santorini. 
Lymphatics.—The lymphatics of the penis, like the veins, are 
divided into a superficial and a deep network. The superficial system 
drains the prepuce, skin and subcutaneous tissue. Some unite to 
form a common trunk, the superficial dorsal lymphatic trunk, which 
empties into the superficial inguinal glands. Others maintain their 
independence and empty separately into the inguinal glands. The deep 
lymphatics, like the deep veins, lie beneath the fascia of the penis. 
They drain the glans penis and communicate freely with the lymphatics 
of the prepuce and the urethra. Running along the groove of the 
dorsum of the penis as a single or as multiple (2 to 4) trunks, they form 
a plexiform network in front of the symphysis, at which level one some- 
times encounters two or more small glands. According to Cuneo and 
Marcille the deep lymphatics empty for the most part into the deep 
lymphatic glands along the femoral and iliac arteries and only excep- 
tionally into the superficial inguinal glands. This course and termina- 
tion of the lymphatics is important to bear in mind in the operation for 
carcinoma of the penis, which disease practically always involves the 
glans first. It is necessary not only to remove the superficial inguinal 
glands on both sides along with the nodes in front of the symphysis, 
but also the deep glands along the femoral vein, under Poupart’s 
ligament and the retro-iliac glands. 
Nerves.—The nerve supply of the penis is extremely rich, receiving 
filaments from both the cerebrospinal and the sympathetic systems, 
the former supplying the integument while the latter pass to the 
erectile bodies. The glans is particularly rich in nerves which termi- 
nate in free extremities and in special nerve endings, the genital nerve 
corpuscles of Krause. The erectile bodies receive filaments from the 
hypogastric plexus through the nervi erigentes which accompany the 
arteries to the cavernous and spongy bodies. 
CONGENITAL MALFORMATIONS. 
Congenital malformations of the penis, as a whole, are extremely 
rare. They have little clinical interest and are referred to merely as 
curious errors of development. They are usually associated with 
developmental defects of other organs, as the bladder, kidneys, uretet-s, 
and rectum. Congenital deformities of one or more of the constituent 
parts of the penis are, on the contrary, relatively common, and certain of 
these represent well-known types; for example, hypospadias, congenital 
phimosis. The penis may be double, absent, concealed, twisted, 
adherent, or cleft. 195 
CONGENITAL MALFORMATIONS 
Double Penis.—Double penis, penis duplex, diphallus verus, is 
an extremely rare anomaly but by no means as rare as generally sup- 
posed. Lebrun16 recently collected 13 cases of double penis with double 
urethra and omitted 4. About double that number, including all cases 
of this anomaly, have been recorded. Several varieties have been 
described: supernumerary glans, 3 cases; double glans with a single 
shaft, diphallus partialis, 3 cases; and two separate well-developed 
penes. These are either superimposed, placed side by side, or separated 
for a greater or less distance. The two urethras are separate and dis- 
tinct, communicating with a common bladder, or they unite in the 
prostatic region (Kiittner’s case15). In 4 cases the bladder was double, 
Fig. 107.—Velpeau and Gorre’s case. 
and each urethra opened separately into the bladder of the correspond- 
ing side. In the frequently quoted case of Alan P. Smith29 a stone 
formed in one of the bladders and was successfully removed. This 
man could void from either bladder at will. One of the most remark- 
able and widely known cases occurred in the person of Jean Battista 
dos Santos, a native of Faro, Portugal. He was exhibited at several 
European clinics, where a minute examination and accurate description 
of the malformation was made. In addition to two well-developed 
penes he presented a deformed supernumerary lower extremity pro- 
jecting between the normal thighs. A wax model of the penile malfor- 
mation is in the Army Medical Museum at Washington. (A descrip- 
tion of this interesting case together with photographs by Air. Hart 196 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
will be found in Lancet, London, 1865, ii, 124.) Curious variations 
in the functions of the two organs have been observed. In 13 cases 
urine was voided by both urethras, Ollsner’s patient24 voided through 
the right and ejaculated through the left penis. Two patients (Nie- 
man,22 St. Hilaire28) passed both urine and semen by both urethras. In 
2 cases with imperforate anus, feces and urine escaped together. 
Keppel14 observed that the right penis of his patient was used for 
urination only, while the left was the only one capable of erection under 
excitation. 
Fig. 108. —Lange’s ease. 
Reduplication of the penis never occurs alone, but is always associ- 
ated with other marks of fetal inclusion. A number of cases have been 
observed in children who presented other abnormalities incompatible 
with life, such as imperforate anus, and it was for the relief of this con- 
dition that they came under observation. In adults the condition is 
nearly always discovered accidentally during examination for some 
other unrelated malady. It is probable, therefore, that this ab- 
normality is not as rare as the number of cases reported would indicate, 
since these unfortunates are careful to guard their secrets and do not 
come under observation except when compelled to by necessity. Other 
abnormalities associated with reduplication of the penis are double 
bladders, hernia, and exstrophy of the bladder, cleft scrotum, imper- 
forate anus, and hypospadias. Volpe’s32 case is unique; this infant CONGENITAL MALFORMATIONS 
197 
with imperforate anus had a double penis, urethra, bladder, and 
scrotum, with a single (horseshoe) kidney and a single ureter opening 
into the left bladder, a fusion of the organs normally double and a 
reduplication of the organs normally single. 
Treatment.—Surgical intervention, except in rare cases, is limited to 
the treatment of associated malformations requiring operation. In 2 
cases an operation was performed for atresia of the anus; 1 (Coles)8 
was successful. In a favorable case an accessory penis can be removed, 
as was done by Lionti17 and Albrecht,2 with very good chances for 
excellent functional results. Except in these rare instances surgical 
treatment is of no avail, and therefore not indicated. 
Absence of the Penis.—Congenital absence of the penis is exceedingly 
rare, and unlike reduplication, is not accompanied by other gross 
malformations of the external genitals or developmental defects in other 
parts of the body. This condition must not be confused with con- 
cealed or apparent absence of the organ, or with pseudohermaphro- 
ditism. The penis is completely wanting, the urethra opens upon the 
perineum or on the anterior wall of the rectum. The subjects of this 
deformity are in other respects normally developed with well-marked 
secondary, sexual characteristics. The scrotum is normal, the testicles 
are present, but not pendant. The extreme rarity of this anomaly 
is evident from the fact that only 7 cases have been recorded. Harris11 
collected 5, added 1 of his own but omitted 1 (Revolat). I have not been 
able to find any others reported since. It is curious that the earlier 
literature contains no mention of this anomaly. There were two 
infants, the others were adults, and in three of these the urethra opened 
into the rectum. Mathews’s18 patient, a man, aged thirty years, had 
been married several years. 11 is secret was known only to his mother 
and family physician previous to marriage. He died of kidney in- 
fection following a simple operation for hemorrhoids. In two adults 
with the urethra opening into the bowel the kidney did not become 
infected. 
Concealed Penis,—In cases of apparent absence, the penis is 
dwarfed and concealed beneath the skin of the scrotum or perineum. 
This condition is easily mistaken for that of true congenital absence. 
Careful search, however, will reveal a rudimentary organ concealed 
beneath the skin. Cases have been described by Chopert, Bouteillier, 
and more recently by Mocquot, and Aievoli.1 In Mocquot’s20 case, a 
man sixty-one years of age, the scrotum was normal and both testicles 
present but not pendant. In the normal position of the penis there was 
a depression surrounded by a fold of skin, in the depth of which a 
cylindrical body could be felt. This was a rudimentary penis, 7 cm. 
long and about the size of one’s little finger. In the case recorded by 
Aievoli the penis was covered completely, even the glans, by the skin 
of the scrotum. 
Treatment.—The treatment consists in the liberation of the penis by 
incision and in supplying a covering of integument from the adjacent 
parts by an appropriate operation. 198 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
In the newborn with retention resulting from this deformity, libera- 
tion of the penis by dissection must be done at once; the plastic opera- 
tion may be deferred until later, as was done by Aievoli. 
Torsion.—Torsion of the penis or twisting in its long axis may 
occur. The frenum then comes to occupy a mid-dorsal position. It is 
usually associated with hypospadias, epispadias, or other penile defects. 
Cases have been reported by Jacobson. Very rarely this deformity 
exists alone and independent of any other deformity, as in Caddy’s7 
case. 
Adherent Penis.—Adhesions between the penis and scrotum 
together with marked incurvation occur as a complication of scrotal 
hypospadias. Treeing of these fibrous attachments and straightening 
the penis constitutes the first step in any operation for hypospadias. 
In the absence of any urethral defect the penis may be enclosed by the 
scrotal integument throughout its entire length. Such a case of webbed 
penis is described by Mummery.21 More commonly the attachment of 
the scrotum extends forward along the under surface of the penis a 
varying distance, and may seriously interfere with coitus (Verge 
palme). The treatment is simple, and consists in severing the attach- 
ments as far as necessary and suturing the loose skin in the corrected 
position. 
Cleft Penis.—There is only one case of transverse cleft or splitting 
of the glans on record. This singular abnormality is described by 
Hofmokl12 in a man, aged sixty-eight years, with congenital phimosis. 
Retracting the prepuce it was discovered that the glans was divided by 
a deep transverse cleft into a thickened dorsal and a thinner ventral 
portion. The urethra opened in the midline at the bottom of the 
deep sulcus. There was a shallow, blind opening on the inner surface 
of the lower segment. This man had been married twice and was the 
father of eight children. 
A vertical cleavage of the glans would appear to be more common, 
but nevertheless extremely rare. When complete, a double glans results 
(see above). Trenkler30 has recently observed a remarkable case of 
cleft penis in a strong, healthy young man without any other congenital 
defect. The appearance was that of a double penis in which the left 
one was rotated slightly under the other. Examination showed that 
in reality the condition was not that of duplication, but that a vertical 
cleft involving the corpora cavernosa and the urethra separated the 
two bodies completely. By drawing the two halves wide apart the 
urethral opening could be seen at the bottom of the sulcus. On the 
inner aspect of either half, extending from the urethral opening to 
the tip, was a narrow band of mucous membrane. These presented 
numerous pits or lacunae, and represented the lateral walls of the cleft 
urethra. 
Hypospadias and Epispadias.—Hypospadias is a congenital defect 
of the anterior urethra, the canal terminating at some point behind the 
normal position of the meatus. This defect varies in degree from a 
mere elongation of the meatus to a complete absence of the urethra in CONGENITAL MALFORMATIONS 
199 
front of the perineum. It never extends beyond this point, hence the 
posterior urethra escapes, the sphincters are competent, and the 
patient is always able to control his urine. Eleven varieties of hypo- 
spadias have been described, but for practical purposes it is necessary to 
distinguish only three, which are, in the order of their frequency of 
occurrence, balanitic (glandular), penile, and perineal (perineoscrotal). 
In balanitic hypospadias the urethra opens just behind the glans at a 
point where the frenum, which is absent, is normally attached. The 
glandular urethra is either entirely wanting, or there may be a shallow 
groove, or a deep furrow, lined by mucous membrane which represents 
the roof of the fossa navicularis. The glans is generally broader than 
normal, somewhat flattened, and slightly incurved. The malformed 
prepuce forms a redundant hood-like fold on the dorsal aspect of the 
glans. This degree of hypospadias causes little inconvenience or inter- 
ference with function and therefore seldom requires treatment other 
than the occasional dilatation of a contracted urethral opening. 
In penile hypospadias the deformity is much greater. The urethral 
opening may be situated at any point along the floor of the penile ure- 
thra, but is usually just behind the glans, midway between the glans and 
scrotum, or at the penoscrotal juncture. Associated deformities are 
much more common in this variety and usually are more marked the 
greater the degree of hypospadias. When the hypospadiac opening is 
in the anterior portion of the penile urethra the penis may be well 
formed and its functions quite normal, but in penoscrotal hypospadias 
the member is usually small, malformed, and markedly incurved upon 
the scrotum to which it may be partially adherent. The corpora 
cavernosa are poorly developed. The urethra in front of the abnormal 
opening is most often obliterated and when an attempt is made to 
straighten the penis this stands out as a tense fibrous cord. Excep- 
tionally it may remain patulous up to the meatus, end in a cul-de-sac, 
or in a secondary fistulous opening. 
Perineal hypospadias represents the extreme grade of the deformity 
and is fortunately very rare. The associated malformation of the 
external genitals is most marked. The scrotum is divided by a deep 
cleft, each half containing a normal testicle, more often an atrophied 
testicle, or, when these have been retained, none at all. In any case 
the cleft scrotum closely resembles the vulva, the two halves represent- 
ing the labia majora. The penis is dwarfed and may be completely 
concealed, except for the glans, by a redundant fold of scrotal tissue, and 
is easily mistaken for an hypertrophied clitoris. The urethral opening 
forms a funnel-shaped depression lined by mucous membrane and con- 
cealed under the retracted and incurved penis. Occasionally the ure- 
thra may continue forward to its tip as a groove on the under surface 
of the stunted penis. In a pronounced case it may be very difficult 
to determine the sex of the individual. The functions of the penis are 
little disturbed in balanitic hypospadias. The stream of urine may be 
very small on account of the contracted opening, or scattered and 
directed to one side or downward as a result of the associated penile 200 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
deformity. In the penoscrotal and perineal variety, function is mark- 
edly interfered with. Coitus is difficult or impossible, and sterility is 
the rule. In urinating, the patient must sit down to avoid wetting his 
clothes; the urine bathes the adjacent parts which become excoriated 
and eczematous. 
Etiology.-—Hypospadias is manifestly a congenital defect and is due 
to an error in development. The posterior, penile, and glandular 
urethra develop separately. At one stage in its development the 
urethra is an open gutter or groove, the sides of which unite in the 
median line to form the floor of the canal. If for any reason the process 
is arrested at any point, or the separate portions fail to unite properly, 
closure is incomplete and hypospadias results. The causes underlying 
the arrest of development are not well understood. The condition is 
unquestionably hereditary. Kaufmann13 has proposed an ingenious 
theory to explain hypospadias and its accompanying deformities. He 
assumes that there is a failure of the separate portions to unite properly 
which results in atresia of the urethra. When the kidneys begin to 
secrete, the urine ruptures the urethral floor behind the point of 
occlusion and hypospadias results. 
Treatment.—In the treatment of hypospadias one aims to correct 
deformities and restore normal function. Whether an operation should 
be advised or not depends upon whether the degree of deformity and 
the resulting disturbance of functions are sufficient to demand surgical 
relief. In balanitic hypospadias operation is rarely, if ever, indicated. 
The deformity is so slight that the disturbance in function is trivial 
and does not justify any surgical operation. Two operative pro- 
cedures have been described, those of Duplay and of Beck. 
Duplay’s Operation for Glandular Hypospadias.—This operation is 
well adapted to cases in which there is a groove on the under surface of 
the glans representing the glandular urethra. The edges of this groove 
are freshened and brought together in the midline over a retention 
catheter by interrupted sutures of fine silk or chromic catgut. When 
the flaps are too short to come together without undue tension, lateral 
incisions into the glandular tissue are made which will overcome this 
difficulty. The retention catheter is retained until complete healing 
takes place. 
Beck’s Operation.4—This procedure is said to be suitable for cases 
in which the hypospadiac opening is just at the margin of or just behind 
the glans and the latter is not grooved on its under surface. A circular 
incision is made about the hypospadiac opening and this is extended 
laterally on either side along the sulcus behind the corona. A longi- 
tudinal incision is then made, beginning at the hypospadiac orifice and 
extending along the line of the urethra. The two skin flaps thus 
marked out are dissected up. The urethra is then mobilized by dissect- 
ing the spongy body free from its bed for a certain distance. The 
glans is now tunnelled by passing a long narrow-blade scalpel from be- 
hind forward through the glans, emerging at its summit. This tunnel 
must be enlarged by dilatation or crucial incision. A pair of Ivocher CONGENITAL MALFORMATIONS 
201 
forceps are now passed through this new meatus, the end of the liber- 
ated urethra seized and drawn through the tunnel. The dislocated 
urethra is sutured in place by interrupted sutures passing through the 
edge of the urethra and glans. The operation is completed by approxi- 
mating the skin flaps to cover the raw surface. The distance the ure- 
thra is dissected free depends upon the amount of forward dislocation 
necessary. The urethra should not be under any considerable amount 
of tension when sutured in its new position, otherwise retraction will 
occur and the result will be a failure either from the sutures giving way 
or from a pronounced incurvation of the penis. Indeed, the tendency 
toward the latter deformity seems to be one of the chief objections to an 
otherwise theoretically ideal operation. The technic is slightly modi- 
fied when the glans is grooved as shown in Figs. 107, 108, 109 and 110. 
My personal experience with Beck’s operation in a small number of 
cases has been 100 per cent, failure, due to recontraction of the dis- 
located urethra and incurvation of the glans. A. C. Woods, of Phila- 
delphia, has reported a similar experience. I am of the opinion that 
the procedure of Beck is faultily conceived for the repair of a defect 
which should rarely, if ever, be subjected to surgical attack. This 
operation as well as the preceding one can be carried out in one stage. 
In penoscrotal and perineal hypospadias an operation is always 
indicated and its object is twofold: to straighten the penis and recon- 
struct the urethra. A number of operations have been described and 
performed which differ in the ingenious methods advised for the repair 
of urethral defects. The different procedures are all modifications of 
three fundamentally different methods, namely, urethroplasty by the 
use of flaps, grafts and transplants. Flaps may be taken from: 
(a) The penis itself, as in the operations of Duplay, Beck, Wood and 
Russell; (b) the scrotum, Landerer and Biddle, Bouisson, Bucknall; 
(c) the abdomen, operation of Itosenberger; or (d) a combination of 
the two latter, procedure of Moutet. Grafts are made use of in 
the operations of Nove-Josserand, Rochet, and Mayo. Transplants 
have been suggested (Tanton) and used in a few cases (Legueu). 
These may be: (a) Heteroplastic, in wThich the urethra, the ureter, 
or a vein of animals is used; (6) homoplastic, in which similar grafts 
are taken from a cadaver; or (c) autoplastic, in which a section of 
the patient’s own vein is used. 
It is quite apparent from the numerous procedures that have been 
suggested that no entirely satisfactory operation for the cure of peno- 
scrotal and perineal hypospadias has been devised. This condition 
still remains one of the most difficult to treat successfully. The 
problem is essentially one of plastic surgery, and, as pointed out 
by Churchman, if one scrutinizes the operative procedures which 
have been proposed by the criteria of sound plastic surgery, not 
one of them fully meets the tests. Success in any plastic operation 
depends largely upon the following conditions: Avoidance of tension 
at all times; care in preserving ample circulation of all flaps; the 
approximation of broad surfaces rather than narrow edges; and asepsis. 202 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
Fig. 109.—Beck’s operation for hypo- 
spadias. (Watson and Cunningham.) 
Fig. 110.—Beck’s operation. (Watson 
and Cunningham.) 
Fig. 111.—Beck’s operation. (Watson 
and Cunningham.) 
Fig. 112.—Beck’s operation. (Watson 
and Cunningham.) CON GEN ITAL MALFORMA TIONS 
203 
The first step in all operations, and common to all, is to straighten 
the penis. A transverse incision is made through the fibrous band 
which holds the penis retracted and incurved on the scrotum. At times 
multiple incisions must be made to completely free the penis. It may 
be necessary to carry this incision into the sheath of the cavernous 
bodies, care being taken not to injure the latter, and if the spongy body 
is too short and interferes with complete liberation of the penis, it 
should be dissected up and allowed to retract. All constrictions having 
been divided, the penis is fully extended and the incision closed by trans- 
versely placed interrupted sutures. It is maintained in an extended 
position by appropriate dressings until healing is complete. At the 
time of the straightening of the penis Pousson advises straightening the 
glans by his technic of “ redressement.” A transverse Y-shaped wedge 
of tissue is removed from the dorsal surface just behind the glans. 
When the edges of the wound are sutured, the incurvation of the glans 
is overcome. 
One should wait from four to six months after the first stage before 
beginning the plastic repair of the urethra in order to be sure no further 
retraction will occur and to allow the scar tissue to become freely movable. 
Fig. 113 Fig. 114 
Figs. 113 and 114.—Duplay’s operation for penoscrotal hypospadii 
(Pousson’s technic.) 
Duplay’s Operation (Pousson’s Technic25).—In this operation the 
urethral defect is repaired by flaps taken from the penis itself. This 
operation or a slight modification is the one most generally used. 
The technic is simple, but failure often results from strangulation 
of the penis and sloughing of the flaps due to too great tension. This 
is practically unavoidable. 
First Stage— Begins by straightening the penis as already described. 
Second Stage.—A preliminary perineal section is done to divert the 
urine through a perineal fistula. This is absolutely essential to the 204 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
success of any operation for hypospadias. An incision is then made on 
the under surface of the penis parallel to its long axis about 8 mm. from 
the midline and extending from the summit of the glans to the level of 
the hypospadiac orifice. At each extremity of this incision, incisions 
AC and BD are made at right angles extending outward a distance of 
Fig. 115.—Beck’s operation for scrotal hypospadias. First step. (Watson and 
Cunningham.) 
6 mm. The flap E thus outlined is then dissected up toward the out- 
side. Shorter incisions (AF, B G) mark out a narrower, inner flap (II). 
Similar flaps are made on the opposite side of the midline, an outer and 
an inner, with this difference, that the longitudinal incision is only 
5 mm. from the midline and the inner flap (II') is therefore narrower. CONGENITAL MALFORMATIONS 
205 
The two flaps (II and IP) are sutured together over a catheter and form 
an inner layer on the floor of the new urethra. As these two flaps are of 
an unequal width, the suture line will be at one side and therefore not 
directly under the outer suture line. Flaps E and E' are then brought 
together to cover in the raw surface and form the outer layer of the 
double urethral floor. 
Fig. 116.—Beck’s operation for scrotal hypospadias. Second step. (Watson and 
(Cunningham.) 
Third, Stage.—Closure of the Perineal Fistida.—Drainage of the blad- 
der through the perineal opening should be maintained until complete 
healing has taken place and one is sure that displacement of the flaps 
due to faulty suturing or infection will not result in the formation of a 
fistula. The perineal fistula is then closed in the usual way. 206 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
Beck's Operation.— This operation makes use of flaps derived from the 
penis and scrotum. On either side of the midurethral line and several 
millimeters distant a longitudinal incision is made extending from the 
summit of the glans to just beyond the level of the abnormal urethral 
opening. These are jointed by transverse incisions at either extremity. 
Fia. 117.—Beck’s operation for scrotal hypospadias. Third step. (Watson and 
Cunningham.) 
The flap thus outlined is dissected up on either side and the edges 
brought together over a catheter in the midline by interrupted sutures, 
thus forming a urethra with an epidermal lining. A flap is now marked 
out on the scrotum with its base at the abnormal urethral opening of 
proper shape and size to cover in the raw surface left by the first flap. CONGENITAL MALFORMATIONS 
207 
This is rotated on its base and sutured in place over the new urethra. 
The scrotal wound is closed by direct suture (Figs. 115, 116 and 117). 
Nove-JpsseramVs OperationP—This is the best-known procedure in 
which urethroplasty is made by tunnelling and the use of grafts. The 
results obtained by the technic originally described were unsatisfactory, 
as a fistula at the juncture of the new-formed and normal urethra was 
practically constant, and the new canal showed a marked tendency to 
contract. This technic was subsequently modified and the results 
obtained by the originator of the operation have been recently fully 
analyzed. Despite the reported success in a few instances, this 
Fig. 118.—Nove-Josserand operation 
for perineal hypospadias. Formation of 
perineal fistula. Incision around hypo- 
spadiac opening. 
Fig. 119.—Nove-Josserand operation 
for perineal hypospadias. Excision of 
hypospadiac opening. Sutures in place. 
operation can hardly be expected to yield uniformly good results 
since the conditions necessary for a free graft to take, namely, rest 
and asepsis, are difficult or impossible to secure in this location. 
The same objection applies to the operation of Rochet and the 
procedures in which free transplants are used. 
Step Owe.—The urine is diverted by a perineal urethrostomy, the 
edges of the urethra being sutured to the skin. Redressement of the 
penis is then made. At the same time the hvpospadiac urethral open- 
ing is excised together with 2 or 3 cm. of the urethra, a ligature placed 
about the stump and the wound in the penile urethra sutured (Figs. 208 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
118 and 119). The penis is immobilized against the abdominal wall 
by appropriate dressings and one waits for two or three months. 
Second, Step.-—This consists in tunnelling the new urethra and apply- 
ing the graft. A trocar is introduced through the urethrotomy wound, 
directed along the course of the proposed new urethra and brought out 
at the position of the new meatus. This tunnel is enlarged by special 
instruments. A dermo-epidermal graft is taken from the inside of the 
thigh, an area free from hair, this is wound spirally around a staff and 
Fig. 120.—Nove-Josserand operation for 
perineal hypospadias. Hypospadiac opening 
closed. Formation of new urethra by tunnel- 
ling with a special instrument. 
Fig. 121.—Nove-Josserand opera- 
tion for perineal hypospadias. Prep- 
aration of graft. This is wound spi- 
rally around a catheter and anchored 
at either end by ligatures. 
fastened at either end by catgut ligatures. The staff carrying the graft 
is now introduced into the tunnel from behind forward and fastened 
into position (Figs. 120, 121 and 122). At the end of about eight days 
the staff is removed and after an interval of about three or four weeks 
bougies are passed to dilate the channel. It has been found that con- 
traction will occur, and to overcome this an internal urethrotomy is 
done after two or three months, just as is done for a stricture in an 
otherwise normal urethra. CONGENITAL MALFORMATIONS 
209 
Third Step.—This comprises the closure of the perineal fistula by 
the usual technic. The operation of Nove-Josserand is suitable for 
perineal hypospadias as well as penile. 
Rochets Operation.—Rochet31 has proposed the transplanting of a 
skin flap taken from the scrotum in place of the graft used by Nove- 
Josserand, while Mayo and Donnet9 each have described a technic 
of transplanting a flap taken from the redundant prepuce in cases of 
penile hypospadias. 
Fig. 122.—Nove-Josserand operation for perineal hypospadias. Introduction of graft 
into the newly formed canal, made by transfixing the tissues. 
For the cure of penoscrotal hypospadias the operation of Bucknall 
appears to more nearly fulfil the conditions necessary for a reason- 
ably uniform degree of success. It will be noted that preliminary 
perineal drainage is not necessary. The technic as described by 
Churchman is as follows: 
“1. Correction of the curvature of the penis if this is indicated, 
is made in the usual manner. A sufficient period of time is allowed 
to elapse (not less than three months) before the cure of the hypo- 
spadias is undertaken. 
“2. The Plastic Operation.—(a) The penis is laid back on the 
pubis and two parallel incisions (| inch apart) are made in the 210 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
skin on the ventral surface of penis and scrotum; these incisions 
are prolonged laterally at either end by small incisions, about J inch 
in length, made at right angles to them (Fig. 123, a and b). I have 
found it convenient to place four traction sutures at c, d, e and /. 
Fig. 123 
Fig. 124 
Fig. 125 
Fig. 126 
Fig. 123.—The first incisions are represented by dotted lines (a and h). Stay sutures 
hold the penis and scrotum in place (c, d, e, f). (Churchman.) 
Fig. 124.—Lateral skin flaps have been dissected up. A central strip of skin remains 
of which the upper or penile portion (a) will form the roof, the lower or scrotal portion 
(6) the floor of the new urethra. (Churchman.) 
Fig. 125.—The penis has been flexed, with the hypospadias opening as a hinge, and 
the lateral flaps are being sutured over rubber tubes; one of these tubes is represented 
by the dotted line (a), the corresponding rubber tube on the lower flap is omitted for 
purposes of clearness. (Churchman.) 
Fig. 126.—An enlarged drawing, showing the way the suture is laid, so as to approxi- 
mate the skin edges (for the formation of the new urethral tube) without penetrating 
them, a, penile skin; b, the scrotal. (Churchman.) CONGENITAL MALFORMATIONS 
211 
“(b) Two lateral flaps are dissected up, leaving the median strip 
of skin untouched (Fig. 124). This strip will form the new urethra, 
the penile portion (marked a) its roof, and the scrotal portion (marked 
b) its floor Each lateral flap should be about \ inch wide and 
the median strip the same width. 
“(c) The penis is flexed onto the scrotum with the hypospadic 
opening as a hinge; the lateral skin flaps are thus brought into flat 
approximation with each other, like the leaves of a closed book, and 
in this position mattress sutures are applied, as shown (Fig. 125). 
These sutures are tied over small rubber tubes, one of which is repre- 
sented (Fig. 125, a) by a dotted line, the corresponding tube on the 
lower flap being omitted for the sake of clearness. The method of 
applying the sutures to produce approximation of the median skin 
flaps without having them penetrate the new urethral tube is shown 
in Fig. 126. The finest suture material should be used and a No. 6 
Fig. 127.—Schematic cross-section, showing the result of the first stage of the opera- 
tion. a, rubber tubes; b, lateral skin flap, penile portion; c, lateral skin flap, scrotal 
portion; d, new urethra. (After Bucknall.) 
catheter inserted and fastened to the glans with a stay stieh. The 
catheter should be inserted before the mattress sutures have been 
applied; it is omitted from the illustration for the sake of clearness. 
The relations after completion of this stage of the operation are 
shown in the s hematic cross-section represented in Fig. 127. No 
dressing should be used. A chloroform mask, suspended from a gauze 
bandage around the waist, with the bell of the mask lying over the 
scrotum, provides the best protection from the bedclothes. Bro- 
mides should be given for pain and to prevent erections. The end 
of the catheter should be allowed to lie in a urinal containing boric 
acid solution. The catheter should be removed on the fifth day and 
alternate stitches on the same day; the remaining stitches may be 
removed a few days later When healing has occurred between the 
lateral skin flaps, which have been sutured in flat approximation, the 
penis is fixed to the scrotum, the hypospadiac opening is closed and 212 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
Fig. 128.—First step in the second-stage operation. The penis has healed in the 
scrotal bed; the edges of the lateral skin flap are seen at a. The skin incision is shown 
at b; it is purposely represented as made further from the penis than is necessary in 
order to indicate that one should err on the side of lifting up too large, rather than too 
small, a flap. A rubber catheter has been inserted in the urethra, in order to protect 
it during the dissection of the penis from the scrotum. (Churchman.) 
Fig. 129.—The dissection of penis from scrotum has been completed; the new urethra, 
distended by the catheter, can be seen bulging against the skin flap. (Churchman.) CONGENITAL ANOMALIES 
213 
a new cutaneous urethra has been formed which now opens near the 
glans (Fig. 128). 
“ (d) The second stage of the operation is not undertaken to com- 
plete the cure of the hypospadias, which has been accomplished by 
Fig. 130 
Fig. 130.—Suture of scrotal flap begun; interrupted and not continuous suture (as 
shown by the artist) should be used, a, cutaneous wings, formed by the healing of 
the two lateral skin flaps, sutured at the first operation. (Churchman.) 
Fig. 131.—Suture of scrotal flap completed. One suture has been placed, beginning 
the repair of the defect in the scrotum. (Churchman.) 
Fig. 131 214 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
the first stage, but to restore the penis to its normal position and to 
cover raw areas. It should be undertaken not sooner than twenty- 
one days after the first operation; it should not be considered until 
healing from the first operation is absolutely complete, no matter how 
long this takes. Indeed, it is probably wise to discharge the patient 
from the hospital for a period of two or three weeks, rather than be 
tempted to intervene too soon. The skin incision is made as shown 
in Fig. 128, b, though not so far out on the scrotum as represented 
in the illustration; this feature is purposely exaggerated in order to 
emphasize the fact that abundant skin should be taken (more will 
be needed than on first thought seems necessary), and that as much 
skin as desired may, with impunity, be lifted up from the scrotal 
redundancy. A catheter should be inserted before the dissection is 
begun, to protect the urethra from injury, and the dissection carried 
out as shown in Fig. 129. The edges of this skin flap are sutured as 
shown in Fig. 130, except that interrupted sutures should be used, 
rather than a continuous one, as illustrated. The result, after these 
interrupted sutures are tied, is shown in Fig. 131. 
Fig. 132.—Schematic cross-section to show the final result, a, roof of urethra, formed 
of penile skin; b, floor of urethra, formed of scrotal skin; c, reflected scrotal skin flap. 
(Churchman.) 
“The raw area in the scrotum is covered by means of a few sutures 
placed as shown at a, Fig. 131. No retention catheter is needed. 
A cross-section of the penis at the end of operation is schematically 
represented in Fig. 132; the method of formation of the new urethra 
from penile and scrotal skin may here be clearly seen.” 
In the plastic repair of urethral defects the transplantation of a 
section of vein or ureter has been suggested. Tanton has success- 
fully experimented on dogs and more recently operated on a patient, 
using the saphenous vein for the transplantation. This procedure has 
also been used by Tuffier, Potel and Leriche, Becker, Stettiner and 
Schmieden. It is probable that this method of urethroplasty event- 
ually will come into more general use. It must be said, however, that 
any operation for hypospadias is difficult, due chiefly to the failure 
to get primary union. A fistula often results from infection and 
breaking down of the wound, which may require a long time and 
repeated efforts to close. Great care and gentleness in handling 
the tissues is necessary for success. Preliminary perineal drainage CONGENITAL ANOMALIES 
215 
is indispensable. At what age should operation for hypospadias 
be undertaken? In cases of marked deformity this should be cor- 
rected early, otherwise development will be seriously interfered with. 
About the sixth year is the most suitable time for the first step. It 
is better, according to Albarran, to wait several years, until the parts 
are fully developed before attempting the plastic repair of the 
urethra, about the sixteenth to eighteenth year. According to the 
experience of some other surgeons, better results are obtained when 
the operation is completed before puberty. 
Epispadias.—In this deformity the urethra lies above the corpora 
cavernosa in the mid-dorsal line and the roof of the canal is partly or 
wholly absent. It is relatively rare. In the department of the Seine 
1 case of epispadias was found in 6000 recruits, while Marshall did 
not find a case in examining 60,000 conscripts. Baron observed 
300 cases of hypospadias for 2 of epispadias. Three degrees of 
epispadias occur: Balanitic, penile and complete, or penopubic. In 
the balanitic form the urethra opens upon the upper surface of the 
glans or at the level of the coronary sulcus, the glandular urethra 
being represented by a groove. In penile epispadias, v7hich is very 
rare, the urethra opens farther back on the upper surface of the penis 
and extends forward as a groove to the tip of the glans. Complete 
epispadias is characterized by complete absence of the roof of the 
urethra and is nearly always associated with exstrophy of the bladder 
and separation of the pubic bones. In these cases the penis is 
deformed; it is short, broad and generally curved upward against the 
pubes. The urethral opening is large, infundibuliform, often admit- 
ting the examining finger. It is usually concealed by an overhanging 
fold of pubic tissue above, and below by the penis, which is strongly 
curved upward against the opening. The prepuce is divided and is 
redundant on the under surface of the glans. In balanitic epispadias 
the functional disturbances are less marked. Coitus is usually diffi- 
cult on account of the brevity of the penis and the stream of urine 
is spattering. In the more marked cases the associated penile 
deformity makes coitus impossible, while the constant dribbling of 
incontinence renders the condition of these unfortunates well-nigh 
intolerable. Incontinence of urine, absent in some cases of most 
marked epispadias, is partial or intermittent in others, and is always 
absolute when the posterior urethra is involved. In the latter case 
there is usually a separation of the pubic bones and exstrophy of the 
bladder, or hernia wdthout exstrophy. 
Etiology.—This condition is obviously due to arrested development 
whereby complete closure of the canal does not take place. No 
satisfactory explanation, however, has yet been offered as to how or 
why the urethra comes to lie above the corpora cavernosa. The very 
rare cases of complete separation of the cavernous bodies with the 
urethral opening situated in the angle between them really represents 
an intermediate stage in the migration of the urethra from its normal 
position to that occupied in epispadias. 216 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
Treatment.—The treatment is either palliative or radical. Pallia- 
tive treatment consists in devising some sort of apparatus, which 
the patient wears constantly, for collecting the urine. The irritation 
of the urine continually bathing the parts, the odor and the leakage 
makes this form of treatment unsatisfactory and insupportable. 
Fig. 133.—Condition before operation. The only evidence of a pendulouo urethra 
is a groove on the dorsum of the penis, lined by urethral mucosa which is sharply demar- 
cated from the skin covering the remainder of the penis. Cross-section shows relation 
of groove to corpora. (Young.) 
The surgical treatment of epispadias is more difficult than that of 
hypospadias as the deformity is greater. In addition to strengthen- 
ing the penis and construction of a urethra by an appropriate urethro- 
plastic operation, the newly formed canal, lying at first on the dor- 
sum of the penis, must be brought into normal position on the under CONGENITAL ANOMALIES 
217 
surface of the corpora cavernosa. And in certain cases the asso- 
ciated incontinence of urine must be controlled in order to obtain 
satisfactory results. 
Fig. 134.—Skin incision. The penis is held in position by two sutures placed in 
glans (G). As indicated by the black line in the diagrammatic cross-section, the inci- 
sion on the left side goes only through the skin and down to the corpus, while, on the 
right the dissection is carried down between the corpora until the skin of the under 
surface of the penis is reached. (Young.) 
In the earlier operative procedures attempts were made to form a 
urethra by employing flaps. No attempt whatever was made to 
bring the urethra into normal position on the under surface of the 
shaft. That so many operations have been devised for the simple 
urethroplasty in epispadias as well as hypospadias is proof abundant 
that uniformly good results are difficult to obtain. Several succes- 218 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
sive operations were required, and a successful result was often delayed 
by the formation of fistula? difficult to heal. The simple procedure 
of Duplay in which the freshened edges of the urethral groove are 
brought together by sutures over a catheter can hardly be seriously 
Fig. 135.—The separation of the two corpora has been completed. The skin edge is 
being retracted to the right and the edges of the new urethra to the left, exposing the 
right corpus (C) and exposing also the space between the two corpora, the floor of 
which is formed by the inner surface of the skin of the under surface of the penis. 
The relations are clearly indicated in the cross-section. (Young.) 
considered. Tiersch’s operation attempts to build up a urethra by 
flaps taken from the penis, prepuce and pubic region. Several opera- 
tions separated by an interval of weeks or months are necessary. 
The formation of fistula? is almost inevitable and delays final healing. CONGENITAL ANOMALIES 
219 
In Beck’s operation the new urethra is formed from the mucous 
membrane obtained by dissecting up the tissues about the infundibu- 
liform urethral opening. The floor of the new urethra is made by 
dissecting up the floor of the urethral groove; the roof, from the tissues 
Fig. 136.—The new urethra is being formed by a continuous suture, bringing together, 
over a catheter (Ca), the edges produced by the original incision, and converting the 
original groove into a tube. The attachment of the urethral tube to the left corpus 
may be distinctly seen both in surface view and cross-section. (Young.) 
above the urethral opening. The two flaps, thus formed, are sutured 
along their edges into a tube. The glans is then perforated and the 
new urethral tube drawn into this opening and sutured to the margin 
of the new meatus. This operation is open to the criticism that the 
blood supply to the elongated flap is not adequately preserved. 220 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
It will be noted that no attempt is made in any of these operations 
to deal with the abnormal position of the urethra. In 1895, Cantwell 
introduced a new principle into the surgical treatment of epispadias 
by providing for the transplantation of the new urethra to its normal 
Fig. 137.—The right corpus (C) has been rotated, carrying the urethra down to its 
new position below and between the two corpora. The latter are being sutured with 
interrupted sutures of chromic catgut. The unfinished suture line above permits a 
view of the underlying newly formed urethra. (Young.) 
position, thus forming “a penis normal in the relation of its compo- 
nent parts and normal in appearance.” The urethra is constructed 
from the urethral groove by dissecting-up flaps on either side and 
bringing these together by sutures in the midline. The corpora cav- CONGENITAL ANOMALIES 
221 
ernosa are now separated by dissection, and the new urethra, dis- 
sected quite free except at its base, is transferred to the bottom of 
the groove between these two bodies. The corpora are then reunited 
by suture along the dorsal midline. The operation is completed by 
suture of the skin. Several cases successfully operated upon by 
Fig. 138.—The operation completed. The two outer edges of the original incision 
were easily brought together in the midline, making a penis and glans almost normal 
in appearance. (Young.) 
Cantwell’s technic have been reported. As pointed out by Young, 
a possible criticism of this technic lies in the long flaps with its only 
blood supply from a narrow pedicle. 
Young’s operation, although developed independently, may be 
considered a modification of Cantwell’s technic. It differs in the 
important respect that a rich blood supply to the new urethral tube  ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
222 
is preserved. This operation has been successfully employed in five 
cases (Young’s Clinic). Sloughing did not occur in any of these. 
The technic is graphically shown in Figs. 133, 134, 135, 136, 137, 138. 
A preliminary perineal urethrotomy is done and a retention cath- 
eter inserted in place. Drainage through this catheter is maintained 
for ten days. This operation seems to be the most satisfactory one 
so far suggested for the treatment of epispadias. 
Fig. 139.—a, dilated condition of prostatic orifice and atrophy of the trigone. Excision 
of anterior wall of dilated prostatic urethra also shown. (Young.) 
These cases of epispadias complicated by incontinence of urine 
offer the greatest difficulties to a successful surgical attack. In a 
recent paper (,Journal of Urology, January, 1922), Young describes 
his operative technic in the treatment of this condition and reports 
two cases in which the result was excellent. The operation is divided CONGENITAL ANOMALIES 
223 
into two stages: the first is aimed at the cure of the incontinence, 
and the second deals with the epispadias. 
First Stage.—The problem presented is the cure of the inconti- 
nence, which is due to a failure of coaptation or muscular development 
along the roof of the urethra, both at the vesical neck and in the 
region of the triangular ligament and external sphincter. Hence, 
Fig. 140.—The roof of membranous urethra excised through epispadiac cavity* 
(Young.) 
the plastic repair of the internal and sometimes external sphincter 
is necessary to accomplish this result. The bladder is opened supra- 
pubically; a good exposure of the internal urethral orifice is obtained. 
This will be found dilated and relaxed. The anterior wall of the 
prostatic urethra and adjacent bladder wall is excised (Fig. 139). If 
the membranous urethra shares in the dilatation, this is exposed by a 224 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
retractor in the epispadic opening. The roof of the membranous urethra 
is then grasped by a clamp and the mucous membrane and adjacent 
tissue excised up to the area already denuded through the supra- 
pubic opening (Fig. 140). In this manner, the entire roof of the 
prostatic and membranous urethra is excised. The prostatic urethra 
Fig. 141.—Showing the approximation of cut edges of prostate with “boomerang needle 
holder” and resultant closure of prostatic orifice. (Young.) 
is now closed by continuous chromic catgut suture. By a continua- 
tion of the same suture the adjacent wall of the bladder is closed 
(Fig. 141). The suture is next placed in the membranous urethra 
through the epispadic opening where this is necessary (Fig. 142). 
The first stage is completed by closure of the suprapubic wound in 
the usual way around a retention catheter in the upper angle of the 
wound. WOUNDS AND INJURIES OF THE PENIS 
225 
Second Stage—At the second operation the technic for the cure 
of epispadias, described above, is carried out. The interval between 
the first and second stage should be sufficiently long to allow complete 
healing from the first operation, and to clear up infection of the blad- 
der when present. In Young’s two cases this interval was two months 
and one year respectively. 
Fig. 142.—Approximation of roof of membranous urethra with consequent closure of 
the external sphincter. (Young.) 
WOUNDS AND INJURIES OF THE PENIS. 
Contusions.—Contusion of the penis is characterized by excessive 
edema and the extravasation of blood into the loose subcutaneous are- 
olar tissue, and is the result of the application of direct violence without 
resulting lesion of the skin. Such injuries are rare and occur when the 
penis is erect, the flaccid organ generally escaping. They result from any 
common accident, as a blow, a fall, the kick of a horse, the passage of a 
wagon wheel, etc. In a personal case the patient was struck by an ear 
of corn thrown by a companion in play. In the curious ease of Dufour, 
the young man while seated, with his penis erect, received a young 226 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
woman roughly on his lap. In another case (Yoillemier) the man 
caught his penis in closing a bureau drawer. Dupuytren records the 
case of a drunken man who had his penis caught under a falling sash 
while urinating out of the window. 
The amount of hemorrhage into the tissues depends upon the extent 
of the injury. This may be slight, amounting to little more than a 
subcutaneous ecchymosis, or it may be abundant and simulate gan- 
grene. In one case (Solignac) the dorsal vein was wounded on the 
edge of the corsets during coitus, producing an abundant hemorrhage, 
difficult to arrest. If the sheath of the cavernous bodies is injured, 
hemorrhage may be very abundant. If the urethra is wounded, there 
is always hemorrhage from the meatus, and the condition is a much 
more serious one. 
Treatment.—This consists in the application of hot, moist compresses 
and a supporting bandage to keep the penis elevated. Absorption 
takes place rapidly, the edema subsides and the discoloration disap- 
pears. When a hematoma forms and is developing rapidly, an incision 
should be made to evacuate the blood and ligate any bleeding-point or 
suture any laceration requiring it. If suppuration occurs, this must be 
treated by free drainage. Injury to the urethra is more serious and 
calls for appropriate treatment to prevent extravasation of urine and 
the formation of a stricture. (See Injuries of the Urethra.) 
Wounds.—The penis may be wounded accidentally in a great 
variety of ways; it may also be wounded maliciously, as in injuries 
inflicted through jealousy; or intentionally, as for example, the self- 
mutilation practised by certain sects and by insane patients. These 
wounds are usually classified as punctured, incised, lacerated, and those 
resulting from fire-arms. 
Punctured Wounds.—Punctured wounds are very rare, and are caused 
by bayonet, sword, or foil thrusts. In a case described by Demarquay 
the injury was due to a fall on a spike. Malgaigne saw a curious case 
in which an open knife carried in the pocket severed the dorsal artery 
of the penis. 
Incised Wounds.—Incised wounds are most often seen as the result of 
self-mutilation by insane patients or criminal mutilation inspired by 
jealousy. One recalls the custom of the barbarous Abyssinians, of 
emasculating their enemies when captured, and the practice among the 
adherents of the cast of Skoptzy of cutting off the penis. Accidental 
injuries of this kind are rare; the case of Nottingham is an exception. 
A young sailor received a deep wound of the glans during intercourse 
from a piece of a glass nozzle which had broken off in the vagina while 
taking a douche. 
Lacerated Wounds.—These result most often from the bite of an 
animal, for example a horse, dog, hog, etc. Less often they are pro- 
duced by machinery. Westbrook’s13 patient was caught in a pulley 
which tore the skin from the pubis, scrotum, and penis. In Powers’s 
case, a lad of six years, the injury occurred in climbing over a barbed- 
wire fence. The skin of the penis was stripped off, turned inside out, WOUNDS AND INJURIES OF THE PENIS 
227 
and hung at the preputial attachment. The nature of the wound 
depends upon the manner in which it was produced. It may be limited 
to the integument which is lacerated, torn, and turned inside out like 
the finger of a glove, as in Powers’s27 case, or the deeper structures may 
be implicated. According to Biondi,6 less force is necessary in the pro- 
duction of lacerated wounds when the penis is erect than when it is 
flaccid. 
Gunshot Wounds.—These are by no means rare. They are usually 
associated with injuries to other organs, the bullet passing through the 
penis or finding lodgment here after passing through neighboring 
structures. In the Civil War Otis recorded 30 cases. When the 
cavernous bodies are pierced, hemorrhage is abundant and a large 
hematoma may result. The scar remaining after healing will interfere 
with erection. 
Treatment.—In the treatment of wounds of the penis one is guided by 
the general surgical principles applicable to wounds of other parts. 
Cleanse the wound and apply an antiseptic dressing. Hemorrhage 
should be controlled by ligating the bleeding-point or by suture of the 
torn sheath of the corpora cavernosa. When suppuration supervenes, 
free incision and drainage are demanded. Healing of wounds of the penis 
is rapid, owing to the abundant blood supply. Even in apparently 
hopeless cases an attempt should always be made to save the organ, 
and amputation is resorted to only when every effort has resulted in 
failure. In one case we obtained a useful organ when this seemed to 
be hopelessly gangrenous. When the urethra is involved in the injury, 
this should receive immediate attention to prevent extravasation of the 
blood and urine and the subsequent development of a traumatic 
stricture. When the urethral wound does not communicate with the 
surface, a retention catheter, if this can be introduced, may be all that 
is necessary. Open wounds of the penile urethra require closure by 
suture, and the drainage of the urine through a perineal fistula will be 
found necessary in most cases for a successful healing of these wounds. 
Rupture of the Penis.—The terms rupture and fracture of the penis 
are used to designate the same lesion, namely, a tear in the fibrous 
sheath of the corpora cavernosa. Strictly speaking, fracture of the 
penis in man does not occur, since there is normally no bone in the 
penis. Among certain animals, as the bull and the sea lion, there is an 
os penis, but fracture of this bone is not observed. Calcification some- 
times occurs in cases of circumscribed cavernitis or Peyrone’s disease, 
and true bone tissue has rarely been found as a pathological product in 
the human penis, as in Gerster’s case.10 Rupture of the penis always 
occurs during erection and is usually due to sudden rough bending of the 
penis downward toward the thighs. It results from a false pass in 
coitus, masturbation, or a direct blow. In Mott’s case this accident 
was due to striking the erect penis against the bed-post. Merkens19 
describes an unusual case in which complete transverse subcutaneous 
rupture of the corpus spongiosum was produced by accidental closing 
of an open door through which the patient was urinating. It is 228 
ANATOMY, ANOMALIES AND INJURIES OF THE PENIS 
probable that the sudden increase in pressure during erection produced 
by a blow or sudden bending of the penis is sufficient to rupture the 
normal fibrous sheath of the erectile bodies, hence the accident plays 
the chief role. In some cases, however, the corpora cavernosa and their 
fascial coverings are weakened by areas of degeneration resulting from 
antecedent disease, and are therefore much more easily ruptured. At 
the time of the accident there is sudden pain at the point of rupture, 
a distinct crackling sound is heard, the penis becomes flaccid, and coitus 
is interrupted. In a short time the penis begins to swell from the 
associated edema and attains enormous proportions. The acute pain 
gives way to a sense of fulness; the penis is bent sharply at the site of 
the tear toward the uninjured side, hence the rupture is always on the 
convex side. Under appropriate treatment the swelling quickly sub- 
sides; the ecchymosis gradually disappears, but a scar often results 
which interferes with erection and may make coitus impossible. Sup- 
puration rarely occurs, and hemorrhage is not often alarming. 
Treatment.—Elevation of the penis and the application of cold com- 
presses suffices in most cases. Incision and suture are rarely required, 
but should not be deferred when indicated by a progressive hematoma. 
Dislocation of the Penis.—In this exceedingly rare accident the 
body of the flaccid penis is forced out of its outer sheath of integument 
and displaced under the skin of the scrotum, pubes, or thigh. The 
injury has been observed in children as well as adults. The mechanism 
of its production is not clear from the cases reported, but evidently the 
body of the penis is squeezed out of its envelope by a force applied to 
its outer extremity, the separation occurring at the preputial orifice or 
more commonly along the coronary sulcus. The deformity is not 
apparent at first, since the skin sheath, filled with a blood clot, may 
present a normal appearance. Very soon, however, difficulty in urina- 
tion attracts attention and examination shows a sheath filled with blood 
and containing no penis. The urethra is usually ruptured in the peri- 
neum and extravasation of urine with its attending symptoms may 
supervene. Careful search will always reveal the presence of the organ 
in its abnormal position. 
Treatment.—In at least two cases (Nelaton and Guth) the penis was 
easily replaced in its sheath, with happy results. This may be difficult 
or impossible, however, owing to the edema and infiltration, in which 
case incision will be necessary to liberate the penis and permit its repo- 
sition in its proper sheath. In the event of a rupture having occurred, 
immediate perineal section will be necessary. 
Strangulation of the Penis. This injury is not at all uncommon. 
It is seen in children as the result of a nurse tying a string or cord about 
the penis to prevent the escape of urine in cases of incontinence. In 
adults, strangulation is produced by rings, bands, the neck of a bottle, 
etc., used for the purpose of masturbation or other sexual perversions. 
The extent of the injury will depend upon the degree of constriction, 
the amount of swelling of the penis, and the length of time the foreign 
body is allowed to remain. As a result of the constriction, the penis BIBLIOGRAPHY 
229 
swells rapidly and the constricting band is buried at the bottom of a 
deep groove; it is soon hidden from view and may be difficult to find. 
The injury will vary from a superficial lesion of the skin in the simplest 
case to section of the urethra and even gangrenous destruction of the 
distal portion of the organ. With the onset of swelling, retention of 
urine is complete and is relieved only by removal of the foreign 
body. When this is delayed, the urethra ruptures behind the constric- 
tion and a fistula results. It is the pain associated with the swelling 
and especially the retention of the urine which compels the patient to 
seek relief, which he usually does in a few hours. Shame and fear of 
detection may delay the visit to a physician and the patient postpones 
seeking relief for a longer time; three weeks, six months, a year, or 
even twelve years in reported cases. The treatment consists in remov- 
ing the foreign body as soon as possible. This is easily done in the 
case of a thread or a thin ring. When the foreign body is a thick ring 
its removal may require considerable patience and ingenuity. In 
AylenV case it required two hours to file through a heavy iron ring. 
When the urethra has been cut into, the resulting fistula must be closed 
according to the principles laid down in the section on Injuries of the 
Urethra. 
BIBLIOGRAPHY. 
1. Aievoli: Arch. gen. de med., Paris, 1906, ii, 2380. 
2. Albrecht: Ztschr. f. Path., 1910, iv, 475. 
3. Aylen: St. Paul Med. Jour., 1905, vii, 46. 
4. Beck: New York Med. Jour., 1898, lxvii, 147. 
5. Churchman: Ann. of Surg., 1920, lxxi, 486. 
6. Biondi: Jahresbericht f. Urog., 1906, p. 251. 
7. Caddy: Lancet, 1894, ii, 634. 
8. Cole: Nashville Med. and Surg. Jour., 1894, lxxvi, 159. 
9. Donnet: Bull, et Mem. de la Soc. de Chir. de Paris, 1906, xxxii, 1002. 
10. Gerster: Ann. Surg., 1913, lvii, 896. 
11. Harris: Philadelphia Med. Jour., 1898, i, 71. 
12. Hofmokl: Arch. f. klin. Chir., 1897, liv, 220. 
13. Kaufmann: Deutsche Chirurgie, L, a, 60. 
14. Keppel: New York Med. Jour., 1898, lviii, 710. 
15. Kiittner: Beit, zur klin. Chir., 1895-6, xv, 364. 
16. Lebrun: Journal d’Urologie, 1912, ii, 380. 
17. Lionti: Deutsche med. Wchnschr., 1914, xl, 393. 
18. Matthew: Quoted by Harris. 
19. Merkens: Deutsche Ztschr. f. Chir., 1911, cxi, 313. 
20. Mocquot: Bull, et M6m. Soc. Anat. de Paris, 1904, lxxix, 344. 
21. Mummery: Rep. Soc. Study Dis. Child., London, 1906-7, vii, 99. 
22. Neimann: Quoted by Lebrun. 
23. Nove-Josserand: Lyon Med., 1897, lxxxv, 198. 
24. Ollsner: Quoted by Lebrun. 
25. Papadopoulos: Th&se de Lyon, 1908. 
26. Pousson: Ztschr. f. Urologie, 1914, viii, 440. 
27. Powers: Ann. Surg., 1909, xlix, 238. 
28. St. Hilaire: Quoted by Lebrun. 
29. Smith, Alan P.: Transactions Med. and Chir. Faculty of Maryland, April, 1878. 
30. Trenkler: Wien. med. Wchnschr., 1914, lxiv, 1079. 
31. Trillat: Arch. prov. de Chir., 1902, p. 311 
32. Yolpe: II Policlinico, fasc., 1903, i, 46. 
33. Westbrook: Long Island Med. Jour., 1911, v, 405. 
34. Young: Jour. Urol., 1918, ii, 237. 
35. Young: Jour. Urol., 1922, vii, 1. CHAPTER VI. 
DISEASES OF THE PENIS. 
By GEORGE W. WARREN, M.D. 
DISEASE OF THE FRENUM. 
A short frenum, which may be classed as congenital, occurs in cases 
where there is no other malformation. This may interfere with com- 
plete emptying of the urethra. It may cause an incurving of the 
penis when the organ is erect. I have seen cases where the subject 
was sterile, due to this marked incurving, and became fertile by simply 
cutting through the frenum. During coitus these short frenums are 
torn and the accident frequently results in a marked hemorrhage, the 
frenal artery being torn. Sexual neurasthenia in some cases is caused 
by these short frenums. Erections are very painful. 
Treatment.—Cutting through the frenum, and sewing together the 
cut edges of the wound, which causes a quicker union and prevents 
hemorrhage, as the frenal artery is caught by the stitch. 
PHIMOSIS. 
Congenital Phimosis.—The opening or ring of the foreskin in this 
condition is relatively to the glans so small that retraction of the fore- 
skin over the glans is impossible. There are necessarily several degrees 
of this condition, from those cases where the meatus of the penis is 
seen with difficulty or not at all to those where the foreskin can be 
retracted, but the blood supply of the glans by this act is cut off or 
impeded. 
In the newborn there is a physiological phimosis which continues 
for a longer or shorter time. The inner leaf of the foreskin, that 
portion in contact with the glans, is adherent to it by an epithelial 
deposit. This condition can be relieved by separation with an instru- 
ment or retraction of the foreskin. If this condition is allowed to 
remain, inflammatory processes supervene and result in adhesions 
between the glans and foreskin. As the patient grows older this phy- 
siological phimosis is relieved by the orifice of the foreskin becoming 
larger at about the second year, and it generally takes the adult form 
between the years of nine and thirteen. 
The normal foreskin can be retracted over the glans easily and pain- 
lessly when the penis is in erection, and when there is no retardation 
of blood circulation while it is thus retracted. 
Congenital phimosis may exist with a prepuce of normal length or 
230 PHIMOSIS 
231 
with one very long or short. In cases of long prepuce the glans is 
covered with an empty sac which lies in folds. Upon urination this 
bag fills with urine and may balloon out to the size of an egg, and the 
urinary stream issuing has little force. 
The opening of the foreskin may be so small that a fine probe cannot 
enter it. In these cases the frequent ballooning of the foreskin causes 
it to become tremendously dilated. This great dilatation causes a dis- 
proportion between the outer and inner leaf of the foreskin. The ring 
of the foreskin, which is the narrowest portion of the same, seems to be 
retracted by the overhanging of the outer leaf. 
In cases of short foreskin (atrophic phimosis) the prepuce is drawn 
tightly over the glans. Here, again, the opening of the prepuce may be 
very small and not in line with the meatus. This causes difficulty in 
urination and may be a serious condition. 
In both of these conditions, long and short foreskin, there may be an 
accumulation of epithelial smegma and urinary sediment, preputial 
stones, and balanoposthitis may occur. These are not, as one would 
expect, constant sequelae of this condition. In both of these lesions, 
when the condition has existed for some little time, there is sometimes 
a trabeculation of the bladder and at times a hydronephrosis with 
dilated ureters. 
The urinary act is always difficult, and, as before stated, in those 
cases of short foreskin where its opening does not correspond to the 
meatus, the child strains and cries with pain upon urination. The 
long foreskin may hold urine and dribble after the urinary act. At 
times the urine retained in the foreskin becomes infected and 
decomposes, and the resulting inflammation may cause urinary 
retention. 
In adults phimosis with short foreskin results in a poorly devel- 
oped glans penis, and the sexual act is interfered with. Many of these 
cases are sexual neurasthenics. 
Retention of urine may sometimes occur in these cases of phimosis, 
when upon this condition balanoposthitis is superimposed. All the 
complications of a balanoposthitis are to be found in these cases of 
phimosis, such as erosion, ulceration and perforation of glans and 
foreskin, stone formation under foreskin, and ammoniacal urine. 
The dangerous sequela of impediment of urination, in cases of 
phimosis, is often underestimated. In cases of marked phimosis 
of children it is not uncommon to find hernia, prolapsed anus, etc., 
due to the marked abdominal pressure necessary to empty the 
bladder. 
Phimosis in Adults: The impediment of urination exists, though not 
so apparent as in children. Dwarfing of the glans penis; sexual neuras- 
thenia may be conspicuous in these cases; balanoposthitis with its 
complications is common; and most important is the danger of cancer 
formation. Three-fourths of all cases of cancer of the penis reported 
occur in cases of phimosis. 
Preputial stones may be a complication of phimosis. They generally 232 
DISEASES OF THE PENIS 
occur in children, but rarely in adults. Two types of stone may exist 
in phimosis: true preputial stones which are formed under the prepuce, 
and stones which are formed in the kidney or bladder, and in their 
escape from the body are caught in the preputial sac by its narrow 
ring. 
True preputial stones are formed from the smegma, epithelial detritus, 
bacteria, and the salts of decomposed urine. They are light in weight, 
soft, brownish bodies without any characteristic shape, often being so 
soft that they mould themselves over the glans, even to the extent of 
covering it. When the number of stones is large they may be faceted. 
Generally they are small in size, but there are exceptions, one being 
reported the size of an egg. They are multiple, as a rule; as many as 
a hundred have been reported. Under the microscope they are seen to 
consist of epithelium, fat molecules, cholesterin crystals, urinary salts, 
and bacteria. 
The hard, heavy stones sometimes found in this location are formed 
in the kidney or bladder. They often gain in size by the accumula- 
tion of smegma and epithelial deposits from the foreskin. Under 
this layer of smegma and epithelium is found as a nucleus a urinary 
stone. This nucleus will show the elements of a true bladder or 
kidney stone. 
These stones, as a rule, cause a chronic balanoposthitis, often accom- 
panied by a thick, purulent secretion. The penis may be swollen and 
edematous, and the prepuce infiltrated. The patient may suffer from 
dribbling of urine or difficulty in urination, and may have frequent 
erections and pollutions. Often they suffer from defective erections, 
due to pain. Usually these patients are not aware of the presence of 
a stone, although they often feel a foreign body under the foreskin which 
at times impedes urination by wedging itself into the ring of the fore- 
skin. The stone tends to ulcerate through the foreskin in long-standing 
cases, resulting in fistula formation. There is danger in these cases of 
bladder and kidney infection. 
Treatment.—Circumcision. 
PARAPHIMOSIS. 
Paraphimosis embraces all conditions in which the glans penis is 
compressed or strangulated by the prepuce. This takes place when 
the glans penis passes forward through a comparatively small pre- 
putial ring and the ring in sliding back over the glans drops into, and 
is held by, the sulcus back of the corona. 
Paraphimosis can exist only in cases in which there is a relatively 
moderate degree of phimosis, and the length of the foreskin must be 
sufficient to allow it to slip back behind the corona. 
It is impossible for paraphimosis to exist in cases in which the fore- 
skin cannot be drawn back over the glans, as in cases of high-grade 
phimosis, or in cases of very short frenum, or where adhesions exist 
between the glans and foreskin. SUBCUTANEOUS INJURIES OF PENIS 
233 
This lesion occurs, as a rule, when the penis is erect. It can take 
place with the penis flaccid, but is then usually accomplished by forcibly 
pulling a tight foreskin back over the glans. 
As the inner leaf is closely adherent to the shaft of the penis for some 
little distance back of the corona, one will readily see that the preputial 
ring cannot be in direct apposition to the shaft of the penis, but is 
separated from it by this layer of the inner leaf. Only in cases of 
atrophic phimosis, where the inner leaf hugs the glans closely, does the 
entire foreskin come back so that the preputial ring lies in direct 
apposition to the shaft of the penis. 
In cases of milder paraphimosis there is only a swelling of the glans 
penis, and behind this is the folded and swollen outer leaf of the prepuce. 
The preputial ring lying in the sulcus is hidden under this swelling of the 
outer leaf. The swelling of the glans is, as a rule, far more marked, and 
it becomes edematous and discolored. Behind, and at times overlying 
it, is the swollen outer leaf. In the sulcus, and more than filling it, 
is a second swelling, consisting of the swollen and edematous inner 
leaf. Only by lifting aside this second swelling can the preputial ring 
be seen. 
A long or short frenum may modify the character of a paraphimosis. 
A long frenum may cause the constriction of the preputial ring to 
occur behind the sulcus. 
The sequelse of this condition are rapid swelling, discoloration, and 
bull* of the tissue, which may go on to necrosis. This takes place just 
in the region of greatest pressure. Gangrene of the ring is rare. The 
gangrenous process generally confines itself to the outer and inner leaf, 
sparing the cavernous tissue. 
Paraphimosis may relieve itself somewhat by gangrenous process of 
the preputial ring. There are cases reported in which by numerous 
inflammatory processes and ulcerations the preputial ring has been 
enlarged, thereby relieving the tendency to constriction. 
The systemic symptoms are mild, patients often not presenting them- 
selves for treatment until the condition has existed for several days. 
Treatment.—In most cases the swollen glans can be compressed 
between the fingers until it can be pushed back through the ring. 
When this cannot be done the constriction should be relieved by 
incision of the preputial ring. Circumcision may be performed after 
the swelling has subsided. 
SUBCUTANEOUS INJURIES OF PENIS. 
Pain may be very intense even in slight injuries, and may cause 
the patient to faint. The bleeding following these contusions is very 
noticeable, even in superficial contusions, and the resulting ecchymosis 
spreads over the pubic region, scrotum and perineum, as well as the 
shaft of the penis. 
The discolorations of skin due to this deep extravasation of the blood 
appear in a cherry or blue red, while the subcutaneous extravasation 234 
DISEASES OF THE PENIS 
appears as a dark blue. This extravasation, as a rule, spreads from the 
deep to the superficial coverings of the organ, and extends over a 
large area. The point of most marked extravasation is the point of 
greatest induration. Subcutaneous tearing of the penis involving the 
corpora cavernosa takes place only when the penis is erect or when 
the corpora cavernosa are involved by inflammation, causing a tight- 
ening of the connective tissue. Formerly this was called fracture of 
the penis. This is not a true fracture, as sometimes happens in lower 
animals, in which an os penis exists; but in man a growth of bone 
occurs only as a rare pathological condition. So-called fracture is a 
tear of the cavernous tissue. This tear, as a rule, extends through 
the albuginea (the fibrous covering of the cavernous body), which, 
when the penis is flaccid, is over 2 mm. in thickness and very tough, 
and when the penis is erect, is spread out to a thinness of 0.25 mm. 
(Ilenle). The force causing the injury, as a rule, is delivered in line of 
the long axis, rarely in the transverse. The injury is rare during 
coitus, but may take place if the organ strikes outside the vaginal 
orifice. It is more often due to a blow by a falling body or the pushing 
of the penis against some foreign body, or by forcibly bending back 
the organ. So-called fracture may result when the patient tries forcibly 
to correct the deformity resulting from chordee, in which case it is 
almost always limited to the corpus spongiosum. 
Symptoms.—The symptoms of fracture are similar to those resulting 
from a grave injury to the urethra. Inability to void often exists when 
the urethra is not injured. This is due to the pressure on the urethra 
from blood extravasation. The absorption of the blood is rapid. 
Diagnosis.—In this instance diagnosis is apparent. The deformity 
of the penis, as a rule, is corrected by the patient, but even in these 
cases where the deformity has been corrected one may feel the break in 
the albuginea and corpora cavernosa. At this point there is a marked 
induration and the blood clots creak under the touch. The pain is 
intense. 
Prognsois.—The prognosis depends upon the presence or absence of 
complications. In some cases the blood is quickly absorbed from 
the parts and the blood spaces of the cavernous body are freed. In 
these cases the function of the penis remains normal. In other cases 
this does not take place and a hard infiltration remains in the cavernous 
body. This causes either a crooking of the penis or else that part of 
the organ in front of the fracture remains flaccid when the organ is 
erect. 
If, as a complication, we have an infection, gangrene and partial 
loss of the organ may result. 
Treatment.—In cases in which the urethra is not involved, a simple 
dressing with a splint is sufficient, care being taken to have a free pas- 
sage for the urine. Where the extravasation is absorbed slowly, or the 
blood clot becomes infected, drainage becomes necessary. OPEN WOUNDS OF THE PENIS 
235 
OPEN WOUNDS OF THE PENIS. 
Tearing and contusions are more often the cause of open wounds of 
the penis than biting, shot, cut, or stab wounds. 
The most common tearing wound is of the frenum; also the tear of 
the prepuce in cases of phimosis is common. In rare cases the whole 
organ is torn off, as where the parts have been caught in machinery, 
etc. It is rare to have the skin torn from the organ, but it does occur. 
In these cases the skin is stripped from the root of the penis and 
rolled up forward. 
Luxatio penis is a condition which is frequently described, though 
not common, but the resulting condition is of serious consequence. 
The skin of the penis is torn through at the inner leaf of the foreskin at 
the sulcus coronalis and the denuded penis is liable to slip back from its 
skin envelope and is lost under the skin of the scrotum or pubis. These 
cases, as a rule, are due to violence, but may follow ritual circumcision. 
The condition resembles the so-called congenital anomaly (phimosis 
scrotalis) in which the penis lies under the skin of symphysis pubis 
or scrotum. The patient directly after the accident presents a short 
skin sac, often filled with blood clot, which can be easily emptied by 
pressure. It is sometimes difficult to find the shaft of the penis. The 
urine is emptied either through the skin sac or from some neighboring 
skin wound. Urination is necessarily interfered with and as it takes 
the path of least resistance the tissues may become infiltrated. After 
a short time the shaft of the penis becomes fixed in its abnormal 
position by scar tissue. 
Wounds in which a portion of the skin has been stripped off, and even 
when there is loss of tissue, heal readily and rarely lead to death. 
Nevertheless, the resulting scars often cause contractions and the dis- 
torted penis may be of little value functionally. 
Treatment.—Fresh wounds of the frenum should be sutured immedi- 
ately with fine thread. The stitch should include the frenal artery. 
In older cases which have been infected it is better to clean the part and 
treat by wet dressings before plastic work is begun, as the swelling which 
is always present will by these means be reduced and thus the ultimate 
result is better. 
The so-called luxatio penis should be reduced at once, the denuded 
penis placed in the skin sac and held by loose stitching. Urinary fis- 
tulse should be excised freely and drained, and the whole covered 
by wet dressing. 
As a rule these cases require several operations before a satisfactory 
result is obtained. In those of long standing in which the shaft has 
been caught and held by scar tissue in its abnormal position one finds 
great difficulty in locating it. The guide, naturally, is the existing 
urinary sinus, as it must lead to the meatus of the penis. Thus one 
opens these sinuses freely and dissects back to the hidden shaft. After 
the shaft is quite freed it is placed in its skin envelope as in fresh cases. 236 
DISEASES OF THE PENIS 
Healing in these instances is usually good, except when infected or 
neglected. 
In those cases in which the skin has been torn it should be united by 
stitches at once. Drainage should be instituted in those where there 
has been marked maceration or when a great amount of dirt has been 
driven into the wound. When there is loss of tissue, plastic work 
should be instituted at once, as the resulting scars of neglected cases 
cause marked distortion of the penis, which can be corrected only with 
the greatest difficulty. 
Contusions of the penis are similar to subcutaneous contusions 
already described, but are of greater intensity, and often involve the 
scrotum and perineum. They are accompanied by shock. The prog- 
nosis of contusions depends upon how early the case is seen and upon 
the absence or presence of complications, such as infiltrations and scar 
formations. When there is injury to the urethra a catheter should 
be passed into the bladder and retained there. There should be an 
immediate attempt to repair all wounds. 
Wounds of the penis resulting from bites are usually severe and are 
due to attacks by animals. Insect bites are serious only as the 
resulting swelling and infection may lead to gangrene of the part. 
BURNS AND FREEZING OF THE PENIS. 
Burns are treated as elsewhere on the body. 
Freezing of the penis is very rare. The symptoms are the same as 
for other parts of the body. The scratching of the patient, due to the 
intense itching, may cause an infection and consequent chronic inflam- 
mation. There is, as a rule, a low-grade urethritis and balanoposthitis 
in these cases. The part is afterward sensitive to cold and heat, as is 
seen in cases of frozen ears. 
STRANGULATION OF PENIS BY FOREIGN BODIES. 
This is not a very rare condition, and is due to the application of 
ligatures or other encircling bodies. Hair is the most common, and 
with children is sometimes applied by the mother or servant with the 
belief that it will stop bed-wetting. When ligatures are used by older 
people, which is rather common, they are used with the idea of 
increasing erection or to prevent nocturnal pollutions. 
Many tubular articles are used by the weak-minded and mastur- 
bators. There is a large variety of these instruments. They are 
applied to the penis before or during erection, and are at times re- 
moved with the greatest difficulty, as the constriction of the enveloping 
instruments allows ingress of arterial blood and obstruction to outflow 
of venous blood. 
In my experience the ligature, especially the ligature of hair, is by far 
the most commonly met with. This ligature is generally applied just 
at the corona and soon causes a marked constriction. In a few days ACUTE INFLAMMATORY PROCESSES 
237 
it is rather a difficult matter to determine the cause of the strangulation, 
as the peripheral end of the penis becomes swollen and soon the liga- 
ture cuts through the skin and underlying connective tissue. The 
prepuce is inflamed by the resulting infections and takes on a markedly 
swollen, angry appearance. The edema makes it hard to find a hair 
ligature, even in an early case; but later, when it has cut into the tissues 
and is covered with granulations, it is most difficult. The constriction 
at this time, if a non-elastic ligature is used, is lessened, and a child 
may carry such a ligature for weeks. If not removed it is at times 
covered by scar tissue from the healing of the wound of entrance. It 
may then cause no further trouble and be carried thus in its connec- 
tive-tissue retainer for years. If the ligature cuts into the urethra 
there is a resulting fistula. 
Solid rings applied to the flaccid penis are firmly caught by the result- 
ing erection. The penis becomes markedly swollen, due to the obstruc- 
tion to the return flow of the blood. Gangrene of the tissue is the 
result. Systemic symptoms in these subjects are not marked. 
ACUTE INFLAMMATORY PROCESSES. 
Edema of the foreskin accompanies all acute inflammatory affections 
and local mechanical interference with circulation. This mechanical 
interference may be due to a tight-fitting dressing, or ligature, or to con- 
striction due to contraction of scar tissue. In cases of general edema 
of the organ it is more marked at the prepuce and most marked at the 
frenum. The under surface of the penis shows the least edema. Edema 
of the glans is first seen on its under surface in the line of the attach- 
ment of the frenum to the orifice of the urethra. When this edema 
continues the glans, being held firmly by the attachment to the frenum, 
can swell only on its upper surface, and this causes the demarcation of 
the glans and frenum to be obliterated. The edema is, as a rule, more 
marked on one side and then the organ is bent in the opposite direc- 
tion. In cases of marked edema, urination at times is interfered with. 
After dorsal or lateral incision of foreskin, there often exists a chronic 
edema of the flaps. 
Acute inflammation of the glans (balanitis) and foreskin (posthitis) 
are rarely separate and will be treated together as balanoposthitis. 
The most common form of this is due to gonorrheal infection.1 Other 
infections are divided by some writers into catarrhal, croupous, diph- 
theritic, and diabetic. The diabetic is a complication of diabetes. 
All cases of balanoposthitis are due to filth, an irritating foreign sub- 
stance retained under the foreskin causing inflammation. Men without 
a foreskin never have balanoposthitis, as the mucous membrane by 
exposure is converted into epidermis. 
1 Although gonorrhea is the exciting cause in this condition there are no gonococci in 
the secretion from the foreskin, the infection of the foreskin being due to another 
organism. 238 
DISEASES OF THE PENIS 
Etiology.—The cause is any form of irritation which may lead to 
inflammation of the mucosa of the glans and foreskin. The most com- 
mon is the retention and decomposition of the secretion of Tyson’s 
sebaceous glands; the accumulation of gonorrheal pus; the products of 
hard or soft chancroidal growth; and eczema or herpes of the glans and 
foreskin. To all these causes must be added uncleanliness, as one 
never finds balanoposthitis when the parts are kept clean. 
Symptoms.—The first symptoms are burning and itching. The fore- 
skin soon becomes swollen, often to such an extent that it cannot 
be drawn back over the glans. There is an increased secretion, due 
to irritation. This may be of a purulent nature, and may be so pro- 
fuse that it drops from the foreskin. The meatus, if it can be seen, 
appears swollen, as well as the lining of the foreskin and the covering 
of the glans penis. Lymphangitis is generally present. The dorsal 
lymphatics are outlined in red lines and are swollen and painful 
to the touch. 
As this inflammatory process continues there is erosion of the epithe- 
lium covering the parts, which may lead to ulceration. In severe cases 
the foreskin, as a whole, is edematous and swollen, and if retracted 
over the glans penis and not reduced, may lead to gangrene. 
Recurrence of balanoposthitis leads to infiltration and increase of 
connective tissue in the foreskin, which may be so great that it is 
impossible to retract it. Other complications are the formation of 
adhesions between the glans and foreskin, as well as preputial stones. 
Balanoposthitis is more common in children, especially at time of 
puberty, and, as above stated, is due to lack of cleanliness. In older 
people, when phimosis is present, a large number will be found to have 
a keratosis, or so-called venereal warts. The danger of malignant 
changes in them is very great. (See Carcinomata.) 
Treatment.—Remove the irritating agent and keep the parts clean. 
Circumcision is advisable in cases of phimosis after the inflammation 
has subsided. If erosions are present after circumcision, one had 
better use a salve with boric acid or one containing 0.5 per cent, 
silver nitrate. 
As stated above, balanoposthitis is one of the complications of dia- 
betes, and is often due to the sugar-charged urine remaining under the 
foreskin. This is a favorable medium for bacterial growth, and when 
this takes place the itching, edema, swelling, and increased secretion 
of Tyson’s glands are present, as in uncomplicated balanoposthitis. 
These subjects having a reduced resistance against infection, the cover- 
ing of the parts soon ulcerates and infiltration of the organ follows. 
The phimosis and scar retraction are often marked. The diagnosis is at 
once suggested by finding sugar in the urine. 
Herpes Progenitalis.—Herpes progenitalis manifests itself in an erup- 
tion of blisters containing a water-like fluid. These blisters may be 
single or in groups. They occur usually on the retroglandular surface 
behind the sulcus, but may appear on the shaft of the penis. They 
have been reported as involving the urethra in their extension. These PHLEGMONS OF THE PENIS 
239 
water-like blisters soon become infected, and then their contents 
become white and cloudy. The breaking of the blister causes ulcer 
formation. The inflammation soon subsides and the ulceration heals. 
Often there is a painful inguinal adenitis as a complication. 
Certain of these cases have neuralgic symptoms, as in herpes zoster. 
In these instances a day or two before the eruption there is marked 
pain and soreness to the touch of the skin of the penis and scrotum, 
the pain sometimes radiating to the glans penis. This symptom dis- 
appears as the vesicles appear. 
Treatment.—Cleanliness, and a saturated solution of argyrol in 
ichthyol to paint over the eruption, and bandage with dry dressing. 
Cause is unknown, although the vesicles seem to follow the nerve 
fibers. Cases show a marked tendency to recurrence. 
Erysipelas.—Erysipelas of the penis is rarely primary. If primary, 
it is due to infection with a streptococcus through some abrasion 
in the penis. 
SKIN AFFECTIONS OF THE PENIS. 
Skin affections in general may involve the penis and ought to be 
considered in connection with the original disease. The most common 
of the skin lesions occurring on the penis are psoriasis, scabies, herpes, 
a leukoplakia preputialis, described by Schuchardt, and venereal 
ulcers. 
PHLEGMONS OF THE PENIS. 
Circumscribed inflammations of the penis are noted in connection 
with eczema, erysipelas, variola, typhus, and infectious diseases of 
severe type. 
Although the above are to be mentioned, the majority of phlegmons 
are secondary to traumatism or to extensions from inflammatory 
processes in the urethra, also after urinary infiltrations, as well as after 
ulcerations, insect bites, erysipelas, etc. 
These phlegmons may be accompanied by gangrene of the skin. In 
such cases the dorsal lymph channels are prominent and painful. 
There is a painful adenitis in the groin. Of the causes of this gangrene 
little is knowm. 
Symptoms.—The condition starts in a typical manner. There is at 
first slight local pain and redness. In more severe cases vomiting 
and fever are early symptoms. The penis, and often the scrotum, are 
swollen. At the end of about twenty hours there appear numerous 
gangrenous spots on the skin. These quickly coalesce and total necrosis 
of the skin of the penis and scrotum results. This is not a deep-seated 
process, but at times results in abscesses of the parts. Often the lymph 
glands in the neighborhood suppurate and abscesses extend to the 
abdominal wall. In severe cases the gangrene becomes demarcated 
in a few days and the symptoms improve. Recovery is the rule, 
although rarely death occurs due to general asepsis. 
Treatment.—Incision for drainage and wet dressings. 240 
DISEASES OF THE PENIS 
Acute Cavernositis.—-Acute cavernositis, an infection localized in the 
cavernous bodies, must be differentiated from a superficial phlegmon. 
Etiology.—Acute cavernositis is due to injuries, extravasation of urine 
into the cavernous bodies in cases of stricture and infected thrombosis 
which occurs in certain blood diseases, as leukemia. 
Symptoms.—At the onset an irregular, hard, painful mass is felt 
which can be localized in the cavernous body. There is painful and, 
at times, difficult, urination, due to the extension of the process to the 
urethra. Suppuration soon occurs and then a fluctuating swelling 
takes the place of the hard mass formerly felt. In neglected cases the 
abscess may break into the urethra or through the skin of the penis. 
As stated above, traumatism and the complications of stricture are the 
causes of the infection. (This type of cavernositis is often spoken of 
as periurethral abscess.) But it may be hematogenous in origin, as it 
occurs in cases of septicemia. 
Diffuse Cavernositis.—The rarer and much severer type of caver- 
nositis, the so-called diffuse idiopathic cavernositis, is, in my belief, 
always hematogenous in origin and is due to pyemic metastasis. 
These patients rarely recover. 
Diffuse cavernositis begins with marked systemic symptoms: chills, 
high fever and marked swelling of the prepuce. Priapism is a char- 
acteristic symptom and is present by the third day of infection. The 
erections may be complete or partial, may last for long periods 
and cause difficulty of urination. Priapism may be due to physio- 
logical irritation of cavernous bodies or to a thrombosis of the same. 
The latter is painless and is generally followed by gangrene of the penis. 
These infections at times go on to abscess formation and they may rup- 
ture into the urethra. Untreated cases of a few days’ standing show 
symptoms of pyemia. Death is not uncommon. At autopsy the 
lungs, liver and kidneys contain abscesses. The penis may remain 
erect after death, held in this position by the thrombosis of the caver- 
nous bodies. Cases which recover may have nothing of the penis left 
but a mass of scar tissue. 
Cases have been reported of diffuse gangrene of the penis which is due 
to thrombosis of its bloodvessels. This thrombosis may extend from 
the iliac, femoral, and periprostatic veins. 
Chronic Cavernositis.—Under this heading may be included: 
Plastic induration of the cavernous body, sclerosis, nodus or nodes, 
ganglions, plastic concretions, indurated plaques of the corpora 
cavernosa and fibrous tumor of the penis. 
This pathological condition has been reported at various times as 
true bony or cartilaginous formation of the penis, which is a mis- 
nomer, as the latter disease (true bony or cartilaginous formation of 
the penis) is a distinct entity. 
Chronic cavernositis was first described, in 1743, by La Peyronie. 
Since that time, Chevalier, Maurise, Iticord, Nelaton, Tupper, 
Delatorde, Zistin, Le Fur, Elsesberg, Hanane, Zur Verth and Scheele 
have written on the subject. LYMPHATICS AND BLOODVESSELS 
241 
Etiology.-—Etiology is obscure, and little is really known about it, 
the usual etiological factors reported are: 
1. Induration of inflammatory origin: gonorrhea, etc. 
2. Induration of syphilitic origin. 
3. Induration of constitutional origin: (a) gout, (b) arthritis, 
(c) diabetes, (d) tuberculosis. 
4. Induration without known cause, the lesion appearing without 
any ascribable cause. 
Symptoms.—The appearance of nodes or plaques, curvature of the 
shaft of the penis, causing painful or impossible coitus, were described 
in the early papers of La Peyronie, and nothing new has been added 
since that time. 
The development of the disease is slow and insidious, unaccom- 
panied by complications. Patients pay no attention to the condition 
until the plaques are fully developed, or until there is difficulty in 
coitus. 
This lesion must be distinguished from enchondroma, fibroma, 
partial ossification of the penis, phlebitis of the dorsal vein and gumma. 
Its occurrence is not rare, although the number of reported cases is 
small. The lesion occurs, as a rule, in middle life, but is found some- 
times in young men. 
Treatment.—Medical treatment has been unsuccessful. Surgical 
treatment consists of the removal of the plaque. This should not 
be undertaken until one is sure that the extension of the process is 
complete. 
The neurasthenic effects of this operation are, as a rule, bad. 
GANGRENE OF THE PENIS. 
Ordinary gangrene of the penis follows traumatism and inflammatory 
processes, as before stated. It also is caused here, as in other parts of 
the body, by loss of blood supply, burns, etc. Infiltration of urine with 
its resulting infection, deep-seated infections in the perineum are also 
peculiar causes of gangrene of the penis. 
There is an acute progressive gangrene of the penis and scrotum 
described by Fournier, Kellemont and others, which occurs, apparently, 
without any specific predisposing cause and has no analogue in other 
organs. It may occur in persons suffering with diabetes, typhus and 
after cantharides poisoning. At times it occurs without any disease 
being present. It may follow bandaging of the penis after the bandage 
has been wet with urine, also after adhesive bands have been used on 
the penis to hold a retention catheter in the urethra. 
Treatment.—Treatment is the same as for gangrene from other 
causes—incision and drainage. 
LYMPHATICS AND BLOODVESSELS. 
Diseases of the bloodvessels and lymphatics are rare. Traumatic 
aneurysm of the dorsal artery, being the most common of these con- 
ditions. 242 
DISEASES OF THE PENIS 
CARTILAGINOUS AND BONY FORMATION. 
True bone formation is found in the penis of some of the lower 
animals. In man, thickened fibrous tissue takes the place of this bone. 
By careful examination this fibrous tissue can be felt normally. 
Pathologically, in old people, the tunica albuginea may become 
infiltrated with a calcareous deposit, which resembles bone. The 
symptoms accompanying the condition are pain and distortion of the 
penis when erect. This distortion is similar to a chordee, with the 
concavity in the direction of the infiltration. Other causes than old 
age, held by some writers, are injury to the cavernous bodies involving 
the albuginea, chronic cavernositis, syphilitic lesions of cavernous 
body, and gout. There is doubt in the minds of many whether 
these latter so-called etiological factors can be proven. Undoubtedly, 
senility is the most common cause, as the pathological process in 
this location resembles senile processes in other parts of the body. 
TUBERCULOSIS OF THE PENIS. 
Primary tuberculosis of the penis in adults is very rare. The glans 
is more often involved than the prepuce. It is a chronic process from 
the start and manifests itself by the formation of granulation tissue, 
which gradually infiltrates the surrounding substance and may invade 
the whole thickness of the penis. This infiltrate undergoes caseation. 
The infection may be acquired by coitus with a female having 
tubercular genitals or by direct infection with tubercular sputum. 
As the infection progresses, isolated masses can be felt in the caver- 
nous bodies and urethra. They are often the size of a pea and as 
they enlarge they extend toward the surface and are felt directly 
under the skin. On section they are seen to be masses of caseous 
tubercles. Their growth is slow, but eventually the skin of the 
penis is involved with a resulting ulceration. In this state one may 
mistake the infection for a hard chancre. Although this infection is 
undoubtedly autogenous in the great majority of cases, the primary 
lesion may not be in the genito-urinary tract. The penis may be the 
seat of a secondary infection in cases where there is a tubercular in- 
fection of the kidney and bladder. These are rare, but when they 
occur, the meatus at first presents a swollen, angry appearance, and 
small miliary tubercles are seen over the surface. The adjacent tissue 
is slightly infiltrated. There is a seropurulent secretion. The whole 
picture is very much the same as that presented by the mouth of a 
ureter which has been infected by a tubercular kidney. 
Tuberculosis of the penis in young children is far more common and 
is often due to direct infection at the time of circumcision by the 
rabbi. 
The old, orthodox circumcision was performed by tearing the fore- 
skin free from the penis by the finger-nail, and the resulting hemor- 
rhage was stopped by sucking the penis with the mouth. This was 
at times performed by a rabbi with infected sputum. The incu- ELEPHANTIASIS 
243 
bation period in these cases is about two weeks. It manifests itself as 
a tubercle, being the typical yellowish or gray-white speck on a surface 
of granulation tissue. These infections progress rapidly; the inguinal 
glands are involved early. The patients always die either by a general 
tubercular infection or by marasmus. A few cases are reported where 
the wounds healed, but after two or three years death resulted from 
tuberculosis of some internal organ. 
Treatment.—Although the tubercular organism is often not found in 
the tissue, one can, as a rule, demonstrate the organism if a deep section 
of the tissue is carefully stained. Excision or amputation of the dis- 
eased tissue is the safest procedure. 
GUMMA OF THE PENIS. 
Gumma of the penis may be located in any of its anatomical divisions. 
When located in the connective tissue just under the skin, it may have 
the appearance of an enlarged lymph gland, but as there are no lymph 
glands in the penis, one should be on one’s guard. These masses are 
prone to break down, and may result in urinary fistula and stricture. 
No pain accompanies this lesion. 
ACTINOMYCOSIS. 
This is a very rare pathological lesion. In the cases reported, pain 
is an early symptom, and there is a redness of the meatus which is 
soon followed by a serosanguineous secretion. In the accompanying 
induration there are small, purulent, knotty masses. These soon 
ulcerate through the skin so that the glans penis is covered with many 
small holes. 
Amputation is the only treatment. 
ELEPHANTIASIS. 
True elephantiasis of the penis is due to infection with filaria. Nat- 
urally these cases occur in countries in which the disease is endemic. 
Here the only cases which have come to my notice are among emigrants. 
A great many were from St. Kits, West Indies. 
The swelling may begin in the foreskin of the penis and then extends 
to the scrotum. The swelling of these parts, like other swellings inci- 
dental to the disease, is due to back pressure of the lymph on the parts, 
due to plugging of its channel which has been occluded by the mother 
worm. The chronic state of this lesion leads to a thickening of the 
skin and increase of connective tissue in the parts involved. This is 
such a rare condition in this country that the cause of the lesions may 
be overlooked. But, as a rule, by careful examination of the blood 
both by day and night, the young filaria will be found. 
Several times each year cases present themselves which have all the 
ear-marks of true elephantiasis, even to the skin thickening and increase 
of connective tissue. The prepuce is often markedly swollen, and that 244 
DISEASES OF THE PENIS 
part at the frenum stands out with great prominence. The most 
common cause of these cases is the complete destruction of the inguinal 
glands, generally by operative removal, or rarely by inflammation. In 
this way there is a lymph stasis. 
Strictures, traumatism, syphilis, lymphangitis, as well as filth under 
the foreskin, all have been reported as causing this lesion. 
If there is no ulceration or infection of the parts, these patients have 
no symptoms referable to the lesion, and their general health is not 
impaired. Ulceration and infection do occur rarely in very marked 
cases. The size of the organ causes a great deal of discomfort. 
Amputation, or excision, including when possible all the tissue 
involved, has proved successful in some instances. 
EPITHELIAL CYSTS. 
In clinics which are attended by many Jews, cases at times are seen 
of epithelial cysts of the remaining foreskin. These are probably due 
to faulty method of circumcision. From the same cause, cases of 
tumor-like formation are seen where there has been poor union of the 
skin, and sebaceous glands have been turned under and in this position 
continue to secrete. 
The secretions of the sebaceous glands at times are retained and cause 
small but oftentimes numerous tumors of the penis. These are situ- 
ated more frequently at the hairy portion of the organ. 
True congenital dermoid cysts have been reported. They never 
attain a large size, but contain the ordinary elements of dermoid cysts 
in other locations. They occur mainly near the raphe. 
DERMOIDS OF THE PENIS. 
TUMORS OF THE PENIS. 
Papilloma of the penis is rare and there is some question if true papil- 
loma does occur. Waldeyer reports a case of nineteen years’ standing 
which was of a very large size. The tumor involved the inner and 
outer foreskin, as well as the shaft of the penis. He made the diag- 
nosis of a true papilloma, as its elements did not involve the connec- 
tive tissue. 
Fibromata are rare and of little importance. The cases reported are 
of the neurofibromata type. 
Chondromata are rarely seen on the penis. 
Lipomata may occur in the skin. 
So-called venereal warts (condylomata acuminata) are common. 
They are present in cases of congenital phimosis and those cases in 
which the glands at the corona are active and the patient does not keep 
the parts clean. The tumor masses are true epithelial outgrowths. 
Treatment is excision. These wart-like growths are prone to malignant 
degeneration. TUMORS OF THE PENIS 
245 
Carcinomata.—Carcinoma of the penis is next to the most common 
skin cancer. It occurs usually at about fifty, rarely before forty years 
of age. 
Congenita] phimosis is an important etiological factor. The 
great majority of reported cases have, or have had, phimosis. Some 
cases have been published where the exciting cause was a wart, or 
syphilitic ulcer, and some authorities lay stress upon trauma or inheri- 
tance. Although the infective theory has been advanced, no cases 
have been proved where cancer of the penis has been acquired by 
intercourse with a woman having carcinoma of the cervix. 
The classification of this newgrowth may be made from a clinical 
or pathological stand-point. Kiittner divides them from a clinical 
stand-point into papillary cancer, carcinomatous swelling, and tumors 
not papillary, but adds that one type can pass into the other. 
Pathologically, they are all epitheliomata and can, according to some 
pathologists, arise from the basic or squamous cells. This naturally 
divides cancer of the penis into two types. This theory is not held by 
many authorities. 
The majority of these epitheliomata occur in the form of papillomata 
and involve, primarily, the glans or inner leaf of the foreskin. Its 
papillae are hard, leaf-like structures in contradistinction to the fine 
vilke seen in bladder papillomata. 
The peripheral growth soon fills the space between the glans and pre- 
puce, and by infiltrating the tissue of the foreskin, breaks through the 
preputial sac in one or more places. The glans which previously has 
been covered by the infiltrated foreskin which could not be retracted, 
may, after this perforation, be seen again. 
It is rare, even in cases of phimosis, to have the outer leaf of the fore- 
skin the primary seat of a newgrowth. Small warty growths on the 
glans may give rise to neoplasm, either by their malignant degene- 
ration or carcinoma may develop near them. The foreskin in these 
cases is soon distended by the swollen glans and cannot be retracted. 
This is due to the disproportion of the size of the glans and the fore- 
skin, while in those cases where the growths occur on the foreskin the 
inability to retract the foreskin is due to the infiltration of the same. 
All newgrowths which are situated under the foreskin are soft and 
moist, but if uncovered, are hard and dry. The papillary branches 
spring from one stem, but this is often overlooked on account of the 
great mass of these branches. Like all epitheliomata, the surface 
cells tend to degenerate, filling the interstices with a white, smegma- 
like, foul-smelling paste. 
These tumors may grow to be several times the size of the glans. 
The growth is often so rapid that large pieces are cut off from their 
blood supply, die and fall off. 
The many ulcerations of the penis, caused by the infiltration of its 
tissue, lead to fistula, and where these enter the urethra, they discharge 
urine. 
By the invasion of the penis by the growth and the subsequent death 246 
DISEASES OF THE PENIS 
of this tissue the organ wastes away. A cauliflower growth perforated 
by many urine-delivering fistuke, connected to the pubis by a short 
stem, the remains of the penis shaft, is often the condition of the patient 
when he presents himself for treatment. The whole penis is eventually 
sloughed off by the continuation of this process. The pubis and 
scrotum may be involved. The patient urinates through sinuses in 
the newgrowth, which connect with the eroded and shortened urethra. 
Kiittner describes a form of carcinoma which he says is rare. It 
appears as an ulcer with raised edges, either on the glans or at the sulcus. 
The growth is slow at first, but from the start the connective tissue of 
the part is involved. 
The other form described by him he claims is the rarest and is char- 
acterized by a grayish-white discharge. It does not have a papillary 
structure and may become very large. The tissue of the tumor has a 
tendency to undergo cystic degeneration. 
Newgrowths of the penis, by extension, may involve the scrotum, 
testicle, prostate, bladder, rectum, and pelvic cavity. The cavernous 
bodies are not involved early, as the albuginea offers an obstruction to 
invasion, but when involved there is an advance of the growth along 
the cavernous tissue. The inguinal glands are the first lymph glands 
to be involved, then the retroperitoneal. Metastases are common, 
although they take place late in the disease. 
Symptoms.—Carcinoma of the penis begins without pain. In cases 
in which a phimosis exists there is itching of the parts, and as ulceration 
takes place it is accompanied by a discharge which may be profuse. 
Urination may be impeded either by the newgrowth obstructing the 
outlet of the foreskin, or by ulceration of the urethra. As the condition 
advances, erections are painful and later disappear. Pain, when present, 
is due usually to the growth invading the glans. The advance of the 
growth is slow, as a rule, often a year elapses before the patient presents 
himself for treatment. 
Diagnosis.—The diagnosis is difficult to make in early cases without 
microscopic sections of the tumor. It may be mistaken for a condy- 
loma. The differential points are: condyloma tissue is soft and cancer 
is hard; the attachment of condyloma is superficial, while cancer is deep. 
It is wise to make microscopic sections of the tissue in all cases. 
This is especially easy to do, as most cases have a phimosis which must 
be relieved when they present themselves for diagnosis. 
Treatment.—Treatment is amputation with radical removal of the 
lymph glands, which drain the field of operation. 
Sarcoma.—Sarcoma of the penis is very rare. It may occur as a 
round or spindle-celled tumor which infiltrates the tissue of the penis. 
Myxomatous types are very rare, while the melanosarcoma are 
somewhat more common. These growths develop fast and the lymph 
glands are soon involved. 
Prognosis.—The prognosis is very bad even in cases of early operation. 
Diagnosis.—The diagnosis may or may not be hard, but rarely is a 
case diagnosticated early enough for a cure. CHAPTER VII. 
GENITAL ULCERS. 
By B. C. CORBTJS, M.D. 
Historical Review.—The Bible is the most ancient as well as most 
reliable source from which early knowledge in regard to genital ulcers 
can be obtained. 
The plague which fell upon the men who frequented the altars of 
Baal is supposed to relate to ulcerations of the penis, while the lamenta- 
tions of King David over the sharp pains in his bones doubtless refers 
to the effects of venereal disease. 
Changes in the throat and soft palate are mentioned by St. Paul 
in his epistle to the Romans. From all these it is fair to infer that 
genital ulcers with their accompanying effects existed in ancient days. 
Hippocrates, among the early medical writers, speaks of ulcerations 
of the genital organs, of tumors of the groin, of ulcerations of the 
mouth, and of extensive pustular eruptions on the body. 
Later, Celsus describes two varieties of ulcers on the penis, which 
he calls “ulcera sicca” and “ulcera humida.” This division fits 
admirably well the description of today—the soft chancre, which 
suppurates freely, and the hard, which scarcely suppurates at all. 
Celsus also describes the phagedena which may invade the ulcers at 
times. 
Aretaeus describes the destruction of the uvula and soft palate. 
Cribasius, like Celsus, divides the ulcers into dry and moist. 
Galen speaks of ulcers of the scrotum, which he divides into two 
classes, deep and superficial. 
Aretaeus and Paul of Aegina both make mention of ulcerations of 
different kinds that develop on the genital organs. 
During the latter part of the fifteenth century (1496) syphilis was 
conveyed by sailors of Columbus to the inhabitants of Seville and 
Barcelona. From this date authentic transmission is well chronicled. 
For want of a name the disease was called morbus gallictus, and on 
account of the primitive character of domestic relations at that time, 
hardly a family in Spain was free from it in 1494. 
The cases became so numerous in Seville that special hospitals were 
opened to cope with the situation. During 1494 the whole of Italy 
was infected, progress being noted from town to town. 
In 1495 France, Germany, and Switzerland became the seats of 
virulent outbreaks. 
Holland and Greece in 1496. 
England and Scotland in 1497. 
Russia and Hungary in 1499. 
247 248 
GENITAL ULCERS 
In 1496 the Decree of the Parliament of Paris required all infected 
persons to leave the city. 
In Scotland, during Cromwell’s time in the seventeenth century. 
In Norway in 1720. 
In Prussia in 1757. 
In Sweden in 1762. 
In Holland in 1789. 
In Uganda (Africa) in 1896. 
At present syphilis exists everywhere in the world, being less frequent 
in the rural districts and most frequent in the large cities. 
No historical sketch, however brief, should close without a reference 
to John Hunter and Philippe Ricord. 
In 1767 John Hunter inoculated himself on the prepuce and glans 
with the pus from a virulent gonorrhea, and produced a chancre as 
well as constitutional syphilis. From this he concluded that the 
secretion from a case of gonorrhea was capable of producing all three 
diseases—gonorrhea, chancroid, and syphilis. 
This unfortunate theory was not disproved until the masterful 
Ricord, by his careful and unbiased observations and researches, 
showed the different clinical entities of gonorrhea, syphilis and soft 
chancre. 
Classification.—Genital ulcers are divided into two classes: 
A. Venereal genital ulcers. 
B. Non-venereal genital ulcers. 
A. Venereal genital ulcers, which may be classified in the order of 
their importance, as follows: 
1. Syphilis. 
(a) Chancre. 
(b) Ulcerated papule. 
(c) Gumma or chancre redux. 
(d) Esthiomene, or syphilitic hypertrophy of the vulva with 
ulcerations. 
2. Erosive and gangrenous balanitis. 
3. Chancroid. 
4. Granuloma inguinale. 
1. SYPHILIS. 
(a) Chancre. —Synonyms.—Primary sclerosis; initial lesion of 
syphilis; hard chancre; Hunterian chancre; ulcus durum. 
Definition.—A true syphilitic chancre may be defined as the initial 
syphilitic lesion formed at the point of inoculation, and the first 
known collection of Spirochaeta pallida. 
Etiology.—Predisposing Causes. — (1) Alcohol; (2) venereal excesses; 
(3) promiscuous sexual indulgence. 
Exciting Causes.—The Spirochaeta pallida of Schaudinn and 
Hoffmann. 
Characteristic Features of the Spirochceta pallida as Observed with 
the Dark-field Condenser.—The spirochetes when examined with the SYPHILIS 
249 
dark-field condenser are much more typical than in the stained speci- 
men, and are exact duplicates of tissue specimens stained by the 
Levaditi method. The most characteristic features are: . 
1. Size.—They vary in length from 7 to 21 microns, being from one 
to three times the diameter of a red blood cell. It is not uncommon to 
see the organism longer than this, but on account of the difference in 
the motions of the two extremities it is possible that these long forms 
are composed of two or more organisms. 
2. Shape.—They are seen to consist of an extremely slender thread 
closely wound in a corkscrew or spiral spring form, the windings 
being very acute. In the fresh specimens the windings are absolutely 
regular, but as the specimen gets older the organism changes form, 
the most frequent change being an obliteration or irregularity of 
the windings in the central portion. This is a very common appear- 
ance in the stained preparations. 
Fig. 143.—Microphotograph. Treponema pallidum. Dark-field view of an expressed 
specimen (serum) from a chancre. X 1100. These are identical with the Levaditi- 
stained spirochetes as shown in Fig. 152. 
3. The Ends.—These are sharp and terminate on the periphery of 
the spiral and not in the centre, as the Spirochseta buccalis and some 
of the other forms do. This peculiarity of the ends is only seen when 
the organism rotates on its long axis. 
4. Motility.—When the specimen is freshly prepared the organism 
is very active and possesses the following motions: (a) A rotation 
on its long axis in either direction; this motion is very rapid, but not 
necessarily accompanied by change of position; as the specimen 
becomes older this motion grows less, (h) It progresses from place 
to place, but not so rapidly as the other forms of spirochetes commonly 
encountered, (c) They have a bending or twisting motion which is 
quite quick and spasmodic. This bending movement increases as the 
specimen ages and at times an organism is seen bent in the form of 
a circle, resembling somewhat a crenated red blood corpuscle. It is 
not uncommon to find two organisms joined end to end. 250 
GENITAL ULCERS 
Histology and Pathology.—The abundant discharge from a fresh, 
specific primary lesion, if untreated, contains a large number of 
Spirochgeta pallida, but if seen before the lesion has broken down, their 
demonstration may be difficult, unless gentle scarification and cupping 
are practised. 
The spirochetes are irregularly distributed in the foci, which accounts 
for failure at times to demonstrate the organism after the Levaditi 
method. This more or less irregular distribution of the spirochetes 
occurs more particularly in fresh lesions. As the spirochetes are 
responsible for the periarteritis and endarteritis, they are found most 
abundantly in tissues immediately surrounding the bloodvessels, in 
the walls of the vessels themselves, in the lymph spaces, and in the 
Malpighian bodies (Figs. 144 and 145). 
Fig 144 —Chancre of penis (low power). Shows moderately advanced lesion, blood- 
vessels much increased, with walls thickened. Marked proliferation of endothelial 
leukocytes into walls of vessels, causing endarteritis. In the connective-tissue stroma 
exudate is marked, consisting of polymorphonuclear leukocytes and plasma cells. 
(Author’s case.) 
The intitial sclerosis shows in the early stages a lymphocyte and 
plasma-cell infiltration around the blood and lymph \ essels in the 
depth of the cutis and the papillary bodies. Gradually the lumen of 
the bloodvessels becomes widely distended, there is swelling and 
proliferation of the endothelium and formation of new capillaries. 
Inflammatory changes and proliferation occur in the tissues surround- 
ing the vessels. This congestion and proliferation of the capillaries 
increases, the vessels become thrombosed, resulting in destruction of 
the vessels and a degeneration of the cellular exudate. Gradually SYPHILIS 
251 
the epithelium covering the lesion shrinks and becomes necrotic, while 
the papilke in the vicinity of the erosion become enlarged and the 
infiltration extends out over the ulcer onto the surrounding epithelium, 
both laterally and deeply; later more extensive inflammatory changes 
result in and about the arteries, veins, and lymph vessels. There is an 
increase of yellow elastic fibers. 
It is this condition which constitutes the specific induration, and 
the amount of induration will depend on the depth of the vessels which 
are affected. 
Incubation.—The period of incubation is from ten to twenty-eight 
days (exceptional cases longer); most frequently from fourteen to 
twenty-one days. 
Fig. 145.—Chancre of penis (high power). Shows wall of bloodvessel infiltrated with 
many endothelial leukocytes. 
Classification: A. Anatomical. B. Clinical. 
A. Anatomical Classification.—The location of the primary lesion 
depends on the site of contact and inoculation and may be anywhere 
on the genitals, i. e., scrotum, labium, urethra, glans penis, etc. 
B. Clinical Classification. 
1. Chancrous erosions. 
2. Chancrous ulceration, superficial and deep. 
3. Indurated papule. 
A chancre is not auto-inoculable after ten days, but may be so 
before. It is, as a rule, single (single point of contact) but may be 
double or multiple (multiple point of contact). The author has had the 
opportunity of observing a case in which there were five lesions arranged 252 
GENITAL ULCERS 
around the glans penis, somewhat resembling a collar, in each of which 
Spiroehseta pallida were demonstrated. 
1. Chancrous Erosions.—After variable periods of incubation, 
depending on the virulency of the spirochete and the receptiveness of 
the host, the chancre manifests itself. At first there is a hvperemic 
area; this later becomes a superficial papule and still later, through its 
inherent pathology, slight traumatism and mild secondary infection 
becomes a superficial erosion, thus marking the beginning of the 
chancre. A common form seen is a “small abrasion,” and on account 
of its insignificant appearance is most frequently permitted to go 
undiagnosed for some time. 
Induration, as a rule, is very slight or entirely absent. Later this 
erosion enlarges and assumes a more deeply red appearance and may 
pass into the following: 
2. Chancrous Ulceration, Superficial and Deep.-—The superficial 
erosion rapidly extends in breadth and depth. Induration is the rule 
and may be marked, but is always superficial at first. The ulcers are 
dusky red, circular and slightly cup-shaped, with smooth, slanting 
walls. A false membrane may be adherent over the lesion, and slight 
irritation causes an abundant exudation of serum. Later the indura- 
tion extends deeper, the ulcer destroying the true skin as well as the 
tissue beneath it. 
3. Indurated Papule.—In this form the lesion occurs where the 
integument is thick; it retains its papular form and may attain large 
dimensions, 0.5 to 2.5 cm. in diameter; its surface remains intact, and, 
as a rule, there is little excretion. 
Morton9 says: “The forms of the chancres differ, depending on the 
anatomical part on which they are located and also on the course and 
situation of the bloodvessels. 
“When they run horizontally and near to the surface, a thin, flat 
layer of infiltration occurs under the skin, which is called parchment 
induration. On the other hand, when the bloodvessels dip down deeply 
into the tissues, the induration is extensive and deep and is called 
Hunterian induration” (Figs. 146 and 147). 
For example, inside the prepuce the parchment chancre often 
occurs; in the sulcus coronarius, a heavy mass of infiltration takes 
place, forming a Hunterian chancre. In the frenulum a thick cord 
occurs, and on the glans a flat erosion. 
Pain.—All primary lesions are characterized by their lack of dis- 
comfort, both local and constitutional, unless complicated by a mixed 
infection or situated where there is continually a change of its base 
(urethral chancre). Inflammation, except over the site, is usually 
slight, the patient’s attention being first drawn to the condition by 
stinging and burning, as if he had been bitten by a fly or some small 
insect. 
In careless individuals and those who are slovenly in their toilet, a 
chancre may attain large proportions before it is noticed. 
In most chancres an abundant exudation of serum can easily be pro- SYPHILIS 
253 
Fig. 146.—Typical Hunterian chancre. (Author’s case.) 
Fig. 147.—Same as Fig. 146, twelve days after injection of 0.5 gm. arsphenamine. 
(Author’s case.) 254 
GENITAL ULCERS 
yoked by gentle irritation or cupping, this being due to the abundant 
vascular supply. 
Diagnosis.—So rapid and exact have become our methods of diag- 
nosis in primary lesions that the physician who fails to avail himself 
of these accurate and specific diagnostic methods should be held 
responsible. 
Many physicians, seeing a lesion for the first time, thoughtlessly 
prescribe a little dusting powder, while all the time the organisms 
of syphilis are multiplying, and daily the possibility of a speedy cure 
lessens. 
A favorite dusting powder for genital ulcers is calomel. This 
dusted on a lesion temporarily destroys the spirochetes in situ and 
it may be several days before all the powder can be removed; in 
the meantime the disease slowly progresses. Occasionally puncture 
of the inguinal glands will reveal the organism, but this is not an 
easy procedure. 
The safest method for the patient and his physician is to treat all 
ulcers in the light of a specific origin—apply no treatment whatever 
and permit no mutilation in the way of cauterization until it has been 
thoroughly demonstrated by a careful laboratory worker that syphilis 
does or does not exist. The removal of sufficient clothing to permit a 
thorough examination of the body should be insisted on. Often the 
clinical picture at the secondary period is so pronounced that added 
laboratory findings are only confirmatory; however, in the primary 
stage, without laboratory confirmation, one should not fed safe in 
making a positive diagnosis. 
The Dark-ground Illuminator.—This method was described by the 
Rev. J. B. Read in 1837. He used practically the same apparatus that 
we are using today. Read described his method just at the time that 
Professor Abbe brought out his well-known substage condenser, and 
in the excitement over Professor Abbe’s invention, the dark-ground 
illuminator was forgotten until rediscovered by Reichert, the micro- 
scope manufacturer of Vienna, in 1907. 
The advantage of this method depends on the illumination, the 
principle of which is the same as that causing dust particles to become 
visible when passing through a beam of sunlight. 
The apparatus of Reichert consists of a metallic plate, having a 
hole in the centre, above which is fitted a piece of glass having a circu- 
lar excavation on its under surface. The sides of this excavation are 
ground at a certain angle and silvered. By means of a revolving disk, 
different-sized diaphragms are used to cover the central part of the 
excavated area, so that when the light is reflected up from the plane 
mirror of the microscope, only the marginal rays reach the glass plate. 
These impinge on, and are reflected by, the silvered sides of the excava- 
tion to a central point 1 mm. above the surface of the glass plate. 
Any solid body here will intercept these rays and appear as luminous 
objects on a dark ground. By this method it is possible to see the 
particles of colloidal substances in their solutions (Pigs. 148 and 149). SYPHILIS 
255 
The Reichert Instrument.—A form of dark-ground illuminator is 
now manufactured by most of the microscope makers, but the Reichert 
instrument is superior to others for the following reasons: 
Fig. 148.—The Reichert apparatus for “dark-ground” illumination, to be attached to 
the microscope stage. 
Fig. 149.—Nernst lamp. For use with the Reichert dark-ground illuminator. 
1. It can be used on any kind of microscope. 
2. The light may be varied at will, by means of the revolving 
diaphragm. 
3. It is possible to change from the dark-ground method to the 256 
GENITAL ULCERS 
ordinary method of transmitted light merely by revolving the dia- 
phragm. 
The method of using the apparatus is as follows: 
The Abbe condenser is removed. A strong light is necessary; one 
may use the sun, an arc light, a Nernst lamp, or an inverted Welsbach. 
With the inverted Welsbach, a six-inch condenser lens is necessary, or 
a large glass globe filled with water serves the same purpose. The 
illuminator is placed on the stage of the microscope, and by means of 
the low power the circle which is etched on the glass plate is brought 
into the centre of the field and the apparatus fixed in this position by 
means of the clips of the microscope. A drop of immersion oil, free 
from air bubbles, is placed on the centre and the prepared slide put in 
place, great care being taken to avoid the formation of air bubbles. 
When the preparation is examined with the low power, if the light is 
placed right and the apparatus centred, a bright central point will be 
observed- The high power is now turned on and the field is seen to 
be dark, with luminous points and bodies. 
Preparation of the Materials.—The method of preparing the speci- 
men is very important. The slide must be 1 mm. thick, and both 
slide and cover-glass must be perfectly clean and well polished, as any 
turbidity or scratches disperse the light and cause annoying halos, 
which prevent the dark-ground effect and interfere with the examina- 
tion. Air bubbles in the specimen also cause these disturbing effects. 
The specimen must be as thin as possible. The observation is best 
made with a dry system. The author uses a Leitz f-inch objective 
and a No. 5 ocular. An oil immersion can be used; in this case, how- 
ever, it is necessary to diminish the aperture of the objective by 
inserting a truncated cone back of the front lens of the objective. This 
cuts out the diverging rays of light, which otherwise would flood the 
field. For diagnostic purposes it is seldom necessary to use the oil 
immersion. 
Method of Obtaining the Material.—For chancre (Fig. 150) it is 
sufficient to clean the lesions thoroughly with warm water. They 
are then irritated by being rubbed vigorously with a piece of cotton 
wrapped on a probe, thus causing an abundant exudation of serum. 
This is collected by means of a capillary pipette as shown in Fig. 150. 
A small drop of this is placed on a cover glass, which is now carefully 
inverted on the slide as in making a fresh blood preparation. It is 
well not to have much admixture of blood, as the blood cells interfere 
somewhat with the observation. 
On looking at a specimen containing serum from a chancre, numerous 
small, round, luminous bodies are seen, which have a very active 
Brownian movement. These particles of albumin are probably identi- 
cal with the blood dust of Muller. If the cleansing has not been 
thorough, various forms of bacteria are often seen, the cocci looking 
like pearls. The leukocytes are seen as a mass of white granules 
surrounding the dark nucleus, the various forms being easily differ- 
entiated. The ameboid movement and the granules in an active SYPHILIS 
257 
Brownian motion are frequently seen. The red corpuscles show as a 
luminous ring surrounding a central pale reddish zone. 
Staining Methods.—Schaudinn and Hoffmann’s many attempts at 
staining the Spirochseta pallida did not prove successful, until finally 
Fig. 150.—Method of collecting serum from suspected lesion by capillary attraction. 
they succeeded with Giemsa’s solution. It would be out of place in 
such a work as this to give a detailed account of all the methods which 
have been developed for this purpose, and mention will be made only 
of those of most practical value. 
Gievisa’s Ordinary Method—(Fig. 151): 
Fig. 151.—Microphotograph of Treponema pallidum from chancre. Giemsa stain. 
X 1100. (Author’s case.) 
1. Fix the film for five minutes in absolute alcohol. 
2. Dilute the stain in tap-water or distilled water to which a drop 
or two of a 1 to 20,000 solution of sodium carbonate has been added; 
use about 30 drops of the stain to every 20 c.c. of water. 258 
GENITAL ULCERS 
3. Pour the stain into a shallow dish and place the preparation face 
downward in it. The slide is prevented from touching the bottom 
of the dish by two pieces of glass tubing. 
4. Staining is complete in from one to twelve hours. 
5. Wash gently in water, and dry. 
Giemsas Rapid Method: 
1. Fix as above. 
2. Dilute the stain with an equal volume of water containing 1 to 
20,000 solution of sodium carbonate. 
3. Pour the stain onto the film, and heat the slide gently over a 
Bunsen burner until vapor is given off. Replace the stain with a fresh 
quantity and heat again. This process should be repeated three or 
four times, the final application lasting two minutes. 
4. Wash in water, and dry. 
Fig. 152.—Microphotograph. Spirochetes from the liver of a congenitally luetic 
infant, stained after Levaditi’s method. X 1200. (Author’s case.) 
Levaditi’s Method (Fig. 152).—This method is really a modification 
of that used by Ramon y Cajal for demonstrating nerve fibrils, and 
owing to its freedom from precipitates in comparison with the other 
silver stains, is now almost universally employed to demonstrate 
spirochetes in the tissues. 
The method is as follows: 
1. Fix fragments of the tissue, not thicker than 1 or 2 mm., in a 10 
per cent, solution of formalin for twenty-four hours. 
2. Wash in water and transfer to alcohol (96 per cent.) for twenty- 
four hours. SYPHILIS 
259 
3. Wash in distilled water until the pieces of tissue fall to the bottom 
of the jar. 
4. Impregnate from three to five days at 38° C. in a 2 per cent, solu- 
tion of silver nitrate in the dark. 
5. Wash in water and reduce overnight at the temperature of the 
room in the following bath: 
Acid pyrogallic 4 gm. 
Formalin 5 c.c. 
Water, distilled 91 c.c. 
6. Wash in water, dehydrate, and embed in paraffin in the usual 
way. 
7. Cut the sections not thicker than 5 microns and mount in Canada 
balsam. Xo further staining is required, though Levaditi has recom- 
mended counter-staining with toluidin blue, neutral red or Giemsa’s 
solution. 
Levaditi and Mamouelian s Rapid Silver Method.—Levaditi recom- 
mends this method for staining tissues which have been removed 
during life, or immediately after death. 
1. The tissue is cut and fixed as in the previous method. 
2. Impregnate in the following solution for twelve hours at room 
temperature, and then for five or six hours at 55° C.: 
Silver nitrate solution, 1 per cent 90 c.c. 
Pyridine 10c.c. 
3. Wash in water and reduce in the following solution overnight: 
Pyridine 17 c.c. 
Acetone 10 c.c. 
Acid pyrogallic (4 per cent.) 90 c.c. 
4. Dehydrate, and embed in paraffin in the usual way. 
5. Cut sections not thicker than 5 microns. 
The India-ink method of Burri, while recommended as short and 
reliable, is a poor makeshift. The demonstration of the spirochetes is 
complicated by too many artefacts (Fig. 153). 
Although a wonderful advancement has been made in the treatment 
of syphilis, comparatively few realize the role that the early diagnosis 
plays in the cure of the patient. 
Many staining methods for the detection of the spirochete have been 
recommended as short and reliable, but none has as many advantages 
as the dark-field condenser, as here the demonstration of the living 
spirochete is characteristic and distinct. From an experience dating 
from the year 1908, consisting of many hundreds of examinations, the 
author considers that the one and only method for use is the dark- 
field condenser. The advantages of this method depend on the 
illumination, which is greatly facilitated by the new Nernst lamp. 
This style of lamp has an advantage over the arc light, in that it gives 260 
GENITAL ULCERS 
a continuous, strong light, with no breaking or closing of the circuit 
or burning out of carbons. 
Noguchi’s method of snipping out a small piece of the lesion and 
macerating it with salt solution in a mortar offers an excellent way of 
obtaining the organism in large quantities, for in this manner they are 
expressed from the lesion and appear abundantly. 
The universal procedure of making a smear from a lesion, just as one 
would do in making an ordinary pus smear, should be emphatically 
condemned, as it is absolutely impossible for the laboratory in this 
way to do itself justice. 
The Wassermann Reaction.—Frequently the Wassermann reaction 
is resorted to as a final word in diagnosis. It must be distinctly 
understood that the Wassermann test cannot be relied on at the period 
of primary invasion; that the reaction is positive in direct proportion 
to the time of the presence of the primary lesion; that the reaction 
is nearly always negative until about three weeks after the first appear- 
ance of the sore, and after that period it is invariably positive. 
Fig 153.—Microphotograph of Treponema pallidum from chancre. Burri’s India- 
ink method. X 1600. (Author’s case.) 
However, during the presence of the primary lesion there are two 
things that we wish to know. They are: 
(1) The result of the Wassermann reaction on the blood, as a 
biological guide to future treatment; and if this should prove positive, 
(2) the result of the spinal fluid examination as a control on future 
complications of the nervous system. 
1. Wassermann Reaction on the Blood.—For example, a patient 
presents himself for examination. Diagnosis is made by finding the 
spirochete in the primary lesion. Assume that the Wassermann 
examination is negative. This shows that the system is not involved 
to any great extent and the possibilities of a speedy cure are good. 
On the other hand, take a similar case in which the diagnosis is made 
by finding the spirochetes in the primary lesion, but with the Wasser- 
mann examination positive. This shows a considerable systemic 
invasion and is not so favorable for a speedy cure. SYPHILIS 
261 
It is not generally recognized that the consumption of even small 
quantities of alcohol, if taken from one to seven days before the 
Wassermann is made, tend to influence the test by producing a false 
negative reaction. Attention was first called to this by Craig and 
Nichols,2 of the United States Army, and since then it has been verified 
by serologists generally. 
2. Spinal Fluid Examination.—During the past seven years,numerous 
observers, both in this country and abroad, have called attention to the 
fact that the nervous system is already involved in early syphilis, a 
thing almost undreamed of before this time.. This involvement seems 
to be due to a selective type of spirochete, and it becomes our duty to 
puncture the spinal canal in those cases which show a strong positive 
Wassermann, if we wish to control the situation here as well as in the 
blood stream. However, spinal puncture should never be performed 
during the period of secondary invasion, lest in the replacement of 
the spinal fluid drawn out for diagnosis, spirochetes might be drawn 
into the subarachnoid space. 
The spinal fluid examination consists of the following: 
1. Wassermann reaction. 
2. Cell count. 
3. Globulin reaction. 
(a) Noguchi. 
(b) Nonne-Apelt. 
4. Pressure. 
Technic.—Lumbar puncture is always performed best with the 
patient lying on his side. Inasmuch as 5 c.c. of fluid are essential 
for a proper examination, it is advisable to perform the puncture only 
in a hospital. During the withdrawal of the fluid, the patient should 
lie absolutely flat (without pillow) and this position should be main- 
tained for twenty-four hours, with the addition of the elevation of 
the foot of the bed after the patient has been removed from the 
operating room. 
1. The Wassermann Reaction.—Of all the tests, the Wassermann 
reaction on the spinal fluid is the most reliable. Frequently, however, 
an error has been made in taking too small a quantity of this fluid; at 
least seven times the quantity that is required for the blood Wasser- 
mann is absolutely essential for accurate results. 
2. Cell Count.—The following standard of Dreyfus,4 based on 750 
punctures, is recommended by Ellis and Swift,6 of the Rockefeller 
Hospital: 
1 to 5 cells per c.mm.—Normal. 
6 to 9 cells per c.mm.—Doubtful, border cases. 
10 to 20 cells per c.mm.—Slight lymphocytosis. 
21 to 50 cells per c.mm.—Moderate. 
Over 50 cells per c.mm.—Marked. 
Technic of Leukocyte Count of Spinal Fluid.—The apparatus 
employed is the Turck. The spinal fluid to be tested is thoroughly 
shaken. Draw up in the white-cell counting pipette 10 per cent. 262 
GENITAL ULCERS 
acetic acid to the mark I, then the spinal fluid to the mark II. This 
gives an employment of 9 parts of spinal fluid to 10 parts of the mixture, 
or t9q- of the mixture is spinal fluid. Blow out the first few drops of the 
solution from the pipette and then place on the chamber just sufficient 
fluid so that with pressure of the cover-glass Newton’s rings appear at 
the four corners. Count the cells in the whole ruled area. This space 
contains yy c.mm. of fluid. The mixture is y spinal fluid and Ty 
diluting fluid. Therefore the number of cells counted x A9- x --f- = the 
number of cells per c.mm. For example, the 9 sq. mm. contains 40 
cells. 40 x t9- x y1 = 49. If cells are so numerous as to cause cloud- 
ing, the spinal fluid must be diluted as for a leukocyte count of the 
blood. 
3. Globulin.—This test may be made after the method of Noguchi 
or the method of Nonne-Apelt. 
Technic of the Noguchi Butyric Acid Test.—To 0.2 c.c. of spinal fluid 
add 0.5 c.c. of 10 per cent, butyric acid in physiological salt solution. 
Boil carefully over a small flame for one minute and add quickly 0.1 
c.c. of normal sodium hydrate and boil again for a few seconds. In the 
presence of excess globulin, a precipitate forms of varying intensity, 
depending on the amount of globulin present. A cloud may appear 
in normal fluid. 
Technic of the Ross- Jones Modification of the Nonne Test.—Float on 
top of about 0.5 or 1 c.c. of supersaturated (by heat) ammonium sul- 
phate solution, about one-half the quantity of spinal fluid. In the 
presence of excess globulin a white ring forms. In case of small 
quantity of globulin, if the ring is either absent or indistinct, shaking 
the tube will cause the clouding to become prominent. 
4. Pressure.—Pressure is estimated by allowing the fluid to run into 
a graduated manometer tube with a bore 3 mm. in diameter and 
reading the height to which the fluid rises. This figure is only relative. 
Necessity for Spinal Fluid Examination in Syphilis.—Ever since the 
discovery of Noguchi11 that the cerebrospinal fluid in paresis, cerebro- 
spinal syphilis and tabes contains live active spirochetes which are 
capable of being transmitted to animals, a new light has been thrown 
upon subarachnoid involvement. How this involvement takes place 
is not exactly known; whether the spirochetes are capable of passing 
through the choroid plexus, or advancing along the lymphatics that 
accompany the nerves, future investigation will have to determine. 
There is little doubt, as Mott10 has already shown, that there is a 
selective type of organism that has a predilection for the nervous 
system. 
Differential Diagnosis.—Notwithstanding the many newer diagnostic 
methods that are in vogue, clinical symptoms should be carefully noted 
and the laboratory carefully checked up, especially since there are so 
many laboratories whose reports are conflicting. 
Scabies.—Occasionally there occurs on the glans penis an isolated 
area of scabies. If the surgeon will take the trouble to have the 
patient remove his clothing, as a rule, numerous evidences of this SYPHILIS 
263 
parasitic affection can be found on other parts of the body. There is 
no period of incubation and microscopical examination for spirochetes 
is negative. The condition remains as a papule with no inguinal 
adenopathy; itching is a prominent symptom, especially after retiring 
at night. 
(See end of chapter for tabulated points of diagnosis of Chancre, 
Chancroid, Herpes Zoster and Erosive and Gangrenous Balanitis.) 
Prognosis.—The prognosis in all uncomplicated luetic lesions is 
excellent, but to say that every case with its attending systemic 
infection can be cured is just as foolish as to say that no case can be 
cured. The curability of syphilis depends on making a prompt diag- 
nosis, for the earlier a case comes under observation, the easier it is to 
effect a cure. That the biological method offers the best means of 
controlling the treatment of the disease there can be no question. 
Unfortunately, the tendency is to give too little treatment. 
Prophylaxis.—The use of a condom during sexual relations is perhaps 
the best safeguard against infection. Metchnikoff’s calomel ointment 
(calomel 20, lanolin 40), if used up to within two hours after exposure, 
has proved a reliable preventative in the army and navy. As reliable 
substitutes, mercurettes (Parke, Davis & Co.) and 50 per cent, mercury 
ointment may be used. Recently, Schereschewsky13 has proved experi- 
mentally upon apes that 40 per cent, quinine is safe and efficient, if 
applied after the same method as the mercury ointment. 
As the primary lesion is only a local manifestation of a general 
infection, the treatment may be divided into local and systemic. 
Local Treatment.—No treatment, either general or local, should be 
instituted before a positive diagnosis is made. 
Excision of the Chancre.—As the initial lesion of syphilis is the first- 
known collection of spirochetes, Lukasiewicz, -Jadassohn,7 and others 
declare that if excision of the chancre is done before the period of second 
incubation, the infection is attenuated. It is reasonable to suppose 
that if we have a large area that is constantly feeding the system with 
infecting organisms, that area should be removed, especially since 
its removal does not entail any serious effects on the patient. When- 
ever it is at all possible, without undue loss of tissue, the chancre 
should be excised. In those cases in which the lesion is so situated 
that its removal would cause extensive destruction of tissue, one should 
be satisfied with thorough cauterization and curettement and the free 
use of calomel. In cases in which either excision or curettement would 
cause a troublesome scar (urethral chancre), calomel dusting powder 
should be used. 
General Treatment.—As soon as the diagnosis of a specific infection 
is established, systemic medication should be resorted to (within the 
next five minutes, if possible). No time should be lost, as every 
minute is valuable. Either arsphenamine or mercury should be given 
at once. The plan that the author has adopted is to give 10 m. of 
2 per cent, cyanide of mercury solution at once, and as soon as possible, 
preferably within the next two hours, a full dose of arsphenamine 
or neoarsphenamine intravenously. EARLY PRIMARY ’ Spirochneta Positive VfcrrtA 
J.NU —— - j SYPHILIS / Blood Wassermann negative _ IMdlllC 
BLOOD WASSERMANN- Finding . .,_.SPIROCHAETA; Date Finding 
When giving reaction state whether—none—mild—moderate—or severe. Regulate Arsphenamine dose to weight of patient, 1 decigram for each 30 lbs. of body weight. 
ARSPHENAMINE ONCE WEEKLY FOR SIX WEEKS 
Date Dose Date Dose Date Dose Date Dose Date Dose Date Dose 
Reaction Reaction Reaction Reaction Reaction Reaction 
1ST WEEK 2ND WEEK 3rd WEEK 4TH WEEK 5TH WEEK 6th WEEK 
MERCURY RUBS FOR FOUR WEEKS-PATIENT SHOULD ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 3 WEEKS 
CALL WEEKLY FOR OBSERVATION. 
N i ■ i - i ■ — i ■ Date Dose Date lDose I Date I Dose 
Date Date Date Date 
Reaction Reaction Reaction 
7th Week 8th week 9th Week IOth Week 11th week 12th week 13th week 
MERCURY RUBS FOR 4 WEEKS ARSPHENAMINE INJECTIONS ONCE WEEKLY FOR 2 WEEKS 
- Date Date Date Date uale uose 
Reaction j Reaction 
14th week 15th week 16th week 17th week 
' 18th week 19th week 
MERCURY RUBS FOR 4 WEEKS ONE INJECTION ARSPHENAMINE 
(Date I Date “I (Date Date Dose 
_____________ ___J Reaction 
20th week 21st week 22nd week 23rd week 
24th week 
BLOOD WASSERMANN- Date Finding SPINAL FLUID WASSERMANN: Date Finding 
Make Blood Wassermann and Spinal Fluid Wassermann at end of course. If Blood Wassermann is positive treat as latent syphilis, [card 5.] If Spinal Fluid Wasser- 
mann is positive, treat as neuro-syphilis, [card 7 1 If Both are negative discontinue treatment. 
DISCHARGE TECHNIQUE: Negative Blood Wassermann every four months for one year after treatment has stopped. 
This system, was developed by D> B C Corbus Chicago Published by Physicians’ record Co., Chicago Illinois Social HyRiene l eague. Chicago 
STANDARD SYPHILIS TECHNIQUE NUMBER 1 
264 SYPHILIS 
265 
Status of Arsphenamine after Twelve Years.—Notwithstanding 
that deaths have occurred both in this country and abroad following 
the use of arsphenamine, and notwithstanding differences of opinion 
regarding its value and toxicity, the author believes it still remains 
the most powerful spirillocide that we possess. If used with dis- 
cretion and judgment, it is the most valuable single weapon we have 
in combating the infection, and as for the contra-indications, in small 
doses, not to exceed 0.3 gm. once in seven to ten days, the author 
believes there are none. That the substance is neither harmful to 
the nervous system or kidneys has been proved by Doinikow3 and 
Wechselmann.15 
Unquestionably the fatalities and complications laid at the door of 
arsphenamine are due to errors in technic. Briefly and in order of 
their frequency these errors are: 
1. Use of water that contains saprophytic bacteria. 
2. Oxidation of the drug. 
3. The question of whether the solution is hypotonic or hypertonic. 
Considering the wide use of arsphenamine, it is safe to say that 
95 out of a 100 doses are given with water that is neither freshly dis- 
tilled, filtered, or sterilized, and, as a consequence, toxic effects are 
common. Few users of arsphenamine or neoarsphenamine realize 
that the drugs are very unstable and that oxidation occurs rapidly; 
in the latter, according to Ehrlich,5 300 per cent, in a half-hour. 
Probably few observers understand that distilled water is capable 
of dissolving red corpuscles, and with an easy water-soluble ars- 
phenamine (as neoarsphenamine is) solutions are often made which 
are capable of doing this in the blood stream after they are injected. 
This is particularly pointed out by Ravaut.12 
For the sake of “safety first,” it is demanded that all solutions be 
made with freshly distilled (not over five hours old) water, properly 
filtered and sterilized. The solution should not be permitted to stand 
over five minutes before using and should always be hypertonic. 
Intravenous Technic for Arsphenamine.—The instruments are* one 
large 250 c.c. cylinder (Fig. 154, B) filter papers, one funnel, one 
intravenous apparatus, like that shown in Fig. 155, one graduated 
pipette (Fig. 154, A), and one stock bottle of normal sodium hydroxide 
solution (4 per cent.) 
The instruments and filter paper having been previously sterilized 
(which may be accomplished for the latter by moist heat and later 
drying between sterile towels, and for the ampoule of arsphenamine 
and a file by immersion in alcohol), the ampoule is opened with the 
sterile file and the contents poured into the cylinder. Fifteen cubic 
centimeters of hot water are added, and the salt put into solu- 
tion. Next the normal sodium hydroxide solution is added (about 
2 c.c.), and shaken thoroughly. A precipitate occurs. Then sodium 
hydroxide solution is added, drop by drop, the solution being shaken 
after each drop until it is absolutely clear, care being taken not to 
add an excess. Next distilled water is added up to 260 c.c. The 266 
GENITAL ULCERS 
whole is then filtered into the receptacle which accompanies the 
intravenous apparatus. Here the outlet is in the side of the cylinder, 
slightly above the bottom, forming a little receptacle that holds any 
foreign material that may get into the cylinder, thus ensuring the 
injection of a more perfect solution. It is not necessary to use normal 
saline solution, as the above solution is very nearly isotonic. 
The arm is thoroughly scrubbed and a constrictor placed above the 
elbow. After taking care that the solution runs through the tube and 
needle easily, and that it is not above 98.6 F., and that air bubbles are 
Fig. 154.—Graduated pipette (A). 
Large 250 c.c. cylinder (B). 
Fig. 155.—Corbus’s intravenous 
apparatus. 
absent, the needle is thrust into the vein, great care being used not to 
puncture the vein except to enter its lumen, for any of the solution 
elsewhere than in the vein will produce a marked paraphlebitis. With 
the two-way cock attachment, it is easy to tell when one is in the lumen 
of the vessel, as the blood will come pouring out. Then remove the 
constriction, turn the cock and send the solution into the vein. With 
the cylinder raised 28 to 30 inches above the patient’s head, and with an 
18- to 20-gauge needle, the solution will enter the vein in from seven 
to twelve minutes. 
It is true that filtering the solution may seem to be superfluous, but SYPHILIS 
267 
often the salt agglutinates and there are small gelatinous particles that 
do not dissolve; and again, sometimes, there may be some splintering 
of glass in opening the ampoule. Therefore, in order to carry out this 
technic in the best possible manner, it is better to filter the solution 
so that it will be perfect. 
When the solution has passed into the vein and the injection is at 
at end, the two-way cock is turned so that the blood returns through 
the side outlet. In this way it is possible to wash the puncture area 
with the patient’s own blood, thus avoiding the use of salt solution. 
Of late years neoarsphenamine, on account of its easy method of 
preparation and administration, has practically superseded arsphena- 
mine. It may be given with the same apparatus in concentrated 
solution or by means of a 10 or 20 c.c. syringe. It is also always w ell 
to filter these concentrated solutions to avoid glass splinters. 
The author’s experience wdth many hundreds of cases, dating since 
the year 1910, has been devoid of accidents or deaths and the above 
technic for arsphenamine administration has been used exclusively. 
Intramuscular Technic for Arsphenamine.—AW intramuscular in- 
jections of either arsphenamine or neoarsphenamine should only be 
mentioned to be condemned. It is true that the method prolongs 
the elimination of the drug, but it is attended by severe pain and 
induration, often followed by abscess and necrosis. 
The time of the presence of the primary lesion is ideal for intra- 
venous medication, as it catches the spirochetes during their passage 
through the tissues. 
(6) Ulcerated Papule.—Occasionally during the period of secondary 
invasion numerous ulcerated papules are seen on the genitalia. 
This is more frequent in the areas in which there is less moisture in 
contradistinction to the condylomata, which occur on moist surfaces. 
The diagnosis should not be difficult, as secondary lesions are, as a 
rule, found on other parts of the body. The Spirochreta pallida are 
easily demonstrated by means of the dark-field condenser and the 
Wassermann is always positive. 
(c) Gumma. Chancre Redux.—Quite frequently are seen the 
so-called chancre redux, which is nothing more than a recurrence at 
the site of the previous primary sore. They may appear any time from 
a few wreeks after the healing of the primary sore to ten to twelve 
years afterward. Occurring after several years, they are regarded as 
gummata by most observers. 
Without any exact time of exposure or apparent period of incuba- 
tion, a small localized papule makes its appearance and rapidly breaks 
down and ulcerates, forming a typical solitary cutaneous gumma. 
The diagnosis should not be difficult with a previous history of lues. 
There is no question but that this form of lesion has been frequently 
reported as a “second case of lues in the same individual,” but this 
was before the discovery of the Spirochseta pallida and the \\ assermann 
reaction. It is possible always to find the spirochetes in a primary 268 
GENITAL ULCERS 
lesion and never possible to find them in a chancre redux with the dark- 
field condenser or any staining method. As the spirochetes are found 
deep in the tissues, however, their demonstration after the tissue 
method of Levaditi is possible. Treatment should be vigorous and 
systematic. 
(d) Esthiomene or Syphilitic Hypertrophy of the Vulva with 
Ulcerations.—Since attention was called in these chapters to Esthio- 
mene or Syphilitic Hypertrophy of the Vulva with Ulcerations, 
numerous articles have appeared, both in American and foreign 
literature. A most excellent description of this condition, described 
by Dr. Arthur Stein, follows with a few alterations. Dr. Stein has 
reviewed with great care the history of this condition, bringing it 
dowm to the present time. 
To avoid confusion in nomenclature, Dr. Stein’s title “Syphiloma 
Vulvse” is accepted as a description of this condition. 
Race.—This condition seems to be most prevalent among colored 
wmmen, although it does occur at times among w7hites that are poorly 
nourished and neglected, such as prostitutes, etc. 
Etiology.—This disease is always due to syphilis even in those rare 
cases in which the relationship cannot be positively established. 
Histological data in the majority of the cases afford conclusive evi- 
dence as to the specific character of the changes. When syphilis is 
not demonstrable, the disease must be considered as indirectly due 
to syphilis, having developed in an infected individual on a soil pre- 
pared and altered by syphilis. As modern methods of investigation 
improve, it will be found that the number of cases w7ill continually 
increase in which positive signs of luetic infection w7ill be found. 
Definition of Lesions.—The lesion is a slowly progressive indurated 
tumor, causing no pain and giving rise to inconvenience only through 
its cumbersome size. The swmllen and indurated vulvar regions 
usually are the site of deep-seated ulcers w hich show no predilection 
for any particular part. This tertiary manifestation of syphilis in 
no way lends itself to confusion w7ith the primary lesion on the genitals 
but constitutes a w7ell-defined pathological picture confirmed by the 
microscopical findings which plainly reveal the familiar features of 
gummata (syphilomata). 
The point of origin of vulvar syphiloma varies greatly although 
three regions are especially susceptible, being in order of frequency, 
the fourchette, the urethra, and the rectum. In certain rare cases 
the genital zone is at first free from all changes, the scleromatous 
lesions beginning with a low7 rectal or anal stricture and spreading 
to the genital organs through the recto-vaginal wall. As a rule the 
labia minora and the clitoris are involved in the ulcerative and hyper- 
trophic process and sometimes the entire vulva is deformed and 
altered in outline. This constant combination of hypertrophy and 
ulceration is characteristic of syphilis. 
In order to present the subject matter as clearly and concisely as 
possible, the description of the changes noted in syphiloma vulvse SYPHILIS 
269 
has been arranged under the separate headings of microscopical, 
gross, and clinical pathology as follows: 
Microscopical Characteristics of Syphiloma.—Histologically, a syphi- 
loma consists of a collection of round cells closely resembling the 
cells derived from inflammatory neoplasms with scanty bloodvessels. 
The affected tissues, like all gummata, undergo processes of necrosis 
and cicatrization with contraction of scar tissue. According to 
Lubarsch33 gummatous nodules are microscopically interpreted as 
granulating inflammatory products which are especially rich in lympho- 
cytes and frequently show fibroblasts and fibrillary tissue. The 
products pass either into solid connective tissue or undergo necrosis 
in the area of the cellular as well as fibrous portions, the original 
general tissue structure often remaining recognizable in the form of 
fibrous strands, traces of bloodvessels, and cells without nuclei. 
Whereas small syphilomata in their earliest stages resemble con- 
dylomata and contain chiefly small inflammatory cells as well as plasma 
cells, those which have attained a large size possess a more variegated 
structure containing plasma cells and epithelioid cells besides small 
round cells of lymphocyte type and presenting diffuse extensive 
caseation often surrounded by small nodules containing epithelioid 
and giant cells. The structures are liable to be confused with those 
of tuberculosis, the following features being of value for the differential 
diagnosis: In syphiloma, the epithelioid cells are usually less numerous 
than the small granulation cells and plasma cells. Fibroblasts and 
fibrillar connective tissue are apt to be conspicuously represented in 
syphiloma but are only exceptionally demonstrable in tubercles. 
Caseation is more extensive as a rule in syphilomata than in tubercles 
and in the former occurs in the stage of connective-tissue trans- 
formation, whereas in tubercles caseation invariably precedes this 
change. As a result a caseated syphilitic focus usually still contains 
demonstrable tissue elements, whereas a caseated tubercle forms an 
amorphous mass. In a general way the diseased tissue presents 
hypertrophic and inflammatory changes. The microscope shows 
an accumulation of embryonic cells in the middle layer of the dermis, 
arranged around the bloodvessels and progressively diminishing in 
frequency at a distance from the vessel. The lymphatics are dilated 
and packed with endothelial cells. The subdermic tissue likewise 
contains a large quantity of dilated vessels. These lesions terminate 
in the formation of scar tissue and sclerosis. 
Gross and Clinical Pathology.—It is a noteworthy fact that the 
affected parts present an entirely different aspect in the living and 
in the dead subject. After death the vulvar protuberances lose their 
turgescence, the perineal elevations and projections become flattened 
and lose their semi-erectile character. The induration and hyper- 
trophy of the vulvar and perivulvar tissue disappear almost entirely. 
The protuberances become softened, flabby, and wrinkled. In the 
living subject the color of the affected region is apt to be reddish or 
purplish in youthful subjects; dull-gray or livid in older women. 
The tegumentary covering of an infected labium majus usually pre- 270 
GENITAL ULCERS 
sents a purplish color, the mucous membrane is often dusky-red, and 
the abnormal coloration frequently extends to the adjacent labium 
minus. 
A fully developed syphiloma of the vulva appears as a more or less 
symmetrical enlargement of the labia majora on both sides, so that 
the shape of the tumor thus formed was compared by Hyde32 to that 
of a horse collar. The clitoris above is enlarged and sometimes 
represented by one or more soft or solid projections. The labia majora 
are much enlarged as a whole, fibrous and thickened, furrowed, ridged 
or the seat of fungosities. In some cases they have been found to 
contain very hard tumors the size of a marble. The labia minora 
are changed and deformed, not infrequently the seat of ulceration 
at their internal aspect and free borders. The vestibule region is 
greatly thickened, superficially or deeply ulcerated, either diffusely 
infiltrated or interspersed with circumscribed nodules. These vulvar 
ulcers have very irregular edges and discharge a scanty and at times 
purulent secretion. 
The luetic process may extend to the perineum and anus mani- 
festing itself in the form of large or small fleshy masses and excres- 
cences. In the second case under my own observations the labial 
ulceration encircled the introitus vaginae and extended for some 
distance into the vagina. Hyde refers to a case in which the vagina 
and the rectum were converted into a wide chasm bridged by a few 
persistent strands of vulvar or vaginal connective tissue. 
Syphilomata, here as elsewhere in the body, may heal, leaving 
deep, radiating, and adherent cicatrices, but are more apt to give 
rise to destructive ulceration, especially in the vulvo-vagino-anal 
region. This behavior can be explained by the existing circulatory 
disturbances due to a primary change of the efferent lymphatics and 
regional bloodvessels through the syphilitic infection. 
Clinically the disease is essentially characterized by its painless- 
ness, non-interference with the patient’s general health and dispro- 
portion between the local changes, and the resulting disturbances. 
The affected parts are not abnormally hot. There is no itching, as 
a rule no tenderness on pressure, and no evidence of acute congestion. 
Until the condition has become complicated by ulceration of the 
vestibule with more or less invasion of the urethral orifice and urethra 
causing painful micturition or by perineal infiltration with ano-rectal 
involvement resulting in painful, sometimes bloody, stools, the patients, 
as shown by my personal observations, and the cases recently reported 
by Gallagher and numerous others scattered through the literature, 
are remarkably free from pain or other subjective symptoms. 
Treatment.—As shown by my personal findings and the above 
quoted observations of other writers, the treatment of syphiloma vulva' 
is both surgical and medical. Operative interference consists of 
excision and destructive cauterization of all tumors and excrescences. 
This radical procedure is usually effective and not followed by a 
recurrence of the condition. Intravenous injections of arsphenamine 
are an essential supplement of the surgical treatment. The prog- SYPHILIS 
271 
nosis is very favorable, as is to be expected in properly treated gum- 
matous changes of tertiary syphilis. 
The following two cases came under my observation at Harlem 
Hospital, New York City (service of Dr. I. Haynes), where they were 
treated simultaneously (Histories Nos. G39 and 691): 
Case I.—L. V., colored, single, aged twenty years, admitted to the 
hospital, May 5, 1919. The family history as well as previous per- 
sonal history is negative. Menstrual periods began at thirteen years, 
occur regularly every twenty-eight days and last three days. She 
has had no miscarriages and no confinements. 
Fig. 156 
Fig. 157 
Fig. 158 
Figs. 156, 157 and 158.—Syphiloma of the vulva. (Stein.) 
Present History.—About a year ago the patient noticed a small 
swelling at her outer genitals. This swelling increased steadily in 
size and three months previous to her admission to the hospital she 
noticed that ulcers were forming in the swelling. These ulcers although 
absolutely painless gradually became more extensive and severe, tak- 
ing on a very offensive odor. The patient has also noted of late the 
development of a rather large tumor, which hangs from the outer 
genitals, between the thighs. 
General Examination.—The patient is a well-developed woman in 
good general condition. The abdomen is negative. The skin, lips, 
mouth, throat, and glands all fail to show any signs of luetic infection. 
Local Examination.—Due to the fact that internal examination is 
very painful to the patient, it is done under anesthetic with the fol- 272 
GENITAL ULCERS 
lowing findings: Introitus vaginse scarred and unyielding and the 
whole surrounding tissue infiltrated. Vagina admits two fingers. 
The greater part of the hymen is destroyed. There is a large ulcer 
on the lower third of the posterior vaginal wall. This ulcer is hard 
in consistency and shows infiltrated walls covered with a dirty purulent 
matter. The uterus and adnexa are found to be perfectly normal. 
The general appearance of the vulva is as follows (see Figs. 156, 
157 and 158): The affection of the outer genitals can be divided into 
two parts, namely, one large tumor originating in the right labium 
minus and two marked indurative processes affecting both labia majora. 
The tumor of the right labium minus measures 3j inches from pedicle 
to its top, inches in depth and 3 inches in width. This tumor is 
extremely hard and shows normal skin on its outer surface, whereas 
on its lower surface, near the pedicle, it presents deeply ulcerated 
areas. The left labium minus is very hard, parchment-like, sausage- 
shaped, nearly 2 inches long, indurated but showing no ulcerative areas. 
The right labium majus is transformed into a sausage-shaped 
mass 3| inches long. The lower portion comprising about two- 
thirds of the entire labium is markedly indurated and ulcerated. 
The left labium majus is similarly affected with marked ulceration 
also present, although in a somewhat lesser degree. 
This indurative process occupies also the entire perineum, extending 
down as far as the anus and showing several condylomata-like growths. 
Rectal examination shows the anus and rectum to be free from any 
indurative process. 
Blood examination: Polymorphonuclear, 72 per cent.; lymphocytes, 
28 per cent.; white blood cells, 8700; red blood cells, nearly 6,000,000; 
hemoglobin, 90 per cent. 
Wassermann test: May 10, 3+; May 12, 4-K Diagnosis: Syphi- 
loma vulvse (edematous, indurative, ulcerative, syphilitic tumor of 
the vulva). 
Treatment.—The pedicle with tumor of right labium minus was 
removed and the stump was ligated with double chromic catgut. The 
wound was properly cauterized. There was no. bleeding. A large 
lemon-shaped piece from the right labium majus comprising the 
indurated areas as well as the ulcerative mass was then excised. 
Spurting vessels, which were rather numerous, were ligated and the 
skin sutured over wound with numerous chromic catgut sutures 
reinforced with silk-worm sutures. 
Exactly the same procedure was followed in regard to the left 
labium majus, only that the area excised was smaller. Before closing 
the skin, the wounds on both sides were thoroughly cauterized. 
The excised parts were sent to the laboratory of the Hospital for 
examination, and I am greatly indebted to Dr. Elise L’Esperance, 
director of the laboratory, for the report on this case, as well as the next. 
Laboratory Report.—Specimen consists of (1) a portion of the 
right labium majus, (2) a portion of the left labium majus, (3) a tumor 
mass from the left labium minus. 
No. 1, specimen from the right labium majus, shows an area of Fig. 159.—Photomicrograph of specimen. (Stein.) 
Fig. 160.—High power photomicrograph of specimen. (Stein.) 
M U 1—18 
273 274 
GENITAL ULCERS 
skin and subcutaneous tissue measuring 6J x 4J cm. Occupying 
about 4x3 cm. of this portion of the labium is a deep, punched-out 
ulcer with hard, densely indurated irregular edges and a base covered 
with grayish necrotic material. On cross section the indurated white 
area is seen to extend from the base of the ulcer for a considerable 
distance into the subcutaneous tissue of the labia. 
Microscopical examination reveals an area of thickened epithelium 
and an edematous subcutaneous tissue at the edge of an ulcer. The 
ulcer shows superficial erosion with exudate of serum, fibrin, and 
polynuclear leukocytes. The base of granulation tissue extends 
through to the subcutaneous tissue and approximates a wide zone of 
round-cell infiltration consisting of many plasma cells and lympho- 
cytes. This infiltration radiates in strands into the deeper tissues 
and is associated with marked perivascular infiltration (Figs. 159 
and 160). 
No. 2, the specimen from the left labium majus, shows an ulcer 
31 x 2 cm. with the gross characteristics of the one encountered on 
the right labium. The ulcer is deeper and the induration more 
marked. Microscopical section reveals an histology almost identical 
with the ulcer on the right labium with the exception that the peri- 
vascular infiltration is more extensive. 
No. 3, specimen of tumor, an oval mass 9 x 6j cm., somewhat 
firm, covered by thickened, dark integument. On cross section, the 
entire area suggests edematous, subcutaneous tissue with a firm 
covering of skin. Microscopical section reveals an intact layer of 
epithelium beneath which the loose cellular subcutaneous tissue shows 
pale-staining and edematous. 
Sections of these three areas having been stained by the Levaditi 
method, a careful search fails to reveal spirochsetse. The location 
of the ulcers, the indolent nature and extensive round-cell and plasma- 
cell infiltration arranged in strands, associated with definite peri- 
vascular character, give strong evidence of the syphilitic nature of 
these lesions. 
Diagnosis.—Syphilitic ulcers of the labia majora. Marked sub- 
cutaneous edema of the labia minora. 
During the weeks of her convalescence the patient received bi- 
weekly intravenous injections of arsphenamine, 0.6 gm., and the 
affected areas showed prompt improvement with rapid healing of 
the wound. 
The patient left the hospital before we were ready to discharge 
her. She returned three months later, however, with a new growth, 
similar to that described above and affecting that part of the labia 
which had not been entirely removed. This second growth was 
removed by operation and the patient was subjected to drastic anti- 
syphilitic treatment, but as before, she left the hospital without 
being completely cured. 
Case II.—J. C., colored, married, aged twenty-two years; admitted 
to the hospital, May 19, 1919. 
The family history, as well as previous personal history, is negative. SYPHILIS 
275 
Menstruation began at thirteen years of age, is regular every twenty- 
eight days and lasts four days. Last period, May 11. No mis- 
carriages. One normal confinement. 
Present History.—The patient states that a painless growth started 
in the vulvar region about two years ago and that this growth has 
gradually become larger and larger, never causing any pain however, 
except for an occasional burning sensation on urination. Upon 
further examination the patient admits that several years ago her 
husband contracted a “cold” of the genital organs. 
General Examination.—Her general appearance is that of a healthy, 
well-nourished woman. Abdomen negative. Lips, mouth and 
throat negative for signs of luetic infection. No glands are palpable. 
Examination of blood shows normal conditions. Wassermann test, 
May 20, 2+. 
Fig. 161.—Syphiloma of the vulva. (Stein.) 
Local Examination.—The right labium minus is transformed into 
a hard, indurated tumor about the size of a lemon. The tumor 
involves the entire right labium minus. The left labium minus 
shows a similar tumor of the same make-up but somewhat smaller. 
Upon pushing the two tumors upward toward the abdomen an ulcer- 
ative area involving the entire lower surface of both tumors as well 
as that of the clitoris is seen. The latter seems to be entirely absorbed 
in the ulcerative area (Fig. 161). 
The labia majora are somewhat indurated although not to any 
such extent as in the first described case. The perineum, however, 
has been entirely dissolved by the ulcerative process, resembling in 
its tissue defect a perineal tear of the third degree. The surrounding 
tissue in the lower third of the posterior vaginal wall is hard, indu- 
rated, and covered with confluent ulcers of a dirty, grayish-yellow sur- 
face. The wall of the rectum is not involved. All of the above 
described ulcers are of exactly the same type, namely, indurated 
with ragged undermined edges and bases covered by a dirty-grayish 
necrotic membrane. 
Diagnosis.—Syphiloma vulvse (syphilitic, indurative, ulcerative, 
edematous tumors of both lobia minora and deep syphilitic ulcers 
of lower third of vagina with destruction of practically the entire 
perineum). 
Operation, May 28, 1919.—The pedicles of both tumors of the labia 
minora were clamped off, burned off with cautery, and stumps securely 276 
GENITAL ULCERS 
ligated with double chromic catgut. The ulcerated area of the lower 
part of the vagina was then also extensively cauterized and the vagina 
tightly packed with gauze. 
This patient also received bi-weekly intravenous injections of 
arsphenamine, 0.6 gm., during her convalescence, with marked improve- 
ment in the local conditions. 
The laboratory report was practically identical with that of the 
first case. 
Laboratory Report.—Specimen consists of (1) portion of right 
labia and (2) scrapings from ulcers in the vagina. 
No. 1, specimen consists of an area from the right labium majus 
measuring 5| x 4 cm. in the distal portion of which there is an indu- 
rated ulcer 3x1 cm., with ragged undermined edges and base covered 
by a grayish necrotic membrane. Histological examination reveals 
a superficial erosion of the epithelium with underlying round-cell 
infiltration, which shows a tendency to radiate from the original focus. 
There is moderate perivascular infiltration, which extends for a con- 
siderable distance under the normal epithelium. 
No. 2, the small bits of material from the vaginal ulcers have no 
definite gross characters. Microscopical examination reveals a deep 
erosion with complete destruction of squamous epithelium associated 
with marked round-cell and plasma-cell infiltration. Their location 
and indolent course appear to warrant the diagnosis of syphilitic 
lesions of the labia and vagina. 
Material from the labia and vagina stained by the Levaditi method 
failed to reveal spirochetes in the tissues. 
2. EROSIVE AND GANGRENOUS BALANITIS. 
The Fourth Venereal Disease. 
Definition.—Erosive and gangrenous balanitis is a specific infectious 
disease with local and constitutional symptoms varying with the 
severity of the infection. 
Etiology.—The cause is a symbiosis of a vibrio and a spirochete. 
These two organisms are always found together in the affection. Both 
have been demonstrated in sections, in the bloodvessels, and in the 
inguinal nodes. 
Predisposing Causes.—1. A long, tight foreskin excluding the air to a 
greater or less degree. 
2. Wetting the labia or penis with saliva. 
3. Unnatural sexual relations after alcoholic excesses. 
In private practice in this country the disease is uncommon, probably 
occurring once in 200 cases; but in dispensary work, in which material 
comes from the lower walks of life, the infection is fairly common. 
Scherber20 reports 81 cases that occurred in Finger’s clinic in four years. 
Bacteriology.—Abundant evidence is at hand to show that in noma 
and in Vincent’s angina the etiological factors are a spirochete and a 
vibrio. Kona says that “ noma begins without exception in gangrenous 277 
EROSIVE AND GANGRENOUS BALANITIS 
stomatitis. If the fusiform bacillus and spirochete found in the mouth 
are etiological factors in gangrenous stomatitis, since the organism is 
found in such abundance in noma, it must be due to the same cause.” 
Fig. 162.—Vibrio and spirochete; culture from case of noma. Slide and culture by 
Dr. Ruth Tunnicliff. 
In the first publication of the writer on this subject17 numerous 
authors were cited and abundant clinical proof was obtained to sub- 
stantiate the pathogenicity of these organisms. 
Fig. 163.—Etiological factors in erosive and gangrenous balanitis. (Author’s case.) 
The author has repeatedly examined the spirochetes found in 
Vincent’s angina under the dark-field illuminator. Here the organism 
is identical with that found in erosive and gangrenous balanitis, the 
motility being one of the characteristic and diagnostic features. 278 
GENITAL ULCERS 
Since the conditions that favor the growth of these organisms— 
heat, moisture, filth, and absence of air—are more ideal in the genitalia 
than in the mouth, it is easy to conceive how an organism may leave its 
normal saprophytic domain and under proper anaerobic conditions 
become pathogenic and produce extensive destruction. 
Examinations of vaginal secretions of 100 normal women showed 
bacteria and spirochetes similar to those found in smegma, but no 
spirochetes of balanitis. 
In 11 cases of clinically evident vulvitis and vaginitis, vibrios and 
spirochetes were found. 
Etiology.—As shown in Fig. 163, the vibrio and spirochete are the 
predominating organisms found. We can easily argue, as did Rona, 
in 1905,18 that if the fusiform bacillus and the spirochete found in the 
mouth are etiological factors in gangrenous stomatitis and gingivitis, 
erosive and gangrenous balanitis must be due to the same cause, since 
the organisms are found in such abundance in these conditions, and 
especially since in the histories of all my cases unnatural sexual relations 
or a wetting of the labia were admitted. 
The vibrio grows under anaerobic conditions on serum-agar. It 
occurs single or in chains of two or more individuals. It is a slightly 
curved, rod-shaped organism with pointed ends, measuring about 2 
microns in length and 0.8 micron in width. It stains by the ordinary 
dyes and is Gram-positive, although the decolorization must be per- 
formed very carefully, as the organism gives up the gentian violet 
readily. It is preferable to use 70 per cent, alcohol for this purpose. 
The spirochete is Gram-negative, but stains with the ordinary dyes; 
with the Giemsa stain it takes a bluish red. These organisms are best 
seen with the dark-ground illuminator. They average from 6 to 30 
microns in length and about 0.2 micron in width. The windings are 
not acute and the ends of the organism terminate in the centre of the 
spiral. The motion of the organisms is very rapid; they travel from 
place to place, resembling small snakes; they have a rotary motion, 
but this is not so pronounced as the backward and forward motion. 
After unsuccessful attempts at animal inoculation with cultures, 
Scherber does not believe in the pathogenicity of the fusiform bacillus, 
and considers the spirochete responsible for the lesions. 
A rapid and simple method of collecting the pus is by capillary 
attraction with small capillary pipettes. These may be pushed deep 
into the ulcers and a quantity of fresh discharge obtained. The pus 
may be examined with the dark-field illuminator, or fixed and dried and 
stained from two to three minutes with carbol-fuchsin. It is to be 
examined without cover-glass with oil immersion. 
Pathology.—The pathological condition in the milder forms of bal- 
anitis erosiva circinata consists simply of a flaking oft’ of the epithelium, 
leaving small superficial erosions. When the desquamation is more 
marked there are bright red ulcers, which are surrounded by a small 
white zone, the remains of the necrotic epithelium (Figs. 164 and 165). 
In the surrounding tissue there is an exudation of leukocytes and EROSIVE AND GANGRENOUS BALANITIS 
279 
plasma cells. The organisms are found in the necrotic membrane. 
At times they can be demonstrated in the tissues and bloodvessels, as 
shown by Scherber and Muller.19 
Fig. 164.—Erosive and gangrenous balanitis (low power). Shows the epithelium 
flaked off at the site of a small superficial erosion. There is an exudation of leukocytes 
but in contradistinction to chancroid and chancre this is not marked. The vascular 
tissue is not increased. (Author’s case.) 
Fig. 165. —Erosive and gangrenous balanitis (high power). Shows a bloodvessel 
with moderate amount of leukocytes in adventitia. There is no proliferation of the endo- 
thelial lining or occlusion of lumen. (Author’s case.) 280 
GENITAL ULCERE 
In the more severe grades of infection there is more venous stasis 
and more exudation, resulting in marked phimosis, which predisposes 
to gangrene. As Scherber and Muller pointed out, the whole condition 
is one of degree only, but for clinical purposes we may distinguish two 
types (1) balanitis erosiva circinata, and (2) balanitis gangrenosa. 
Symptoms.—Balanitis erosiva circinata commences with the appear- 
ance of one or more small, grayish-white patches in the preputial sac. 
At the time of the development of the erosion an offensive thin pus is 
produced of a characteristic stinking odor and of the usual yellowish 
white; in the more severe cases it becomes grayish white or grayish brown. 
Pus from the lesions is innocuous. In its development the inocula- 
tion never becomes pustular, but necrosis of the epithelium always 
represents the beginning, and the future process is polycyclic. 
Infection shows a preference for the sulcus coronarius, next on the 
inside of the prepuce, and last on the glans. In development all of the 
glans penis is involved, and under favorable anaerobic conditions the 
whole fossa navicularis is affected. It must be borne in mind that more 
or less phimosis is an essential factor. 
In the mild cases the foreskin may be easily retracted, but in the 
more severe forms marked phimosis develops; there is considerable 
itching and burning behind the glans; the act of urination is practically 
without pain. In contradistinction to the gangrenous form, in this 
type of the disease constitutional symptoms are slight or absent. 
As the process follows no hard-and-fast lines, there are certain devia- 
tions from the foregoing picture. The process may be limited to the 
glans and the inner surface of the foreskin may be unaffected. This 
may be extreme or mild, but it is always present on the covered portion 
of the glans. 
The inflammatory condition may remain a purely erosive, superficial 
process and may recover spontaneously. Berdal16 says that in simple 
cases healing takes place in four or five days. Scherber has seen spon- 
taneous healing almost completed in forty-eight hours by simple wash- 
ing and admission of air by retracting the foreskin. lie further states 
from observation that the height of the development usually occurs in 
from four to eight days after exposure to infection, and that he had 
seldom seen cases of four weeks’ incubation and cases persisting for 
three or four weeks. 
In a number of cases the process does not remain superficial, but 
develops deep diphtheritic and gangrenous ulcers, which complicate 
the clinical picture in many ways. 
In some cases, when the foreskin can be retracted, after removal of 
the pus, small, round ulcers can be seen inside of the erosions, varying 
in size from that of a pin-head to that of a pea. These ulcers are 
moderately deep and, on the whole, flat and surrounded by a red zone. 
They are covered by a closely adherent pseudomembrane. In other 
cases the ulcers are more extensive and deeper, the average size being 
about that of a dime. These may become confluent and extend over 
the whole surface of the sulcus or the inner surface of the foreskin. EROSIVE AND GANGRENOUS BALANITIS 
281 
These balanitie ulcers are of a somewhat irregular outline, and are 
surrounded by small inflammatory, slightly elevated borders. These 
borders are clean cut and the sides somewhat slanting; the bases are 
uneven, with a firm yellowish-white or yellowish-brown membrane, 
which is often edematous and swollen. When more edematous, this 
false membrane appears as a sort of friable slime. Here and there 
may be hemorrhagic spots which sometimes give rise to hemorrhages 
from the base of the ulcer. 
In the severe forms the constitutional symptoms are more marked. 
Scherber and Muller noticed chills and fever in a majority of their 
cases, and at the onset, vomiting. The average temperature ranges 
from 100° to 101° F. There is marked edema, the external skin being 
red and edematous; the infiltration may extend to the root of the penis 
in some cases. The dorsal lymph cord is usually palpable and the 
inguinal nodes are enlarged, but not painful. Unless the phimosis is 
complete there is no pain on urination; when, however, the urine is not 
able to pass freely and dilates the preputial sac, there is considerable 
pain. 
The discharge is the most profuse in this type of the disease. By 
gently irrigating the preputial sac with sterile water and wiping the 
external urethral orifice, gonorrhea can easily be excluded by using the 
two-glass urine test. 
In the majority of cases of balanitis gangrenosa, there occurs a 
marked edema of the subcutaneous tissue of the penis which extends 
to the root and causes a marked phimosis. If the ulcer is situated on 
the inner surface of the foreskin, it shows externally as a dark, bluish-red 
area within the surrounding bright red inflammatory tissue. The con- 
gestion and abnormal pressure, due to edema, favor the progress of the 
disease. 
Soon the foreskin over the ulcer becomes black, and a complete 
necrosis of the part occurs. If the ulcer is situated on the glans, in a 
short time it may produce complete destruction of the glans or may even 
cause an extremely rapid gangrene of the organ, which may extend 
even to the root of the penis, as may be seen by the author’s fourth 
case, herein described. 
The ulcers in these cases are deep, the edges sharp and perpendicular, 
the base grayish green or brownish; or the penis may show hemorrhagic 
areas or be changed into a black necrotic mass. 
The discharge at this time is more offensive than in the erosive type; 
it is grayish yellow or yellowish brown, and at times it may be slightly 
hemorrhagic, but always with the same characteristic odor. The 
inguinal nodes are enlarged; there is a mild grade of sepsis present, and 
general malaise is marked. There may be vomiting and the tempera- 
ture may reach 104° F. The tenderness of the part is extreme. 
Diagnosis.—This disease is not so uncommon as one might suspect. 
Unfortunately it is usually mistaken for chancroidal infection. The 
period of incubation may be the same in the two conditions; but with 
the characteristic thin yellowish-white, offensive discharge, in which one 282 
GENITAL ULCERS 
finds a vibrioform organism and a spirochete, the diagnosis should not 
be difficult. 
The ulcers of the two forms of infection may simulate each other 
very closely. In this form of balanitis, when the infection is at all 
severe, there is marked phimosis and considerably more inflammatory 
reaction. The enlarged inguinal lymph nodes are painless, while with 
a very insignificant chancroidal sore a suppurating bubo is often present. 
Chancroidal ulcers are, as a rule, multiple, but they do not spread 
with great rapidity as do those of the ulcerative form of balanitis. 
Whereas the borders of the ulcers in both diseases have a clean-cut, 
punched-out appearance, there is greater tendency to undermine the 
wall in a chancroidal infection. 
On account of the indolent adenopathy that accompanies balanitis 
erosiva, it must be differentiated from syphilis. In syphilis the period 
of incubation is longer, although the two infections may occur simul- 
taneously, as reported in one of Scherber’s cases, as well as in one of my 
own. When such a condition exists, we may be compelled to defer our 
diagnosis of syphilis until the period of incubation for syphilis has 
elapsed; or in case of a mixed lesion, the Spirochseta pallida may easily 
be demonstrated by the dark-ground illuminator, and is so characteristic 
as to be easily differentiated from the spirochete of balanitis. 
Herpes preputialis always occurs as groups of small insignificant 
vesicles in which local reaction is mild or entirely absent. This con- 
dition simulates the mild form of balanitis erosiva somewhat, but in 
herpes one fails to find the organisms characteristic of balanitis. 
Treatment.—As a prophylactic measure, the practice of circumcision 
should be encouraged; it is absolutely impossible for balanitis to exist 
in a person who has been circumcised. 
In many cases in which the condition is mild and the foreskin can 
easily be retracted, all that is necessary is a thorough cleansing; but in 
the mild ulcerative forms in which there is the slightest evidence of 
phimosis, a dorsal incision should be made. As the organism of bal- 
anitis is anaerobic, this incision serves the twofold purpose of admitting 
air and of exposing the diseased parts for treatment. 
The natural tendency in this disease is to burn all the sloughing 
ulcers, but such treatment subjects the patient to needless punishment. 
As said before, the organisms of the disease are anaerobic, and as hydro- 
gen peroxide liberates oxygen when in contact with organic matter, it 
acts as a specific for this form of infection. 
The ordinary 2 per cent, solution is sufficient, but in severe cases of 
gangrenous balanitis stronger solutions of peroxide may be procured 
and painted on the parts. 
Report of Cases. 
Case I.—Erosive type (Fig. 166), previously reported. 
History.—The patient, M. M. W., aged forty years, married, denied 
all previous venereal history. After four days’ incubation the patient EROSIVE AND GANGRENOUS BALANITIS 
283 
noticed itching and burning around the glans penis. There were no 
constitutional symptoms. During the first week this continued as a 
mild balanitis. The patient was able to retract the foreskin. Treat- 
ment was neglected. At the end of the first week conditions suddenly 
became worse; the foreskin began to swell and the patient was unable 
to retract it. At this time he presented himself for examination. 
Examination.—The general muscular development was good; there 
were no scars or evidence of previous venereal disease. The penis was 
swollen and edematous; the edema extended about half-way up the 
shaft of the penis, giving it a pear shape. The skin over the glans 
portion was red and slightly injected. There was complete phimosis. 
Exuding from the opening was a thin, yellowish-white pus, with a pene- 
trating odor; in the pus a vibrio and a spirochete were found. There 
Fig. 166.—Erosive type, Case I. Balanitis erosiva foreskin not retracted; ulcers seen 
on margin. (Author’s case.) 
was constant burning pain, which was increased on the slightest press- 
ure. There was no urinary pain. The dorsal lymph cord was easily 
palpable; the inguinal nodes were enlarged but not tender. There was 
no fever. 
Treatment.-—With a small hard syringe 2 per cent, hydrogen peroxide 
was injected every hour into the preputial sac. By the second day the 
foreskin could be retracted, showing numerous small ulcers with slough- 
ing bases and sharp borders, involving the sulcus and the covered 
portion of the glans. 
These healed rapidly under the above treatment. 
Case II.-—Erosive type, complicated by syphilitic infection. 
History.—C. E., male, aged nineteen years, single. No previous 
venereal disease; gives history of many exposures. Last exposure four 284 
GENITAL ULCERS 
days previous; unnatural relations. After six days of incubation, 
patient presented himself at my clinic at the Post-Graduate Hospital. 
Examination.—Well-developed individual; general examination neg- 
ative. Pulse and temperature normal. No enlargement of the lymph 
nodes; profuse yellow discharge from the preputial opening. Moder- 
ate amount of phimosis present. Foreskin was retracted with little 
difficulty, showing numerous typical superficial erosive ulcers, both in 
the sulcus coronarius and on the glans penis. Complicating this, how- 
ever, was a hard, indurated, erosive chancre seen just back of the 
corona on the left side. The sulcus was filled with purulent discharge, 
as seen in Fig. 167. 
Fig. 167.—Erosive type, complicated by syphilitic infection, Case II. Foreskin 
retracted; grayish purulent secretion in sulcus coronarius and a few small erosions on 
the glans. (Author’s case.) 
By examination with the dark-field illuminator it was possible 
to make a differential diagnosis at once, for there were present the 
Spiroehseta pallida, the spirochete of erosive and gangrenous balanitis, 
and numerous vibrios. No other method could have given such prompt 
diagnosis. 
Treatment.—Two per cent, hydrogen peroxide and salvarsan with 
prompt resolution of erosive condition. 
Case III.—Erosive type; more advanced stage. 
History.—F. P. E., male, aged twenty-one years, single, private 
patient. No history of any previous venereal disease; incubation six EROSIVE AND GANGRENOUS BALANITIS 
285 
weeks (patient’s statement), at which time unnatural relations were 
had with the idea of avoiding exposure by the ordinary channels. 
Examination.—Large, corpulent individual; general examination 
negative: Pulse and temperature normal. Considerable phimosis 
present; penis slightly swollen. Extreme tenderness on examination. 
Foreskin was not retractable; patient stated that during the month 
previous there was a little itching behind the glans, but that twenty- 
four hours before presenting himself for examination it suddenly began 
to swell and was extremely painful on examination. Profuse stinking 
discharge. Dorsal lymph cord was palpable; slight, painless inguinal 
adenopathy was present. 
Fig. 168.—Erosive type, more advanced stage, Case III. Foreskin retracted after 
dorsal incision; deep erosive ulcers with necrotic bases just back of the sulcus coronarius. 
(Author’s case.) 
Operation.—Dorsal and ventral incisions were made, showing both 
superficial and necrotic ulcers present at borders of glans and sulcus 
coronarius, as seen in Fig. 168. Numerous vibrios and spirochetes 
were obtained from the necrotic ulcers. 
Treatment.—Two per cent, hydrogen peroxide, thorough cleaning 
with hand syringe every two hours; prompt recovery; unable to obtain 
second photograph. There is no doubt that this case would have gone 
on to gangrene had not prompt treatment been instituted. 
Case IV.—Erosive type. 
History.—P. O. S., male, aged twenty-six years. History of previous 
gonorrhea. Unnatural relations were held thirty-six hours previously. 
Examination.—Typical pear-shaped swelling of the penis, foreskin 
retracted. Whole of glans penis and sulcus coronarius covered with 
superficial ulcers; average size about the head of a pin; profuse 286 
GENITAL ULCERS 
purulent discharge, containing vibrios and spirochetes. Dorsal lymph 
cord palpable; no adenopathy. 
This patient was so slovenly and careless that after two days of 
marked improvement he discontinued treatment and had a recurrence, 
with a later cure. 
Case V.—Erosive type; previously reported. 
History.—M. W. M., male, aged twenty-six years. Denied syphilis; 
had had a supposed chancroidal infection two years previously. Two 
weeks before presenting himself the patient had intercourse. After 
three or four days there was a little itching beneath the prepuce. At 
the end of six days he presented himself for examination. 
Examination.—The temperature and pulse were normal. The gen- 
eral nutrition was good, and there were no signs of latent syphilis. 
There was a large indurated swelling of the penis. From the preputial 
orifice exuded a thin, yellowish-white, stinking discharge. This was 
examined for gonococci, but none were found. There was phimosis, 
but it was not complete. With dilatation, the finger was gently passed 
between the foreskin and the glans. The whole covered portion of the 
glans and the inner leaf of the foreskin were covered with small ulcers, 
having necrotic, sloughing bases. Those on the inner leaf extended to 
the border of the preputial fold; by gently pulling back the foreskin the 
whole could be plainly seen. The dorsal lymph cord could be easily 
felt and the inguinal nodes were enlarged but not tender. There were 
no constitutional symptoms. 
Treatment—The patient was given a wash of hydrogen peroxide, full 
strength (2 per cent). As he did not return to the clinic it is pre- 
sumed that his condition was satisfactory 
Case VI.—Gangrenous type, previously reported. 
History.—The patient, A. G. G., male, aged forty-three years, denied 
all previous venereal history. He had had intercourse nine days pre- 
viously; at this time the patient said that the prostitute lubricated 
the labia with saliva. The following day the glans portion began to 
swell; there were chilly sensations; no nausea or vomiting. Previous 
to this time the patient’s glans penis was exposed between the preputial 
fold, and the foreskin could be retracted. On account of the rapid 
phimosis that developed this could not be accomplished later. The 
local symptoms increased rapidly; by the third day gangrene had set in. 
Examination.—When the patient presented himself at the clinic he 
was well nourished; muscular development good. There was a slight 
septic intoxication. The entire preputial covering for a distance of 
three inches was a black, necrotic mass (Fig. 169). By gentle manipu- 
lation the necrotic mass could be drawn away and deep sloughing ulcers, 
with sharp borders, could be seen extending into the penis above the 
glans. There was considerable thin, slimy pus present, with an odor of 
necrotic tissue. Here we were able to find the organism in large num- 
bers. The remaining portion of the penis was dark red and infiltrated, 
the edema extending to the root; the inguinal lymph nodes were en- 
larged. The patient’s temperature was 102° F.; malaise was marked. EROSIVE AND GANGRENOUS BALANITIS 
287 
Treatment.—The patient was sent to the County Hospital. Here 
the necrotic foreskin was cut away, and just above the glans portion, 
h ig. 109. Gangrenous type, Case \ I. Appearance on examination. (Author’s case.) 
1'iG. 170. Gangrenous type, Case VI. Appearance forty-eight hours later. 
(Author’s case.) 288 
GENITAL ULCERS 
Differential Diagnosis between Syphilitic Chancre, Chancroid, Herpes, and 
Erosive and Gangrenous Balanitis. 
Syphilitic chancre. 
Chancroid. 
Herpes. 
Erosive and gan- 
grenous balanitis. 
Etiology 
Spirochaeta pal- 
lida 
Ducrey-Unna 
bacillus 
No organism 
Symbiosis, vibrio 
and spirochete. 
Incubation 
F ourteen to 
twenty-one 
days 
Two to five days 
None 
Three to five 
days; may be 
longer. 
Location 
Generally on 
genitals; may 
be anywhere 
Generally on gen- 
itals ; rarely else- 
where 
Generally on 
genitals; may 
be anywhere 
Always on glans 
penis behind 
closed foreskin; 
may extend to 
adjacent parts. 
Number 
Usually single, 
but may be 
double; must 
be so from on- 
set 
Usually multiple; 
may develop ad- 
ditional ulcers at 
any time dur- 
ing activity of 
infection 
Usually multi- 
ple, later con- 
fluent 
Usually multiple. 
Auto-inoculable 
Possible up to 
ten days 
Possible at any 
time 
No 
Only possible un- 
der anaerobic 
conditions. 
Onset 
Starts as erosion 
or papule 
Pustule or ulcer 
Group of vesi- 
cles 
Small, superfic- 
ial erosion. 
Course 
Remains as ero- 
sion or ulcer- 
ates. 
Ulcer extends 
Forms superfi- 
cial ulcer 
Becomes con- 
fluent ; rapid 
coalescence. 
Induration 
Usually present 
Rare 
None 
Slight. 
Pain 
Little or none 
Very painful 
Burning and 
itching 
Very painful. 
Shape 
Round or oval 
symmetrically, 
irregular 
Round or oval 
unsymmetri- 
cally, irregular 
Irregularly 
rounded, bor- 
der polycyclic 
Irregular round 
or oval; border 
polycyclic. 
Depth 
Superficial, cup- 
shaped or sau- 
cer-shaped; may 
be elevated 
Deep, excavated 
or punched out 
Superficial 
Superficial at 
first, may ex- 
tend deep. 
Surface 
Smooth and 
shining; dark- 
ish red mem- 
brane frequent 
Rough, moth- 
eaten, grayish, 
warty appear- 
ance 
Bright red super- 
ficial granula- 
tion 
Rough necrotic 
centre; slightly 
reddened bor- 
der; may be 
yellowish- 
brown mem- 
brane. 
Edges 
Sloping, but may 
be elevated 
Clean cut, may be 
undermined 
Sharp, not un- 
dermined 
Clean cut; not 
undermined; 
somewhat 
slanting sides. 
Bottom 
Smooth and 
shining 
Uneven and irreg- 
ular ; no luster 
Bottom even; 
diffuse inflam- 
matory tissue 
Gray and irregu- 
lar; no luster. 
Secretion 
Slight unless ir- 
ritated, then 
profuse; serous 
Abundant and 
purulent 
Slight, seropuru- 
lent 
Profuse, stink- 
ing, gray to 
grayish-brown 
discharge. 
Adenitis 
Constant; indo- 
lent 
When present, 
always inflam- 
matory 
No glands 
Constant, indo- 
lent. 
Gangrene 
Rare, unless com- 
plicated by ero- 
sive and gan- 
grenous balani- 
tis 
Rare, unless com- 
plicated by ero- 
sive and gan- 
grenous balani- 
tis 
Never 
Often. CHANCROID 
289 
at the site of the inner preputial fold, two deep ulcers could be seen. 
The glans portion was necrotic. In forty-eight hours (Fig. 170) the 
entire glans, together with about one and a half inches of the shaft of 
the penis, sloughed off, leaving a short stump (Fig. 171). The patient 
was treated with irrigations of potassium permanganate three times a 
day, but the organism had already invaded the deeper layers, and 
gangrene was unavoidable. 
Fig. 171.—Gangrenous type, Case VI. Appearance five months after, showing small 
stump left. (Author’s case.) 
3. CHANCROID. 
Synonyms.—Simple ulcer; simple venereal ulcer; soft chancre or ulcus 
molle. 
Definition.—A specific infectious ulcer usually acquired during the 
sexual act, almost always situated upon the genitals, but may be 
found on any part of the body. 
Etiology.—A. Predisposing Causes.—(1) Race—most frequent 
among colored people. (2) Phimosis, causing retained secretions. 
(3) Filth and poverty and debauchery and degeneration go hand in 
hand with this infection; as a consequence, it is more frequent in 
dispensary practice than in private work. During the author’s 
five years’ experience at the Post-Graduate Hospital, situated in the 290 
GENITAL ULCERS 
centre of Chicago’s “red-light” district, he was particularly struck 
by its frequent occurrence in the colored race. (4) Poor and ill- 
nourished individuals do not resist the infection well. 
B. Exciting Cause.—Ducrey-Unna bacillus. 
Description.—It is a short rod-shaped bacillus with slightly rounded 
extremities, occurs often in chains, sometimes in groups, either in 
cells or between them, and is readily stained with methylene blue, 
carbol-fuchsin, or borax-methyl-violet. It is decolorized by Gram’s 
method. 
On account of the contamination by extraneous organisms, the 
demonstration of the Ducrey-Unna bacillus is difficult; however, if 
the ulcer is sealed with flexible collodion for twenty-four hours to kill 
all the extraneous organisms, the finding of the bacillus should not 
be difficult. 
Pathology.—Microscopically, there is found at the bottom of the 
epithelial erosion an infiltration of leukocytes, which extends laterally 
only a little beyond the hyperemia. The exciting cause of the ulcer, 
the delicate and difficult to stain little rods (Ducrey-Unna bacillus) 
line the tissue. These bacilli make their way out from the hyperemic 
area along the course of the lymph spaces into the lymphatic channels; 
as these lie open with unobstructed lumen, the rapid march of the 
infection to the neighboring glands is the rule (Figs. 172 and 173). 
As a consequence of secondary infection with other bacteria gaining 
entrance through the local ulcer, an extended necrotic disintegration 
can reach into the surrounding tissue. This may extend both laterally 
and deeply and lead to wide destruction of tissue. Such a condition 
is known as phagedena. Occasionally the lymphatics that drain a 
given ulcer appear as red streaks or lines, passing backward to the 
regional lymphatic glands. These are easily palpable and may be 
quite painful. 
Symptoms.—Incubation twenty-four hours to three days; occasion- 
ally five to nine days are given by the patient; at this time, however, 
the ulcer is well advanced. 
After sexual indulgence, with varying periods of incubation, a small 
congested spot makes its appearance; this rapidly forms a small 
macule which later develops into a pustule, surrounded by a hyper- 
emic zone. This usually increases rapidly in size, the superficial layer 
of the cutis is either pulled off or falls off, revealing an ulcer, the exact 
size of the superficial crust. 
These ulcers are deep and have a characteristic punched-out appear- 
ance. The edges are steep and are frequently undermined. The floor 
has a dirty gray, moth-eaten appearance, and, until this dirty gray, 
sloughing base is replaced by granulation tissue, healing will never 
occur. The discharge is purulent, profuse and may be bloody at times. 
Constitutional symptoms are absent and remain so unless there is 
lymphangitis or inguinal adenitis. 
Pain.—In contradistinction to the specific lesion of syphilis, 
chancroidal ulcers are extremely painful and are capable of auto- CHANCROID 
291 
inoculation, often spreading to a great extent. A single ulcer is 
seldom seen; multiplicity is the rule. 
Fig. 172.—Chancroid (low power). Shows infiltration of stroma with lymphoid 
cells and polymorphonuclear leukocytes. No increased vascularization. No infiltration 
of bloodvessel walls. (Author’s case.) 
Fig. 173.—Chancroid (high power). Shows bloodvessels with polymorphonuclear 
leukocytes in lumen, but no thickening of walls. 292 
GENITAL ULCERS 
Location.—The ulcers are, generally, confined to parts where the 
greatest friction during coition takes place. In the female, the labia 
or vestibule is most frequently involved; occasionally the external 
urethral orifice is the site of infection. In the male, abrasion or 
tears take place most frequently in the sulcus coronarius, around the 
frenulum, at the edge of the prepuce and the external urethral orifice. 
These places are the sites of predilection. When the ulcer is situated 
at or within the external urethral orifice, urination is always painful. 
Occasionally a gland follicle becomes the site of infection; here the ulcers 
may burrow deep and undermine the surrounding tissue and the gland 
opening may be the smallest part involved. 
Mixed Sore.—It is indeed common to find both chancroid and 
chancre in the same individual, either in the same ulcer, or in different 
ulcers. Often an inflammatory hardness is present in chancroid that 
simulates the induration of the specific chancre. 
Diagnosis.—There is no single condition that receives such careless 
attention as do simple ulcers that occur on the genitals. Few observers 
realize the importance of an exact diagnosis, especially if the infection 
is syphilitic. Unfortunately, the Ducrey-Unna bacillus is difficult to 
find and is little known in this country. Fortunately, however, a 
diagnosis can be reached by exclusion, which is just as accurate and 
more rapid than finding the exciting cause of chancroid itself. Every 
genital ulcer should be examined carefully for the Spirochseta pallida 
and search continued diligently until the presence of the organism is 
excluded before any mutilation or treatment is practised in the way 
of cauterization, dusting powders, etc. There is no longer any excuse 
for haphazard diagnosis in genital ulcers. It is true that clinical 
appearances, multiplicity, lack of induration, etc., may be clear and 
characteristic, but no one should permit an ulcer to come under his 
care without a thorough microscopic examination. 
In most American text-books frequent reference is made to gan- 
grenous conditions that often accompany chancroid. This condition, 
described in detail in the latter part of this chapter, is caused by a 
symbiosis of specific organisms. Here careful microscopic examina- 
tion with the clinical history will permit of an exact diagnosis. For 
further discussion on the diagnosis of chancroid, see Chapter on 
Syphilis. 
Herpes, occurring on the genitals, is often mistaken for chancroid 
infection, unless seen during the vesicular stage; these erosions are 
superficial, have little discharge and are not painful. Lymphangitis 
and adenitis are lacking; microscopic examination is negative. 
While the Wassermann reaction, the technic of which can be found 
in any modern text-book on clinical diagnosis, is absolutely valueless 
as far as an early diagnosis is concerned, occasionally an ulcerated 
papule or chancre redux (see description) may simulate chancroid 
infection. Here the application of the test should be a valuable aid in 
diagnosis; however, the fact should not be lost sight of that the con- 
sumption of large quantities of alcohol just before the test is made may 
cause a negative reaction and the test prove worthless. CHANCROID 
293 
Treatment.—Prophylaxis.—The wearing of a condom during the 
sexual act is the most reliable preventative; thorough cleansing with 
soap and bichloride (1 to 5000) may be employed; however, the latter 
will not always prevent infection. 
It should be borne in mind that no treatment of any kind should be 
instituted until an accurate diagnosis is made; then treatment should 
be prompt and efficient. 
As the exciting organism lies deep in the tissues, cauterization has 
been the favorite method of attack for years, and it is rather strange 
that so many different caustics and methods of application should be 
recommended. Taylor, as cited by Watson and Cunningham,14 
recommends the application of liquefied phenol, followed immediately 
by the application of nitric acid. Care should be taken to use con- 
siderable pressure and to undermine the edges, without touching any 
of the healthy skin with the caustic. This is a favorite method of 
the author. 
By applying the phenol first, considerable local anesthesia is pro- 
duced, so that the subsequent burning with nitric acid is not so 
painful. Under no consideration should phenol or silver nitrate be 
used alone, as only the superficial portion of the lesion is scarified, 
underneath which infection is sealed up and a resulting adenitis is 
rapidly manifested. 
Iodoform as a dusting powder is superior to all others; its odor may 
be destroyed by cumerine, gr. ij to 5 j, or by placing in the bottom of a 
stocking or tobacco pouch ground coffee, over which a layer of cotton 
is placed. The affected part is then dusted with iodoform and tied 
into the sack. 
A favorite and efficient ointment that may be applied is the following: 
* Iodoform 2.5 
Balsam of Peru 5.0 
Petrolatum 50.0 
The use of dusting powders is pernicious and is to be condemned, as 
most of them have no real antiseptic properties and only tend to crust 
over the lesion and hasten absorption, with resulting adenitis. 
Morton recommends the chloride of zinc pulp, which is prepared by 
adding a few drops of water to chloride of zinc. 
A favorite method in some hospitals is the continued application of 
phenol, neutralizing each application well with alcohol. 
Robbins and Seabury first apply a 25 per cent, solution of copper 
sulphate in distilled water to the sore, next the short high frequency 
spark from a rather fine-pointed vacuum electrode is applied directly 
to the lesion for one to three minutes, depending on the extent of the 
ulceration. Especial care is exercised in carrying the point of the 
electrode w’ell down into any fissure or undermined edge, and the 
area of application should extend over the edge of the sore about 
of an inch into the doubtfully healthy area. 294 
GENITAL ULCERS 
The current is not turned off until every crack and crevice has 
been thoroughly treated and the surface of the sore is changed to a 
dark greenish-gray. It is then wiped dry and some antiseptic powder 
is lightly applied to the entire mucous surface of the preputial cavity. 
If the sore is exposed, it should be covered with a thick moist dressing, 
for which any very dilute antiseptic solution may be used, as a 1 to 
10,000 or 1 to 20,000 mercuric chloride solution; or even tap water 
answers nicely in most cases. This should be changed once or twTice 
daily, and must not be allowed to stick. 
The patient is instructed to return in two days, and, if the work 
has been carefully done, the wound will present a perfectly healthy 
granulation that will go on to complete healing in a few days. If 
the sore does not look clean, the application is repeated at the second 
visit. 
Chancroid, situated at the urethral orifice, should not be cauterized 
if it is at all possible to cause its healing without so doing. 
Complications.—1. Phimosis.—This condition is a common and often 
troublesome complication of chancroid; the condition per se is not so 
serious as the delay in the diagnosis of the ulcer that is causing the 
condition. Often it is possible to retract the skin enough to obtain 
material for diagnosis. However, when this cannot be accomplished, 
prompt incision and exposure of the ulcer is recommended. It is true 
that the line of infection may become infected if chancroid is present, 
but the patient, on the other hand, may be saved from the period of 
secondary syphilitic invasion, and this is worth while. 
It is possible in some cases to cause a resolution of the condition 
by immersing the glans in hot water and irrigating with hydrogen 
peroxide. 
Ten per cent, iodoform in glycerin is recommended as an efficient 
method. However, all palliative treatment should be discouraged 
until a positive diagnosis has been made. 
2. Paraphimosis. — Occasionally this condition is seen associated 
with genital ulcers. Contrary to the condition of phimosis, there is 
no obscuring of the etiological factor, and after a diagnosis has been 
made, either incision of the constricting band or manual reduction can 
be resorted to. 
3. Phagedena.—Before the days of antiseptic surgery, phagedena was 
a very formidable complication of chancroid. Its etiology was little 
understood. We have come to know that the Ducrey-Unna bacillus is 
always present, associated, as a rule, with the streptococcus, although 
almost any pyogenic organism may be found at times. Numerous 
text-books still confuse phagedena with gangrenous conditions that 
occur around the glans penis. It must be distinctly understood that 
this form of gangrene has a distinct and separate bacteriology (see 
Erosive and Gangrenous Balanitis), and should no longer be mistaken 
for phagedena. 
Treatment.—As this condition is almost always associated with 
debility and malnutrition, tonics and supportive treatment shoidd be INGUINAL ADENITIS 
295 
instituted. Locally, the ulcers must be cauterized, so that nothing 
but healthy tissue remains. At times it may be necessary to use the 
actual cautery. A continuous hot-water bath, either by means of the 
sitz-bath or immersion of the organ in a vessel of hot water, greatly 
facilitates resolution and repair. 
Sequelse.—(1) Lymphangitis; (2) lymphadenitis. 
Lymphangitis always accompanies chancroid infection in a greater 
or less degree, and in the milder form needs no treatment. However, 
in debilitated individuals, sometimes this is very severe and distressing. 
Continued hot soaking or hot, moist applications should be employed, 
and if softening and fluctuation become manifest, incision should be 
promptly made. 
INGUINAL ADENITIS OR INGUINAL BUBO. 
This is a frequent and severe complication following chancroidal 
infection. 
Etiology.—1. Predisposing Cause.—The condition occurs frequently 
among the poor, laboring classes, who attend the free dispensaries, 
for among them heavy lifting and walking predispose to the infection. 
Among the better class of patients, inguinal adenitis is rather infrequent. 
2. Exciting Cause.—The exciting cause is the Ducrey-Unna bacillus. 
The chancroidal form of infection invariably causes an inguinal adenitis 
unless the primary infection is attended to promptly. 
Symptoms.—The adenitis generally occurs in the second or third 
week of the chancroids, unless the ulcers have been carelessly 
cauterized, in which case it occurs earlier. If the ulcer is on the right 
side, the right inguinal glands become involved; if on the left side, the 
left side is involved; however, when the ulcer is on the frenulum, or on 
both sides, either or both sides may be involved. 
Pain is the first symptom that attracts the patient’s attention, and 
this is increased with walking or the slightest exertion. 
On palpation the individual inguinal glands that run parallel to Pou- 
part’s ligament are easily identified. The glands are hard and very 
tender while the skin over the mass is slightly congested and freely 
movable. At this period the glands may either undergo resolution and 
recede or the condition may become progressively worse. Consider- 
able peri-adenitis occurs, the glands become matted together in 
irregular, tender masses and adherent to the skin and the subjacent 
tissue; the former becomes boggy, dusky red, and edematous, and soft- 
ening occurs rapidly, in some cases with spontaneous rupture. Fre- 
quently the exact counterpart of the chancroid is depicted in an inguinal 
adenitis. The base of the suppurating glands is-dirty gray, and there 
is extropjon of the walls with undermined edges (virulent bubo). 
On cross-section, such a gland shows numerous miliary abscesses. 
Some, of course, undergo resolution, but many break down, become 
confluent, and leave the whole gland as an abscess cavity, with the 296 
GENITAL ULCERS 
gland capsule alone as the limiting membrane. Occasionally, the 
extension of a phagedena into the inguinal adenitis is seen, forming a 
serpiginous ulceration. 
• Treatment —Prophylactic.—The prompt and early surgical treat- 
ment of all chancroidal ulcers (see Treatment under Chancroid) 
should be resorted to. Never cauterize the chancroids with silver 
nitrate or phenol alone, as these both tend to seal over the top of 
the ulcer and cause absorption from the under strata, which invari- 
ably produces an adenitis in twenty-four hours. 
Palliative.—The sore having been previously cleansed and cauter- 
ized, the parts are shaved and scrubbed, hot bichloride (1 to 5000) 
or boric acid dressing are applied, the patient is bandaged firmly with 
a spica bandage and put to bed. 
This hot dressing is changed every two or three hours. This 
procedure, with rest in bed, will cause both resolution in the glands 
that are not too far involved and will hasten softening in those that 
are far advanced. Continuous wet alcohol dressings, in the same men- 
ner that the wet bichloride dressings are applied, may help to cause 
resolution in some cases. Hyperemia applied after the method of 
Bier by means of a bell glass is admirable to promote resolution and 
hasten softening. The common practice of painting the parts with 
tincture of iodine has little or no value. 
Surgical.—This treatment should be withheld until the bubo has 
softened and there is fluctuation; then simple incision at right angles to 
Poupart’s ligament offers the best method of drainage. The wound 
is wiped dry and packed with iodoform gauze. Frequent swabbing 
with tincture of iodine and dressing with wet or dry gauze offer the 
best means of causing resolution. 
Except for the management of chancroid itself, no other condition 
has received so many diverse forms of treatment. Complete extir- 
pation of the glands is a favorite method of radical cure, but unfortu- 
nately being septic in the beginning, these wounds do not heal kindly, 
and occasionally grave complications arise from wounding of deep- 
seated bloodvessels and lymphatics. 
Frequently the chancroidal adenitis may be complicated with the 
indolent adenitis of lues, and here the application of prompt and 
energetic specific treatment, as a rule, causes rapid resolution. 
Phagedena as a complication of adenitis calls for heroic treatment. 
The patient is best anesthetized, and with the actual cautery all 
infectious and necrotic tissue is removed; subsequently the ulcers are 
treated with hot dressings and tincture of iodine irrigations. 
GRANULOMA INGUINALE. 
Granuloma inguinale is a non-inflammatory disease affecting the 
skin of the groin, prepuce, perineum and vulva. It is characterized by 
the development of a small papule which, after rupture, persists in a 
slow proliferation of granular tissue without tendency to local healing. GRANULOMA INGUINALE 
297 
Historical.—The earlier most complete study of this condition was 
made by Aragao and Vianna,45 of Rio Janerio. The disease has been 
present in the more torrid countries for many years and yet has been 
described as a distinct entity only during the past decade. More 
recently the presence of this disease within the United States has 
been noted by Symmers and Frost,64 Randall, Small and Belk,65 and 
others. 
The organism originally described by Donovan55 is found in smears 
made from the granular tissue exudate and is considered pathognomic. 
The present method of treatment most in vogue was described by 
Aragao and Vianna,45 in 1912. They pointed out the almost specific 
action of antimony and potassium tartrate (tartar emetic) when 
given in intravenous solution. Since that time, Hoffman,56 Reed 
and Wolf,61 Campbell,50 Cummings,53 Cuthbert54 and others, in addi- 
tion to those already cited, have made valuable contributions on the 
success of this form of therapy. 
Our most recent and comprehensive study of granuloma inguinale 
occurring in the United States is that of Randall, Small and Belk.67 
Etiology.—With few exceptions, the disease is found almost solely 
in negroes. Both males and females are affected, the former some- 
what more commonly. 
The exact mode of infection is not determined but the location 
suggests a direct contact with an infected individual. It is more 
common in southern and tropical countries, notably South America 
and Australia, but is also endemic in the United States. It has here 
been reported in coastal regions both North and South. Randall 
believes that it has been prevalent in Philadelphia for more than the 
past twenty-five years. 
The specific organism originally described by Donovan,55 in 1905, 
is considered pathognomic of the disease, although it is not always 
demonstrable. The organism is a Gram-negative, non-motile, non- 
sporulent, encapsulated bacillus. 
Smears can be made from the granular tissue after removing the 
surface exudate with sterile gauze. A cotton swab or wire loop may 
be used. A thin spread on the slide is essential. The Wright or 
Giemsa method of staining is used. 
The organisms appear as small, rounded pinkish bodies with a 
dark blue coccoid body in the centre. The pinkish outline is due 
to the presence of a wide capsule and this must be decolorized to 
obtain the true outline of the body proper. These organisms are 
found in the cytoplasm of large mononuclear cells. At times they 
are said to appear in nests, without capsules and presenting a bipolar 
stain. Non-encapsulated forms occur in the polymorphonuclear 
cells. 
Secondary organisms are few in number compared with the usual 
smears from other ulcerative conditions about the genitalia. 
Cultural studies have been reported by Aragao and Vianna,45 
Walker,65 Lynch59 and Randall, Small and Belk.67 Considerable 298 
GENITAL ULCERS 
difference of opinion as to the specific causative agent may be said 
to still exist. The recent work of the latter group is most pertinent 
and suggestive. 
The organisms do not liquefy gelatin or coagulate serum. Freshly 
isolated cultures hemolize blood. Milk is coagulated and acidified. 
Fig. 174.—Smear from lesion; Wright’s stain. X 800. Donovan’s organisms in 
and about mononuclear cells. A rounded “nest” of non-encapsulated organisms 
appears in the disintegrating cytoplasm of one of the cells. (Randall, Small and Belk.) 
Fig. 175.—Smear from lesion; Wright’s stain. X 1200. Intact mononuclear cell 
showing cytoplasm studded with Donovan’s organisms—capsules narrow or absent. 
(Randall, Small and Belk.) GRANULOMA INGUINALE 
299 
Indol is not produced. All the common sugars are fermented. Dulcit 
and rice starch are not. These organisms grow luxuriously on all 
Fig. 174.—Preparation from acid dextrose agar culture; Wright’s stain. X 1200. 
Capsules stained, typical morphology. (Randall, Small and Belk.) 
Fig. 175.—Young broth culture; Wright’s stain. X 800. Bipolar staining and solid 
staining of organisms. No capsules. (Randall, Small and Belk.) 
the ordinary culture media and are favored by an acid reaction. The 
colonies appear as grayish-white, translucent, glistening, dome- 
shaped elevations on round regular bases from 1 to 3 mm. in diameter. 300 
GENITAL ULCERS 
They are not unlike the surface growth, characteristic of the Fried- 
liinder bacillus. 
Pathology.—“ Stained sections of granuloma inguinale show a super- 
ficial cellular area surmounted on a base of dense, hyaline, connective 
tissue. The transition is rather sudden, but no distinct line of demar- 
cation separates the two elements. The cellular area is composed 
of young connective tissue, relatively small in amount, many endo- 
thelial leukocytes, and a smaller number of polymorphonuclear 
neutrophiles. The proportion of the latter varies considerably, 
appearing most numerous in untreated cases. They are probably 
an index of secondary infection. Many lymphocytes are also present 
and an occasional eosinophile. Bloodvessel formation is present as 
in any active granulation tissue. At the margin of the granulation, 
the squamous epithelium of the skin is seen partially destroyed and 
replaced. Further out this merges into normal skin, under which, 
however, the subcutaneous tissues are infiltrated for a little distance 
by round cells. This would indicate that the lesions extend somewhat 
farther than would appear on superficial inspection of the granulating 
area. A feature worthy of note is the proliferation of squamous epithe- 
lium near the edges of the granuloma, where finger-like projections 
extend for some distance into the deeper tissues. In some cases this 
suggested a squamous-cell carcinoma.”—(Randall, Small and Belk.) 
Symptoms.—Subjective symptoms are few. The irritation of the 
denuded surfaces from the pressure of clothing is usually the only 
complaint of pain. The granuloma is not painful to the touch and 
only severe irritation will cause pain. 
Objective symptoms: the lesion starts as a small papule, which 
after rupture and the exudation of slightly purulent fluid, refuses 
to heal and spreads slowly. A resultant overgrowth of reddish-pink, 
exuberant granulation tissue occurs. It is not at all like an ulcer, as 
the edges are redundant and overlap the apparently healthy skin 
margin. There is a scanty exudation, mucoid in character, which 
is practically odorless. 
On the larger flat skin surfaces, the older lesions show a tendency 
toward cicatrization in some areas but continuing to spread in others. 
The most frequent location is in the groin. Spreading occurs 
upward as far as the anterior-superior spine and downward through 
the fold of the groin, often involving the perineum, prepuce, anal 
region and buttocks. The glans and shaft of the penis may become 
extensively eroded. 
In the female the labia majora are most acutely affected, although 
the groin is also involved. Extension may occur into the rectum and 
vagina and enormous swelling of the entire vulvo-perineal region fre- 
quently results. 
Noticeable secondary anemia is present in most cases. There is 
an absence of leukocytosis, eosinophilia, or other cellular or plasmo 
tests of the blood. 
Diagnosis.—The diagnosis is based upon the characteristic clinical PLATE V 
Granuloma Inguinale. 
(Colored photograph and case history kindly furnished by Dr. Alexander 
Randall.) 301 
GRANULOMA INGUINALE 
picture and the bacteriological finding of the specific organism. The 
therapeutic result from the use of antimony intravenously may also 
be regarded as an indication of the accuracy of the diagnosis. 
Chancroidal sores can be differentiated by their ulcerated, under- 
mined edges and the presence of their foul purulent discharge. 
Tertiary syphilis is the most confusing to rule out. Condylomata 
acuminata and condylomata lata resemble the granuloma closely 
when the latter occur about the anus. 
Tuberculosis cutis has been a most frequent diagnosis for granuloma 
inguinale. 
The possibility of mixed infections of granuloma and syphilis, or 
chancroid, must be borne in mind. In those cases where the Wasser- 
mann test is positive, a double infection undoubtedly exists. Erosive 
and gangrenous balanitis must be excluded. 
Any sore occurring in the groin, perineum or genital region, which 
is. resistant to ordinary antiseptics or intravenous arsphenamine, 
should be examined for the specific organism of granuloma inguinale. 
Prognosis and Treatment.—Until the advent of antimony therapy, 
the treatment of these lesions was very disappointing. Salves, 
escharotics and antiseptics have no value; vaccine therapy is useless; 
excision leads to recurrence; arsenic is of no benefit; roentgen ray 
brings about a slow but inconstant healing which is prone to recurrence. 
Under antimony therapy, the prognosis is extremely good. This 
is given in the form of tartar emetic. Intravenous administration 
is essential. The initial dose is given as 0.04 gm. and this is pro- 
gressively advanced to a maximum dosage of 0.10 gm. 
Injections may be given daily or less frequently; the symptoms of 
intolerance for the drug being the guide. Intolerance consists of 
rheumatoid pains in the joints associated with stiffness. 
The drug is prepared by dissolving the powder in sterile normal 
saline solution and is best preserved in sealed sterile ampoules. 
The typical organism disappears from the surface and cannot be 
found in smears after the third or fourth injection. Healing promptly 
follows. 
The amount of drug administration necessary to effect a cure varies, 
apparently, with the extent of the lesion. According to Vianna, it 
is advisable to continue injections at weekly intervals for from three 
to four months after complete healing has occurred. 
Case Report.—W. II., male, aged forty-nine years, denies venereal 
disease. Lesion began two years before hospital admission as a small 
raised papule on the right side of the scrotum. It has gradually 
increased in size without showing any evidence of healing. The 
second lesion appeared several months after the first. The patient 
has had no pain or local discomfort. 
Physical Examination.—Negative throughout. Wassermann test 
negative on all antigens. Lesion appears as seen in colored illustration. 
Smears taken from the lesion found to be positive for the characteristic 
organisms of granuloma and the same organisms obtained in cultures. 302 
GENITAL ULCERS 
Lesion.—Scrotum is large and pendulous. On the right side is a 
raw area measuring 10 x 6 cm. with raised edges and a clean sur- 
face of granulation tissue. There is no ulceration or undermining; 
no discharge or odor present no enlargement of inguinal glands. 
Just anterior to this, the primary lesion, is a smaller one, about two- 
thirds the size of the former one, and of similar character. About 
the periphery of the larger lesion may be seen some nodules, some 
of which are as yet unruptured and covered with normal epithelium, 
while others show characteristic granulation surfaces. In the groin 
above is a similar small nodule. These undoubtedly are new pro- 
liferating areas. 
Treatment.—December 12, 1921.—Patient given intravenously 0.05 
gm. of sodium antimony thioglycolate. No toxic reaction recorded. 
December 14, 1921. Patient given 0.06 gm. of the same drug 
intravenously. 
December 17, 1921. Patient given 0.10 gm. of the same drug 
intravenously. 
Lesion on this date recorded as being paler in color and decidedly 
drier, and has lost its raw appearance. About the periphery can be 
seen early proliferation of epithelium. (Unfortunately this was the 
last of this drug at that time in our possession.) 
On December 20, 22, 24, 27, 30 and January 3, 5, and 9, the patient 
was given 0.10 gm. of tartar emetic intravenously. The lesion was 
completely healed on January 10, 1922. 
The patient was given four further injections of tartar emetic on 
January 23, 25, 27 and 31, and then discharged on his own request 
with orders to continue treatment in the Out-patient Department. 
The patient did not follow out the above instructions, and returned 
under our care on April 25, 1922, with a recurrence of active granuloma 
lesions about the periphery of the former ones. At this time, he was 
given fourteen injections of the triamid of antimony thioglycolate, 
totalling in all 1.2 gm. of the drug and a second time was completely 
healed. * 
B. NON-VENEREAL GENITAL ULCERS. 
1. Ulcers accompanying diabetes found on the glans penis of the 
male and on the vulva of the female, usually shallow without inflamed 
edges. 
2. Ulcers accompanying infectious diseases. 
(а) In measles, usually in little girls. 
(б) In diphtheria caused by the specific bacillus. Rare in the 
male, but sometimes found on the penis. In the female 
found chiefly on the inner side of the labia and on the 
clitoris. In appearance like venereal ulcers, but dis- 
tinguished by the bacterial findings. 
(c) In typhus fever, also more frequent in the female. 
* See article by Dr. Alexander Randall, Journal of Urology, 1922. NON-VENEREAL GENITAL ULCERS 
303 
(.d) Tuberculous ulcers; rare in the male, more frequent in the 
female; usually secondary to tuberculosis in neighboring 
organs, but may be due to direct infection. The ulcers 
are shallow, with their edges but little inflamed, showing 
numerous dentations. The base of the ulcer is usually 
clear and granulating, containing small grayish nodules. 
3. Ulcers which are due to localization of skin diseases on the genitals. 
Herpes Progenitalis.—These ulcers are round or oval, with thin edges 
often showing the characteristic grouping of herpes, but not invariably. 
Found in the male on the prepuce, glans, or sulcus; in the female mostly 
on the labia. 
Etiology.—Predisposing Causes.—It is said to be more common in 
those who have venereal diseases. Phimosis with retained secretions 
and coitus are exciting factors. Males and females are equally affected. 
Bergh11 claims that it is more frequent in women at the time of 
menstruation. 
Herpes progenitalis, the same as herpes in other parts, is due to a 
peripheral neuritis, and may depend on reflex irritation of neighboring 
ganglia due to local or internal secretions. 
Symptoms.—Herpes progenitalis begins as a single lesion or in groups, 
the same as are seen on the face or lips. Slight burning and itching 
are first noticed, and the slightly red area soon develops minute 
vesicular points, which rapidly increase in size to that of a pin-head or 
slightly larger. Frequently these lesions become chafed, causing rup- 
ture of the vesicles, the area becomes confluent or presents several 
small excoriated areas which become irritated by secretions and slight 
infections of ordinary pathogenic organisms. 
Diagnosis.— In an individual recently exposed sexually, presenting 
a confluent patch of herpes that have become excoriated, the diagnosis 
should not be attempted without a careful examination for spirochetes. 
In the early cases, however, the distinct vesicles, rapid onset, and 
absence of glandular swelling should be conclusive. 
Treatment.—Prophylactic.—Where phimosis is present, circumcision 
should be performed. Frequent washing of the parts should be 
attended to. As this condition is self-limited, in the doubtful cases 
where there is any question of a diagnosis, all treatment should be 
withheld. Where the diagnosis is positive, however, simple ointments 
or dusting powder are satisfactory. 
BIBLIOGRAPHY. 
1. Bergh, R.: Moilatsh. f. prakt. Dermat., 1890, x, 1. 
2. Craig, C. F., and Nichols, Henry: War Dept. Bull. No. 3, June, 1913, p. 51. 
3. Doinikow, Boris: Miinchen. med. Wchnschr., 1913, lx, 796. 
4. Dreyfus, Georges L.: Miinchen. med. Wchnschr., 1912, lix, 2567. 
5. Ehrlich, P.: Ztschr. f. Chemotherap. u. verwandt. Geb., 1912, i, 1. 
6. Ellis, Arthur W. M., and Swift, H. M.: Jour. Exp. Med., 1913, xviii, 162. 
7. Jadassohn, J.: Arch. f. Dermat. u. Syph., 1907, lxxxvi, 45. 
8. Kurz, Lena: Jour. Obstet. and Gynec. Brit. Emp., 1913, xxiii, 353. 
9. Morton, Henry H.: Genito-Urinary Diseases and Syphilis, Philadelphia, F. A. 
Davis & Co., 1912. 304 
GENITAL ULCERS 
10. Mott, F. W.: The Cerebrospinal Fluid, Lancet, 1910, ii, 79. 
11. Noguchi, Hideyo: Jour. Am. Med. Assn., 1913, lxi, 85. 
12. Ravaut, Paul: Ann. de mod., 1914, i, 49. 
13. Schereschewsky, J.: Deutsch. med. Wchnschr., 1913, xxxix, 1310. 
14. Watson, F. S., and Cunningham, John H.: Diseases and Surgery of the Genito- 
urinary System. Philadelphia, Lea & Febiger, 1908. 
15. Wechselmann, Wilhelm: Salvarsan Therapy, 2d ed. 
16. Bataille and Berdal: Med. mod., 1891, ii, 340. 
Dind: Rev. med. de la suisse romande, 1911, xxxi, 592. 
Ellerman: Centralbl. f. Bakteriol., 1905, xxxviii, 383. 
Kallionzis, E.: ’lavpfaii) wpoodog ’Ev hvpu, 1910, xv, 385. 
McDonagh: West Lond. Med. Jour., 1911, xvi, 131. 
Romeo, P.: Gazz. d. osp., 1910, xxxi, 1257. 
Tunnicliff, Ruth: Jour. Infect. Dis., 1906, iii, 148. 
Tunnicliff, Ruth: Jour. Infect. Dis., 1911, viii, 316. 
Weaver, G. H., and Tunnicliff, Ruth: Jour. Infect. Dis., 1905, ii, 446. 
17. Corbus, B. C., and Harris, Frederick G.: Jour. Am. Med. Assn., 1909, lii, 1474. 
18. Rona, S.: Arch. f. Dermat. u. Syph., 1905, lxxiv, 171. 
19. Scherber and Muller: Arch. f. Dermat. u. Syph., 1905, lxxvii, 77. 
20. Scherber: Handbuch der Geschlechts-Krankheiten, 1910, i, 153. 
21. Abraham, T. B.: Later Syphilides of the Mucous Membranes, Power and Murphy. 
A System of Syphilis, 1914, v, 156. 
22. Boulton, P.: Extensive Syphilitic Disease of the Vulva, British Med. Jour., 1883, 
ii, 1017. 
23. Darre, H., and Delaunay, P.: Clinique diagnostic des ulcerations vulvaire, Gaz. 
des hop., 1904, lxxvii, 657. 
24. Duncan, J. M.: On Lupus of the Pudendum, Med. Times and Cire., 1884, ii, 671. 
25. Dupuy, R., and Rullier, G.: Remarques sur la symptomatologie et la nature du 
scler&me genito-ano-rectal (esthiomfene de la vulve) Rev. de gynec. et de chir. abdom., 
1907, xi, 1007. 
26. Fournier, A.: Logons sur la syphilis chez la femme, Paris, 1873, p. 500. 
27. Gallagher, J. F.: Syphilitic Indurations of the Vulva, Surg., Gynec. and Obst., 
1919, xxviii, 482. 
28. Gaucher and Nathan: Syphilide chancriforme de la vulve, Bull. soc. frang. de 
dermatol. et. syph., 1908, xix, 104. 
29. Heller, J.: Ueber Esthiom&ne, Arch. f. Dermatol u. Syphil., 1912-1913, p. 401. 
30. Huguier, P. C.: Memoires sur l’esthiomfene de la region, vulvo-anale, Mem. Acad, 
med., 1849, xiv, 501. 
31. Idem. De l’esthiom&ne de la vulve et du perinee These de Paris, 1849. 
32. Hyde, J. N.: The Syphiloma of the Vulva, Jour. Cutan. and Genito-urin. Dis., 
1889, cii, 121. 
33. Lubarsch, O.: Die syphilitschen Neubildugen. Aschoff’s Pathologische Anatomie, 
1911, Uth ed., p. 542. 
34. Morris, Malcom: Diseases of the Skin, 1917, p. 455. 
35. Peckham, Grace: A Contribution to the Study of the Ulcerative Lesions of the 
Vulva, Commonly Called Lupus or Esthiom&ne, Am. Jour. Obst., 1887, xx, 785. 
36. Pozzi, L.: Esthiom6ne de la vulve. Traite de gynecologie clinique et operatoire, 
1907, 4th ed., p. 1288. 
37. Stein, A., and Heimann, W.: Esthiombne and Secondary Elephantiasis Vulva: 
(Ulcus Vulva: Indurativum Edematosum), Surg., Gynec. and Obst., 1912, xiv, 345. 
38. Taylor, I. E.: On Lupus or EsthiomOie of the Vulvo-anal Region, Tr. Am. Gynec. 
Soc., Philadelphia, 1881, vi, 199. 
39. Taylor, R. W.: Chronic Inflammation, Infiltration, and Ulceration of the External 
Genitals of Women with a Consideration of Esthiomime or Lupus of These Parts, New 
York Med. Jour., 1890, li, 1. 
40. Thorn, B. P.: Syphilis and Malignancy, Am. Jour. Syphilis, 1918, ii, 40. 
41. Verchere, F.: La scler&me anovaginal, Rev. gynec. et de ehir. abdom., 1898, ii, 
1078; Bull. soc. frang. de dermat. et de syph., 1908, xix, 207. 
42. Vignolo-Lutato, K.: Beitrag zur Kenntniss des tertiaeren, anorektalen und vul- 
vaeren Syphilids, Dermatol. Ztschr., 1914, xxi, 501. 
43. Robbins and Leabury: Jour. Am. Med. Assn., vol. lxix, 1217-1219. 
44. Aragao: Brazil-med., Rio de Jan., 1919, xxxii, 74. 
45. Aragao and Vianna: Mem. do Inst. Oswaldo Cruz, Rio de Jan., 1912, iv, 211, 
46. Breinl and Priestley: Med. Jour., Australia, 1916, i, 237. 
47. Thorp: Med. Jour., Australia, 1917, ii, 4. 
48. Goodman: Arch. Dermat. and Syphil., 1919, i, 151. BIBLIOGRAPHY 
305 
49. Benjamins: Nederl. Tijdschr. v. Geneesk., Amst., 1921, i, 25. 
50. Campbell: Jour. Am. Med. Assn., 1921, lxxvi, 648. 
51. Christopherson: Lancet, March 12, 1921, 522. 
52. Crichlow: Jour. Trop. Med. and Hyg., 1921, xxiv, 74. 
53. Cummings: British Med. Jour., November 20, 1920, p. 775. 
54. Cuthbert: British Jour. Dermatol., 1920, xxxii, 44. 
55. Donovan: Indian Med. Gaz., 1905, xl, 414. 
56. Hoffman: Muenchen. med. Wchnschr., 1920, lxvii, 159. 
57. Lasbrey and Coleman: British Med. Jour., February 26, 1921, p. 299. 
5S. Low and O’Driscoll: Lancet, January 29, 1921, p. 221. 
59. Lynch: Jour. Am. Med. Assn., 1921, Ixxvii, 925. 
60. Quintini: Gac. Med. de Caracas., 1921, xxviii, 56. . 
61. Reed and Wolf: New Orleans Med. and Surg. Jour., 1921, lxxiv, 25. 
62. Sen Gupta: Indian Med. Gaz., 1921, v, 13. 
63. Summons and Irving: Med. Jour., Australia, 1921, No. 5, 83. 
64. Symmers and Frost: Jour. Am. Med. Assn., 1920, lxxiv, 1304. 
65. Walker: Jour. Med. Research, 1918, xxxvii, 427. 
66. Randall, Small and Belk: Jour. Urol., vol. v, 6, 539. 
67. Randall, Small and Belk: Surg., Gynec. and Obst., June, 1922, p. 717. CHAPTER VIII. 
INFECTIONS OF THE URETHRA AND PROSTATE OTHER 
THAN TUBERCULOSIS. 
By B. S. BARRINGER, M.D. 
GONORRHEA. 
Prevalence of Gonorrhea.—It is highly probable that every male 
who indulges in promiscuous intercourse sooner or later acquires a 
gonorrhea. The percentage of males so affected varies according to 
different authorities, and according to various countries between 50 
and 100 per cent. 
‘‘Morrow estimates that 60 per cent., and Forscheimer that 51 per 
cent, of the adult male population of the United States have gonorrhea. 
He adds that 20 per cent, of these young men will become infected 
before they are twenty-one years of age; over 60 per cent, before they 
pass their thirty-eighth year.” (Keyes.) These are statistics of nine 
years ago. Another specialist says, “roughly speaking, one may say 
that most German men have had gonorrhea; and one in five, syphilis.” 
“Blanchko calculates that among clerks and merchants in Berlin 
between eighteen and twenty-eight years of age, 45 per cent, have had 
syphilis and 120 per cent, have had gonorrhea; in Breslau 77 per cent, 
have had syphilis, 200 per cent, have had gonorrhea. (If the percent- 
age of gonorrhea is placed at 200 per cent, the average is two attacks.)” 
(Flexner.) * 
“Among women gonorrhea is more severe and less common than 
among men. The proportion of men to women is 16 to 1. It is shock- 
ing to learn that almost one-third of the reported cases of gonorrhea 
occurred in married women to whom the infection had been conveyed 
by their husbands.” 
“In the United States Army, in prevalence, gonorrhea stands first 
(12 per cent.+); as a cause for discharge from the army it stands fourth; 
as a cause of death it is negligible.” (Keyes.) 
Reasons for Prevalence.—Illicit intercourse is responsible for most 
gonorrheas. To study the reasons for the prevalence of gonorrhea is to 
study the reasons for prostitution. 
Flexner says: “No wonder that where practice is so general, theory 
has accommodated itself so far as to assume that sexual intercourse on 
the male’s part is necessary and wholesome. Up to recent times this 
has been an undisputed dogma. The universality of demand has been 
condoned on the assumption that it represented an irresistible impulse. 
* Flexner’s book ‘ ‘ Prostitution in Europe ” has been much quoted because it is remark- 
able and modern. 
306 307 
ANATOMY OF THE MALE URETHRA 
“In the first place, however strong the spontaneous sex impulse may 
be, it is really like any other impulse capable of restraint through the 
cultivation of inhibition. Except for the futile efforts of the church, 
European* society has for centuries been singularly free from any such 
effort. Women have been regarded as inferior creatures and have 
accepted the status assigned them; they have therefore failed to 
resent masculine immorality. The restraint that might thereby be 
imposed upon men—be it much or little—has been generally lacking. 
Europe has been a man’s world; managed by men and largely for men; 
for cynical men at that. Men inured to the sight of human inequality; 
callous as to the value of lower class life, and distinctly lacking in respect 
for womanhood.” 
The unrestrained masculine sexual impulse accounts for a certain 
amount of illicit intercourse; to this is added an artificial sexual excita- 
tion, “an artificial supply of prostitutes is created and an artificial 
demand is worked up.” 
A striking example of deliberate business organization along these 
lines is to be found in Paris, where close adjoining one another in the 
Rue Pagal are found a dance hall, a cafe, and an assignation house 
under one management.” 
The Remedy.—The remedy does not lie in any regulation of prosti- 
tution; in any segregation of prostitutes; in any prophylactic treat- 
ment ; in any antigonorrheic vaccination; or in any conscience-solving 
eugenic test. Flexner says, “ the women’s movement will unquestion- 
ably destroy the passivity of German women in respect to masculine 
irregularities.” This would seem to be the key to the remedy. In- 
sistence upon the part of wives and mothers for masculine continence. 
The old and absurd physiological objections that masculine continence 
leads to various nervous disorders, even to impotence, still are wide- 
spread. Sexual education is in its infancy: “As the boy matures, the 
actual danger involved in immorality may be so depicted as to exert a 
detrimental effect; but the main remedies must continue to be from 
the higher motification.” In some sex teaching there exist curious 
practices; for instance, the young man is urged to be continent, and 
at the same time told how to use preventatives. 
The urethra, “the outlet of the bladder,” extends from the bladder 
neck to the end of the penis, and is divided into a posterior (4 cm.) and 
an anterior (12 cm.). The posterior urethra is in turn divided into two 
parts: a prostatic (2.5 cm.), which runs from the bladder sphincter, or 
base of the prostate, through the prostate to its apex; and a membran- 
ous (1.5 cm.) part which runs from the apex of the prostate to the bulb. 
This pierces, is limited by, and receives fibers from the anterior and 
posterior layers of the deep perineal fascia. The anterior, spongy or 
ANATOMY OF THE MALE URETHRA. 
* What Flexner says of Europe is true, perhaps in a lesser degree, of the whole civilized 
world. 308 
INFECTIONS OF URETHRA AND PROSTATE 
penile urethra runs from the triangular ligament to the end of the penis, 
and is surrounded by the erectile tissue of the corpus spongiosum. 
Landmarks of the Urethra.—The only part of the urethra visible 
is the meatus. By means of the urethroscope the interior of the urethra 
may be examined throughout its length. 
The Penile Urethra.—The penile urethra runs from the meatus 
urinarius along the under surface of the penis (where it may be easily 
felt) to the penoscrotal angle, thence to the scrotoperineal angle, 
where it may be palpated by depressing the scrotum. The anterior 
urethra ends in the bulb whose lower limit is at a point midway 
between the scrotoperineal angle and the centre of the anus. This 
spot is the “ central tendon” where the perineal muscles meet. 
Fig. 178.—The lumen of the urethra, seen in a sagittal section: 1, bladder; 2, cul- 
de-sac of the bulb; 3, neck of the bladder; Jj., prostatic widening; 5, narrowing at the 
membranous portion; 6, neck of the bulb; 7, penile narrowing; 8, fossa navicularis; 9, 
meatus. (After L. Testut.) - 
Membranous Urethra.—The finger introduced into the rectum will feel 
the membranous urethra on the front wall just behind the internal 
sphincter of the rectum. It runs from this point to the apex of the 
prostate, which can be felt farther up the rectum. If a sound is intro- 
duced into the urethra, the membranous, as well as the prostatic, por- 
tions can be better palpated. This method of palpation is especially 
valuable to determine the presence of an early carcinoma of the prostate 
which generally starts posteriorly in the lobes and is felt between the 
sound and the rectum. 
Prostatic Urethra.—This runs in the median line from the apex of the 
prostate to its base (felt on the front wall of the rectum). The two 
lateral lobes of the prostate may be felt; but it takes a long finger to ANATOMY OF THE MALE URETHRA 
309 
reach much above the base of the prostate. The seminal vesicles are 
at either angle of the base of the prostate and extend upward and 
outward along the bladder. 
Size of the Urethra.—The urethra begins at the vesical orifice, which is 
wide, usually large enough to admit the tip of the index finger, and may 
be dilated to 36 to 40 F. It becomes still wider in the prostate, but 
after the membranous urethra is reached, narrows down to 26 to 30 F. 
Again, in the bulb it enlarges; then narrows again in the penile portion, 
widens out in the fossa navicularis, and narrows down again at the 
meatus. The meatus is the narrowest and least dilatable part of the 
entire urethra; it averages 24 F. in size. 
Interior of the Urethra.—The interior of the urethra is not a smooth, 
unbroken surface, but shows small and large indentations, and the 
orifices of glands. 
The indentations of the urethra are known as the Lacunae of Mor- 
gagni, and are situated in the anterior urethra, the large ones along the 
roof and the smaller ones along the sides. They are like pockets in the 
mucous membrane opening toward the end of the penis, and are from 
5 to 12 mm. deep. On the roof of the fossa navicularis is an unusually 
large indentation, the lacuna magna. 
The ducts of various glands enter the urethra directly or into one of 
these lacunae. The lacunae of Morgagni can be seen through the 
urethroscope, but the openings of the glands, if uninflamed, are gener- 
ally not discernible. 
Glands of the Urethra.—(1) The glands of Littre. (2) Cowper’s 
glands. (3) The prostate. (4) The seminal vesicles. 
The glands of Littre are situated chiefly along the roof and sides, a 
few in the floor, of the anterior urethra; and rarely in the membranous 
and prostatic urethra. They lie in the submucosa, are lined with 
prismatic epithelium, have a duct which pierces the mucous membrane 
obliquely, and opens toward the end of the penis. They normally 
secrete mucus, and on occasion stubbornly harbor bacteria. When 
normal, they cannot be palpated, but when inflamed, they can often 
be felt along the anterior urethra as nodules from the size of a bird- 
shot up. 
Cowper’s glands are two racemose glands as large as a bean, situated 
on either side of the membranous urethra just behind the bulb and be- 
tween the layers of the triangular ligament. Their ducts are 30 to 40 
mm. in length, run along the urethra, pierce the anterior layer of the 
triangular ligament, and enter the bulbous urethra; when Cowper’s 
glands are inflamed, they can be felt with one finger in the rectum and 
one on the perineum on either side of the membranous urethra. 
The prostate gland “belongs physiologically to the sexual organs,” 
and is somewhat of the size and shape of a horse-chestnut. It lies with 
its base toward the bladder, its apex against the posterior layer of the 
triangular ligament. The urethra and ejaculatory ducts run through 
its substance. Its glands empty by ducts (30 or 40) into the prostatic 
urethra; these ducts point toward the apex of the prostate. 310 
INFECTIONS OF URETHRA AND PROSTATE 
Lowsley8 has done much work on the anatomy of the prostate, and 
I quote extensively from his authoritative work. 
“Wilson and McGrath found the average adult gland to vary in 
length from 3.3 cm. to 4.5 cm., with an average of 3.4 cm. In width 
there is a variation from 3.4 to 4.5 cm., average 4.4 cm. Thickness 
varies from 1.3 cm. to 2.4 cm., average 1.5 cm. The weight averages 
16 or 17 grams. 
“The prostate gland is in every instance divided into five portions 
corresponding to the five original groups of tubular evaginations noted 
in the embryo. The division between the middle and two lateral lobes 
becomes less and less noticeable as age advances, but the orifices of the 
middle lobe tubules are in every instance widely separated from all 
other tubular orifices and quite closely grouped together. The middle 
lobe tubules always grow backward behind the vesical orifice outside 
of the broad ribbon-like sphincter of its orifice and its tubules are 
never found imbedding themselves in it or extending within the 
sphincter. 
“ The lateral lobes during the period of middle age become more and 
more prominent and cause a bulging of the lateral surfaces to a marked 
degree, thus making the transverse diameter of the organ proportion- 
ally greater than in prepuberty specimens. 
“The posterior lobe is fairly well separated from all of the other 
portions of the gland and is divided off by a rather firm, and in some 
instances quite thick, connective-tissue partition. It is always present, 
as is the lobe itself, and is intimately attached to the ejaculatory ducts, 
which are not imbedded in this partition but seem to be set upon its 
anterior surface. 
“The posterior lobe is always present and is the part of the gland 
felt per rectum. Its tubules are in most respects similar to those of 
the other lobes. 
“The anterior lobe varies greatly in different specimens. At the 
time of birth it consists of two small unimportant tubules with very 
few branches. In the postpuberty specimens the anterior lobe is 
quite prominent and is made up of tubules which branch extensively 
and are apparently actively secreting prostatic fluid. 
“The branches of tubules* all extend backward toward the base of 
the prostate, with the exception of a few of the most anterior tubules 
of the lateral and posterior lobes. The collecting ducts are situated 
at the most anterior portion of a given group of branches and pass 
quite directly toward the verumontanum. 
“In the verumontanum the tubules turn and run forward for a 
slight distance and about nine-tenths of them open on the lateral walls 
of the verumontanum, in such a manner that there is a little leaflet 
of tissue covering the orifice, which is an exceedingly important factor 
* Poroz9 has studied the course of these ducts and concludes that they are best emptied 
by massaging the gland from its base downward toward its apex. Gonococci invade 
these ducts of the prostate, in every posterior urethritis, and it is here that they most 
stubbornly persist. ANATOMY OF THE MALE URETHRA 
311 
in protecting the tubules of the gland from an inpouring of urine and 
other foreign matter when the posterior urethra is put under pressure. 
The direction of the openings of the tubules of the prostate and ejacu- 
latory ducts is an important consideration also, because instrumenta- 
tion will frequently cause an infection by forcing foreign substances 
into them. In the adult prostate there is noted a great change in the 
mucosa. I have found in my specimens that the tubules and their 
branches are lined by a single layer of high cylindrical cells with the 
nuclei at their bases. In some places there is a piling up of the cylin- 
drical cells. Near the orifices of the ducts the epithelium is transi- 
tional in type, being similar to that of the urethra itself. 
“The capsule of the prostate is composed of a structure which is 
made up of closely knit connective-tissue fibers and surrounds the 
entire organ, except at the base between the entrance of the ejacula- 
tory ducts into the substance of the prostate and the junction of the 
bladder wall with the gland. Here the tubules of the middle lobe 
are almost free and have as a consequence very thick muscular and 
connective-tissue walls. The large bloodvessels which supply the 
prostate, run in the capsule and intralobular partitions for the most 
part and are most numerous on the anterior portion of the capsule. 
“ The epithelium of the vasa deferentia is made up in part of simple 
ciliated columnar, and in part of stratified, ciliated, columnarc ells with 
two rows of nuclei. The cilia are often absent, however, and vary a 
great deal. In the ampulla of the vas deferens the epithelium is for 
the most part simple columnar in type.” 
The seminal vesicles are two lobulated pouches between the base of 
the bladder and the rectum. They are about 7 cm. in length, and can 
be felt by a finger in the rectum extending upward and outward beyond 
the margins of the prostate. When normal, they can be felt with 
difficulty, and when enlarged, only the lower part is palpable. 
The anterior extremities of the seminal vesicles converge toward the 
base of the prostate where each joins the corresponding vas deferens to 
form the ejaculatory ducts. 
The canal system of these organs is intricate, and varies in different 
specimens from a simple straight tube to tubes with many twists. 
Either the straight or twisted tubes may have diverticula. 
The blood supply is from the middle hemorrhoidal and the inferior 
vesical arteries which enter the vesicles at their upper and outer poles. 
“In this locality the vesicle is in closest relation to the ureter.” 
The vesicles have a thick muscular wall, and are lined with cylin- 
drical epithelium in the young which in later life becomes cuboidal. 
The vesicles in addition to being seminal reservoirs have a secretory 
function and add one of the important constituents to the semen. 
A complete understanding of the pathology and treatment of 
urethritis rests upon a knowledge of various points of dissimilarity 
between the anterior and posterior urethra. The following is a table 
of such points: 312 
INFECTIONS OF URETHRA AND PROSTATE 
Anterior Urethra. 
Surrounded by erectile tissue (corpus 
spongiosum) for entire length, excepting 
for | inch in the roof cf the bulb. 
Many glands of Littre in roof and sides. 
Ducts of Cowper’s glands enter bulb. 
“ External urinary tract in free com- 
munication with the surface of the body 
and harbors all the microorganisms that 
may be thereon.” 
Fixed at only one end (triangular liga- 
ment) therefore can assume any curve (e.g., 
on passing a sound) without causing pain 
to the patient. 
Fluid may be introduced into anterior 
urethra and held there by compressing 
urethral meatus. 
The introduction of a foreign body (e. g., 
fluid or catheter) into the anterior urethra 
causes only pain or burning. 
Inflammation causes simply pain. 
There are no voluntary muscles sur- 
rounding the anterior urethra which can 
resist the introduction of a fluid or an 
instrument. 
Posterior Urethra. 
No erectile tissue covering. 
Very few glands of Littre. 
Ducts of prostatic glands enter pros- 
tatic urethra. 
Verumontanum with ducts of seminal 
glands in prostatic urethra. 
‘ ‘ The lowest section of the aseptic 
internal urinary tract—entirely free 
from bacteria harbored by anterior 
urethra.” 
Fixed at one end by the triangular 
ligament and at the other by the pros- 
tate; so having a fixed “U” curve which 
when straightened (for example on intro- 
duction of a cystoscope) causes pain to 
the patient. 
Fluid cannot be retained in posterior 
urethra. The compression of the sur- 
rounding muscles drives it either back 
into the bladder or forward into the 
anterior urethra. 
The introduction of a foreign body 
(fluid or a catheter) into the posterior 
urethra causes pain plus a desire to 
urinate. 
Inflammation causes pain plus fre- 
quency of urination. 
By means of the perineal muscles the 
introduction of an instrument or fluids 
can be voluntarily resisted; therefore go 
gently as the sound or catheter ap- 
proaches the posterior urethra. 
THE GONOCOCCUS. 
Microscopic Characteristics.—Source of Specimen.—In a urethral 
gonorrhea a specimen for staining is most often obtained by pressing 
or “milking” the urethra, when a drop of pus is expressed. If there 
is no urethral drop, we may have to centrifugalize the urine which has 
just been passed and examine the sediment; or we may have to fish a 
shred from the urine with a pipette or platinum loop. The shreds 
most profitable to examine are those small ones which because of their 
richness in pus and paucity in mucus fall to the bottom of the glass of 
urine. 
If the prostate and seminal vesicles are suspected of harboring the 
gonococcus, a drop of pus may be expressed from the urethra by mas- 
sage of these. Sometimes after such massage the prostatic pus does 
not enter the anterior urethra, but instead is forced back into the 
bladder, whence it may be obtained for examination either from the 
patient’s passed or catheterized urine. 
Preparation of Slide.—If the glass slide is grease-free, heat is the only 
necessary method to fix the specimen. To remove the grease, wash the 
slide in soap and water before using, and then dry it. 
Spreading.—The drop of pus to be examined may be spread upon 
the slide by dipping the edge of another slide in the pus and streaking THE GONOCOCCUS 
313 
it. along the first slide. Another good method is to wind the end of a 
tooth-pick tightly with cotton, dip this into the pus and gently streak 
the pus along the slide. 
Urinary shreds are generally too thick to be examined; so they should 
either be flattened by pressing between two glass slides, or teased out 
with the end of a pipette. 
Fixing.—Allow the preparation to dry in the air and then pass it 
several times through a Bunsen flame. 
Staining —Methylene Blue.—The smear is covered with a saturated 
aqueous solution of methylene blue for five seconds, then washed in 
running water, dried, and examined with the oil-immersion lens. 
Fig. 179.—Photomicrograph of gonococci. (Ed.) 
Appearance of Gonococci.— Typical.—The gonococcus of Neisser is 
morphologically a micrococcus which occurs in pairs (diplococci), 
separated by a fissure, each individual being kidney or coffee-bean 
shaped. This pairing (occasionally quadrupling) is in marked con- 
trast to the irregular grape-like massing of staphylococci, and the 
wreath or chain-like arrangement of streptococci. 
Gonococci have an affinity for the protoplasm of pus cells, and often 
completely fill the cell. 
Atypical.—Gonococci may appear wholly between the pus cells 
arranged so as to resemble staphylococci or streptococci; or only one 
or two may appear in a pus cell. 
Value and Limitations of Methylene-blue Stain.—Acute Gonorrhea.— 
For a common working diagnosis of acute gonorrhea the methylene- 
blue stain is the popular stain, and with it to supplement the clinical 314 
INFECTIONS OF URETHRA AND PROSTATE 
evidence one cannot go far wrong. If the gonococci are typical as to 
arrangement and intracellularity, the only slip-up that can occur is 
through mistaking the gonococcus for that rare inhabitant of the 
urethra, the Micrococcus catarrhalis. And this mistake is not deadly, 
as the treatment for catarrhalis urethritis is much the same as that 
of gonorrheal urethritis. If the cocci examined do not have a typical 
appearance, then a Gram stain should he made. 
Chronic Gonorrhea.—It is a different story in chronic gonorrhea. 
Both streptococci and staphylococci may be mistaken for gonococci. 
The Gram stain alone is of value. 
The methylene-blue stain should never he used to verify a cure of gonor- 
rhea. 
Gram Stain.—The gonococcus, in addition to its other peculiarities, 
is what is called “Gram-negative,” which means that in a slide which is 
treated by Gram stain and decolorized by alcohol the gonococci do not 
take, or are negative to the Gram stain; while other organisms to be 
differentiated from the gonococci are supposed to take or be positive 
to the Gram stain. 
Staining Slide.—The smear on the slide is prepared as outlined above. 
“The Gram stain is so frequently carried out in a loose and inaccurate 
manner that it seems worth while to note the method of staining 
employed at the Cornell laboratories. It is essential for the success 
of this stain that the various steps be measured by the watch. The 
film, after fixation by heat, is treated with an anilin water, gentian- 
violet solution for a period of three minutes, blotted, and a Lugol solu- 
tion applied for two minutes. The film is again blotted and washed 
in absolute alcohol for thirty seconds. In the case of spreads made 
from exudates, differentiation in absolute alcohol is continued for a 
longer period, the time allowed depending upon the thickness of 
the film. As a counter-stain, a very weak watery solution of basic 
fuchsin is employed, which is allowed to act for thirty seconds. The 
anilin water, gentian-violet solution is made up according to the fol- 
lowing formula: Anilin water, 3 parts; absolute alcohol, 7 parts; 
distilled water, 90 parts. This mixture is thoroughly shaken and 
filtered through a well-moistened filter. To the close filtrate add 
2 grams of Grubler’s powdered gentian violet, shake well, and set 
aside for twenty-four hours. For staining purposes, pipette off the 
supernatant fluid, which obviates the necessity of filtration. This 
solution will keep for from four to six weeks, and does not immediately 
deteriorate, as is popularly supposed. A watery solution of Bismarck 
brown gives a better counter-stain than the basic fuchsin, unless this is 
employed in very weak solution to avoid overstrain. Unfortunately, 
the brown has to be made up fresh. (Keyes.) 
As with the methylene-blue stain, the Gram stain is not used to 
verify a cure of gonorrhea. 
Method Employed for the Isolation of the Gonococcus.—To 
establish the diagnosis of gonorrhea beyond all question of doubt the 
isolation and identification of the specific causative agent is essential. THE GONOCOCCUS 
315 
Absolute certainty concerning this point is demanded only in certain 
cases of medicolegal importance (rape, divorce, etc.). 
In acute cases the recovery of the gonococcus from the discharge, 
as a rule, presents no difficulties, providing suitable culture media are 
selected for this purpose. In chronic cases success depends upon the 
selection of the most favorable culture medium for the development of 
the gonococcus and upon adherence to certain details in securing the 
material for examination and preparing the cultivation. But even 
under the most favorable circumstances repeated examinations are 
frequently required before a definite opinion concerning the nature of 
the disease can be given. 
The method given below has been followed in the bacteriological 
department of the Cornell Medical College for several years. A 
comparison of the results secured by means of cultural methods and by 
the complement-fixation tests in the same cases indicating the degree 
of reliability of the two methods is given under “ Complement-fixation 
Test.” 
Collection of Material for Examination.—The patient is requested to 
appear at the laboratory with a full bladder. After wiping the urethral 
meatus and end of the penis with an aqueous solution of carbolic acid 
(1 to 60), followed by alcohol (50 per cent.), the patient is instructed 
to empty the bladder completely. The first portion passed is collected 
in large sterile test-tubes and is treated as indicated below. The 
main object of this step in the procedure is to mechanically sterilize 
the urethral canal. A sterile dressing is now applied to the end of the 
penis and after the lapse of thirty minutes the prostate and seminal 
vesicles are thoroughly massaged, the meatus is again sterilized and 
the urine passed is collected in a sterile test-tube of large size. 
Material from both samples of urine is now transferred to sterile centri- 
fuge tubes and centrifugated at high speed for fifteen minutes. If the 
amount of sediment secured by these means is small, pour off the clear 
supernatant fluid, add more urine, and repeat centrifugation. The 
sediment thus obtained is employed for the preparation of films, which 
are stained with methylene blue in the usual manner. The number of 
bacteria found in the films determines the amount of material employed 
for cultural purposes. In addition three films from each sample are 
prepared and stained according to the Gram method. 
Cultural Methods.—Schwartz12 has described the following method 
for culturing the gonococcus. 
1. Agar Medium.-—Five hundred grams of fresh lean meat—veal 
or beef—is finely minced and thoroughly mixed with 1000 c.c. of 
distilled water. This mixture is allowed to stand on ice for twenty- 
four hours. The liquor is then decanted and the remainder expressed 
through cloth, adding enough distilled water to make 1000 c.c. Boil 
until the albumen of the meat infusion coagulates. Correct to an 
acidity of pH 7.6 by the use of yy NaOII. In order to eliminate 
the effect of C02, which is acid to phenolsulphonephthalein, media 
should be titrated at as nearly 100° C. as possible, for then in sub- 316 
INFECTIONS OF THE URETHRA AND PROSTATE 
sequent sterilizations the reaction will be less likely to be altered by 
driving off the C02 dissolved in the media. Boil again for a short 
time, filter and make up to 1000 c.c. with distilled water. Add 10 
gm. peptone (Baeto.-I)ifco.), 5 gm. NaCl (C. P.) and 15 gm. agar, 
and boil until all is dissolved. If the media is to be used in hot cli- 
mates or in the summer, 20 gm. of agar should be used instead of 
15 gm. This will give firm slants even after the addition of the hydro- 
cele fluid. Let cool to 50° C. and then add the whites of three fresh 
eggs. Starting with a low flame, boil for ten minutes and again 
strain through cloth. Filter through a folded filter. This filtra- 
tion is very slow, but can be hastened by placing the flask and fun- 
nel in an autoclave at ten pounds’ pressure. Place 5 to 6 c.c. of the 
medium in each tube, and plug with a cotton stopper. The test- 
tubes best suited for this work measures about 150 mm. in length 
and about 16 mm. in diameter, and are made of heavy glass. Thin 
tubes are apt to crack when flamed and stoppered. These tubes are 
then autoclaved at ten pounds’ pressure on three successive days. 
This sterilization changes the reaction from pH 7.6 to pH 7.4. 
The hydrocele, ascitic or pleuritic fluid, having been collected 
under the most rigid aseptic surgical technic, is tested to insure its 
freedom from any bacterial organism. If sterile, it is kept in the 
refrigerator until needed. Lncontaminated hydrocele fluid is essen- 
tial because of the great difficulty of sterilizing it if contaminated. 
Freshness of the fluid is not an essential, as we have had just as 
good results with fluid kept in the refrigerator for six months, as 
with the fluid a few hours old. 
The tubes of agar are melted and placed on a water-bath at about 
50° C. To this melted agar is then added, hydrocele, ascitic or 
pleuritic fluid, in the proportions of 1 c.c. of fluid to 2 c.c. of agar. 
This proportion will permit the agar to harden into a firm slant and 
should produce about 0.5 c.c. of water of condensation in the angle 
of the slant when the agar is firm. Tubes are then slanted or Petri 
dishes poured and allowed to harden. 
The tubes are then stoppered so as to be air tight, with sterile 
rubber stoppers, and kept in the incubator to insure their sterility 
and to have the media warm when wanted for use. Undoubtedly 
some of our early failures at primary culture were due to the fact 
that we had not kept the medium warm, and had attempted to grow 
gonococcus on cold media. The gonococcus is very sensitive to 
changes in temperature, and material, such as pus and urine, sup- 
posed to contain gonococcus, should not be allowed to cool. Cultures 
made from urethra or vagina should be kept at or near body tem- 
perature before being transferred to the incubator. The stoppering 
prevents evaporation and drying of the media. This is important 
as moisture is essential to the luxuriant growth of the gonococcus. 
2. Liquid Medium.-—If fluid media is desired, it is made exactly 
as above, except that the agar is omitted and after autoclaving, 1 
c.c. of a 10 per cent, sterile solution of dextrose, maltose or whatever 
sugar is desired is added. THE GONOCOCCUS 
317 
The hydrocele, ascitic or pleuritic fluid is added in the same pro- 
portions as above. More can be used if desired, but 2 to 3 c.c. per 
tube is sufficient to insure a good culture. These tubes are stoppered 
in the same manner as the agar slants, and kept in the incubator. 
This enables us to test the sterility of the medium as well as having 
it maintained at body temperature and ready for use at any time. 
Fig. 180 
The stoppering of the tubes is quite important, as it prevents the 
drying out, hardening and cracking of the medium as well as the 
evaporation of the water of condensation. Also the number of con- 
taminations is much smaller with the sterile rubber stoppers than 
when the ordinary cotton plugs are used. 
Swartz describes a simple method used to reduce oxygen tension 318 
INFECTIONS OF THE URETHRA AND PROSTATE 
in culture tubes, which reduction is essential for luxuriant growth 
of the gonococcus. This method has enabled us to grow the gono- 
coccus from all cases showing organisms in smears and from a num- 
Fig. 181 
her in which the organisms could not be demonstrated microscopi- 
cally. A pure culture can nearly always be obtained if great care is 
taken to cleanse the meatus and surrounding skin with alcohol and THE GONOCOCCUS 
319 
the culture material obtained on a platinum loop from some distance 
within the urethra. An occasional contamination with the staphylo- 
coccus or a diphtheroid bacillus occurs. The planting should be 
heavy, and care should be taken not to cut the surface of the media. 
We have never obtained a growth in the depths of a stab culture. 
We have found it of distinct advantage to inoculate the water of 
condensation in the angle as well as to stroke the slant and then gently 
flow the water of condensation over the surface of the slant. 
Description of Colonies.—On slants, the colonies begin to appear 
in fifteen to eighteen hours (Fig. 180, B) as small translucent points. 
In twenty-four to thirty hours the growth even in primary cultures 
(Fig. 181, A and B) is usually very heavy. The colonies appear 
as delicate grayish moist-looking translucent spots which tend to 
remain discrete for a few days. Individual colonies are circular, 
with scalloped margins, sometimes slightly raised, and delicate radial 
striations. The centres are granular and viewed by transmitted 
light have a brownish hue, and occasionally a yellow tinge. The 
growth appears slimy, but is easily removed from the slant by wash- 
ing with normal salt solution and makes a flaky emulsion. 
The growth does not appear as quickly in the liquid media as on 
the slants, requiring forty-eight to seventy-two hours. The growth 
is never as heavy in the liquid and appears as a delicate film on the 
surface, with or without tiny strings hanging from its under surface. 
As the culture ages, some of the organisms sink to the bottom. The 
fluid medium is never clouded by the gonococcus. If a contamina- 
tion is present, the medium becomes cloudy. 
The viability of the gonococcus on this medium is about seven 
days, and subcultures should be made every few days. We have 
been able to secure growth on several occasions from ten-day old 
cultures. 
We have not seen any gonococci in our work wrhich were not 
Gram-negative. All the strains with which we worked fermented 
glucose, but failed to ferment maltose, levulose, saccharose, lactose 
and galactose and failed to grow on ordinary media, with but one 
exception. Involution forms were rare in primary cultures, but 
appeared after two or three subcultures. After a strain had been 
subcultured for several weeks, occasionally the growths would not 
be profuse. A transfer from solid to liquid media for several genera- 
tions usually restored the luxuriant growth. 
The Complement-fixation Test.—Schwartz and McNeil10 published 
their first article on the complement-fixation test in 1911. They say: 
“The chief point of departure from the methods of previous investi- 
gators in this line has been in the use of many different strains of 
gonococci in the preparation of the antigen, instead of only one. We 
were led to do this by the knowledge that different strains of the 
gonococcus seemed to differ considerably one from another, and the 
possibility suggested itself that perhaps the serum of a patient infected 
with one strain of the gonococcus might only fix complement in the 320 
INFECTIONS OF THE URETHRA AND PROSTATE 
presence of an antigen from the same strain, or from some closely 
allied strains, but might not do so in the presence of an antigen pre- 
pared from some widely separated strain. In case we proved this 
point we realized that the method would be too cumbersome for clinical 
application if all of the sera had to be tested against separate antigens 
prepared from a number of different strains of gonococci. 
“The idea occurred to us that possibly an antigen prepared from a 
mixture of all the different strains might work satisfactorily; in other 
words, that a ‘polyvalent’ antigen might detect the presence of gono- 
coccal antibodies every time that a single strain would do so.” 
The Research Laboratory of the New York City Department of 
Health has been working to perfect the technic of the complement- 
fixation test, which is as follows: 
Materials: Patient’s serum, gonococcus antigen, guinea-pig comple- 
ment, indicator (sensitized cells), 0.9 per cent, saline solution. 
The patient’s serum and all reagents are pipetted in one-tenth the 
original Wassermann volumes.* The serum is removed from the clot 
twenty-four hours after bleeding and is kept in the ice-box at 8° C. 
until it is tested. The serum is inactivated by heating in the water- 
bath at 56° C. for thirty minutes. 
The patient’s serum is mixed in a test-tube with the standard dose 
of gonococcus antigen and the standard dose of guinea-pig comple- 
ment. This mixture is placed in the water-bath for one hour at 
37° C. to allow the reaction to take place. 
The complement-fixation reaction is invisible and must be demon- 
strated by an indicator. For this purpose sensitized cells are used. 
The sensitized cells consists of 0.1 c.c. of a 5 per cent, suspension of 
sheep cells mixed with the standard dose of antisheep amboceptor. 
These are added to all the tubes at the end of the fixation period. 
If any free complement is in the test-tube after the fixation period, 
it will combine with the sensitized cells producing hemolysis of the 
sheep cells. If there is no free complement in the test-tube after 
the fixation period, that is, if all the complement has been fixed by 
the combination of patient’s serum and gonococcus antigen, there 
will be no hemolysis in the test-tube. 
If the patient’s serum contains gonococcus antibody, there will 
be complete or partial fixation of complement. If the patient’s 
serum contains no gonococcus antibody there will be no fixation of 
complement. 
In order to be sure that the reactions in the test-tube are due to 
the combination of antibody with antigen, the following controls 
must be made with every set of diagnostic tests: 
The patient’s serum must be tested for anticomplementary reac- 
tion to guard against false positive diagnosis, and it must be tested 
for natural antisheep amboceptor to avoid false negative results. 
The antigen must be tested for anticomplementary reaction to 
avoid false positive diagnoses. 
* These dates have been kindly supplied by Miss M. A. Wilson, of the New York 
Department of Health. THE GONOCOCCUS 
321 
The complement must be tested for hemolytic activity to avoid 
false negative results. Although the complement dose has been 
carefully standardized before the tests are made, a control must be 
put in with the tests in order to be sure that the complement has 
not deteriorated during the period of the test. 
The sensitized cells must be tested for stability to avoid false 
negative results. 
The accuracy of the test depends upon the most careful adjustment 
of all the reagents, also the cleanliness, neutrality and accurate cali- 
bration of the glassware, and upon the skill of the technician. 
The greatest cause of variation in reports from different labora- 
tories lies in their treatment of the complement. Some laboratories 
use 0.1 of 1 to 10 dilution of complement (its hemolytic and fixative 
values being unkown) with varying doses of antisheep amboceptor 
to sensitize the cells. Others use a constant dose of complement, 
measured by its hemolytic value without regard to its fixative value; 
whereas the technic given here described a complement dose measured 
by its hemolytic and fixative values. It is a well-known fact that 
guinea-pig serums vary in their hemolytic values and it is recognized 
by a few laboratories that the guinea-pig serums also vary in their 
fixative value for gonococcus complement-fixation. Where large vol- 
umes of complement are required to test many patients’ serums on 
one day, it saves time to make preliminary tests of each guinea-, 
pig serum before pooling for diagnostic tests. Otherwise all the 
tests may have to be repeated the next day, causing delay in reports 
and embarrassment to the technician. All guinea-pig serums should 
be tested for hemolytic activity, natural antisheep amboceptor and 
gonococcus fixative value before being pooled for diagnostic tests. 
Some of the writers who have observed this phenomenon have sought 
to counteract it by pooling a large number of guinea-pig serums. 
If such a pool contains more fixable than non-fixable serums, it will 
give reliable complement-fixation tests; but if the pool contains more 
weakly-fixing, or negative serums, the pool should not be used for 
testing patient’s serums. 
Diagnostic tests should always be made by experienced technicians, 
never by untrained laboratory assistants. 
To Keyes5 is due the first careful comparison between the relative 
merits of the complement-fixation test and a careful bacteriological 
test. In his series “complement-fixation test has been found wrong 
in 1 examination out of 47; bacteriological test, 1 in over 100 examina- 
tions.” 
Cases Used In.—McNeil8 says: “In cases of anterior gonorrheal 
urethritis in the male, and acute vulvo-vaginitis in the female, a positive 
reaction is practically never obtained. But shortly after the posterior 
urethra in males, and the cervix and the glands of Bartholin in females 
are involved the same patient reacts positively.”* 
* This last statement is borne out in the recent article. “Resection of Bartholin’s 
Glands,” Barringer, Williams and Wilson, New York State Jour. Med., April, 1922. 322 
INFECTIONS OF THE URETHRA AND PROSTATE 
The complement-fixation test is, therefore, sooner or later positive 
in cases (in the male) of posterior urethritis, prostatitis, seminal vesicu- 
litis, epididymitis, cystitis, pyelonephritis, arthritis, etc. 
Time of Appearance.—A positive reaction in the blood may not be 
looked for until the gonococci have persisted long enough to cause 
such a reaction; this usually takes about a month. “I have obtained 
a reaction in twelve days.” (Keyes.) 
Time of Disappearance.—“A positive reaction usually persists from 
six to eight weeks after a cure has been effected. It has also been 
found that antibodies disappear from the blood of rabbits immunized 
to gonococci in about the same period. Therefore, if a strong positive 
reaction is obtained seven or eight weeks after a probable cure, the 
patient should be treated as if he still harbored gonococci.” (McNeil.) 
A negative reaction has been obtained two weeks after cure. 
Effect of Vaccines of Complement-fixation Test.—If gonococcus vac- 
cines are given to a patient who has a fading or weakly positive 
complement-fixation test, the vaccines will change this weakly positive 
to a strongly positive test. 
If a patient has not recently had a gonorrhea, the giving of vaccines 
will affect his complement not at all.* 
It is possible that vaccines given to a patient whose complement- 
fixation test has recently become negative might change this negative 
into a positive complement-fixation test. If this be so, its medico- 
legal value is obvious. 
Vaccines given to animals cause a complement-fixation test to per- 
sist for about fifty days. It is probable that this is a good index for 
the time of persistance in man. 
Weakly Positive Complement-fixation Tests.—As far as my experience 
goes a complement-fixation test either weak or strong is caused alone 
by gonococcal inflammation. 
A weakly positive complement-fixation test is interpreted as meaning 
that a gonorrhea is nearly or already cured. It should, however, be 
interpreted in relation to the clinical symptoms. If the clinical symp- 
toms are at variance with the weakly positive test, then another 
complement-fixation test should be made after a period of some weeks 
or a culture should be the final test of cure. 
I do not believe, however, that I have ever seen a weakly positive 
complement-fixation test become strongly positive (if vaccines are not 
given) or a weakly positive do anything else than become rapidly 
negative. 
Practical Value.—In all cases of anterior gonorrhea a clear urine or a 
bacteriological test are necessary to declare a patient cured. In all 
cases of posterior urethritis I have, with very few exceptions, used the 
complement-fixation test alone. Its results, of course, must be inter- 
preted with discretion. If a patient has a general arthritis, and a 
complement-fixation test pronounces this gonorrheal in origin, gono- 
* Schwartz is my authority for these two statements. THE GONOCOCCUS 
323 
cocci are not necessarily present in the urethra. In case of differential 
diagnosis between rheumatoid arthritis and gonorrheal arthritis the 
complement-fixation test fixes the diagnosis. Naturally, the comple- 
ment-fixation is negative if an arthritis is due to a non-gonorrheal 
seminal vesiculitis. 
Keyes has pointed out its value in solving certain medicolegal 
problems. 
“A married man had acquired a gonorrhea several months pre- 
viously and had infected his wife. No gonococci were found in the 
urine, and he was declared free from infection, although his urethritis 
was not cured. His wife was also examined and pronounced cured. 
No blood test was made upon either. Yet six months later he returned, 
denying extramarital exposure, but showing a fresh gonorrhea two 
weeks old. Both he and his wife immediately submitted to the 
complement-deviation test, and both were negative. Four weeks later 
he was positive and she negative, while she remained clinically clean. 
This development of a positive reaction in him showed his infection to 
be a fresh one due to extramarital exposure, in spite of his fervent 
denials.” 
The accuracy of the complement-fixation test varies according to the 
experience of the serologist in doing the test. 
If a serologist has but recently taken up the test, his results should 
be checked up by comparison with the clinical and bacteriological 
findings. And even if performed by a serologist experienced in doing 
the test, a similar checking up should take place from time to 
time. 
Etiology of Gonorrheal Urethritis.—This disease is practically always 
acquired by coitus on the part of the male with a woman infected with 
gonorrhea. One who treats gonorrhea should be acquainted with vari- 
ous peculiarities in its transmission, because the afflicted male always 
wishes to place the blame for his disease; wishes to know why he has 
acquired it; and why another male friend, possibly the husband, is 
free from it. 
Wertheim says husband and wife may become so immune to each 
other’s gonococci that it is impossible to have a further exacerbation of 
the disease between these two. When a third person trespasses, how- 
ever, he may acquire an acute gonorrhea, while neither of the original 
pair have any manifestations of the disease. 
The male may have used a protector (condom). “Such a gonorrhea 
is acquired during preliminary skirmishing.” 
One of two men who have connection with the same woman may 
acquire gonorrhea and the other not. Difference in the conformation 
of the urethral meatus may have caused this; a wide meatus predis- 
poses. Also one may have been intoxicated, which also favors the 
acquisition. It is well to remember that a medical certificate alleging 
freedom of the woman from gonorrhea means nothing. Such certifi- 
cates are generally given by physicians who are incompetent and 324 
INFECTIONS OF THE URETHRA AND PROSTATE 
untrustworthy. Such a certificate may antedate the present gonor- 
rhea. It is probable that the female is infectious at times and at other 
times uninfectious; for example, the local congestion due to menstrua- 
tion may bring forth the hidden gonococcus. 
Pathology of Acute Gonorrheal Urethritis.—Acute Anterior Gonorrhea. 
—Our knowledge of this dates to the work of Finger, Gohm, and 
Schlagenhaufer2 who inoculated criminals condemned to death and 
then found by an immediate postmortem the changes caused by the 
gonoccocus. Keyes sums up their work as follows: 
“ Thirty-eight hours after inoculation the gonococci had only just 
begun to effect an entrance between the epithelial cells. The lacunae of 
Morgagni were crowded with the cocci; diapedesis had begun and intra- 
cellular gonococci were found among the few leukocytes on the surface 
of the epithelium. At the end of three days the inflammatory process 
was well under way. The surface of the mucous membrane was covered 
with pus, its epithelium infiltrated by bacteria from one side and by 
leukocytes from the other. The inflammation showed four striking 
characteristics, viz.: (1) The pavement-epithelium of the fossa navic- 
ularis, although swollen with leukocytes, resisted the invasion of the 
gonococci almost absolutely; (2) the cylindrical epithelium of the penile 
urethra was generally invaded; (3) this invasion was most marked 
about the crypts and glands, which were packed with pus and gonococci; 
(4) the subepithelial connective tissue, though showing every evidence 
of inflammation, contained few gonococci except in the neighborhood 
of the crypts and glands.” 
The inflammation extends until gonococci have penetrated deep into 
the layers of the mucous membrane, which has become acutely con- 
gested, the epithelium undergoing mucous degeneration and exfoliating 
in patches. Later the mucosa is occupied by embryonic cells, becomes 
thick, inelastic, and bleeds easily. The inflammation may extend 
beyond the mucosa to the submucous layer and even to the corpora 
cavernosa. This may be accompanied by phlebitis, arteritis, or 
lymphangitis. 
The ducts of many of the urethral glands and crypts are inflamed. 
The inflammation in the ducts may simply resolve or the inflammation 
may cause closure of the orifices of the ducts and extend into the glands, 
which may be converted into pus sacs. Such an abscess cavity may 
discharge through the gland duct into the urethra or rupture directly 
through the mucous membrane; or the gland may enlarge and finally 
rupture externally through the corpus spongiosum. 
In most cases, if the patient be properly treated, or at least let alone, 
the inflammation travels slowly toward the posterior part of the anterior 
urethra, the gonococcus diminishing in virulence the while. The 
inflammation may be restricted to the anterior urethra and never reach 
the posterior. 
Acute Posterior Gonorrhea.—In most cases, however, the gonorrhea 
does reach the posterior urethra, sometimes stormily, sometimes quieth. THE GONOCOCCUS 
325 
These stormy invasions are generally the result of improper and too 
early instrumentation or indiseretions on the part of the patient; rarely 
to a virulent infection. 
By the time the gonococci reach the posterior urethra their virulence 
is generally diminished and the body has been manufacturing antibodies 
for some days. So the posterior urethra may be acutely inflamed, or 
attacked by somewhat enfeebled gonococci, which results in a more or 
less subacute inflammation. 
Almost every posterior urethritis involves both the membranous and 
prostatic urethra. The glands of the membranous urethra are few and 
inflammation of this portion is always overshadowed by the prostatic 
involvement. The verumontanum may be acutely inflamed and the 
inflammation may travel to the seminal vesicles or by way of the 
seminal ducts to the epididymis. Acute epididymitis is commoner 
than acute seminal vesiculitis. 
Pathology of Acute Gonorrheal Prostatitis.—Acute prostatitis is of 
three different grades. 
1. Catarrhal 'prostatitis probably occurs in all cases of posterior 
gonorrhea; the gonococcus enters the prostatic ducts and causes a pro- 
liferation and desquamation of epithelium and leukocytes. This may 
resolve or become chronic. 
2. Follicular prostatitis is more infrequent than catarrhal. The 
gonococcus enters a prostatic duct and causes a purulent inflammation. 
The walls swell and the mouth of the duct is blocked with pus; a small 
abscess forms which breaks through the duct or through the surface of 
the gland. 
3. Parenchymatous Prostatitis.—All parts of the prostate are affected; 
the glands may be primarily so, and the fibromuscular stroma second- 
arily involved. 
There is marked congestion and serous infiltration; then small round- 
celled infiltration with enlargement of the gland. This form may 
resolve completely, but it often goes on to chronic induration and leaves 
an enlarged prostate. The most severe form is purulent inflammation 
with abscess formation, when a half or all of the prostate may become 
a pus sac. This may break into the urethra, or into the rectum, 
or appear in the perineum, or ischiorectal fossa. A periprostatic 
abscess may follow a prostatic abscess. We may have finally 
periprostatic phlebitis, which may cause thrombosis and metastatic 
abscesses. 
Urinary infiltration with gangrene of the perineum and gangrene of 
the penis, because of compression and thrombosis of the “plexus pubes 
impar,” may occur. 
Pathology of Cowperitis.—Acute inflammation of Cowper’s glands 
follows the same grades of inflammation as are seen in the prostate. 
If an abscess of Cowper’s glands forms, it generally points in the peri- 
neum on either side of the bulb. 
Pathology of Chronic Gonorrheal Urethritis.—The acute inflammation 
generally passes over into the subacute and chronic forms within a 326 
INFECTIONS OF THE URETHRA AND PROSTATE 
few weeks. The discharge and gonococci diminish. The embryonic 
infiltrations are resorbed and the epithelium is gradually regenerated, 
but probably in no case are the cylindrical epithelial cells restored as 
such. In their place is put down pavement-epithelium. Gonococci 
do not attack pavement-epithelium as readily as they do cylindrical, 
which accounts for the severity of the first gonorrhea and comparative 
mildness of future attacks. Aside from the above the urethra may 
return to normal. With subsequent inflammations or with a severe and 
long first gonorrhea, this pavement-epithelium may be replaced by 
flat squamous epithelium which still further resists the entrance of the 
gonococcus. 
Gonorrhea becomes chronic because the inflammation persists in 
glands and crypts of the urethra. The glands of Littre may become 
small pus sacs because of occluded ducts; these sacs may rupture and 
the gland become obliterated, filled with scar tissue; or they may be 
converted into cysts. The crypts may become reddened. The 
mucosa because of the chronic inflammation may lose its grayish-yel- 
low color and its striae and become red. (Soft infiltration of Oberlander.) 
With the progress of the inflammation this redness may change 
to a grayish color because sclerosis of the bloodvessels and that part 
of the urethra become a more or less rigid tube. In places the 
caliber of the tube may be encroached upon. There may be papillary 
growths and granulating areas. This is the hard infiltration of Ober- 
lander, which is the beginning of stricture formation and is most often 
seen in the anterior urethra. Stricture of the posterior urethra is 
relatively rare. 
Pathology of Chronic Prostatitis.—Chronic prostatitis may follow 
an acute prostatitis but it usually begins insidiously, and gives rise to 
but few symptoms in its early stage. Most cases are gonorrheal or 
postgonorrheal in origin. Masturbation and sexual excesses are factors 
in its cause. Cystitis and even pyelonephritis sometimes are accom- 
panied by a prostatitis. 
Various bacteria are found in the prostatic secretion, from the 
gonococcus and streptococci, staphylococci, and colon bacilli. 
The glands of the prostate show proliferation and desquamation of 
epithelium, and their lumen occluded by pus and epithelium. Later 
there is periglandular round-celled infiltration. Sclerosis and contrac- 
tion of the new tissue takes place and causes destruction of glandular 
tissue or dilatation from obstruction of the gland ducts. The gland 
may therefore feel small and firm or, more often, enlarged with soft, 
“mushy” spots. Sometimes there are small points of suppuration 
throughout the prostate. 
Pathology of the Seminal Vesicles.—Belfield was the first to get 
radiographs of both normal and diseased seminal vesicles. Through a 
cut in the vas he filled the vesicle with collargol and then took radio- 
graphs. Cabot, Barney and others have done likewise. It is diffi- 
cult to say what percentage of posterior gonorrheas affect the seminal THE GONOCOCCUS 
327 
vesicles. Caulk* says “That 90 per cent, of gonorrheas became 
posterior and that 90 per cent, of these cause involvement of the 
seminal vesicles.” If the seminal vesicles are involved by the gonor- 
rheal inflammation, then the processes may be acute, subacute or chronic. 
Because of the convoluted tubules of the vesicle and the small urethral 
exit, cure of the condition is often very difficult. In acute infections, 
which are almost invariably caused by the gonococcus, we may have 
obstruction of the ducts, abscess formation, perivesicularinfiltration, etc. 
This inflammation may result in the pus emptying through the main 
duct into the urethra or it may become subacute or chronic; or the pus 
sac may rupture into the ischiorectal fossa, rectum, or peritoneal 
cavity. The gross pathology of chronic inflammatory lesions of the 
seminal vesicles is quite variable. They may be large, firm, and 
distended with obstructed ducts and abscess formation. There is 
apt to be a perivesicular infiltration, so that one may not be able to 
outline the confines of the vesicle because of their being matted down 
with a plastic exudate. In fact, operative experience in acute seminal 
vesiculitis, in which the rectal touch has seemingly demonstrated 
swollen vesicles and supposed abscesses, has shown that the vesicles 
in such cases are not distended with pus but the process is usually one 
of perivesicular infiltration. In the chronic process gonococci are 
rarely found. Staphylococci, streptococci, colon and tubercle bacilli, 
and various other unclassified bacilli have been isolated. Not infre- 
quently sterile cultures are obtained from the seminal fluid. Cabot 
and Barney found that the perivesical adhesions were most frequent 
at the lower end of the vesicle and the vas, and that if one vesicle is 
involved, its fellow “may be safely accused.” Caulk says that “the 
seminal vesicle bears an important pathological significance also on 
account of its proximity to the ureter. Young, Squier, and Voelcker 
have reported cases of renal infection due to ureteral stricture second- 
ary to the vesicular infiltration.” 
Symptoms of Acute Anterior Gonorrheal Urethritis.—Incubation.—The 
limits of this period are two and twelve days; oftener five to seven 
days. (Experimental inoculation produces a discharge on the second, 
third, fourth and fifth days.) A non-gonorrheal urethritis occurring 
in a damaged urethra and caused by sexual strain, excessive alcohol, 
etc., often has a very short incubation, say twenty-four hours. So also 
an acute exacerbation of a chronic gonorrhea. A long foreskin may 
mask the discharge for some days. 
Invasion.—If a patient is intelligent, he generally notices the early 
symptoms of gonorrhea, itching, tickling, or burning in the meatus. 
If unintelligent, he often delays his visit to the physician until the 
tickling has become (on the second or third day) a vigorous burning 
on urination along the course of the anterior urethra and a urethral 
discharge has become established. Or the patient’s attention may 
* Caulk1 has written a very complete review of the “Surgery of the Seminal Vesicles 
and their Ducts.” I have closely followed and quoted from this review. 328 
INFECTIONS OF THE URETHRA AND PROSTATE 
have been attracted by the red and swollen meatus which accompanies 
the discharge. The inflammation may reach its height very early 
(in a few hours), or late (a number of days). The factors which modify 
the attack are the vigor of the strain of gonococcus with which the 
patient is affected; the natural or acquired immunity of the patient 
(acquired by previous attacks of gonorrhea), the age of the patient 
(boys and old men are prone to severe attacks), and the treatment. 
Local Symptoms.—When the attack has reached its height, there are 
four cardinal local symptoms: discharge, burning on urination, red 
meatus, and painful erections. 
The discharge is formed of the products of the inflammation, pus, 
epithelial cells and gonococci. It is at first mucoid, then rapidly 
changes to typical thick, yellowish pus. Later it loses its yellow color 
and again becomes mucoid. The discharge varies in quantity accord- 
ing to the severity of the inflammation and the period of time between 
urinations. When the patient urinates, the urethra is washed fairly 
free of pus. The discharge is usually greatest in the morning because 
of the long interval without urination. It may be tinged with blood. 
Burning on Urination.—The acid urine passing over the inflamed 
urethra causes pain. This pain is an index of the acuteness of the 
attack, and may be very severe or inconsequential. 
The red and swollen meatus is the index of the condition of the 
anterior urethra in acute gonorrhea. It is the main differential point 
between a new infection and an exacerbation of an old gonorrhea. 
In the latter the infection comes from the posterior urethra, and when 
it reaches the anterior it is in a subacute stage, which accounts for the 
absence of an inflamed meatus. Reinfections run a much milder 
course than new infections, and naturally are liable to be more chronic. 
Painful erections are due to the stretching of a rigid and inflamed 
urethra. Normally the urethra is elastic and easily distensible. 
The inflamed urethra may be so rigid and fixed that when the corpora 
cavernosa distend on erection the penis, as a whole, may curve down- 
ward. This is known as chordee, and often causes excruciating pain 
and perhaps bleeding. 
I in A ttacks.—The above describes a typical attack. There 
may be all grades of infection, from an attack in which the one symptom 
is urethral discharge, which contains gonococci, to a hyperacute attack 
which rapidly invades the posterior urethra. 
General symptoms are often present in a mild degree. Lassitude, 
slight temperature, loss of appetite, and possibly chills may accompany 
the attack. 
Urine Changes.—Urine running from the bladder reservoir over a 
urethra covered with pus washes off that pus so that when the urine 
is passed it contains pus cells in suspension. This causes the urine 
to become more or less cloudy; or if there is no free pus but only 
shreds of pus in the urethra, the urine is clear, with the shreds floating 
in it. Because of these facts, and because the urethra is divided into THE GONOCOCCUS 
329 
an anterior and posterior part, various tests have been suggested to 
determine by the examination of the urine the source of the pus and 
shreds. 
The two tests most in use are Thompson’s* two-glass test and 
Kollman’s five-glass test. 
Using the two-glass test the first glass is cloudy while the second is 
clear, although the .first two may be cloudy if the discharge is very 
profuse. 
Diagnosis.—The diagnosis is principally between non-gonorrheal 
urethritis (p. 334) and an acute exacerbation of an old gonorrhea. In 
the latter the short incubation, the lack of a red meatus, the history, 
and the presence of a posterior urethritis (pus in the prostate) generally 
clinch the diagnosis. 
Course.—An acute anterior urethritis may resolve or become a 
chronic anterior urethritis. More likely it is complicated by an acute 
or subacute posterior urethritis. 
Complications of Acute Anterior Gonorrhea.—These are abscess of the 
urethral glands, peri-urethritis and peri-urethral abscess, balanoposthi- 
tis, lymphangitis and adenitis, and inflammation of the erectile tissue. 
Abscess of Urethral Glands, Peri-urethritis and Peri-urethral Abscess. 
—Any of the urethral glands may be invaded by the gonococcus, the duct 
of the glands plugged by the inflammation and the gland suppurate. 
* The most popular, the simplest and perhaps the least accurate is the two-glass test 
of Thompson, viz.: the bladder is full of urine. The patient passes four ounces of urine 
into a first glass and the remainder into a second glass. We may then have one of four 
conditions: 
I. First glass cloudy, second glass clear. 
II. First and second cloudy. 
III. First glass clear, second cloudy. 
IV. Urine clear but shreds in first or second, or both. 
(It is supposed that the cloud is due to pus. This can definitely be determined by the 
microscope. If the cloud is due to phosphates, acetic acid dropped into the urine will 
clear it. If the cloud is due to internally administered copaiba, acetic acid will not clear 
the urine.) In acute gonorrhea, I means an anterior urethritis and no inflammation 
above the cut-off muscle. In chronic gonorrhea, I may mean an anterior and posterior 
urethritis. It never means bladder or kidney pus. II generally means an anterior and 
posterior urethritis. It may mean only an anterior urethritis with such a profuse dis- 
charge of pus that the first four-ounce wash of urine is not enough to cleanse the urethra 
of pus. It may mean bladder or kidney pus. Ill means a posterior urethritis. The 
prostate laden with pus has squeezed this pus into the urethra with the final bladder 
squeeze occurring at the end of urination. IV may mean a mild anterior or posterior 
urethritis or both. The two-glass test must be interpreted in conjunction with the symptoms. 
If there is a conflict between the two, a further test, the Kollman, must be made. Kollman 
Test Modified: The anterior urethra is washed (using sterile water) with a syringe or 
through a small rubber catheter passed as far as the bulb. The washings are continued 
until the return irrigation is clear. The patient then passes urine into a second glass 
(four ounces). This represents posterior urethral pus or shreds. The prostate is then 
massaged and urine is passed into a third glass, which represents the prostatic contents. 
The fourth glass of passed urine represents pus coming from above the prostate (bladder 
or kidneys). I confess that I rarely now use this test. I also confess to treating as a 
chronic urethritis a case of tuberculosis of the kidney for some weeks before I suspected 
something wrong and did a cystoscopy. At present if in doubt I always put a catheter 
into the bladder and carefully observe the washings. If the first four or five washings 
(two ounces each) are cloudy or persist in their shreddy contents, I then cystoscope or 
urethroscope the patient. 330 
INFECTIONS OF THE URETHRA AND PROSTATE 
According to the length of the duct and the acuteness of the inflam- 
mation the abscess discharges its contents directly into the urethra or 
through its duct and so heals. The abscess often gives localized pain, 
and if the urethra is palpated, can be felt as a small shot-like mass 
along the urethra. Not infrequently these abscesses are multiple and 
can be felt along the entire pendulous urethra. Such cases are often 
very acute and run a long course. Cases in which there is a suddenly 
increased urethral discharge with perhaps reinfection of the urethra 
are generally due to the rupture of a urethral abscess. 
Often the abscess does not rupture into the urethra but involves the 
peri-urethral tissues and points externally. A favorite place for such 
an abscess is just back of the frenum. Occasionally an abscess can be 
incised intra-urethrally through an endoscope. Generally, however, 
there is a distinct space corresponding to the duct of the gland between 
the abscess and the urethra. Then the abscess points externally and 
is opened through a small incision. Healing is generally rapid. In 
certain cases, however, a urethral fistula is left which requires opera- 
tion to close. 
Balanoposthitis.-—This usually occurs because of a tight foreskin 
which retains the gonorrheal pus. Sometimes the patient retracts the 
foreskin back of the corona but cannot get it back. The resulting 
paraphimosis can often be reduced. If not, a dorsal incision has to 
be made. 
Lymphangitis and Adenitis.—This is seen fairly often. The inflamed 
lymph channels can be felt as hard, tender cords extending along the 
dorsum of the penis. Sometimes an enlarged gland is also felt. Under 
appropriate treatment this readily subsides. I have never seen one 
suppurate. 
Inguinal adenitis and suppuration of the inguinal glands are not 
rare. 
“Inflammation of the erectile tissue, spongeitis, and cavernitis” are 
extremely rare complications of gonorrhea, if we except that type of the 
former that manifests itself in chordee.” (Keyes.) 
Symptoms of Acute Posterior Gonorrheal Urethritis.—The membranous 
and prostatic urethra, and the prostate are always attacked in posterior 
urethral gonorrhea. In most cases it is probable that the seminal 
vesicles are also attacked. Whether or not posterior urethritis is 
classed as a complication of urethral gonorrhea, it is a fact that in the 
majority of cases of gonorrhea the posterior urethra is invaded by the 
gonococcus. As the posterior urethra is intimately associated with the 
function of urination, acute inflammation of the posterior urethra is 
accompanied by disturbances of urination. 
The patient gives a history of a preceding anterior urethritis, or if 
the acute posterior urethritis is an exacerbation of an old posterior 
gonorrhea, then the history of this. 
Frequency of Urination.—The patient generally has increased fre- 
quency, particularly at night. He may arise once at night, or in a 
severe attack he may urinate as often as every fifteen minutes, day and THE GONOCOCCUS 
331 
night; he may have increased pain on urination; or pain particularly 
at the end of urination, caused by the closing down of the sphincter on 
the inflamed prostatic urethra; this pain may be in the perineum, 
hypogastrium, in the rectum, at the end of the penis or along the 
urethra. For the same reason he may possibly have a terminal 
hematuria. 
Urinary Changes.—Using the two-glass test the second urine is 
cloudy. 
Course.—Acute posterior gonorrhea remains at its height from a num- 
ber of days to a week, and then all the symptoms may gradually sub- 
side until the patient is left with a slight urethral discharge, generally 
in the form of a “morning drop” (chronic gonorrhea), or one of a 
number of complications may set in. 
Complications of Acute Posterior Gonorrhea.—These are cowperitis, 
prostatic abscess, seminal vesiculitis, epididymitis, (see p. 325), cystitis, 
(see p. 301), pyelonephritis, peritonitis. 
Cowperitis.—We generally say that an abscess originating on either 
side of the membranous urethra is due to an abscess of Cowper’s glands. 
Such an abscess is rarely diagnosed when small, probably because of 
the infrequence with which we try to palpate Cowper’s glands. Gen- 
erally, when a diffuse abscess appears on one or both sides of the bulb 
(if stricture, prostatic abscess, and ischiorectal abscess can be excluded), 
we attribute such an abscess to a cowperitis. The deep layer of the 
perineal fascia prevents an abscess originating in Cowper’s glands from 
traveling backward, which accounts for its appearance in the perineum. 
Luys reports two cases in which a more or less chronic cowperitis was 
diagnosed by palpating the enlarged Cowper’s glands and expressing 
(intra-urethrally) the pus therefrom. 
The cure consisted in massage of the glands and irrigation and dila- 
tation of the urethra. Generally, however, the abscess points exter- 
nally and either ruptures or is incised. 
Prostatic Abscess.—The division line between acute prostatitis and 
prostatic abscess is hard to draw. A patient may have only the symp- 
toms of a posterior urethritis and yet may have a small superficial 
prostatic abscess which makes itself known by rupturing into the 
urethra and relief in the patient’s symptoms. As a rule, however, a 
prostatic abscess of any magnitude involving a part of one or both lobes 
of the prostate gives the following symptoms: 
1. It occurs in the course of an acute or subacute gonorrhea. 
2. The symptoms of the preceding posterior urethritis, dysuria, pain 
and frequency become worse. If there be only an antecedent acute 
anterior urethritis and the prostatic abscess is the result of an over- 
whelming infection, the dysuria, pain, and frequency begin intensely. 
The pain of the acute prostatitis, referred generally to the region of the 
prostate, is surprisingly acute and tenacious. I remember one patient 
with an acute parenchymatous prostatitis who had, for nearly two 
weeks, an intensely acute pain “like a hot coal” in his prostate. He 
could not sit down—particularly on a cushion; hard surfaces seemed 332 
INFECTIONS OF THE URETHRA AND PROSTATE 
best adapted for sitting—and his pain was only controlled by the gen- 
erous use of morphin. 
3. Acute retention of urine, partial or complete, is often present. 
If an acute retention occurs during an acute gonorrhea, it is nearly 
always caused by a prostatic abscess. The retention may be the only 
symptom. 
4. The general symptoms may be those of any acute infection, chill, 
vomiting, fever, etc. 
Physical Signs.—The prostate (by rectal examination) is enlarged as 
a "whole or in part. It may be very tense and hard, or if the abscess 
is formed, soft and fluctuating. The gentlest palpation may cause one 
of the abscesses to rupture. 
Course.—If only miliary abscesses are present, these may resolve 
without any appreciable increase in the discharge of pus. An abscess 
may form which may rupture into the urethra or rectum; or it may 
point in the ischiorectal fossa or in the corpora cavernosa or in the 
scrotum. A prostatic abscess rarely ruptures in the portion of the 
prostate anterior to the urethra. Periprostatic abscesses often com- 
plicate matters. 
Thrombosis and metastatic abscess are fairly rare. 
Acute seminal vesiculitis is always associated with posterior ureth- 
ritis, the symptoms of "which often mask the symptoms of the former. 
It is hard to tell, however, how often a posterior urethritis is com- 
plicated by a seminal vesiculitis. The finger passed into the rectum 
reveals an enlarged, tense, seminal vesicle above the prostate. 
The inflammation may resolve and the seminal vesicle may discharge 
its pus into the urethra, or more rarely it may rupture into the ischio- 
rectal fossa, rectum, or peritoneal cavity, or the condition may become 
chronic. 
Symptoms of Chronic Anterior Urethral Gonorrhea.—It is hard to say 
exactly when a gonorrhea ceases to be acute and becomes chronic. 
When the acute symptoms, the burning on urination, and the frequency 
of urination cease and examination shows that gonococci are still 
present, then the case goes into the chronic list. Many an acute case 
never becomes chronic. Every chronic case is potentially acute, and 
as long as the gonococci are present in the urethra or its glands acute 
flare-ups may occur. 
Cause.—'The reason that gonorrhea becomes chronic involves the 
many questions of a patient’s resistance, previous damage to the 
urethra, malformations of the urethra, improper treatment, virulence 
of the gonococci, etc. Because of these many factors it is impossible 
to make more than a poor guess as to what cases will become chronic. 
If accurate bacteriological tests are made, it will be found that in most 
chronic cases the gonococcus is associated with other organisms. What 
effect these have in causing the gonorrhea to persist is unknown. 
Apparently the other organisms are fairly innocuous, and it is the 
gonococcus that does damage. 
While the symptoms of a chronic anterior and posterior urethral THE GONOCOCCUS 
333 
gonorrhea are much the same; while the site of the inflammation is 
only revealed by the physical examination; and while the one often 
exists in conjunction with the other, it is nevertheless a fact that if we 
determine which focus is the principal one the eradication of this focus 
will often cure-the gonorrhea in the secondary focus. 
For example, if we find that chronic anterior and posterior gonorrhea 
exists and that the prostate is full of pus, proper treatment of the pros- 
tate will cure the gonorrhea. If there are cysts or granulations in the 
anterior urethra, then eradicating these will generally cure the gonor- 
rhea in both anterior and posterior urethra. 
Urethral Discharge.—It is this discharge which generally brings the 
patient to the physician. The discharge may be pussy, mucoid, or 
watery; yellow, white, or colorless. The discharge shows under the 
microscope pus cells and epithelia, either predominating; gonococci are 
found either intracellularly or extracellularly. 
Pain, if present, is generally an itching or mere tickling referred to 
the end of the penis or urethroscrotal angle or indefinitely along the 
urethra. 
Physical Examination.— Urine.—There are shreds* or pus only in 
the first passed glass of Urine. 
Palpation.—Enlarged glands may be felt along the urethra. If a 
sound is introduced into the urethra, the glands can be more easily felt. 
Instrumentation.—A silk or metal bulbous bougie as large as the 
meatus will admit is introduced and roughenings, granular places that 
easily bleed or distinct strictures are sought. 
The meatus should be at least 24 F. to make such an examination 
efficient. If it is not as large as this, a meatotomy to 26 or 28 F. 
should be first performed. 
Urethroscopy.—The more often urethroscopy is done in intractable 
cases, the more often is the cause of the persistence of a stubborn 
gonorrhea found. An open tube urethroscope with or without water 
dilatation or a urethroscope with a lens system with water dilatation 
maybe used. For purposes of diagnosis I personally prefer the latter. 
Pathological changes caused by the gonococcus and seen with the 
urethroscope are (1) chronic diffuse inflammation; (2) inflammation 
around ducts of urethral glands; cysts of the urethral glands; (3) 
granulations or polypi; (4) phosphatic incrustations on an inflamed or 
ulcerated base. 
Indications for Urethroscopy.—It should be done in all cases of 
persistent gonorrhea. The one absolute contra-indication is acute 
inflammation of the urethra. 
* Keyes emphasizes the fact that: (1) “ Shreds are no index of gonorrhea. They are 
currently found in the urine passed by men who have never had gonorrhea. (2) The 
shape and size of shreds does not indicate what part of the urethra they come from. 
(3) Shreds mean chronic, localized inflammation of the urethra. (4) Shreds heavy with 
pus sink rapidly in the urine. They indicate active inflammation or ulcer or stricture. 
(5) Lighter shreds often testify to an inflammation so mild that it presents no danger 
and is entirely uninfluenced by treatment. Shreds call for treatment by dilatation 
(unless this irritates).” 334 
INFECTIONS OF THE URETHRA AND PROSTATE 
Diagnosis.—I do not believe that from the symptoms or physical 
signs a gonorrheal urethritis can be differentiated from a non-gonorrheal 
urethritis. Either may be acute or chronic; either may be of short or 
long duration; the final test is to find the gonococcus either in a smear 
or by a culture. 
Such conditions as tuberculosis of the urethra, leukoplakia, and other 
rare conditions may give all the symptoms of a non-gonorrheal ureth- 
ritis. They will be revealed by the urethroscope. 
Other conditions from which an anterior urethritis must be diagnosed 
are infections above the triangular ligament. These can be accurately 
diagnosed by the five-glass test, by the urethroscope, and by the 
cystoscope. 
Evidence of Cure.—Clinical.—If the urine from the urethra is pus- 
free, that urethra is gonococci-free. This means pus-free as regards 
any shreds in the urine and pus-free after massage of the anterior 
urethral glands, and dilatation of the anterior urethra. If the patient 
has pus in the anterior urethra in which gonococci cannot be found, a 
silver nitrate solution (1 or 2 per cent.) or a sound may be used to stir 
up any latent gonorrhea. I now never use this method. It may stir 
up a somewhat intractable urethritis. Cultural methods are more 
accurate. 
Complement-fixation Test (p. 319).—A positive reaction in anterior 
urethritis, no matter how acute or how chronic, is never obtained. 
A similar condition of affairs is found in acute vulvo-vaginitis in the 
adult female. 
Culture.—If the anterior urethritis is not pus-free, a culture has to be 
relied upon. 
Complications of Chronic Anterior Gonorrhea.—The one important 
complication is stricture of the urethra (p. 414, Chapter X). 
Symptoms of Chronic Posterior Urethral Gonorrhea.—Chronic posterior 
urethritis is chronic prostatitis either alone or combined with a chronic 
inflammation of the seminal vesicles or chronic inflammation of the 
verumontanum. 
Etiology.—It is the gonococcus we always seek, and here in the 
prostate it loves to stick. Two factors in the etiology are important: 
1. In prostatitis originally caused by the gonococcus, if the prostatitis 
persists and if no new gonococcal infection occurs, the gonococcus is 
gradually replaced by other organisms, so that at the end of the fourth 
year (this is the long limit) all cases are gonococci-free. (These are 
statistics from the Lehrbuch der Urologie.) Keyes, less conservative 
and probably more accurate, says: “ I believe that the gonococcus does 
not persist in the male urethra for more than three years; while in at 
least 90 per cent, of cases it disappears, with or without treatment, 
within the year.” 
2. Not all cases of prostatitis are gonorrheal in origin. In 358 cases, 
Young, Geraghty, and Stevens found that a previous history of gonor- 
rhea was present in but 73.2 per cent. The remaining cases gave 
histories of masturbation (which is a good general history of all genito- THE GONOCOCCUS 
335 
urinary cases) or prolonged sexual excitement, traumatism, instrumen- 
tation, infectious diseases. In 14 per cent, no etiology was obtained. 
Urethral Discharge.—A chronic urethral discharge is often the sole 
symptom of a prostatitis. Such a discharge may be caused by the 
prostatic secretion running into the anterior urethra or by an accom- 
panying anterior urethritis. 
Disturbances of Urination.-—The day and night frequency of the 
acute prostatitis may persist and be a feature of the chronic form. 
There may be urgency, pain on urination, or terminal pain—typical 
irritable prostatitis. There may be obstruction to urination caused by 
contracture of the bladder neck; the obstruction causing partial or 
complete retention. Our attention then turns from a less important 
prostatitis to the graver contracture. 
Pain.—As abnormalities of the verumontanum are being more 
studied, we are coming to believe that many of the pains formerly 
attributed to a diseased prostate are due to some pathological condition 
of the verumontanum. As the two often occur together it is hard to 
differentiate the symptoms caused by either. A diseased prostate 
perhaps plus a diseased verumontanum may give a feeling of fulness 
or pain or burning in the prostate itself. This is often relieved after 
emptying a prostate of its contents by massage. Pain in the urethra 
either referred to the penoscrotal angle or to the end of the penis is 
probably more often due to disease of the verumontanum. Perineal 
pain is often present or the pain may be referred to the testicles or 
cord. 
Because of the varied sites of the prostatic pain, confusion in the 
diagnosis often arises, and an appendicitis, ureteral or bladder stone and 
many other conditions have been confused with a simple prostatitis. 
Disturbances in the Sexual Function.—These are probably more due 
to disease of the verumontanum than to prostatitis. They comprise 
all the symptoms usually classed under sexual neurosis, viz., premature 
or delayed ejaculation, too frequent seminal emissions, poor or painful 
erections and the like. 
Exacerbations.—Those patients who have frequent flare-ups (not 
reinfections) due to sexual, alcoholic, or instrumental excesses generally 
have a focus in the prostate. These attacks are commonly and fairly 
accurately designated by the patients as strains. 
Physical Examination.—Pus in the Urine.—The modified method of 
Kollman may be used, but the more practical office method is to have the 
patient empty his bladder, then massage the prostate and examine the 
drop that generally appears at the meatus. If it contains pus cells, 
then the prostate is the offending member. Sometimes a drop does not 
appear at the meatus; instead the pus is forced back into the bladder. 
If so, have the patient pass the few cubic centimeters of urine that have 
collected in his bladder. This is examined under the microscope. 
Palpation.—An enlarged boggy prostate which pits on pressure, or 
a lumpy and hard prostate, may be felt; or one may feel an entirely 
normal prostate from which a drop of pus may be expressed. If a 336 
INFECTIONS OF THE URETHRA AND PROSTATE 
stained specimen is carefully examined, gonococci will usually be found, 
but this examination is not to be depended upon. A complement- 
fixation test or a culture is the only safe test. 
Warning.—An acute epididymitis is not infrequently caused by the 
too frequent or too harsh massage of the diseased prostate. Gentle- 
ness first! 
Instrumental.—A bulbous bougie as large as will pass the meatus 
(24 F. at least) is introduced into the posterior urethra as far as the 
vesical sphincter. This is withdrawn and any roughenings, narrowings, 
or undue bleeding on the withdrawal of the bougie are noted. 
Contracture of the bladder neck cannot be diagnosed in this way 
(see Yol. II). 
Urethroscopy.—By using the modern irrigating urethroscopes we 
more often find a reason for the deadly persistence of the gonococcus 
in the posterior urethra. Urethroscopy tells us nothing of what is 
happening in the interior of the prostate, but is used to reveal patho- 
logical processes of the posterior urethra, and particularly of the 
verumontanum. 
Pathological Lesions Seen hy Urethroscopy: (1) Enlarged and boggy 
verumontanum; (2) cysts of the verumontanum or posterior urethra; 
(3) granulations or papilloma of the verumontanum or posterior ure- 
thra; (4) inflammation around the ejaculatory ducts; (5) diverticula, 
natural or acquired (postoperative), of the posterior urethra; (6) in- 
crustations on an inflamed or ulcerated base. 
Indications for Urethroscopy.—These vary with the type of the in- 
strument used. I believe more and more that urethroscopy is worthless 
with the non-irrigating instruments. It should be performed in all 
stubborn cases of chronic prostatitis. This indication has naturally a 
wide latitude and what would be an indication for one urologist would 
not be such for another. Urethroscopy should always be the last of all 
examinations. 
Contra-indications.—All acute inflammations of the urethra. 
Urethroscopy to Confirm Cure.—Much has been written particularly 
by the German urologists about never discharging a case as cured with- 
out complete urethroscopy. I believe, however, that urethroscopy 
does not tell when a patient is cured but why a patient is not cured. 
Course of Chronic Prostatitis.—Cases may be very stubborn; they may 
relapse so often that a cure seems impossible. Opposed to this is the 
extreme mildness of others which immediately respond to appropriate 
treatment. In no case can a physician, with any degree of accuracy, 
predict the course; all that he can do is to intelligently follow the course. 
Complement-fixation Test.—This is positive when a posterior gonor- 
rhea has been present for a month or more. Occasionally if the posterior 
urethritis is very acute, it appears earlier (see p. 322 et seq.). 
Diagnosis.—The differential diagnosis is between gonorrheal pros- 
tatitis and (1) non-gonorrheal prostatitis; (2) seminal vesiculitis; 
(3) inflammation of the verumontanum; (4) papillomata, granulations, 
ulcerations, and rarer conditions, as tuberculosis, leukoplakia of the THE GONOCOCCUS 
337 
posterior urethra; (5) inflammation of the urinary tract above the 
prostate. 
1. Non-gonorrheal Prostatitis.—A prostatitis troubles a patient not 
especially because of its symptoms but because he believes it an uncured 
gonorrhea. Most cases of prostatitis are in fact gonorrheal in origin, 
therefore a smear of the prostatic secretion, or a culture, or a comple- 
ment-fixation test for gonorrhea is made to determine if gonococci are 
still causing the trouble. Whether the prostatitis is gonorrheal or not, 
the patient is now put on an appropriate course of treatment. If treat- 
ment of two or three weeks fails to produce any effect, then urethros- 
copy or cystoscopy should be performed. 
2. Seminal vesiculitis is always accompanied by prostatitis. Which 
is the principal infection is determined partially by palpation and par- 
tially by first massaging the prostate and examining the secretion and 
then massaging the seminal vesicles and examining their secretion. 
3. Inflammation of the Verumontanum.—This, like the above, is prob- 
ably always accompanied by prostatitis, and it is probable that the 
treatment used to cure the prostatitis in most cases cures the inflamma- 
tion of the verumontanum. The differentiation is made by examining 
the prostatic secretion microscopically and the verumontanum through 
the urethroscope. 
4. Cysts, papillomata, granulations, ulcerations, and rarer condi- 
tions, as tuberculosis and leukoplakia, can be differentiated with the 
urethroscope alone. The first four are frequently caused by gonor- 
rhea; they are particularly prone to be about or on the verumon- 
tanum; and when present keep up inflammation. 
5. Inflammation of the urinary tract above the prostate. In these 
cases a complete cystoscopy is often necessary to make the diagnosis. 
Evidence of Cure.—Clinical.—Practically all urologists believe that a 
pus-free urine means a urethra free from gonococci. 
But most urologists insist that a patient remain a certain length of 
time pus-free before declaring a man cured. Keyes puts this at three 
months. By pus-free is meant neither free pus nor pus shreds in the 
morning urine or in the urine passed after massage of the prostate and 
seminal vesicles. If three months have not elapsed or if a patient has 
free-pus or pus shreds in his urine or pus in the secretion expressed from 
the prostate and seminal vesicles, then a negative culture or negative 
complement-fixation test is necessary to declare the patient gonococcus- 
free. Most cases of this class, if they still harbor gonococci, indicate it 
by having an acute exacerbation of the urethritis or by an attack of one 
of the complications of gonorrhea; seminal vesiculitis or epididymitis. 
These exacerbations are apt to follow sexual indiscretions, instrumenta- 
tion, too violent exercise, or the immoderate use of alcohol. 
Complications of Chronic Posterior Gonorrhea—In acute flare-ups 
chronic posterior gonorrhea may present any or all of the complications 
of acute posterior gonorrhea. Practically the only other complication, 
if we except chronic seminal vesiculitis (p. 338), is contracture of the 
bladder neck (see Yol. II). 338 
INFECTIONS OF THE URETHRA AND PROSTATE 
SYMPTOMS OF SEMINAL VESICULITIS. 
Caulk1 gives a brief and pithy summary of the symptoms which may 
be caused by seminal vesiculitis: 
“Various chronic discharges, many chronic bladder distresses; the 
numerous referred pains in the back, sacral region, hips, legs, perineum, 
groins, testicles, and penis; recurrent epididymitis and sexual derange- 
ments; a vast array of joint processes of an infectious nature, such as 
articular rheumatism, rheumatoid arthritis, arthritis deformans, and 
hypertrophic arthritis, numerous renal aind cardiac complications, 
digestive upsets, and an array of nervous and mental manifestations 
which are almost inconceivable.” 
The finger passed into the rectum reveals an enlarged more or less 
tense seminal vesicle to the outer and upper angle of the prostate. 
The whole vesicle can by no means be felt. If a radiograph is desired 
the vas is exposed by a small incision in the scrotum and 10 per cent, 
collargol injected by means of a small needle into the cavity of the vas. 
This may be easily done after a little practice without incising the vas. 
Immediately following the collargol injection a radiograph is taken. 
TREATMENT OF GONORRHEA. 
Prophylaxis Against Gonorrhea.—The real prophylaxis against gonor- 
rhea, as suggested in another place, begins with the education of 
youth against promiscuous sexual intercourse. 
The lesser and more uncertain prophylaxis is applicable to those 
who have indulged in promiscuous intercourse: (1) Prolonged sexual 
intercourse favors the acquisition of gonorrhea, as does also drunken- 
ness on the part of the male; the latter because it increases congestion 
of the sexual organs and also tends to prolong intercourse. (2) Gono- 
cocci live in the alkaline semen, and the alkaline secretion of the 
urethral glands tends to keep them alive. They readily die in an acid 
medium; therefore the desirability of the subject urinating immediately 
after coitus (thus mechanically cleansing the urethra and saturating 
it with an acid urine). (3) Soap and water vigorously applied to 
the penile head probably cleanse better than antiseptics. The sooner 
they are applied the more certainty of killing the gonococci. In addi- 
tion an antiseptic solution, such as bichloride of mercury, 1 to 2000, 
may be used to wash the head of the penis. 
If the patient follows all this with urethral injections he may suc- 
ceed in evading the enemy. Probably the best injections are a 0.5 or 
1 per cent, protargol, 10 to 20 per cent, argyrol, or 1 to 4000 acrillavine. 
These are carried in bottles and injected by means of a syringe or are 
put in small collapsible tubes (one tube sufficing for one application) 
and injected therefrom. The army has used, with a good deal of 
success, calomel preparations. Henry4 recommends the following: 
Calomel 50 grams 
Vaseline liq . . 80 c.c. 
Lanolin 70 grams TREATMENT OF GONORRHEA 
339 
Sailors carry tubes of this, and part is injected into the urethra and 
part is smeared over the head of the penis. Henry tells of 529 sailors 
who were exposed to infection, only 4 of whom acquired gonorrhea. 
Hygiene Cleanliness.—The instructions under this head apply par- 
ticularly to cases of acute gonorrhea. 
The end of the penis is washed in soap and water at least once a day. 
If there is a foreskin, this is retracted and well cleansed. The patient 
then thoroughly washes his hands with soap and water (individual 
soap and individual towel), and, while a patient very rarely infects him- 
self (“ in fifteen years of office experience I cannot recall a single case 
of conjunctival infection among the patients who came to see me with 
urethral gonorrhea”—Keyes), it is well to instruct the patient not 
to rub his eyes with his fingers. 
Discharge.—If the discharge is slight, almost any dressing which 
prevents soiling the patient’s clothes is sufficient. If it is profuse a 
strip of two-inch gauze bandage, perforated to admit the glans penis, 
is used. The gauze is slipped back of the corona and the foreskin is 
pulled forward, holding the gauze in place. Lacking foreskin, the 
penis is held in a gauze bag. 
The patient is particularly instructed not to use a common bath 
tub while the acute discharge lasts and to keep the discharge away from 
the toilet seat. This to protect other members of the family. 
Rest.—Much sleep; rest as much as possible; reduced physical exer- 
cise; riding instead of walking; no dancing; all of these are important. 
Under this head is sexual rest; erections are harmful. A suspensory 
bandage or jock-strap is advised in the acute stage. 
Food.—Alcohol is absolutely contra-indicated. Spices are forbidden, 
although the writer believes that they rarely do harm. Coffee and 
tea should be used in moderation. Water should be much increased 
in an anterior gonorrhea; as the oftener the urethra is washed out by 
the diluted urine the better. In posterior gonorrhea, however, too 
much water may do .harm. The frequency of urination that it causes 
may irritate the urethra. 
Bowels.—At least one movement a day is necessary. 
Internal Medication.—Balsamics: 
Compound Salol.—Salol, 3| grains; copaiba, 10 minims; oleoresin 
cubeb., 5 minims; pepsin (1 to 3000), 1 grain. 
Salol and Santal.-—Salol, 4 grains; oleoresin santoli, 5 minims; 
oleoresin cubeb., 5 minims; olive oil, 5 minims; pepsin (1 to 3000), 1 
grain. 
Sandalwood oil, 10 minims. 
Wintergreen oil, 10 minims. 
Stearosan, 10 minims. 
All of these are given in capsule: One capsule three times a day after 
meals, with a full glass of water. There are many other combinations 
and many other more or less non-irritating preparations of sandal- 
wood oil. These suffice, however 
I prefer compound salol or sandalwood. If these upset the stomach 340 
INFECTIONS OF THE URETHRA AND PROSTATE 
I try stearosan or reduce the number of capsules or stop them entirely. 
If the sandalwood gives pain in the kidney regions, cut down or 
entirely withdraw the capsules, resuming the treatment carefully in a 
day or so. Any of these given over a long period loses its efficiency; 
therefore the need of changing them. 
The rule for their administration is to give them as soon as the patient 
presents himself with an acute gonorrhea and stop (unless there is 
indigestion or kidney congestion) when the urine becomes clear (not 
meaning free from shreds). 
Anodynes.—One of the standard anodynes which is given to decrease 
the pain on urination is the following prescription: 
—Liq. potassse 8- 25 gr. 
Tr. hyoscyami 15- 35 gr. 
Aq. cinnamomi q. s. ad. 100 gr. 
M. Sig.—Teaspoonful in water every 3 hours. 
This, as the prescription shows, combines an alkali with an anodyne. 
Alkalies alone may be given in the form of an alkaline water, or simple 
bicarbonate of soda. If there is much pain, as for instance occurs in 
prostatic abscess, morphin or one of its derivatives may be indicated. 
For prostatic pain and tenesmus, suppositories of morphin are often 
used. Morphin thus given probably does not act locally, but only 
quiets the pain after absorption. The morphin is therefore better 
given by mouth or hypodermically. Hot and cold water are excellent 
anodynes. Hot hip baths may be taken, with the water as hot as can 
be borne; or the patient may urinate while the penis is immersed in a 
vessel of hot water. Cold water is particularly useful in combating 
painful erections. Bromides are also used for this purpose: sodium 
bromide, grains 30, before retiring. 
In the following pages certain methods of treatment are discussed. 
For the application of these methods see Case Treatment of Gonor- 
rhea. 
Fig. 182.—Urethral syringe. 
Anterior Urethral Injections.—The patient uses an all-glass, two-dram, 
blunt-nosed, urethral syringe (Fig. 182). All-glass because it may be 
cleaned easily; quarter-ounce to prevent too large an injection; blunt- 
nosed to prevent hurting the urethra. He fills the syringe half-full 
of the solution which is in a bottle with a wide enough neck to admit 
the syringe. He urinates. The syringe is held in his right hand. The 
end of the penis is grasped behind the corona between the middle and 
ring fingers of the left hand. The urethral meatus is held open with 
the thumb and index finger of the same hand. The blunt nose of the 
syringe is firmly placed in the meatus and the injection slowly intro- 
duced. The syringe is removed and the meatus closed by the same TREATMENT OF GONORRHEA 
341 
thumb and index finger and the fluid thus retained in the urethra. 
The perineal urethra is not compressed to prevent the fluid from enter- 
ing the posterior urethra. This injures the urethra and excites, 
rather than hinders, the extension of the gonorrhea into the posterior 
urethra; forcing a gonococcus-laden injection into the posterior urethra 
and so causing a posterior urethritis is largely a myth. Injuring 
a urethra by a too large injection or by an injection violently given is 
another thing. The fluid is held in the urethra varying lengths of time, 
according to the injection used (silver salts for five minutes, or until 
they burn; astringent injections for one-half minute). The injection 
is used from one to three times a day. The syringe is washed in hot 
water at least once a day. 
Posterior Urethral Irrigation.—The most satisfactory method of 
irrigating the posterior urethra is as follows: 
A soft-rubber 16 F. catheter is introduced into the bladder. This 
catheter serves two purposes: (1) the irrigating solution is introduced 
through it into the bladder; (2) it acts as a sound and squeezes pus out 
of the ducts of the urethral glands, smooths down granulations, etc. 
The catheter is now withdrawn and the patient empties his bladder; 
so irrigating the urethra. Some recommend the insertion of the 
catheter as far as the posterior urethra, but not into the bladder, and 
then injecting the irrigating fluid. This seems to be a little more 
likely to harm the urethra than if the former method be used. 
Another way of irrigating the posterior urethra is to force the fluid 
into the bladder without the aid of a catheter. The patient is told 
to relax the sphincters of his posterior urethra (he soon gets the knack) 
and then the fluid is forced into the bladder either by means of a 
large hand syringe whose blunt nozzle is inserted into the urethral 
meatus or by gravity. The gravity apparatus, about three feet above 
the level of the patient, is so arranged as to be elevated or lowered at 
will. In my experience this method is not so good as the catheter 
method. 
The most popular solutions used are: Argyrol, 1 to 10; protargol, 
1 to 400 to 1 to 200; silver nitrate, 1 to 10,000 to 1 to 1500; potassium 
permanganate, 1 to 5000 to 1 to 2000; zinc sulphate, 1 to 500 to 1 to 
200; zinc permanganate, 1 to 4000 to 1 to 2000; silver permanganate, 
1 to 4000 to 1 to 2000; acriflavine or neutral acriflavine 1 to 4000 to 
1 to 10,000. 
Acriflavine.—This drug, placed last in the above list, deserves a 
paragraph of its own, because it bids fair to supplant the older drugs 
in the treatment of urethra gonorrhea. 
Browning, of Glasgow University, first conducted a series of experi- 
* Organic Silver Salts.—There are many of these on the market. Protargol seems by 
all means the best. Argyrol in a 5 to 10 per cent, solution often works well in early 
cases as an anterior injection. It is less irritating than protargol and for that reason 
many prefer it in the acute inflammatory stage, later changing to protargol when the 
argyrol ceases to be effectual. Some skip the protargol an d change to one of the astrin- 
gent injections. All organic silver salts should be made up fresh. After being a week 
in solution they deteriorate. 342 
INFECTIONS OF THE URETHRA AND PROSTATE 
ments upon the germicidal action of acriflavine (disameno-methyl- 
acridinium-chloride) which showed it to be a very powerful anti- 
septic, differing from the antiseptics in general use “in that its 
bactericidal potency is much increased by contact with serum.” It 
was found to kill the gonococcus in dilution of 1 to 50,000,000. In 
1918, Davis and Harrell,13 of Johns Hopkins, gave the first report in 
this country on acriflavine in the treatment of gonorrhea, experi- 
mentally but clinically. They used it in strength of 1 to 1000 in 
treating urethral gonorrhea. Their conclusions were: 
1. Acriflavine will inhibit the development of the gonococcus in a 
protein containing medium in a dilution of 1 to 300,000. (This is 
600 times the strength of protargol.) 
2. It will penetrate through the submucosa of the urethra and 
bladder. 
3. It is non-toxic, and only slightly irritating to the urethral mucous 
membrane. 
4. The average duration of gonorrhea under this treatment is 
distinctly less than with the usual methods. 
5. In an occasional case it seems without effect upon the course 
of the disease. 
Hyman,14 Davis,15 Keyes,16 Ashcraft and Kennel,17 Jeck18 and 
others have published articles on its use. 
I have used it for three years. The practical suggestions as to its 
use are as follows: 
1. It acts best in a dilution of 1 to 4000 to 1 to 10,000. 
2. It should be made up in normal saline solution. 
3. It should never be used more than once a day. 
4. At first it should be used with caution and diluted, because in 
a certain percentage of cases (10 per cent.?) it causes irritation, and 
cannot be used at all. This irritation manifests itself more by cloudy 
urine (pus) than by burning urination. 
5. It is best used in anterior urethritis by means of a gentle hand 
irrigation, using a small blunt-nosed syringe; 5 c.c. are injected into 
the urethra at a time, and allowed to flow out, this procedure is 
repeated five or six times. For a posterior urethritis, by forced or 
catheter injection in the same dilution. 
6. At the first signs of its irritating, withdraw all local treatment, 
trying again in two or three days a much weaker solution. If this 
still irritates, resort to the older methods. 
7. In cases of acute anterior urethritis, which have shown a dis- 
charge from one to four days, a cure may be expected in two weeks 
in 50 per cent, of cases (Hyman). 
8. The patient must be observed for some time after his apparent 
cure, because after urine is pus free and treatment is stopped, there 
may be a recrudescence of the attack. 
I believe that it is the drug of election in all cases of acute urethritis, 
and should be first used until it is proved to be irritating and therefore 
unsuitable. 343 
TREATMENT OF GONORRHEA 
Prostatic Massage.—A finger cot is placed on the index finger of the 
right hand; the base of the finger cot is surrounded by cotton to 
protect the hand from being soiled. The protected finger is dipped in 
vaseline; the patient leans over the edge of a table or chair; the left 
hand is placed on the patient’s left shoulder for leverage and the right 
index finger is inserted into the rectum as far as it will go. The upper 
Fig. 183.—Massage of prostate. Arrows indicate direction and extent of prostatic 
massage. Prostate below, seminal vesicles and bladder above. 
margin of the prostate is felt and the massaging finger presses on the 
prostate as the finger is withdrawn; the right lobe first and then the 
left lobe is massaged downward in this way (Fig. 183). If in addition it 
is wished to massage the seminal vesicles, these are felt above the upper 
and outer angles of the prostate and pressed upon in that position. In 
almost every case it is desirable to massage the prostate at the same 
time the seminal vesicles are massaged, because if there is infection 
of the latter there is always infection of the former. According to 
indications the massage varies from a gentle pressure on the prostate, 
lasting a second, to vigorous stripping of the prostate for one or two 
minutes. No matter how chronic the case, massage should always be 
very gentle at first. 
Fig. 184.—Olivary bougie. 
Exploration with Bulbous Bougie.—Some prefer a urethroscope, 
some a sound, and some a bulbous bougie in examining the urethra 
for patches of inflammation, granulations, etc. All instrumental 
examinations are, of course, reserved for cases of chronic urethritis. 
A bulbous bougie, metal or gum-elastic, as large as can be admitted 
into the urethral meatus is first used (Fig. 184). If the meatus will 344 
INFECTIONS OF THE URETHRA AND PROSTATE 
not admit at least a 24 F. bougie the meatus is eut (to 28 F.) and then 
the exploration is undertaken after the meatotomy wound has healed. 
The bulbous bougie is passed as far as the bladder neck and then 
gently withdrawn, and any strictures, roughenings, or granulations 
(which easily bleed) are noted. Sometimes because of strictures a 
number of different sizes of bulbous bougies are used. 
Dilatation by Sounds and Kollman Dilator.— 
Either of these is indicated when the exploration 
of the urethra shows granulations, indurations, 
or slight strictures, or when the urine contains 
shreds which cannot be eliminated by irrigations, 
instillations or prostatic massage. 
When dilating by sounds we begin with the size 
of the bulbous bougie (the writer but rarely uses 
the bougie, preferring sounds, silk or metal) used 
and increase it one or two numbers twice a week. 
If the increase in size causes much bleeding and 
pain we go very slowly and perhaps reduce the 
size of the sound. Sounds best adapted are 
those with the Benique curve. The size of the 
sound used is limited by the size of the meatus. 
Therefore, when a small meatus is present or 
when more dilatation than sounds will produce 
is wished we use a Kollman dilator (Fig. 185). 
The dilators best adapted are those with the 
Benique curve. 
Kollman dilatation takes place twice a week, 
and the first dilatation is such as to cause the 
patient slight pain and slight bleeding. There- 
after the dilatation progresses much more 
rapidly than with sounds. 
When shreds come from the posterior urethra, 
dilatation is often alternated with prostatic 
massage. 
Contra-indication to Dilatation.—When the 
urine is cloudy with pus, dilatation should 
rarely, if ever, be made. Dilatation should not 
be begun until the urethra has become accus- 
tomed to less vigorous instrumentation, such 
as that by passage of rubber catheters. 
Urethral Instillations.—By means of special 
instruments a small quantity (1 or 2 c.c.) of 
a solution is distributed along the urethra. The instrument used is 
the Keyes or Guyon instillator, which is a 2 c.c. syringe attached to 
a hollow sound, 16 F. size (Fig. 186). This is filled with the solution 
and the instrument introduced into the urethra in the same manner as 
a sound, until the tip is just beyond the cut-off muscle in the posterior 
urethra; one can generally feel the instrument jump slightly when 
Fig. 185. — Kollman 
posterior urethral dilator, 
Guyon curve. TREATMENT OF GONORRHEA 
345 
passing the cut-off muscle. Half the solution is injected with the 
instrument in this position and the remainder injected as the instru- 
ment is withdrawn. 
Use.—Instillations are generally used in chronic inflammations of 
the urethra. In these cases after the urethra has become accustomed 
to urethral washes larger in quantity and milder in strength than the 
instillations, one instills a 0.25 or 0.5 per cent, silver nitrate, 1 to 5 per 
cent, copper sulphate, or other solution. Sometimes instillations are 
given in cases of subacute urethritis, using either protargol, 5 to 10 
per cent., or argyrol, 10 per cent, and upward. 
Fig. 186.—Keyes’ deep urethral syringe. 
Case Treatment of Gonorrhea.—Case I.— Acute Anterior Gonorrhea. 
—The patient had a slight urethral discharge of one day’s duration. 
Incubation four days. His first gonorrhea. Neither burning nor 
urinary frequency. Discharge contained pus cells and many typical 
intracellular gonococci (methylene-blue stain). Meatus slightly red. 
First urine cloudy; many shreds. Second urine clear. 
This being the patient’s first gonorrhea, his urethra is particularly 
vulnerable to infection and we may expect an acute and long attack. 
On the other hand, he came on the second day of his discharge before 
any acute symptoms had set in, and some days before the height of 
the inflammation. In this stage the gonococci are mostly along the 
surface of the urethra, having only slightly penetrated the epithelial 
layer, and are probably not yet in any of the crypts. Therefore they 
are easily accessible and in a position to be readily killed. 
Should one of the so-called abortive treatments be used?* The 
answer is in the foot-note. 
* Abortive Treatments.—These are recommended by many urologists and are applied 
to cases like the above in which the discharge has persisted for but two or three days. 
In most of the various modifications a strongly caustic solution—5 to 20 per cent, silver 
nitrate is a favorite—is injected into the anterior urethra with the idea of killing all the 
gonococci at one fell swoop (by some a urethroscopic application instead of injection 
is recommended). The unfortunate part played by these treatments is that they fail 
in a goodly percentage of cases to kill all the gonococci and they invariably do much 
damage to the urethra. With the few gonococci left this damaged urethra is as a virgin 
field; and the ensuing gonorrhea is much worse than it would have been had the patient 
been left entirely alone. 
If any attempt at abortive treatment is to be made a gonococcicide must be chosen that does 
not harm the urethra. 346 
INFECTIONS OF URETHRA AND PROSTATE 
An anterior irrigation of 1 to 10,000 acriflavine is given once a day. 
On the second day the discharge is less, urine is clear but contains 
shreds; continue treatment. On the third day the discharge is slight. 
It is examined and gonococci are found in one pus cell as against 
many gonococci at the time of first examination. The patient is 
seen every day for a week, increasing the strength of the acriflavine 
to 1 to 4000 and in the second week using it every two days. 
By the seventh day he had no discharge. Urine showed only a 
rare shred; no gonococci found. On the fifteenth day internal medi- 
cation and injection discontinued. Twenty-sixth day urine clear, no 
shreds. 
Proof of Cure.—The patient now has the choice of (a) having a 
bacteriological examination made. If this proves to be negative he 
is discharged. This examination is preceded by a gentle massage of 
the anterior urethral glands, which are emptied of their contents by 
milking the anterior urethra from behind forward; and also of the 
prostate, because one cannot be sure that the urethritis has remained 
wholly anterior. Or (b) he is told to wait at least two months, at 
which time if his urine is pus-free he is discharged. 
Irrigation of Janet.—Instead of using acriflavine as an internal 
injection in this case the Janet method of potassium permanganate 
injection might have been used. This method is used by a great many 
urologists and in a great many urological clinics. 
As far as my experience has been with the method it rapidly checks 
a urethral discharge, but the gonococci persist in the urethra much 
longer than when the silver salts are used. 
Keyes describes the method of Janet: “ He irrigates the anterior 
urethra twice a day for three or four days, then increases the interval 
from twelve to eighteen hours. When the cloudiness of the first urine 
is pretty well gone he makes the interval twenty-four hours. When the 
discharge is no longer purulent he makes it forty-eight hours. 
“When the second urine becomes cloudy he irrigates the posterior 
urethra according to the same method, twice a day at first, later every 
day or every other day. For each irrigation of the posterior or ante- 
rior urethra he employs 500 c.c. of fluid at a temperature of 110° F. 
“ If the case is seen before the appearance of marked inflammatory 
symptoms he employs a 1 to 500 solution of permanganate, immediately 
followed by a like quantity of boric acid solution. If this does not 
prove too irritating he continues at this strength until the inflammation 
has subsided sufficiently to permit intervals of thirty-six to forty-eight 
hours, when he drops to 1 to 4000 or 1 to 6000 permanganate and 
omits the boric acid. 
“If the posterior urethra becomes inflamed he begins irrigating it 
with solutions of 1 to 4000 down to 1 to 10,000. If these are well borne 
he increases the strength to 1 to 3000 or 1 to 1000 and follows it with a 
boric acid irrigation. 
“If the patient is first seen after the appearance of acute inflam- 
matory symptoms the irrigation is begun at 1 to 10,000 to 1 to 4000 TREATMENT OF GONORRHEA 
347 
strength, and only for the anterior, even if the posterior urethra is 
inflamed. lie begins treatment of the posterior urethra only when the 
anterior inflammation is under control. 
“In the declining stage he gives a daily irrigation of 1 to 6000 to 
1 to 8000.” 
Other Methods.—Valentine and the other followers of the Janet 
method in this country adopt his treatment with certain variations. 
They usually employ much weaker solutions (1 to 4000 to 1 to 20,000) 
and larger quantities (1000 c.c. or more), and often irrigate the posterior 
urethra every day or every other day as a routine measure. 
The method in which this Janet irrigation is used is the following: 
The solution is put in a wall tank which can be easily raised or 
lowered (the height is about three feet above the level of the patient); 
from the lower part of the tank runs a rubber tube, on the end of which 
is a blunt-glass or soft-rubber urethral nozzle. 
There are two-way nozzle devices by which a continuous inflow and 
outflow may take place. The best way, however, is to allow the urethra 
to fill up with the fluid, then withdraw the nozzle and allow the fluid to 
flow out. Instead of the wall tank a hand syringe may be used. 
Case II.—Acute Anterior and Silent Posterior Gonorrhea.—Patient 
came with his second gonorrhea. His discharge of three days’ duration 
contained many gonococci (methylene-blue stain). Meatus is red- 
dened. First urine cloudy; second urine clear. This case was put on 
exactly the same treatment as Case I. In three weeks he had only pus 
shreds in his clear first urine; in some of these shreds typical gonococci 
were found. The shreds still persisting, I changed the injection to 
astringent zinc and lead* and inquired carefully as to the patient’s 
getting up at night to urinate (generally the first hint of a posterior 
urethritis). Finally, because of the persistence of the urethritis, I 
gently felt his prostate, which was not enlarged, but I massaged from 
it pus cells (page 335). 
His anterior urethritis had crept back into his posterior urethra 
without giving the usual disturbance to urination, and the prostatic 
involvement was the cause of his persistent urethritis. Because his 
prostate was not enlarged, and because of the mildness of the urethritis, 
I did not immediately put the patient on prostatic rubs, but instead 
gave him bladder washes (every second day) of 1 to 4000 acriflavine 
for once or twice and then silver nitrate solution, 1 to 10,000 at first, 
increasing until 1 to 2000 is used. This increase in strength occurred 
* Astringent Injections—These are used in the anterior urethra (as a hand injection) 
in subacute and chronic anterior gonorrhea and in non-gonorrheal urethritis. The one 
most used by me is 
B—Zinc sulphatis 0.25 gr. iv 
Liq. plumbi subacetatis dil 100.00 S iij 
Sig.—Shake. Inject morning and night. 
Other solutions are zinc sulphate 1 to 500 to 1 to 100; potassium permanganate 1 to 
3000 to 1 to 5000. There are many others. They are held in the urethra about half a 
minute. It is well to remember that both astringent injections and silver salt injections 
may keep up a urethral discharge. If the discharge does not diminish or cease when 
hand injections are used totally withdraw, for a time at least, these injections. 348 
INFECTIONS OF URETHRA AND PROSTATE 
in about four or five washes. The patient should have after each 
silver wash a slight feeling of warmth in the urethra, but no vigorous 
burning. 
After the third or fourth silver wash the patient’s urine completely 
cleared. In a week he was pus-free (both morning urine and urine 
passed after prostatic massage) and in four weeks his complement- 
fixation test was negative. 
Case III.—Acute Anterior and Posterior Gonorrhea.—The patient 
came with the second gonorrhea (twenty-four hours’ duration, seven 
days’incubation); burning on urination; no frequency; smear showed 
pus cells and gonococci (methylene stain); first urine cloudy; second 
clear. His treatment was anterior injections of 0.5 per cent, pro- 
targol and compound salol capsides. 
The patient, instead of using a urethral syringe, used an eye dropper 
to inject himself. This resulted in trauma of the urethra with bleeding 
and a rapid extension to the posterior urethra, which extension was 
revealed by clouding of the second glass of urine and by the patient’s 
getting up twice at night to urinate and increased pain on urination. 
Injections were stopped temporarily. His pain grew much less. In 
one week he was again put on anterior injections of protargol. Within 
two weeks his urine became clear and contained but few pus shreds. 
Bladder irrigations of silver nitrate 1 to 10,000 were very gently started. 
After two or three of these his urine was absolutely clear and massage 
of the prostate showed no pus in the prostatic secretion. 
One month later his complement-fixation test was negative. 
Case IV.—Acute Anterior Gonorrhea and Acute Prostatitis.—The 
patient had a urethral discharge five days; two days’ incubation. This 
is the second gonorrhea; the first occurred eight years ago and lasted 
months because of many exacerbations. First urine cloudy; second 
urine clear. Slight discharge contains rare pus cell, a few of which 
are filled with gonococci (methylene-blue stain). Meatus not red. 
This is apparently a new gonorrhea. Because of the slight amount of 
pus in his first urine (an active case usually has a cloudy urine on the 
fifth day), and because of a short incubation, it was thought that this 
might be an exacerbation of an old gonorrhea; so his prostate was 
gently massaged and in the discharge a few pus cells were found (by a 
few pus cells is meant eight to ten to the field, using one-fifth objective) 
and here and there a number of leukocytes were clumped together. 
I still was in doubt as to whether or not this was a new gonorrhea. 
So I took a complement-fixation test, which would be positive if it were 
a reinfection. His test was negative. 
He was treated with great care because of the difficulty in curing 
his first attack. The case was treated as Case I, and at the end 
of three weeks his urine was clear, with a rare shred and no gonococci 
found. 
He was seen infrequently now, and at the end of six weeks his urine 
still remained clear. Because of the old attack a sound (24 F.) was 
gently passed into the bladder to learn the condition of his urethra. TREATMENT OF GONORRHEA 
349 
Much bleeding resulted, from granulations in his bulb left by the first 
gonorrhea. Thereupon he developed a severe posterior urethritis and 
prostatitis, due to the sounding and the extension of his uncured 
anterior gonorrhea into his posterior urethra. Profuse discharge; first 
and second urines cloudy; prostate large, hot and tender. Urinated 
every hour, day and night, with much pain. 
He was put on the palliative treatment of prostatic abscess.* 
This patient used hot rectal irrigations very frequently; also morphin 
to control the pain. More than once I was moved to suggest operation 
on his prostate because of the intense pain, which was more or less 
continuous for two weeks. 
1 put him on vaccines in the second week, but they had little effect 
(in another case, less acute, vaccines seemed to control the pain). He 
had no chills, and his temperature kept around 101° F. 
At last, however, the pain broke. Then he was put on sandalwood oil 
and rectal irrigations but once a day. This was continued for a week. 
Now rectal irrigations were stopped. He was kept on a balsam for 
nearly three months, during which time he had slight exacerbations of 
prostatic pain and pus in his urine. At the end of three months his 
urine was clear, rare pus shred, no gonococci found. Complement- 
fixation test positive. Therefore gentle massage of his prostate twice a 
week was began; at first without irrigation, and later with potassium 
permanganate solution 1 to 5000 in his bladder (by catheter). Two 
months later his blood became doubtful, which meant cure. 
Case V.—Prostatic Abscess.—The patient came with a history of an 
acute exacerbation of an old posterior gonorrhea. He had a slight 
discharge which contained extracellular gonococci (methylene-blue 
stain) but not sufficiently typical to be called gonococci; so a Gram 
stain was made. This showred gonococci. He had much pain in his 
* Palliative Treatment of Prostatic Abscess. 
1. Rest in bed and daily catharsis. 
2. Stop all urethral injections. 
3. Rectal douche. 
By means of hot (rarely cold) water applied rectally, acute inflammation of the pros- 
tate, prostatic pain and vesical tenesmus are often controlled. Any two-way tube (one 
for inflow and one for outflow) which may be introduced into the rectum for an inch or 
two suffices. The most satisfactory is the Chetwood. This costs about $1.50 and is made 
of glass. A single rectal tube, such as comes with an enema outfit, may be used. With 
this hot or cold water is allowed to flow into the rectum; then by disconnecting the tube 
the water is allowed to flow out again, and so on. The bag containing the water should 
be two or three feet above the level of the anus. With any apparatus a number of trials 
on the part of the patient are necessary to get the tube working properly. The seat of 
the toilet is the best place for administering the therapy. At least two quarts of water 
should be used either at as hot a temperature as can be borne by the hand, or as cold as 
runs from the tap. A teaspoonful of salt may be added to the pint. This salt solution 
is supposed to be non-irritating. Such irrigations should be given as often as three times 
a day, if the patient’s acute symptoms demand it; otherwise not as often. Hot irriga- 
tions are always tried first, and if these have no effect on the prostatic pain, or urinary 
frequency, change to cold. 
4. Hyoscyamus mixture or morphin to alleviate the painful urination. 
5. If the patient has complete retention of urine, he should be gently catheterized 
three times a day. It is probably better not to follow the catheterism with a bladder 
wash. If a bladder wash is given, however, a very mild antiseptic solution should be 
injected through the catheter and allowed to flow out and the catheter then removed. 350 
INFECTIONS OF URETHRA AND PROSTATE 
prostate; he urinated day and night, every three-quarters of an hour; 
prostate large and irregular and periprostatic tissues infiltrated; tem- 
perature 99° F.; no residual urine. He was put on the palliative treat- 
ment of prostatic abscess. 
The following week his temperature steadily rose until it reached 
103° F. He had much pain in the urethra and in both groins. At the 
end of this week his prostatic abscess was drained through the urethra;* 
no free pus obtained, but broken-down material evacuated from his 
prostate. 
He went home on the sixth day after operation. Before going home 
his testicles were well strapped up; notwithstanding this he had an 
epididymitis which responded to rest in bed and heat. His perineal 
fistula rapidly healed, and he was left alone for two months, when pus 
* Operative Indications and Operation for Prostatic Abscess.—If the complete retention 
is not relieved in a very few days, if the temperature remains persistently above 100° F., 
if there are chills, then the prostatic abscess should be operated upon. 
Operation.—The urethra is opened by perineal section. (See Chap. XI.) The index 
finger is introduced into the prostatic urethra and the other index finger introduced into 
the rectum and the lobes of the prostate palpated between them. The lobes of the pros- 
tate are now entered by the urethral finger and any abscess cavity evacuated. If the 
abscess has broken beyond the confines of the prostate and has pointed in the perineum, 
wide incision and drainage are indicated. A perineal drainage tube is inserted into the 
bladder and removed in twenty-four hours. A patient can often leave the hospital in a 
week. He must be careful, however, as epididymitis often follows indescretions. The 
perineal wound should heal in three or four weeks. 
Stevens19 has devised a method of opening these abscesses intraurethrally. Under 
general anesthesia, with a guiding finger in the rectum, a sound is introduced as far 
as the prostatic urethra, and the tip of the sound thrust through the urethra into the 
abscess. Stevens reports a number of cases successfully operated upon in this way, 
and with no fatalities. 
I20 have used, in 15 cases, an aspiration method for the cure of prostatic abscess. 
The procedure is as follows: 
The patient is put in the lithotomy position, the perineum prepared as for operation, 
no general anesthesia is given. With the gloved index finger of the left hand in the 
rectum the perineum is anesthetized with 5 of 1 per cent, novocaine and adrenalin, 
using for this purpose a 32-inch, 18-gauge needle. The anesthetic is injected ahead 
of the needle. The needle enters between the urethra and rectum, and the point of 
the needle palpated just in front of the prostate by the rectal finger. This is import- 
ant because upon it depends the accuracy with which the needle is plunged into the 
different lobes of the prostate or seminal vesicles. From this point the needle is thrust 
forward into the lobe of the prostate in which the abscess is thought to be. A 5-c.c. 
syringe is attached to the needle and suction applied. If pus is found it is aspirated, 
the needle being gently pushed back and forward and the point rotated so that all 
of the pus may be aspirated from the abscess cavity. Each lobe of the prostate is 
punctured and if there is any suggestion of supraprostatic abscess or abscesses of the 
seminal vesicles these are likewise punctured and aspirated, the guiding finger in the 
rectum always indicating the way for the needle. A needle of the lumbar puncture 
type with not too acute a point is the best for the operation. Naturally the same 
needle is used for the anesthetization as for aspirating the pus, no withdrawal of the 
needle being necessary. 
These 15 cases have been saved general anesthesia, perineal section, damage to the 
prostatic urethra and long convalescence by aspirating pus from the prostate by the 
needle method. Up to date no untoward results have followed this method, and no 
cases have had to be operated upon subsequent to the aspiration. 
Subsequent experience has indicated that the method should be restricted to gono- 
coccus infections. Abscesses of the prostate caused by streptococcus, staphylococcus 
or colon bacilli do not do well after aspiration. The method should not be used when 
the abscess has broken through the capsule of the prostate and is pointing in the ischio- 
rectal fossa or has extended toward the seminal vesicles. Here operation is indicated. TREATMENT OF GONORRHEA 
351 
was found in his prostate and his complement-fixation test was posi- 
tive. 
Notwithstanding bi-weekly rubs of his prostate, followed by perman- 
ganate potassium (1 to 4000) in his bladder, a positive complement- 
fixation test persisted for six months. 
Treatment was given up after three months and he was told to get 
himself in good physical condition and to depend upon this to rid him 
of his last gonococci. His complement-fixation test was finally 
negative. 
CaseVI.—Acute Anterior and Posterior Gonorrhea; Acute Gonorrheal 
Arthritis.—The patient came with a history of his second gonorrhea (two 
weeks’ duration) complicated by an acute general arthritis which began 
two days previously. Ilis arthritis was mostly in the small bones of the 
feet. His very profuse discharge contained gonococci; first and second 
glasses very cloudy. Meatus very small (about 12 F.). This was 
immediately cut to 24 F., and just behind the meatus was the opening 
of a perimeatal gland from which pus could be squeezed. The duct 
ran just under the mucous membrane of the urethra. This duct was 
opened up so that its cavity communicated freely with the urethra. 
Because of this slight operation, which gave free drainage for the 
gonorrheal pus, the arthritis immediately cleared up and the patient’s 
gonorrhea promptly improved. Within two weeks he was put on a 
protargol anterior injection and sandalwood-oil capsules. In two weeks 
he had only a morning drop, with clear urine and shreds in the first. 
A sound was passed to the posterior urethra and caused undue bleeding 
in the bulb, where a slight constriction was found. The 24 F. sound 
was grasped on withdrawal. 
His posterior urethra was therefore irrigated every other day with 
silver nitrate solution beginning 1 to 10,000 and reducing to 1 to 2000. 
This course was followed to accustom the urethra to instrumentation 
so that the Kollman dilator or sounds could be used. These were 
indicated because of the slight strictures and granulations which were 
found by the sound. He was stretched with a Kollman dilator 
twice (to 30 F. then to 34 F., an interval of one week between 
stretchings). This cured him. 
Case ATI.—Persistent Complement-fixation Long after an Apparent 
Cure.—This patient came with an acute anterior gonorrhea. In one 
month his urine was clear; there were a few pus cells in his prostate. 
He was told to return for a complement-fixation test. He did not 
return until nearly two years later, when he wished the test preparatory 
to marriage. In the interval, as far as I could ascertain, he ‘had no 
symptoms and no new attacks of gonorrhea. He had a very few pus 
cells in his prostate; no gonococci were found in these, but his comple- 
ment-fixation was positive. A positive complement-fixation persisting 
as long as this means that the patient harbors gonococci. His prostate 
was massaged but three or four times; the massage was followed by 
bladder irrigations; one month later his complement-fixation was 
doubtful and one month later negative. This shows the extraordinary 352 
INFECTIONS OF URETHRA AND PROSTATE 
efficiency of prostatic massage in some cases; all cases do not react to 
massage as well as this! 
Case VIII.—Gonococcal Reinjection of the Urethra.—The patient had 
a urethral discharge for four days. This was his third gonorrhea; the last 
one occurred one year previous. Incubation of this attack one day; 
meatus not red. No burning on urination. Discharge showed one or 
two cells which contained gonococci. He gave a history of a number of 
these attacks, each of short incubation. Because of this history, and 
because he had not had a red meatus, and because of the difficulty to 
find typical gonococci in the discharge, it was thought that this was 
a reinfection of the urethra from an old prostatic gonorrhea. His 
prostate was gently rubbed, therefore, and the drop of pus expressed 
from it showed typical gonococci. He was put on anterior injections 
of protargol which within three or four days entirely cleaned up his 
urethral discharge. Then because of prostatic infection, a catheter 
was very gently introduced into his bladder and 0.5 per cent, protargol 
injected, and the patient passed this out. As this gave no reaction, his 
prostatic massage was gently begun, followed by a mild permanganate 
bladder wash, 1 to 4000. A month of this (twice a week), with the 
prostatic massage increasing in severity, cleared his prostate of pus, and 
a month later his complement-fixation test was negative. 
Case IX.—Peri-urethral Abscess.—This case came with a history of 
gonorrhea of two weeks. For three days he had a swelling on the 
under surface of the penis two inches back of the end. This was 
evidently a gonorrheal abscess of a peri-urethral gland. It was defin- 
itely pointing and was incised* the pus evacuated and the urethra 
wrapped in a wet bichloride dressing. No urethral treatment was given 
until the abscess healed—about two weeks. Then the treatment did 
not differ from that of any anterior gonorrhea. 
Case X.— Non-gonorrheal Prostatitis and Infection of the Verumon- 
ianum.—This patient came with a morning urethral discharge which, 
had persisted since his second attack of gonorrhea two years previous. 
His urine was clear and contained many shreds. When a discharge per- 
sists for this length of time it generally means a prostatitis. Therefore 
his prostate was examined. His prostatic secretion showed much pus. 
Blood for complement-fixation was negative for gonococcal infection. 
This was therefore a comparatively harmless, postgonorrheal pros- 
tatitis. The prostate was rubbed twice a week. Each rub was 
followed by an instillation of silver nitrate (0.25 to 0.5 per cent.) or a 
potassium permanganate bladder wash 1 to 4000 or 1 to 5000. These 
were continued for a month, changing occasionally to the Kollman 
dilator. His discharge by this time was reduced to a morning drop, 
which no slight-of-hand of mine seemed to be able to cure. I urethro- 
* Operative Treatment for Peri-urethral Abscess.-—These abscesses are allowed to point 
and then, under aseptic precautions and local anesthesia, are incised. The incision is 
parallel to the course of the urethra, wide, and extends down to the bottom of the abscess. 
Unless these peri-urethral abscesses are the result of a stricture or prostatic abscess, no 
perineal section with drainage of the bladder is necessary. TREATMENT OF GONORRHEA 
353 
scoped him and found a large and boggy verumontanum. This was 
probably the explantion of his infection, so I burned it with acid 
nitrate of mercury. The discharge still persisted, however, and I 
apparently was unable to cure it. 
Case XI.—Postgonorrheal Neurosis.—Patient came complaining of a 
pain in his deep urethra. He had a gonorrhea seven years previous and a 
second one five years later which, because of the above pain, he believed 
still persisted. His urine was clear and contained a very large number of 
shreds which,under the microscope, showed no pus. He has few pus cells 
in his prostate. A year previous his blood gave a negative complement- 
fixation test. Urethroscopic examination shows a few papillomata just 
back of the verumontanum. These were destroyed by touching them 
with acid nitrate of mercury. When he was examined again three 
weeks later his papillomata were cured, but his pain was still present. 
This is characteristic of these cases. Even if the cause for a neurosis 
is found and removed the symptoms, especially that of pain in the 
urethra, very often persist indefinitely. 
Case XII.—Cured Gonorrhea.—This patient came asking for guaran- 
tee of cure from a gonorrhea which he had five years ago. His present 
urine was absolutely clear; no shreds. The urine passed after vigorous 
massage of the prostate and vesicles showed on centrifuging absolutely 
no pus. He was guaranteed to be free without a complement-fixation 
test. 
Case XIII.—Incrustation of the Urethra Causing Urethral Discharge. 
—The patient came because of a slight morning urethral discharge 
containing pus and epithelial cells, but no gonococci; his complement- 
fixation test was negative, and there was no pus in a drop massaged 
from his prostate. He was stretched with the Kollman dilator and 
the bladder irrigated with various solutions—permanganate 1 to 4000, 
silver nitrate 1 to 2000, and he was given instillations of 0.5 per cent, 
silver nitrate. All of this had no effect on his urethral discharge. He 
was then urethroscoped and in his bulb were a few ulcers of the mucous 
membrane with calcareous deposits on them. These were scraped off 
with a cotton swab and the ulcers touched up with 10 per cent, silver 
nitrate (through the urethroscope). His discharge immediately 
stopped and he was cured. 
Vaccines and Vaccine Therapy.—The fact that gonorrhea is in most 
cases a localized and not a general infection explains the reason why 
vaccines are rarely used with success in combating this disease. The 
more general the gonorrhea, the more hope of success of any vaccine 
therapy. Thus cases of gonorrheal arthritis sometimes yield to 
vaccine, while cases of epididymitis or prostatitis rarely show improve- 
ment. 
Because different strains of gonococci are used to prepare the antigen 
used in the complement-deviation test, it is plausible that a vaccine 
prepared from different strains of gonococci might work better than a 
one-strain vaccine. Many prefer such a “polyvalent” vaccine and 
report favorable results from its use. 354 
INFECTIONS OF URETHRA AND PROSTATE 
Another method is to try on both animals and patients the efficacy 
of vaccines made of different strains of gonococci and use the strain 
which proves most efficacious. 
Dosage.—Always start with a very small dose, because we do not 
know how a particular individual is going to react. 
A gonococcal vaccine is used in which 1 c.c. equals 100,000,000 to 
500,000,000 of dead gonococci. 
Begin with 1 to 20,000,000 and repeat every fourth day, gradually 
increasing the dose according to the way a patient reacts. 
Autogenous Vaccines.—Many prefer these to regular stock vaccines. 
The objection to them is that it takes some time to have them made up. 
Their dosage is the same as that of stock vaccines. 
Antigonococcus Serum.—Rogers and Torry have derived from rams a 
polyvalent serum which has been used in cases of gonorrheal arthritis 
and epididymitis. Two c.c. of this serum are injected every second or 
third day, generally intramuscularly. 
Those using the serum report much the same result as those using 
vaccines. The serum injections, unlike the injection of the vaccines, 
may be followed by redness and swelling at the point of injection, chills 
and temperature. 
To sum up, both vaccines and sera are uncertain in their action; 
generally have, as nearly as can be determined, absolutely no result; 
and rarely, only too rarely, achieve a brilliant cure. 
TREATMENT OF SEMINAL VESICULITIS. 
The treatment is non-surgical and surgical. The non-surgical means 
of curing a seminal vesiculitis are similar to those for curing a prosta- 
titis. Rectal injection of hot water; massage of the seminal vesicles 
(with great care if the condition is at all acute), urethral washes to get 
rid of the debris massaged out of the vesicles, etc. 
Squier classifies the indications for surgical treatment under three 
headings—pus, pain and rheumatism. 
1. Under the first he includes (a) the acute cases, developing in the 
course of gonorrhea, often mistaken for prostatic abscess, in which the 
perivesiculitis simulates prostatic enlargement; (b) cases of recurrent 
epididymitis following acute urethritis and vesiculitis; (c) cases of 
chronic vesiculitis which simulate spermatorrhea; and (d) those in 
which the discharge from the urethra occurs during defecation and 
those in which non-operative treatment has been faithfully carried out. 
2. Under pain he includes various referred symptoms (p. 338). He 
reserves surgery for cases which resist local treatment. 
3. In the rheumatic group he includes acute, subacute, chronic and 
the deforming types of arthritis in which a definite relationship can 
be determined between the joint and the vesicle. 
Cabot reserves operation for cases of crippling arthritis. 
I have had but 2 patients on whom I have performed seminal 
vesiculotomy in whom the results were brilliant. Both had com- TREATMENT OF SEMINAL VESICULITIS 
355 
plete and long courses of treatment at the hands of competent physi- 
cians, and both were confined to bed crippled. They both left the 
hospital walking, and in one, at least, the result was permanent. 
Only too often, however, the arthritis becomes temporarily better 
after the operation, and then returns as bad as before. 
Operations.—I shall again follow Caulk in describing the operations 
on the vesicles. These may be divided into: 
“Vasotomy with injections of the vesicles, vesiculotomy, and vesic- 
ulectomy. Vasotomy, heralded by Belfield, has been employed by 
him in many cases of vesiculitis. It does not at present seem to have a 
substantial hold on the profession in the surgery of these organs. He 
has reported excellent results and others have corroborated his state- 
ments. The technic is simple, consisting in making a small scrotal 
vasotomy and allowing argyrol, collargol, or some other solution to find 
its way into the cavities of the vesicles. Owing to its simplicity it seems 
to be an operation which should be more frequently employed, and 
seems indicated particularly in many of the cases of chronic discharges 
which are not benefited by local treatment. 
“ Seminal vesiculotomy and vesiculectomy may be performed either 
perineally or through the ischiorectal region. The perineal approach 
is by far the most commonly employed. The usual steps are as follows : 
with the patient in the lithotomy position, a Y-shaped incision is made 
similar to Young’s perineal incision for prostatectomy; the apex of the 
prostate is exposed, then there are various modifications by different 
men. In order to bring down the vesicles, Young uses a tractor similar 
to the one he employs in prostatectomy work, excepting that it is longer 
and passes directly into the bladder from the meatus. By means of 
rotating this instrument against the symphysis, he is able to bring the 
vesicles nicely into the wound, and he is at liberty to undertake what- 
ever he deems necessary. 
Squier, after exposing the apex of the prostate, and by traction, is 
able to pull the vesicles down for a satisfactory exposure. After the 
apex of the prostate has been exposed, and either the tractor or the tape 
is inserted, the prostate is brought into the wound and the rectum 
separated, dissection being between the two layers of Denonvillier’s 
fascia. When the vesicles are exposed they will be found to be covered 
by the same fascial layers between the two layers which cover the 
prostate. These must be divided before the vesicles can be attacked. 
After division of the fascia, the prostate vesicles and vas can be 
examined. There is usually a perivesicular exudate which occasionally 
makes exposure difficult. One can then open and drain the vesicles in 
any place desired, or can remove any part of the vesicular wall which 
may be indicated. It is very frequently necessary also to incise the 
ampullae of the vasa. This operation should be used on both vesicles 
and vasa. After one has incised the vesicles, the operation may 
be considered complete, or the prostate may also be drained at the same 
time if it seems advisable. Tubes and gauze drainage are used. The 
gauze should be placed in the incised cavities and the tube down 356 
INFECTIONS OF URETHRA AND PROSTATE 
to this point. The wound is partially closed by bringing together 
the levator and muscles with catgut, and the skin with either catgut 
or silk. 
In Fuller’s operation for seminal vesiculotomy the patient is placed 
in the knee-chest position, thigh and knees sharply flexed, the knees 
well separated. He makes a cut on either side of the anus, taking 
care not to injure the sphincter. The forefinger is inserted into the 
rectum, and acts as a guide to prevent injury to the rectum. The 
levator ani muscles are cut; then the space between the prostate and 
rectal wall is dissected bluntly with the finger, and the tip of the seminal 
vesicle exposed. Along a grooved director passed to the vesicle, the 
vesicle is incised. The cavities of the vesicles are packed with gauze. 
Fuller has done this operation about 200 times. 
Operations on the Vas Deferens.—If the operation for relief of sterility 
following double epididymitis (p. 362) is excepted, the two principal 
operations on the vas are vasotomy and vasectomy. Vasotomy has 
been employed by Belfield, Cabot and others for the injection of silver 
salts into the seminal vesicles for the treatment of various affections of 
these sacs. The vas is grasped between the finger and thumb, and 
raised until it is just underneath the scrotal skin. The skin is excised 
over it, and the vas exposed. 
Vasotomy is unnecessary in most cases because, with very little 
practise, a fine needle may be inserted into the lumen of the vas, and 
fluid injected without incision. 
Vasectomy has been used on men so old as to have lost the power of 
procreation, and who have recurrent attacks of epididymitis secondary 
to infection of the posterior urethra and bladder. The incision is 
the same as in vasotomy, and both of these operations may be done 
under local anesthesia. 
Vasectomy has also been suggested and used for the sterilization of 
criminals and the unfit. 
GONORRHEAL EPIDIDYMITIS. 
Acute gonorrheal epididymitis is the most frequent complication of 
posterior urethral gonorrhea, and is also the most frequent disease of 
the testicle. This disease is important because it not infrequently 
results in obliteration of the vas deferens, thereby preventing sperma- 
tozoa from reaching the seminal vesicles and urethra. If the disease 
is bilateral and severe enough to cause obliteration of both vasa de- 
ferentia, sterility results. 
Etiology.—Gonorrheal epididymitis is always preceded by a posterior 
gonorrheal urethritis; while this posterior urethritis is generally acute, 
it need not necessarily be so. The epididymitis may simply occur in 
the course of a posterior urethritis, or more often is caused by improper 
instrumentation (passage of a sound, etc.), or the trauma following 
prostatic massage. Trauma of the testicle, itself, may be a predis- 
posing factor. It occurs in from 20 to 30 per cent, of all cases of GONORRHEAL EPIDIDYMITIS 
357 
gonorrhea, although one is apt to see it much more often in clinics than 
in private practice. “ When the epididymitis precedes the urethral dis- 
charge, as it sometimes does, we have to do probably with a 
relapsing gonorrhea and not with a new infection. ” (Keyes.) 
Pathology.—The inflammation running down the vas deferens attacks 
the globus minor first; it may stop here, but it generally goes on and 
attacks the globus major. The seminiferous tubes are swollen, edema- 
tous and infiltrated; abscess formation is rare; resolution generally 
takes place. According to the length and the severity of the inflamma- 
tion, more or less fibrous tissue is formed. Many tubules may be 
obliterated and the lumps in the epididymitis may take a number of 
months to finally resolve. The testicle proper is practically never 
involved. 
Symptoms.—Local Symptoms.—The testicle presents all the evidences 
of acute inflammation: Swelling, often redness, edema of the skin and 
tenderness. Because the infection travels down the vas, the pain and 
swelling are generally first felt in the tail of the epididymis; thence the 
swelling may extend to the head of the epididymis and back along the 
cord. The swelling of the cord often causes very intense pain because 
of its strangulation in the external abdominal ring. After a number 
of days, sometimes a week or more, the pain and swelling subside. Not 
infrequently acute epididymitis of the opposite side follows, but both 
testicles are very rarely involved at the same time. The urethral dis- 
charge and cloudy urine may entirely clear up during the course of the 
epididymitis and may recur again with the fading of the inflammation. 
In a certain number of cases, however, acute epididymitis causes a 
temporary cessation of the urethral discharge. Relapses occur in a 
number of cases. 
General Symptoms.—These are fever, generally not above 100° F., and 
the other constitutional symptoms of a mild infection. 
Diagnosis.—When a patient has a gonorrhea which is followed by 
acute epididymitis the diagnosis is not difficult. Occasionally, how- 
ever, when the epididymitis is subacute it is difficult to differentiate it 
from a tuberculosis or a colon bacillus infection of the epididymis. 
Careful examination of the centrifuged urine for the gonococcus, the 
colon bacillus or tubercle bacillus and palpation of the prostate and 
seminal vesicles help to determine the nature of the process. In 
certain rare cases the use of tuberculin for diagnosis probably 
assists. 
Beer* cites one case in which a distinct focal reaction followed the 
injection of tuberculin. The epididymis became more swollen and 
painful. The writer has lately had a case which gave a general tuber- 
culin reaction which was followed by no focal reaction in the involved 
epididymis. This epididymitis eventually cleared up and was prob- 
ably a colon infection. 
* The Use of Tuberculin in the Diagnosis of Obscure Conditions of the Genito-urinary 
Tract, Med. Record, October 11, 1913. 358 
INFECTIONS OF URETHRA AND PROSTATE 
The complement-fixation test should not be neglected in making the 
diagnosis; it is invariably sooner or later positive (generally within two 
weeks after the beginning of the epididymitis). Syphilitic testicle, 
malignant disease of the testicle, and other rarer conditions are to be 
thought of. 
Prognosis.—Death rarely is caused by gonorrheal epididymitis; there 
are, however, a few fatal cases recorded in which death from peritonitis 
or pyemia followed. 
Watson and Cunninghamf quote Benzla who “ investigated the num- 
ber of offspring begotten by the soldiers of the German Army who had 
had gonorrhea, and found that 10.5 per cent, of those who had the 
disease without epididymitis were childless, while of those who had 
unilateral epididymitis 23.4 per cent, were childless, and those with 
bilateral epididymitis 41.7 per cent, were childless.” Keyes states that 
“ patients who have recurrent attacks of epididymitis are less likely to 
be sterile than those who have but a single attack.” The reason for 
this is obvious. If the epididymitis has closed the vas deferens in 
the first attack, the gonococci cannot again come through the vas and 
cause a second attack. 
Treatment.—The first prophylactic measure is to prevent if possible 
an anterior gonorrhea from extending into the posterior urethra. The 
second is, if posterior gonorrhea has become established, to be cautious 
and gentle in entering the posterior urethra with instruments. During 
the acute stage of the gonorrhea no instrument should be put into the 
urethra, and the prostate should not be massaged. A suspensory is also 
advised, but it is a question whether it ever prevents the occurrence of an 
epididymitis. When once the epididymis is inflamed the following meas- 
ures should be taken. The patient should be put to bed andkept there until 
the temperature is normal and acute pain has subsided. The testicles 
should be elevated as much as possible. To do this a suspensory bandage 
or jock-strap is inadequate. Keyes16 has developed in the Urological 
Service at Bellevue Hospital an adhesive suspensory for treating 
gonorrheal epididymitis. Collings21 describes this. The suspensory 
consists of two pieces of adhesive plaster stuck together at right 
angles to each other in the form of a “T.” The average size of 
the larger strip of adhesive is 22 inches long by 4| inches wide and 
the smaller one 22 inches long by inches wide. This latter piece 
is divided into three |-inch strips, the two lateral ones being used 
for perineal straps and the centre one to hold a roll of crinolin gauze 
1 inch long by § inch diameter, to the suspensory. The purpose of 
this pad of gauze is to prevent the scrotum from slipping down 
between the bandage and the perineum. The skin of the scrotum 
is protected from the adhesive plaster by a piece of gauze. 
In applying the suspensory, one hand holds the crinolin pad in 
the perineum; the scrotum is lifted up so that the weight of the 
testicle is taken off the spermatic cord; the other hand places the 
* Genito-urinary Diseases, Lea & Febiger, 1908. GONORRHEAL EPIDIDYMITIS 
359 
broad strips over the inguinal regions so that they centre over the 
anterior-superior spines. The perineal straps are then brought 
around the legs in the gluteal folds and join the broad strips at the 
anterior-superior spines. 
To make the suspensory more durable and stick to the skin better, 
a piece of adhesive 2 inches wide incorporating the two previous 
strips is run from the great trochanter of one femur to the other. 
Fia. 187.—Suspensory for epididymitis. (Codings.) ' 
An average of 30 cases of gonorrheal epididymitis a month are 
admitted to the wards. Usually the patient is free from pain and 
the temperature is normal forty-eight hours after treatment is started. 
At the end of another forty-eight hours he is allowed out of bed and 
goes home on the fifth or sixth day. 
A re-admission to the hospital after discharge for a recurrence of 
symptoms is rare, perhaps one case in three months. 
If in the first few days the pain does not subside and the tem- 360 
INFECTIONS OF URETHRA AND PROSTATE 
perature is still up, epididymotomy, after the method of Hagner, is 
performed. This form of treatment is necessary in 7 per cent, of 
the cases. 
The non-gonorrheal non-tuberculous type of epididymitis is treated 
by this method and watched closely to see which way the tide will 
Fig. 188.—Anterior view of suspensory for epididymitis. (Codings.) 
turn. Sometimes an operation is avoided but in the majority of cases 
the epididymis soon suppurates and surgery is resorted to. 
As far as I know this is the only method by which the testicles can 
be properly elevated, and is much better than the old method of 
placing a broad band of adhesive plaster across the thighs and allow- GONORRHEAL EPIDIDYMITIS 
361 
ing the testicles to rest on this. External application of heat or cold 
may be applied to the testicle. This apparently does not particularly 
influence the inflammation but lessens the pain. The same is true of 
applications of various irritative drugs applied to the scrotum. A 
favorite one is 50 per cent, guaiacol in glycerin; this relieves the pain 
but I doubt if it hastens the recovery. It irritates the scrotal skin. 
Fig. 189.—Perineal view of suspensory for epididymitis. (Collings.) 
Barney* has devised a rubber bandage which is so.placed around 
the testicle as to exert a uniform pressure on it. 
Vaccines.—Many recommend vaccines beginning with 20,000,000 
bacteria and repeating every second day in ascending doses. Occa- 
sionally they do good, but more often not. 
* Acute Gonorrheal Epididymitis Treated by the Method of Bier, Boston Medical and 
Surgical Journal, October 28, 1909. 362 
INFECTIONS OF URETHRA AND PROSTATE 
Operative Treatment.—Hagner first suggested the following operation 
for acute epididymitis: 
“At the juncture of the swollen epididymis and testicle, an incision 
6 cm. to 10 cm. in length, depending upon the amount of enlargement, 
is made through the scrotum down to the tunica vaginalis, which is 
opened at the juncture of the epididymis and testicle. After the serous 
membrane is opened, all the fluid is evacuated and the enlarged epidi- 
dymis examined through the wound. The testicle, with its adnexa, is 
delivered from the tunica vaginalis and enveloped in warm towels. 
The epididymis is then examined and multiple punctures made through 
its fibrous covering with a tenotome, especially over those portions 
where the enlargement and thickening are greatest. The knife is 
carried deep enough to penetrate the thickened fibrous capsule and 
enter the infiltrated connective tissue. When the knife is through the 
thickened covering of the epididymis, a very marked lessening of re- 
sistance will be felt. If pus be seen to escape from any of the punctures, 
the opening is enlarged and a small probe inserted in the direction 
from which the pus flows. By this method, I believe there is less 
danger of injuring the tubes of the epididymis than by cutting with the 
knife. After the probe is passed in, pus will be evacuated by light 
massage in the region of the abscess, and a fine-pointed syringe is used 
to wash out the cavity with 1 to 1000 bichloride of mercury, followed 
by physiological salt solution. The testicle is then restored to its 
normal position, and in every case the tunica vaginalis is thoroughly 
washed with 1 to 1000 bichloride, followed by normal salt solution. 
The incision of the tunica vaginalis is lightly closed with a running 
catgut suture; a cigarette drain of gauze is then laid over the incision, 
the skin being brought together with a subcutaneous silver-wire 
suture, the cigarette drain passing out at the lower angle of the 
wrnund.” 
This operation is to be considered only in extremely acute cases. It 
has not as yet been determined whether the operation increases or 
decreases the occurrence of sterility. 
Declining Stage.—Various methods of hastening the resorption of 
the exudate have been suggested, such as strapping the testicle with 
adhesive plaster or with a rubber bandage. Personally I believe that 
just as good results are achieved by using Alexander’s Bellevue bandage 
for a week or two after the acute inflammation has subsided. No ure- 
thral injection, or instrumentation should be used until a number of 
weeks have elapsed, as these may cause an acute exacerbation of the 
epididymitis. 
Recurrent Attacks—Acute gonorrheal epididymitis is not often com- 
plicated by acute recurrences. These are much more often seen in 
epididymitis occurring with hypertrophy of the prostate and infection 
of the posterior urethra and bladder. Ilecurrent attacks of epididy- 
mitis may be treated precisely as the original attack. 
Sterility in Bilateral Gonorrheal Epididymitis.—In sterile marriages 
the fault lies with the male in over 15 per cent, of the cases, and in NON-GONORRHEAL URETHRITIS 
363 
probably most of these there is azoospermia due to chronic epididymitis 
of the globus minor, and occlusion of the ducts leading to the vas. For 
these cases Martin7 introduced the operation of epididymovasotomy. 
An anastomosis is made between the vas deferens and the head of the 
epididymis. The testicle is exposed, together with the epididymis, and 
the nearby vas. A portion of the globus major is incised, from which 
incision spermatic fluid will ooze. This should contain motile sperma- 
tozoa. If spermatozoa are not found at the first incision, various other 
incisions should be made in the globus major until spermatozoa are 
found. The vas is incised longitudinally, and its lumen opened. The 
edges of this incision are sewed to the edges of the wound in the epidi- 
dymis. Martin uses fine silver wire, and fine needles for the suture. 
Naturally such an operation is deferred until any disease of the urethra 
or seminal organs—strictured urethra, prostatitis, seminal vesiculitis— 
is cured. 
Lespinasse has perfected an operation in which he sutures the 
patent vas over a tubule containing spermatozoa, then a fine needle 
and silk thread, such as is used in arterial suture, is passed through 
the lumen of the tubule into the lumen of the vas and then out of 
the vas and so externally. This is gently pulled upon from day to 
day until it is removed and so a patent way for the spermatozoa 
formed. 
It is probably better to operate upon one side first rather than 
on both sides simultaneously. If the operation be a success, then 
the second one need not be done. To ensure the patency of the 
vas deferens, argyrol may be injected into the cut vas at the time of 
operation. If the argyrol appears in the urine, the vas is patent. 
GONOCOCCAL INFECTION OF THE BLADDER AND KIDNEYS. 
In spite of the frequency of gonorrhea of the male urethra gonorrheal 
cystitis or pyelonephritis is extremely rare. The gonorrhea seems to 
stop at the internal urethral orifice or the trigone. The only case of 
gonorrheal cystitis that I have seen was in a woman. Here the gono- 
cocci evidently reached the urethra in virulent form and the patient 
passed nearly pure blood for two or three days. There are probably 
not more than twenty cases of gonorrheal pyelonephritis* in the litera- 
ture. In symptoms it does not differ from any other pyelonephritis, and 
the diagnosis is made by finding gonococci in the specimen of urine 
obtained from the kidney. 
NON-GONORRHEAL URETHRITIS. 
Postgonorrheal Urethritis.—A patient may have all of the symptoms 
of a urethritis after the gonococci have disappeared from his urethra. 
* E. MacD. Stanton11 gives the bibliography of these cases in an article, “A Clinical 
and Histopathological Study of the Gonococcal Infection of the Kidney.” 364 
INFECTIONS OF URETHRA AND PROSTATE 
This is caused primarily by damage to the urethra by the gonococcus 
and secondary infection by some other organism (see Bacteriology). 
The symptoms are those of a chronic gonorrheal urethritis only the 
gonococcus is not present. The complications are limited to a 
prostatitis or seminal vesiculitis. 
Traumatic Urethritis.—There are a great many causes for this: 
Instrumentation, passage of a stone, introduction of caustic injections 
by mistake, or with the idea of aborting a gonorrhea, crushing the penis, 
or bending the erect organ. Such a urethritis is often followed by 
permanent damage to the urethra, and stricture. 
Syphilitic Urethritis.—The urethra may be the site of a chancre 
which may be entirely overlooked until the secondary syphilitic 
eruption appears. The only symptoms may be those of a mild 
urethritis, discharge, urethral burning, etc. 
Secondary syphilitic inflammation of the urethra as well as of the 
bladder and even the kidney have been described. These are generally 
in the form of mucous patches. 
Herpetic, Eczematous, Diathetic, and Ingestive Urethritis.—The 
first may occur in eczematous patients, with an exacerbation of an 
eczematous attack. Patients with gout, patients with an attack of 
grippe, and diabetic patients may have symptoms of urethritis, which 
occurs during an acute exacerbation of the disease. Alcohol, can- 
tharides, arsenic, purgative mineral wraters, iodide of potash, tur- 
pentine, asparagus, have all been accused of lighting up a mild urethral 
inflammation. 
Treatment.—The treatment of all these forms of urethritis consists in 
removing their cause and then treating them as one would a chronic 
gonorrheal urethritis, giving preference to astringents. Vaccines 
apparently do no especial good. 
Is a Non-gonorrlieal Urethritis a Bar to Matrimony?—This is more 
or less of an unsolved problem. It is reasonable to suppose that a 
woman may be infected by these non-gonorrheal organisms, which 
infection may cause vaginitis, which inflammation might possibly 
cause a woman to become sterile. Indeed, I have seen a case of a 
violent but short-lived vaginitis of this sort follow shortly after marriage. 
The husband had a non-gonorrheal urethritis and stricture. Most 
urologists believe, howrever, that a man vrith a non-gonorrheal urethritis 
can marry and that no trouble will follow. It seems to be the 
consensus of opinion that the gonococcus alone is responsible for 
endometritis, salpingitis, etc. 
Urethrorrhea, Prostatorrhea, Spermatorrhea.—The causes for these 
conditions are various. Masturbation is always put first; undue 
sexual excitement is another cause assigned. Often they are 
postgonorrheal. 
The symptoms are a mucous discharge from the urethra, either con- 
stant or only during defecation. The discharge may contain simply 
mucous or may contain prostatic cells or spermatozoa. Their principal 
importance lies in the fact that the occurrence of the discharge makes BIBLIOGRAPHY 
365 
the patient think he has “ lost his manhood ” or is being much weakened 
by this sexual drain. 
Keyes says that “the only cure is common sense, the only relief 
matrimony.” Hygiene, exercise in the open, getting the patient’s 
thoughts oft' his sexual apparatus, and keeping him away from a 
physician are all indicated. 
BIBLIOGRAPHY. 
1. Caulk: Surg., Gynec. and Obst., November, 1915. 
2. Finger, Gohm, and Schlagenhaufer: Arch. f. Derm. u. Syph., 1894, xxviii, 277 
3. Flexner: Prostitution in Europe. 
4. Henry: The Military Surgeon, May, 1912, xxx, 520. 
5. Keyes: Am. Jour. Med. Sc., 1912. 
6. Lowsley: Anatomy of the Human Prostate Gland, Tr. Am. Med. Assn., 1915; 
January, 1913. 
7. Martin: University of Pennsylvania Med. Bull., March, 1902; Thera. Gaz., 
December, 1909. 
8. McNeil: Archives of Pediatrics, September, 1913. 
9. Poroz: Anatomy of the Prostate, Folia Urologica, May, 1914. 
10. Schwartz and McNeil: Am. Jour. Med. Sc., May, 1911. 
11. Stanton: Urolog. and Cut. Rev., November 2, 1913, i. 
12. Swartz: Jour. Urol., August, 1920. 
13. Davis and Harrell: Jour. Urol., 1918, ii, 257. 
14. Hyman: Urologic and Cutan. Review, June, 1920, xxiv, 325. 
15. Davis: Am. Jour. Med. Sci.. 1921, clxi, 251. 
16. Keyes: Jour. Am. Med. Assn., November 13, 1920, lxxv, 1325. 
17. Ashcraft and Kennel: Hahnemannian Monthly, May, 1919. 
18. Jeck: Read at New York Acad, of Med., May 19, 1922. 
19. Stevens: Jour. Urol., June, 1921. 
20. Barringer: Jour. Urol., May, 1922. 
21. Codings: Jour. Urol., June, 1922. CHAPTER IX. 
DISEASES OF THE URETHRA IN THE FEMALE. 
By ALFRED T. OSGOOD, M.D. 
ANATOMY OF. THE FEMALE URETHRA. 
The female urethra, unlike that of the male, has a solely urinary 
function. In contrast with the urethra of the male, it is a short, wide 
channel analogous to the membranous portion of the male urethra. 
This canal is a tube of approximately cylindrical shape whose length 
is 3.5 cm. (2.5 to 5 cm.), and whose wall is 0.5 cm. in thickness, begin- 
ning at the outlet of the bladder and extending almost vertically 
downward, when the woman stands erect, to the vestibule of the 
vagina. The diameter of the lumen of the urethra is about 8 mm. 
(7 to 10 mm.). 
The mucous membrane of the urethra is thrown into longitudinal 
folds when at rest by contraction of the surrounding muscles, so that a 
transverse section of its lumen presents a median point from which 
radiating lines diverge between these folds like the spokes of a wheel—• 
the picture presented at the extremity of a straight examining tube 
(urethroscope). 
The epithelium of this lining mucous membrane is of the stratified 
squamous type, except near the bladder, where it takes on the character 
of the bladder mucosa, which bears transitional epithelium. In the 
inner third of the canal the mucosa presents5 many small tubular glands, 
while the outer portion contains fewer, more widely scattered, and 
somewhat larger glands. On each side of the external urethral orifice, 
usually just within the canal, are found the openings of the para-urethral 
ducts (the largest of which are called Skene’s glands). These ducts 
may open upon the vestibule outside of the mucous membrane of the 
urethra. 
The mucous membrane often pouts somewhat at the external urethral 
meatus upon the vestibule of the vagina, forming a slight eminence. 
The external orifice is found in varied forms; commonly it assumes the 
shape of an inverted Y by reason of the prominence of a longitudinal 
fold upon its floor. It is seen as a vertical slit with prominent margins 
or as a dimple or depression in the eminence with radial folds in its 
lining membrane. The prominent folds of mucous membrane upon 
the margins of the meatus may overlie the orifice in such a way as to 
conceal the lumen, so that in a child or adult with small vulva and 
intact hymen, careful observation is needed to detect the lumen of the 
canal. 
366 ANATOMY OF THE FEMALE URETHRA 
367 
The submucosa is a stratum of loose areolar tissue, separating the 
epithelial layer from the innermost (longitudinal) muscular layer, con- 
taining elastic fibers and a network of cavernous venous spaces which 
form a spongy, erectile tissue. The mucous membrane with its 
numerous longitudinal folds is a cylinder within the cylinder com- 
prising the muscular sheath, and is loosely connected with it by the 
submucosa. 
Subjacent to this submucosa is a sheath or cylinder of longitudinal 
smooth muscle fibers, thin near the bladder and thicker near the ex- 
ternal orifice. Outside of the longitudinal smooth muscle layer is the 
second layer of smooth muscle fibers which are arranged in circular or 
ring fashion about the tube. This circular layer is of importance, for its 
upper portion surrounds the beginning of the urethra at the vesical 
outlet to form the involuntary sphincter of the bladder, which must be 
considered, as Kalisher1 has plainly demonstrated, not as a part of the 
bladder musculature, but as a urethral muscle extending into and 
forming a part of the smooth muscle underlying the trigone of the 
bladder (sphincter trigonalis, lissosphincter internus). This circular 
layer of smooth muscle is thick and well defined about the inner one- 
third of the urethra, extending obliquely about the urethra from its 
anterior surface downward and backward to form the muscular layer 
of the trigonum vesicse. About the rest of the urethra it forms a cylin- 
drical sheath, becoming thinner as it approaches the external urethral 
orifice. 
These smooth muscle layers are not voluntarily controllable, and are 
innervated by nerve fibers from the pelvic ganglions of the sympathetic 
hypogastric plexus. 
The third and most important of the muscle layers surrounding the 
urethra is the outermost striated, voluntary muscle the “sphincter 
urogenitalis,” or compressor urethrae muscle, which is found between 
the two layers of the triangular ligament of the perineum. 
These striated fibers surround completely only the upper portion of 
the urethra above the urethrovaginal septum, where bands interlace 
both in front of and behind the urethra to form a ring muscle. Some 
fibers extend upward beneath the urethra toward the bladder in a longi- 
tudinal direction. Where the urethral and vaginal walls run parallel 
the fibers of this muscle do not decussate below the urethra in the 
urethrovaginal septum, but extend downward on each side to end 
in the lateral aspects of the vagina. The anterior extremity of the 
urethra near the orifice is not surrounded by the sphincter urogenitalis 
muscle, i. e., that part of the canal in front of the anterior layer of 
the triangular ligament of the perineum. The anterior layer of the 
triangular ligament serves to suspend and fix the urethra in the 
subpubic angle. This striated muscle, sphincter urogenitalis, or 
compressor urethrae is innervated through branches of the pudic 
nerve. The urethra may be divided for description into two2 parts. 
1. This portion extends from the bladder wall to the point where it 368 
DISEASES OF THE URETHRA IN THE FEMALE 
meets the urethrovaginal septum—the urethra libera. This portion, 
measuring about 1 cm. in length, is surrounded by areolar tissue which 
loosely fills the surrounding space between the symphysis pubis (2 cm. 
anterior to the urethra) and the anterior vaginal wall behind. On each 
side of this urethra libera the anterior (mesial) margins of the levator 
ani muscles pass down close to the urethra, passing the vaginal wall as 
well, to reach insertion in the rectal wall, median perineal tendon, and 
external anal sphincter. 
This free portion of the female urethra is surrounded, as in a sling, 
by the posterior fibers of the sphincter urogenitalis or compressor 
urethrae muscle. Some of the fibers of this muscle run upward in a lon- 
gitudinal direction upon the posterior surface of the urethra toward the 
bladder. This is the only part of the female urethra completely sur- 
rounded by fibers of this voluntary muscle. 
This portion of the urethra surrounded by the internal involuntary 
sphincter muscle and these circular fibers of the compressor urethrae 
muscle are particularly liable to injury by pressure of the child’s head 
during delivery, and lead to the discomforts of incontinence so com- 
monly found in women who have borne children. 
2. The second (lower) portion of the urethra is that part extending 
from the point where the free portion of the urethra and the vagina 
come into relation to form the urethrovaginal septum. This is the 
vaginal portion of the urethra, and measures approximately 2\ cm. in 
length. The compressor urethrae muscle extends around the anterior 
and lateral walls of this part of the urethra without extending into the 
urethrovaginal septum beneath the canal. 
The course of the urethra from the bladder to the vestibule of the 
vagina follows a slight curve beneath the symphysis pubis, whose con- 
cavity is directed anteriorly, and the canal is separated from the 
symphysis about 1.5 to 2 cm. In the erect posture (standing or sitting) 
the course of the urethra is nearly vertical, while in the dorsal position, 
as during examination, it is practically horizontal, and its slight curve 
can be disregarded clinically. 
In passing a straight instrument, such as a urethroscopic tube, it is 
in fact more comfortable for the patient and simpler for the surgeon if 
no attempt is made to follow the gentle curve. The tip of the instru- 
ment by this method impinges against the less sensitive superior wall 
and glides smoothly into the bladder. 
The inferior (posterior) urethral wall lies upon the median line of the 
anterior vaginal wall, but separated from it by tissue of 0.5 or 1 cm. 
in thickness, which is called the urethrovaginal septum, consisting of 
dense connective tissue containing elastic and muscle fibers. 
The internal urethral orifice is found normally at the lowest point of 
the bladder. The vesical trigone is less marked than in man, and the 
ridge called the uvula vesicse is usually absent, so that the shape of this 
orifice is nearly round. It lies 2.5 cm. posterior to the lower half of the 
symphysis pubis. 
The external urethral orifice lies in the sagittal plane of the vestibule PHYSIOLOGY OF THE FEMALE URETHRA 
369 
1 or 1.5 cm. from the lower margin of the symphysis, and at a variable 
distance from the vaginal margin. It presents diverse forms (sagittal 
cleft, star, triangular) of opening, upon a more or less well-defined 
papilla, commonly with a ridge upon the lower margin or floor, which 
produces the inverted Y-shape in many cases. This is the narrowest 
portion of the canal, varying in size, as does the external urethral 
meatus in man. Skene’s ducts and a varying number of smaller 
para-urethral ducts open upon the margin of the external meatus 
usually in the sulci between the median fold upon its floor and lateral 
walls. These ducts are of particular importance, since they often 
are the lodging-place of prolonged infection, especially that produced 
by the gonococcus. 
The blood supply of the urethral tissues arises from branches of the 
internal pudic, inferior vesical, and vaginal branch of the uterine 
arteries. Its veins pass into the vesicovaginal and prevesical or 
pudendal plexuses. About the upper part of the urethra (neck of 
bladder) the veins in the submucosa are abundant, giving rise to the 
darker color of the mucosa at this point. 
The lymphatics of the urethra pass to nodes of the hypogastric chain 
and to nodes in the inguinal regions. 
Sensory nerves of the urethra come from the pudic and through the 
sympathetic nerves of the pelvis. 
PHYSIOLOGY OF THE FEMALE URETHRA. 
The female urethra is the channel of outlet for the renal secretion 
from the reservoir called the urinary bladder. 
The ability to retain fluid in the bladder depends upon muscular 
closure of the tube. Paralysis of these muscles results in inability of 
the bladder to retain its contents—incontinence. 
The urethra occupies, therefore, a most important place in the 
function of urination. The musculature of the bladder undertakes that 
part of this function which embraces the storing up of fluid by dilatation 
and its forcible expulsion by contraction of the detrusor. 
The internal, plain muscle, involuntary sphincter of the bladder 
surrounds the beginning of the urethra at the vesical outlet. Yersari 
demonstrated that this muscle is distinct from the musculature of the 
bladder. It is a thickened portion of the circular plain muscle layer 
of the urethra. It is intimately related with part of the bladder 
(trigone and orifice) and with part of the urethra. 
Surrounding the urethra at a lower point (i. e., distal to this in- 
ternal sphincter) is a second sphincter of striated muscle which may 
be held in contraction through voluntary effort to close the canal 
and retain urine in the bladder, reinforcing the function of the internal 
sphincter. 
“The chief physiological factor in the closure of the urethra, and 
therefore in the normal retention of urine, is the internal sphincter.”2 
By the action of this muscle, urine is retained in the bladder of the dead 370 
DISEASES OF THE URETHRA IN THE FEMALE 
body, and in the living the tonic contraction of the internal sphincter 
permits the accumulation of urine in considerable amounts, with 
periodic evacuation. 
Rehfisch, Hanc, von Zeissl and others have adduced experimental 
evidence, which indicates that relaxation of the internal sphincter pre- 
cedes the contraction of the detrusor in normal urination, and is the 
main factor in the process of micturition incited by desire. Lesions 
which induce dilatation of the internal sphincter and contraction of the 
detrusor can often be traced to that area within the urethra which is 
surrounded by the internal sphincter. Failure of the sphincters to 
perform their function of control of urine in the bladder (incontinence) 
points directly to some defect which may lie within the canal which 
these muscles are designed to occlude, or to failure of one or both 
of the sphincters themselves, to produce complete closure of the 
outlet. 
The sensation of desire to void urine is doubtless one which arises 
about the bladder outlet (often, if not always, in the lumen of the ure- 
thra), and normal control consists not only in contraction of the external 
voluntary sphincter, but in accentuation of inhibitory impulses to the 
spinal centre controlling the reflex act of micturition, so that efferent 
impulses do not accomplish complete relaxation of the internal sphinc- 
ter, even though contractions of the bladder detrusor may be so strong 
as to be painful. 
Interruption of the act of urination can be accomplished by woman 
as well as by man, although in the female the voluntary sphincter is a 
weaker muscle and does not embrace the urethra so completely as in the 
male. This interruption is produced by contraction of the internal 
involuntary sphincter, not through voluntary control of this muscle 
itself, but through a check upon the reflex in the spinal cord transmitted 
to it from the cerebrum. 
These features of the physiology of micturition are emphasized be- 
cause of their important bearing upon disturbances of function and 
diseases of the female urethra. 
The female urethra does not possess the highly sensitive structures of 
the prostatic urethra, yet the juxtavesical portion of the female urethra 
is its most sensitive part, and stimulation of its mucosa induces the 
desire for urination, and often (if not always) sets in action the spinal 
reflex of micturition. 
The urethra is often overlooked or disregarded in the mechanism of 
urination when its importance is paramount. Every complaint of 
painful urination should focus the attention of the investigator upon 
the urethra as the seat of origin of this symptom. Abnormally fre- 
quent urination points to a disturbance of the sensory nerves (“ sense 
of titillation”) in the grasp of the internal sphincter, which induces 
a dilatation of this muscle and a reflex contraction of the bladder 
musculature. 
All treatment for the relief of abnormalities of the function of urina- 
tion must take into account the anatomical structure of the urethra EXAMINATION OF THE FEMALE URETHRA 
371 
with the muscles which surround it and the physiological action of these 
structures. 
The function of urination is usually ascribed by physiologists to the 
bladder, so that clinical application of these physiological studies leads 
not uncommonly to the ascribing of all changes in this function to 
abnormalities in the bladder itself, while the all-important urethra is 
forgotten. 
MEANS AND METHODS FOR EXAMINATION OF THE FEMALE 
URETHRA. 
Preparatory to examination the patient should present herself with- 
out voiding urine and without cleansing the vulva by bath or douche for 
from four to six hours preceding the time of examination. 
Urethral instruments must be sterilized and manipulated with all 
aseptic precautions. The methods for sterilization, etc., of instruments 
is elsewhere considered. 
The preparation of the patient consists in washing the vulva with 
green soap and water. After covering with sterile towels the legs 
of the patient, and the examining table where contact with the 
hands of the surgeon or with instruments is possible, drape a sterile 
towel over the inner side of each thigh so that its inner margin falls in 
the median line of the vulva. By this means a margin of towel may be 
used to retract beneath it the labia minora and majora, exposing the 
vestibule and meatus urinarius. 
The meatus and vestibule are then carefully washed with a solution 
of bichloride of mercury 1 to 2000 or other antiseptic solution. 
Instruments are lubricated before insertion into the meatus with one 
of the numerous soluble colorless jelly-like lubricants made from certain 
mosses (K. Y. jelly, etc.). Glycerin is a less satisfactory lubricant and 
oily substances, such as olive oil, vaselin, etc., are very undesirable, 
chiefly because they befog a lens or electric-light bulb. 
The position of the patient for this examination is important, and 
doubtless the best from the stand-point of the examiner is the knee- 
breast position, because in this position the abdominal contents fall 
downward and forward, relieving the bladder and entire pelvic cavity 
of pressure, permitting the ingress of air into the bladder and collecting 
the urine at the vertex instead of the base as it escapes from the ureters, 
thus relieving the examiner of the troublesome outflow of urine into the 
urethroscopic tube during examination of that part of the urethra close 
to the vesical outlet. This position, however, has distinct disad- 
vantages to the patient. It is offensive to her to be thus exposed and 
examined, and it is uncomfortable and fatiguing after a short time. In 
some cases, however, it is necessary to resort to this position. 
The common dorsal position, as for gynecological examination, is 
usually the most practicable one and the one assumed with least com- 
plaint on the part of the patient. Nine out of ten urethroscopic exami- 
nations can be satisfactorily made with this position. The dorsal 372 
DISEASES OF THE URETHRA IN THE FEMALE 
position with the pelvis elevated and the body supported by shoulder 
braces, simulating the Trendelenburg position, is sometimes resorted 
to, but offers only slight advantage. 
The Sims posture is often very satisfactory, and with the foot of the 
table elevated may compare with the knee-breast position in favorable 
features. The Sims position frequently has to be used when stiffness of 
the hip or spine (ankylosis, old fracture, etc.) interferes with the dorsal, 
the knee-breast, or knee-elbow position. 
Inspection.—The patient is placed in the usual dorsal position, with 
knees separated and thighs flexed, as for any gynecological examination, 
and the labia minora are gently separated, exposing the vestibule and 
vaginal orifice. 
By careful inspection the urethral orifice and the vestibule may 
reveal excessive or abnormal secretion. For the detection especially of 
inflammatory changes in and about the urethra it is imperative that this 
inspection shall be made before any cleansing of the vulva has been 
done by a nurse or by the surgeon, because it is important to note 
whether secretion is present about the whole vulva (as with profuse 
vaginal discharge), whether there is secretion, swelling, or unusual 
redness about the meatus, the para-urethral ducts, the vulva or the 
vaginal outlet for the differentiation of a generalized purulent infection 
from an isolated lesion in or in connection with the urethra. 
The first inspection should note the size, shape, and color of the 
meatus and of the vestibule about it as well as the presence or absence 
of secretion and the source of secretion. The anterior vaginal wall 
should be seen, when possible, to detect scars beneath the urethra or 
swelling projecting upon this surface. 
The mouths of para-urethral ducts, usually invisible in the normal 
state, may sometimes be brought into view by displacing the lips of the 
urethra or gently pressing downward upon the median fold upon the 
floor of the meatus. If these ducts harbor an infection they are dis- 
tinguished as red points about the size of the head of a pin. The most 
satisfactory means of exposing these orifices of Skene’s or para-urethral 
ducts to view is that proposed by Kelly, using two probes bent to the 
shape of hairpins, or two hairpins even, which can be satisfactorily 
sterilized by boiling, to serve as retractors. 
Palpation.—It should be made a practice always to palpate upon 
the vestibule and vaginal orifice with pressure toward the meatus before 
pressure is exerted upon the full extent of the urethra per vaginam 
since the external urethral meatus may be the seat of isolated sensitive- 
ness or induration or the para-urethral ducts alone may be the source of 
a little secretion. 
With the index finger in the vagina so that its pulp is in contact with 
the median portion of the anterior vaginal wall, pressure is exerted upon 
the urethra from the bladder floor to the outermost part of the canal, 
in an effort to express any secretion toward the meatus and to note the 
consistency of the urethral wall and determine points of sensitiveness. 
Normally the urethral canal feels like a rounded tube when thus EXAMINATION OF THE FEMALE URETHRA 
373 
palpated through the vagina. It moves slightly from side to side as it 
rolls beneath the finger, and no complaint of pain is made by the patient. 
Points of sensitiveness are often valuable signs, pointing the way to the 
discovery of lesions when other means of investigation are employed. 
Localized indurations or dense thickening in the entire wall of the 
urethra with immobilization point to peri-urethral inflammation or in- 
filtration. Localized nodes and small peri-urethral abscesses can be 
better defined by palpating the urethral canal per vaginam after a 
solid instrument, such as a sound or glass or silver catheter, has been 
inserted through the canal. 
This instrument affords a firm body against which the urethral wall is 
pressed, and brings into prominence abnormal areas against the pal- 
pating finger. 
Anesthetics.—The urethra is highly sensitive as compared with the 
bladder, vagina, or rectum and anus. Examination, therefore, to be 
satisfactorily carried out must be made with extreme gentleness and 
deftness. Local anesthetics are frequently employed, and general 
anesthesia is necessary when very painful lesions exist, yet in the ma- 
jority of cases no local or general anesthesia is used for examining the 
urethra, or for passing catheter, cystoscope, or other instrumentation. 
It is better to use no anesthetic which so changes the bloodvessels by 
contraction or dilatation that the color of the mucous membrane is 
altered. Cocaine blanches an inflammatory area so that its pathologi- 
cal redness fades, destroying thereby an important feature. Cocaine is 
so surprisingly toxic to some individuals, and absorption by the urethral 
mucosa is so rapid that it should not be advocated. It is, however, the 
most certain of all our local anesthetic drugs for allaying pain. 
Novocain, 4 per cent, solution or weaker, is less toxic and causes less 
disturbance of the natural appearance than cocaine, and, while less 
positively analgesic, is commonly very satisfactory. Alypin, 5 per cent, 
or 10 per cent, solution, is commonly used, and many others are com- 
mended. 
Spinal anesthesia with tropacocain (dose 1 c.c., 5 per cent, solution) 
injected through the third or fourth lumbar interspace is an efficient 
and useful means for making an examination of the urethra, or for 
treatment of urethral conditions, in cases impossible to examine and 
treat under local anesthesia. The general anesthetics, nitrous oxide, 
nitrous oxide and oxygen, ether and chloroform must be resorted to as 
indicated. 
In highly neurotic subjects or in cases with great pain the preliminary 
employment of morphin, morphin and atropin, or morphin and 
scopolamin, injected hypodermically, is useful. 
The use of suppositories of opium or morphin is often advantageous. 
To anesthetize the urethra with a local anesthetic, soak a small 
pledget of absorbent cotton with the solution and place it over the 
external meatus and surrounding vestibule, and, allowing the labia 
minora to close together over it, hold it, if need be, in place five minutes. 
Take up into a conical-tipped urethral syringe 2 to 4 c.c. of the same 374 
DISEASES OF THE URETHRA IN THE FEMALE 
solution and inject this slowly through the urethra, making sure that 
none escapes from the external meatus about the syringe tip, which 
should occlude this orifice. If this solution is slowly injected it distends 
the urethra and comes into contact with its entire surface until the 
sphincters relax and permit it to enter the bladder after a minute or 
two. This usually gives satisfactory anesthesia, and is commonly 
employed. 
A stick applicator wound for 3 cm. from its tip with absorbent cotton 
and wet in the anesthetic solution may be slowly passed through the 
entire urethra and left in place for three minutes to produce excellent 
anesthesia, but it has the great disadvantage of rubbing the surface 
epithelium so as to produce slight abrasions, especially at the site of 
inflammatory lesions, ulcerations, polypi, etc., and may give rise to 
trouble in inspection or through persistent hemorrhage. It is to be 
avoided, therefore, when the urethra is the object of examination, 
although often useful for anesthetization of the urethra for cystoscopy. 
With the insertion of the urethroscopic tube points of special sensi- 
tiveness can be anesthetized as they are encountered by withdrawing 
the obturator, and, holding the instrument perfectly steady, applying 
to the mucosa with which the obturator was in contact a swab wet with 
the anesthetic solution. It is sometimes necessary in this way to 
anesthetize the margin of the internal sphincter and the uppermost 
part of the urethra. 
Urethroscopy.—Instruments.—To observe the mucous membrane 
within the urethral canal some form of speculum or urethroscope is 
required. 
For visual examination of the urethral mucous membrane (urethros- 
copy) an instrument (urethroscope) is necessary which either (1) opens 
and holds apart the normally apposed walls so that they may be illumi- 
nated and clearly seen, or (2) one which by a prism or lens reflects light 
falling upon a small part of the wall and carries the picture out to the 
eye through a system of lenses. 
Urethroscopic instruments of many varieties have been constructed 
and commended since Griinfeld (1881) studied the urethral mucosa 
through a glass-windowed tube reflecting light from a head mirror into 
this tube. A complete description of the many which possess merit and 
of their use is not here attempted. 
The most simple has proved, after the use of practically every form 
thus far presented, to be the most serviceable. My own choice is the 
straight tube with a strong light thrown through it from a small electric 
bulb, such as the light-carrier made by H. Id. Young for his straight 
male urethroscopic tube or by light reflected from the head-mirror. 
Illumination by a small electric bulb carried into the inner extremity of 
the tube is useful especially when the light is sheathed in a compartment 
separated from the examining tube (Furniss’s female urethroscope). 
Urethroscopes which are modifications of the cystoscope with lens sys- 
tems require skilful manipulation and encumbering paraphernalia 
entirely unnecessary for routine work of simple, rapid, painless and EXAMINATION OF THE FEMALE URETHRA 
375 
adequate inspection blit should be available for examination of the 
vesical outlet and for special cases. 
The Kelly urethroscope and cystoscope is a cylindrical metal tube 
provided with an obturator whose end is smoothly rounded and whose 
ocular outer extremity is expanded in funnel shape. It is provided 
with a grip or handle set upon the funnel expansion and at an angle 
suitable for easy manipulation. Three or more of these instruments of 
different sizes (24, 27, 30 Charriere scale) should be at hand for use in 
urethrae of varied caliber. The most useful size is the No. 30 Charriere 
scale (10 mm. diameter), while in young girls and small women the 
urethra will usually admit an instrument No. 24 Charriere scale 
(8 mm. diameter). 
Its shaft with obturator in place is lubricated and introduced through 
the urethra to the bladder and the obturator withdrawn permitting the 
escape of urine which is collected in a sterile glass or bottle for complete 
examination. 
By means of absorbent cotton swabs on stick applicators, a dozen or 
more of which should be at hand, the urine in the tube and bladder floor 
is quickly wiped away, and, throwing the light through the tube, the 
bladder wall is seen and the instrument is slowly withdrawn until the 
internal sphincter margin falls like a fringe or curtain over the inner 
extremity of the tube and closes down over it like an iris diaphragm to a 
pin-point opening and then to closure of the bladder cavity. If the 
patient is in the dorsal position, urine flows into the tube rapidly, so 
gentleness and patience in swabbing for a moment or two is necessary 
to obtain a clear view of the margin of the vesical outlet to study its 
shape and color and to observe abnormalities. Since this is a highly 
sensitive portion, it is often well to insert a swab soaked in 4 per cent, 
novocain or other anesthetic, and to hold it for one minute so that it 
comes in contact with the sphincter margin. Facility and rapidity at 
this point render this application of anesthetic necessary rarely, and 
only in cases of highly sensitive lesions or markedly excitable 
women. 
When the internal sphincter has closed over the end of the tube the 
outer portions of the urethra are easily kept free of fluid by the occa- 
sional wiping with dry absorbent cotton on an applicator, and, by 
very slowly drawing the tube outward, little by little, each and every 
part of the urethral wall comes into view and its characteristics are 
noted. 
Any area upon the roof, floor or lateral walls can be inspected and 
treated by tilting the tube so that this part is encircled by the inner 
orifice of the tube. The shortness and mobility of the female urethra 
make this maneuver even more simple than in urethroscopy in the 
male. 
The normal urethral mucous membrane beyond the end of the 
urethroscopic tube appears in the form of a flattened funnel with 
radial lines from the central body extending outward to the margins 
of the examining tube. This appearance is only obtained when the 376 
DISEASES OF THE URETHRA IN THE FEMALE 
central point (or the long axis) of the lumen of the tube corresponds 
with the same point of the urethra. It is fundamental that beginners 
should understand this and learn to hold the tube straight in the axis 
of the urethra and withdraw it in the same axis while inspecting. To 
study noteworthy areas the tube end is diverted toward them and then 
the proper direction of the tube must be resumed. 
The radially directed lines seen in the mucosa are sulci between 
longitudinal folds of the mucous membrane. The sulci in the normal 
mucosa number about ten. If, now, we observe but three or four such 
sulci we realize that swelling has occured to obliterate many sulci and 
large smooth rugae or folds represent the abnormal area. 
The orifices of crypts and glands in the mucosa are found here and 
there in the normal case often with difficulty, but when these orifices 
are the seat of an inflammatory process or the glands are distended with 
inflammatory material, then they are distinctly visible by the redness of 
their margins contrasting with the surrounding mucosa or a tiny fleck of 
white or yellow material marks them and a tumefaction in the mucosa 
presents itself. 
In some cases a ridge or fold of normal mucous membrane is found 
upon the floor of the urethra running down from the trigone of the 
bladder (colliculus cervicalis). This ridge may be continuous through 
the length of the urethra or it is lost about 1 cm. anterior to the 
internal sphincter. Often a longitudinal fold is to be found upon the 
floor just within and extending out through the external meatus. 
About 1 cm. from the external meatus a definite change in the shape of 
the canal takes place sometimes so that it appears as a transverse slit, 
and 0.5 cm. within the external meatus the canal becomes a vertical 
cleft. 
The external urethral orifice is usually the narrowest part of the 
canal, and while it is not so distensible or dilatable as the rest of the 
tube, it is usually dilatable to a considerable degree. This is an area of 
marked sensibility and the vestibule and urethral orifice may require 
the application of a swab of novocain (4 per cent.) or alopin (5 per cent.) 
or cocaine (5 to 10 per cent.) before a satisfactory examination can 
be conducted with due consideration of the patient. 
When a urethroscope or other instrument is to be introduced, in- 
spection usually suffices to decide upon the size that will comfortably 
pass the meatus. The most efficient examination of the entire urethral 
wall is made with the urethroscope which separates the folds to the 
greatest reasonable extent without causing pain. An instrument of 
small size necessitates more searching into the depths of sulci and 
more turning of the instrument from side to side with greater discom- 
fort and a more prolonged observation even in the most experienced 
hands. A too small instrument usually gives rise to more pain than 
one which smoothly passes but fills the urethral tube. 
When the meatus is found with diameter smaller than the rest of the 
urethra and dilatation is necessary, this is easily carried out by anesthe- 
tizing with novocain or other mucous membrane anesthetic on cotton EXAMINATION OF THE FEMALE URETHRA 
377 
which is applied to the vestibular surface of the meatus and inserted 
within the orifice. Then insert a conical metal dilator and gently 
press it into the orifice until the requisite size has been attained. If 
this dilatation is slowly carried out with gentleness, no tear or bleeding 
will result in the usual case but a small tear of 1 or 2 mm. will occasion 
little or no bleeding and no subsequent pain or ill-effect. 
Occasionally in multipart and the aged the external meatus is larger 
than the main channel, so that care must be exercised that no forcible 
dilatation within the meatus is produced by the introduction of too 
Fig. 190.—Young’s urethroscope and light carrier. 
large an instrument. If the meatus is fibrous and rigid, a small cut in 
the median line on the floor may be necessary to enlarge it after the 
interstitial injection of an anesthetic by means of hypodermic syringe 
and needle. 
The best means of determining the size of the lumen of the urethra 
is by use of silk-elastic bougies-a-boule, so commonly employed in the 
male urethra for the detection of stricture. By this instrument con- 
strictions or narrowness of caliber are appreciated with greater delicacy 
and its use is attended with less risk of traumatism than with any solid 
instrument. 378 
DISEASES OF THE URETHRA IN THE FEMALE 
Each type of urethroscope and each modification of each type has its 
champions. No attempt is made here to fully set forth the advantages 
Fig. 191.—Buerger’s cysto-urethroscope. 
Fig. 192.—McCarthy’s close vision cysto-urethroscope. 
or unfavorable features of any. That the reader may be able to recog- 
nize some of the best forms, a few are represented in illustrations. 379 
MALFORMATIONS OF THE FEMALE URETHRA 
The following instruments should be at hand for every urethroscopic 
examination: 
Urethroscopes with obturators. 
Light-carrier or head-mirror. 
Lubricant. 
Cotton swabs on stick applicators—12 + . 
Urethral forceps. 
Platinum loop. 
Glass slides for microscopic preparations. 
Evacuator. 
Urethral probe or searcher. 
Conical dilator or set of female sounds, graduated sizes. 
Urethral syringe. 
Anesthetic solution. 
For Treatment. 
High-frequency machine. 
Silver nitrate solutions. 
'Urethral curette. 
Urethral scissors. 
Fig. 193. —Kelly’s urethroscope and cystoscope. 
MALFORMATIONS OF THE FEMALE URETHRA. 
Congenital defects of the urethra in the female are rare. Hypospa- 
dias, the commonest of these errors in development, is by no means so 
common as in the male. 
Absence.—Absence of the urethra has been observed rarely. In this 
case the bladder has opened into the vagina, or other marked develop- 
mental anomalies have been present at the same time, such as exstrophy 
of the bladder or patulous urachus for outlet of the urine. Atresia of 
the urethra, in which some parts of the wall have been formed without 
a patent channel, has been found in a few cases when some such anoma- 
lous opening of the urinary bladder as noted in association with absence 
of the urethra has been present as an associated defect. 380 
DISEASES OF THE URETHRA IN THE FEMALE 
Malposition.—Malposition of the urethra occurs occasionally as a 
congenital deformity when the urethra is usually found in a position to 
one side of the median line, so that the external orifice is not in the 
median line of the vestibule. Ordinarily in this case a second dimple- 
like depression is present in a corresponding position on the other side, 
indicating a partial formation of two urethral canals or the bifurcation 
of the channel. Associated with this defect have been found malforma- 
tions of the vagina (double vagina) and uterus. 
Double Urethra.—Cases of double urethra (two urethrae) have been 
recorded—one canal arising from a congenital bladder-diverticulum in 
some cases. Bifurcation or forking of the urethra, in which case the 
single urethral canal arises from the bladder and divides into two canals, 
with separate openings on the vestibule, is more common than two dis- 
crete canals. Both of these abnormalities must be differentiated from 
peri-urethral fistulous tracts, which are rarely congenital and sometimes 
the result of inflammatory processes. In many of these cases one 
channel serves as the urethra while the other is accessory and non- 
functionating. The abnormal opening of one ureter upon the vestibule 
or near the urethra must be distinguished from these urethral abnor- 
malities. 
Hypospadias.—Hypospadias in the female is a pathological rarity, 
for while some degree of it is found in 1 out of every 400 males, only 
35 to 40 cases have been reported in the female. Hypospadias is a de- 
fective development of the external portion of the inferior urethral wall 
by which the external meatus appears as an oblique opening on the 
anterior vaginal wall. It is to be distinguished from congenital urethro- 
vaginal fistula in which an opening in any part of the urethral floor con- 
nects with the vagina, while the urethral floor anterior to the fistula is 
intact. Usually a furrow of urethral mucosa upon the superior wall or 
roof of the urethra can be followed out to or near the normal site of 
the external meatus on the vestibule. Cases are recorded of this 
deformity ranging from slight defect near the external meatus to total 
absence of the lower wall of the urethra combined wfith congenital 
vesicovaginal fistula, i. e., a persistent urogenital sinus. Other defects 
in development of the vagina or vulva have been found in association 
with hypospadias (large clitoris, posterior displacement of vaginal out - 
let, vagina opening into urethra, etc.). The malposed meatus is often, 
as in man, markedly constricted, producing the same train of symptoms 
as stricture of the urethra, and may lead to dilatation of the urethra and 
laxity and loss of control of the sphincters. Infection of any part of the 
urinary tract above a constricted hypospadiac meatus and all sequelae 
of stricture may result. 
Symptoms.—The urine may be voided naturally and no symptoms of 
the presence of this anomaly be evident to the subject if the meatus is 
well forward on the anterior vaginal wall, but the urine may flow into 
the vagina if the hymen be intact, and later dribble from the vaginal 
outlet, soiling the clothes and thighs. In hypospadias of marked degree, 
when the inferior wall of the urethra is deficient for the greater part of MALFORMATIONS OF THE FEMALE URETHRA 
381 
its extent, there has usually been partial or complete incontinence of 
urine because of defect in the formation of the sphincters, so that urine 
constantly bathes the vaginal wall and macerates the skin of the vulva 
and thighs. Such a victim can only by the most scrupulous cleanliness 
avoid the all-pervading odor of decomposing urine. This distressing 
condition impels the patient to seek relief, and is often the adequate 
basis for operative repair of the defect. In some of the cases of this 
defect in which a very small vagina and the urethra had a common 
outlet (the vaginal), “coitus intra-urethram” had been carried on for 
years. 
Treatment.—Cases of defect of the floor of the anterior portion of the 
urethra with sufficiently patulous orifice which give rise to no great 
difficulty except strict attention to cleanliness require no surgical inter- 
vention. If the orifice is constricted it may be anesthetized with 
cocaine or novocain and dilated to a sufficient extent or incised and the 
caliber maintained by occasional dilatation. 
The reformation of the inferior wall by plastic operation may be 
accomplished by one of the methods described for the treatment of 
fistula. 
Epispadias.—Epispadias is that deformity of the urethra character- 
ized by partial or complete absence of its superior wall. In the female 
it is much more rare than in the male. No ve-Josser and and Cotte4 
collected a record of all reported cases in 1907. 
Associated defects of the pelvic bones (separation of pubic bones) of 
the vulva, vagina, and anterior abdominal and bladder walls are often 
present with epispadias. The causation of this defect is unknown. 
Three grades of epispadias have been recognized as follows— 
1. The urethra opens just beneath the clitoris. 
2. The urethra opens beneath the symphysis and above or through 
the divided clitoris. 
3. The urethra opens behind the symphysis and is associated with 
separation of the pubic bones and some degree of exstrophy of the 
bladder with maldevelopment of the internal sphincter. 
The symptoms of epispadias relate to the soiling of the pubic region 
by the escape of urine in this abnormal situation. In the extreme 
degree of epispadias there is complete incontinence, so that the victim 
is constantly bathed in urine. 
Treatment.—The simple defect of the external extremity of the 
superior wall just below the clitoris necessitates no surgical treat- 
ment. 
Cases of second degree epispadias (subpubic epispadias) with no 
defect of the internal sphincter of the bladder and its resulting inconti- 
nence of urine may demand cosmetic procedures to conceal the disfigur- 
ing features of the deformity. This may often be satisfactorily accom- 
plished by plastic operation to restore the defective junction of the 
labia majora and minora in the median line or to reform the mons 
veneris and clitoris. The conditions presented in each case must 
determine the procedure. 382 
DISEASES OF THE URETHRA IN THE FEMALE 
Cases of second or third-degree epispadias (subpubic or retropubic), 
with partial or complete incontinence, present a very difficult problem 
with reference to the means to restore or to form a substitute for the 
bladder-sphincter. No satisfactory substitute for a physiological 
sphincter has yet been devised. Whenever possible the tissues of the 
sphincter should be brought together to surround a reformed urethral 
canal. 
Epispadias combined with exstrophy of the bladder becomes a prob- 
lem of bladder surgery usually necessitating elimination of the bladder 
and urethra with deviation of the urine from its normal course by trans- 
plantation of the ureters, nephrostomy, etc. 
INJURIES OF THE FEMALE URETHRA. 
The commonest injury to the female urethra is that produced in 
childbirth through compression of its muscular tissue between the 
child’s head and the symphysis or between instruments (forceps, etc.) 
and the symphysis. This injury usually is not evident at the time of 
its production, and its effects may not be apparent for months or even 
years. Retention of urine, necessitating catheterization after child- 
birth and after operations upon the uterus, appears to be due to con- 
tusion or other injury to the nerve supply of the sphincters and to the 
vascular, lymphatic, and muscular structures of the vesical outlet 
without visible or palpable lesion. 
It is apparent that the severe pressure, often prolonged, to which the 
urethra is subjected may result in a serious contusion or even laceration 
of the muscular fibers and of the mucosa. The later development of a 
weakened area in the wall may be followed by dilatation of the canal, 
or by the formation of an area of chronic infiltration or even of scar 
formation. The injury to the circular muscular fibers, to the internal 
sphincter and to the external voluntary sphincter (compressor urethrae) 
may result in weakening their normal contractile power with resulting 
partial incontinence so frequently observed. This injury, then, may be 
reckoned as a common cause of urinary incontinence and of urethrocele. 
Its result is not always to produce incontinence, but by the injury 
to the bloodvessels, lymphatics, nerves, and mucous membrane changes 
follow slowly which appear later upon examination of the urethra as 
abnormal chronic congestion, chronic edema or an area of defectively 
nourished mucous membrane which does not possess the normal resist- 
ance to infection, so that chronic ulceration, abnormal hyperplasise 
(polypi and villous excrescences), and chronic infection may result. 
The injury to nerves, while undemonstrable, may reasonably account 
for the changes in sensibility (hypersensibility or hyposensibility), or 
abnormalities in muscular, vascular, or trophic control. 
Many of the disturbances of the function of urination and many of 
the lesions of the urethra must be attributed to this common but often 
overlooked cause of urethral injury—puerperal trauma. INJURIES OF THE FEMALE URETHRA 
383 
Blows upon the urethra, as in falling astride of a board or rail, 
have been reported, but are rare because of the well-protected position 
of the urethra beneath the pubic arch, covered by the soft tissues of the 
vulva and perineal body. Transverse rupture and severe lacerations 
have, however, been observed. 
Fracture of the pelvis produced by falls and crushing accidents have 
resulted in severe lacerations of the urethra by tearing or by puncture 
of its wall by ends of the fragments of fractured bones. 
The urethra is in rare cases injured in coitus. With imperforate 
hymen, coitus has been accomplished per urethram by the gradual 
dilatation of the repeated act until a marked enlargement of its caliber 
has been produced and partial incontinence has resulted. 
Examination of the urethra and the bladder cavity by the finger in- 
serted into it is an obsolete and unjustifiable procedure. The dilatation 
so effected is beyond the limit of safety, and has resulted in permanent 
injury and incontinence of urine. There are rare cases of abnormally 
large urethra, hypospadias, fistula, etc., in which the finger can be 
introduced through the canal without resistance, and in such cases this 
means of examination may be permissible. 
Fissure or the persistent unhealed tear in the mucous membrane in 
which ulceration or chronic inflammation exists has been caused by 
forcible, rapid, and too wide dilatation of the internal sphincter or of the 
meatus. This injury is produced by the introduction of the finger, by 
too rapid dilatation with calibrator or sounds, or through the stretching 
necessary to extract a calculus from the bladder per urethram or from 
the lumen of the urethra itself. 
Operative injuries are produced by intentional or unintentional in- 
cisions into its wall, resulting in fistula or stricture, or in damage to the 
sphincters controlling micturition. In operations upon the anterior 
vaginal wall, anterior colporrhaphy, cysts, and in vaginal approach to 
the interior of the pelvis, the urethra is sometimes damaged and the 
resulting scar formation may compromise its caliber. 
Operations upon the urethra itself are to be kept in mind as a source 
of injury. Overzealous treatment can seriously impair the mucous 
membrane and give rise to an irritability and hyperesthesia of very 
rebellious character or provoke and prolong a chronic infection. 
Serious hemorrhage difficult to control and recurrent may result 
from rough and rapid dilatation, cauterization, or incision. 
Catheter-trauma.—Catheterization. — The injury to the female 
urethra, which is a common and potent cause of those troubles often 
incorrectly described or referred to as postoperative cystitis or bladder 
irritability, is that produced by simple catheterization. The bladder in 
women is often infected by the passage of a catheter. When carelessly 
done this is common, but even every attention paid to the strictest 
precautions and the most detailed aseptic technic does not rid catheteri- 
zation of its dangers, although, of course, the risk of infection is thus 
minimized. 
The writer is convinced that the commonly used glass catheter is 384 
DISEASES OF THE URETHRA IN THE FEMALE 
dangerous because of the trauma which may easily be produced bv the 
use of this rigid instrument, and such slight traumatism may be 
followed by infection. 
The soft-rubber catheter is far because, although the 
urethral mucosa can easily be injured by it, there is much less likelihood 
of such injury in its use. Furthermore, for its use, greater accuracy in 
introduction is necessary, and this is an advantage, since it demands a 
good view of the external meatus, which offers the opportunity to expose 
and cleanse the vestibule and keep it unsoiled before inserting the instru- 
ment. When resistance is met it is recognized by bending of the catheter, 
that a point has been reached where slow and gentle pressure is called 
for—not the hasty push that drives the instrument into the bladder. 
In some hospitals the soft-rubber catheter has been discarded for the 
glass because the records showed more infections with it than with the 
glass catheter. This can be explained to my mind because the rubber 
catheter is the more dangerous when improperly employed without 
good light, full exposure of the part, and complete asepsis. The surface 
of the rubber catheter holds dirt and infectious matter after touching 
the vagina or vulva more readily than the smooth glass, and it carries 
this infectious contamination into the urethra better than does the 
glass. If, however, the surgeon or nurse inserts the tip of the clean 
rubber catheter accurately into the meatus, allowing no extraneous 
contact with any part of the catheter, and slowly, with gentleness, 
guides it through the urethra, less traumatism will be caused by it than 
by the glass catheter, and infection of the urethra and bladder will 
rarely follow. 
While cystitis may follow catheterization the writer is convinced that 
the much more common injury or ill-effect is not cystitis but a urethral 
trauma and urethritis. This urethral trauma or infection may readily 
extend to the bladder, producing cystitis; but cystitis is not ordi- 
narily a serious matter, and will clear up promptly when the source of 
its infection (usually urethral or renal source) is remedied. Cases 
commonly called “catheterization cystitis” persist with perfectly clear 
urine, but with abnormally frequent urination, discomfort during and 
after urination, and the urethroscopic evidence of chronic non-purulent 
urethritis, these cases are usually promptly curable by urethral 
treatment only. 
PROLAPSE OF THE FEMALE URETHRA. 
This extrusion of the mucous membrane through the external meatus 
may be partial (i. e., part of the circumference) or complete when the 
entire circumference pouts through the vestibule. It is due to an ab- 
normal redundancy of the mucosa and laxity of the areolar tissue be- 
tween mucosa and muscular layers of the wall, which accounts for its 
appearance in little girls, or it is due to senile atrophy and retraction of 
the vagina and vulva in the aged. In the aged the muscular and con- 
nective tissues of the urethra apparently share in this atrophy while PROLAPSE OF THE FEMALE URETHRA 
385 
the mucosa does not, for the muscular walls appear to be shorter, 
narrower and more fibrous and the mucosa more redundant than 
normal. 
While the condition is most common in children and in the aged, it is 
occasionally observed between the fifteenth and fiftieth years as a result 
of prolonged labor, or of conditions which induce repeated straining 
in urination for a long time (vesical calculus, urethritis, urethral 
calculus, polyp, etc., prolonged paroxysms of coughing, etc.). 
In children the condition has been brought on by constipation, 
whooping-cough, vesical calculus and vulvovaginitis. 
Prolapse may be sudden in onset or of slow development. In the 
aged the development is usually very gradual. 
Complete prolapse of the entire circumference is more common than 
the partial. Partial prolapse appears as a pedunculated tumor, pro- 
truding from the meatus, whose base is attached to some part of the 
wall within the canal. 
The lesion appears on examination to be a tumor at the meatus, red 
like the normal mucosa when recent or blue when congested; later it 
may be fissured, ulcerated or necrotic. It is exquisitely tender, and 
bleeds when touched. The meatus is displaced when the bulging is 
greater in one part than in others but is usually easy to find with a 
catheter or probe. The mucosa presents in recent cases the character- 
istic appearance of the urethra and is continuous with the mucous mem- 
brane covering the vestibule at the meatus and with the urethral 
mucosa within the canal. These points are important in distinguishing 
this condition from prolapse of the bladder mucosa through the urethral 
canal or the protrusion of a prolapse of the ureteral mucosa through 
this channel. Caruncle, polyp, hemorrhoidal condition of veins of the 
urethra and very marked edema or inflammatory swelling must be 
carefully differentiated. Urethroscopic examination will give positive 
information regarding the origin of the lesion, the site of its base, the 
relation to the urethral wall and the condition of the wall above the 
tumor. 
The subjective symptoms usually complained of are the presence of a 
tender and readily bleeding area at the external meatus, a sense of 
burning pain during urination with the feeling that there is some foreign 
substance in the canal and a desire to expel it by urination. 
Treatment.—Prolapse of acute onset has been observed to retract 
without treatment and give no further sign of its presence. Prolapse 
has also been relieved without recurrence by manual reduction through 
pressure with the fingers to replace the extruded mucosa. 
Stockel advises, in young children, the treatment employed years ago 
by Fritsch, which consists in passing a silk catheter to the bladder, 
passing a sling of strong silk ligature over the prolapse close to the 
external meatus and tying this down upon the circumference of the silk 
catheter. He says that the protruded tissue becomes desiccated and falls 
off, so that the catheter may be removed in three days, complete healing 
without serious infection follows rapidly and no general anesthetic has 386 
DISEASES OF THE URETHRA IN THE FEMALE 
been necessary. In children as well as adults and the aged the total 
excision of the redundant portion and suture of the margin of the 
mucosa by interrupted fine catgut sutures around the meatus is 
preferable. 
Retraction of the mucosa within the canal during resection is pre- 
vented by grasping its edge with forceps as it is divided or by placing 
sutures before severing it. 
Israel recommended cutting radial lines into the prolapse with the 
cautery knife. This as well as astringent and caustic applications may 
have served in certain cases but excision and suture is the best pro- 
cedure. A partial prolapse in aged women has been treated success- 
fully by deep radial cauterization with the high-frequency spark, but 
this treatment is prolonged and attended with bleeding and necrosis 
which for a time presents an unfavorable condition. It is not to be 
recommended, although it may accomplish the desired result. 
Under local anesthesia combined with interstitial injection of a weak 
solution of the anesthetic the operation of excision can be done in short 
order. 
CALCULUS OF THE FEMALE URETHRA. 
Urethral calculus in the female is rare as compared with this con- 
dition in the male. Like prostatic calculus in the male, calculi may 
originate7 in the tubular glands of the female urethra, leading to the 
formation of a pocket about them. Calcareous deposit may take place 
in a pouch or diverticulum connected with the lumen of the urethra by 
a small or large orifice. Most calculi found in the urethra, however, 
are of renal and vesical origin and have been arrested in the canal in 
the course of their descent. Vesical calculi sometimes present pro- 
longations into the urethra. Foreign bodies inserted into the urethra 
(hairpins, parts of darning needle, etc.) have been caught in the canal 
and served as a nucleus for the deposit of urinary salts. 
Since the external meatus is usually narrower than the rest of the 
channel a calculus is commonly found by inspection, palpation or 
instrumental examination at this point. 
Usually inflammation is set up in the tissues in contact with a 
calculus producing a purulent urethral discharge and pyuria. 
Symptoms.—Calculus may lie in a sacculation connected with the 
urethra or in the canal close to the external meatus without causing 
noteworthy symptoms. 
A calculus or any foreign body in the urethra creates greater or 
less disturbance of normal urination—painful and abnormally frequent 
urination with a constant desire to urinate and with a discharge of 
mucus and pus from the canal and perhaps pus and blood in the urine. 
Diagnosis.—If a calculus is not visible at the urethral outlet, its 
presence can usually be determined by palpation of the urethra through 
the vaginal wall when an abnormal, tender, hard mass suggests its 
presence. With a finger in the vagina, a metal or glass catheter or other 
instrument may be easily brought into contact with it in the urethra. NEOPLASMS OF THE FEMALE URETHRA 
387 
Calculus in a diverticulum having a small communicating opening 
into the urethra may not give the grating characteristic of contact 
between calculus and the instrument, but the examiner is able to 
determine the position of the dense mass felt through the vaginal wall 
when the urethral instrument is inserted as a guide. 
If a calculus is firmly held by the urethra itself or by means of 
the finger, a urethroscope may be inserted to view it and to aid in 
its removal. 
X-ray examination will show the presence of most calculi in the 
urethra but the necessity for this means for diagnosis rarely arises. 
Treatment.—When a calculus is suspected by the examiner, he should 
make sure that it does not escape him by being pressed or pushed back 
into the bladder. This is done by pressure upon the canal behind the 
calculus, closing that avenue of escape and holding it while an instru- 
ment is being passed or the meatus dilated. 
If the external meatus is narrow, it may be useful to dilate or incise 
it under local anesthesia. By simple pressure from behind some calculi 
and foreign bodies may be extruded which cannot be passed naturally. 
Calculi may be grasped and delivered by urethral forceps, by a 
curette or bent probe or sling of wire which has been used to reach 
behind a calculus and pull it forward. 
Calculi have been removed from the urethra with the aid of a large 
urethroscopic tube through which one could see and accurately grasp 
in forceps a calculus which defied removal without the aid of the 
tube. 
Calculus material in a pouch or diverticulum calls for treatment 
of the diverticulum primarily for such a pouch will soon be refilled 
with deposit if the pocket is left after removal of its contents. (See 
Treatment of Diverticulum.) 
Calculus may be intentionally pushed backward into the bladder 
where it may be crushed by a lithotrite and its debris washed out or it 
may be grasped by suitable forceps inserted into the bladder under 
the guidance of cystoscopic observation and so delivered through the 
cystoscope or through the urethra. 
The urethral portion of a vesical calculus is to be removed with the 
vesical calculus by litholopaxy or by operation upon the bladder. 
After calculus has been removed from the urethra an examination of 
the bladder by means of the cystoscope should be made for the discovery 
of other calculi lying ready to follow the first and in the majority of 
cases a complete examination of the entire urinary tract (kidneys, 
ureters and bladder) by the means elsewhere described for the detec- 
tion of calculus is indicated. 
NEOPLASMS OF THE FEMALE URETHRA. 
The neoplastic structures originating in the tissues of the urethra 
commonly observed are those confined to the mucous membrane and 
its bloodvessels and usually benign in character, namely, papilloma, 388 
DISEASES OF THE URETHRA IN THE FEMALE 
polyp, cyst, and angioma. Other benign tumors arise from the con- 
nective tissue (fibroma) or muscular tissue (myoma) or from both 
(fibromyoma), but these are comparatively rare. 
Malignant tumors primary in the tissues of the urethra are very rare 
but of great significance because of the gravity of the condition, the 
importance of early recognition of their nature and the necessity for 
prompt and radical removal. The malignant neoplasm most commonly 
found is carcinoma originating in the mucous membrane. Sarcoma is 
very rare. 
Caruncle.—The frequently observed raspberry-like tumor at or just 
within the external meatus in women is known by the name caruncle. 
This term does not distinguish a particular type of tumor, histologically 
considered, from others of the same gross appearance found in this 
situation. This tumor is found at all ages but is most common after 
thirty years of age. 
Pathology.—Clinically, every small raspberry-like tumor about the 
external meatus is called a caruncle unless it reveals growth, invasion 
of underlying tissue or ulceration when cancer should be suspected. 
Cancerous tissue may exist in such a tumor at the external meatus of 
a woman, without growth, extension or ulceration. Only upon his- 
tological examination of the excised tissue can the benign and can- 
cerous conditions be differentiated. Young, of Boston, has made a 
careful study of 19 tumors removed under the clinical diagnosis of 
caruncle at the Massachusetts General Hospital during the last 
twenty years. lie found 5 of them to contain tissue of definite 
carcinomatous characteristics. This is a surprisingly large proportion 
of malignancy in neoplasms of the urethra, for the opinion prevails 
that primary carcinoma of the urethra, and vestibule is exceedingly 
rare. 
Neuberger,3 in a pathological study of caruncle, described three 
varieties: (1) granuloma (not a neoplasm but a raspberry-like tumor 
found about the external meatus of women due to chronic inflamma- 
tion); (2) papillary angioma; (3) telangiectatic, non-papillary mucous 
polyp. Caruncle may be said to be any tumor found at the external 
meatus of the female consisting of vascular polypoid, papillary or 
granular tissue. 
It is convenient to group these tumors under such a term, for neo- 
plasms of every variety found at this point give rise to about the same 
symptoms and require the same radical treatment. All have the 
vicious tendency to recur; all are highly vascular, are usually sensitive, 
bleed upon being disturbed by touch or as a result of dilatation and 
contraction of the canal in urination; all produce a sense of burning 
during urination; all increase in size, either slowly or rapidly; all should 
be regarded as potentially malignant. 
Symptoms.—Caruncle may lead to such distress through pain, pain- 
ful and frequent urination, hemorrhage, etc., that the patient may 
become bed-ridden and loses flesh and strength. Neurasthenia or 
melancholia may supervene. Caruncle may exist without giving rise NEOPLASMS OF THE FEMALE URETHRA 
389 
to subjective symptoms of any kind. Young reports 35 per cent, 
symptomless. 
Treatment.—The thorough excision of caruncular tumors has been 
the accepted treatment, and promises certain success. Care must be 
exercised in the excision and closure of the wound to leave cicatrices 
which will not later constrict the urethra or meatus. 
Complete wide excision of caruncle is for so small a tumor often a 
troublesome, bloody, and perhaps unnecessarily destructive attack upon 
the urethral orifice. 
Angioma, papilloma, polyp, granuloma, and small tumors present- 
ing the mixed characters of these neoplasms found in other parts 
of the body have been as successfully destroyed by the Oudin high- 
frequency current as by excision with the knife. This form of 
electric cauterization has been extensively used in the destruction of 
caruncle, and is our most satisfactory means of treatment. 
By excision the specimen may be obtained for pathological study and 
the nature of the growth determined, whereas unless a part of the tumor 
with its base is excised beforehand, the destruction of the tumor by 
cauterization (Oudin, cautery, galvanocautery, etc.), as well as .r-ray or 
radium treatment, eliminates the possibility of histological examination. 
Oudin Spark; Method of Application.—After thorough anesthetiza- 
tion of the mucous surface by the application of cotton wet with novo- 
cain or cocaine, and the interstitial injection of the same anesthetic 
beneath the tumor through a hypodermic needle, the wire (electrode) 
is inserted into the little mass and the current turned on for 15 to 30 
seconds at a time. The application is made at three or four points 
in the tumor. Two or three applications of this treatment usually 
suffice. 
Cautery; Method of Application.—For the use of the actual cautery 
general anesthesia is necessary. The flat, thin cautery blade is best 
and should be used to sear furrows deep into the base of the tumor 
from each side. The furrows should meet in the median line of the 
urethral floor above the tumor and extend downward and inward to 
meet beneath its base, cutting out a half-cone-shaped piece of tissue 
which includes the caruncle. The application of the dull red cautery 
to the surface of the tumor itself often effects its complete destruction, 
but healing is sluggish and much pain may ensue. 
Galvanocautery; Method of Application.—With local and interstitial 
anesthesia, or with general anesthesia, the galvanocautery needle is 
inserted into the base of the mass at several points for about one-half 
minute each. Healing takes place by granulation after necrosis of the 
tumor. 
Cauterization by means of chemicals (nitric acid, trichloracetic acid, 
etc.), while efficiently destructive of the tumor in some instances, 
presents disadvantages which have led to the abandonment of this 
method in favor of electric or thermal cauterization or operation. 
Fibrous and smooth-muscle tumors (fibroma, myoma, and fibro- 
myoma) develop rarely in the tissues of the urethral wall but appear as 390 
DISEASES OF THE URETHRA IN THE FEMALE 
protrusions usually upon the anterior vaginal wall, where they can be 
felt especially when a solid instrument has been passed into the urethral 
canal. Such a neoplasm may constrict the lumen of the urethra and 
give rise to symptoms like those of stricture. It may grow to such a 
size as to protrude from the vaginal outlet and interfere with coitus. 
The overlying mucosa of the urethra may present chronic congestion 
and edema with or without infection or ulceration. 
Very small fibromata or myomata may call for no treatment. Large 
tumors or those giving rise to symptoms should be dissected out through 
an incision of the anterior vaginal wall without opening, if possible, the 
mucous canal of the urethra. 
Cysts.—Cysts of the urethral mucous membrane of minute size are 
frequently observed in urethroscopic examinations. Many of these are 
innocent tumors calling for no interference. Some, however, occasion 
symptoms of irritation like that of a foreign body or of partial occlusion 
of the channel, and under these circumstances they must be destroyed. 
Cysts are usually destroyed by thorough cauterization with the high- 
frequency spark (Oudin) after the application by swab of a strong local 
anesthetic through a urethroscope. 
Clipping them off at the base with urethral scissors sometimes 
succeeds, but is likely to be followed by recurrence because the amputa- 
tion is not complete, and troublesome bleeding may follow. Simple 
puncture or splitting with a small knife is in some instances adequate. 
Papilloma. Polyp.—Hypertrophied projections from the surface of 
the mucosa in the form of papilloma or polyp are very commonly 
observed in all parts of the urethra, but are especially to be found about 
the internal meatus on the margin of or just outside the internal 
sphincter. These growths are also frequently found near the external 
meatus. They may attain such size or be in such number as to choke 
the lumen, giving rise to the same symptoms as stricture. 
Etiology.—Their etiology is obscure. In some, but by no means 
in the majority of cases, a history of a preceding urethritis is obtained 
or the evidence of chronic urethritis is revealed by urethroscopic exami- 
nation. In many of the cases personally observed there has been found 
a mild chronic inflammation in the mucosa about them, but whether 
this is to be regarded as the cause of the hypertrophic growth or the 
growth has induced the irritation which has led to inflammation of 
the tissue, has been impossible to determine. 
These outgrowths, even though very small, occupy an important 
place in diseases of the female urethra, for they give rise to exceedingly 
distressing symptoms and are often difficult to detect. 
Symptoms.—Those developing at the internal sphincter especially 
produce aggravated symptoms such as vesical tenesmus, painful, 
difficult and very frequent urination, hematuria, often marked. They 
may escape the experienced examiner who employs both cystoscope 
and urethroscope to find them. 
One or many of these papillary growths may be present and give no 
symptoms such as detailed above. When, however, one or more of NEOPLASMS OF THE FEMALE URETHRA 
391 
them is grasped by the internal sphincter, the most intense irrita- 
bility is aroused and bleeding may be quite profuse. The blood may 
escape into the bladder or into the urethra or both. Terminal 
hematuria (i. e., blood in the last portion or the last drops of urine 
passed) is common. Such symptoms may disappear after a few 
moments or hours or they may be persistent for weeks or months. 
A notable symptom usually is the exquisite sensitiveness of that part 
of the urethra in which the little villus is found, so that the passage of a 
catheter or other instrument calls forth a cry or start as this area is 
touched, and in many cases no cystoscopic or urethroscopic examina- 
tion can be carried out without generous application of cocaine to this 
part. Patients are seen with whom general anesthesia (gas and 
oxygen) and complete relaxation (ether) is required to accomplish 
the examination properly. 
These little tumors do not stand up for inspection as they are de- 
picted in illustrations, but lie flat against the wall, often concealed in a 
furrow or fold of the mucous membrane, so that diligent search with the 
cystoscope or urethroscope is necessary. 
For those at the vesical outlet the most satisfactory means of dis- 
covery consists in the use of a close-vision cystoscope (Buerger’s 
cysto-urethroscope or McCarthy’s close-vision cystoscope or similar 
instrument) with the light and lens on the margin between bladder 
and urethra, while fluid is injected through the instrument into the 
bladder. By revolving the instrument, examining all about the 
sphincter’s margin while the fluid washes through the instrument 
into the urethra, the little villi are spread out and fall back toward 
the bladder and come into view. In some cases of obscure hematuria 
this plan has revealed a little papillary shred of mucosa pouring out its 
blood. 
The straight urethroscopic tube (Kelly) will serve to discover many 
of these tumors and through it they are accessible to treatment, but in 
many-cases its use fails to bring them into view at the sphincteric margin. 
They can sometimes be well shown by means of instruments which 
employ air distention. The ordinary examining cystoscope often shows 
the projection of these tumors into the bladder. The same excrescences 
are found about the bladder surface of the vesical outlet and may form 
a fringe all about its circumference. They do not always give rise to 
symptoms or call for treatment. When they do fall into the urethra 
from the bladder, or arise in the urethra, they are likely to be real 
trouble-makers. Destruction of them is demanded. 
In the urethral canal itself these papillary outgrowths are found by 
the urethroscope only and here the straight tube must be used to 
stretch out and illuminate all parts of the wall especially where deep 
folds are seen. A full-sized tube stretches the wall so that during slow 
withdrawal any projection from the wall falls into full view over the 
inner open extremity where it may be moved about by a probe or ap- 
plicator, examined in different aspects and subjected to treatment. 
Sometimes many of these papillomata are to be found in the urethra. 392 
DISEASES OF THE URETHRA IN THE FEMALE 
When one or more project from the external meatus they are readily 
found on lifting aside the labia minora. 
These tumors are delicate wisps of tissue often but they may contain 
some connective tissue and possess considerable body. Their bases 
may hold firmly to the surrounding mucosa, as attempts to remove 
them by avulsion proves through producing quite a tear running out 
from the base. They carry a single-looped bloodvessel or are highly 
vascular with many vessels large in proportion to the size of the growth. 
They may recur after removal particularly when the base is not treated 
by caustic or cautery. 
Treatment.—Rarely the simplest form of treatment, such as the appli- 
cation of a weak solution of silver nitrate (instillation) or crushing by 
forceps or amputation with scissors, will completely cure the patient. 
Incomplete destruction of the whole growth, however, is prone to lead 
to recurrence in a short time. 
The best means at our disposal for the treatment of this lesion is the 
high-frequency spark (Oudin current). The wire electrode is passed 
into the base of the growth and the current is passed into it for a 
few flashes or for fifteen seconds, and the growth destroyed with small 
likelihood of recurrence. 
Amputation of the tumor at its base by means of little urethroscopic 
scissors with the application of the silver nitrate stick or cautery to the 
base is effectual, but after cutting the tissue, blood often obscures the 
base and interferes with the application and effectiveness of the silver 
nitrate. 
The use of the silver nitrate stick or strong solution applied to these 
papillary growths will not infrequently effect their removal. Several 
applications are often necessary. This is painful and by no means so 
certain as cauterization by the Oudin spark. 
Cauterization with electric or other (actual) cautery is equally as 
effective as the Oudin spark but it is not so completely controlled; its 
effect is deeper and less defined. 
Malignant Neoplasms of the Female Urethra.—Cancer of the urethra 
is very uncommon, although Young, of Boston, in a recent communica- 
tion reports that many of the small tumors, clinically considered 
caruncle, which had been removed and preserved at the Massachusetts 
General TTospital Laboratory presented definite evidence of malignant 
growth to be classified only as cancer. 
Primary carcinoma of the urethra arising from its mucous membrane 
itself, apart from the view presented by Young (and referred to under 
the subject of Caruncle), is throughout the literature very rare; 
probably not more than 25 to 30 critically studied cases have been 
recorded. 
Carcinomatous involvement of the urethra by the extension of a 
tumor from neighboring tissues has been reported in numerous cases. 
Carcinoma which originates in the para-urethral ducts, in peri-urethral 
tissues in the vestibule, labia, clitoris, vagina or bladder may make its 
way into the urethral tissues. NEOPLASMS OF THE FEMALE URETHRA 
393 
Sarcoma is still more of a curiosity than carcinoma in connection with 
the urethra. 
Since these forms of neoplasm may be found in, or connected with, 
the urethra, it behooves the examiner to be on his guard for their 
recognition and for early thorough eradication of them when 
found. 
Any rapidly progressing neoplastic tissue or tumor which tends to 
destroy, through ulceration, the neighboring tissue, which gives rise to 
pain, great tenderness and to recurrent hemorrhage (while it may be 
called a caruncle) should be under suspicion, as a malignant growth and 
at least a part should be removed with a section of its base for critical 
pathological study and diagnosis of its nature. Wide excision of the 
entire tumor as soon as malignant characteristics are recognized is the 
safer course whatever the subsequent report upon its histology may 
prove. 
We have as yet had insufficient time since the introduction of the 
Roentgen rays, radium and the high-frequency spark into therapeutics 
to draw hard-and-fast lines in the critical judgment of the final 
effectiveness of these means in the treatment of cancer and sarcoma. 
Yet in the light of our present knowledge and the experience gained 
through the treatment of small superficial skin cancer, x-ray cancer, 
vesical neoplasms, rodent ulcer, cancer of the lip, eye, etc., we can under 
unusual circumstances commend these means for the destruction of very 
small malignant neoplasms. These agents present advantages in that 
the tissue is not squeezed or handled; already invaded lymphatics and 
vessels are not traumatized or cut across, as with the knife, leaving in- 
visible remnants in the freshened medium of healthy tissue for further 
propagation; the resulting scar is smaller and complete destruction 
with proper technic is attainable in some cases. The disadvantages of 
radium, the Roentgen rays and even of the high-frequency spark are that 
the “ dosage” has not been determined, stimulation instead of retarda- 
tion or destruction may be the startling effect, and defining the action 
to the neoplastic tissue is not possible. 
Every malignant neoplasm removable by excision should not be 
tampered with by these uncertain agents. Wide and thorough excision 
of malignant neoplasms in or connected with the urethra offers the 
greatest security for eradication. 
Large or inaccessible growths must be excised by circumscribing 
incision carried out in normal tissue and, under the conditions found in 
each case, as much of the natural channel preserved as possible with 
immediate or secondary plastic repair. The meatus should be left as a 
broad, deep opening. The vaginal and urethral mucous linings should 
be sutured in apposition where the vaginal portion of the urethra has 
been amputated. The internal sphincter should be left intact if 
possible. Vesicovaginal or suprapubic drainage should be provided 
during the healing process in many cases to prevent infection and 
sloughing after urethral suture. 
When the entire urethra must be sacrificed the problem becomes 394 
DISEASES OF THE URETHRA IN THE FEMALE 
one of bladder surgery with permanent suprapubic drainage, vesico- 
vaginal fistula, transplantation of the ureters, nephrostomy, or other 
provision for urinary outflow. 
STRICTURE OF THE FEMALE URETHRA. 
The female urethral mucous membrane presents a lining layer com- 
posed of squamous epithelium. Columnar epithelium is present in the 
relatively few ducts and glands and it is analogous anatomically to 
the membranous urethra in the male. Stricture of the membranous 
urethra in the male is exceedingly rare because of the resistance to 
infection offered by squamous epithelium and the absence of glandular 
structures in or continuous with its mucosa; and so it is in the female 
urethra. 
Gonorrheal ulceration of the female urethra, the forerunner of strict- 
ure, has not been observed and Stockel6 states that “ deeply penetrating 
ulcerations of the mucous membrane with veritable loss of substance 
which cicatrize to form stricture do not occur in gonorrhea of women 
which has been properly treated or not treated at all.” and he considers 
such ulcerations due, when found during or aftei gonorrhea, to improper 
treatment with caustics. 
The causes of stricture in the female are peri-urethral abscess, often 
gonorrheal in origin, injury of the urethra in childbirth by the child’s 
head or by obstetrical instruments, other injuries of the urethra which 
are followed by the formation of a cicatrix, and healed ulcerations of 
tuberculous or syphilitic nature. 
Constrictions of the urethral lumen due to a cicatrix in the under- 
lying vaginal wall, to abscess or tumor in the urethra or neighboring 
tissues are not considered here. Stricture is an acquired narrowing of 
the lumen of the canal through the formation and contraction of a 
cicatrix which results from healing of a laceration, a rupture or a de- 
structive, ulcerative process extending through the mucous membrane 
of the urethra into its submucosa. This cicatricial tissue is found at 
one point of the circumference, in a segment or occupying the entire 
circumference (annular), and it may extend to greater or less extent 
along the canal in a longitudinal direction. Stricture of the female 
urethra is usually single, although multiple strictures may be found. 
Constriction of the lumen and firm fibrous infiltration of the entire 
urethra is occasionally observed in the aged. Its etiology is obscure. 
Symptoms.—Stricture may present no subjective symptoms for a 
long period but may be discovered upon the occasion of some necessary 
instrumentation of the urethra by the surgeon or nurse (catheterization, 
cystoscopy, etc.). 
The subjective symptoms develop gradually and may be present for 
months or even years before the patient calls them to the attention of 
the surgeon. 
The column of urine expelled through the canal becomes gradually 395 
STRICTURE OF THE FEMALE URETHRA 
smaller, requiring a longer time for evacuation of the bladder and call- 
ing forth contraction of the abdominal muscles during inspiration to 
increase intra-abdominal pressure to aid in expelling the urine. Drib- 
bling after the act of micturition has been completed is common as well 
as interruption of the flow during the act. 
Infection in the mucosa of the urethra behind the stricture extending 
into the bladder (cystitis) with pyuria are inevitable late results. 
Kolischer has called attention to ulceration of the mucous membrane 
behind the stricture, dilatation of this part of the canal, congestion and 
edema of the region of the internal sphincter, inflammation of the 
bladder wall especially about the vesical outlet and trigone and hyper- 
trophy of the bladder musculature with increased trabeculation. 
Diagnosis.—The history of one or more of the causative factors: of 
difficulty in urination of gradual development, of straining during the 
act, of interruption of the flow and of the annoying after-dribbling lead 
to an examination. A stricture in the female may be impassable with 
any instrument—impermeable stricture. 
The urethroscope will demonstrate the smooth cicatricial tissue and 
its pale color and the coarctation of lumen. It may be possible to find 
the channel through the stricture by searching for it with urethroscope 
and probe or filiform. This examination should always be resorted to 
before concluding that the urethra is impermeable to instruments and 
applying the treatment demanded by the condition. 
Treatment.—Gradual dilatation by solid instruments of larger and 
larger size until the normal caliber is reached and maintained is the 
best plan when feasible. 
All undue traumatism and pain should be avoided through gentleness, 
very slow progress and the use of local anesthetics. Dilatation such as 
to produce bleeding should be guarded against in this treatment. 
The time required in treatment for the restoration to normal caliber 
and maintenance of this dilatation varies greatly but no patient should 
be considered cured who has been under observation for less than two 
years, and a longer time may be requisite. 
Internal Urethrotomy.—This procedure is indicated in cases which 
resist gradual dilatation, so that progress is not observed or is very slow, 
in cases which require immediate relief because of the infection in the 
urethra or bladder behind it, when catheterization must be facilitated 
or cystoscopic examination is demanded, and when the patient refuses 
to undergo the prolonged but preferable gradual dilatation. 
No case in which internal urethrotomy is done escapes the necessity 
for gradual dilatation. The passage of solid instruments should always 
succeed any operative procedure to assure the patency of the canal. 
After internal urethrotomy, which provides an immediate enlargement 
of the caliber, the recontraction may be rapid unless the lumen is 
maintained by the repeated passage of solid instruments. 
Internal urethrotomy in the female is carried out in the same way as 
in the male. A filiform is passed through the stricture to which a 
straight shaft of a Maisonneuve urethrotome is attached. When 396 
DISEASES OF THE URETHRA IN THE FEMALE 
this has been passed through the stricture, the knife of proper size is 
passed through its groove, cutting the stricture upon the floor and 
later upon the roof (upper wall). The canal should be cut to admit a 
sound of 28 or 30 French size. 
Bleeding may be excessive as a result of this procedure, so that a 
cautery knife operated through an urethroscopic tube is preferred by 
many. 
External Urethrotomy.—In the female this should consist in complete 
exposure of the stricture by incision through the anterior vaginal wall, 
excision of the fibrous tissue followed by end-to-end suture of the 
proximal and distal ends of the tube. Longitudinal incision with ex- 
cision of the fibrous tissue in A -shape, leaving intact the mucosa on the 
roof of the canal, and then lateral suture of the longitudinal incision (as 
in simple pyloroplasty) is a satisfactory method. 
External urethrotomy should always be accompanied by drainage of 
the bladder by a small rubber tube or catheter passing through a punc- 
ture or buttonhole opening into the bladder floor through the anterior 
vaginal wall. 
This drainage should be maintained for about ten days to assure 
healing of the sutured urethra before the urethra is permitted to 
resume its function. 
DIVERTICULUM OF THE FEMALE URETHRA.—URETHROCELE. 
Diverticulum or urethrocele is a pouch formed by dilatation of a 
circumscribed portion of the inferior wall of the urethra. 
Its cause is ascribed to an injury of this wall in childbirth or to the 
destruction of the sustaining muscular structures of its wall by an 
inflammatory process or by a foreign body such as calculus. 
It occurs most commonly in women who have borne several children 
and in whom repeated traumatisms to the vaginal wall and the sub- 
jacent musculature of the urethra have contused these tissues. Less 
common are the cases due to weakening of the wall from peri-urethral 
inflammation. 
A pocket beneath the urethra formed by the rupture of an asbcess 
into this canal is simply a chronic abscess cavity and is to be dis- 
tinguished from true urethrocele which forms by bulging of the mucous 
membrane downward like an acquired hernial sac into a weak spot in its 
outer wall. The condition has not been found attributable to con- 
genital maldevelopment. 
Such a pouch in a multipara may exist and gradually increase in size 
without being recognized for a long period if no infection of its mucous 
lining occurs and urinary salts are not deposited in the cavity. Pouches 
connecting with the urethra which are the result of abscess formation 
usually persist as chronic abscess cavities and are especially prone to 
hold a calcareous deposit of urine sediment. 
Those reported have varied in size but have commonly been found as 
tumefactions presenting upon the anterior vaginal wall 1 or 2 cm. in DIVERTICULUM OF FEMALE URETHRA—URETHROCELE 
397 
diameter. If the connection between the diverticulum and the urethra 
is large, pressure upon its vaginal aspect gives the sense of a lax-walled 
cyst and its contents, expressed into the urethra, appear at the external 
meatus. If, on the other hand, the urethral opening is small or occluded 
by calcareous material, the tumor feels tense or hard. 
An instrument (catheter, small sound, or probe) may be inserted 
along the floor of the urethra into the sacculation and felt therein by the 
finger in the vagina. By examining the urethral floor with the urethro- 
scope its opening into the urethra and sometimes the wall of the cavity 
can be explored. 
Cysts of the vaginal wall never communicate with the urethra. 
Calculus retained in the urethra tends to form a bulging dilatation 
of the wall or pocket with ulceration of the mucosa. 
Cystocele is more voluminous and not a circumscribed tumor on the 
vaginal wall but a protrusion carrying the vaginal wall with it. 
Symptoms.—Painful and abnormally frequent urination, pyuria, 
hematuria in some cases, a tender area on the anterior vaginal wall, 
and a urethral purulent discharge are the evidences of the condition. 
The patient may report relief gained through pressure upon the tender 
area in the vagina which empties the sac. 
The examiner by inspecting the anterior vaginal wall and palpating 
the tender tumor found there expresses its contents which flow out of 
the external meatus. He may feel through the urethrovaginal septum 
an instrument passed per urethram into the sac. Urethroscopy reveals 
the abnormal extent of the floor of the urethra or gives a view of the 
interior of the pouch through a narrow opening into which a probe 
passes. 
Treatment.—Infection of the lining membrane of diverticulum is the 
rule, so that healing after removal and suture is problematic. The pos- 
sibility of a resulting urethrovaginal fistula and its subsequent treat- 
ment must be kept in mind. 
The ideal method of treatment of urethrocele is the total excision of 
the entire sac through a vaginal incision under local and interstitial or 
general anesthesia. With a sound or silver catheter in the urethra an 
incision is made through the vaginal wall into the sac of the divertic- 
ulum, bisecting it. Each half is then dissected out and the mucous 
membrane of the urethra cut through along the margins of the divertic- 
ulum. This wound may be closed by interrupted sutures from side to 
side, passing through all tissues of the bed of the sac from the vaginal 
mucosa to the submucosa of the urethra. 
The excision of an elliptical area of the vaginal wall and urethro- 
vaginal septum shelving inward to the urethral canal may be advan- 
tageous in some cases. 
Simple incision of the sac and packing of the wound which heals by 
granulation has resulted favorably, but often requires subsequent 
closure of the fistula. Incision and cauterization of the wall with pack- 
ing of the wound has likewise succeeded. 398 
DISEASES OF THE URETHRA IN THE FEMALE 
INFLAMMATIONS OF THE FEMALE URETHRA. 
Infection of the urethra of the female is a condition the importance 
and frequency of occurrence of which is not sufficiently impressed 
upon the medical profession today. Some of the reasons for this 
ignorance are to be found in the total absence of this subject in under- 
graduate instruction of many of our medical schools and the brief 
and inadequate treatment of it in text-books as well as the inex- 
perience of gynecologists and the medical profession as a whole in 
the careful study and localization of lesions in the urinary tract. 
Many surgeons make frequent use of the cystoscope but rarely, if 
ever, employ the urethroscope. Urethroscopy is a more difficult pro- 
cedure than cystoscopy, demanding patience, skill and experience, and 
offers the only means for positive determination of most of the lesions 
and diseases of the urethra. 
Acute, generalized purulent urethritis in the female is usually due to 
infection with the diplococcus of Neisser (gonococcus). 
The diagnosis of one variety of acute urethritis from another depends 
upon the demonstration of the bacterial growth found in the exudate. 
No case of acute urethritis can be called gonorrheal until positive and 
authoritative demonstration of the gonococcus has been made in the 
exudate. It is unscientific and morally wrong to fail to prove by the 
best bacteriological evidence the character of the germ present in any 
case of urethritis. No case of acute urethritis can be diagnosticated 
without bacteriological study. 
Acute Simple (Non-gonococcic) Urethritis.—Acute purulent inflam- 
mation of the entire urethra due to infection by other organisms than 
the gonococcus is seen in prolonged irritation of the mucosa by a 
catheter retained through the canal for drainage of the bladder and in 
the presence of other foreign bodies (calculus, inserted objects such as 
pins, hairpins, etc.) and after repeated traumatisms or irritations, such 
as the frequent use of the catheter or overzealous exploration and 
treatment. 
Infection of the urethra by unclean, rough, or frequently repeated 
catheterization is, in my opinion, very frequently the condition com- 
monly and improperly called cystitis. This does not imply that 
infection of the bladder (cystitis) is uncommon through catheter 
infection but it does imply that the bladder is carelessly regarded as 
the seat of an inflammation or lesion which can be shown to lie in the 
urethra in many cases. In many of such cases the cystoscope shows 
normal conditions within the bladder. 
Acute inflammation of the urethra of non-gonococcic origin is a con- 
dition of far greater consequence than is usually accorded to it because 
of the rapid disappearance of all gross manifestations of its presence 
through simply removing the cause of its inception (i. e., removal of 
foreign body, cessation of catheterization, etc.) and the improvement in 
the subjective symptoms. This form of urethritis is regarded as of little 
consequence just because these signs and symptoms can so readily be INFLAMMATIONS OF THE FEMALE URETHRA 
399 
explained and so obviously and promptly relieved. Complete cure, 
however, does not always follow this manifest improvement. In the 
majority of cases, to be sure, there is no persistence or recurrence of 
symptoms or signs and a cure does take place. In many cases, on the 
other hand (and every surgeon can recall such), there is a persistence of 
the subjective complaints or a recurrence of them after a time. The 
urine then may present no pathological elements, complete examination 
of the urinary tract (excepting the urethra) shows no renal, ureteral or 
vesical abnormality and gynecological examination affords no evidence 
of the cause. When an examination of the urethra is made, the lesions 
of chronic urethritis are revealed and the history of catheter infection 
(cystitis?) is recalled. 
An acute inflammation of the urethra often accompanied with 
involvement of the contiguous bladder mucous membrane (cysto- 
urethritis, trigonitis, cervico-urethritis so called) is a common condition 
the etiology of which is obscure. Among the laity this is the well-recog- 
nized “cold in the bladder.” Exposure to cold, errors in diet, highly 
acid urine, alcoholic excess, chemical alteration of the urine other than 
abnormal acidity due to obscure metabolic processes have all been put 
forward in explanation of the cause of this condition. 
It is well to compare the condition with the prostatic infections of 
obscure etiology the symptoms of which, signs, course, duration, and 
treatment correspond with it. 
In these cases the colon bacillus is most commonly found in the 
urine and in pus obtained from the urethra and in many cases a history 
of intestinal disturbance preceding or coincident with the urethral and 
vesical symptoms is elicited. Staphylococci and streptococci are also 
commonly found in this “simple” (so-called) urethritis. 
The striking frequency of this urethral and vesical condition in 
association with tonsillitis and grippe has been observed repeatedly. 
Hunner has called attention to the association of urethral and pharyn- 
geal conditions and the literature is now voluminous concerning the 
relations between, or the coincidental abnormalities of certain nasal 
structures and the urethra and genital organs. In many of these cases 
symptoms of acute urethral inflammation have been present. 
Treatment of Acute Non-gonoccocic Urethritis.—The removal of the 
cause of the inflammation is the chief feature in its care and no further 
treatment is usually called for. The calculus, foreign body or catheter 
must be removed from the canal. Catheterization must be stopped or 
interrupted for a period when this is possible. The technic of cathe- 
terization should be carefully studied and errors corrected. 
Injections of argyrol or of some astringent such as zinc sulphate may 
aid in hastening the subsidence of discharge and relieve discomfort, yet 
these medicaments are usually unnecessary unless the symptoms persist 
for three or more days after removal of the cause. 
Prophylactic treatment against the chronic urethritis which com- 
monly follows this simple acute urethritis consists in the early recog- 
nition of its existence, the correction of the causative factors and local 400 
DISEASES OF THE URETHRA IN THE FEMALE 
urethral treatment by means of injections (silver salts, zinc sulphate, 
etc.) or through the urethroscope (at a later period, not during the acute 
stage) if the subjective or objective symptoms persist. 
Gonococcic Urethritis.—Gonococcic urethritis in the female may 
occasion such slight discomfort and be of such short duration that 
the patient finds no occasion for recourse to the physician. She may 
have no discomfort in the urethra and no disturbance of urination—no 
subjective indication. The fear of detection even in aggravated 
cases commonly induces the subject to conceal what evidence she has 
discovered during the short time that symptoms are present. 
The very general ignorance of women, of laymen (and it must be 
admitted of physicians often), of the significance of the symptoms of 
gonococcic infection in the female with its insidious, far-reaching, and 
calamatous extension serves to hamper its discovery (often difficult 
at best) and its prompt efficient treatment. The male practically 
always knows that he has acquired an infection while the female 
rarely does. 
While one should carefully guard against the indictment of a woman 
presenting a history of urethral irritability and purulent discharge or of 
any case with acute, subacute or chronic urethritis, as of gonococcic 
origin, it may be presumed that a girl or woman exposed to infection 
of gonorrhea with the history of symptoms of urethritis supervening 
has had gonorrheal urethritis. 
Upon this presumption only rests in many cases the ascribing of the 
lesions of chronic urethritis, suburethral abscess, infection of para- 
urethral ducts without demonstration of the gonococcus to an original 
gonococcic infection, and with this frequently justified presumption 
many cases are explained. 
A woman may have, in fact, commonly does have, a gonococcic acute 
urethritis without realizing that she is the victim of any pathological 
process, wherefore her history is not a factor comparable with the 
search for the pathological evidence and the bacterium. She asserts 
and believes that there is “nothing the matter with her” and only by 
the most painstaking scientific search, in which asepsis, perfect clinical 
and laboratory technic, constant experience with microscope and com- 
plete knowledge of the pathology of the disease plays each its important 
part, can the proof or actual evidence of the nature of the lesion be 
determined. 
Women who present themselves to a practitioner for a certificate of 
freedom from gonococcic infection commonly are subjected to examina- 
tion by inspection, palpation, and urinary examination. These means 
are obviously inadequate for the discovery of nearly all cases except the 
acute and florid. Most subsiding and chronic cases are not revealed 
by such superficial means which, so far as they go, give normal signs 
only, and the proof of the disease is neglected. The failure of medical 
examination of prostitutes to reveal gonococcic infectiousness is due to 
the very insidious hiding of the bacterium in folds of the mucosa or 
beneath the epithelium in ducts and glands. INFLAMMATIONS OF THE FEMALE URETHRA 
401 
Gonococci beneath the epithelium actively promoting a small focus of 
infection are not discoverable by any means. It is only when they 
come upon the surface or can be brought to the surface that they can be 
obtained for examination. This is one of the reasons why a single 
examination is never adequate to give the basis for the opinion that a 
urethral mucous membrane is not infectious. Several examinations 
under the most favorable circumstances for finding the bacteria and the 
most careful observation over a long period of time with complete 
cooperation on the part of the patient are always necessary before the 
opinion of non-infectiousness can be given honestly and fairly in any 
suspicious case. 
Lack of cooperation on the part of the patient, who may be very 
fully informed, will nullify the value of findings in markedly infectious 
cases of urethritis. Simply by passing through the urethra a small 
part of the urine just before the examination, all evidence of the 
presence of pus and bacteria can be washed away and then the urine 
obtained in the examiner’s office is normal, and of urethral secretion 
there is none. 
The patient is then said to have an “ irritable bladder,” or is said to 
be suffering from a “psychic or hysterical” complaint, without demon- 
strable lesion, because the urethra is not subjected to adequate and 
competent scrutiny. 
In such cases the acute condition has disappeared from the 
greater part of the mucosa, but is persistent as an infection in one 
or more localized, perhaps minute, areas where redness, swelling and 
hypersensibility may still be found by means of the urethroscope. 
These conditions are always obscure until exploration by the urethro- 
scope finds the lesion. 
Pyuria without Urethral Discharge.—That acute purulent lesions 
persist in the urethra giving pyuria without discharge of pus from the 
external meatus and with normal bladder and normal kidneys there is 
little question. An ulceration or persistent infection at the vesico- 
urethral junction or in the urethra just outside the internal sphincter 
has been observed which produced a surprising amount of purulent 
secretion that passed back into the bladder, making the urine 
densely turbid. Secretion from this lesion does not find its way 
through the external voluntary sphincter, but like that of purulent 
prostatitis in the male, does escape through the internal sphincter into 
the bladder. Treatment of the bladder in such cases accomplishes 
nothing but is wasteful of time and effort, while direct treatment of the 
urethral lesion is the only means of relief. 
Examination for Gonococcic Infection.—The following plan should be 
followed when the female urethra is to be examined for the detection of 
the diplococcus of Neisser, and the same principles apply for examina- 
tion of the cervix, glands of Bartholin and vagina, all of which are 
usually examined at the same time. 
The patient must take no douche or bath, and must not wash the 
vulva for twelve hours preceding the examination. She should not 402 
DISEASES OF THE URETHRA IN THE FEMALE 
void the urine for at least three hours, and it is preferable that twelve 
hours elapse preceding the examination. It is often well to instruct 
the patient to come to the examination early in the morning without 
voiding urine since retiring the night before. 
No washing of the vulva by a nurse is permitted when the patient is 
prepared for examination. 
The labia are separated and specimens of any secretion are taken up 
with a platinum loop or thoroughly sterilized cotton swabs and spread 
upon glass slides, labelled according to the site where secretion is found, 
and cultures made at the same time upon suitable media. Thus often 
one set of three to six slides is labelled labia minora; another set, vesti- 
bule; and still others, external meatus; vaginal orifice; vagina; right 
Bartholin; cervix, etc. This, it may readily be seen, promises labor for 
the laboratory, but that is what the laboratory is for, and the duty of 
the conscientious examiner demands at least that the work be thor- 
oughly done. 
Secretion obtainable at the external urethral orifice must be sepa- 
rately collected upon a set of slides to differentiate it from that obtained 
within the urethra. The urethra may be free of infection while its 
outlet is bathed in pus from the vagina or from an infected para-urethral 
duct which may open outside the canal. 
The urethral meatus is then opened by separating its margins with 
the fingers and the vestibule and orifice are washed with cotton sponges 
wet with salt solution and then dried with sterile gauze. The platinum 
loop (fired and cooled) or a sterile cotton swab on an applicator is in- 
serted into the canal 0.5 cm. and withdrawn and the secretion upon it 
spread immediately upon slides. This may be repeated several times 
to obtain a sufficient number of specimens for careful search. It can be 
done painlessly and without trauma. 
No vaginal examination by means of the finger or speculum should 
be made until these specimens from the urethral orifice and canal have 
been secured. 
Now the hairpin retractor of Kelly or a bent probe is inserted into the 
urethral meatus to expose the orifice of one and then the other of Skene’s 
ducts while pressure is made below the floor of the anterior part of the 
urethra against the vestibule or upon the anterior wall of the vagina, 
close to the vaginal outlet, and the appearance of secretion expressed 
from the duct taken up and preserved on specially labelled slides 
(left, Skene; right, Skene, etc.). 
The whole urethra is then stroked from the bladder to the external 
meatus (from behind, forward) through the anterior vaginal wall. This 
can be done in infants often without strain or rupture of the hymen. 
Several specimens of all secretion thus obtained must be preserved 
upon labelled slides and cultures made at the same time on appropriate 
media, such as blood serum, etc., for bacteriological study. 
If search is to be made (as must commonly be the case) in the vagina, 
cervix, vulvovaginal glands, etc., this should now be carried out. 
The vagina is then cleansed by douche or by sponges on sponge INFLAMMATIONS OF THE FEMALE URETHRA 
403 
holders and mopped dry with gauze or cotton, and the vulva is washed 
with salt solution and dried with gauze. 
The patient is then instructed to urinate into two sterile beakers— 
a small portion, or the first gush of urine, in one, and the remainder of 
the bladder contents into the other. All of the urine in glass No. 1 
should be centrifugalized and the sediment thoroughly searched for 
pus and for bacteria, and cultures should be made from this sediment 
under laboratory precautions. 
The patient again takes her place on the table and a critical examina- 
tion of the entire urethral mucosa is made with the urethroscope, 
through which all adherent mucus and pus upon the walls is secured for 
bacteriological examination, and lesions are carefully noted. 
No case of suspected gonorrheal infection of the urethra has had a 
thorough or adequate examination unless a routine as complete as this 
has been followed, and no case can be declared free of gonorrheal in- 
fection unless repeated complete tests of this sort are carried out after 
stimulation of the urethra and para-urethral ducts with silver nitrate or 
other irritant directly applied. The doubtful expedient of the ingestion 
of alcoholic beverage to irritate this part of the urinary tract may aid in 
promoting the appearance of discharge, which is to be searched for the 
offending organism. 
Acute Gonococcic Urethritis.—This is an acute exudative inflamma- 
tion of the mucous membrane involving the entire extent of the canal, 
due to the lodgment and growth upon and in the mucosa of the gono- 
coccus or diplococcus of Neisser. 
It is acquired by adults almost exclusively in coitus, although the 
bacteria may be transferred through freshly soiled objects, such as 
douch-nozzle, towels, toilet seats, etc. Infection except through sexual 
contact is very rare in adults, while the transference of the bacterium 
from an infected source to the more delicate and more susceptible mu- 
cous membrane of the vulva of the infant or young girl is common 
through contaminated objects, such as clinical thermometers, diapers, 
towels, toilet seats, the hands of attendants and nurses. 
The little girl who sleeps in bed with an infected individual may 
acquire this infection from secretion deposited upon the bedclothes or 
through handling by infection-carrying hands. This source of infection 
is common among the poorer classes who visit our free clinics, and is 
not uncommon among all classes. In children the urethra is readily 
infected, but is rarely the site of persistent and chronic foci. Long- 
continued vulvovaginitis in children is usually due to chronic infection 
in the cervix uteri. Repeated reinfections of the urethra from this 
source may occur. 
Acute gonococcic urethritis in the female is usually a short-lived 
process, lasting from three or four days to three weeks in untreated 
cases. The acute symptoms consist in itching or burning in the ure- 
thra, with a scalding sensation during urination, frequent desire for 
micturition, more or less urethral discharge of pus containing gonococci, 
and occasionally some blood or terminal hematuria. These symptoms 404 
DISEASES OF THE URETHRA IN THE FEMALE 
last for a few days and arouse often slight attention on the part of the 
victim, so that she does not consult a physician. When the pain is 
great or frequent, imperative calls for urination with strangury arise, 
or the discharge is florid and she is unaccustomed to vaginal discharge, 
or blood is observed at a time apart from a menstrual period, any of 
these conditions may lead her to seek medical examination for relief. 
It is, however, to be remembered that a woman will usually patiently 
bear the above-mentioned discomforts in the hope that they will soon 
pass away, and she commonly ascribes them to some indiscretion in diet. 
Her hope is often fulfilled, and she believes herself unaffected by any 
serious condition because of the subsidence of all subjective symptoms 
after a few days. On the other hand, symptoms may be aggravated 
and prolonged, and the victim may immediately seek medical advice. 
On examination in the acute case the external meatus is dark red and 
swollen, with discharge flowing from it or readily expressed by the 
slightest pressure. The vestibule, meatus, and urethra per vaginam 
are exquisitely tender to touch. The secretion transferred to a micro- 
scopic slide shows pus with the characteristic biscuit-shaped extra- 
cellular and intracellular diplococci, which are negative to the Gram 
stain, and cultures from this secretion grow the characteristic colonies 
of this organism on suitable media. The orifices of Skene’s ducts may 
stand out as pouting red points when exposed just within the meatus. 
Pressure upon these ducts through the vestibule or through the vagina 
shows a drop of pus at the orifice, and palpation of the urethra per 
vaginam gives pain, causes an increase of the discharge at the meatus, 
and the normal cord-like feeling of the urethra above the vagina is 
changed by the soft thickening of its walls, due to the inflammatory 
infiltration. If gonococci are not found in the secretion from the 
urethra, but are present at this time in secretion from other parts of 
the genital tract, this bacterium may reasonably be presumed to be 
the exciting cause of the acute urethritis and subsequent searches will 
usually reveal them in the urethral secretion. 
The examination of the vagina, vulvovaginal glands, and cervix is 
now usually proceeded with and the vagina cleansed and dried with 
gauze, and the vestibule, labia, and vaginal outlet cleansed by washing 
and dried with gauze. 
The patient passes urine into two sterile beakers. In the portion 
voided first, shreds, pus and gonococci are found. The second beaker 
may contain clear urine or it may be cloudy or turbid with pus. The 
pus in the second beaker may be due to purulent inflammation in the 
juxtavesical portion of the urethra corresponding with posterior 
urethritis in the male; it may be due to cysto-urethritis or to 
cystitis. 
In acute inflammation of the urethra, when the gonococcus is readily 
demonstrated in the secretion, no urethroscopic examination should be 
attempted. It is painful, requiring thorough anesthesia with novocain 
or cocaine, and the introduction and manipulation of the instrument 
produces traumatisms, with trifling hemorrhages even in the most deft INFLAMMATIONS OF THE FEMALE URETHRA 
405 
hands, tending to give rise to extension and aggravation of an already 
grave inflammatory process. No catheter or other instrument should 
be passed through an acutely inflamed urethra unless imperatively 
necessary. 
If voluntary urination is interfered with by reason of the pain and 
swelling in the canal, the patient must be instructed to attempt to 
void urine while sitting in the hot sitz bath or while hot applications 
are made to the vulva and pubic regions, so that catheterization and 
its trauma may be prevented. 
During or subsequent to the acute stage of gonorrheal urethritis the 
inguinal lymph nodes may be found to be enlarged and tender or even 
to be the seat of abscess formation. 
After a few days (one to ten days, but two to four days commonly) 
the subjective and objective symptoms and signs rapidly disappear. 
Urination becomes normal, urethral discharge is slight, mucoid, with 
little pus, and the redness and swelling of the meatus disappear. There 
persists, however, for ten to fourteen days longer the evidence of 
urethritis in shreds in the urine, a little more than normal secretion 
from the mucosa, and pus is to be found in the shreds and in the 
urethral secretion as well as some gonococci. 
The orifices of Skene’s ducts will usually show for a week or two 
as distinct red points, just within the meatus on each side, and from 
them may be expressed a tiny drop of pus in which gonococci may be 
found on careful search. 
If the urethroscope is employed in this stage, red points and infil- 
trated areas are to be found along the urethra, and these are most 
numerous and most marked in the parts of the mucosa which are pro- 
vided with glands, notably at the upper extremity and near the external 
meatus. These infected areas are the lesions which persist as chronic 
foci of inflammation. 
In this subsiding stage the woman may consider herself well even if 
she has recognized during the florid stage that a definite disease process 
has been in action, yet the secretion from the urethra is highly infectious. 
Now the active process has subsided, and there persists for a short 
or long time the periods described as the subacute and chronic stages. 
The subacute stage is merely a continuance of the subsiding acute 
process. It is an indefinable period, during which very slight subjective 
and objective symptoms and signs remain. It may be said to have a 
duration of from two to five weeks. 
It is well known and has been stated above that acute gonococcic 
urethritis in the female usually subsides in less than ten days to a sub- 
acute condition of relative comfort, as the patient observes, and one in 
which the objective signs are scarcely manifest. This subacute stage 
has a duration of from ten days to five weeks. Urethritis persisting 
longer than five weeks is to be called chronic. 
The pathological condition has during the first two to ten days been 
an active acute exudate inflammation of the entire mucous membrane. 
The entire inner membrane (epithelium) is during this stage swollen, 406 
DISEASES OF THE URETHRA IN THE FEMALE 
deep red in color, and covered with yellow fluid pus. The bloodvessels 
are dilated, leukocytes are packed into the submucous and mucous 
layers and escape upon the surface, which is secreting an abnormal 
quantity of mucus, and the epithelium is desquamated as individual 
cells or in plaques or groups of cells. Minute hemorrhages take place 
into the mucosa and upon its surface. The gonococci are to be found 
in the epithelial cells and penetrating between cells in the mucous and 
submucous layers, and within the leukocytes. 
Wherever crypts, lacunae, folds, or glands exist the inflammatory 
process extends into the depths, and gonococci penetrate into the lower- 
most recesses and out into the surrounding tissues about such crypts 
and glands. Minute abscesses are thus formed, which, bottle-like, may 
be shut off from the canal through adhesion or occlusion of their outlets, 
to open again as the inflammation surrounding them subsides, with dis- 
charge of the infectious contents into the main channel of the urethra, 
giving rise to recrudescence or recurrence of the diffuse inflammation 
throughout the canal. These pockets of infection in glands, crypts, 
and sulci are the sites of long-persisting lesions, often microscopic in 
size, but large in their potency for recurrent or chronic infection. 
Some minute lesions may extend or coalesce to form gross areas of 
suppuration, called suburethral and peri-urethral abscess, and perfora- 
tion of such a suppuration through the vaginal wall brings about 
urethrovaginal fistula. It is to be particularly noted that glandular 
structures are found in the upper third and in the lower third of the 
urethra, and that these portions present the chronic lesions and are 
the sites of suburethral abscess. 
Infection of the para-urethral (Skene’s) ducts affords a nidus for long- 
continuing suppurative inflammation or recurrent abscess formation. 
In glands and gland-like structures the gonococcus finds its natural 
habitat, and it is in these structures that it maintains acute, subacute, 
and chronic inflammation untouched by medicaments applied to the 
lumen of the urethra, and undiscovered, it may be, by any of the means 
which we now possess for searching it out. 
Treatment of Acute Gonococcic Urethritis.—It may be stated, at the 
outset, that the proper care of any woman infected by the gonococcus 
demands the most painstaking attention to every detail, and treatment 
to be effective must be carried out in part by a nurse and in part by the 
surgeon. A nurse should care for her wants while she remains in bed, 
apply compresses, give urethral treatments, regulate the diet, and see 
that water is taken. This can be accomplished only among those who 
have command of their time and the means to provide themselves with 
every necessity. In many cases no such plan can be carried out. The 
patient may not, for varied reasons, take to her bed, admit a nurse to 
her home, and permit daily treatment by a surgeon. The feasible 
approach to ideal care often consists in the daily visit to the physician’s 
office, where treatment is administered. A daily renewal of the anti- 
septic tampon and irrigation of the urethra can be made. The effective- 
ness of these means, however, is lost after a few hours, so that she is INFLAMMATIONS OF THE FEMALE URETHRA 
407 
practically without treatment during the greater part of each twenty- 
four hours. 
Abortive treatment is impracticable because of the fact that the 
appearance of symptoms sufficiently marked to attract the patient’s 
attention indicates a stage of inflammation when the bacteria have 
penetrated beneath the superficial epithelium, so that medicaments 
applied to the surface fail to reach and kill them. 
The vagina, vulvovaginal glands, and cervix must be protected, if not 
already infected. If infection has taken place in any part of the genital 
tract, appropriate treatment must be carried out at the same time with 
that directed to the urethra. 
In the very acute, florid, and fortunately rare cases of urethritis, with 
exquisite pain and tenderness, no local treatment should be undertaken 
until the aggravated symptoms have subsided; but the protection of 
the vagina and cervix may be attempted in some cases by the insertion, 
twice daily, of a tampon saturated with 2 per cent, protargol and the 
repeated cleansing of the vulva with warm solution 0.5 per cent, pro- 
targol or 1 to 2000 potassium permanganate. Vaginal douches admin- 
istered by the patient herself present an element of danger in the 
introduction of a nozzle which may carry contamination as it enters 
the vagina. The application to the vulva of clean hot compresses, 
frequently renewed, offers the safest palliative measure. 
The patient should remain in bed and an opiate given, if necessary, 
to secure quiet. She should be kept upon a fluid diet, milk chiefly, and 
drink copiously (10 to 15 glasses a day) of water, preferably alkaline 
water. This course is required for two or three days at most, when the 
pain usually subsides. 
In the less aggravated cases the application of clean hot compresses 
is beneficial, while the patient remains in bed for the greater part of the 
day and limits exercise to the minimum. The compresses should be 
available in abundance, and each should be destroyed after once having 
been applied, so that the infectious secretion is removed. A compress 
is removed when cold or soiled, and at each micturition. 
A vaginal tampon soaked in 2 per cent, protargol or other antiseptic 
is to be renewed daily. 
Injection through the urethra (argvrol, protargol, silver nitrate, 
potassium permanganate) into the bladder (with the aid of novocain 
1 per cent, previously if need be) should be used during the active stage 
four or five times in twenty-four hours. Sufficient quantities (5 iv to 
vj) should be used so that the bladder is filled and stimulated to expel 
the fluid again through the urethra in voluntary urination. If silver 
salts (argyrol, protargol, silver nitrate) or potassium permanganate 
(1 to 2000) is used, there is little danger of infection of the bladder by 
this means. 
The use of a catheter or recurrent irrigating tube (Janet) or other 
instrument in the inflamed urethra is contra-indicated. Its trauma is 
more to be feared than that of an antiseptic fluid gently injected, which 
enters the bladder and is expelled again voluntarily. 408 
DISEASES OF THE URETHRA IN THE FEMALE 
Bland, simple diet, consisting largely of milk and laxative food, 
should be taken. Alcohol and condiments must be avoided. The 
bowels should be kept free by some vegetable cathartic. Laxative 
salts and aperient waters often are irritating. 
The treatment of the subsiding stage of the acute gonococcic ure- 
thritis consists in a relaxation of the strictness of diet and quiet, but by 
no means of the local treatment. Antiseptic tampons should still be 
used daily to serve as protection against infection of the cervix. In- 
jections of one of the silver salts per urethram are to be continued 
daily, twice or three times if possible. Copious water drinking should 
continue and condiments and alcohol must be avoided. Exercise 
should be limited. 
The conclusion that a cure has been obtained can only be reached 
when repeated search forthe gonococcus has failed to reveal its presence, 
when no pus is found in the urethral secretion or in voluntarily voided 
urine, when no sign of inflammatory lesion is found in the mucosa 
examined by urethroscope or about the external meatus, and when 
the gonococcus complement-fixation test of the patient’s blood proves 
negative. Not one or several of these factors are adequate for a clean 
bill of health. All must be clear in indication of health before the 
patient is to be regarded as cured. 
It is well to be ultracautious, and conservative, and to give no assur- 
ance of cure until one to three months after an apparent cure, during 
which period examinations of the parts affected and searches for the 
bacterium are to be made at intervals. Unsuspected recrudescence is 
common. 
Complications of Acute Urethritis.—Acute urethritis is in practically 
every case which is due to the gonococcus accompanied by infection of 
the para-urethral glands—Skene’s ducts. 
The treatment of these infected ducts is best carried out after the 
acute urethritis has subsided, and should consist in the effort to destroy 
the duct by cauterization. The injection of antiseptics or weak solu- 
tions of caustics, so generally advised, is usually a prolonged treatment 
and futile as a curative measure. 
The duct can usually be sounded by a fine probe or large hollow 
needle, the point of which has been dulled and rounded. The 
wire electrode for high-frequency spark cauterization or galvano- 
cautery can thus be used to destroy the infected channel, or injec- 
tions of strong silver nitrate solution, 20 per cent, to 50 per cent., 
or of 95 per cent, carbolic acid may be made into the depths of 
the duct through a needle such as used for intramuscular mercurial 
injections. 
Cystitis or inflammation of the trigone or vesical outlet (cervico- 
urethritis) commonly complicates urethritis in the female. Treatment 
of the urethral inflammation disregarding the bladder usually results in 
speedy recovery of the bladder inflammation. 
Topical applications to the trigone and vesical outlet may be neces- 
sary during the subsiding stage. Treatment, however, which consists INFLAMMATIONS OF THE FEMALE URETHRA 
409 
in injections through the urethra into the bladder accomplishes the 
double purpose. 
Suburethral abscess is a complication of acute or chronic urethritis, 
which fortunately rarely follows. This abscess is found below the 
urethra in the urethrovaginal septum by extension from submucous 
glands, which are infected and do not discharge their contents into the 
urethra. The periglandular tissues are infiltrated and inflamed, or 
several minute intraglandular abscesses fuse together to form a gross 
lesion the size of a hazel nut or hickory nut, giving rise to great pain, 
exquisite sensitiveness, and pain and difficulty in voiding urine. 
Suburethral abscess is found beneath the anterior one-third of the 
urethra, in which case the para-urethral ducts are usually the seat of 
origin of infection or the suburethral abscess is found below that part 
of the urethra nearest the bladder (posterior one-third) when the origin 
is in the glands of the mucous membrane of this part. The proximity 
to the internal vesical sphincter gives rise to great pain, constant desire 
to void urine, strangury, etc. 
Suburethral abscesses tend to rupture into the urethral canal rather 
than through the denser tissues of the vesicovaginal septum and the 
vaginal mucosa, which sometimes does take place. 
The treatment of suburethral abscess consists in giving vent to it as 
promptly as possible. This can be accomplished by incising the over- 
lying vaginal wall into the abscess cavity, but the danger of urethro- 
vaginal fistula as a consequence is great and its repair may be trouble- 
some at a later date. This should be the treatment of abscess near the 
external meatus. The writer believes it to be preferable in the case of 
abscess near the bladder (posterior one-third) to give a general anesthetic, 
dilate the urethra to normal limits (30 or 31 Charriere scale) and, if this 
does not result in discharge of the abscess into the urethra, to incise the 
floor of the urethra into the abscess, to give the natural physiological 
drainage without opening the vaginal wrall. The likelihood of fistula 
formation is less and healing has been prompt and uneventful in one or 
two cases so treated. Bleeding may be quite profuse, but is usually con- 
trollable by pressure per vaginam. A retained catheter is usually neces- 
sary for a day or two, and opiates are required to control the pain. 
Chronic Urethritis.—Inflammations of the urethra which persist over 
a long period of time are found in the female as in the male almost 
without exception in and about glands of the mucous membrane or in 
gland-like structures. Chronic urethritis is usually the aftermath of an 
acute inflammation and the persistent lesions are confined to those 
parts in which glandular structures are found, namely, in the proximal 
one-third or the distal one-third of this tube. While in many cases it is 
difficult to demonstrate a purulent exudate in urethral discharge, in 
shreds in the urine or in suppurative foci by means of urethroscopic 
examination, there is always a suppurative process going on in the 
tissue as the basis of this chronic urethritis. When the gonococcus has 
been the original invader, this organism may in many cases persistently 
reside in the depth of gland-like structures and maintain a low grade of 410 
DISEASES OF THE URETHRA IN THE FEMALE 
suppurative inflammation. When the gonococcus is recoverable in the 
urethral exudate the diagnosis of chronic gonococcic urethritis is made. 
When, however, the gonococcus is not demonstrable in the secretion 
obtainable from the urethra while other organisms are present, the 
organism found may be either the original invader or it may be one 
which has replaced the gonococcus in the inflammatory tissue (second- 
ary infection). 
The sequela of chronic inflammation, such as stricture, “ proliferating 
urethritis,” and “fibrous urethritis” (Legueu) have been considered 
elsewhere. 
Infection by the gonococcus is the most frequent cause of chronic 
urethritis, and, while authoritative statistics upon its frequency are not 
available, it is recognized as a common condition. Many cases of 
chronic urethritis are ascribable, with reasonable presumption, to a 
previous transient acute urethritis of gonococcic origin. 
Many cases of chronic urethritis in women, on the other hand, are the 
result of acute infection of the glandular structures of the mucous 
membrane, especially in the juxtavesical portion of the canal produced 
through traumatism during catheterization, during childbirth, and 
through various possible injuries of the urethra, as well as the results of 
those little-understood and often inexplicable cases of urethral lesions 
occurring during epidemics of grippe, and as complications of tonsillitis, 
pharyngitis, nasal and dental lesions. The writer has seen cases of 
urethral inflammation with purulent exudate coincidental with 
suppuration about a tooth which disappeared (were apparently cured) 
when the dental lesion was removed. 
Pathology.—The pathological condition differs from that found in 
acute urethritis in the absence (usually) of inflammation diffused 
throughout the entire mucous membrane of the canal, while the glan- 
dular structures maintain the discrete foci. There may be but one 
gland-like structure involved, as when one of Skene’s ducts presents the 
only focus, or multiple foci may be present, as when many minute lesions 
are found in the upper or lower portion of the canal. These lesions may 
give rise to a visible purulent exudate which is found at the external 
meatus or is readily brought to view by pressure upon the canal in 
such a way as to force it to the meatus. There may, on the other hand, 
be so minute an amount of exudate that none is visible even after 
massage of the urethra, and centrifugalization of the first portion of 
urine passed may reveal only a few scattered leukocytes by microscopic 
examination of the sediment. 
Chronic urethritis is observed in all ages, uncommonly in childhood, 
more frequently in young adults and is most common in those who have 
borne children. It is not uncommon in women of advanced age. 
Symptoms.—The symptoms of chronic urethritis are those so often 
erroneously attributed to “cystitis” and “irritable bladder,” namely, 
discomfort or pain, painful urination at the bladder outlet, abnormally 
frequent desire for urination, rarely urethral discharge, pus and shreds 
in the first portion of urine voided, pyuria and hematuria in some cases. 411 
INFLAMMATIONS OF THE FEMALE URETHRA 
The symptoms of vesical irritability, discomfort at the bladder out- 
let, sense of titillation, pain on retention of urine, frequent or constant 
desire to pass urine, are all sensory disturbances arising in the urethra, 
producing impulses to the reflex centres of micturition. When in- 
hibitory control of this reflex is inefficient to check it, involuntary 
urination takes place. 
If such injury as the traumatism to the urethral structures produced 
in some cases of childbirth has weakened the internal and especially the 
external voluntary sphincter, the irritation caused by the lesions of 
chronic urethritis may start the reflex of micturition, and the damaged 
musculature of the sphincters fails to occlude the canal in spite of 
voluntary efforts, and involuntary micturition takes place. 
Changes in the urine may be noticed by the patient if marked pyuria 
or hematuria is manifest. Marked pyuria may be due to a chronic 
suppurative lesion in the urethra, outside of the bladder, whose exudate 
passes back through the sphincter, clouding the bladder contents. 
Extension of the urethral inflammation through the sphincter to the 
mucosa within the bladder, upon the trigone and about the vesical 
outlet is common but does not always take place. 
All cases presenting the above-mentioned symptoms should be sub- 
jected to critical examination of the urethra. 
Diagnosis.—Palpation of the urethra per vaginam will usually localize 
areas of special tenderness, and rarely small nodular thickenings or 
larger infiltrations can be thus appreciated. Exudate can some- 
times be expressed from the meatus by pressure upon the canal per 
vaginam from the bladder outlet downward to the urethral orifice. 
This exudate is to be examined carefully for morphological elements 
(pus particularly) and by search for bacteria in stained spreads as well 
as culturally. The type of bacterium should always be determined. 
Exposure of the lower 1 cm. of the urethra about the external meatus 
by means of retractors will often reveal the inflammatory swelling, 
redness, and exudate present in this part. 
The orifices of ducts which open upon this mucous membrane, are 
often plainly visible to the naked eye, but more clearly seen with a 
magnifying glass by red areolae surrounding them. 
The lesions inside a narrow meatus and those located farther within 
the urethra are only discoverable through the urethroscope. In fact, 
no case of chronic urethritis can be diagnosticated or efficiently treated 
without the use of the urethroscope. 
By means of the urethroscope areas of soft infiltration, of dense 
induration, as well as the common multiple minute points of swelling, 
redness, and suppuration can be readily recognized and directly treated. 
“Granular urethritis” is the chronic inflammation of the mucous mem- 
brane which resembles granulation tissue and is found in isolated cir- 
cumscribed areas or occupying the whole extent of the canal. The 
gross appearance as seen by the urethroscope is the same in the chronic 
inflammation due to the gonococcus and in that due to pyogenic cocci, 
the colon bacillus or other organisms. The differential diagnosis 412 
DISEASES OF THE URETHRA IN THE FEMALE 
between the inflammations produced by different bacteria is made 
solely by the demonstration of the bacterium present. 
Treatment.—The treatment of chronic urethritis produced by the 
gonococcus and by other organisms is in general the same, and consists 
chiefly in direct topical application to each lesion. This can be done 
satisfactorily only through the urethroscope. 
Gonococcic inflammation because of its infectiousness demands 
special and stringent precautions against transmission to others. When 
chronic gonococcic urethritis is present, all contaminated vulvar pads, 
compresses, clothing, etc., must be destroyed or sterilized and preserved 
from contact with other individuals. Coitus is interdicted and the 
patient, nurses, and others concerned in the case must be instructed 
concerning the dangers of contamination to the eyes and other parts, 
and the strictest cleanliness observed. The dangers of infection of 
children (male as well as female) must be particularly pointed out. 
The patient must sleep alone. 
The direct treatment of the lesions discovered by the urethroscope 
aims to destroy each focus. If the superficial tissue (the mucosa of the 
canal) presents evidence of inflammation, each point should be treated 
by applying silver nitrate solution upon a small swab through the ure- 
throscope. Novocain or cocaine anesthesia may be needed for each 
examination and treatment. The strength of solution of silver nitrate 
applicable varies with each case. Usually it is best to begin with a 
weak solution and observe the result, but the strongest solution up to 
20 per cent, or even to the use of the pure stick silver nitrate fused upon 
a probe should be employed when possible. The high-frequency spark 
after cocainization is in some cases very effective especially when 
hypertrophic tissue is found. 
The result of any treatment of the urethra is in some cases surpris- 
ingly painful after the effect of the local anesthetic has been lost, so that 
the direction should be that the patient keep as quiet as possible (in 
bed) for three to six hours after the treatment, and resort to hot sitz 
baths, hot douches and hot applications, hot-water bag, compresses, 
etc., as needed. Morphin is required in some cases. 
Lesions which lie beneath the surface epithelium must be exposed for 
treatment and for free drainage or destroyed by the high-frequency 
spark. Localized indurated areas which harbor a chronic inflammatory 
focus should be incised with a knife, or scissors of special form, through 
the urethroscope or laid open by the electric cautery knife or actual 
cautery. 
Para-urethral ducts which persistently harbor infection are treated by 
passing a small hollow needle through the extent of the duct and injecting 
slowly a drop or two of 95 per cent, carbolic acid or 20 per cent, silver 
nitrate, or by passing the wire electrode and destroying the duct by 
cautery or high-frequency current. These means of treatment of 
chronic infection of para-urethral ducts are often adequate, but some 
cases are more promptly cured by incising the canal upon a fine grooved 
director, to lay it open upon the vaginal wall for evacuation of its con- INFLAMMATIONS OF THE FEMALE URETHRA 
413 
tents and direct treatment of the tissue involved. Suburethral abscess 
is rarely the lesion maintaining a chronic urethritis. 
Chronic urethritis is by these means curable. The treatment may 
demand application to the diseased area once in ten days for a long 
period (one to six months). Four to six treatments are almost always 
required before the patient experiences decided relief from the distress- 
ing subjective symptoms, and still more treatments are usually needed 
to restore the pathological areas to normal appearance. 
An area of urethral mucous membrane (glandular structures) which 
has once harbored a chronic inflammation remains a part of lowered 
resistance, so that a recurrence (reinfection) is common. Each recur- 
rence requires repetition of treatment, but recurrences recognized and 
treated at their inception are usually readily controlled. Cases of 
chronic urethritis complicated by incontinence of urine are common. 
The cure of the inflammatory lesion often results in complete restora- 
tion of urinary control. When the incontinence is due to damaged 
tissue of the sphincters or to laxity of the urethral tissues produced by 
urethrocele, cystocele, or prolapse of the uterus, bladder and urethro- 
vaginal tissues, operative restoration to normal conditions must be 
sought. 
Nervous diseases which affect the bladder and its sphincters must 
always be sought for in every case presenting symptoms of chronic 
urethritis, incontinence or retention of urine, or pain referred to the 
urethra. 
No case presenting typical signs and symptoms of chronic urethritis 
shoidd escape examination for those vesical, pelvic and nervous condi- 
tions which produce similar symptoms and signs. 
BIBLIOGRAPHY. 
1. Kalisher: Urogenit. Musculatur des Dammes. 
2. Luciani’s Human Physiology, ii, 461. 
3. Neuberger: Berliner klin. Wchnschr., 1894, No. 20. 
4. Nove-Josserand and Cotte: Revue de Gynecol, et Chir., 1907, xi, 963. 
5. Schafer: Microscopic Anatomy, Quain. 
6. Stockel: Veit’s Handbuch der Gynecol., ii, 287. 
7. Virchow: Archiv fur path. Anat., 1853, v, 403. CHAPTER X. 
STRICTURE OF THE URETHRA. 
By EDWARD L. KEYES, M.D. 
URETHRAL STRICTURE. 
Stricture of the urethra is an abnormal constriction or loss of dis- 
tensibility of that channel. 
Stricture occurs in the female as well as in the male urethra. In 
either sex it may be classed as congenital, inflammatory, and traumatic. 
Further subclassification may be made as follows: 
Congenital. 
Traumatic. 
Inflammatory. 
Gonorrheal. 
Tuberculous. 
All others. 
Stricture of the male urethra 
Stricture of the female urethra 
It is important to specify how much narrowing or loss of distensi- 
bility of the urethra constitutes stricture, for whether the lesion be 
congenital or acquired, it merits the name of stricture only after it has 
reached a point of contraction at which it is inevitable either that 
symptoms result or that further contraction ensue. But the size varies 
with different types of stricture as well as for different urethra?. It is 
equally impossible to specify the precise size to which a stricture must 
be dilated in order that its tendency to recontraction may be controlled. 
Thus a congenital stricture no larger than 20 F. is likely to give no 
symptoms unless its possessor acquire a gonorrhea, which cannot be 
cured until the stricture is cut. 
On the other hand, any traumatic scar surrounding the urethra will 
soon contract sufficiently to cause symptoms to be clinically a 
stricture. 
For gonorrheal stricture, Oberlaender recognizes “ hard infiltrations” 
of various degrees (p. 301), a urethroscopic tube of 23 F. size being the 
criterion. Infiltrations of the first degree do not perceptibly impede 
the passage of the urethroscope and are not lacerated by it. Infiltra- 
tions of the second degree admit the instrument but are abraded by it. 
Those of the third degree do not admit the urethroscopic tube. We 
may accept this classification and recognize that infiltrations of the 
first degree only remotely and rarely form the basis of stricture, while 
those of the second and third degree may be spoken of as true strictures. 
414 STRICTURE OF THE URETHRA 
415 
It is to be remembered, however, that the sound or bougie commonly 
employed for the diagnosis of stricture engages in a stricture far more 
gently than the sharp-edged urethroscope. Hence, the sound to be 
used should be several sizes larger, viz., about 26 F. 
This distinction between an infiltration of large caliber and one of 
small caliber is not an artificial one, for the gonorrheal scar that does 
not offer any impediment to the passage of a 23 F. urethroscope, or 
26 F. sound, is so slight a scar and impedes the outflow of urine so 
little that the congestion upon its surface is likely to remain slight; and 
even though untreated, it may probably (and in some cases certainly) 
cause no stricture, no real constriction of the urethra, even after many 
years. 
Moreover, the diagnosis or treatment of these infiltrations of the 
first degree is rather that of the urethritis which they maintain than of 
the scar itself. They are diagnosed by the urethroscope and the 
bulbous bougie, while the true or tighter strictures may be better 
diagnosed by the sound. They are treated largely for the purpose of 
curing the urethritis upon them and behind them, with the assurance 
that if this urethritis is thoroughly cured the infiltration of the first 
degree will show no further tendency to contract and the urethritis no 
more than a very remote tendency to relapse. 
Thus we may dismiss the whole subject of infiltration of the first 
degree to the topic of chronic anterior urethritis, where it properly 
belongs. With it we dismiss the theory of strictures of large caliber, 
promulgated fifty years ago by Otis, and which for a quarter of a 
century dominated the treatment of chronic urethritis in this country. 
Otis’s claim that the urethra is an evenly calibrated tube, bearing a 
certain relation to the size of the penis, is too fantastical and medieval 
even to require discussion at this day. His routine practice of cutting 
the urethra to such size as 40 and 45 F. cannot be too thoroughly con- 
demned as a routine, for the knife should, as far as possible, be replaced 
by the dilator, and the object of treatment of infiltration of the first 
degree should be, not the dilatation of the urethra to a theoretical 
limit, but the cure of chronic urethritis, by whatever dilatation is 
necessary to that end. In exceptional cases internal urethrotomy 
is required for the treatment of chronic urethritis just as much today 
as it ever was. 
Statistics.—Our knowledge of the pathology of urethral stricture is 
founded upon the researches of Sir Henry Thompson on stricture itself, 
and those of Oberlaender, in A'ienna, and of Wassermann and Halle, in 
Paris, on chronic urethritis and the inflammatory process which leaves 
the scar we call stricture. Upon this basis of pathological fact we shall 
found our clinical observations. 
These relate to 583 cases of gonorrheal stricture, 55 cases of traumatic 
stricture, a large number of congenital strictures, almost all at the 
meatus, and a few due to tuberculosis, syphilis, and other causes. The 
mere number of these cases might be equalled in the case books of any 
urologist, but their interest arises from the fact that almost all of them 416 
STRICTURE OF THE URETHRA 
were private patients* whose condition was noted with care for a 
considerable number of years. Of no less than 120 we have records 
extending over ten years or more, while of one-half of these (62 to be 
accurate) the records extend for twenty years or more. Thus we are 
able to estimate the progress of this disease and the result of its treat- 
ment rather more accurately than has been heretofore done. 
GONORRHEAL STRICTURE OF THE MALE URETHRA. 
Gonorrheal stricture of the urethra is a scar in the wall of the canal 
produced by gonorrheal inflammation of its glands—a scar of sufficient 
extent to grasp a 26 F. sound. 
Etiology.—The cause of gonorrheal stricture is not simply gonorrhea. 
Indeed, stricture very rarely follows a well-treated gonorrhea. The 
relative frequency of stricture in the clinic as compared to private 
practice is evidence that neglect and the trauma of unskilful local 
treatment play a large part in its etiology. 
Thus sometimes the brutal breaking of a chordee, or the clumsy 
passage of a sound actually tears the mucosa and produces a stricture 
that is more traumatic than gonorrheal. Yet, as a rule, the trauma is 
only a subsidiary cause. The careless instrumentation or overfrequent 
injection merely intensifies, instead of lessening, the infection, inflames 
the urethral glands more severely, increases-the periglandular exudate, 
and thus produces more scar, more stricture. 
Stricture is due rather to intensity than to duration of urethritis. To 
be sure, Wassermann and Hallef long ago proved chronic anterior 
urethritis a sclerotic process; but their inference that stricture is due 
to chronic urethritis is not justified, for the extent of the sclerosis in 
chronic urethritis is determined, not by the duration of chronic inflam- 
mation—ancient anterior urethritis without stricture is a commonplace 
observation—but by the acute outbreaks that precede or interrupt it. 
Stricture and chronic urethritis have a common cause. They do not 
cause each other; though stricture keeps up the inflammation, while 
this in turn adds to the scar. 
Pathology.—Gonorrheal stricture is but a cicatrization of the patho- 
logical process that causes chronic anterior urethritis. The pathology 
of stricture begins, as it were, where that of the active inflammation 
leaves off. Gonorrheal anterior urethritis becomes chronic through 
continued suppuration in the glands of the urethra. The glands con- 
tinue to suppurate because of bad drainage, their ducts being obstructed 
by the inflammatory exudate in the urethral wall. This inflammatory 
periadenitis varies in extent and intensity; sometimes a mere swelling 
of the mucosa itself, sometimes extending with the glands, and beyond 
* From our hospital records we have borrowed only the operative statistics of perineal 
section. 
t We assume the reader’s familiarity with the phenomena of chronic urethritis, 
described in Chapter VIII. GONORRHEAL STRICTURE OF THE MALE URETHRA 
417 
the glands, into the surrounding corpus spongiosum, and even beyond 
this into the subcutaneous tissue. These processes have been described 
in reference to gonorrhea. Suffice it to state that the mildest of 
them results in superficial scarring of the mucosa, which at most can 
only cause a slight contraction of the urethra. The more extensive 
and intensive processes result in grave stricture, peri-urethral abscess, 
fistula, etc. 
With the cicatrization of this peri-urethral exudate a scar is formed in 
the urethral wall. This contains a large proportion of elastic fibers. 
It tends to contract. It diminishes the lumen of the urethra. At first 
the actual encroachment upon the urethral lumen is slight, but the 
physiological impairment is great. The outflow of the urinary stream 
meets an obstacle in this rigid portion of the urethral wall, an obstacle 
that continues to harbor gonococci or other bacteria in its inflamed 
glands, and whose surface is eroded or idcerated. Repeated impact of 
the urinary stream against this tends to dilate the urethra behind it 
and to intensify the chronic urethritis about it. As a result, more peri- 
glandular exudate is formed, more scar results, the urethral lumen is 
still further narrowed, while the chronic urethritis is encouraged. The 
complications of anterior urethritis, viz., peri-urethritis and peri- 
urethral phlegmon, abscess, and fistula, are common results of neglected 
stricture. 
Urinary sepsis due to retention and infection of the upper urinary 
tract results from stricture, just as it does from prostatism (q. v.); but 
inasmuch as the patient with stricture is usually several decades younger 
than the possessor of an enlarged prostate, his younger and stronger 
muscles tell in his favor. His bladder is more likely to become hyper- 
trophied (sclerosis with thickening of the wall, but without dilatation 
of the cavity) than atrophied. If relieved of his stricture, even after 
his kidneys have suffered grave damage, his expectation of life may be 
considerable. 
Postmortem examination of urethral stricture may only reveal a 
transverse scar in the mucosa so slight that it can be felt rather than 
seen when the urethra is split open. The surface of the mucosa may look 
normal; it may be eroded, granulating, pouched from back pressure, or, 
in the more extreme cases, utterly distorted by irregular masses of scar 
and areas of suppuration. 
Location of Stricture. — In the preceding paragraphs gonorrheal 
stricture has been described as though it affected the anterior urethra 
exclusively. Such is not the case. Gonorrheal stricture of the mem- 
branous urethra has been observed, and one occasionally operates upon 
a urethra strictured not only from meatus to bulb but also throughout 
the posterior urethra. 
Gonorrheal stricture of the posterior urethra does not, however, con- 
cern us here. Its one important clinical expression, viz., stricture at 
the neck of the bladder, gives the symptoms of, and is therefore dealt 
with in connection with, prostatism. Stricture of the remainder of the 
membranous and prostatic urethrae is never seen alone; it is but a 418 
STRICTURE OF THE URETHRA 
complication of graver stricture in the bulb.* With the exception of 
stricture at the neck of the bladder, gonorrheal strictures of the posterior 
urethra may therefore be dismissed with the statement that they add 
nothing to the clinical picture or to the treatment of gonorrhea of the 
anterior urethra. They appear indeed to be singularly amenable to 
dilatation. 
In the anterior urethra, gonorrheal stricture is coterminous with 
gonorrheal urethritis, with the urethra itself. An utterly neglected case 
thus sometimes presents irregular bands of stricture at short intervals 
from one end of the urethra to the other. But such cases are rare. The 
symptoms of neglected stricture usually cry for relief long before so 
extensive a process can develop. 
In the majority of cases strictures are pathologically single, though 
they may be clinically multiple, i. e., there is but a single scar affecting 
a greater or less extent of the urethra, upon the surface of which there 
may be one or more ridges presenting points of obstruction to the 
examining instrument. Hence the clinician notes the frequency of 
multiple strictures while the pathologist asserts their rarity in that 
very class of (postmortem) cases in which their multiplicity should be 
most apparent. Thus Thompson13 found only 41 cases of multiple 
stricture among 270 museum specimens. Only 8 of these extended 
throughout the urethra. 
Thompson10 suggests the following division of the urethra for the 
classification of gonorrheal strictures: 
1. “The bulbomembranous, from one inch in front of to three- 
quarters of an inch behind the junction of the spongy with the mem- 
branous urethra. This region contains the majority of strictures; 
they lie rather in front of than behind the junction of the bulb with the 
membranous urethra. 
2. “From the anterior limit of region 1 to within 2\ inches of the 
meatus.” 
3. “The terminal 2| inches of the canal.” 
Thompson found 215 (67 per cent.) strictures in region I, 51 (16 
per cent.) in region II, 54 in region III. Among 564 of our cases 345 
(61 per cent.) were in region I. 
The Form of Stricture.—It is convenient to speak of linear, annular, or 
tortuous strictures. These terms correspond to clinical characteristics. 
Two more important points in reference to the form of stricture 
must be borne in mind: In the first place the scar of stricture of the 
penile urethra is built up chiefly from the floor of the urethra. Its 
orifice is, therefore, eccentrically placed and usually near the roof 
of the canal. But quite the opposite is often the case in the bulbous 
urethra. 
In the second place, irregular, multiple strictures usually become 
progressively narrower as they approach the bulb. Even though the 
stricture extends over only a short portion of the urethra, its tightest 
* Thompson states that while stricture is most common in the bulb, “the liability 
of this part to stricture appears to diminish as it approaches the (bulbomembranous) 
junction, where it is less common, while behind it is very rare.” GONORRHEAL STRICTURE OF THE MALE URETHRA 
419 
point is likely to be the deepest; while if its extent is considerable, 
examining instruments impact upon tighter and tighter bands until the 
tightest point of all is found in the deeper portion of the bulb. Thus the 
minimum size noted by us in 459 cases is shown in the subjoined table: 
In regions II and III. 
In region I. 
Impassible . 
3 
35 
Filiform to 
9 
F. . . . 
21 
131 
10 to 
19 
F. . . . 
68 
88 
20 to 
26 
F. . . . 
62 
51 
154 
305 
Hence, of the anterior strictures, less than 16 per cent, contracted 
below 10 F., while of the perineal strictures, 54 per cent, did so. An- 
terior strictures contract to a far less degree than perineal strictures. 
We note, however, that when the anterior structures do contract 
below 10 F. the bulb of the urethra is likely to be free from tight 
stricture. An impassible or filiform stricture at or about the peno- 
scrotal angle implies an open canal beyond. 
Symptoms.—The symptoms of urethral stricture, like those of pros- 
tatic retention, may bear little relation to the gross pathological con- 
dition. Thus a patient complaining only of a chronic urethral dis- 
charge may be found to suffer from an extensive and very tight stricture; 
while another who suffers from acute complete retention of urine may 
have but a single narrow band that obstructs the urethra rather by 
congestion than by actual contraction of scar. Furthermore, the most 
treacherous stricture cases resemble those cases of prostatism of which 
the local symptoms are few, but whose general debility, resulting from 
mild chronic urinary septicemia, may bring them to a state of 
incurable renal deficiency before they even consult a physician. 
Onset.—The accompanying table compiled from our cases and those 
of Sir Henry Thompson shows that the symptoms of stricture usually 
begin within one year of the gonorrhea causing it. Exceptionally, and 
doubtless through neglect on the part of the patient to be thoroughly 
treated for a chronic urethritis, the slight scar resulting from this may, 
after many years, result in true stricture. 
Keyes. 
Thompson. 
Total. 
Per cent. 
Within 1 year 
. . . . 121 
81 
202 
54 
1 to 5 years . 
.... 38 
41 
79 
21 
G to 10 “ ... 
. ... 27 
22 
49 
13 
11 to 15 “ ... 
.... 7 
20 
27 
7 
16 to 20 “ ... 
.... 8 
0 
8l 
21 to 30 “ . . 
. . . . 9 
0 
9 f 
5 
Over 30 “ ... 
. . . . 2 
0 
2J 
212 
164 
376 
It will be noted that Thompson’s cases, founded upon pathological 
observation, average a much earlier onset than ours, founded upon 
clinical data. Doubtless his figures are the more correct. 
The Initial Symptom.—We have tabulated the initial symptom of 
422 cases with the following result: 420 
STRICTURE OF THE URETHRA 
Chronic urethral discharge 238 
Obstruction to urination . 77 
Frequency of urination 53 
Acute complete retention of urine 31 
Pain 8 
Peri-urethritis . • 7 
Hemorrhage 3 
Overflow from retention 2 
Persistent chordee 2 
Epididymitis (symptoms of) 2 
Pyonephrosis (symptoms of) 1 
This list will bear various interpretations. It suggests among other 
things that some patients are far more alert to observe their symptoms 
than others; that the symptoms of catarrh usually antedate those of 
obstruction; that the obstruction may come on so gradually as not to 
fix the patient’s attention until it has become complete or until the 
hemorrhage from an ulcer, or the pain and fever from a secondary 
infection of kidney or epididymis, clamor for relief. 
Chronic Urethral Discharge.—The chronic urethral discharge of 
stricture (commonly called gleet) is usually little more than a drop of 
pus at the meatus in the morning. By the time definite stricture 
develops, gonococci are likely to have disappeared and been replaced 
by other bacteria. The urine passed always contains shreds, and these 
are usually of considerable size. These shreds are derived from the 
inflamed or ulcerated surface of the stricture and the adjacent portions 
of the urethra. 
The presence of free pus enough to cloud the urine depends upon a 
superadded urethritis, prostatitis, or infection of the upper urinary 
tract. It should be borne in mind that large shreds are suggestive 
of stricture, while free pus in the urine is to be referred to the inflamma- 
tion accompanying stricture. 
Frequent and Obstructed Urination.—As the stricture grows tighter 
the act of micturition requires more effort and the last drops of urine 
dribble away. Chronic urethritis is kept up and this inflammation 
extends to the prostate. The resulting irritation and infection of the 
prostate, bladder, and kidneys cause f requent and painful urination. 
These symptoms are by no means pathognomonic of stricture. Indeed, 
the dysuria due to infection may quite overshadow the sense of 
obstruction due to stricture. 
Changes in the shape or the force of the urinary stream may be due to 
so many conditions other than stricture that they deserve no special 
notice. The split or deflected stream is usually due to a drop of mucus 
in a tight meatus. The shape of any stream is imparted to it by the 
nozzle from which it flows. 
Acute Retention—Acute complete retention of urine (sudden com- 
plete—or almost complete—occlusion of the urethra) is due to the 
sudden congestion of a canal already partially obstructed by stricture. 
This congestion is similar to the like condition complicating prostatic 
retention, and is attributable to like causes, e. g., voluntary retention of 
urine, alcoholism, exposure to cold, etc. Though the stricture is usually GONORRHEAL STRICTURE OF THE MALE URETHRA 
421 
very tight, I have seen cases of acute complete retention of urine due to 
stricture that readily admitted a 20 F. sound. Moreover, it is a 
commonplace observation that the patient whose stricture is so tight 
that no instrument can be passed through it may yet retain his 
ability to urinate, refuse further treatment, and go several months or 
years before acute retention occurs. 
The retention due to stricture differs in one most important particu- 
lar from that due to prostatism. Either condition may cause acute 
complete retention, but partial retention is not caused by urethral 
stricture unless that stricture is complicated by some form of prostatic 
retention, such as prostatic abscess or stricture at the neck of the 
bladder. Hence, the kidneys of a patient with stricture defy neglect in 
spite of repeated attacks of acute complete retention for a much longer 
time than those of the victim of prostatic retention. For the strictured 
urethra, if it permits the bladder to empty at all, permits it to empty 
completely. A large proportion, perhaps a majority, of attacks of acute 
retention with stricture are relieved almost spontaneously. The 
patient at first vainly struggles to urinate. If inexperienced, he 
promptly becomes panic-stricken and increases his agony by struggling 
to overcome what is for the moment an insurmountable obstacle. The 
torturing spasms recur every few moments until a physician brings 
relief, or the spasm relaxes and a dribbling, hesitating stream gradually 
relieves the retention. (The third possible alternative, viz., death by 
exhaustion or rupture of the bladder, I have never seen.) 
The experienced victim, on the other hand, recognizes the thin stream 
that foretells retention and takes his precautions accordingly. He re- 
strains his efforts to urinate, lies down, takes a hot hip-bath, and so often 
wards off the attack. Yet these palliatives sometimes fail, and he, too, 
has to summon professional aid. 
The recurrence of acute retention depends more on the accident of con- 
gestion than on the tightness of the stricture. Most patients who have 
had complete retention may look for repeated relapses at intervals of 
a few weeks or months unless they submit to dilatation. But excep- 
tionally they escape for an extraordinary length of time. Thus, I have 
records of one patient who had but three acute retentions in eight years, 
though never dilated. Another had a single retention (undilated) ten 
years before he came for treatment. A third, discouraged by the failure 
of any instrument to pass his stricture, consulted no physician and had 
no retention for fifteen years thereafter. But such reprieves are neither 
to be expected nor to be desired. During these years the destructive 
effects of renal retention and infection progress silently but steadily. 
Ileviorrhage.—Apart from the bleeding excited by instrumentation, 
or resulting from acute prostatitis, hemorrhage is a rare symptom of 
stricture. It is likely to occur early, to be quite profuse, to assume the 
form of urethrorrhagia (hemorrhage between the acts of urination), 
with more or less hematuria. The bleeding during urination is likely 
to be terminal (most marked toward the end of the act). This bleed- 
ing, like that of fissure in ano, is due to ulceration, and is promptly 422 
STRICTURE OF THE URETHRA 
and brilliantly controlled by dilatation. The passage of a single 
sound may promptly control profuse hemorrhage. Such hemorrhage 
was noted three times as the initial symptom, and in four other of 
our cases as a striking symptom. 
Sexual Symptoms.—The sexual deficiency, the impotence, the neu- 
rasthenia, and the various pains radiating from the prostate and 
seminal vesicles, that were attributed by a preceding generation to 
urethral stricture, are much more commonly seen in patients who 
have no stricture whatever, and are themselves rarely directly refer- 
able to stricture. Tight stricture does, indeed, often cause inflam- 
mation of the coliculus, the prostate, or the vesicles such as will 
interfere with their function; but sexual symptoms are due to sexual 
causes. They are not relievable by dilatation of the stricture. 
Pain.—Various types of pain result from stricture: Painful urination 
has been alluded to. Painful erection amounts practically to chordee 
in some cases of extensive stricture in the region of the penoscrotal 
angle if accompanied by considerable inflammation. Perineal and 
other pains are due to the accompanying or resulting inflammations of 
the internal sexual organs. 
Complications of Stricture. — Prostatitis and Vesiculitis. — These 
complications are so common as to be almost part of the usual clinical 
picture of the disease. 
Renal Retention and Infection.—We have already insisted that the 
silent progress of renal infection, sclerosis and dilatation, is the most 
insidious and dangerous complication of stricture. It is the cause of 
urethral chill and urinary septicemia (whether or not excited by the 
passage of instruments), and of almost all the deaths resulting from the 
stricture itself or from its treatment. Unnumbered lives are shortened 
through reduction of renal efficiency. Even though the stricture itself 
be properly controlled, the resulting renal lesion permanently impairs 
the resistance of its host to such hardships, accidents and maladies as 
he may encounter. 
No statistics can convey the precise importance of these secondary 
renal lesions. The least we can do is to be always on the alert, to 
include them in our diagnosis, and to make allowance for them in our 
treatment. 
Peri-urethritis and Prostatic Abscess.—Peri-urethral phlegmon and 
suppuration either at the site of stricture, or arising from the prostate 
or Cowper’s glands, was noted in 52 of our cases. The course and 
treatment of these complications do not materially differ from those 
described as complications of gonorrheal urethritis (p. 329). 
Epididymitis.—Infection of the epididymis, as a result of urethral 
stricture, is usually the work of the bacillus coli or of the pyogenic cocci. 
Hence it is much more likely to suppurate than is gonorrheal epididy- 
mitis. Although this complication discourages urethral instrumenta- 
tion, it may nevertheless be imperative to relieve a tight stricture, even 
in the presence of an acutely inflamed epididymis. Under such con- 
ditions the complication may sometimes prove an argument whereby GONORRHEAL STRICTURE OF THE MALE URETHRA 
423 
the surgeon may persuade the patient to submit to perineal section 
together with drainage of the epididymis. 
Other Complications.—Among the rarer complications noted in our 
cases, we may mention 2 cases of prostatic stone, 3 of bladder stone, and 
2 of stone in the kidney. Rheumatism wTas only once noted. One 
would fancy its actual frequency much greater than this. 
Complications Dae to Treatment.—Among the most important com- 
plications of urethral stricture are those resulting from improper treat- 
ment. Too great brutality in passing instruments may result in added 
scar, urethral chill, urinary septicemia, epididymitis, peri-urethritis, 
prostatic abscess. Failure to enter the stricture may result in false 
passage and peri-urethritis. Enthusiastic internal urethrotomy may 
result in permanent incurvation of the penis, of which 5 cases appear 
upon our list. 
Course and Prognosis.—Inasmuch as the clinical picture of gonorrheal 
urethral stricture is a composite of scar and inflammation, more or less 
controllable by treatment and subject to the vicissitudes of intercurrent 
gonorrheasand other sources of irritation, it is obviously quite impossible 
to compose a picture that shall adequately represent the usual course 
of this disease. Slight chronic urethral discharge may be for many 
years the only symptom, while this may be absent altogether, and 
only the large shreds in the urine suggest the presence of stricture. 
Retentions may be frequent and rapidly recurrent. Yet exceptionally 
a single retention, relieved without any real treatment of the stricture, 
may be followed by an interval of years before retention recurs. Per- 
haps the interval between the appearance of symptoms suggesting 
stricture and the beginning of treatment, will hint, as well as figures 
can, how various is the progress of this malady. 
We have tabulated the time at which treatment was begun in 285 
cases. 
Cases. 
Per cent. 
Within six months 
. . . . 68 \ 
32 
From six to twelve months ..... 
. . . . 22 / 
During second year 
. . . . 27 \ 
36 
“ third to fifth year 
. . . . 77 / 
“ sixth to tenth year 
. . . . 39 
14 
“ eleventh to twentieth year . 
. . . . 39 
14 
Beyond twentieth year 
. . . . 13 
4 
Yet in all this uncertainty there is some regularity of prospect which 
may be sketched as follows: 
The progress of stricture is measured by the promptness and inten- 
sity of its onset on the one hand, opposed by the efficiency of treatment 
on the other. Thus a stricture that has for its only symptom a mild 
gleet, or that begins many years after the last gonorrhea, is likely to be 
a slight scar, to contract slowly and may perhaps be neglected with 
impunity for a considerable period. On the other hand, a stricture that 
begins early and with symptoms of obstruction or retention is likely to 
be a dense scar and to progress rapidly. 
Furthermore, acute retention of urine, whether relieved by dilatation 
or not, usually recurs within a year, if the stricture is neglected. 424 
STRICTURE OF THE URETHRA 
Strictures of the pendulous urethra contract more slowly, and even 
when neglected to a less degree than those in the bulb. Yet (as we 
shall see) strictures of the bulb are far more amenable to dilatation 
than those of the anterior urethra. 
Although in the absence of intercurrent gonorrhea acute prostatic 
or renal suppuration are rarely seen before the stricture has become 
very tight, peri-urethral phlegmon and suppuration may result from 
a stricture of relatively large calibre. 
Cure.—Stricture is part infiltrate, part scar. Inasmuch as it is 
scar it cannot be cured. But its contraction may be prevented and 
even overcome by resolution of the infiltrate under the massage of 
dilatation. But one cannot dilate scar. When the scar of stricture 
is the cause of constriction (as it is much more commonly in the 
narrow pendulous urethra than in the wider bulb), no dilator or 
sound will even dilate it. The most they can do to scar is to tear 
it. To open the scar one must cut it, then dilate, and thus splice 
the ring with new scar 
It is impossible to assure any patient with absolute certainty that 
his stricture will never recontract. But in this matter the distinc- 
tion between stricture of the bulb (Thompson’s region III) on the 
one hand and stricture of the pendulous and scrotal urethra (Thomp- 
son’s regions I and II) on the other is striking. 
The deeper strictures, though they can often be readily dilated, 
show an almost universal tendency to recontract. A fully dilated 
stricture is likely to recontract to the point of giving retention in 
from one to five years. Exceptionally the recontraction is slow, so 
that even ten to fifteen years later a small sound can still be passed, 
while most exceptionally the stricture does not Yecontract at all. 
At least I have followed several cases for more than ten years that 
showed no evidence of recontraction.4 
Stricture of the bulbous and scrotal urethra, on the other hand, if it 
has once formed a dense scar, is very rebellious to dilatation; but when 
cut to no larger size than 34 F. may usually be kept widely dilated by 
the passage of sounds, and if this treatment is continued until the 
cut has healed and the adjacent urethritis is cured, no further recon- 
traction of such a stricture need be feared. It is not to be forgotten, 
however, that such strictures are often accompanied by stricture of the 
bulbous urethra. This shows the usual tendency to recontract. 
Diagnosis.—The diagnosis of urethral stricture must include the 
diagnosis of chronic anterior urethritis and of such complications as 
peri-urethritis, prostatic abscess, renal infection and retention, etc., 
since the presence of these materially influence the prognosis and 
treatment. 
Moreover, the diagnosis of stricture itself contains an element of 
prognosis; for one must determine not only whether actual stricture 
exists, but whether stricture is likely to occur, or, if previously existing 
and under control, to recur. 
History and urinalysis are of value in the correlation of diagnosis. GONORRHEAL STRICTURE OF THE MALE URETHRA 
425 
But for a precise diagnosis we depend upon the examination of the 
patient. 
Asepsis and Anesthesia.—The diagnosis of stricture is made by the 
introduction of instruments into an inflamed canal. Among the most 
important results of stricture are renal retention and infection. The 
capacity of infected kidneys to withstand shock may be gravely 
impaired, though the patient may appear in smiling health. Such 
cases are in the same state of unstable renal balance as are the pro- 
statics. The passage of sounds is peculiarly qualified to excite an 
acute suppurating nephritis. Therefore the precautions elsewhere 
laid down for urethral asepsis and antisepsis must be most minutely 
observed. Instruments must be passed with the greatest gentleness, 
and it is actually a measure of precaution to precede the passage of 
urethral instruments by an injection into the urethra of 1 per cent, 
novocaine solution, to be retained at least fifteen minutes before the 
instruments are introduced. This is grateful to the patient, for it 
diminishes his pains, though this should not be taken advantage of 
by the surgeon. He should be more than gentle. 
The Urethroscope.—The urethroscope which is so useful for the pre- 
cise diagnosis of chronic anterior urethritis may also be employed for 
the diagnosis of stricture of large calibre. The straight open-end tube 
should be used. If the stricture is large enough to admit the tube, 
the urethral wall is seen to be rigid in that it does not fall together 
into the usual radiating folds. Indeed, the scar, if dense, holds the 
urethra relatively open on the end of the urethroscope. The surface 
of the mucous membrane is usually inflamed, eroded and even ulcer- 
ated, most markedly at the point of stricture and to a less degree 
both before and behind this. If the surface inflammation is under 
control, however, the mucosa looks shiny, whiter than normal and 
quite bereft of its usual folds. 
The tight stricture which will not admit the urethroscopic tube 
usually bleeds so freely that the examination is of little value. 
The Olivary Bougie.—This is the favorite instrument for the diag- 
nosis of stricture. With a complete set of bougies (from 6 to 26 F.) 
one may diagnose with accuracy the size of the various constrictions 
in the anterior urethra. Filiform strictures elude precise diagnosis by 
the bulbous bougie, but all other constrictions are perceptible as bands 
through which the bulb of appropriate size slips with a jump. 
The urethrometer of Otis theoretically gives the most accurate 
picture of urethral constrictions. I have never employed it. 
Sounds and Bougies.—The urethroscope gives a picture of the surface 
lesions of the canal. The bulbous bougie gives precise information as 
to the tightness of each stricture band. The sound and the bougie do 
not give such precise information, but they do tell us that stricture does 
or does not exist. They inform us as to its approximate diameter and 
dilatability. 
The sound elicits the essential diagnostic sign of stricture, viz., 
grasping. 426 
STRICTURE OF THE URETHRA 
We begin our examination by passing a 26 F. bulbous bougie. 
(Stricture of the meatus should be cut (p. 433).) This is gently intro- 
duced until it meets an obstacle. If a stricture of large calibre, this 
obstacle is passed with a jump, while the patient announces a cor- 
responding pain. If a tighter band is encountered farther down the 
bulb cannot be pushed by this, but must be withdrawn—with a hitch 
over the large structure—and replaced by a smaller one. Thus, we 
calibrate strictures as far as the bulb. But the bulbous bougie may 
fail to engage in the bulbomembranous junction of the most normal 
urethra. Strictures at this point must, therefore, usually be cali- 
brated by sounds. 
If it engages in a stricture, the sound passes onward with a distinct 
sense of resistance, while the patient complains of more or less pain. 
The maneuver at this juncture must be extremely gentle. If the 
stricture is in the bulb, the unwary operator may be misled by the 
fact that he can depress the handle of the sound into the belief that 
its point is progressing toward the bladder. To avoid this error let 
him watch closely the disappearance of the shaft within the meatus. 
The progress of the point of the sound is measured by the disappear- 
ance of its shaft. 
But if the sound, thus gently introduced, progresses with no undue 
resistance into the bladder, the true stricture (as distinguished from 
purely inflammatory or spasmodic obstruction) grasps the instrument 
and resists its withdrawal. Any sound that will thus gently enter 
the unstrictured urethra will, if properly directed, fall out again by 
its own weight. But true stricture grasps the sound, which can only 
be withdrawn by force. Indeed, the effort to withdraw the instru- 
ment may be greater than that required to introduce it. This grasp- 
ing of metal instruments is pathognomonic of stricture. Woven 
bougies are sometimes, rubber catheters often, grasped by spasm of 
the cut-off muscle in the unstrictured urethra. 
If the sound fails to engage, smaller instruments are successively 
introduced until one enters the stricture. At or below 20 F. it is 
safer to employ woven bougies rather than metal instruments, and 
with these to continue, if necessary, until a number 10 F. fails to 
pass. Then we know that either the stricture is so small it will only 
admit a filiform bougie (a so-called filiform stricture), or else there is 
no stricture at all. For no final diagnosis of stricture can be made until 
an instrument shall have passed through and been grasped by the scar. 
Suggestions of the presence of stricture other than this are indeed 
many. The patient’s history or other physical signs may point to 
stricture. The sounds which fail to pass may be interrupted before 
their points have settled well into the bulbous portion of the urethra. 
The most gentle manipulation may produce profuse bleeding. Such 
signs point to stricture; but they do not infallibly prove its existence. 
If all but filiform instruments fail, a few attempts may be made with 
these. But these tentative sounding may so bruise the stricture that 
even a filiform will not find its way in. It is therefore wiser to defer GONORRHEAL STRICTURE OF THE MALE URETHRA 
427 
any serious attempt at passing a filiform until the following day. Then 
we may resume the examination, beginning with the passage of filiforms. 
Some emergencies, e. g., an acute retention of urine, do not permit 
delay. The diagnosis of stricture must be combined with the relief of 
retention. Under such circumstances it may be wiser to begin at once 
with filiforms, since these are so much more likely to enter the stricture 
if no previous instrumentation has been attempted. The manipulation 
of filiforms is described in reference to treatment (p. 430). 
After the diagnostic instrumentation the urethra should be cleansed 
with the routine antiseptic irrigation or instillation, preferably an 
instillation of 1 to 1000 silver nitrate solution. 
The Diagnosis of Impending Stricture.—Of even greater importance 
and delicacy than the diagnosis of existing stricture is the diagnosis 
that stricture is about to occur. Yet it is only by correctly diagnosing 
such a condition that effective treatment can be employed; treatment 
calculated to cure. 
Impending stricture should be suspected in every case of chronic 
anterior urethritis. Intelligent treatment with the Kollman dilator 
will lead to the resorption of those inflammatory exudates that cause 
urethritis and form the origin of the scar that would subsequently 
form stricture. 
But if the patient has been treated elsewhere, and one does not feel 
sure that he ever had a true stricture, the diagnosis of a possible recur- 
rence should be deferred for a year. At the end of this interval without 
treatment, if the urethra readily admits a full-size sound and the ure- 
throscope shows no important sclerosis of the wall of the canal, the 
patient may safely be dismissed as free from the prospect of 
relapse. 
Treatment.—The treatment of gonorrheal stricture may be preventive, 
palliative or curative. 
Preventive Treatment.—The preventive treatment of stricture 
begins long before the stricture. Its foundation is a discreet management 
of acute gonorrhea; for a gonorrhea thus managed should leave behind 
little or no trace of its passage in the form of peri-urethral exudate. 
Just as the breaking of chordee, the use of cauterizing injections, too 
much zeal in the passage of urethral instruments, etc., are causes of 
gonorrheal exacerbations and complications, so gentleness and dis- 
cretion eliminate these causes and prevent stricture. 
Once chronic anterior urethritis has been established, the treatment 
of this, and especially the treatment with the Kollman dilator, is cal- 
culated to cause resorption of the exudate before it forms the dense 
peri-urethral scar which we call stricture. For even though the founda- 
tions of this scar are laid down by acute attacks of gonorrhea, the scar 
itself may be very slow to form, and still slower to show any perceptible 
tendency to contract. 
Palliative Treatment.—The palliative treatment of urethral stric- 
ture consists in dilatation. From what has been said in discussing the 
progress of stricture, it will be readily understood that dilatation may 428 
STRICTURE OF THE URETHRA 
occasionally cure a stricture. But, the prime object of dilatation is to 
control stricture, not to cure it. No amount of stretching can banish 
a scar from the urethral wall. So long as the scar is there it is likely to 
recontract. The physician, therefore, will be well advised to consider 
his dilatation purely palliative. 
Antisepsis and Anesthesia.—The most rigorous asepsis of instru- 
ments, patient’s urethra and physician’s hands should be practised as a 
matter of routine. But, inasmuch as the patient’s urethra cannot be 
cleansed of the bacteria that lurk within its glands, the two essential 
elements to prevent complications are: 
1. Extreme gentleness in the passage of all urethral instruments, 
whereby the urethral wall is spared and the foci of infection within are 
not stimulated to activity. 
2. Antisepsis; preferably by an instillation of silver nitrate (1 to 
2000) after the passage of instruments. This may often be properly 
supported by the administration of hexamethylenamin, 1 gm. twice or 
three times a day, for two days preceding the operation. 
The anesthesia produced by filling the anterior urethra with 5 
per cent, novocain for 15 minutes before the passage of instruments 
may be employed for each dilatation. But, though this is extremely 
useful to gain the patient’s confidence for the first dilatation, its routine 
use tends to encourage brutality in the passage of instruments into the 
urethra and is rather to be discouraged. It is usually quite possible 
after a few treatments to proceed with dilatation without any local 
anesthetic. Indeed, the patient may not note the omission. 
Dilatation.—Instruments Required.—A complete equipment of dilat- 
ing instruments includes filiform bougies and followers, woven bougies, 
conical sounds and dilators. 
Filiforms and Followers—The filiform bougie should have a smooth, 
rounded, olivary point and a flexible neck, which can be temporarily 
bent at any required angle. One should possess instruments whose tips 
vary considerably in size. 
Filiforms are made in two types. The one, a whalebone instrument 
to be used with a tunnelled sound or catheter; the other, a woven 
instrument, to the butt end of which is affixed a screw, whereby it can 
be screwed to a following sound or catheter. I much prefer the latter 
type. It has a more flexible point which can be set at an angle by a 
drop of collodion. Its screw junction with the following instrument is, 
of course, much smoother than that of the whalebone-tunnelled 
combination. But the woven instruments are relatively destructible, 
and can, therefore, not be employed in hospitals or dispensaries under 
ordinary circumstances. 
Filiforms are sometimes made with their points set in curious cork- 
screw shapes; these have no advantage. The point of the filiform 
should be a little offset from its centre; so that, after it has been intro- 
duced as far as the face of the stricture, it may be revolved to make its 
point search over a limited area for the orifice. Any complicated 
angulation is wasted. GONORRHEAL STRICTURE OF THE MALE URETHRA 
429 
The followers for whalebone filiforms are made of metal. The screw 
instruments for the woven filiforms are themselves woven. A complete 
set runs from 10 to 20 F. One should possess catheters, as well as 
sounds, of this description. 
Woven Bougies.—With the filiform and its followers the stricture can 
be conveniently dilated to 10, 15 or even 20 F., though it is preferable 
to use woven olivary-tipped bougies, after the first passage of filiform 
and follower. A set of bougies runs from 10 to 22 F. Bougies weighted 
with shot, or with a lead core, are rather preferable; since their weight 
makes them dilate the stricture somewhat more forcefully. 
Sounds.-—When skilfully manipulated, the conical steel sound ac- 
tually causes less pain than the woven bougie. But the sharp point of 
a small-sized sound is so likely to catch in the urethral wall that, as a 
general rule, one employs woven instruments up to size 20 F., and sounds 
from this point to the limit of the meatus. I rarely employ a sound 
larger than 29 F. 
On the other hand, the fixed curve of a steel sound makes it an ad- 
mirable instrument for entering the orifice of a tight stricture in the 
bulbous urethra. I have not unfrequently entered a stricture with the 
10 or 12 F. steel sound, the orifice of which I could not locate with the 
filiform. But the maneuver is so difficult that it should only be 
attempted by the skilled practitioner; the uninitiated will inevitably 
drive the sharp point of a small sound into the urethral wall. 
Dilators.—For sizes larger than the meatus will admit, the dilator 
should be employed. All modern dilators are modifications of the 
Kollman instrument. I have never employed an instrument with an 
irrigating attachment, or one that dilates only a portion of the urethra. 
The model I employ has a Benique curve, and is made to dilate the 
whole urethra. Here, again, I differ from the opinion of those who 
consider that precise treatment requires dilatation of only the strictured 
point. I despair of such precise diagnosis. The strictured urethra is 
likely to be chronically inflamed throughout. The more fully it is 
dilated the better. 
Dilatation of Strictures at the Meatus.—It is a waste of time to attempt 
dilatation of strictures of the terminal inch of the urethra. They 
should be cut (p. 433). 
Dilatation of the Pendulous and Scrotal Portions.—Strictures in this 
region may be dilated if they have existed for a relatively brief period. 
But, as a rule, they do not yield to dilatation. 
Unless they dilate readily they should be subjected to internal 
urethrotomy, as described below. 
Strictures of the Bulbous and Membranous Urethra.—These, the most 
common of gonorrheal strictures, yield most admirably to dilatation. 
Unless complicated by trauma or peri-urethritis they can, as a rule, be 
controlled for an indefinite period by the intelligent passage of sounds. 
Yet even here urethrotomy is called for when dilatation fails. 
The Technic of Dilatation— Let us suppose a stricture in the bul- 
bous urethra that will admit only a filiform instrument. By describ- 430 
STRICTURE OF THE URETHRA 
ing the series of treatments whereby this is fully dilated we shall 
cover the whole ground. 
The diagnosis has been established by vain attempts to pass larger 
instruments. We now resort to filiforms. 
After the preliminary asepsis and anesthesia we select a filiform, bend 
its tip a little eccentrically, and introduce it slowly into the urethra. It 
catches here and there, whereupon we withdraw it, rotate the point to 
one side, and so pass the obstacle. If we are fortunate the filiform 
passes the stricture readily, but usually it is obstructed. It will not 
engage in the stricture. Then it must be patiently and gently moved 
up and down, turning the point now to the right, now to the left, but 
searching for the orifice of the stricture rather toward the roof of the 
urethra than toward its floor. If the point of the filiform finally slips 
into the stricture, it may be obstructed by catching in the utricle or 
some pocket of the posterior urethra. That the filiform has passed the 
stricture is recognized by estimating the depth to which it has pene- 
trated in the urethra. That it is caught in the posterior urethra is veri- 
fied by a finger in the rectum pressing against the membranous urethra. 
The filiform is gently moved to and fro until the pressure of the finger 
makes it ride out of this obstacle and into the bladder. Then the fol- 
lower is screwed or slipped onto the filiform and gently pushed into the 
bladder. 
The filiform is not so sure a guide as might be imagined; it will 
buckle, and even break, if the follower is pushed in with too great haste. 
The size of the follower should vary with the age and density of the 
stricture. If the stricture is thought to be but a single band, and the 
scar so slight that no definite irregularity can be felt in the perineum 
at the point of stricture, one may sometimes advantageously employ a 
follower as large as 14 or 16 F. But if the scar is an ancient indurated 
mass, the first instrument passed should be no larger than a 10 F., and 
it is often wiser to attempt no further dilatation until several days later. 
The operation is followed by the customary instillation of silver 
nitrate, the instillator being placed as accurately as possible, in the 
hope that some of the solution may pass into the posterior urethra. 
If the filiform fails to enter the stricture, several alternatives present 
themselves: The instrument may be withdrawn and tried again, after a 
different angle has been given to its point; or filiforms with larger or 
smaller bulbs may be tried; or one may fill the urethra with filiforms, 
and push in first one and then another, in the hope that one of them 
may enter the stricture or the urethra may be distended with oil and 
a single filiform slipped between the fingers that pinch the meatus to 
retain the oil. 
If these maneuvers fail, and if the stricture is a relatively narrow 
band down to the face of which a urethroscope can be introduced, 
one may attempt the passage of filiforms through the urethroscope 
guided by the eye. Young speaks highly of this procedure, but I 
have had no success with it. 
In quite a number of instances, having failed to introduce a filiform, GONORRHEAL STRICTURE OF THE MALE URETHRA 
431 
I have succeeded in passing a 10 F. steel sound (with the Van Buren 
curve); but this instrument must be employed with the greatest 
imaginable gentleness, otherwise the sharp point of the sound will 
perforate the scar and produce a false passage. 
Even after failing with all instruments, the operation should be 
followed by an instillation of silver nitrate against the face of the 
stricture. If no complications ensue, the gentle attempt to pass 
instruments may be repeated day after day for several days, until the 
patient’s and operator’s patience are exhausted. But the appearance 
of any complication, such as fever, retention, or peri-urethritis, calls 
for immediate operation. 
In the absence of such complications there is no limit to the number 
of attempts that may be made to pass a stricture with filiform, but it is 
probable that the patient’s interests will be best served by prompt 
operation after the failure of two or three attempts at instrumen- 
tation. 
But before this final decision is reached the physician should once 
again try to pass a 20 F. sound into the stricture to be sure that, after 
all, this cannot pass. Thereby he will be saved the mortification later 
of passing a sound after the anesthetic has been administered. 
When a filiform finally has been passed, after many fruitless efforts, 
one is tempted to tie it in to act as a guide for further dilatation. There 
is no objection to this, but unless the stricture is particularly compli- 
cated, or unless all followers have failed to pass, the tying in of a 
filiform is unnecessary. 
Subsequent Dilatation.—If the stricture has been satisfactorily di- 
lated by filiforms and followers, no further attempt at instrumentation 
should be made (unless retention demands it) until the fourth or fifth 
day; then the same procedure as before should be followed, the first 
instrument used being chosen with relation to previous experience. At 
this second instrumentation it is prudent not to attempt to dilate the 
stricture much wider than at the preceding sitting. Thus, if the first 
dilatation was to 10 or 12 F., 10 or 12 F. may again suffice, for the object 
of dilatation of a very tight stricture is to iron out its irregularities 
rather than to dilate it rapidly. By the third or fourth treatment these 
irregularities are usually sufficiently smooth to permit dilatation to 
proceed more rapidly. 
The ideal interval is from five to seven days, for time must be given 
to the surface of a stricture to recover from the trauma of one instru- 
mentation before a second is attempted. The rapidity of dilatation is, 
of course, never twice the same; but if the stricture yields rapidly, one 
need not fear to advance as much as five to ten numbers on any one 
occasion. Each sitting is begun with the passage of an instrument at 
least one or two sizes smaller than the largest instrument that has been 
passed. If this fails to enter one may have to return to the smaller 
instrument—to begin all over again, as it were. If it enters and is 
rather tightly grasped the next sound to be passed should be but one 
size larger. But if the first instrument is not tightly grasped, one may 432 
STRICTURE OF THE URETHRA 
skip several sizes, sometimes three or four, with advantage. It is much 
wiser not to pass more than three sounds on any one day. These should 
be passed with the utmost gentleness; and while it is not quite true that 
they should enter by their own weight, they should very nearly do this. 
There is no advantage in leaving the sound within the grasp of the 
stricture for more than a moment. Each treatment is concluded with 
an instillation of silver nitrate. 
Bougies are used up to about 20 F.; sounds to the limit of the meatus; 
dilators to the full size, which should be 30 F. or a little higher. 
After the stricture has been so dilated that the dilator enters readily 
and can be screwed up to 30 or 32 F. without being tightly grasped or 
without exciting hemorrhage, the interval between instrumentation is 
lengthened from one to two weeks; then to a month; to three; to six 
months on condition that the stricture shows no tendency to recontract. 
Thereafter the dilator must be introduced to celebrate New Year’s day 
and the Fourth of July for the rest of the patient’s life, if the stricture 
is in the bulb. 
The more intelligent type of patient may be instructed how to boil 
his sound and to wash his hands and penis and to introduce a full-sized 
sound. Although there is less danger of urethral chill following the 
gentle and cleaner passage of a sound by a surgeon, if that instrumenta- 
tion be followed by the instillation of silver nitrate along the urethra, 
yet it is so contrary to human nature for any man to return year after 
year for treatment, that it seems fair in many instances to entrust the 
sound to the patient. If at any time he fails to introduce the instru- 
ment he must, of course, appeal for professional aid. 
Operative Treatment of Stricture.—Indications for Operation.—The 
failure of dilatation is the only excuse for operation upon urethral 
stricture. This failure may be of several kinds. Thus stricture of the 
meatus can never be dilated; we know beforehand that dilatation will 
fail and we operate accordingly. 
Stricture of the pendulous urethra is amenable to dilatation only 
when the scar has not become fully organized. Tight stricture, or 
dense stricture, or stricture that is palpable, as a thickness of the corpus 
spongiosum in the pendulous urethra, may be dilated up to a certain 
point, but must be cut in order to be cured. 
Stricture of the bulbous urethra, on the other hand, if of gonorrheal 
origin and not complicated by retention or peri-urethritis, may usually 
be controlled by dilatation. But if the stricture cannot be dilated, or 
if it persistently relapses in spite of intelligent treatment, or if retention 
or infection of kidney, prostate, or peri-urethral tissue require drainage, 
which dilatation does not afford, then operation (external urethrotomy) 
is indicated. 
It is the part of wisdom to err on the side of operating too early 
rather than too late. Peri-urethritis always requires operation, and a 
stricture that remains impassable or proves rebellious in the course of 
dilatation should be operated upon as soon as the patient’s consent 
can be obtained. GONORRHEAL STRICTURE OF THE MALE URETHRA 
433 
Choice of Operation.—For strictures of the meatus, meatotomy. For 
strictures of the pendulous and scrotal urethra, internal urethrotomy 
upon the roof of the canal. For strictures of the bulbous urethra, 
external urethrotomy. 
Choice of Anesthetic.—For meatotomy or internal urethrotomy local 
anesthesia suffices after a preliminary hypodermic injection of mor- 
phin. A solution of 10 per cent, novocaine is injected into the ante- 
rior urethra and there retained for twenty minutes. This gives ample 
anesthesia for any internal urethrotomy. 
The choice of anesthetic for external urethrotomy is still a subject of 
much discussion. The basis of the discussion is the difficulty of de- 
termining (by phenolsulphonephthalein or any other test) the precise 
condition of the patient’s kidneys. The stricture that requires opera- 
tion is usually an ancient one and may have impaired the kidney 
function far more than is suspected. For this reason perineal section, 
casually performed, has an extremely high mortality. But if the danger 
of renal death is borne in mind and the patient with urethral stricture 
submitted to the same careful examination and preliminary treatment 
as is the candidate for prostatectomy, the question of anesthetic will be 
solved along similar lines. Local anesthesia by means of novocain and 
adrenalin within the urethra, as for internal urethrotomy, aided by 
massive infiltration of the perineum behind the point of operation with 
0.25 per cent, novocain (and adrenalin) solution, covers the field except- 
ing only the posterior urethra and bladder neck. But the sensitiveness 
of these is impaired and does not occasion either operator or patient 
any grave inconvenience. 
I have also employed sacral anesthesia with varied success, and spinal 
anesthesia in many instances with no mishaps.5 
Gas and oxygen is, generally speaking, the anesthetic of choice; 
parasacral anesthesia I have not employed. 
Meatotomy.—The straight, blunt-pointed bistoury is the best instru- 
ment with which to cut the meatus. We need also several sounds to 
measure the resulting caliber of the urethra. 
The end of the patient’s penis is washed with soap and water, the field 
of operation anesthetized by inserting a piece of cotton soaked in 1 
per cent, novocain (adrenalin) solution. After this has been in place 
twenty minutes it is removed, the bistoury inserted into the urethra, 
well within the second meatus, the head of the penis compressed very 
tightly from side to side, and the knife quickly withdrawn, cutting the 
floor of the urethra to the required depth. Only the experienced opera- 
tor can expect to achieve the desired result with a single stroke of the 
knife. The tyro should cut too little rather than too much, and should 
remember that the internal meatus at the depth of about 1 cm. is often 
tighter than the orifice itself. A 28 or 30 F. sound is immediately 
introduced. If this will not pass readily, further cutting is re- 
quired. 
If adrenalin has been employed the after-bleeding is usually slight. 
No suture or cauterization of the wound is worth considering. But 
gentle lateral compression should be made until the bleeding stops. 434 
STRICTURE OF THE URETHRA 
Then a large dressing should be applied with a penis bag and the penis 
held against the groin with a jock-strap or bandage. The patient is 
instructed how to remove his bandage before urinating, and how to stop 
bleeding by lateral compression of the glans penis. He is seen daily and 
the wound kept open by the passage of a probe. No further attempt to 
pass a sound should be made until a week has passed, and thereafter a 
sound about two sizes smaller than the one originally passed should be 
introduced often enough to keep the urethra open until it has healed; 
this always requires at least two weeks. 
Complications.—I have never seen any complications other than 
bleeding follow meatotomy. The control of the bleeding may be en- 
trusted to the patient himself unless his mental or social circumstances 
are such that it seems wiser to make the operation a formal one and keep 
him in bed for a day or two under the care of a nurse. 
Internal Urethrotomy.—Instruments Required.—Of the many 
types of urethrotomes the Otis is the best suited for those strictures 
that will admit it, while tighter strictures may be cut by the Maison- 
neuve. Appropriate sounds to measure the resulting urethral caliber 
and an indwelling catheter may be needed. 
The Operation.—The operation may be performed under local anes- 
thesia as described above. It is, however, unsafe to perform it in the 
office. The patient should be at his home or in a hospital. 
Inasmuch as the urethra is inevitably infected and this infection lies 
largely beneath its surface, gentle irrigation of the anterior urethra to 
cleanse it of gross pus, and soap and water wash to the penis, fulfil the 
requirements of asepsis of the patient’s person. Asepsis of instruments, 
operator and operating field is carried out as for a major operation. 
The stricture or strictures have been previously located and cali- 
brated. 
In almost every instance the Otis urethrotome may be introduced. 
It is passed into the grip of the stricture and about 2 cm. farther, its 
knife pointed toward the roof of the canal. This places the dial in a 
very inconvenient position, yet it ensures against cutting too deeply, for 
a deep cut on the roof merely enters the septum between the corpora 
cavernosa, while a similar violation of the floor or sides of the canal 
would open the peri-urethral cellular tissue and result in abscess. The 
urethrotome is now screwed up to about 35 F. and the knife slowly 
withdrawn until it is felt to jump through the strictured portion of the 
urethra. The urethrotome is then immediately screwed down to its 
smallest size and withdrawn. A 30 or 31 F. sound is passed to the 
bulbous urethra, hut no farther. 
If at the first attempt one deems it unwise to screw the urethrotome 
all the way up to 35, or if after the cutting the sound does not pass freely, 
a second cut upon the roof may be made. The meatus may be cut by 
turning the instrument over and cutting on the floor at this point. If 
after the division of the first stricture other unsuspected points of 
constriction are found, these must be cut. During this whole operation 
no instrument has been introduced into the membranous urethra. 
The surgeon now estimates the amount of bleeding. If this is slight GONORRHEAL STRICTURE OF THE MALE URETHRA 
435 
no dressing is required other than a hood of gauze to keep the bed-c overs 
clean. The patient is left to urinate at will, with the assurance that 
since nothing has been introduced into the posterior urethra, urethral 
chill will not occur. 
But if the bleeding following the operation is severe it is wiser to tie a 
catheter into the bladder: the mere presence of this instrument stays 
the hemorrhage in almost every instance. Any bleeding that persists 
may be controlled by pressure. But if much pressure is required it is 
wiser to adjust small splints to the dorsum and the venter of the penis, 
making pressure upon these, so that the penis will not be strangled in 
case of erection. This indwelling catheter should remain in place two 
to four days. 
Complications.—The precaution alluded to excludes any danger from 
urethral chill or any other forms of urinary infection. The method of 
controlling hemorrhage has been described. Peri-urethritis as a result 
of overcutting I have not seen. Among over 150 operations reported in 
our case-books there was 1 death from pyemia. 
If the stricture is too small to admit the Otis instrument the Maison- 
neuve may be employed. If it is impassable, perineal section is per- 
formed and the urethrotome passed from behind forward. 
After-treatment.—If the indwelling catheter is used this is withdrawn 
on the second, third, or fourth day. Thereafter the patient goes about 
his business as usual. The first sound is passed between the tenth and 
the fourteenth day. It is well to begin with a woven bougie of about 
16 or 18 F. size. This gently dilates the urethral wound and may be 
followed by a 24 or 25 F. bougie or sound. No attempt is made to 
pass a larger instrument at the first sitting. 
Thereafter the patient returns for instrumentation every five days, 
and as soon as the stricture can be dilated to 25 F. without considerable 
bleeding, further dilatation up to 30 F. is carried on with the Kollmann 
dilator. As soon as the full size is reached without causing considerable 
hemorrhage the interval between sittings is increased to two weeks, and 
dilatations are continued at this interval until the wound is healed and 
the urethritis controlled. This will usually take about three months. 
The patient is then requested to return after an interval of six months. 
If at the end of this time the urethritis has not relapsed and the stricture 
has not recontracted, he may be dismissed as cured; otherwise he may 
require further dilatation or cutting. 
External Urethrotomy with a Guide.—Instruments Required.— 
In addition to the usual instruments, external urethrotomy requires a 
curved, sharp-pointed bistoury, a female catheter (preferably of metal), 
two or three grooved staffs of different sizes, or if the stricture is known 
to be too small to admit these, filiforms and tunnelled followers. The 
groove of all staffs and followers should be as wide as possible, so that 
the knife plunged into the perineum may readily find it. The familiar 
soft-rubber perineal tube with a lateral as well as a terminal eye is 
usually employed for drainage after the operation; but one should have 
at hand a double-current tube for continuous irrigation in case the 
bladder neck is so torn as to bleed alarmingly. 436 
STRICTURE OF THE URETHRA 
The Operation.—The operation performed by the expert when the 
stricture is of sufficient caliber to admit a grooved staff is quite different 
from that employed for a tighter stricture or by a less experienced 
operator. 
The Operator is Expert: The Stricture Admits a Staff.—The patient is 
placed in the lithotomy position, i. e., with the buttocks brought down 
so that they overhang the edge of the table and both hips and knees 
sharply flexed and supported by some form of stirrup. If the table is 
low the operator’s comfort requires that the patient’s buttocks be 
elevated on a sand bag. 
The usual asepsis is employed. 
A grooved staff is introduced into the urethra and passed into the 
stricture and well into the bladder (to prove that the instrument is not 
in a false passage). It is then partially withdrawn and passed to an 
assistant, who holds it in such a position that its groove projects in the 
median line of the perineum so as to be readily palpable. With his 
other hand this assistant pulls the scrotum up out of the operator’s way. 
The operation is now performed with a single thrust of the knife. The 
curved, sharp-pointed bistoury is plunged through the perineum into 
the groove of the staff at a point about 4 cm. in front of the anus, where 
the staff begins to curve away from the perineum up toward the mem- 
branous urethra. The point of the knife is then carried backward in 
the groove of the staff for 1 or 2 cm. until it just enters the membranous 
urethra; then with a downward stroke its point is withdrawn so as to 
cut a hole through the urethra, the perineum and the skin quite large 
enough to admit the finger readily. Some practise is required to per- 
form this stroke accurately. It is essential that the mucosa of the 
urethra be widely incised. 
As soon as the knife is withdrawn the operator introduces his fore- 
finger, feels for the groove of the staff, and makes sure that his finger 
rests against this with no mucous membrane between. Then taking 
the handle of the staff in his left hand he slowly withdraws this while 
pressing quite firmly against the groove with his finger in the wound. 
As the tip of the staff slips from beneath this finger it feels the roof of 
the canal and follows this backward into the membranous urethra and 
thence into the bladder. If the deeper portion of the stricture has not 
been sufficiently incised at the first stroke of the knife a grooved director 
may be introduced through the perineum and the floor of the urethra 
sufficiently divided with a scalpel to admit the tip of the finger, after 
which the remaining fibers are torn. The finger as it enters notices the 
presence or absence of any prostatic areas suggestive of stone, abscess, 
etc., and on withdrawal it sweeps the roof of the urethra to be sure there 
is no projecting band of stricture there. If such a band is found it is 
nicked or cut away. 
A 30 F. sound is then introduced into the meatus and passed into the 
bladder. If this is obstructed, meatotomy or internal urethrotomy are 
performed as required. 
The rubber perineal tube is then grasped by a long forceps in such a GONORRHEAL STRICTURE OF THE MALE URETHRA 
437 
way as to bend its tip like an elbowed catheter. It is thus readily 
introduced into the bladder, the forceps withdrawn, and a syringeful of 
1 to 5000 silver-nitrate solution washed through the tube to make sure 
that it is in proper position. If the fluid fails to return, this may be 
either because the tube is too far in or not far enough in, or because its 
eye is obstructed by clots. Clots may be aspirated with the piston 
syringe. The proper position of the tube will be assured if the operator 
is careful to insert into the wound a length only a little more than that of 
his own forefinger. 
After the tube has been properly placed it is held in by a catgut 
suture that catches the two edges of the wound and is wound four or five 
times around the tube (pins or needles stuck through the tube soon 
destroy it). 
The patient’s legs are then let down, a thick dressing applied under 
a T-bandage, the testicles being well supported by this; the patient is 
then removed from the table to his bed, and after reaching his bed the 
proper function of the tube is again tested. After this a large rubber 
tube is attached, leading over the side of the bed into a bottle. 
Precautions.—Experience and skill are required to perform the opera- 
tion in this manner. The tyro by making his first incision wrong is 
likely never to get his finger into the urethra, but will burrow with it 
outside of the mucosa which lies between him and the staff. Then on 
withdrawing the staff and realizing that he is lost he will fail to reinsert 
his guide, then he will cut through the roof of the urethra and never 
reach the bladder. 
A precaution to be applied to every form of external urethrotomy is 
not to pack the urethra around the tube. The immediate profuse 
bleeding promptly ceases; or may be controlled by firm pressure of the 
external dressing against the tube. Packing about the tube is likely to 
excite much more hemorrhage, when it is removed a few days later, 
than would have occurred in the first place. Furthermore, it encourages 
infection and delays healing. 
Some operators prefer to apply an indwelling catheter and sew the 
urethra rather closely about this, wdiile leaving the skin of the perineum 
open. But I believe the wound heals better if a straight perineal sinus 
remains as left by the perineal tube. 
After-treatment.—If there is any grave question of the kidney func- 
tion this is stimulated as after prostatectomy by injection of salt solu- 
tion through the rectum, forcing fluids by mouth, and fresh air. The 
perineal tube is usually removed at the end of twenty-four to forty-eight 
hours, but doubtful renal function may encourage longer drainage. In 
this event it is wise to replace the large tube by a smaller one, either in 
the perineum or through the anterior urethra, and to get the patient out 
of bed as much as possible. 
The immediate convalescence of perineal section is likely to be stormy. 
The patient’s temperature may rise to 103° F. immediately after opera- 
tion or immediately after removal of the perineal tube. The unfamiliar 
operator will have great difficulties with the drainage of his tube. The 438 
STRICTURE OF THE URETHRA 
bladder will fill with urine or with clots; the patient will suffer grave 
agony and may even die, septic and exhausted, as a result. But experi- 
ence and good nursing avoid these complications. 
Clots may be sucked out of the bladder readily enough, and if the 
tube when placed properly does not relieve the patient’s spasms, it 
should be removed. 
While the tube is in place the bladder should be irrigated once or 
twice daily, preferably with silver nitrate solution. 
After removal of the tube no further irrigation is attempted so long 
as the patient progresses satisfactorily. An immediate rise of tempera- 
ture may be watched for forty-eight hours. If at the end of this 
time it remains up a catheter should be tied in and water forced. 
Under these circumstances rather high doses of urotropin are sometimes 
of service. Good drainage, fresh air, and forced water are our chief 
reliance. If all goes well no instrument is introduced into the bladder 
until about the twelfth day, when a 20 or 22 F. steel sound is passed 
into the urethra after anesthetization with novocain. If no incision has 
been made upon the roof of the urethra the instrument is likely to enter 
the bladder quite readily, but if the roof has been incised its point will 
catch here and need to be deflected toward the floor before it will pass 
the stricture. 
If any real difficulty is encountered, this may be overcome either by 
introducing the finger into the perineal wound or more neatly by passing 
a grooved director from the wound into the bladder and introducing 
the sound on this; or else by inserting the two ends of a filiform into 
the wound; one toward the bladder and one toward the meatus, 
using this as a guide. After the introduction of the first sound but one 
more instrument should be passed, preferably a 25 F. sound. This is 
followed by an instillation of 1 to 1000 silver nitrate, the solution being 
trickled along the posterior and anterior urethra. 
On two occasions I have seen such profuse bleeding follow the extrac- 
tion of the perineal tube or the passage of the first sound that I was 
moved to give the patient an anesthetic, reinsert a tube in the 
perineum and pack around it. 
The subsequent passage of sounds is made at the usual five or seven 
days’ interval. Much more skill is required to enter the lacerated 
urethra than to pass any stricture. The inflammatory irregularities 
following operation persist for at least a month. It is wiser during the 
first two weeks not to attempt to stretch the urethra above 25 F. Sub- 
sequent to this the dilator should be used and the urethra opened to 
30 F. The fistula should heal within two to six weeks. It requires no 
particular care beyond the destruction of exuberant granulations. The 
healing may be encouraged by swabbing the sinus with trichloracetic 
acid or by touching with silver nitrate fused on a probe. If these meas- 
ures fail the sinus must be excised and the perineum sutured in layers 
around a small tube. 
The Surgeon is Inexpert or the Stricture is too Tight to Admit a Grooved 
Staff.—The operation is performed as above described except that the GONORRHEAL STRICTURE OF THE MALE URETHRA 
439 
staff is cut down upon widely instead of by touch and the way into the 
bladder is made certain by a guide inserted through the perineal wound. 
With the patient in the lithotomy position a staff is inserted through 
the stricture, or if this will not enter, a filiform bougie is introduced, and 
upon this a small tunnelled staff is passed, either through the stricture 
or down to it. The tissues are made tense over the staff and divided 
in the median line, layer by layer; skin, superficial fascia, fat, muscle 
and then the bulb itself. 
The incision of the bulb is signalled by a gush of blood which is to be 
disregarded. The floor of the urethra is incised just in front of the 
stricture, widely enough to expose the filiform and follower plainly to 
view. With artery clamps the divided edges of the mucosa are now 
seized. (The unfamiliar operator will grasp the sheath of the corpus 
spongiosum; this will lead him nowhere. lie must seize the mucosa 
itself on each side.) The urethra is steadied between these clamps, the 
follower withdrawn, but the filiform left in place (or if a grooved staff 
has been employed this is not withdrawn). 
The floor of the urethra is then longitudinally divided back to the 
point of stricture, the urethra being drawn out into the perineum by the 
application of successive pairs of clamps along its cut edges. When the 
orifice of the stricture has thus been brought into view with the 
filiform (or staff) disappearing through it, a grooved director is inserted 
in the general direction of the long axis of the patient’s body (almost at 
right angles to the part of the urethra that has already been incised). 
If this grooved director is known to be in the bladder, the filiform (or 
staff) is withdrawn and the floor of the stricture divided by a knife 
introduced into the groove of the director. The finger is then intro- 
duced into this cut and guided by the director until it passes through 
the dilated prostatic urethra and the ring of bladder neck into the 
bladder cavity. 
If during any part of the operation the operator becomes lost in the 
perineum he may usually find his way by passing a female catheter 
alongside of the grooved director; a gush of urine through the catheter 
announces that it has reached the bladder. The rest of the operation 
is performed as described above, with the exception that the urethra 
may well have been extensively damaged and require suturing, espe- 
cially that part of the floor anterior to the point through which the 
perineal tube goes. The bulbocavernosus muscle and superficial 
tissue are also brought together by catgut suture so as to bury the 
urethra deep within the perineum and thus to minimize the prospect of 
persistent fistula. 
External Urethrotomy without a Guide.—If after the patient 
has been anesthetized no sound or bougie, large or small, or even 
filiform, can be introduced into the stricture, about 20 c.c. of 0.5 per 
cent, solution of methylene blue is injected into the urethra and 
patiently milked through the stricture and into the bladder (I have 
employed this device a number of times and have never known the 
coloring matter not to enter the bladder unless there was an open fistula 440 
STRICTURE OF THE URETHRA 
or a large peri-urethral abscess). The excess of solution is then per- 
mitted to escape and the anterior urethra washed out with one or two 
injections of water, so that no excess of coloring matter shall remain to 
soil the wound when the urethra is cut open. 
The patient is then put in the lithotomy position and as large a staff 
as the urethra will admit is passed to the face of the stricture in the 
perineum. The urethra is incised upon this as described in the pre- 
ceding section, layer by layer. The mucosa is readily identified and 
grasped on each side by artery clamps. The staff is withdrawn. Now 
comes the delicate part of the operation. 
The wound in the urethra and in the superficial tissues must be wide 
enough to permit the canal to be drawn almost flush with the perineal 
skin. The clamps are now steadied and the operator closely inspects 
the urethra, inserts the probe to its deepest point, and gently incises the 
floor of the urethra upon this. By the aid of further pairs of clamps the 
whole of the urethra and the face of the stricture are laid out flat before 
the operator. He now searches every corner of this surface for the 
orifice of the stricture with the point of a filiform bougie. It will 
usually be found much nearer the posterior angle of the wound (and 
what might be termed the lower surface of the corpus spongiosum) 
than would be supposed. 
If the orifice of the stricture is not found the bulbocavernosus muscle 
is cut and stripped away from the bulb (if more room is needed the 
superficial tissues may be divided transversely or in Y-shape). When 
the bulb has been freely exposed by good retraction of the superficial 
tissues it is deliberately cut transversely, posterior to the point where it 
has been divided longitudinally, in the vain search for the orifice of the 
stricture. At some point the blue mucosa will again be encountered 
and from this point the passage into the posterior urethra with filiform 
and grooved director is easy. 
1 have only once failed to find the orifice of the stricture by the longi- 
tudinal incision of the bulb. In that case the transverse incision readily 
disclosed it. The surgeon who shoidd fail by either device is thereby 
proved so unfamiliar with the perineum that he had better make no 
further attempt to find the urethra at the apex of the prostate, but 
rather take refuge in suprapubic incision of the bladder and retrograde 
catheterization by a Benique sound passed through the bladder and 
thence into the posterior urethra. The floor of the urethra is incised 
upon the point of this instrument and the remainder of the operation 
concluded in the usual manner. 
Other Devices for Finding the Orifice of the Stricture.—Various other 
methods have been employed to find the way through the stricture. 
Thus we may mention the Wheelhouse staff, which is no longer used, 
and Young’s suggestion that we identify the apex of the prostate 
through the Y-shaped prerectal incision upon the membranous urethra 
and work backward from this into the stricture. Any surgeon skilful 
enough to perform this operation could much more readily enter the 
stricture by the method described above. GONORRHEAL STRICTURE OF THE MALE URETHRA 
441 
Sinclair’s device for retrograde catheterization consists of a trocar and 
cannula, to be plunged through the space of Retzius into the bladder, 
after this has been distended with fluid forcibly injected through the 
urethra (unless it is already distended with urine). Through this 
cannula a probe is introduced into the posterior urethra and up to the 
posterior face of the stricture. The urethra is incised upon this, the 
stricture divided, internal urethrotomy done, if necessary, and a soft- 
rubber catheter left in the suprapubic wound to drain the bladder. No 
perineal or urethral drain is used. The inexperienced surgeon will find 
it much safer to perform suprapubic section for his retrograde catheteri- 
zation, for there is a distinct possibility that the trocar may enter the 
peritoneum. 
Under local anesthesia the opening of the urethra may be found 
if the patient can be persuaded to urinate. 
Resection oe the Urethra.—The urethral mucosa grows with such 
amazing rapidity and covers such incredibly large gaps that even when 
the removal of dense scar tissue about the urethra leaves a wide gap no 
attempt at skin grafting is necessary. Indeed, such grafts rarely take. 
Sections of the saphenous vein have been employed to take the place of 
portions of the urethra, but the epithelium does not live. The only 
requirement for filling a gap in the urethral wall is to fix the two ends of 
the urethra as near together as may be and in such a position that a 
sound will readily enter the posterior end, for if subsequent passage of 
sounds is possible, we may look for a happy outcome. 
Cabot's Resection.—Hospital surgeons impressed by the frequency 
with which patients return after a few years’ interval for repeated 
perineal sections have endeavored to devise operations whereby better 
results could be obtained and the stricture perhaps definitely cured. 
The two modern efforts to achieve this result are Pasteau’s and Cabot’s. 
The former is not applicable to stricture but is an excellent operation 
for the treatment of rupture of the urethra (q. v.). The aim of Cabot’s 
operation is to divide the stricture upon the floor of the urethra in the 
usual manner and to reunite the longitudinal incision by transverse 
suture, thus puckering the urethra, as it were, and enlarging the lumen of 
the stricture. 
The steps of the operation are as follows: The urethra is steadied by 
a sound instead of a staff. The bulb is exposed in the usual manner but 
not incised. The bulbocavernosus muscle is stripped away and the 
bulb itself separated from the corpora cavernosa for a space of at least 
3 cm. The bulb is now opened over the point of the sound and the 
stricture incised in such a manner that the urethra is opened for a short 
distance behind as well as in front of it. Beginning at the tightest point 
of the stricture (i. e., approximately at the middle of the longitudinal 
incision in the bulb) the adjacent edges of the mucosa and underlying 
corpus spongiosum are sutured transversely with fine catgut introduced 
on a curved intestinal needle. A small sound is left in the urethra while 
successive sutures are taken in each side and clamped, but not tied, 
until the whole wound has been caught in sutures running from before 442 
STRICTURE OF THE URETHRA 
backward and calculated to close the wound transversely on the sound 
in the urethra. The sutures are then tied, beginning with the ones first 
introduced and ending with those central ones that approximate the 
anterior and posterior ends of the original incision. Drainage is pro- 
vided by a small catheter introduced into the urethra at a point pos- 
terior to the incision in the stricture. The perineum is sutured over the 
incision in the urethra; the small catheter left in place for two weeks; 
the bladder irrigated daily. Cabot advises daily gentle injection of 
argyrol into the anterior urethra. We have thought that the trauma 
from this did more harm than the antisepsis did good. 
Cabot’s operation is obviously only applicable to relatively narrow 
strictures. In seven or eight cases it has given me better results than 
simple urethrotomy; but the urethra is much puckered by the opera- 
tion and one must be extremely gentle in the first attempts to introduce 
sounds. 
'Resection of Fistula, etc.—External urethrotomy for stricture 
may be complicated by peri-urethritis, fistula, etc., or by masses of scar 
left by ancient peri-urethritis. The following rules should guide the 
operator, viz.: 
1. The main incision should be in the central line of the perineum, no 
matter how many accessory incisions are required. 
2. Fistulte must be widely opened to their ultimate ramifications. A 
pocket in the perineum will not heal. 
3. Masses of hard scar tissue must be excised, even though this sacri- 
fice the urethral wall. But every effort must be made to leave an even 
roof to the urethra as a guide to sounds. 
4. It is preferable, though not essential, to excise the fibrous walls of 
all fistula. 
5. If the urethra has been completely divided its roof must be 
repaired as well as possible and its floor left wide open so that sub- 
sequent sounds may readily enter the posterior segment. 
6. In order to avoid subsequent fistula the perineum must be 
reconstructed as well as possible. 
TRAUMATIC STRICTURE. 
The urethra may be torn, punctured, or incised in any part of its 
course. Punctures or linear incisions (e. g., false passages from 
rough instrumentation, tears resulting from the extraction of 
calculi or foreign bodies, bullet wounds, urethrotomy incisions, etc.) 
usually heal without leaving any stricture; for unless peri-urethritis 
ensues the scar occupies so small a portion of the circumference of the 
canal that its contraction does not appreciably encroach upon the 
lumen. 
The types of injury likely to result in stricture are (1) the so-called 
straddle injury (whereby the membranous urethra is partly or wholly 
torn across); (2) fracture of the pelvis (with the same result); (3) 
prostatectomy (which may leave a stricture at the bladder neck); TRAUMATIC STRICTURE 
443 
(4) the Bottini operation (which may so cauterize the junction of the 
bulbous and the membranous urethra as to leave stricture there), and 
(5) injuries to the erect penis (such as breaking a chordee). 
With the postprostatectomy stricture we have no concern here. Of 
the others it may be said that they contract much more rapidly, require 
operation for their relief much more often, and recur after operation 
with much greater -obstinacy than do gonorrheal strictures. Thus, 
among 44 personal cases, all appeared within six months of the injuries 
excepting 4. Although an interval of from five to twenty years in- 
tervened in these 4 cases between the trauma and the diagnosis of 
stricture, each one had received more or less treatment during this 
interval; treatment that might have controlled the stricture in some 
degree. But, as a rule, traumatic stricture, from whatever cause, defies 
such casual treatment and contracts very rapidly. Among 28 accu- 
rately described cases I find 23 impassable or filiform in size, the other 
5 had contracted to 10, 15, 17, 18 and 24 F. Of 44 cases tabulated, 31 
were operated upon in our office and many others elsewhere. Ob- 
viously, traumatic stricture contracts much more obstinately than 
gonorrheal stricture. 
Pathology.—The pathological changes that constitute traumatic 
stricture are but the scars left by the various types of ruptures in the 
urethra mentioned above. As Bazy has pointed out, the rupture may be 
so slight that only the mucosa is torn, but, as a rule, the whole thickness 
of the urethra has been divided in part or all of its circumference. The 
typical resulting scar therefore is a narrow one as contrasted with the 
broad, irregular scar of gonorrheal stricture; but it is a dense and elastic 
scar, contracting rapidly and resisting dilatation. 
Symptoms and Course.—The chronic urethral discharge (gleet) which 
is the prevailing symptom of gonorrheal stricture cuts but a slight 
figure among the symptoms of traumatic stricture. Thus among 21 
cases only 2 showed gleet as a first symptom, while 10 complained of 
frequent and obstructed urination, and 9 of acute retention. In many 
instances the stricture came on so immediately after the injury that the 
hematuria which is so prominent a symptom of rupture of the urethra 
was also the first symptom of the stricture itself. Indeed, the symp- 
toms of stricture usually follow immediately upon those of the rupture. 
If the injury is so severe that the patient cannot urinate or requires 
attention for other injuries the urethral rupture is immediately diag- 
nosed, the patient is operated upon, and if properly treated he may be 
relieved from any symptoms of stricture for a considerable time. Thus 
weeks, months, and exceptionally years may intervene before the trau- 
matic stricture is diagnosed. But if the injury is only severe enough to 
cause slight hematuria the patient may not consult a physician, no 
attempt may be made to treat the condition, and always within a few 
weeks the stricture declares itself by obstructing urination. 
The very beginning of traumatic stricture therefore depends largely 
upon treatment, and its subsequent course is even more dependent upon 
this. Operation which is not often necessary in the treatment of 444 
STRICTURE OF THE URETHRA 
gonorrheal stricture is almost invariably an essential part of the 
treatment of traumatic stricture. The stricture must be incised. If 
it recontracts thereafter it must be incised again. Thus only will its 
tendency to recontraction be finally overcome. 
Treatment.—A slight injury to the urethra sufficiently severe to cause 
hemorrhage should at least be identified by urethroscopy and treated 
by the passage of sounds according to the rules already laid down. 
Graver injuries, including almost all injuries to the bulb and posterior 
urethra, require prompt perineal section and subsequent sounding as 
a preventative of stricture. Doubtless stricture will follow such 
operation, but it will be less resilient and intractable than if the oper- 
ation had not been done. 
For the cure of traumatic stricture internal urethrotomy for anterior 
strictures and external urethrotomy for stricture of the membranous 
urethra yield surprisingly good results. If the after-treatment is con- 
ducted for a sufficient length of time, as stated above, the failure of 
one perineal section is no reason why another will not succeed. 
On several occasions patients have come to me in despair on account 
of the recurrence of symptoms or the physician’s inability to pass 
sounds a few weeks after operation. They were promptly put in the 
hospital, the stricture reincised, and thereafter the case presented no 
unusual difficulties. Such patients I have had under control for as 
long as ten years. They need rather more frequent dilatation than 
gonorrheal patients, but they are just as controllable; and once the 
operative wound has healed and the stricture takes a full-sized sound 
its resilience is usually conquered. 
Pasteau’s Operation.—But the stricture may recontract viciously 
after repeated external urethrotomies. Such cases may be relieved 
by Pasteau’s operation, which consists of excision of the scar and 
perineal urethrostomy of both cut urethral ends. The patient thus 
urinates through his perineum, and is left in this condition for at 
least six months, while both segments of the urethra are kept well 
open with sounds. Then the second stage of the operation is per- 
formed: (a) Suprapubic drainage; (6) sound threaded through both 
urethral segments into the bladder; (c) sufficient flap circumcised 
about the two orifices to turn in, closing the urethra; (d) deeper 
tissues well freed on either side so as to build up a perineum over 
the new urethra; (e) withdraw sound; (/) leave skin very loosely 
sutured for drainage. 
CONGENITAL STRICTURE. 
Congenital narrowing of the urethral lumen may be very considerable 
and yet cause no symptoms. Hence the pathological condition must 
be distinguished from the clinical. The former must be considered 
first. 
Englisch,1 in his compendious study, has collected 155 cases of atresia 
and 208 of congenital stricture affecting every portion of the urethra; 
for although the urethra is indeed developed from three sources (the CONGENITAL STRICTURE 
445 
posterior urethra from the urogenital sinus, the balanitic from an infold- 
ing of skin, and the intervening anterior urethra from the penile groove) 
nevertheless congenital stricture may occupy any portion of the canal. 
It may be membranous or fibrous. A large if not a major proportion 
of strictures are not associated with other defects of development. 
The stricture is usually of no great width (in contrast with atresia 
which may extend over the greater part of the urethra). 
The meatus urinarius and the so-called second meatus (a constriction 
at a depth of about 1 cm. within the urethra) are the usual site of con- 
genital stricture. Indeed, in this region it is familiar to all while else- 
where it is extremely uncommon (I have seen less than half a dozen 
clinical cases). 
Etiology.—The cause of congenital stricture is either maldevelopment 
or inflammation of the urethra before birth. (Englisch believes that 
some so-called congenital strictures are the result of non-gonorrheal 
urethritis in infancy, due to balanitis, masturbation, or the exan- 
themata.) 
Pathology.—The stricture may be due to a valve of mucosa, to a 
constriction of all coats of the urethra, or to scar. 
Complicating hypospadias, dilatation, and fistula are not uncommon. 
Tight stricture results in dilatation of the upper urinary tract similar 
to that which results from retention in later life. 
Clinical Types.—1. The tightest strictures, amounting almost to com- 
plete atresia, produce enormous renal dilatations which either kill the 
child at about the time of birth or gravely' interfere with parturition 
because of their size. The interest of such cases is purely pathological 
and obstetrical. The stricture is often found in the region of the 
verumontanum.3 
2. If the stricture permits the infant to survive, symptoms are often 
first noted between the fifth and tenth years. Congenital stricture may 
be suspected in cases of (a) incontinence of urine, especially if this be 
diurnal, (6) poor nutrition associated with evidence of renal deficiency, 
(c) unexplained hematuria. 
3. The stricture may, however, have so large a caliber that it excites 
no symptoms until in adult life an intercurrent urethritis calls attention 
to it. If the urethritis is gonorrheal the true origin of the stricture is, 
of course, overlooked. Bazy therefore insists that congenital strictures 
are much more common, than we suppose. 
4. The stricture interferes, with the passage of urethral instruments. 
Most meatus strictures fall in this category. 
Diagnosis.—This is usually made by the exclusion of trauma and 
gonorrhea (except in the case of meatus strictures). 
It has been my good fortune to identify congenital strictures thrice 
by careful perineal section. 
It is difficult to arrive at a clinical criterion as to the exact amount of 
constriction that constitutes a congenital stricture. Certainly only 
those strictures require attention that cause retention, interfere with the 
cure of urethritis or prohibit the passage of urethral instruments. 446 
STRICTURE OF THE URETHRA 
Doubtless it is fair to consider any stricture tighter than 18 F. a poten- 
tial, if not an actual, cause of retention. 
Treatment.—Englisch wisely observes that “the earlier the obstacle 
develops, the more extended are the alterations of the urinary tract 
higher up.” He believes that treatment by dilatation is often useful. 
Stricture of the meatus will not dilate. It must be cut. All the deeper 
congenital strictures I have recognized have required operation. 
OTHER TYPES OF STRICTURE OF THE MALE URETHRA. 
Tuberculosis.—Tuberculosis of the prostate very rarely results in 
urethral constriction. Occasionally it causes a stricture of the bladder 
neck, producing frequency of urination or residual urine. This, if not 
organized, yields to (and its symptoms disappear following) the passage 
of the cystoscope. Cicatricial stricture of the deep urethra after the 
subsidence of the prostatic lesion requires operation for the contracture 
(q. v.). 
Tuberculosis of the anterior urethra is so rare that it may be dis- 
missed with the statement that it is usually unimportant but may 
require the routine treatment.8 
Syphilis.—The scar of gumma about the meatus may cause stricture. 
The existence of syphilitic stricture of any importance elsewhere in the 
urethra is doubtful.9 
Chancroid. This may also leave a scar that constricts the meatus. 
Bilharzia.—Pfister7 states that stricture of the prostatic urethra may 
result from Bilharzial inflammation. The infection may rarely extend 
to the anterior urethra and even to the corpora cavernosa. 
Stone, Foreign Bodies, and Cancer may obstruct the urethra. 
They can scarcely be said to cause stricture. 
STRICTURE OF THE FEMALE URETHRA 
Stricture of the female urethra, whether congenital, traumatic, or 
gonorrheal, merits only that its existence be known. Like stricture of 
the male urethra it is a cause of frequent urination, pyuria, retention. 
It may be relieved by dilatation or by internal urethrotomy. It is 
not at all uncommon. Women, like men, often suffer grave symp- 
toms from strictures of rather large calibre. 
BIBLIOGRAPHY. 
1. Englisch: Folia Urolog., 1909, iv, 288, 376. 
2. Halle: Annal. d. ural. d. org. Gen.-Urin., 1891, ix, 143; 1894, xii, 244. 
3. Heinecke: Zeit. f. Urol., 1913, ii, No. 1. 
4. Keyes: Trans. Amer. Genito-Urinary Surg., 1915. 
5. Keyes and MacKenzie: New York Med. Jour., November 9, 1912. 
6. Minet: Guyon’s Annales, 1911, i, 46. 
7. Pfister: Verhandl. d. Deut. Gesellsch. f. Urol., 1911, iii. 
8. Sawamura: Folia Urol., 1910, iv, No. 9. 
9. Tauton: Progress Med., 1910, p. 607. 
10. Thompson: Stricture of the Urethra, 1858, 2d edition, p. 84. SECTION III. 
DISEASES OE THE SCROTUM AND 
TESTICLE. 
CHAPTER XI. 
ANATOMY AND PFIYSIOLOGY, MALFORMATIONS, 
INJURIES AND TORSION OF THE TESTICLE. 
By GEORGE GILBERT SMITH, M.D. 
THE TESTICLE AND EPIDIDYMIS. 
Embryology.—The testicles develop during the first third of fetal 
life. Each testis appears first as the genital ridge upon the ven- 
tromesial border of each Wolffian body (Fig. 194). Peritoneal infold- 
ings give rise to solid cords of cells which extend inward from the peri- 
toneal surface of the genital ridges to connect with the glomerular 
capsules of some of the Wolffian tubules (Fig. 195). Before reaching 
the glomeruli, these cords, which later acquire lumina, form a net of 
anastomosing tubules, which becomes the rete testis. Of the Wolffian 
tubules, ten to fifteen are utilized in this way. The glomeruli atrophy 
and the tubules become coiled canals which form the ductuli efferentes 
in the globus major of the epididymis. The Wolffian duct, into which 
they empty, persists as the ductus epididymidis and its continuation, 
the vas deferens. Of the Wolffian tubules not utilized in this way, one 
or more may persist as very small pedunculated bodies springing from 
the globus major or from the upper pole of the testicle. The organ of 
Giraldes or paradidymis is thus explained; the hydatid of Morgagni is 
said to be a remnant of the duct of Muller. (In the female the duct 
of Muller becomes the Fallopian tube.) One or more of the lower 
Wolffian tubules may persist as aberrant ducts leading off the ductus 
epididymidis in the globus minor23 (Fig. 196), 
Descent of Testicle.—As the testicle takes definite shape a fold of 
peritoneum develops, extending from the lower pole of the testis down- 
ward and outward across the iliac fossa. In the free border of this fold 
develops the gubernaculum, a cord of connective tissue, in which are 
found smooth muscle fibers, supposedly derived from the muscles of the 
447 448 
INJURIES AND TORSION OF THE TESTICLE 
Fig. 194.—From a reconstruction of a 
13.6 mm. human embryo (F. W. Thyng). 
bl., bladder; /., fimbriae;g.g., genital ridge; 
g.p., genital papilla; M.d.,Mullerian duct; 
p., renal pelvis; r., rectum; ur., ureter; 
us., urogenital sinus; W.d., Wolffian duct. 
(Lewis and Stohr.) 
Fig. 195.—Diagram of the development 
of the testis, based upon figures by Mac- 
Callum and B. M. Allen, c., glomerular 
capsule; i.c., inner or sex cords; M.d., 
Mullerian duct; o.c., outer or rete cords; 
W.d., W.t., Wolffian duct and tubule. 
(Lewis and Stohr.) 
ureteY 
bladder 
Mriculus prostaticus - 
bulbourethral gland 
seminal vesicle 
prostatic gland. 
urethra— 
ductus deferens 
appcndi x epididymidis 
para didymis 
.appendix testis 
- ductulus 
efferens 
convoluted tubule 
- rcte testis 
straight tubule 
ductulus aberrans 
ductus epididymidis 
Fig. 196.—Diagram of the male sexual organs (Modified from Eberth, after Waldeyer.) 
The course of the Mullerian duct is indicated by dashes. (Lewis and Stohr.) THE TESTICLE AND EPIDIDYMIS 
449 
abdominal wall.17 Interiorly the gubernaculum has attachments in 
Scarpa’s triangle, to Poupart’s ligament, to the pubic bone, to the root 
of the penis, to the perineal fascia and ischium, and to the bottom of the 
scrotum.17 As the lumbar spine grows, the testicle is left behind, so to 
speak, and thus begins its descent. Whether further descent comes 
about through the same means—that is, by the body growing away 
P Peritoneum. P. V. Processus vaginalis. 
T. Testicle. T.V. Tunica vaginalis. 
S. Scrotum. F.C. Fibrous cord or thread. 
Canal. 
Fig. 197.—Diagram of the descent of the testicle. (Watson and Cunningham.) 
from the testicle—or whether the gubernaculum shrinks and exercises 
an active pull is not known. The fact remains that by the sixth month 
the testis is at the internal inguinal ring, drawn down by the guber- 
naculum and connected with its place of origin by the spermatic vessels. 
The vas deferens, the lower end of which is now attached to the pros- 
tate, is drawn outward and downward, passing in front of the ureter and 
hooking over it. 450 
INJURIES AND TORSION OF THE TESTICLE 
During their descent the testicle and epididymis have been sur- 
rounded by peritoneum except where the membrane is reflected off the 
epididymis. A diverticulum of the peritoneal cavity, the processus 
vaginalis, has preceded the testis into the scrotum. The testicle enters 
the inguinal canal, passes out through the external ring, and at birth or 
shortly after reaches its position in the scrotum. The peritoneal canal 
then becomes obliterated in its upper part, leaving the lower part to 
form a serous sac for the testicle (Fig. 197). 
ANATOMY OF THE TESTICLE. 
The testes are a pair of somewhat oval, slightly flattened bodies of a 
grayish-white color, measuring about an inch and a half in length, one 
inch from before backward, and rather less in thickness.7 As the tes- 
ticles hang in the scrotum the long axis is directed upward, slightly 
forward and outward (Figs. 198 and 199). 
spermatic 
I cord 
I (+ cremaster) 
tunica vaginalis 
propria 
head of 
■'epididymis 
appendix of 
'' epididymis 
superior extremity 
medial surface 
appendix 
of testis 
interior border 
lateral surface ,r' 
\tunica vaginalis 
7 communis 
inferior extremity / 
Fig. 198.—The testis and epididymis, with their investing membranes, seen from in 
front. (Sobotta.) 
The posterior border of the testis bears a crescentic body, the 
epididymis. The upper extremity of the epididymis, or globus major, 
lies upon the upper pole of the testis and is enveloped by a serous cover- 
ing except at its attachment to the testicle. The body of the epididymis 
is applied against, but is separated from the testis by an infolding of the 
serous covering of the organ, which forms an intervening pocket termed ANATOMY OF THE TESTICLE 
451 
the digital fossa. The lower and smaller extremity, or globus minor, is 
attached to the testis only by connective tissue and by the serous cover- 
ing. Irom the globus minor the vas deferens proceeds upward in the 
loose tissue outside the serous sac. 
The spermatic cord, which contains the bloodvessels of the testis, 
enters that organ at a point on the posterior superior border, mesial to 
the epididymis. 
Arising from the groove between the globus major and the testicle is a 
fairly constant structure, the appendix testis, or hydatid of Morgagni, 
this has been found in 90 per cent, of testes examined and is a peduncu- 
spermatic cord -- 
tunica vaginalis communis 
head of epididymis 
tunica vaginalis propria 
appendix of testis 
superior ligament of epididymis 
appendix of epididymis 
sinus of epididymis 
posterior border of testis 
lateral surface 
of testis 
inferior ligament of epididymis _ 
anterior border 
'' of testis 
tail of epididymis 
Fig. 199.—The testis and epididymis, with their investing membranes, seen from the 
lateral surface. (Sobotta.) 
lated tumor consisting of vascular connective tissue and containing 
fragments of canals lined with simple columnar epithelium, sometimes 
ciliated.23 It is thought to represent the Mullerian duct. Attached to 
the globus major of the epididymis is the paradidymis, or organ of 
Giraldes. 
The tunica vaginalis, which lines the cavity in which the testis and 
epididymis are contained, consists of a parietal portion and a visceral 
portion. The parietal layer extends for some distance above the testis, 
and the space which it lines is considerably larger than the organs con- 
tained therein. The testis and epididymis are completely invested by 
the visceral portion, save at the points of contact between the two, at 452 
INJURIES AND TORSION OF THE TESTICLE 
the posterior border of the testis, where the spermatic cord is attached, 
and at the inner, posterior aspect of the epididymis. 
The attachment of the testis to the scrotum at this point is frequently 
called the mesorchium. As Rigby and Howard40 have pointed out, the 
mesorchium, properly speaking, lies between testis and epididymis, and 
is usually short; the attachment of testicle and epididymis to the scrotal 
wall should be called the urogenital mesentery. 
Finer Structure.—Testis.—The testis is enveloped in a tough fibrous 
coat called the tunica albuginea. At the point of entrance of the 
spermatic vessels this becomes thicker and forms the mediastinum, 
or corpus highmori. The inner layer of the tunica albuginea is very 
vascular, and from it spring fibrous septa which, passing to the medi- 
astinum, divide the testis into some 200 cone-shaped lobules. Each of 
head of epididymis 
spermatic cord 
mediastinum 
* testis 
lobules of 
testis ‘ 
septula of 
testis ‘ 
tunica '' 
albuginea 
Fig. 200.—Longitudinal section of the testis and epididymis. (Sobotta.) 
tail of epididymis 
these contains three or four seminiferous tubules, which can be un- 
ravelled and appear to the naked eye like fine threads. They unite to 
form a smaller number of straight tubules, the tubuli recti, and these in 
turn open into the rete testis, a complicated network of canals occupying 
the mediastinum (Fig. 200). 
Epididymis.—From the rete testis some fifteen or twenty ducts, so 
coiled as to present cone-shaped masses with their apices toward the 
testicle, carry the secretion to the main duct of the epididymis. The 
smaller ducts are the vasa efferentia, the single duct is the ductus epid- 
idymidis. About 20 feet long when unravelled, this duct comprises the 
body and lower pole of the epididymis, and leaves it as the vas deferens 
(Fig. 196). 
Histology of the Testicle.—Aside from the connective-tissue frame- 
work, three kinds of cells occur in the testis. Two of these are found in ANATOMY OF THE TESTICLE 
453 
the seminiferous tubules—the sustentacular or supporting cells, often 
called the cells of Sertoli, and the sexual cells (Fig. 201). The latter may 
Spermatids. _ 
Blood vessel with 
blood corpuscles, 
Sustentacular cell. 
Interstitial cells. 
Spermatogonium. 
Fat 
granules- 
Spermatids. 
Sustentacular cell. Spermatogonia, beneath Sustentacular cells, 
large spermatocytes. 
Fig. 201. —Cross-sections of seminiferous (convoluted) tubules of a mouse. 
(Lewis and Stohr.) 
X 360. 
Fig. 202.— Cross-section of a 
convoluted tubule of the testis at 
birth. (Eberth.) 
Fig. 203.—Sustentacular cells, a, isolated 
(Kolliker). Golgi preparations. (Bohm and 
von Davidoff.) 
appear in any one of the five stages through which they must pass before 
becoming mature spermatozoa. (See Physiology of the Testicle, p.457.) 
The sustentacular cells extend from the basal membrane of the tubules 454 
INJURIES AND TORSION OF THE TESTICLE 
toward the lumen. Early in life they form a syncytium; later, as 
spermatogenesis takes place, they become cylindrical in shape, with an 
outline made irregular by the pressure of the sexual cells which develop 
spermatozoa. 
Heads of 
Spermatid. 
Spermatocyte 
Nuclei of sus- 
tentacular cells. 
Sperma- 
togonium. 
Crystalloids in 
interstitial 
cells. 
Interstitial con- 
nective tissue. 
Fig. 204.—From a longitudinal section through a convoluted tubule of a human testis. 
X 360. (Lewis and Stohr.) 
between them (Figs. 202 and 203). Each cell has an ovoid nucleus 
with a distinct nucleolus; the protoplasm contains fat droplets, brown 
granules, and at times crystalloid bodies in pairs.24 
section 
of a ductulus 
eflerens. 
Connective tissue 
Blood vessel. 
Epithelium Circular muscles 
of the ductus epididymidis. 
Transverse section of a 
ductulus efferens. 
Fig. 205.—From a section of the head of a human epididymis, showing sections of the 
ductus epididymidis in the centre and of ductuli efferentes on the sides. X 50. (Lewis 
and Stohr.) 
The third kind of cell, the interstitial cell, or cell of Leydig, occurs 
in the loose connective tissue between the tubules. These cells are 455 
ANATOMY OF THE TESTICLE 
derived from the mesothelium of the genital ridge;51 they are usually 
round or polygonal in shape, without distinct cell boundaries. Their 
protoplasm contains pigment and other granules, fat droplets, and rod- 
shaped crystalloids. During fetal life (Fig. 204) the interstitial cells 
are relatively abundant; after birth they rapidly diminish and are not 
much in evidence until puberty, wrhen they undergo a renewal of growth 
and remain constant. After puberty they recede somewhat until 
senile changes set in, when they again increase. 
Histology of Epididymis.—The epithelium of the convoluted tubules 
of the testis becomes more simple in the tubuli recti and rete testis, and 
in the efferent ducts of the epididymis consists of groups of columnar 
cells alternating with cuboidal cells. Often the tall cells, and occasion- 
ally the short ones, are ciliated. The efferent ducts have a circular 
coat of smooth muscle fibers containing elastic fibers. The ductus 
..Epithelium. 
Tunica propria. 
Inner longitu- 
dinal muscles. 
Circular 
muscles. 
Outer longitu- 
dinal muscles. 
Connective 
tissue. 
Fig. 206.—Cross-section of the human ductus deferens. 
X 24. 
(Lewis and Stohr.) 
epididymidis is lined by a two-rowed epithelium with rounded basal 
cells and tall outer columnar cells. The latter have in the middle of 
their upper surfaces long non-motile hairs. A thick circular muscle 
layer surrounds the duct24 (Fig. 205). 
The vas deferens at the epididymal end is lined with two-rowed, 
ciliated epithelium, and is surrounded by three layers of smooth muscle, 
the inner and outer longitudinal, the middle layer circular (Fig. 206). 
Blood Supply of Testicle and Epididymis.—The chief artery of the 
testis is the internal spermatic, which is given off the abdominal aorta 
just below the renal arteries, supplies a branch to the ureter as it crosses, 
and passes with the spermatic cord through the inguinal canal to the 
testicle. Before entering the testis it gives a branch to the globus 
major of the epididymis. The main stem then passes into the medias- 
tinum, where it breaks up into many branches. These reach the 456 
INJURIES AND TORSION OF THE TESTICLE 
parenchyma through the tunica vasculosa and through the septules, 
and form capillary plexuses around the convoluted tubules. The body 
and tail of the epididymis are supplied by the deferential artery, which 
adheres closely to the vas deferens until it reaches the epididymis. This 
artery is a branch of the inferior vesical, or sometimes of the superior 
vesical.28 A third artery enters the lower pole of the testis or epididy- 
mis. This is the external spermatic, funicular or cremasteric artery, 
which is given off the deep epigastric and runs in the fibrous sheath of 
the spermatic cord. 
Picque and Worms38 have shown that in dogs there is free anastomosis 
between these three arteries. The exact nature of the anastomosis 
varies, but in every case of the 24 which they studied, the existence of 
such a communication was clearly shown. They found no connection 
between the arteries of the testicle and those of the scrotum. 
The veins follow the arteries in the testiqle and epididymis. Upon 
issuing from these organs, they form a plexus, the pampiniform plexus. 
The plexus is part of the spermatic cord, and consists of eight to ten 
veins; they traverse the inguinal canal, and near the internal ring ter- 
minate in two main trunks which higher up unite to form a terminal 
stem. The right terminal vein enters the inferior vena cava, the left 
one enters the left renal vein. The spermatic veins are provided with 
valves both in their course and at their terminations, but occasionally 
the valve at the orifice of the left spermatic vein is absent.7 
Lymphatics.—The lymphatics which drain the testes follow the 
spermatic cords and enter the lumbar nodes. These nodes, it will be 
remembered, also receive the drainage from the kidneys. The lymph- 
atics of the vas deferens empty into the external iliac nodes.29 
Nerves.—The nerves for the testis accompany the spermatic artery, 
and are derived from the aortic and renal plexuses. In the epididymis 
the nerves form the plexus myospermaticus, which is a network in the 
muscular coat of the ducts, provided with sympathetic ganglia. 
PHYSIOLOGY OF TESTICLE AND EPIDIDYMIS. 
The testis appears to have two functions. One is concerned with the 
production and development of spermatozoa, the other has to do with 
the furnishing to the organism of an internal secretion. The first 
function is carried on by the cells lining the convoluted tubules, namely, 
the sustentaeular cells and the sexual cells; the second, by the inter- 
stitial cells. The function of the sustentaeular cells is to support and 
nourish the sexual cells during their development. Fig. 203 shows 
several spermatozoa with their heads embedded in the protoplasm of a 
sustentaeular cell. It has already been mentioned that these cells 
abound in fat. Von Ebner49 has described a circulation of this fat from 
the base of the sustentaeular cell toward the lumen of the tubule, dur- 
ing the course of a spermatic generation. As the spermatozoa devel- 
oped, the fat diminished. Hanes and Rosenbloom14 have shown that 
the testes from cryptorchid pigs, in which there is very little sperma- PLATE VI 
SPERMATIC 
ARTERY"' 
CREMASTERIC 
L ARTERY 
DEFERENTIAL 
"artery 
_SEMINAL 
"duct 
ANTERIOR 
GROUP OF— 
VEINS 
POSTERIOR 
-GROUP OF 
VEINS 
_ ANASTOMOSIS 
OF VEINS 
The Arteries of the Testis and the Cord. (Gray.) PLATE VII 
Arterial Supply of Human Adult Testis. A Portion of the 
Gland has been Removed so as to Show the Penetration of the 
Arteries through the Mediastinum into the Glandular Tissue. 
A, B, main terminal branches to testicle; C, branch following spermatic 
cord and encircling and supplying vas deferens; CA, capsular artery—a 
branch from B; C.E., caput epididymis—shown in outline; D, branch of cap- 
sular artery lying on innermost side of albuginea; E, outline of epididymis; 
F, central artery connecting vessels of mediastinum with capsular branches; 
M, mediastinum. X 3§. (Hill.) PLATE VIII 
Sagittal Section of Human Testis; to show Blood Supply. Injected 
with Red and Blue Celloidin, cleared in 1 per cent. KOH and 20 per 
cent. Glycerin. X 4. 
AA, ascending artery; AV, ascending vein; DA, descending artery; DV, descending 
vein; M, mediastinum; VD, vas deferens; TA, tunica albuginea; TP, tunica parietalis. 
(Hill.) PHYSIOLOGY OF TESTICLE AND EPIDIDYMIS 
457 
togenesis, contain an excessive amount of fat, and they have also shown 
that as the fat passes toward the lumen of the tubule, it changes from a 
neutral fat to a lipoid. 
No further function of the sustentacular cells has been demonstrated. 
The sexual cells undergo a transformation which is called “ sperma- 
togenesis.” The cells pass through five phases: (1) The spermatogonia, 
or mother cells, lie nearest the basal membrane of the tubule. (2) 
Above them are the primary spermatocytes, which are larger; their 
nuclei usually show spiremes or other indications of cell division. (3) 
Secondary spermatocytes lie still nearer the lumen, and beyond them 
are (4) the spermatids. Each 
mother cell eventually divides 
into 4 spermatids. (5) Each 
spermatid develops into a sper- 
matozoon. Van Beneden16 has 
shown that in ascaris the number 
of chromosomes of the mother cell 
has been reduced, during these 
cell divisions, so that each sper- 
matozoon contains only one-half 
as many chromosomes as did the 
mother cell. Von Bardeleben48 
extended this discovery to man, 
and it has been further shown 
that the mature spermatozoon 
contains one-half the number of 
chromosomes characteristic of the ' 
tissue cells of the species in ques- 
tion16 (Fig. 204). 
The change from spermatid to 
spermatozoon is shown in Fig. 
207. 
Mature spermatozoa are di- 
vided into three parts — head, 
neck and tail. When they be- 
come free they float in the albu- 
minous fluid secreted in small 
amount by the tubules of the testis. They pass to the epididymis, 
in which they accumulate and in the secretion of which they first 
become motile. About 60,000 spermatozoa occur in a cubic milli- 
meter of seminal fluid.24 
In addition to its secretory function the epididymis, according to 
some observers, functions also as an organ of excretion. Belfield has 
demonstrated that particles of dyestuff after being injected into the 
anterior abdominal wall may be found in the tubules of the epididymis. 
He attributes this to the excretory function of the epididymis, due 
to its derivation from the Wolffian tubules, which were excretory 
organs. 
Fig. 207. —Diagrams of the development 
of spermatozoa. (After Meves.) a.c., 
anterior centrosome; a./., axial filament; 
c.p., connecting piece; ch.p., chief piece; 
g.c., galea capitis; n., nucleus; n.k., neck; 
p., protoplasm; p.c., posterior centrosome. 
(Lewis and Stohr.) 458 
INJURIES AND TORSION OF THE TESTICLE 
Interstitial Cells.—It is a well-known fact that if the testes are 
removed from man or animal early in life the castrated individual will 
show failure of development of the so-called “ secondary sexual char- 
acteristics.” * If the testes do not descend into the scrotum their sper- 
matogenetic function in many cases atrophies. The tubules of the 
testis show fatty or fibrous degeneration, but the number of interstitial 
cells increases. In such cases the secondary sexual characteristics are 
well developed, and sexual desire may be above the average.13 
This seems fairly conclusive evidence that the interstitial cells are 
responsible for an internal secretion which has considerable influence, to 
say the least, in the development of sex characteristics. 
As Pappenheim and Schwartz35 point out, lesions of other glands of 
internal secretion, such as the adrenals and pituitary body, are regularly 
accompanied by poor development of the sex characteristics, so that 
the testes alone are not responsible. Pappenheim and Schwartz main- 
tain, furthermore, that the sustentacular cells cannot be excluded, 
inasmuch as they do not atrophy in many cryptorchids. Whitehead51 
presents a case which comes near to answering their argument. A stal- 
lion was not cured of his sexual desire by the removal of two apparently 
normal testicles. Two years later a third testis was removed from the 
abdominal cavity. His desire ceased. The testis on section showed 
marked increase of the interstitial cells, and atrophy of the sustentacular 
cells as well as of the sexual cells. 
The interstitial cells contain granules which have the same staining 
reactions as do the granules in the cells of other organs of internal 
secretion. On the evidence so far presented it seems justifiable to state 
that the interstitial cells are at least intimately concerned in and neces- 
sary for the normal development of the secondary sexual characteristics. 
There is considerable evidence to show that their existence is essential 
to sexual desire. 
MALFORMATIONS 
OF THE TESTICLE. 
Anomalies in 
number 
In excess 
In deficiency 
Polyorchism 
Absence 
Fusion 
Anorchism 
Synorchism 
A. Anomalies in 
development 
Anomalies in 
size 
In excess 
In deficiency 
Hypertrophy 
Atrophy 
At some point in its nor- Retention 
mal course 
Outside its normal course Ectopia 
B. Anomalies in 
development j 
Testicle 
llfe , , 
undescended 
Testicle 
descended 
Upside down Inversion 
Hind side foremost Retroversion 
Adapted from Monod and Terrillon, p. 2.) 
* Such as deep voice, masculine form, hairy growth on body, etc., as well as sexual 
desire. MALFORMATIONS OF THE TESTICLE 
459 
Polyorchism.—There seems good evidence that cases of more than 2 
testes have occurred in man. D. S. Lamb19 reviewed the literature on 
this point, and although he found the condition mentioned by Aristotle 
b.c. 350, and a good many times thereafter by other observers, he found 
only 23 cases in which the theory was supported by the presence of vas 
or epididymis in connection with the alleged extra testicle. It cer- 
tainly is probable that in many cases the observer was misled by an 
encysted hydrocele or vestigial tumor, which happened to yield testic- 
ular sensation when squeezed. Lamb found reports of 6 cases, how- 
ever, in which a third testicle was discovered at operation or at autopsy: 
2 of them were in horses, 1 in a dog, 3 in men. 
Fig. 208.—Ectopic testis, transverse section. 
Lamb himself reported the case of a man examined during life by 
Lamb and numerous other observers, all of whom agreed upon the 
existence of a third testicle. 
Arbuthnot Lane20 removed a third testis from the right side of the 
scrotum of a boy, aged fifteen years. It was the size of a marble, but 
had no testicular sensation. It had a tunica vaginalis and vas deferens 
of its own. Microscopic sections were made. The other testis occupy- 
ing the right side of the scrotum was extruded and seemed normal. 
The left was not exposed, but felt normal on palpation. 
Whitehead51 reports the examination of a third testis removed from 460 
INJURIES AND TORSION OF THE TESTICLE 
the abdomen of a horse which had had two testes removed in the usual 
manner two years before. It seems, therefore, that although extremely 
rare, triorchism may occur. 
Anorchism.—Jacobson17 credits to the French writers this classifi- 
cation of deficiencies in the seminal apparatus. 
1. Absence of the testicle only. 
2. Absence of the testicle, the epididymis, and a portion, more or less 
extensive, of the vas deferens. 
3. Absence of the whole apparatus. 
4. Absence of all or part of the excretory apparatus, the testicle 
being present. 
5. Bilateral anorchism. 
Jacobson, writing in 1893, had found recorded 5 cases of absence of 
the testicle only. The unilateral absence of testis, epididymis, and a 
portion of the vas was met most frequently; there were but 2 cases 
recorded of entire absence of the whole seminal apparatus. Absence of 
the epididymis alone may occur. Gruber, professor of anatomy in 
Petrograd, writing in 1868, could collect only 23 cases of unilateral and 
7 of bilateral anorchism which wTere verified by autopsy.17 
Synorchism.—The fusion of both testicles within the abdomen has 
been reported by Cruveilhier.6 Their fusion within the scrotum has 
been reported by Lenhossek21 and by A. E. Halstead,12 in whose case 
the epididymes were fused (Fig. 208). 
Hypertrophy and Atrophy.—The condition of atrophy of one testicle 
is not infrequent, and many times no history of a preceding lesion can be 
found to account for the condition. In some of these cases, the other 
testicle appears to have undergone hypertrophy. 
IMPERFECT DESCENT OF THE TESTICLE. 
The descent of the testicle may be stopped at any point. Retention 
within the abdomen is the least common variety, and, as the testis is 
hidden from view, the condition is called “ cryptorchism.” The term is 
loosely applied to other forms of arrested descent as well. Within the 
abdomen, the organ may remain in the iliac fossa close to the spine, or 
may stop just inside the internal inguinal ring. The most usual form of 
incomplete descent is the “inguinal,” in which the testis is retained 
within the canal. Or the descent may stop just after the testis has 
emerged from the canal. (Cruroscrotal or scrotofemoral retention.) 
The testicle may be movable and change its positions frequently, so 
that at times it belongs in one group, at times in another. 
The cause of arrest of descent of the testicle is not clearly worked out. 
Certain it is that in operations for this deformity, shortness of the 
spermatic vessels offers the greatest obstacle to placing the testis in 
the bottom of the scrotum. Eccles10 mentions a number of conditions 
which may be factors in producing the anomaly. These are: 
Conditions associated with the mesorchium: 
1. The mesorchium may be too long. The testis would then hang IMPERFECT DESCENT OF THE TESTICLE 
461 
too freely within the abdominal cavity, and thus be prevented from 
engaging in the opening into the inguinal canal. 
2. Adhesions may have formed between the peritoneum of the 
mesorchium and the adjacent portion of the peritoneum. 
3. An abnormal persistence of the plica vascularis may unduly tether 
the testis. 
Conditions associated with the testis and its component parts: 
1. The spermatic vessels may be too short. 
2. The vas deferens may be of insufficient length. 
3. The testis itself may be of abnormal size as compared with the 
usual size of the track along which it has to leave the abdomen. 
4. The epididymis may be of abnormal size. 
5. There may be a fusion of the two testes. 
6. Certain forms of hermaphroditism. 
Conditions associated with the gubernaculum testis: 
1. There may be a deficiency or absence of the lower or scrotal 
attachments. 
2. may be a deficiency of the activity of its muscular fibers. 
3. Possibly even a want of its upper attachments may lead to a fault 
in descent. 
Conditions associated with the cremaster: 
1. A want of action of the internal fibers of the cremaster before the 
testis has reached the inguinal canal. 
2. A retraction by the action of the cremaster of the testis after it has 
gained its normal position in the scrotum . 
Conditions associated with the route along which the testis passes: 
1. An ill-development of the inguinal canal. 
2. An ill-development of the superficial abdominal ring. 
3. An ill-development of one-half of the scrotum. 
Other conditions not falling under the above headings: 
1. Pressure of a truss for an accompanying hernia preventing the 
onward passage of the testis from the inguinal canal to the 
scrotum. 
In certain cases, although the body of the testis proper may be re- 
tained within the canal, the vas and even the epididymis may descend 
to a much lower level, and can be felt outside the canal.10 
Incidence.—Incomplete descent of the testicle during the first few 
months of life is quite common. Soch in the examination of 143 male 
infants of from one to four months of age, found this condition in 14 
per cent. In 60 per cent, of these it was bilateral. The great majority 
of such testicles descend during the first year, and a few of the remaining 
descend during the years before puberty. Odiorne and Simmons3" re- 
ported 3 cases in which descent occurred at fourteen years of age. 
In adults incomplete descent of the testicle is by no means rare. 
Marshall25 found 12 cases in 10,800 recruits (0.1 per cent.). Hempel15 
gathered statistics which showed that in 7,000,000 Austrian recruits, 
14,000 were so affected (0.2 per cent.). 
Neither side appears to be particularly liable to this anomaly 462 
INJURIES AND TORSION OF THE TESTICLE 
(Jacobson). Of the 77 cases reported by Odiorne and Simmons, 15 
were bilateral, 39 were on the right side, 23 on the left. 
Ectopic Testis.—When the testicle, instead of reposing at some point 
along the usual path of its descent, lies outside that path, the condition 
is known as ectopia. The testicle may become ectopic through violence 
(see Injuries of Testicle); the condition is then known as luxation of the 
testicle. Congenital ectopia is believed to be due to an abnormal pull 
exerted by certain fibers of the gubernaculum, associated perhaps with 
some abnormality of the testis or inguinal canal which hinders proper 
descent. Constant pressure by an accompanying hernia, especially if 
further progress is impeded by some abnormality ahead of the testicle, 
may also be a factor in driving it out of its course (Eccles). 
Fig. 209.—Inguinal retention, on both sides, in a boy aged twelve years; interstitial 
subvariety. The dotted lines indicate the position of the testes. The left is a little 
lower than the right. The scrotum is ill-developed. (Osborn.) 
The varieties of ectopia are: 
1. Interstitial. The testicle lies properitoneally (Ilempel) or in front 
of the aponeurosis of the external oblique. 
2. Penile. The testis lies in the soft tissues between the root of the 
penis and the pubes. Two cases have been reported by W. Popow,33 
and one by J. Poupart.37 
3. Crural (or Femoral). The testis lies in Scarpa’s triangle. Jacob- 
son17 quotes several cases in which the testis left the abdomen by the 
crural canal. Eccles10 casts doubt upon the accuracy of the observa- 
tions in such cases, and says that in careful dissections the cord has 
always been found to lie in front of Poupart’s ligament. 
4. Perineal. The testis lies in the perineum; the scrotum on the side 
of the ectopia is usually atrophied. A firm band of tissue holding the 
testicle to the spine of the ischium can generally be felt. This is the IMPERFECT DESCENT OF THE TESTICLE 
463 
type of ectopia most frequently encountered, and seems to result in 
less damage to the testicles than do the other kinds15 (Fig. 209). 
5. Transverse. Both testes descend by the same inguinal canal. 
Cases have been reported by Lenhossek,21 in 1845, Jordan,18 in 1885, 
Berg,2 in 1904, and A. E. Halstead,12 in 1907. 
Inversion and retroversion of the testis need only be mentioned. 
The latter condition, in which the epididymis is toward the front, is 
said by Rigby and Howard39 to occur once in every twenty men, a 
statement which we cannot believe represents the facts. 
The Effects of Incomplete Descent upon the Testis Itself.—The effects of 
incomplete descent upon the testis are much the same whether the organ 
is arrested in its normal path or whether it is ectopic. The exposure of 
the testicle to the pressure of overlying tissues and to repeated knocks 
Fig. 210.—Section from undescended testicle removed from man of twenty-nine years. 
Position pubic. The testicle was soft, 2x1 cm. in diameter, and fastened to the wall of the 
hernial sac. The greater part of the organ was composed of rather dense fibrous tissue 
with many small oval nuclei and containing large numbers of Reinke’s crystals. There 
were many interstitial cells. The tubules were scattered irregularly throughout the 
sections and for the most part were represented by masses of hyaline tissue. This case 
illustrates the more advanced type of atrophy. (Odiorne and Simmons.) 
such as a normally descended gland would escape are the only factors 
which are known to have a harmful influence.1 The atrophy is 
probably due to anemia caused by constant pressure upon the circu- 
lation in the testis and results in small, soft testicles with disturbed 
function. 
The fact remains that practically all undescended testicles show 
definite changes in function and in morphology. The spermatogenetic 
function weakens or disappears entirely; undescended testicles are 
usually, though not always, sterile. The sexual cells disappear, although 
their supporting cells, the sustentacular cells, show no alteration except 
an increase in the amount of fat which they contain. Men with bilateral 
undescended testes, on the other hand, are not impotent; the interstitial 
cells show hyperplasia, and this overdevelopment is more marked in 464 
INJURIES AND TORSION OF THE TESTICLE 
undescended testes the fellows of which are wanting. In some testicles 
the degenerative changes advance so far that even the interstitial 
tissue is affected, the entire testis becoming merely a fibroma31 (Figs. 
210 to 212). 
Fig. 211.—Section from an inguinal testicle from a man of twenty-three years. The 
testicle was 3 x 1.5 cm. in diameter. There was no increase in the fibrous tissue, which, 
however, contained many small areas of interstitial cells. The basement membrane 
of the tubules was only slightly thickened, but they contained only sustentacular cells, 
no spermatogenetic cells being seen in any section. (Odiorne and Simmons.) 
Fig. 212.—Section from an inguinal testicle from a man of thirty years. The fibrous 
tissue was increased and contained many interstitial cells. The tubule in the lower 
part of the field is nearly obliterated by the thickening of the basement membrane. 
The tubule in the upper part of the field shows active spermatogenesis in the lower por- 
tion. (Odiorne and Simmons.) 
The age at which these changes occur is variable; authorities differ 
on this point. The subject is of considerable importance, inasmuch as 
the best time to operate depends upon the age at which degenerative 
changes commence. G. Bellingham Smith43 examined six undescended IMPERFECT DESCENT OF THE TESTICLE 
465 
testes from boys under the age of puberty and found all of them smaller 
than normal, with fewer tubules and more interstitial cells. This 
condition held even in a testis from a three-year-old boy. On the 
other hand, a number of instances have been reported of young men 
with both testicles undescended who have been fertile.1 Odiorne and 
Simmons published microphotographs from an undescended testicle 
in a man, aged thirty years, in some of the tubules of which active 
spermatogenesis was going on (Fig. 212). Beigel1 found living 
spermatozoa in the semen of a man, aged twenty-two years, with 
bilateral inguinal retention. Monod and Terrillon27 and Jacobson17 
believe that in young adults undescended testes may still be fertile, 
but that with the atrophy which is certain to follow, sterility is sure 
to result. 
In addition to the above-mentioned changes the undescended testicle 
is likely to be tender, and is particularly liable to injury. If retained in 
the inguinal canal the pressure of the fascia as the abdominal muscles 
contract may be the cause of pain. Ectopic testicles of the perineal 
type are particularly exposed in riding horseback. Those of the penile 
type suffer during intercourse. Undescended testicles are liable to any 
of the diseases which affect the normal organ, perhaps to an even greater 
degree, and the process, if inflammatory, may set up a peritonitis 
through the open processus vaginalis. Hydrocele may exist. Eccles 
relates a case in which the fluid collected in the scrotal part of the 
tunica vaginalis, while the testis remained in the inguinal canal. 
Torsion is especially prevalent in undescended testes. In the 32 
cases of torsion collected by Scudder42 in 1901, 47 per cent. wTere in 
undescended testes. Eccles (p. 64) gives the following predisposing 
causes for torsion of the retained testicle: 
1. Imperfect descent of the testis. 
2. Abnormally long mesorchium. 
3. Practical absence of a mesorchium. 
4. Action of the gubernaculum testis. 
5. A congenital twist of the cord. 
6. A roomy tunica vaginalis. 
7. A flattened condition of an imperfectly descended testis. 
He believes that the chief predisposing cause at work is partial 
descent with a freely movable testis. 
The exciting causes of torsion he considers to be: 
1. Muscular effort. 
2. A mechanical twist. 
3. The action of the cremaster. 
4. The application of a truss. 
5. Attempts at a reduction of the hernia by taxis. 
6. Approach of puberty. 
The symptomatology, pathology and treatment of torsion will be 
taken up under Torsion of the Testicle. 
Coincident with failure in the descent of the testicle, there fre- 
quently exists failure of the processus vaginalis to close. A path is 466 
INJURIES AND TORSION OF THE TESTICLE 
thereby left open for the protrusion of the abdominal viscera. Every 
undescended testis, says Moschkowitz, is accompanied by a potential 
or an actual hernia. In the 92 undescended testes reported by Odiorne 
and Simmons, hernia was present in 49 (57 per cent.). Of these, 10 
were strangulated. In some cases the hernia occupies a separate sac, 
or the hernial sac may invaginate the tunica vaginalis as it blocks the 
inguinal canal. A hernia of such a type is doubtless brought about by 
the dilatation of the inguinal canal caused by the retained testicle. The 
testicle may act as a ball valve and bring about strangulation of the 
hernia or may block its progress through the canal and force it to 
burrow out between the muscular layers. 
Diagnosis.—The differential diagnosis between strangulation of a 
hernia accompanying an undescended testis and acute epididymitis or 
torsion of the testicle itself may be difficult, particularly in the first 
twenty-four hours. A strangulated hernia is less painful locally but 
more disturbing generally; the vomiting is more persistent, the tem- 
perature normal or subnormal; the abdomen increasingly distended. 
Torsion of an undescended testicle is most painful at first, the pain 
decreasing after a few hours. There may be nausea, but the vomiting 
is not so marked a feature. The temperature is normal or slightly 
elevated. Locally, the tenderness is intense, the swelling only moder- 
ate in degree. The overlying skin may be reddened. Clear urine and 
a negative history of urethritis favor both these diseases, whereas the 
presence of a urethral infection would make one strongly suspicious of 
acute epididymitis. If epididymitis is developing, the temperature is 
likely to be elevated; the testicle is not much enlarged, but is acutely 
tender. The overlying skin reflects the underlying inflammation by 
edema and redness. After the first twenty-four hours, the epididymis 
may be differentiated from the testicle. 
* Whichever diagnosis is arrived at, there is but one safe course. 
Operation at once is indicated, not only to relieve the possible strangu- 
lated hernia, but to prevent the infection which may develop in torsion 
or in epididymitis from spreading to the peritoneal cavity through the 
hernial sac which is almost always present. 
Treatment of Undescended Testicle.—To recapitulate briefly, the unde- 
scended testicle if left alone is almost sure to cease functioning; it is 
liable to injury, to torsion, perhaps to tumor growth. The chances are 
more than even that sooner or later a hernia will develop. In very 
young children the descent of the testis may be encouraged by gentle 
massage above and behind the gland (Langenbeck). The use of a 
forked truss is not advised by Moschkowitz. If the testis does not 
descend of its own accord, operation is indicated. 
Age at Operation.—Most writers on this subject are agreed that 
operation before the age of three is contra-indicated by smallness of 
the parts and the difficulty in keeping the child dry. As to the time of 
election for operation, there is a diversity of opinion. Moschkowitz 
does not operate on children under three years. Bevan thinks from 
six to twelve years is the best time; Eccles, from six to eight years. IMPERFECT DESCENT OF THE TESTICLE 
467 
Operative Treatment.—In the history of operative treatment of un- 
descended testicle three operations appear—orchidectomy, reposition of 
the organ within the abdomen, and orchidopexy, or the placing of the 
testicle within the scrotum. Today the only indications for orchid- 
ectomy are the presence of neoplasm or of such injury to the testicle 
through gangrene, inflammation or fibrous change as to render it worth- 
less or dangerous to the individual. Reposition of the testes wuthin the 
abdomen is bad surgery. Their function will be destroyed, and if any 
of the accidents to which the testicle is liable should befall them, they 
are inaccessible. The only justifiable operation for an otherwise healthy 
retained testicle is orchidopexy, and every undescended testicle which 
can be palpated should, according to Bevan,4 be so treated. Even 
intra-abdominal testes, provided they give symptoms, should be brought 
into the scrotum. The first operation for this purpose was described by 
Schuller41 in 1881. He advised closing off the processus vaginalis to 
make a tunica vaginalis, repair of the accompanying hernia and suture 
of the testis to the bottom of the scrotum. Various modifications of 
this operation were suggested, the innovation usually consisting of a 
new method of anchoring the testicle in the scrotum.30 None of these 
was generally successful, however. The testicle would retract. It re- 
mained for A. I). Bevan,3 in 1899, to suggest an operation which would 
give the three essentials—namely, a viable testis, the permanent estab- 
lishment of that testis well down in the scrotum, and the repair of the 
accompanying hernia. 
Bevan pointed out that the structure which prevented the placing of 
the testicle in the scrotum was not the vas deferens, but was the sper- 
matic cord. He therefore lengthened this cord as much as possible by 
separating the adhesions between its loops and by freeing it from the 
peritoneum of the lateral and posterior walls of the abdominal cavity. 
If it was still too short he cut it, leaving the testicle to draw its blood 
supply from the deferential artery. Although anatomical researches 
by Picque and Worms have demonstrated a constant anastomosis 
between the spermatic, the deferential and the funicular arteries, the 
complete division of the spermatic cord has frequently resulted in 
atrophy of the testicle. Bevan himself, writing upon this subject 
in 1918 (Surgical Clinics, Chicago, 1918, ii, 1101-1117), still advised 
the employment of this technic in case the testis could not be brought 
into the scrotum without tension upon the cord. He said that in 
between 400 and 500 cases, division of the cord was necessary in 
only 10 per cent. Pie admitted that necrosis or atrophy resulted 
in about 16 of his cases. The fact that since Bevan’s first article, a 
number of modifications in technic have been devised, all of which 
aim to make unnecessary the division of the cord, is proof that this 
step in the operation is unsatisfactory. (I)avison,9 Keyes,53, Mixter,26 
Wolfer.52) 
C. G. Mixter,26 reporting end-results in cases of undescended tes- 
ticle operated at the Children’s Hospital, Boston, states that of 9 
cases in which the spermatic cord had been severed 7 reported, and 468 
INJURIES AND TORSION OF THE TESTICLE 
in every case the testicle showed marked atrophy. In 14 cases, in 
which no spermatic vessels were cut, no testicles were atrophied. 
Three cases in which the spermatic vessels were cut had undescended 
testicles on the other side; Mixter says “In every case the testicle 
was atrophied on the side where the vessels were cut, while where 
the vessels were left intact the testicle developed normally.” 
It is our feeling, therefore, that the ligation and division of the 
spermatic cord should be avoided, as it is almost certain to result in 
atrophy of the testicle. The other points to which Bevan calls atten- 
tion, particularly the stripping of the peritoneum off the cord, are 
important. 
The time at which the operation should be done is preferably 
when the boy is between eight and fourteen years of age. It may 
be done much earlier, if the accompanying hernia is troublesome. 
In such cases a truss should never be worn. 
The steps of the operation are as follows4 (Figs. 213 to 225). 
Fig. 213.—Undescended testicle. (Bevan.) 
If the gland is palpable, make an incision three inches long over the 
inguinal canal. Do not carry the incision below the external inguinal 
ring. Open the canal. Divide the cremasteric and transversalis 
fascise. Open the processus vaginalis. Divide the sac at its neck, and 
free the peritoneal portion from the spermatic cord. Close the lower 
portion of the processus vaginalis* around the spermatic cord by means 
of a purse-string suture, to form a tunica vaginalis. Draw down on the 
cord, meanwhile dividing with tissue forceps the little bands of fascia 
which bind the loops of the vessels together. With one finger in the 
abdominal cavity, free the spermatic vessels from the posterior surface 
* Closure of the processus vaginalis around the spermatic cord, as advised by Bevan, 
is almost certain to produce a hydrocele.—Editor. IMPERFECT DESCENT OF THE TESTICLE 
469 
of the peritoneum. Distend the scrotum with the fingers and place the 
testicle therein. If the spermatic cord is still too short it may be 
divided between ligatures. If this is done the vas and its artery must 
be handled with particular care, since the blood supply of the testis 
Fig. 214 
Fig. 215 
External oil/'pie 
\ Cremastericfascia divided 
Point at which vapicalprocess 
should he divided 
Fig. 216 
Figs. 214 to 217.—Undescended testicle. (Bevan.) 
Fig. 217 
depends upon their integrity. After the testis is placed in the scrotum 
a purse-string suture is taken through the neck of the scrotum in front 
of the vessels. The suture should pass through the superficial fascia 
and the pillars of the external inguinal ring as well. 470 
INJURIES AND TORSION OF THE TESTICLE 
The neck of the hernial sac is then closed and the conjoined tendon 
sutured to Poupart’s ligament in front of the cord. The aponeurosis 
of the external oblique and the skin are closed in the usual way. 
Vaginal process cut across 
\ atone testicle 
Vaginalprocess ligated 
\ Parse suing suture to forma 
\ \ tunica naainalis 
Fig. 218 
Fig. 219 
Testicle freed 
ready forreplacement.| 
IMa&m#pocfat fQW 
| in rigid side wS|§|| 
if scrotum, for reception 
\| of ffie testicle 
Fig. 220 
Figs. 218 to 221.—Undescended testicle. 
Fig. 221 
(Bevan.) 
A few minor changes from this operation have been suggested. 
Moschkowitz removes the parietal portion of the processus vaginalis 
instead of using it to make a tunica. Davison9 divides the deep epi- 
gastric artery and the floor of the inguinal canal, thereby bringing the IMPERFECT DESCENT OF THE TESTICLE 
471 
spermatic vessels to the external inguinal ring in a more direct line 
than if they had to pass through the internal inguinal ring. 
Wolfer52 divides the transversalis fascia as far as the pubes, lifts up 
the epigastric artery and vein, brings the testis down behind the latter, 
Skin 
Conjoined tendon 
\ External oblique 
! Superficial /ascia 
\ | / , Skin 
Superficial fascia 
Extern ad oblique 
Purse strt/uf suture , 
\ retaining testicle i/, 
| ti/e scrotum 
I Testicle replaced-' 
Spermatic cord ! jfSj 
Pouparts ligament 
Fig. 222 
Fig. 223 
Sl;i/z 
Superficial fascia 
.Sper/natic vessels 
External oblique 
Vas defends & vessels 
Spermatic vessels j 
liqated & divided. 
Fig. 224 
Fig. 225 
Figs. 222 to 225.—Undescended testicle. (Bevan.) 
and by stripping the spermatic cord off the bulge of the peritoneum, 
he materially shortens its course. Moschkowitz mentioned a proced- 
ure similar to this in 1910, and declared it to be an “unnecessary and 
bothersome refinement.” 472 
INJURIES AND TORSION OF THE TESTICLE 
Orchidopexy in the case of extopic testes is usually made easy by 
the fact that the spermatic cord is already of sufficient length. It is 
desirable to obliterate the old bed of the testicle; otherwise recurrence 
may take place. 
INJURIES OF THE TESTICLE 
Luxation or Dislocation of the Testicle.—Luxation or dislocation of 
the testicle is usually the result of an accident, such as the passage of a 
wagon wheel across the pelvis. The testicle may be driven over the 
pubes or toward the anterosuperior spine of the ilium. Guiteras11 
records a case in which the testicle was torn loose from the body and 
tail of the epididymis and was driven out of the scrotum and under the 
skin on the side of the penis. A review of the literature by Nicolas,32 in 
1899, disclosed 3 cases in which the testis had been driven onto the side 
of the penis, 3 in which it had been driven over the pubis and 2 in wdiich 
it was forced into the groin. Nicolas says that unless the testis is 
replaced, it undergoes atrophy. Summerhayes44 reported a case in 
which the testicle was extruded through a rent in the scrotum by a 
blow from a log of wood. 
Hematocele.—Hematocele is a frequent accompaniment of injuries 
of the testicle. The tunica fills with blood, which clots and forms a 
tender, solid-feeling tumor, which does not transmit light. Later on, 
this will liquefy and become a dark brown, oily-looking fluid, or will be 
entirely absorbed. From an injury of less severity, traumatic hydrocele 
may result. Hydroceles of this origin are only temporary. Severe 
injuries of the testicle itself are not met with very frequently. The fact 
that the testes lie in a movable bed, between the fleshy parts of the 
thighs, saves them from many a crushing blow. The most frequent 
type of injury is that sustained by falling astride some hard object, such 
as a fence. In such cases the testicles are caught between the hard 
object and the bony pelvis. 
Terrillon and Suchard,45 in experimental work on dogs, showed that 
punctured wounds and foreign bodies in the testicle caused only local 
disturbance. Slight blows upon the fixed testicle caused only a feeble 
reaction. More severe blows caused reaction in both testis and epididy- 
mis, more marked in the latter. The epididvmal canals were dilated, 
the cilia of the epithelium was lost, and the epithelium was thickened 
in places by the accumulation of new cells. Injuries of still greater 
degree caused the formation of fibrin in the tunica, and in the testis the 
degeneration of peripheral tubules and an inflammatory reaction in the 
interstitial tissue. Terrillon and Suchard thought this inflammation 
would result later in the formation of scar tissue and the consequent 
atrophy of the testis. Injuries of the most severe type caused rupture 
of the tunica albuginea. The testicle contained ecchymotic areas and 
was of a yellowish-red color; the epididymis wras swollen and ecchy- 
motic, and examination of microscopic preparations showed prolifera- 
tion in the interstitial tissues as well as in the canals. TORSION OF THE TESTICLE 
473 
Terrillon and Hu chard conclude that changes are more marked in the 
epididymis than in the testis. In the former the epithelium is chiefly 
involved; in the latter, the interstitial tissue. The subsidence of the 
interstitial reaction is likely to cause scar formation with resulting 
atrophy of the testicle. 
The treatment consists of rest, elevation of the scrotum and the 
application of ice. 
TORSION OF THE TESTICLE. 
Incidence.—Torsion is probably more frequent than would appear 
from the cases reported. Without doubt a number of cases are thought 
to be orchitis or epididymitis, and if they quiet down, the diagnosis is 
never made. From 1840, when the first case was reported, to 1901 
Scudder42 collected 31 instances from the literature and added 1. In 
1907 Rigby and Howard39 collected 40 cases. 
Age.—Torsion may occur at any age. It has been reported in a new- 
born child and in a man aged sixty-two years. It is chiefly a disease of 
adolescence. Of Scudder’s series of 32 cases, 75 per cent, were under 
twenty-four years of age; 20 of the 32 were between the ages of thirteen 
and twenty-three years. 
Cause.—That torsion is due primarily to some anatomical abnormal- 
ity is indicated by the fact that of Scudder’s 32 cases of torsion, 47 
per cent, were of undescended testicles. A number of those who have 
reported cases have mentioned finding some anomaly, such as an 
unusually long mesorchium. 
The predisposing factors which have been found associated with 
torsion of the undescended testis are given on page 465. In connec- 
tion with fully descended testicles, Rigby and Howard mention the 
following anomalies: 
1. Abnormal attachment of the common mesentery and vessels to 
the lower pole of the testis and to the globus minor, so that the testis is 
attached by a narrow stalk instead of by a broad band. 
2. Elongation of the globus minor. 
3. Capacious tunica vaginalis. 
The exciting cause may be exercise or violent straining, but 2 cases 
are reported by Rigby and Howard in which torsion occurred during 
sleep. In a case recently operated at the Massachusetts General 
Hospital the torsion came on during sleep. A case of recurrent torsion 
has been recorded47 in which the patient learned to untwist the torsion 
himself. 
Pathology.—Upon opening the tunica, more or less bloody fluid is 
evacuated; the testis and epididymis appear swollen, indurated and 
almost black in color. The spermatic cord is thrombosed belowr the 
twist, normal above. The twist may consist of from one-half a turn to 
four half-turns, in either direction. The cut surface of the testicle 
resembles blood clot. Hemorrhagic infarction may occur, or hemor- 
rhage between the lobules (Scudder). In one of Rigby and Howard’s 474 
INJURIES AND TORSION OF THE TESTICLE 
cases, microscopical examination showed no normal testicular cells. 
Later stages of the lesion will show atrophy, more or less complete, or 
sloughing. The latter is more liable to occur if hernia coexists, Rigby 
and Howard believe, as the bacteria of the intestine are thus brought 
nearer to the devitalized testis. 
Fig. 226.—Gangrene of the testicle due to torsion of the cord. The testicle and epi- 
didymis were gangrenous from a point just above the epididymis. Testicle and epi- 
didymis considerably enlarged from edema. There were areas of hemorrhage and 
beginning necrosis on the surface and in the interior of the organs. There was associated 
hydrocele of the cord dependent upon the strangulation of the cord. (Scudder.) 
Symptoms.—Severe, sudden pain in the testicle, sufficient to cause 
slight shock with nausea and vomiting, occurs at the time of the twist. 
Not infrequently this occurs at night. The temperature may rise 
slightly. The skin over the affected testicle becomes edematous and 
red. Differentiation between the testicle and epididymis on palpation 
is lost. At first the tumor is exquisitely sensitive; after a few7 days the 475 
BIBLIOGRAPHY 
acute tenderness subsides, but tenderness on pressure may persist for 
weeks. 
Diagnosis.—In the case of torsion of the undescended testis the 
condition most difficult to differentiate is strangulated hernia. (See 
page 4G6.) With the testicle fully descended, hernia is more easily 
excluded. To diagnose the case as acute epididymitis is the most 
usual mistake. In the early hours of epididymitis, before the epi- 
didymis shows much swelling, the physical signs are indeed similar. 
The sudden onset of an ‘'epididymitis” in a boy or youth who shows no 
evidence of urethral infection is strongly suggestive of torsion. Epi- 
didymitis is seldom so excruciatingly tender during its inception. 
Treatment.—If the case is seen within the first hour or two, an at- 
tempt may be made to untwist the cord. The testis is supported by one 
hand and gently rotated with the other. As one cannot be sure of the 
direction in which the testicle has turned, this measure does not offer 
much hope. It was done successfully by Nash31 one hour after the 
onset, but atrophy subsequently occurred. When torsion occurs in an 
undescended testicle the gland should be removed promptly to avoid 
the possibility of peritonitis. With fully descended testes expectant 
treatment may be employed. The patient should be kept in bed, the 
scrotum elevated, and ice applied. Rigby and Howard followed this 
treatment in 4 cases. Two of the testes atrophied very little; one 
disappeared altogether; none sloughed. The operative reduction of 
the torsion with suturing of the testicle to prevent recurrence has 
always resulted in atrophy and seems to offer no better chances for 
preserving the testicle. It seems justifiable to try the expectant method 
for a few days, as even an atrophied testicle means more to the patient 
than none at all. If, however, the symptoms do not speedily subside, 
or if tenderness of the testicle persists, orchidectomy should be done. 
BIBLIOGRAPHY. 
1. Beigel: Virchows Archiv, xvii, S. 144. 
2. Berg: Ann. of Surg., August, 1904. 
3. Bevan: Jour. Am. Med. Assn., 1899, xxxiii, 773-775. 
4. Bevan: Jour. Am. Med. Assn., September 19, 1903, xli, 718-723 
5. Broche: Quoted by Odiorne and Simmons. 
6. Cruveilhier: Traite d’Anat. Path. Gen., vol. i, p. 301. 
7. Cunningham: Text-book of Anat., 1903, p. 849. 
8. Cunningham: Text-book of Anat., 1903, p. 1104. 
9. Davison: Surg., Gynec. and Obst., 1911, xii, 283-2N8. 
10. Eccles: The Imperfectly Descended Testis, New York, 1903, pp. 10-12. 
11. Guiteras: Med. Rec., 1896, xlix, 11-13. 
12. Halstead: Surg., Gynec. and Obst., 1907, iv, 129-132. 
13. Hanes: Jour. Exp. Med., 1911, iii, 338-354. 
14. Hanes and Rosenbloom: Jour. Exp. Med., 1911, iii, 335-364. 
15. Hempel: Ueber Ektopia Testis, 8°, Kiel, 1911. 
16. Howell: Am. Text-book of Physiology, 1901, ii, 445. 
17. Jacobson: Diseases of the Male Organs of Generation, 1893. 
18. Jordan: Deut. Med. Wchnschr., 1895, xxi, 525. 
19. Lamb: Proc. of the Am. Assn, of Anat., 1896, pp. 47-60. 
20. Lane: Brit. Med. Jour., 1894, ii, 1241. 
21. Lenhossek: Anatomischer Anzeiger, 1845. 476 
INJURIES AND TORSION OF THE TESTICLE 
22. Lenhossek: Quoted by Halstead: Surg., Gynec. and Obst., 1907, iv, 129-132. 
23. Lewis and Stohr: A Text-book of Histology, 1914, p. 344. 
24. Lewis and Stohr: A Text-book of Histology, 1914, pp. 335-341. 
25. Marshall: Edinburgh Med. and Surg. Jour., 1828, xxx, 172. 
26. Mixter: Undescended Testicle in Children, Boston Med. and Surg. Jour., 1916, 
Ixxv, No. 18, p. 63. 
27. Monod and Terrillon: Maladies du Testicule, 1879, p. 46. 
28. Morris: Human Anatomy, 5th edition, p. 610. 
29. Morris: Human Anatomy, 5th edition, p. 744. 
30. Moschkowitz: Ann. of Surg., 1910, vii, 821-835. 
31. Nash: Brit. Med. Jour., 1893, i, 742. 
32. Nicolas: Th£se de Paris, 1899. 
33. Ochsner: Jour. Am. Med. Assn., September 19, 1903, xli, 723. 
34. Odiorne and Simmons: Ann. of Surg., 1904, xi, 962-1004. 
35. Pappenheim and Schwartz: New York State Jour. Med., 1910, No. 12, p. 548. 
36. Popow: Bull, de la Soc. Anat., 1888, p. 653. 
37. Poupart: Un Type Nouveau d’Ectopie Testiculare, Thfese de Paris, 1897. 
38. Picque and Worms: Jour, de l’Anat., 1909, xlv, No. 1, pp. 51-64. 
39. Rigby and Howard: Lancet, 1907, i, 1416. 
40. Rigby and Howard: Torsion of the Testes, Lancet, 1907, i, 1415-1421. 
41. Schuller: Zent. f. Chir., 1881. 
42. Scudder: Ann. of Surg., 1901, xxxiv, 234-248. 
43. Smith, G. B.: Guy’s Hosp. Rep., 1896, liii, 215-240. 
44. Summerhayes: Brit. Med. Jour., 1896, ii, 1036. 
45. Terrillon and Suchard: Arch, de Phys. normale et pathologique, Paris, 1882, 2 S., 
ix, 325-335. 
46. Th(\se de Paris, 1897. 
47. Van der Poel: Quoted by Rigby and Howard, Lancet, 1907, i, 1416. 
48. von Bardeleben: Verhandlungen der anatomischen Gesellschaft; Anatomischer 
Anzeiger, 1892, vii. 
49. von Ebner: Kollikers Llandbuch der Gewebelehre des Menschen, 6th edition, iii, 
pt. 2, 451. Leipzig, 1902. 
50. Whitehead: Am. Jour. Anat., 1904, iii, 167-182. 
51. Whitehead: Anat. Record, 1908, ii, 177-182. 
52. Wolfer: Surg., Gynec. and Obst., 1915, pp. 228-231. 
53. Keyes, E. L. and MacKenzie: Jour. Am. Med. Assn., 1917, lxviii, 349-351. CHAPTER XII. 
DISEASES OF THE SCROTUM. 
By A. RAYMOND STEVENS, M.D. 
The most common pathological lesions of the scrotum are those 
inflammatory conditions secondary to diseases of the testicles, the 
urethra, and the rectum. These scrotal complications will be dealt 
with in their appropriate connections in the sections devoted to the 
above-named primary seats of infections. 
ANATOMY OF THE SCROTUM. 
The scrotum is a loose pouch of skin investing the testicles and part of 
the spermatic cords. It varies markedly in size in different individuals, 
and with changing conditions in the same individual. In debilitated 
persons and the aged and from the effect of heat it relaxes and becomes 
pendulous; in the robust and the young and under the influence of cold, 
emotion, and exercise it is contracted and thicker. The layers are skin, 
dartos, and loose areolar tissue. 
The Skin.—The skin of the scrotum is thin, semitransparent, and 
elastic, is darker in color here than elsewhere, and has a sparse growth 
of hair. It contains in the derma many sebaceous and sweat glands. 
Superficially its epidermis is similar microscopically to that over the rest 
of the body. Below this is the derma, rich in elastic fibers and involun- 
tary muscle. The surface of the skin is divided into lateral halves by a 
slight median ridge, extending from the penis to the margin of the anus. 
From this, on either side, extend rugse with a generally horizontal 
arrangement, determined by muscular fibers in the derma, parallel to 
the surface and running, as a rule, transversely. 
Dartos.—The dartos is immediately beneath the skin and intimately 
associated therewith. But contrary to the statement of some anato- 
mists, it can be dissected from the skin. The line of cleavage is proved 
microscopically to be between the muscle layer of the derma and that of 
the dartos. The dartos is a reddish-brown stratum, best developed in 
front and at the sides, continuous with the suspensory ligament of the 
penis and the superficial fascia of the abdomen, groin and perineum, 
and at the sides is attached to the ischiopubic rami. It is the con- 
tractile portion of the scrotum, containing connective tissue, elastic 
fibers, and considerable unstriped muscle, the fibers of which are 
placed at right angles to those of the derma. It is very vascular and 
entirely free from fat. The dartos forms two sacs, for the correspond- 
ing testes, and these unite in the median line to form the septum scroti. 
477 478 
DISEASES OF THE SCROTUM 
Areolar Tissue.—Beneath the dartos is a very loose thin bed of 
vascular areolar tissue, continuous with Colles’s fascia behind and the 
deep fascia of the abdomen in front. Scrotal hematomata are com- 
monly situated here. 
Bloodvessels.-—The arteries supplying the scrotum are the external 
pudics (from the femoral arteries) and the superficial perineal branch of 
the internal pudic. The veins accompanying the arteries empty into 
the saphenous and internal pudic veins. 
The lymphatics of the scrotum all terminate in the inguinal and 
femoral glands. The observations of M or ley would seem to show 
£pidemus 
Sebaceous & — 
sweat glands 
Hernia 
Blood vessels - 
Smooth muscle- 
Connective tissue 
Blood vessels 
Jtaiios 
Svtoofh muscle. 
Connective tissue 
Areolar 
(issue 
Blood vessels 
Connective (issue - 
Fig. 227.—Diagramatic section of scrotal "wall. 
a free anastomosis of the lymphatics of the two halves of the scrotum, a 
free communication of these with the lymphatics of the penis, and to 
a less extent with those of the thighs and perineum. The fine network 
between the skin and dartos empty into lymph trunks which dip at once 
through the dartos. There are ten to twenty main trunks on either 
side, which course toward the inguinal glands. It is surgically interest- 
ing that the uppermost ones may curve up 1 to 2.5 cm. on the side of the 
penis, thence run 1 cm. above the pubic spine, parallel to Poupart’s 
ligament, ending in a gland sometimes only 4 cm. from the anterior 
superior spine. No collecting trunks are found to accompany the 
internal pudic vessels; and there apparently is no connection between INJURIES OF THE SCROTUM 
479 
the lymphatics of the scrotum and those of the tunica vaginalis and 
testicles. 
Nerves.—The nerves supplying sensation to the scrotum are branches 
of the ilio-inguinal, superficial perineal branches of the pudic nerve, the 
inferior pudendal (from the small sciatic), and the genital branch of 
the genitocrural. The sympathetic nerves accompanying the vessels 
supply the muscle fibers of the dartos. 
ABNORMALITIES OF THE SCROTUM. 
The half of the scrotum corresponding to an undescended testicle is 
frequently rudimentary. In pseudohermaphroditism the scrotum is 
cleft, the halves resembling labia majora. Partial cleft scrotum may 
accompany congenital defects elsewhere in the genito-urinary system, 
e. g., abnormalities of the penis and urethra, and ectopia vesicse. 
Abnormal pigmentation of the scrotum may be mentioned here 
to note that the pigment granules are placed histologically in the same 
location as those normally found—that is, in the deepest cells of the 
epidermis. 
INJURIES OF THE SCROTUM. 
Stab, puncture, and gunshot wounds are subject to the same surgical 
consideration as similar injuries elsewhere. Growing hematomata 
should be freely incised, clots removed, and bleeding-points ligated. 
Free drainage must be established in the presence of infection or an 
injury to the urethra. 
Hematoma.—Hematoma without rupture of the cutaneous surface 
is common, and is easily produced by blows upon the scrotum. It is 
important to differentiate hematocele and hemorrhage within the 
testicle from hematoma in the substance of the scrotal wall; the former 
frequently requires operation while the latter rarely does, but is best 
treated by rest, elevation, and cold applications, with perhaps a com- 
pression bandage. 
Loss of Substance.—Loss of substance from accident or attempts 
at emasculation may lead to serious bleeding. Control of hemorrhage 
is of first importance, then surgical cleanliness and subsequent aseptic 
dressing. The reparative power of the scrotum is amazing. After the 
loss of over two-thirds of this tissue, leaving the testicles exposed and 
dangling, it is quite possible for nature to repair this vast rent and 
restore a satisfactory scrotum, without surgical interference. So that 
one method of treatment after all hemorrhage is controlled is merely to 
keep the raw area covered with a mildly antiseptic dressing. However, 
the course of such repair is slow and may be further prolonged by 
active fungous outgrowth of granulations from the testicles, necessitat- 
ing application of the actual cautery. Better results in extensive 
injuries and a shorter convalescence are obtained by surgery. By 
loosening the skin of the inner and anterior aspects of the thighs, flaps 
may be cut with horizontal sides, and with the externally placed 480 
DISEASES OF THE SCROTUM 
attachments broader than the free end. These when sewed together 
will easily cover the testicles and form an adequate sac. In some 
cases, after loosening the skin from underlying tissues over a wider 
area, including the perineum, the edges may be apposed without actual 
flap formation, and with ultimately good results. If only the anterior 
wall of the scrotum is wanting the simplest procedure is to draw upward 
the remaining portion of the sac and suture it to the upper skin margin. 
Should the skin of the base of the penis also be trimmed away the penis 
may be pushed under that part of the scrotum drawn forward and 
brought out at a lower level. Subsequently flaps of skin from the lateral 
aspects of the scrotum are used to cover any raw surface on the penis. 
Suture of the Scrotum.—As already stated, the dartos is closely 
attached to the skin, and its muscular fibers are generally at right 
angles to those in the skin. This explains the tendency of the skin 
edges to curl in regardless of the direction of the incision. Approxima- 
tion of the skin does not necessarily include the dartos and areolar layer, 
and subsequently bleeding from this very vascular region may occur, 
forming a large hematoma. This may be guarded against by employ- 
ing hemostatic sutures. Each is applied about 1 cm. from the margins 
of the wound, penetrating both layers of the skin and dartos, and 
returning in the reverse direction 1 cm. apart, the knot is tied on the 
side first entered. Subsequently a line of continuous sutures accuratqly 
approximates the. skin edges; or both objects may be attained in a very 
practical way by one line of sutures, interrupted or continuous, applied 
about 0.5 cm. from the margins of the wound and taking each time a good 
bite of the deeper structures. By another method, using interrupted 
sutures, each stitch is. carried one way through both skin and deeper 
structures, and returning takes only a small bite of skin. Obviously, 
the knot is tied on the side first penetrated by the needle. 
CUTANEOUS DISEASES OF THE SCROTUM. 
Cutaneous diseases will be dealt with very briefly. Fuller discus- 
sions are readily found in works on dermatology. 
Erythema Intertrigo (Chafing).—Erythema intertrigo affects the 
lateral and posterior aspects of the scrotum. It may occur at any age, 
but more commonly in children and fat individuals. Uncleanliness, 
wetness (urine or perspiration), and friction in walking are the three 
chief etiological factors. The treatment is simple; cleanliness, dry- 
ness, the use of a dusting powder, and a suspensory with perhaps some 
padding of cotton. Dermatitis or eczema may develop, requiring 
appropriate lotions or ointments. 
Eczema Simplex.—Eczema simplex is said to be more frequently met 
with in persons of rheumatic or gouty diathesis. Its common seat is 
the lateral and posterior aspects of the scrotum. The lesions and 
symptoms are those of eczema in other parts of the body. Treatment 
in milder cases consists simply of support of the scrotum, avoidance of 
friction, and application of a dusting powder, such as the oxide or stear- 481 
CUTANEOUS DISEASES OF THE SCROTUM 
ate of zinc. Itching is relieved by 2 to 4 per cent, carbolic acid applied 
alone on gauze or incorporated in some simple lotion or ointment. 
Eczema Marginatum.—Erythema marginatum is ringworm modified 
by erythema or eczema intertrigo, and, indeed, the parasitic nature of 
the affection may be obscured by these accompaniments. It occurs 
on the moist regions of the scrotum in patches, which present well- 
defined margins and elevated borders and characteristic central healing 
and peripheral advance. Treatment should be directed first to any 
associated erythema or eczema. Subsequently the affected spots are 
painted on several occasions with tincture of iodine; or unguentum 
hydrargvri ammoniati is well rubbed in daily and the applications 
continued some days after an apparent cure. 
Pityriasis Versicolor.—Pityriasis versicolor occurs as yellowish- 
brown spots or patches on the scrotum, and is caused here as elsewhere 
by a vegetable parasite, Microsporon furfur, which attacks clean as 
well as dirty skins. There may be mild itching but often no symptoms 
exist. This vegetable growth may be made to disappear by daily 
scrubbing with soap and water followed by application of 25 per cent, 
aqueous solution of sodium hyposulphite. Recurrence is frequent. 
Pediculi Pubis.—Pediculi pubis are sometimes found about the 
hair of the scrotum, usually in association with a similar occupation of 
the hair of the pubic region. The ova (“ nits”) are tightly attached to 
the hairs and their presence is as pathognomonic as the parasite. An 
eczema may coexist in the uncared-for cases. The parasite and their 
ova are easily killed by unguentum hydrarg., by 1 to 1000 solution of 
bichloride of mercury, by kerosene, or the tincture of larkspur. In 
patients harboring a large colony, and especially in uncleanly indivi- 
duals, it is advisable first to shave all hair from the parts. 
Scabies.—Scabies is carried to the genitalia by the hands. The 
characteristic “ burrows” of the parasite of scabies, Acarus scabiei, may 
be seen. Numerous punctate abrasions and excoriated papules and a 
few crusts are often found. Itching, most marked at night, is almost 
invariably present. Treatment is simple and effective: a warm bath, 
sulphur ointment rubbed over all affected regions morning and night 
for several days, followed by another bath and a change to fresh clothes. 
A second course of treatment may be required, if a bland lotion or oint- 
ment does not clear up the skin in a few days. 
Syphilis—Syphilis of the scrotum is common, most frequently seen 
as papules, which on the moist surfaces become macerated and abraded. 
If untreated, they may develop papillary outgrowths, forming warty or 
cauliflower-like excrescences (condylomata). Ulceroserpiginous lesions 
may develop here, and less frequently gummata or single ragged ulcers. 
The occasional development of chancre of the scrotum must be empha- 
sized. Only cleanliness is necessary locally if the intensive constitu- 
tional treatment of syphilis be instituted. 
Lupus.—Lupus of the scrotum is comparatively rare. 
Pruritus.—Pruritus occurs with some of the above diseases and 
also without demonstrable skin lesions. The latter cases have fre- 
quently some constitutional debility, as gout, rheumatism, or diabetes. 482 
DISEASES OF THE SCROTUM 
Treatment is often most unsatisfactory except as affording temporary 
relief. One must first institute dietetic and hygienic measures aimed at 
fundamental constitutional disorders. Tonics or alkalies may be 
indicated. Turkish baths are sometimes beneficial. Locally, thymol, 
weak carbolic acid, or menthol in lotions or ointments and sometimes 
hot water relieve the symptoms temporarily. 
Sebaceous Cysts or Steatoma.—These are formed, as elsewhere on 
the skin, from sebaceous glands dilated by retained secretion. Small 
palpable cysts of the scrotum are present in many individuals, and not 
infrequently isolated ones attain a diameter of 5 to 10 mm. Single 
cysts may occur anywhere on the scrotum; large groups are more com- 
monly found on the anterior aspect. They are yellowish, rounded, and 
firm, within (not under) the skin, the larger ones protruding externally. 
They cause no symptoms unless infected; then they are tender and the 
surrounding skin is reddened. No treatment is indicated except for 
cosmetic results or for inflammation. They may be excised under local 
anesthesia; or incised, the contents evacuated, and the sac destroyed by 
curetting, or by cauterization—easily done with pure carbolic acid. 
Varicose Veins.—The veins of the scrotum may show marked vari- 
cosity, which has been confused with varicose veins of the pampiniform 
plexus. This should not occur if careful palpation is made. However, 
the two conditions frequently occur together. Small telangiectatic 
spots may accompany the varicosity. Usually no treatment is needed. 
Bruyneel1 reported an instance of spontaneous rupture of varicose veins 
of the scrotum, with loss of about 200 c.c. of blood, in a man of seventy- 
seven years. It is conceivable that the size of the mass may be a source 
of annoyance. The veins are largest in lax, elongated scroti and the 
easiest treatment is excision of the skin area most involved and its con- 
tained veins, careful hemostasis by ligature and proper placing of deep 
skin sutures. 
INFLAMMATION OF THE SCROTUM. 
Edema.—Edema may be secondary to severe anemia and to organic 
disease of the heart, kidneys, or liver, and is then often part of a general 
anasarca. It may be due to mechanical pressure on veins or lymphatics 
draining the scrotal tissues, or edema may be inflammatory in origin, 
from infection of the testicles, perineum, groins, or scrotal wall. In 
every case the treatment should be directed to the primary trouble. In 
the edemas of systemic causation and those due to mechanical pressure, 
rarely are any local measures indicated other than support by strap- 
ping or a suspensory, cleanliness, and dryness of the skin. It is un- 
usual that tension develops sufficiently to endanger the vitality of 
the skin. When it does so a few punctures may be made in the skin and 
the parts kept covered with a sterile wet dressing, and every care taken 
to prevent infection. 
Cellulitis and Abscess. — Cellulitis and abscess are in the vast 
majority of cases secondary to inflammation of deeper structures, but 
may be due to infection of the scrotum per se. Cold, wet applications INFLAMMATION OF THE SCROTUM 
483 
and support of the parts will suffice for milder infections. Severe 
cellulitis and abscess require incision and drainage. 
Erysipelas.—Erysipelas is most frequent in old or debilitated indi- 
viduals. The onset is announced with a chill, high fever, and malaise. 
Locally a bright red spot develops and gradually spreads over part or all 
of the scrotum. The latter swells markedly, is sometimes covered with 
blebs, and may finally become gangrenous. On the other hand (and 
usually), there may be complete resolution and a return to normal. 
The constitutional symptoms are those of erysipelas elsewhere. Also 
the bacteria found here are the same as those causing the disease in 
other locations. It is worthy of note that in some cases resembling 
erysipelas of the scrotum clinically the Klebs-Loeffler bacillus has been 
cultivated from the wound discharge. The treatment, general and 
local, is similar to that of erysipelas in other regions, remembering 
always to keep the scrotum elevated. Numerous local applications 
have had a period of popularity. Cold compresses wet with boric 
acid solution are as satisfactory as any local treatment. 
Gangrene.—Gangrene of the scrotum may be due to infection of 
deeper structures (urethra or testicles), through vascular obstruction 
and bacterial invasion of the scrotal wall; to primary scrotal infection 
(e. g., erysipelas); to mechanical or chemical or thermal injury; to 
trophic disturbances; and to systemic conditions acting as primary or 
predisposing causes (diabetes, cardiovascular and renal diseases, al- 
coholism, general debility). Gangrene may be made of rarer occur- 
rence by aseptic care of wounds, free incision (not too long delayed), 
timely surgical treatment of the deeper inflammations, and pains- 
taking care of the medical conditions mentioned above. Treat- 
ment is logically at once directed to the underlying causative 
factors. Locally, incision through the dartos is to be made, and all 
definitely gangrenous tissue excised. Aseptic dressings are changed fre- 
quently until all evidence of active inflammation has disappeared. The 
testicles are never involved secondarily, and if the loss of substance 
has been great, are left freely exposed. Left to Nature, those large 
gaping wounds will heal fairly rapidly and with finally satisfactory 
results. But in many instances, a quicker convalescence may be had by 
some plastic operation (noted under Injuries). 
Emphysema.—Emphysema is seen in connection with general sub- 
cutaneous emphysema, sometimes with scrotal gangrene or wounds in 
which gas-producing organisms are present. Treatment is multiple 
incision and free drainage in the infected cases. When an anaerobic 
organism is the offender, frequent irrigation with hydrogen peroxide 
should be done. 
Ulcerating or Sclerosing or Serpiginous Granuloma of the Pudenda.— 
This is a disease of the tropics, occurring especially in the dark races, and 
generally contracted through sexual relations. It usually starts on the 
penis, as a nodular elevation of skin, very vascular and prone to break 
down and bleed. It extends very slowly by peripheral advance or by 
auto-infection of neighboring skin, especially in moist areas. The 
scrotum is often involved, showing a dense, uneven white or pigmented 484 
DISEASES OF THE SCROTUM 
scar within the serpiginous, raised periphery. The thighs and anal region 
may be involved. The lymph glands are not infected; the general 
health is good. It resembles lupus vulgaris somewhat, but is found only 
about the genitalia. The etiology is not determined. Treatment is 
unsatisfactory unless the case be seen early enough for excision. 
Calculi.—Calculi of the scrotum have been described. They are 
calcified hematomata, true urinary calculi which have ulcerated through 
from the urethra, or the remnants of calcareous deposits in old urinary 
fistulse. 
Fig. 228.—Solid form of elephantiasis. (Charles.) 
ELEPHANTIASIS (FILARIAL) OF THE SCROTUM. 
The term elephantiasis arabum is used to describe large diffuse 
enlargements of the scrotum, consisting of hard edema and hyperplasia 
of both the skin and connective tissue. While it is comparatively 
common in certain tropical countries, in the localities favorable for 
breeding of mosquitoes, it is rare in colder climates, and most of the 
patients seen have resided in the tropics. It is particularly prevalent 
in Samoa and Huahine. 
Etiology.—The observations and deductions of competent students 
of elephantiasis are convincing in ascribing this condition, in at least 
the majority of cases, primarily to a nematode, known as Filaria san- ELEPHANTIASIS OF THE SCROTUM 
485 
guinis hominis (or Filaria nocturna, or Filaria bancrofti). This is one 
of five or six filarise found in man, and one of the two of these which are 
pathogenic. The larval forms frequently found in the blood are trans- 
parent, colorless, and cylindrical, 0.3 mm. long and about the diameter 
of a red blood corpuscle. In a fresh specimen the larvae wiggle within 
encasing sheaths without changing position on the slide. They are in 
the peripheral blood only at night, mostly at midnight, the time of 
greatest activity of the mosquito. This periodicity may be reversed 
by having the patient sleep in the daytime. During their absence 
from the peripheral vessels, the larvae are in the larger arteries, the 
lungs, and to a less extent in the heart muscle. Several observers have 
described a parasite, morphologically the same as Filaria bancrofti, 
present in peripheral blood in the daytime as well as nighttime. But 
this is not the rule. 
The complete life-cycle involves two hosts, man and certain mos- 
quitoes (Manson mentions eight species which may serve as inter- 
mediate hosts). The mosquito, feeding on the blood of an infected 
individual, takes in the larval form of filaria; these escape from their 
sheaths in the mosquito’s stomach, and then acquire locomotion; they 
enter the thoracic muscles, and in the next twelve to twenty days in- 
crease in size and develop an alimentary canal and other parts; the 
majority reach the proboscis of the mosquito and are usually arranged 
in pairs. The mosquito now is capable of infecting human beings 
when feeding on their blood and possibly through drinking water when 
dying in the same. In man the filarise soon reach the lymphatics, 
attain sexual maturity, and pour larvae into the lymph, thence to the 
blood. The adult worms are hair-like, transparent, and 4 to 9 cm. long, 
the female longer than the male. The sexes live together, often in- 
extricably coiled in lymphatics, lymph varices or glands. 
Filarial disease does its chief harm through obstruction of lymphatic 
vessels. This may be caused by the adult worm, alive or cretified, 
acting as a plug, inducing thrombus formation, or inciting inflammatory 
thickening of the vessel wall and consequent narrowing of its lumen. 
The microfilariae (larvae) have no known pathological effect, but ova 
have been found in the lymph, and as they are incapable of traversing 
lymph glands, it seems quite possible that lymph stasis may sometimes 
be caused by ova being lodged in the glands. 
Pathology.—The immediate results of obstruction are lymphatic 
varicosities or edema, or both. These conditions are most common for 
obvious reasons on the lower extremities. The scrotum is involved next 
in frequency. Lymph varicosities of the scrotal wall cause a moderate 
or greater enlargement called lymph scrotum. The skin is soft and 
silky and on inspection presents evident varices. Microfilariae are 
usually present in the lymph locally. Often the inguinal and femoral 
glands are enlarged. Erysipelatous inflammation is a frequent com- 
plication. Lymph scrotum may remain such or become elephan- 
tiasis, which is the combined result of lymph stasis and recurrent 
inflammation. Lymph stasis alone causes varices and edema only. 
The sequence of events is lymph stasis (from causes already given), 486 
DISEASES OF THE SCROTUM 
lymphangitis, imperfect absorption of the inflammatory products, and 
gradual, intermittent, progressive, inflammatory hypertrophy. The 
derma is dense, fibrous, and enormously hypertrophied. The con- 
nective tissue is increased in bulk and has a blubbery appearance; on 
section there is a free oozing of lymph. Bloodvessels are enlarged and 
lymphatics dilated. 
Symptoms.—Beginning as edema or lymph scrotum the scrotum is 
only a little enlarged. Attacks of lymphangitis with cellulitis and fever 
may occur. After this subsides the parts do not return quite to nor- 
mal Increased edema and recurrent lymphangitis lead to greater 
enlargement. The scrotum in typical elephantiasis may weigh 200 
pounds (one of 224 pounds is recorded). The mass is pyriform in 
shape; a transverse section of the upper part is triangular with the 
apex toward the anus. The skin is leathery, rough and coarse, and pits 
little, if at all. It is thickest at the bottom, thinnest at the top, and thin 
and soft at the sides and posteriorly. It gradually merges all around 
into the healthy skin. Mouths of follicles are sometimes very distinct; 
the hair is coarse and sparse. The penis is at the upper and anterior 
part, at the bottom of a channel formed by the foreskin and skin of the 
penis dragged inside out by the enlargement of the scrotum. The 
testes are usually in the posterior part of the mass, nearer the bottom 
than top, each held there by its hypertrophied gubernaculum testis. 
The spermatic cords are thickened and very long, and hydroceles are 
usually present. The tumor may grow rapidly or slowly; may become 
enormous in two or three years or may never grow large. An attack of 
lymphangitis may intervene, causing painful cord-like swellings of 
lymph trunks and glands, with redness of the overlying skin, chill and 
high fever, headache, perhaps vomiting, and sometimes delirium. 
The general health may be excellent except during the attacks of 
inflammation. The scrotum is cumbersome and unsightly and sexual 
relations become impossible. Gangrene may supervene; abscesses 
sometimes form; eczema or ulcerations may occur; and varices may 
rupture, allowing escape of lymph. 
Associated conditions due to filariasis are orchitis; hydrocele; lymph- 
angitis; abscess; varicose glands; arthritis; synovitis; elephantiasis 
and lymph varices elsewhere, especially in the legs; chyluria, chylocele, 
chylous ascites, and chylous diarrhea caused by rupture of varicose 
lymphatics in the urinary tract, tunica vaginalis, peritoneum and 
intestinal tract. 
Diagnosis.—The larval forms of the Filaria sanguinis hominis are 
commonly present in the lymph of the varices of lymph scrotum, and 
may be found in the blood. Because the adult worms have usually 
died, it is rare to find microfilariae in the blood in elephantiasis. Indeed, 
in filarial countries a smaller percentage of people with elephantiasis 
than of those without elephantiasis have these parasites in the blood. 
However, they should be looked for microscopically, using thick prepa- 
rations made at night. These may be studied fresh, or after being dried 
and stained (without fixing) for one hour in weak carbol-fuchsin (4 
drops of saturated alcoholic solution to one ounce of water). In some 487 
ELEPHANTIASIS OF THE SCROTUM 
cases the blood shows an eosinophilia, and with the acute conditions 
a leukocytosis. An associated lymphangitis, with its constitutional 
symptoms, is suggestive. A history of residence in tropical or sub- 
tropical climates is generally elicited. 
Lymph stasis due to other causes may give the picture of lymph 
scrotum and an added inflammation may cause an actual elephantiasis. 
However, the scrotal condition would be accompanied or even over- 
shadowed by other symptoms, which, with the history, would lead to a 
correct diagnosis of syphilis, pyogenic infection, or mechanical obstruc- 
tion of the lymphatics. 
Prophylaxis.—The life-cycle of the Filaria bancrofti can be completed 
in neither man nor mosquito, but only by passage of the parasite from 
one to the other. One human being cannot contract filarial disease 
from another, but becomes infected only by the form of the parasite 
developed in the mosquito. Prevention of filariasis and its many con- 
sequences hinges on the elimination of the mosquito. Its breeding 
places should be dealt with according to methods now generally known 
in civilized communities. Individuals harboring filarise and all unin- 
fected people in tropical climates should be carefully protected from 
mosquitoes. It is possible, though not proved, that water to which 
mosquitoes have had access may convey the parasite. Hence all drink- 
ing water in the tropics should be boiled. 
Treatment.—While simple lymphatic edema may subside it seems 
generally recognized that lymph scrotum and elephantiasis do not 
recover spontaneously. They remain stationary for years or recede 
somewhat in bulk after an attack of lymphangitis, but such scrota 
never again become normal. 
The cure of filariasis involves the destruction of the adult parasites. 
Xo known drug is efficient to this end. The worms often die after 
plugging a lymph trunk, especially after lymphangitis, and thus a spon- 
taneous cure of the active infection may occur. But the numerous 
sequelae of the obstruction remain. When the site of the entrapped 
worm is surgically accessible, operation may really cure the disease. 
But the location of the parasite cannot often be diagnosed during life. 
When scrotal involvement is the only sign of filariasis it seems probable 
that the worm is in the inguinal glands. Primrose16 reported a case 
cured clinically and according to blood examination by surgical removal 
of part of the scrotum in which the adult worm was found. Cunningham5 
operated for elephantiasis, did not find any filaria in the specimen re- 
moved, but larval forms were found in the blood before operation and 
none afterward; the patient was clinically well at the end of twenty 
months when the case was reported and has remained well since. 
Lymph scrotum should be kept clean and dry and a well-fitting sus- 
pensory worn. Chyluria and elephantiasis of the leg have followed sur- 
gical intervention. If anything is attempted, a complete excision is the 
best procedure. 
Lymphangitis and fever are treated by confining the patient to bed, 
elevating the scrotum, and applying ice-bags or, better, cold compresses. 
Morphine may be necessary to relieve pain. The bowels are kept open, 
light diet given, and a copious quantity of water should be taken. 488 
DISEASES OF THE SCROTUM 
Elephantiasis of the scrotum, if small and not burdensome, had better 
be merely guarded against injury, or perhaps bandaged tightly. If 
large, excision is not only feasible but advisable. In parts of India this 
is one of the commonest of operations. One surgeon reports having 
removed “over a ton” of scrota! The immediate and remote results 
are good as regards comfort and sightliness and the patient’s working 
efficiency. Attacks of fever often cease after operation. Coitus and 
procreation become possible. The general mortality of the operation is 
a trifle over 5 per cent. Charles/ Maitland,11 Murray15 and Calvert3 have 
reported (totaling their cases) 560 operations of excision of the scrotum 
for elephantiasis with only 6 deaths. Charles had a series of 140 
consecutive unselected cases without a death and Calvert a series 
of 151. 
The operation is preceded if possible by elevation of the scrotum 
(sometimes with compression as well) and frequent cleansing for two or 
three days. Erosions or ulcerations of the skin should be healed before 
operation. The usual preoperative preliminaries of examination and 
preparation are to be observed. The patient is placed in the lithotomy 
position. A figure-of-eight tourniquet (around waist and base of scrotum) 
may be used to control bleeding; some operators of large experience 
advise against it. The incisions outlining the tissue to be removed must 
all be made in healthy skin. Three primary incisions are made: one in 
the median line from near the pubis to the preputial orifice, through 
which the penis is freed by the finger, and two over the cords, and far 
enough into the scrotum to permit of liberating the testicles, cutting of 
the gubernaculi, and delivery from the wound of cords and testicles. 
Then follows the complete excision, of the diseased tissue. Care is 
needed to avoid the dorsal vein of the penis, and also the bulb of the 
urethra, which is pulled downward by the mass. Hemorrhage is con- 
trolled more by torsion than by ligature. The skin of the inner aspects 
of the thighs is dissected free and the two edges sewed together after 
placing the testicles on the perineum beneath the flaps thus obtained. 
Perineal drainage is employed. The skin about the penis is sutured to 
the tunica albuginea (not the connective tissue) while the penis is held 
extended, avoiding suturing over the urethra. If the foreskin be the 
least involved, trim it off close to the glans penis. If healthy, save it 
and stitch to the tunica albuginea. The raw surface of the penis is 
covered at once with Thiersch grafts obtained from the thigh. Hydro- 
celes are usually encountered and are dealt with by excision of the sacs. 
Varicocele may be excised. Inguinal hernise are occasionally found, 
and are subjected to radical cure if the patient’s condition permits. 
Castration is advisable if the testicles are infected or entirely atrophied. 
Two cases of concomitant epithelioma of the penis have been reported 
in the literature. This condition would necessitate, in addition to the 
scrotal operation, amputation of the penis and careful dissection of 
the inguinal groups of glands. 
The knees are kept tied together for some days after operation. 
Annoying erections are best controlled by an ice-bag. 
Wise and Minett12 in enumerating the situations where adult filarise, NEOPLASMS OF THE SCROTUM 
489 
alive or cretified, have been found, report them in the inguinal glands in 
25 cases. This would make it appear wise to remove the inguinal 
glands of patients who are in good condition if there be larvae present 
in the blood before operation and elephantiasis of the scrotum is the 
only other evidence of filariasis. 
Ivondoleon8 has recently advised in cases of edema of the scrotum 
and early elephantiasis, incision of the skin over both testicles, excision 
of a strip of fascia 3 or 4 cm. broad, incision and turning back of the 
tunicse vaginalis as for hydrocele, and suture of the skin without 
drainage. 
Castellani12 has recommended daily injections of 2 c.c. fibrolysin for 
fibromatosis of the legs. But there would appear little use for this 
method in the scrotum, where radical operation is so efficient. 
Elephantiasis of Non-filarial Origin.—Elephantiasis of non-filarial 
origin represents sporadic cases of unknown etiology in patients who 
have not visited the tropics. Instances have been mentioned in which 
the condition was due to the blocking of the lymphatics by a scar, or by 
infection, or after operative removal of the inguinal glands with, of 
course, a supervening infection in the scrotal wall. A slight degree 
of elephantiasis may occur writh ulcerating granuloma of the genitalia. 
A similar condition is referable to tertiary syphilis in rare cases. A con- 
vincing report of such a case was made by McDonagh;10 the scrotum 
measured 28f>- inches in circumference, and was reduced by mercurial 
treatment to 13| inches. 
Fig. 229.—Cancer of the scrotum. 
NEOPLASMS OF THE SCROTUM. 
New growths of the scrotum are relatively uncommon. The least 
uncommon and most important is epithelioma, known as chimney- 
sweep’s cancer. It is a rarity in America but more frequently met 490 
NEOPLASMS OF THE SCROTUM 
with in England. Morley14 found records of 30 cases at the Manchester 
Royal Infirmary from 1906 to 1910, and (for comparison) only 25 of 
carcinoma of the penis. It was seen in former days chiefly among 
chimney-sweeps, and nowadays is particularly found among workers in 
paraffin and other coal-tar products. Butlin2 showed years ago by 
very interesting statistical data that the irritation of soot and coal-tar 
products was a marked predisposing etiological factor. 
Cancer begins in the form of one or more warts, apparently remaining 
benign for years; or as a superficial, painful, ragged, vascular ulcer with 
hard base and edges with a scab on its surface, situated usually on the 
lower part of the scrotum. Pathologically this is a true epithelioma. 
Clinically it is slow growing, and the glandular involvement is relatively 
late. Metastasis to other organs is uncommon. If untreated the growth 
may gradually involve testicles, perineum, and penis. The treatment is 
thorough excision of the scrotum and enucleation of the inguinal and 
femoral glands, preferably in one mass (see paragraph on Lymphatics 
of the Scrotum). Unless adherent the testicles and cord should not 
be removed. 
Adenocarcinoma metastasis in the scrotum has been reported. 
Primary melanosarcoma is of rare occurrence. Instances of angioma, 
lymphangioma, fibroma, lipoma, chondroma, osteoma, hydatid cyst, 
atheromatous cyst, and dermoid cyst of the scrotum, have been recorded. 
BIBLIOGRAPHY. 
1. Bruyneel: Un cas de rupture de varices du scrotum, Bull. Soc. de med. de Gand, 
1908, lxxv, 106. 
2. Butlin: Cancer of the Scrotum in Chimney-sweeps and Others, Brit. Med. Jour., 
1892, i, 1341; ii, 1. 
3. Calvert: The Operation for Removal of Elephantiasis of the Scrotum and Penis; 
Notes on Two Hundred Consecutive Cases, Indian Med. Gaz., Calcutta, 1905, xl, 
161-163. 
4. Charles: The Surgical Technic and Operative Treatment of Elephantiasis of 
the Generative Organs, Based on a Series of One Hundred and Forty Consecutive 
Successful Cases, Indian Med. Gaz., 1901, xxxvi, 84. 
5. Cunningham: Filariasis, Ann. Surg., October, 1906, p. 481. 
6. Daniels and Wilkinson: Tropical Medicine and Hygiene, 1909. 
7. Greene: Cancer of the Scrotum, Boston Med. and Surg. Jour., 1910, clxiii, 755, 
792. 
8. Kondoleon: Die Lymphableitung des Scrotum, Zentralbl. f. Chirurgie, Leipsic, 
September 26, 1914, xli, No. 39, 1513. 
9. Kuhn and Giihne: Zur operativen Behandlung der Elephantiasis Scroti, Archiv 
f. Schiffs. u. Tropen-Hyg., Leipzig, 1913, xvii, 457. 
10. McDonagh: Case of Syphilitic Elephantiasis of the Scrotum, Proc. Roy. Soc. 
Med., London, 1911-1912, v, Dermat. Sect., 67. 
11. Maitland The Operation for Removal of Elephantiasis of the Scrotum and 
Penis, Indian Med. Gaz., 1901, xxxvi, 161. 
12. Manson: Tropical Diseases, 1914, 5th edition. 
13. Matas: The Surgical Treatment of Elephantiasis, etc., Am. Jour. Trop. Dis., 
New Orleans, 1913, i, 60-85. 
14. Morley: Lymphatics of the Scrotum in Relation to Radical Operation for Scrotal 
Epithelioma, Lancet, 1911, ii, 1545. 
15. Murray: Elephantiasis of the Scrotum and Penis, Indian Med. Gaz., 1902, xxxvii, 
457. 
16. Primrose: Filariasis in Man Cured by Removal of Adult Worms in an Operation 
for Lymph Scrotum, Canada Prac., Toronto, 1905, xxx, 135-146. 
17. Whiting: Gangrene of the Scrotum, Ann. Surg., Philadelphia, 1905, xli, 841-862. CHAPTER XIII. 
HYDROCELE, HEMATOCELE, SPERMATOCELE AND 
VARICOCELE. 
By HENRY L. SANFORD, M.D. 
HYDROCELE. 
Definition.—Hydrocele in its ordinary form is an abnormal accumula- 
tion of serous fluid in the cavity of the tunica vaginalis. Normally a 
few drops of fluid are present between the visceral and parietal layers of 
the tunica as a protection to the testis. 
Other forms of hydrocele represent collections of fluid contained in 
other structures than the cavity of the tunica vaginalis, either com- 
municating with it or distinct from it. A brief reference to the embryo- 
logical development of these structures will aid in explaining the origin 
of these other types. 
Anatomy.—Before its descent into the scrotum the testis is a retro- 
peritoneal abdominal organ and has no direct relation with the true 
abdominal cavity. As it descends on the gubernaculum testis it carries 
with it the anterior covering of peritoneum, wdiich is to become the 
visceral layer of the tunica vaginalis, and as the testis passes through the 
internal ring and the inguinal canal it pushes before it a pouch of parietal 
peritoneum which is called the processus funicularis, and which in turn 
becomes the parietal layer of the tunica vaginalis. 
In the scrotum the visceral layer of the tunica, after covering the 
testis, passes over onto the epididymis, which it includes between its 
two leaves, and is then reflected onto the parietal layer of the tunica. 
Jt. thus happens that the posterior inner border of the testis where it is 
apposed to the epididymis has no peritoneal covering, and so it main- 
tains its original retroperitoneal character. 
After this complicated migration of the testis is completed a door is 
shut after it to hold it in position. If this door does not close soon after 
birth or, in other words, if the cavity of the funicular process of peri- 
toneum through which the testis descended does not become obliterated, 
conditions are present which admit of various abnormalities. Among 
them are some of the types of hydrocele to be considered. 
Varieties.—Hydroceles may be classified* according to their ana- 
tomical location into: 
1. Hydrocele of the testis. 
2. Hydrocele of the cord. 
3. Complications of 1 and 2. 
4. Hydrocele of a hernial sac. 
* Jacobson’s Classification. 
491 492 
HYDROCELE, HEMATOCELE AND VARICOCELE 
1. Hydroceles of the testis include (A) those of the tunica vaginalis, 
where the fluid is in a sac directly connected with the tunica vaginalis. Of 
these there are four forms: 
(1) The ordinary type, distending the closed tunica vaginalis; 
(2) The congenital type, where the sac of the tunica vaginalis com- 
municates directly with the abdominal cavity, due to complete failure 
of the processus funicularis to close; 
(3) The infantile type, in which the sac of the tunica vaginalis and 
a portion of the processus funicularis are filled with fluid, but no con- 
nection exists with the abdominal cavity, representing partial failure of 
closure of the processus funicularis; and 
(4) The inguinal type, a hydrocele in relation to an undescended 
testis. 
(B) Encysted hydroceles of the testis, in which the fluid is in a sac 
distinct from the tunica vaginalis, as in encysted hydroceles of the epi- 
didymis when the fluid is contained between the two layers of visceral 
tunica as it passes from the testis over onto the epididymis, and 
encysted hydroceles of the testis, where the fluid is between the tunica 
albuginea and the visceral layer of the tunica. These are rare types. 
2. Hydroceles of the cord may be of the diffused type, a serous col- 
lection of the nature of edema in the cellular tissue of the cord, or of the 
encysted type, fluid in a distinct sac originating either from some unob- 
literated portion of the processus funicularis, or from a cyst formed 
independently of this process, by dilatation of persistent tubules of the 
organ of Giraldes. 
3. Complications of these forms of hydrocele represent any two forms 
coexisting or any form occurring with hernia. 
4. Hydrocele' of the sac of a hernia may occur by the effusion of fluid 
into a hernial sac, the contents of which have been reduced with subse- 
quent obliteration of the neck of the sac. 
Hydroceles may also be considered according to their course as acute 
and chronic, and as to their origin as symptomatic and idiopathic. While 
all idiopathic hydroceles are chronic it is not equally true that all 
symptomatic hydroceles are acute. 
Acute Hydrocele.—Acute hydrocele is the direct sequel of inflamma- 
tion and infection of the testis and epididymis and occasionally follows 
trauma. The cavity of the tunica vaginalis is filled with a varying 
amount of fluid which may be serous, fibrinous, or purulent. Gonorrhea 
and tuberculosis of the epididymis are the two infections which most 
often produce symptomatic hydrocele, the former a very acute type, 
the latter tending to a more chronic course. Other causes which may 
produce this form of hydrocele are infections by the pneumococcus, the 
colon bacillus, by typhoid, erysipelas, rheumatism, syphilis, and neo- 
plastic growths. 
Course. —The course of acute hydrocele corresponds to that of its 
cause: it tends to recovery as the primary disease improves and 
becomes chronic as the cause persists. The exciting factor may 
entirely disappear, however, and leave behind it a persistent hydrocele. 493 
HYDROCELE 
Symptoms.—The symptoms of acute hydrocele depend on the viru- 
lency of the infecting agent. Pain may be severe or absent. In acute 
gonorrheal epididymitis the tension of the complicating hydrocele is 
often responsible for a considerable part of the severe pain, as is shown 
by the remarkable relief which follows the release of the fluid in epi- 
didymotomy. The hydrocele accompanying tuberculous epididymitis 
on the contrary rarely causes any discomfort. The sac of an acute hydro- 
cele may be obliterated by plastic exudate, or suppuration may occur in it. 
Diagnosis.—The diagnosis may be made by the means to be described 
under the chronic type. 
Treatment.—-The treatment is usually palliative. If the causative 
infection runs a short, acute course, and the amount of fluid is small, 
with rest, elevation of the scrotum and hot, moist dressings, the effusion 
may be left to absorb. Severe pain with considerable fluid demands 
aspiration, which may be repeated if necessary. 
Suppuration requires incision and drainage. None of these measures 
are curative, and the treatment of the underlying condition is the proper 
treatment for the hydrocele. Injection of the sac is usually unsuccess- 
ful in this type of hydrocele, and should not be done. When the fluid 
fails to be absorbed after some weeks, the hydrocele becomes chronic. 
Chronic or Idiopathic Hydrocele.—Etiology.—Persistence of an acute 
hydrocele is a common cause of the chronic type. This occurs espe- 
cially after infections of the testis and epididymis which tend to run a 
chronic course. Cases of primary disease of the tunica vaginalis have 
been reported as the cause of chronic hydrocele without being secondary 
to diseases of the testis or epididymis. Hildebrand4 described a gumma 
of the tunica vaginalis and De Vlaccos4 two cases of tuberculosis of the 
tunica. The latter considered the hydrocele analogous to a tuberculous 
ascites, and believes that the tuberculosis originated in the abdomen, 
with transmission of infection through an open processus funicularis, 
settling at its lowest point. 
Trauma is considered a cause of chronic hydrocele. In this way the 
frequent occurrence of hydrocele among circus-riders is explained. 
Injuries at birth have been held responsible for certain instances of 
congenital hydrocele. 
Recent statistics have noted an unusually large number of hydro- 
celes occurring as a postoperative complication following resection of 
veins in varicocele. (See under Varicocele.) 
Besides all these cases, however, to which an etiological factor may be 
assigned, there still remain a large number of hydroceles the cause of 
which is not known, and to which the term idiopathic is given. These 
cases are seen frequently in tropical countries, especially India and 
Egypt, and various investigators have adduced different reasons for 
their occurrence. Madden4 believes this type is due to loose tropical 
clothing, which allows greater trauma to the testis, and to oriental 
sexual excesses, both of which tend to hyperemia and serous exudate. 
Pfister4 thinks there is a connection between bilharzia and hydrocele, 
while Salm4 claims to have found filarial embryos in six out of twelve 
East Indian hydroceles. Others have not confirmed this. Some 494 
HYDROCELE, HEMATOCELE AND VARICOCELE 
chronic irritation of the local circulation is believed by many to be the 
probable causative factor. 
Chronic hydrocele differs from varicocele in that it shows no predi- 
lection for either side, and it often is bilateral. All ages are subject 
to hydrocele. Posner,24 however, is impressed with the number of 
hydroceles he has met with in old men in association with prostatic 
hypertrophy, and believes it is a possible cause of the idiopathic type. 
Pathology.—The pathology of hydrocele involves a study of the fluid, 
the sac, and the effects, if any, of the presence of the hydrocele on the 
testis and epididymis. 
The Fluid.—Amount.—The hydroceles one sees today contain from 
4 to 10 ounces of fluid. Patient, un’ess they come from remote dis- 
tricts, rarely allow them to get larger without seeking relief. Before the 
days of surgical asepsis, operations were regarded with considerable 
dread, and cases of enormous size are on record. Mursenna (1796) 
reported a case where the sac measured 17 by 27 inches; Leigh, in 1607, 
one where the tumor weighed 120 pounds, and Casper, a case in which 
the sac held 5 gallons. 
Fig. 230.—Idiopathic hydrocele. 
Physical and Chemical Properties.—Hydroceles in simple uninfected 
cases contain a clear serous liquid resembling blood serum. It is of a 
straw or greenish-yellow color; the reaction is neutral; its specific 
gravity varies from 1020 to 1026, and it has no odor. The fluid is 
cloudy if infected, and may be brownish red with a coffee-ground 
sediment in case of old hemorrhage. It contains about 6 per cent, of 
albumin made up of serum albumin and globulin with some fibrinogen. 
Glucose has been found in it. It differs from ascitic fluid by containing 
salts and fibrin. Occasionally on opening a hydrocele there are found 
in the fluid fibrous bodies about the size of a pea which are concretions 
of earthy phosphates or carbonates covered with fibrin. Keyes15 
believes they probably originate as deposits of hydrocele salts on some HYDROCELE 
495 
warty growth on the sac wall, which later breaks off and becomes free 
in the fluid. 
Microscopical examination of the fluid shows some endothelial cells, a 
few leukocytes, cholesterin crystals, and in many cases spermatozoa. 
Bacteria are present in infected cases, and blood if there has been spon- 
taneous or traumatic hemorrhage from the sac wall or testis. There are 
often seen glistening drops which have been considered fat drops but 
which Posner24 thinks are lipoids, analogous to the lecithin bodies of 
the prostate. He believes these bodies impart motility to the sperma- 
tozoa, as does the lecithin of the prostate. The presence of sperma- 
tozoa is explained by the supposition that a rupture of semen-preparing 
tubules has occurred into the hydrocele sac and that a communication 
between these tubules and the sac must continue to exist. If this is 
true the cholesterin crystals found in hydrocele fluid may be accounted 
for as coming direct from the testis. 
Winslow reports 6 cases in which spermatozoa were found in hydro- 
cele sacs under different conditions. One case was a man, aged 
eighty-three years, who had a large hydrocele on the right side for 
thirty years. Aspiration yielded 900 c.c. of whitish fluid containing 
many motile spermatozoa. 
From Caforio’s5 study of hydrocele fluid he believes it to be an 
exudate of bacterial origin rather than a transudate from chronic passive 
congestion, otherwise he would expect hydrocele more often to compli- 
cate varicocele, and vice versa. He finds also that transudates in gen- 
eral have a lower specific gravity and smaller albumin contents than 
hydrocele fluid. 
The Sac.—The cavity of the sac in hydrocele may be single or multi- 
locular. Adhesions between the layers of the tunica may be formed as a 
result of fibrinous exudate subsequent to infection or irritant injections 
producing partial obliteration. In hydroceles of long standing the sac 
wall is usually much thickened. This appears especially about points 
of puncture from previous tapping. Calcification may occur in 
localized areas. 
The Testis and Epididymis— Primary disease of these organs in 
many cases is the cause of the hydrocele, but they may also suffer as a 
result of the presence of the hydrocele. Pressure of the fluid on the 
testis and thickening of the connective tissue about it has produced 
atrophy and loss of function of the organ. The epididymis may also 
be involved. 
Symptoms.—The objective symptoms of hydrocele are those of a pear- 
shaped tumor of one or both sides of the scrotum, the arger portion 
below, and the smaller above, sharply tapering into the cord. It is 
smooth in outline, elastic to the touch, dull to percussion, and trans- 
lucent to light. It cannot be reduced into the inguinal canal, and gives 
no impulse on coughing unless complicated with hernia. In hydroceles 
of large size the skin of the scrotum is tense and glazed, but shows no 
redness or edema and is movable over the tumor. The cord leading to 
the hydrocele is normal in size. The growth of the tumor is slow, 
enlarging gradually from the bottom of the scrotum toward the inguinal 496 
HYDROCELE, HEMATOCELE AND VARICOCELE 
canal. The testis is usually situated behind and somewhat below the 
centre of the tumor; very rarely it is at the front, and then only as the 
result of adhesions. 
Subjectively chronic hydroceles rarely cause any pain or tenderness 
unless some complicating infection is present. The fluid gathers 
slowly and may reach some size before the patient notices it. Hydro- 
celes do, however, produce discomfort from their weight, and if of a 
large size, invagination of the penis into the encompassing tumor 
makes urination difficult with attendant excoriation of the skin by 
the urine. Coitus may be interfered with either because erections are 
poor or because the outflow of semen is obstructed. Cases are on 
record in which spermatozoa were absent in the semen when the 
hydrocele was distended, but reappeared after tapping. Prostatics 
who have hydrocele are sometimes hard to catheterize. 
Fig. 231.—Hydrocele. Diagnosis by transillumination. 
Diagnosis.— The Light Test.—The property possessed by simple 
hydrocele of transmitting light through its fluid contents is the means 
most often invoked in making a diagnosis. If the observer looks 
through a hollow tube held tightly against one side of the hydrocele, 
while an electric light bulb or other source of light is held against the 
opposite side, a pinkish light will be seen glowing through the tumor 
and a darker shadow cast by the more solid testis may sometimes be 
made out. This test often fails when the contents of the hydrocele 
are cloudy, when its walls are thickened, and in the presence of adhe- 
sions or multilocular cyst formation. Translucency is also a charac- 
teristic of some soft tumors of the testis when a portion of the contents 
is fluid; it is observed in some hernias in infants and in some hydatid 
cysts. This method of diagnosis therefore is by no means infallible. HYDROCELE 
497 
Unless it extends up into inguinal canal a hydrocele is sharply 
defined at its upper border, into which the cord of normal size passes. 
Puncture of the hydrocele and recovery of the typical fluid is the 
surest means of diagnosis. It should never be done, however, unless 
the presence of hernia can be absolutely ruled out. 
A cytological examination of the aspirated fluid does not always give 
an idea of the causative factor of the hydrocele, but many authors are 
agreed that the presence of a large percentage of mononuclear leuko- 
cytes is strong evidence of a tuberculous hydrocele. 
Besides these methods, the history of the slow gradual development 
of a painless tumor is of aid in making a diagnosis. 
Differential Diagnosis.—Hydrocele must be differentiated from hernia, 
spermatocele, hematocele, chylocele, and solid tumors of the testis. 
Hernia give an impulse on coughing, is tympanitic to percussion and 
is reducible unless incarcerated or strangulated. In the latter case the 
previous history of a reducible tumor with the recent acute symptoms 
would prevent confusion in diagnosis. It must always be remembered, 
however, that hydrocele and hernia often coexist, especially in children. 
Spermatocele is differentiated by its rarity, by the fact that the testis 
is usually in front and below, instead of behind as in hydrocele, and by 
the predominance of seminal elements in the fluid contents on aspira- 
tion. The differential diagnosis is impossible, however, in the intra- 
vaginal type of spermatocele, which can only be identified at operation. 
Hematocele can usually be distinguished by the recent history of 
injury, by its solid and inelastic feel, by the opacity of its contents, and 
by the presence of skin ecchymoses. A hydrocele may be converted 
into a hematocele by spontaneous or traumatic hemorrhage from the 
sac wall, the latter sometimes follows aspiration of a hydrocele, if the 
trocar wounds a vessel in the sac. 
Chylocele is characterized by its occurrence in the tropics, its parasitic 
origin, and by the creamy character of the fluid, which shows a layer of 
fat at the top on settling. 
Solid tumors of the testis differ from hydrocele in their rapid growth 
associated with pain, in their non-elastic feel, with absence of fluctua- 
tion, and the development of inguinal glands. There is frequently 
enlargement of the cord leading to the growth. 
Prognosis.—In children cures of hydrocele may occur spontaneously 
and occasionally after a single tapping. For this reason certain authors 
advise expectant treatment with children. Other authors find hernia 
complicating hydrocele in infants so frequently that they recommend 
early radical cure of both conditions. 
In adults chronic hydrocele shows no tendency to spontaneous 
recovery. It never endangers the patient’s life except under the rarest 
complications of hemorrhage and infection. The percentage of cures 
under the various methods of treatment is discussed under that heading. 
Complications.—Two or more forms of hydrocele may coexist, and 
hernia frequently accompanies hydrocele in children. Suppuration 
is uncommon in chronic hydrocele. Rupture of the hydrocele sac is 
usually regarded as rare, but Hastings13 believes it a more frequent 498 
HYDROCELE, HEMATOCELE AND VARICOCELE 
accident than is commonly supposed. It may occur as the result of 
trauma or muscular action, rarely spontaneously. The tunica vaginalis 
in such cases is nearly always the seat of pathological changes, usually 
with fibrous thickening, and areas of fatty degeneration. A ruptured 
hydrocele must be differentiated from elephantiasis of the scrotum, 
from extravasation of urine, and from strangulated hernia. Hemato- 
cele may be the result of the rupture of the sac. Rupture only rarely 
results in a cure, usually the hydrocele refills, unless the cavity of the 
sac is filled with blood clots. 
Treatment.— Historical.—There is scarcely a disease for the cure of 
which physicians for centuries have devised more numerous or more 
ingenious methods of treatment, than for hydrocele. Until anatomists 
of the time of Monro, Hunter and Pott discovered the true nature of 
hydrocele, there was “ supposed to be an immediate connection between 
the coats of the testicle, liver, kidneys, and other viscera, and the col- 
lection of water in hydrocele was considered a deposition from these 
parts, tending to free them and perhaps the system at large from diseases 
of importance.” Various kinds of internal medication were accordingly 
used, with local applications in the form of counter-irritants. Simple 
tapping of the hydrocele was a very early measure. Electricity and 
electropuncture were employed, on the principle that the current acted 
as a counter-irritant and also possessed some coagulating power on 
albuminous fluids. The injection of irritant fluids into the sac following 
aspiration was among the earliest methods of treatment, and is still 
used today. Among the fluids which have been used are wine, various 
acids, iodine, chlorine, zinc chloride, alcohol, ether, chloroform, adrena- 
lin, bichloride of mercury, ferric chlorate, chloral hydrate, ergotin, and 
silver nitrate. The introduction of foreign bodies into the sac after 
aspiration has also been extensively practised with the idea that the 
injection of an irritant fluid had too transitory an effect to produce 
complete obliteration of the sac. Some of the substances used have 
been rubber tubes, silk, catgut,30 and metal strips.17 
Vaccine therapy has been used in hydrocele. Mallanah16 reports cures 
of six cases in which an injection of from five to ten million of either B. 
pyocvaneus or Staphylococcus aureus vaccine was made into the 
hydrocele sac after aspiration of the fluid. Severe reaction occurred, 
followed by increase in size of the hydrocele, later regression to a 
cure. 
Autoserotherapy in the treatment of hydrocele consists in total or 
partial aspiration of the sac, followed by subcutaneous or intramuscular 
injection of the patient with his own fluid. This has been extensively 
practised in recent years by foreign investigators, but there is little 
American literature on the subject. This method is analogous to 
similar work which has been done in tuberculous exudates of the pleura 
and peritoneum. The amount of fluid injected varies with different 
workers from 1 to 20 c.c. with an average dose of 5 c.c. The size of the 
dose is reported to make little difference in the amount of local reaction 
or the effect on the hydrocele. Injections are made either in the thigh, 
buttock, or abdomen. Most authors who have tried this procedure HYDROCELE 
499 
have reported a rapid absorption of the fluid in the hydrocele following 
the autoserotherapy. The absorption takes place within the first 
twenty-four hours and then remains stationary. There is seldom local 
reaction or fever. In most cases relapses occur, sometimes imme- 
diately but not later than two months. These cases require several 
reinjections. 
In 73 cases Caforio6 reports that absorption of the fluid in the hydro- 
cele took place in 96 per cent. Relapses occurred in 80 per cent, but by 
continuing the injections 42 per cent, were permanently cured, as 
shown by absence of relapses over periods varying from several months 
to years. The injection of hydrocele fluid from other patients (hetero- 
serotherapv) produced no effect. Investigators are not agreed as to 
how this method produces the results claimed, and until the nature of 
the process involved in the cure is better understood, it must be regarded 
as only in the experimental stage. 
Radical surgical operations on hydrocele have been done for centuries. 
Incision and drainage of the sac was practised as early as the time of 
(Alsus, who also excised a portion of the skin at the same time. But the 
tremendous reaction resulting from the infection of the wound made 
surgery the resort of the more adventurous until the days of cleaner 
methods. 
When Lister introduced the principles of antisepsis, hydrocele was 
one of the first diseases on which their value was demonstrated. Volk- 
mann, in 1876, gave his name to an operation w'hich consisted in wide 
incision of the sac, swabbing its cavity with carbolic acid and sewing the 
edges of the sac to the skin with catgut. Permanent drainage was thus 
secured until obliteration of the sac by granulation took place. Yon 
Bergmann, in 1885, was one of the first to practise excision of the sac. 
Since that time many surgeons have devised changes in the technic of the 
handling of the sac, and in providing a new bed for the testis. 
Present Methods of Treatment.—The methods of treatment which 
need concern us seriously today are two: 
1. The purely palliative procedure of tapping or aspiration, and 
2. The radical operations which seek to obliterate or remove, wholly 
or in part, the membrane which secretes the serous fluid. These are of 
two types: (a) The closed operation of aspiration and injection, and (b) 
the open operations, consisting in total or partial excision, or eversion of 
the sac, or a combination of the two. 
Simple Tapping.—Indications.—Aspiration of the fluid of a hydro- 
cele does not contemplate a cure but merely the relief of symptoms. It 
is employed when the patient will not consent to a more radical pro- 
cedure or when some constitutional condition contra-indicates any 
operation. It may be used to advantage in children when the hydro- 
cele is uncomplicated, and at times results in a cure. 
Technic.—After proper preparation of the skin and after locating the 
position of the testis the hydrocele is made tense by grasping it from 
behind between the palm and fingers of one hand. A spot free from 
large bloodvessels on the lower tense anterior surface of the hydrocele is 
selected and a sharp medium-sized trocar plunged smartly and quickly 500 
HYDROCELE, HEMATOCELE AND VARICOCELE 
into the sac, using one finger firmly fixed on the trocar about one-half 
inch from its point as a guard against too deep penetration. With a 
sharp instrument the pain of puncture is slight and only momentary, 
and often no local anesthetic is needed. 
On withdrawing the needle from the trocar, if the fluid does not run 
through the cannula, it generally means that the point of the trocar has 
pierced only the skin and not the tunica vaginalis, so that farther in- 
sertion is necessary. Care must be taken not to let the cannula slip 
out of the cavity of the tunica vaginalis into the space between it and 
the skin during the withdrawal of the fluid, as this results in infiltration 
of the scrotum. A collodion dressing of the puncture wound and a 
suspensory complete the aspiration. 
In old men with large hydroceles a partial removal of the fluid is wise, 
followed later by withdrawal of the remainder. Congestion and 
hemorrhage have been reported following too great changes in local 
conditions after the complete aspiration of a large sac. 
After tapping, the hydrocele usually refills in from two to six months. 
Many patients are content with a semi-annual relief of their burden 
over a period of many years. 
Complications.—The trocar may wound the testis when it has been 
pulled out of its usual posterior position by adhesions. This rarely 
produces any serious trouble. Hemorrhage from the sac wall due to 
puncture of a vessel of some size by the trocar may produce hematocele. 
Both of these accidents may be avoided by transillumination of the sac 
in selecting a point of puncture. The course of bloodvessels and the 
position of the testis are thus made clear. 
Aspiration and Injection.—This ancient method of treatment is 
still in considerable use today. It seeks to produce obliteration of the 
cavity of the tunica vaginalis by the injection into it of an irritant 
following the aspiration of the fluid. The drug which has proved the 
least painful and the most sure in its results as an injection is carbolic 
acid. 
Indications.—This procedure is indicated in a restricted class of cases, 
namely, in simple uncomplicated hydroceles when the fluid is clear and 
the sac wall unchanged. It is not adapted for congenital hydroceles, for 
symptomatic hydroceles with accompanying disease of the testis or 
epididymis, for hydroceles in which the sac wall is indurated, infected, or 
calcareous, for multilocular hydroceles, nor for hydroceles complicated 
with hernia. 
Technic.—A hypodermic needle detached from its syringe is inserted 
into the upper portion of the hydrocele sac, and after the escape of fluid 
through the needle shows that it is in the sac it is left in position while 
the hydrocele is completely aspirated to the last possible drop by a 
trocar introduced into its lower anterior portion. The trocar is then 
withdrawn and a hypodermic syringe containing from 5 to 20 minims of 
pure carbolic acid crystals, deliquesced by heat, is attached to its pre- 
viously inserted needle. The acid is then injected into the sac and the 
scrotum thoroughly kneaded in order to spread the acid through the 
sac cavity. Care should be taken not to burn the scrotum by spilling HYDROCELE 
501 
any of the acid; alcohol will neutralize the effect of any that might 
escape. Both puncture wounds are sealed with collodion, and a snug 
suspensory applied. 
Some authors advise washing out the sac after aspiration with sterile 
salt solution until the wash water returns clear, in order to remove as 
much albuminous material from the sac wall as possible and to prevent 
it from neutralizing the effect of the acid. Keyes15 has failed to note 
any advantage in this method. 
Pain is inconsiderable owing to the anesthetic effect of the carbolic 
acid. Confinement to bed is not necessary after the injection, though 
usually patients remain quiet one or two days. 
After the injection the sac partially refills with inflammatory exudate 
over a period of a week or ten days, after which it usually begins to 
recede. If still large and tense at the end of that time the sac should 
be emptied again by aspiration without a second injection. If it then 
refills for a second time the case is not suitable for injection and open 
operation is indicated. 
Keyes believes that failures of the injection method are due to three 
causes: (1) improper selection of cases; (2) errors of technic, as incom- 
plete evacuation (the most frequent cause of failure) and failure to 
aspirate a second time, which is sometimes part of the cure; (3) the use 
of iodine instead of carbolic acid, the former being more painful and less 
certain in its results. 
Open Operations.—Indications—One of the many variations of 
open operation may be performed in any type of hydrocele except in 
those cases in which the patient’s preference or condition allows of 
palliative treatment only. Open operation is especially indicated, 
moreover, in those forms of hydrocele mentioned above in which the 
injection treatment is contra-indicated or likely to fail. It gives the 
operator the additional advantage of examining the testis and epi- 
didymis for the presence of pathological changes, with the opportunity 
for appropriate treatment. 
Technic.—Local or general anesthesia may be used. After proper 
preparation of the parts a high incision, three or four inches in length, 
according to the size of the hydrocele, is made, beginning over the 
external abdominal ring and extending downward along the course of 
the cord. The tunica vaginalis is exposed and the subsequent steps 
differ according to the type of operation to be done. 
Simple Eversion (Andrews’s “Bottle” Operation).—The tunica 
vaginalis is opened at its upper pole and the fluid evacuated. The testis 
is brought outside the scrotum and extruded through the opening in the 
sac, which is made only large enough to admit of the passage of the 
testis through it. The sac is then turned inside out and left without 
suture, or one or more sutures may be passed through the cut edges of 
the sac, securing it behind the cord to prevent reinversion. The testis 
and everted sac are now returned to the scrotum and the wound closed 
without drainage. In this operation the convalescence is short and 
there is little danger of hemorrhage, owing to the absence of much 
dissection. There is seldom any testicular pain and the everted sac 502 
HYDROCELE, HEMATOCELE AND VARICOCELE 
soon shrinks. The disadvantages of the operation are that it is not 
successful in old, thickened hydroceles, and that recurrence is not 
uncommon. 
Excision and Eversion (Winkelmann’s Operation) is the procedure 
accepted today as the best type. After dissecting free the parietal layer 
of the tunica the sac is trimmed off down to within one-half inch of its 
visceral insertion and the two cut edges of the parietal stump are sewed 
behind the testis by a continuous catgut suture. Great care must be 
taken to secure firmly all bleeding-points in the cut edges of the stump of 
the sac to prevent subsequent hemorrhage. The wound is closed with 
or without drainage, as may seem best in the individual case, and a snug 
support is applied over the dressing. 
Fig. 232.—Hydrocele. The operator’s hand rests on the unopened sac, which has been 
dissected free down to the cord. 
Bartlett1 has described a method of total extirpation of the unopened 
hydrocele. It involves a rather unnecessarily tedious dissection, and is 
suited only to a restricted class of cases. Vautrin28 believes that in 
long-standing hydroceles with thickened walls, excision with eversion is 
not enough to prevent recurrence, and he makes a new bed for the testis 
in the connective tissue of the scrotum. This he finds an absolute safe- 
guard against relapse. Volkmann’s operation of wide incision of the 
sac, followed by swabbing its cavity with carbolic acid and allowing it to 
become obliterated by granulation, has been abandoned on account of 
the slow convalescence and the likelihood of recurrence due to local- 
ized failure of obliteration. Von Bergmann's operation of simple 
excision of the sac has also been generally replaced by one of the 
methods given above. 
Operative Complications.—Operat ons for hydrocele may be followed 
by hemorrhage, atrophy of the testis, and recurrence of the disease. HYDROCELE 
503 
Hemorrhage may take place as a result of the tearing of vessels 
during the separation of the sac wall or from the stump of the sac, 
and may develop some hours after operation, at which hemostasis 
was apparently complete. This can be guarded against at the time 
of operation by nice attention to separation of the sac along the 
proper line of cleavage, where one meets little bleeding, and by 
scrupulous care in tying off all bleeding-points. Porzelt35 advises 
tapping large hydroceles a day or two before the radical operation, 
in order to relieve tension and allow bloodvessels to regain their 
tone, thus reducing likelihood of postoperative hematoma. During 
the first twenty-four hours following operation, all cases should be 
frequently inspected for evidence of bleeding. If hemorrhage occurs 
Fig. 233.—Hydrocele. The sac has been excised to within one-half inch of the 
testis. The last stitch is being taken in the everted edges, which are being sewed behind 
the cord. 
there is early complaint on the part of the patient of pain and a sen- 
sation of tension in the scrotum. When the loss of blood is slight 
it may be left to be absorbed; when large the treatment becomes that 
of hematocele. 
Atrophy of the Testis.—Certain authors believe that the presence of 
the parietal layer of the tunica is necessary to integrity of the testis and 
that its removal in a radical cure for hydrocele interferes with testicular 
function. Others claim that the apparent atrophy of the testis which 
has been reported after operations on hydroceles is due either to a press- 
ure atrophy from the long-continued presence of the hydrocele or to 
some unusual operative complication which has damaged the testis. 
Rolando4 extirpated the tunica in dogs and later removed the testis at 
varying intervals following the primary operation. He reported that 
the testes removed early were smaller and softer than normal and 
showed thickening of the albuginea with no evidence of spermatogenesis 504 
HYDROCELE, HEMATOCELE ‘AND VARICOCELE 
Those removed two or three months later showed spermatogenesis, but 
not in normal amount. At all events this complication is rare and 
cannot be considered a contra-indication to a radical cure of hydrocele. 
Recurrence.—The liability to recurrence after radical operation will 
be considered under the heading of Results. 
Results of Various Types of Operation.—Bruns4 has collected statistics 
from a large number of operators, from which may be compared the 
merits of the two types of radical operation and the chances of subse- 
quent recurrence. 
Aspiration and Injection.—From reports of operators using either 
iodine or carbolic acid as an injection fluid he found 1593 cases with 95 
known relapses, or 6.1 per cent. Of these cases a certain number had 
been followed up for a period varying from a few months to some years. 
There were 505 cases with 57 relapses, or 11 per cent., undoubtedly 
proving that the percentage of relapse for the entire series was too low. 
Of these 505 cases which had been later investigated, iodine had 
been used in 420 cases with 45 relapses, or 10.7 per cent; carbolic 
acid had been used in 85 cases with 12 relapses, or 14 per cent. 
Reports showed that carbolic acid was less painful and caused less local 
reaction, consequently a shorter convalescence. There were no reports 
of intoxication from carbolic acid, as has been the case with the use of 
iodin. 
Open Operations.-—Of all types of open operations results were se- 
cured from 1216 cases with 30 relapses, or 2.4 per cent. Of these there 
had been late investigation of 412 cases with 22 relapses, or 5.33 per 
cent. Thus the injection method for the whole series shows two and a 
half times the percentage of relapse that the whole series of open opera- 
tions offers (6.1 per cent, as against 2.4 per cent.). 
Choice of Method of Treatment.— Tapping has its place as a purely 
palliative measure in cases in which the patient’s desire or condition 
makes it necessary, and it occasionally may result in a cure in children. 
Aspiration and injection may be expected to produce a definite 
number of cures in a selected class of cases. It possesses the advantage 
of ambulatory treatment, short convalescence, and the avoidance of 
whatever slight danger attends any cutting operation. It is followed, 
however, by a much greater percentage of failures than the open 
operations. 
Open operations involve hospital confinement and a longer con- 
valescence. They are adapted, however, to all types of hydrocele and 
are followed by fewer recurrences. Since it is not alone the simplicity 
of the method to be chosen but the sureness of result that should guide 
the surgeon in his advice to patients, the open operation remains the 
most rational proceeding in that it gives the best guarantee of cure. 
Hydroceles due to Abnormalities of Development. 
These forms of hydrocele are produced by interference with the oblit- 
eration of the peritoneal process in which the testis descends through the 
inguinal canal, and require separate mention. The particular type of HYDROCELE 
505 
abnormality associated with each of these forms has already been 
described under Varieties of Hydrocele. 
Congenital Hydrocele.—This form, of hydrocele occurs in infancy 
and is generally idiopathic. Rare symptomatic cases have been re- 
ported with congenital lues and accompanying orchitis. The idio- 
pathic type is due to muscular straining in crying or too tight binders, 
causing pressure on the unclosed processus funicularis. Peiser23 reports 
73 cases, of which 26 were double, 33 on the right side and 14 on the left. 
In the prone position the fluid can usually be pressed back into the 
abdomen. 
Diagnosis.—Congenital hydrocele and hernia frequently coexist. 
Both extend through the inguinal canal and both give an impulse on 
coughing. When either condition exists alone they may be differentiated 
by the fact that hernia is resonant on percussion and gives a gurgling, 
jerky reduction; it is not translucent and the testis can be identified. 
Hydrocele is dull to percussion, gives an even, slow reduction, is trans- 
lucent, and until after reduction the testis is lost in the hydrocele. When 
both conditions are present, the signs may be confusing. 
Prognosis.-—Many cases are cured spontaneously during the first year. 
Complication with hernia somewhat decreases the probability of 
spontaneous cure. 
Treatment.—Since hernia is a frequent complication some authors9 
prefer radical treatment between the third and sixth months to expec- 
tant treatment. If present the hernial sac may be treated at the same 
time. Injection treatment should never be used in this type. 
Infantile Hydrocele.—This is more common than the congenital 
form; because the fluid does not communicate with the abdominal 
cavity the hydrocele is always irreducible. Hernia is a frequent com- 
plication. “Hydrocele en bissac” is a rare type of infantile hydrocele 
in which a portion of the hydrocele is in the scrotum and a portion in the 
abdomen. 
Treatment. — Open operation, never injection, on account of the 
possibility of hernia coexisting. 
Inguinal Hydrocele.—This is a rare form of hydrocele surrounding 
an undescended testis. The treatment of the testis governs the treat- 
ment of the hydrocele. 
Hydrocele of the Cord.—Hydroceles of the cord are of two varieties, 
diffuse and encysted. 
Diffuse Type.—The true diffuse form is a boggy infiltration of the 
connective tissue about the cord following the rupture of a hydrocele or 
spermatocele. Under the name of multilocular hydrocele of the cord are 
grouped echinococcus cysts, cysts of fetal remains and other rare types. 
Symptoms.—The diffuse and multilocular types present a boggy 
tumor of irregular outline, which may extend from the scrotum to the 
inguinal canal or higher. The mass may be somewhat translucent, with 
slight impulse on coughing, and partial reducibility. 
Diagnosis.—The tumor is to be diagnosed by its translucency and 
general irregular, boggy feel. In other respects it suggests an incar- 506 
HYDROCELE, HEMATOCELE AND VARICOCELE 
cerated omental hernia, and may occasionally be identified only after 
incision. 
Treatment.—Often no treatment is advisable; incision has been used. 
Encysted Hydrocele of the Cord. —This form represents a localized col- 
lection of fluid in the course of the cord. The fluid does not communi- 
cate with the tunica vaginalis below nor the peritoneum above. Cysts 
may be large or small, single or multiple. They occur more often in 
children than adults. 
Treatment.— Tapping alone in children is often curative. Aspiration 
and injection with carbolic acid is useful in cases where the cyst is below 
the external ring. For cysts in the inguinal canal excison is indicated 
on account of the danger of hernia as a complication. Hematocele may 
follow injury to one of these hydroceles of the cord and demands the 
usual treatment of hematocele of the tunica vaginalis. 
Hydrocele of a Hernial Sac.—A collection of fluid in the sac of a 
hernia after its contents have been reduced and after either spontane- 
ous or artificial obliteration of the neck of the sac. It must be differen- 
tiated from a recurrent hernia. 
Treatment.—Excision. 
HEMATOCELE. 
An hematocele is formed when there is hemorrhage into the cavity of 
any form of hydrocele. Hemorrhage into the tissues is properly 
termed hematoma. As . infiltrations of the scrotum and testis with 
blood often accompany the bleeding into the hydrocele sac, we fre- 
quently have the combination of hematocele and hematoma, to both of 
which, however, the former term is generally applied. 
Etiology.—Hematocele may be traumatic or spontaneous in origin. 
If traumatic (1) it follows blows or crushing injuries of the scrotum and 
its contents, in which case the hemorrhage may infiltrate the scrotum 
as well as the hydrocele sac, or (2) it may be the result of hemorrhage 
subsequent to any operation upon a hydrocele or upon the epididymis 
or testis. Spontaneous hemorrhage into a hydrocele sac may occur in 
conditions of arteriosclerosis and scorbutus. 
Whitney4 reports a case of spontaneous rupture of a bloodvessel 
in the wall of a hydrocele in a case of syphilis. 
Symptoms.— Traumatic hematocele develops quickly with pain and 
tension in the scrotum and rapid increase of size of the hydrocele sac. 
Skin ecchymoses are frequently present. Spontaneous hematocele is of 
slow and insidious development, is almost never painful, and resembles 
the growth of a hydrocele. The contents of a recent hematocele are 
fresh blood, which later becomes brownish or chocolate-colored from 
admixture with fibrin and disintegration. The sac cavity may be 
entirely obliterated by fibrinous growths projecting from the sac wall 
and pressure on the testis in long-standing cases may cause its complete 
atrophy. Barrington1 reports a case of spontaneous rupture in a 
hematocele of nine years’ duration. Examination of the testis removed SPERMATOCELE 
507 
at operation showed that though it appeared normal maeroscopically, 
there was entire degeneration of the tubules. 
Diagnosis.—With a definite history of recent injury to or operation 
on the scrotal contents, the diagnosis of hematocele is easy and is made 
by the same signs as those presented by acute hydrocele minus the 
translueency and with the usual added presence of ecchymoses. The 
real difficulty in diagnosis is to differentiate the slowly developing pain- 
less hematocele caused by spontaneous hemorrhage into the tunica 
vaginalis from a neoplasm of the testis. Woolfenden3 reports a sup- 
posed case of hematocele, which was assigned to students by examiners 
for the degree of M.B., which at later operation proved to be a sarcoma 
of the testis. 
Treatment.—Ordinary traumatic hematocele requires the same treat- 
ment as acute hydrocele—rest, elevation, and hot, moist dressings. 
Many authors recommend the application of ice and cooling lotions, but 
they are not as grateful to patients, in our experience at least, as some 
form of heat. Extensive hemorrhage with danger of atrophy of the 
testis from pressure or suppuration demands incision and drainage. 
With the more slowly developing type of hematocele due to spontaneous 
hemorrhage, unless the history is perfectly clear, it is far safer to operate 
to prove or exclude the presence of a malignant growth of the testis. 
Orehidectomy is indicated in long-standing hematocele. 
CHYLOCELE (GALACTOCELE). 
This is a rare condition in which chyle is present in the tunica 
vaginalis. It is usually seen in the tropics and is due to the presence 
of the Filaria sanguinis hominis in the lymphatics of the cord, causing 
engorgement and leakage of the chyle into the tunica vaginalis. It 
resembles hydrocele except that its contents are milky and the patient 
presents the symptoms of filariasis. 
Treatment.—The treatment consists in excision, with an attempt to 
remove the affected lymphatics. 
SPERMATOCELE. 
Etiology.—Spermatoceles are true retention cysts in or about the 
epididymis or rarely of the testis and are produced by any process 
whiclHblocks the outlet of seminiferous tubules, leading to distention 
of the tubule by semen, which continues to be secreted, and cyst forma- 
tion. The present view discredits the theory of the origin of sperma- 
tocele in fetal remains. 
With relation to the tunica vaginalis these cysts may be extravaginal 
or intravaginal. The extravaginal type is the more common and usually 
arises behind the testis and between it and the epididymis, and develops 
in a direction in which there is no covering of tunica vaginalis. The 508 
HYDROCELE, HEMATOCELE AND VARICOCELE 
intravaginal type develops from some portion of the epididymis, which 
is covered with tunica vaginalis, and pushes it ahead of it in its growth. 
These cysts may attain large size and entirely fill the cavity of the tunica 
vaginalis. Their rupture into the cavity is held to be a cause of hydro- 
cele as well as to account for the presence of spermatozoa found in 
some hydroceles. Spermatocele occurs mostly between the ages of 
twenty and forty; there are few cases in old men. It is more fre- 
quent on the right than on the left side and may be bilateral; it may 
accompany hydrocele. 
One family is on record in which there are three sons, all of whom 
developed in the course of their young maturity, right-sided sperma- 
tocele.* 
Pathology.—Spermatoceles conform to the type of true retention cysts 
in that they arise from a preformed cavity, they are lined with its 
epithelium, and their contents correspond to that of the affected organ. 
Injection preparations have been made from spermatoceles showing 
direct connection with seminiferous tubules. The larger cysts which 
usually occur in young adult life are attributed to obstructive processes 
in the vasa efferentia, and the smaller cysts of later life, to senile cystic 
enlargement of the tubules. 
Fluid.—The fluid of spermatocele is milky and filled with seminal 
elements. Its amount rarely exceeds three or four ounces, although 
cases have been reported in which over fifty ounces were withdrawn. 
As distinguished from hydrocele fluid it is cloudy, neutral, of light 
specific gravity (1009), and contains less solids and albumin. The 
spermatozoa may be motile or dead. The former occurs if a connection 
exists between the cyst and seminiferous tubules, through which fresh 
semen is constantly supplied. If the spermatozoa are dead* it is sup- 
posed that the connection with vasa efferentia has been lost. 
Symptoms.—The cysts of young adult life present the signs of a slowly 
growing painless enlargement at the top of the testis. Pain at the end 
of intercourse has been reported in a few cases of the intravaginal type. 
The tumor is usually heart-shaped and may grow to large size, produc- 
ing a sense of dragging on the cord. It is not translucent, may be 
fluctuant, and is elastic and tense. The position of the testis depends 
upon the direction of growth of the spermatocele, and may be pushed 
forward, downward, or backward. 
Diagnosis.-—The demonstration of a heart-shaped tumor above and 
behind the testis and the recovery of the typical fluid by aspiration 
are the chief means of diagnosis. The shape of the tumor, however, is 
not constant nor its position with relation to the testis. The tes*is and 
epididymis can be more clearly palpated than in hydrocele, when they 
are surrounded by it. If the spermatocele is complicated by hydrocele, 
or if it is of the intravaginal type, the diagnosis will only be made by 
aspiration. Hydrocele of the cord cannot at times be differentiated 
from spermatocele. The former occurs chiefly in childhood, however, is 
* Personal communication. VARICOCELE 
509 
distinctly separable from the testis and epididymis and fixed as a part 
of the vas. 
Treatment.—Small cysts require no treatment. Aspiration and 
injection are usually ineffectual and not to be advised. Larger cysts 
should be excised. After incising the skin over the cyst it is opened, 
its contents evacuated, and the cyst wall shelled out. Often a well- 
defined pedicle is found which should be tied off. The wound is 
closed with or without drainage as seems best. 
VARICOCELE. 
Varicocele is a condition in which there is dilatation, elongation, 
and tortuosity of the veins of the spermatic cord. It is generally 
limited to the spermatic vein, although occasionally the cremasteric 
and deferential veins may also be affected. 
Anatomy.—The spermatic vein originates at the posterior border of 
the testis as a thick network of eight to ten vessels called the pampini- 
form plexus, most of which lies anterior to the cord. These veins pass 
upward through the inguinal canal and unite into one trunk in the ab- 
dominal cavity. The vein of the right side passes into the vena cava, 
the left vein into the left renal vein. 
Symptomatic Varicocele.—Varicocele may be symptomatic or idio- 
pathic. The symptomatic type is the result of obstruction to the sper- 
matic vein by some abdominal tumor. It is rare, occurs late in life, 
develops rapidly, and is associated with malignant growths, especially 
of the left kidney, though it may be produced on either side. White14 
reports a case of acute left varicocele of six weeks’ duration which 
immediately disappeared on the removal of a pyonephrotic left kidney. 
Diagnosis.—The age of occurrence, its rapid and painless develop- 
ment, and the fact that when the patient lies down the veins do not 
empty themselves as in ordinary varicocele are the principal points of 
diagnosis. 
Treatment.—The varicocele disappears with the removal of its cause. 
Idiopathic Varicocele.—Etiology.—This type is a common condition 
in young men between the ages of fifteen and thirty-five. In a study of 
403 cases Barney1 found 81 per cent, occurred between those ages, and 
were unmarried. Youth and celibacy seem to be suggestive factors. 
The classical location is the left side (over 90 per cent.), the right side is 
rarely affected alone,and both sides more rarely. Of 3911 cases, Curling1 
found 3360 on the left, 282 on the right, and 269 bilateral. Sistach,1 
in 7611 cases, found 308 on the right and 305 bilateral. 
Many causes have been adduced to account for varicocele. To say 
that the spermatic veins are long and tortuous, with a vertical course, 
and receive little or no support from the loose surrounding tissues, 
offers a seemingly reasonable explanation, but these factors are present 
in every male, and all men do not have varicocele. To account for the 
preponderance of left-sided varicoceles are the anatomical facts; that the 
left testis hangs lower than the right, the left spermatic vein is conse- 
quently longer; it has no valves, and empties at right angles into the 510 
HYDROCELE, HEMATOCELE AND VARICOCELE 
left renal vein, where it is less advantageously drained than on the right 
side, where the vein enters the vena cava at an acute angle and a lower 
level. These facts are undoubtedly of importance, but they still do not 
explain the occurrence of varicocele in the young and its comparative 
absence in the old, in whom conditions would be supposedly ideal for its 
development. The most probable explanation is that varicocele is a 
functional disorder, due to a local chronic passive congestion induced 
by unrelieved sexual stimulation or by overindulgence. This hypothe- 
sis would account for the frequent disappearance of varicocele under the 
normal sex relations of married life and its absence in old men whose 
sexual powers are in abeyance. A congenital diathesis to varices, con- 
stipation and trauma, claimed as contributing factors, probably have 
no relation to the production of varicocele. 
Pathology.—The veins may be merely tortuous and dilated, or the 
process may go on to the stage of complete break-down of the valves 
with fatty atrophy, areas of thickening, and phlebolith formation. 
Symptoms.—Varicocele may produce no subjective symptoms even 
though of considerable size. Conversely a small developing varicocele 
may be the cause of a great deal of dragging pain along the course of the 
cord and in the testis. This is probably analogous to the pain in the 
leg at the time of development of a varix. 
Mental symptovis varying from mild sexual neurasthenia to melan- 
cholia are often associated with this as with other genital diseases. 
The quack and the charlatan have found in varicocele a gold mine. 
The objective symptoms are the low-hanging testis, the relaxed 
scrotum, and the mass of enlarged tortuous veins. The scrotal veins 
may at times be affected also. When the patient lies down the veins 
empty themselves and the varicocele disappears. Atrophy of the testis 
follows a long interference with its circulation, but is comparatively 
uncommon (11 per cent.).1 Many cases of restoration of the testis to 
normal size and consistency after operation have been reported, and 
certain authors believe that the apparent atrophy was merely under- 
development. 
Diagnosis.—The peculiar feel of the enlarged veins in varicocele is so 
characteristic that it is not likely to be confounded with any condition 
except an omental hernia. This may be differentiated as follows: If 
after the veins are emptied by having the patient lie down the finger is 
held over the external ring and the patient rises, the varicocele, if one is 
present, refills, while an omental hernia is held back by the finger. The 
complicating presence of a hydrocele or hernia may make the diagnosis 
more difficult. 
Treatment.—Many varicoceles require no treatment, as they produce 
no discomfort. The local symptoms produced by many others may be 
entirely relieved by the use of a snug suspensory. The patient should 
be strongly assured that his disease is not serious and that it will not 
lead to impotency or any other of the dire results of which these sufferers 
are apprehensive. Mental symptoms should be met by a rational 
psychotherapy, with sex hygiene and marriage offered as a solution of 
the trouble. VARICOCELE 
511 
Indications for Operation.—For the cases in which for various causes 
the foregoing measures do not suffice, operative treatment is indicated. 
In Barney’s1 series of 403 cases the patients came to operation for the 
Fig. 234.—Varicocele. The veins have been separated from the cord, and ligated 
above and below. 
Fig. 235.—Varicocele. A section of the veins has been excised, and the two stumps 
are being tied together. 512 
HYDROCELE, HEMATOCELE AND VARIOCELE 
following reasons: unrelieved and persistent pain, 270; no speeial rea- 
son given, G8; inconvenience, 22; mental symptoms, 18; qualifications 
for civil, army, or navy service, 17; recurrence following previous 
operation elsewhere, 8. 
In the German army15 a suspensory is first tried with officers and 
men complaining of symptoms from the varicoceles. If they are not 
relieved by this treatment operation is done. 
Operation is indicated then in varicoceles for persistent pain unre- 
lieved by a suspensory; for uncomfortable size; in cases in which 
atrophy of the testis is feared; and in the presence of marked neurotic 
symptoms. The operation in itself, however, will not cure sexual neu- 
roses, and we have seen patients who were so disappointed at lack of 
immediate results that their last state was worse than the first. A 
course of psychotherapy following the operation is important with 
neurotic patients, and no operation should ever be done on them with- 
out the existence of a definite pathological condition in the veins. Other 
indications for operation are the absence or disease of the other testis, 
the complication of hernia or hydrocele of the same side, a history of a 
recurrent phlebitis, thrombosis, spontaneous rupture, or calcareous 
condition of the veins. 
Types of Operation.—Varicocele may be treated by subcutaneous 
ligature or by open operation, involving excision of a portion of the veins 
with elevation and support of the testis. 
Subcutaneous ligation of the veins of a varicocele is a blind and un- 
surgical procedure. It presents the danger of hemorrhage from the 
wounding of a vein with a needle and the possibility of recurrence from 
the failure of the ligature to obliterate the vein. It offers, further, no 
support for the testis. The method should be abandoned in view of the 
simplicity and efficiency of the following operation. 
Open Operation.— Technic.—Local or general anesthesia may be used, 
preferably the latter if the patient is neurotic. A high incision two 
inches long is made above the inguinal canal with its lower end over the 
external ring. The dissection is carried down to the cord with its over- 
lying veins and the fascia enclosing it opened. At this level the veins 
have united into three or four trunks, and may easily be separated from 
the vas and its vessels. By pulling up the testis into the incision the 
separation may be carried down to within one inch of it. The separated 
mass of veins is ligated above and below and a sufficient section is 
excised so that by approximating the two stumps the testis will be 
elevated to a proper position opposite its mate. Great care should be 
taken to secure firmly all the cut veins by individual ligatures if neces- 
sary. The distal stump of veins is then brought up to the proximal 
stump and tied to it, which serves as a support for the testis. Fascia 
and skin are closed without drainage and a suspensory dressing applied. 
Patients should be kept in bed about a week. 
Ablation of the scrotum with the idea of providing a support for the 
testis is a useless procedure, as the scrotal skin which remains is capable 
of further stretching. It is also unnecessary for the purpose of remov- VARICOCELE 
513 
ing redundant tissue, as this will slowly contract when the weight of 
the testis is removed by elevation. 
Certain authors feel that joining the cut ends of the veins does 
not in itself produce a sufficient support for the testis and have advised 
various measures. Jacob elevates the testis by attaching the distal 
stumps of the excised veins to the fibres of the external ring. Allison 
shortens the fascial covering of the veins, excising a cuff of fascia 
and bringing the edges together. Turner accomplishes this by sewing 
up a longitudinal slit in the fascia transversely. 
Complications.—Atrophy of the testis and secondary hydrocele 
have been rare sequels to operative treatment of varicocele in the 
writer’s personal experience. Other observers have recently reported 
an unusually high percentage of complications. (See under Results.) 
The formation of the secondary hydrocele is thought by Douglas 
to be due to disturbance of circulation, predisposed by the presence 
of a slight amount of infection in the thrombosed stumps of the excised 
veins, which anastomose with the veins accompaning the vas deferens. 
Hence the development of a hydrocele may be the unavoidable sequel 
of a properly performed operation for varicocele. These secondary 
hydroceles in some cases absorb spontaneously, others require tapping; 
certain others will need radical operation. 
Results.—In the series quoted above a certain number of the cases 
were investigated at periods of from one to ten years after operation. 
Of these, 36 per cent, still complained of some pain in the groin or 
testis; 27 per cent, had some form of sexual neurosis; and 15 per cent, 
had recurrences. On the other hand, there was no case of atrophy 
of the testis; in 30 per cent., the testis had grown larger since opera- 
tion, and 80 per cent, acknowledged they had been distinctly benefited. 
Jacob,20 in a series of 237 cases operated upon in a French Military 
Hospital between 1909-1914, reports no serious postoperative com- 
plications, and no case of atrophy of the testis. He was able to 
observe these men during the year or two years of their military 
service, and a portion of them he examined still later, and found 
them well. 
Allison17 reports 300 operations for varicocele following which were 
4 hydroceles requiring operation. 
In the United States Army during the years 1914, 1915 and 1916, 
there were 1082 hospital admissions for varicocele, an average admis- 
sion rate of 2.74 per 1000. Of these cases, 655 were operated upon, 
and the results were recorded as successful, although it is not certain 
how much opportunity there was to check end-results.* There are 
at present no statistics available at the Surgeon-General’s Office as 
to results of operations for varicocele in army hospitals during the 
World War. 
In sharp contrast to these favorable statistics, are reports of bad 
end-results following varicocele operations, which began to appear 
during and after the recent World War, incident to the large number 
* Personal communication from the Surgeon-General’s office. 514 
HYDROCELE, HEMATOCELE AND VARICOCELE 
of operations which were done on enlisted and drafted men. Blood- 
good18 issued a warning against indiscriminate operating on vari- 
coceles for the following reasons: (1) That most varicoceles dis- 
appear spontaneously by the age of thirty; (2) that neurasthenics 
with varicocele are rarely relieved of their nervous symptoms hv 
operations; (3) that postoperative complications of hydrocele, which 
is more annoying to the patient than the original condition, and 
atrophy of the testis, are too frequent to be ignored. 
He also adds that where a patient has both varicocele and hernia, 
excision of veins should never be done at the-time of radical cure for 
hernia, as danger of atrophy of the testis and secondary hydrocele 
is much greater. 
Douglas19 reports a series of 303 cases operated upon at St. Luke’s 
Hospital, New York, between January 1, 1917, and April 1, 1920. 
Of these the end-results were checked in 116 cases. In 76 cases 
examined personally, 37 were well; 30 had secondary hydrocele, of 
which 22 were large; 4 had atrophy of testis; and 2 still had varico- 
cele. Letters were received from 40, of whom 30 were well; 7 had 
hydrocele and 3 had pain. Of the 116 cases, 35 per cent, had hydro- 
cele and 4 per cent, atrophy of testis. From these discouraging 
results, Douglas concludes that operation for varicocele should not 
be performed except for well-marked cases with painful symptoms 
and in non-neurasthenic subjects, certainly not in the type of cases 
previously referred by the various medical examining boards for 
admission to army and navy.* 
He further says that in view of malpractice suits resulting from 
some cases in this series, the surgeon should protect himself by explain- 
ing to the patient the possibility of postoperative hydrocele or atrophy 
of the testis. Every care should also be taken during operation to 
avoid trauma to the veins of the cord to prevent hematoma and 
infection and thus limit thrombosis. 
The writer cannot believe that the bad results in this last series 
can be taken as a criterion of average results to be expected in civil 
life. It seems possible that in time of war poor selection of cases, 
insufficient time for convalescence and the rigorous conditions of 
active service combined to produce these complications. These 
figures should impress upon the surgeon the definite possibility of 
postoperative complications and cause him to select his cases for 
operation with care. 
BIBLIOGRAPHY. 
Hydrocele. 
1. Bartlett: Extirpation of the Unopened Hydrocele, Jour. Am. Med. Assn., 1909, 
liii, 2149. 
2. Bennett: A Case of Traumatic Hydrocele and Injury to the Perineum, Clin. 
Jour., London, 1910, xxxvii, 289. 
* The present provision in the United States Army Regulations on varicocele con- 
cerns the rejection of applicants for enlistment who have large and painful varicocele. BIBLIOGRAPHY 
515 
3. Blakeway: Encysted Hydrocele of the Epididymis, St. Bartholomew’s Hosp. 
Rep., 1911, xlvi, 192. 
4. Bruns: Die Behandlung der Hydrocele (Inaugural Dissertation), Berlin, 1912. 
5. Caforio: Sulla patogenesi dell’ idrocele essenziale contributo alia diagnosi differen- 
ziale fra essudati e transudati, Gazz. internaz. di med., 1912, xv, 1089. 
6. Caforio: Ricerche ulteriori sull’autosieroterapia dell’ idrocele, e sul meccanismo 
di azione degli autosieri, Riforma med., 1912, xxviii, 982 and 1014. 
7. Cummins: Hydrocele en Bissac, Jour. Roy. Army Med. Corps, 1912, xviii, 76. 
8. D’Alberto: Nuovo processo di cura radicale dell’ idrocele, Gazz. d. osp., Milano, 
1910, xxxi, 561-562. 
9. Dunn: The Association of a Patent Funicular Process with Certain Forms of 
Hydrocele, Brit. Med. Jour., 1909, ii, 758. 
10. Fiori: Dell’ autosieroterapia in generale con speciale riguardo ai risultati dell’ 
autosieroterapia dell’ idrocele, Riv. ospedal., Roma, 1912, ii, 1-8; also Med. ital. Napoli, 
1912, x, 1-8. 
11. Formiggini: Contributo alio studio delle cisti del funicolo spermatico di origine 
connettivale, Riforma med., Napoli, 1913, xxix, 1269 and 1300. 
12. Fracassini: Sopra una varieta non comune d’idrocele, Policlin., Roma, 1910, 
xvii, 1518-1521. 
13. Hastings: On Rupture of the Tunica Vaginalis in Hydrocele, Lancet, 1910, i, 
916-919. 
14. Lockwood: Hydrocele of the Cord, Urol, and Cutan. Rev., 1914, xviii, 534. 
15. Keyes: Diseases of the Genito-urinary Organs. 
16. Mallanah: A Vaccine Treatment of Hydrocele, Brit. Med. Jour., 1912, i, 184. 
17. Marcozzi: Une nouvelle methode de traitement de l’hydrocele avec le fil de 
magnesium, Ann. des mal. des organ. Genit. Urinaires, 1*909, i, 739. 
18. Morestin: Hydrocele rompue, Bull, et mem. Soc. de chir., 1912, xxxviii, 542-544. 
19. Morestin: Hydrocele vaginale traitee par la ponction formolee, Bull, et mem. Soc. 
de chir., 1912, xxxviii, 1460; ibid., 1913, xxxix, 791. 
20. Moschcowitz: Hydrocele of the Tunica Vaginalis; Two Recurrences after the 
Winckelmann Operation, Ann. Surg., 1913, lviii, 561. 
21. Muller: Ein Beitrag zur operation der hydrokele, Zentralb. f. Chir., 1913, xl, 1140. 
22. Nicoll: Six Cases of Hydrocele in Infants Treated by Operation, Brit. Med. Jour., 
1913, i, 384. 
23. Peiser: Ueber Phimose und Hydrokele in Sauglingsalter, Berlin, klin. Wchnschr., 
1912, xlix, 1084-1086. 
24. Posner: Zur Pathologie und Therapie der Hydrokele, Berlin, klin. Wchnschr., 
1911, xlviii, 390. 
25. Ransohoff: Venous Thrombosis and Hydrocele of the Inguinal Canal, Ann. 
Surg., 1908, xlviii, 247. 
26. Squier: An Unusual Type of Hydrocele, Jour. Am. Med. Assn., 1913, lx, 1226. 
27. Tait: Recurrence of Hydrocele after Radical Treatment, California State Med. 
Jour., 1913, xi, 258. 
28. Vautrin: La cure operatoire de l’hydrocele vaginale, Arch. gen. de chir., 1913, ix, 
897-913. 
29. Vecchi: Alio studio del liquid d’idrocele, Gazz. med. ital., Torino, 1912, Ixiii, 
211 and 221. 
30. Whitney: Hydrocele and its Radical Cure by the Insertion of Catgut, Boston 
Med. and Surg. Jour., 1911, clxv, 204-211. 
31. Wilkinson: The Radical Operation for Hydrocele, Am. Jour. Dermat. and Genito- 
urinary Dis., 1911, xv, 376. 
32. Zaffiro: Contributo all studio dell’ idrocele multiloculaire e delle cisti connettivale, 
Gior. di med. mil., Roma, 1913, Ixi, 108-119. 
33. Zdanwicz: Zur Frage iiber die Anwendung der Autoserotherapie bei Hydrokele, 
Ztschr. f. Urol., 1913, vii, 386. 
34. Coleman: Abdominal or Bilocular Hydrocele, British Med. Jour., 1918, ii, 629. 
35. Porzelt: Zur Frage der Behandlung der Hydrocele, Zentralbl. fur Chir., 1919, xlvi, 
100-102. 
36. Schiitter: Ueber einen Fall von Hydrocele Bilocularis Intra-abdominalis Permagna, 
Miinchen med. Wchnschr., 1921, lxviii, 399-401. 
1913, i, 384. 
1. Barrington: Spontaneous Rupture of a Hematocele of the Tunica Vaginalis, 
Brit. Jour. Surg., ii, No. 7, p. 398. 
2. Harrison: Hematocele Studied with Reference to Etiology, Pathogenesis, and 
Therapeutics, Virginia Med. Semimonthly, 1911-12, xvi, 53. 
Hematocele. 516 
HYDROCELE, HEMATOCELE AND VARICOCELE 
3. Woolfenden: On the Similarity between the Signs of Hematocele and Early 
Malignant Disease of the Testis, Med. Press and Circ., 1911, xcii, 198. 
4. Whitney: Hematocele of the Tunica Vaginalis with Report of an Unusual Case, 
Boston Med. and Surg. Jour., 1916, clxxv, 51-54. 
Spekmatocele. 
1. Ebert: Ueber Spermatocele (Inaugural Dissertation), Leipzig, 1912. 
2. Hanusa: Ueber Spermatocele, Beitr. z. klin. Chir., 1910, lxix, 255. 
3. Posner: Remarks on Spermatocele, Am. Jour. Urol., 1908, iv, 237. 
4. Whitney: The Etiology and Diagnosis of Spermatocele, with a Report of Three 
Cases, Am. Jour. Urol., 1907, iii, 175. 
5. Crossan: Spermatocele, Ann. Surg., 1920, lxxii, 500. 
6. Winslow: Spermatoceles and Hydroceles containing Spermatozoa, Surg., Gynec. 
and Obst., 1920, xxx, 569. 
Vaeicocele. 
1. Barney: Varicocele: An Analysis of Four Hundred and Three Cases, Pub. Mass. 
Gen. Hosp., 1910, iii, 335. 
2. Blech: Varicocele: its Pathology with Reference to the Soldier and a New Opera- 
tion for its Relief, Mil. Surg.. 1910, xxvi, 5-39. 
3. Corner: Ligation of the Spermatic Artery in the Operation for Varicocele, Lancet, 
1911, ii, 1094. 
4. Frank: Eine neue Methode zur Operation der Varikokele, Zent.ralb. f. Chir., 1914, 
xli, 588-590. 
5. Heineck: The Modern Operative Treatment of Varicocele of the Spermatic Cord, 
Illinois Med. Jour., 1910, xviii, 551-569. 
6. Istomin: Zur pathologischen Histologie und Klinik der Varikokele, Deutsch. 
Ztschr. f. Chir., 1909, xcix, 1-46. 
7. Istomin: Zur Frage der operativen Behandlung der Varikokele, Zentralb. f. Chir., 
1914, xli, 93-95. 
8. Lameris: Zur Behandlung der Varikokele, Milnchen. med. Wchnschr., 1910, Ivii, 
674-677. 
9. Madden: Lymphatic Varicocele, Lancet, 1912, i, 17. 
10. Mariani: Blasenneuralgie infolge von Varikokele, Ztschr. f. Urol., 1911, v, 656. 
11. Schwarz: Der Einfluss der Leiste auf die Varicocele, Beitr. z. klin. Chir., 1910, 
lxix, 547-568. 
12. Van Hook: Varicocele Operations, Surg., Gynec. and Obst., 1914, xviii, 759. 
13. Volpe: Nuovo metodo di cura chirurgica del Varicocele, Policlin, Roma, 1910, 
xvii, sez. prat., 227. 
14. White: Brit. Med. Jour., 1914, ii, 177. 
15. Wolf: Erfahrungen mit der von Nilson angegebenen Modifikation der Narathschen 
Varikozelenoperationen, Deutsche med. Wchnschr., 1912, xxxviii, 1929-1932. 
16. Zironi: Contributo clinico al trattemento operativo del Varicocele, Clin. Chir., 
Milano, 1911, xix, 1215-1241. 
17. Allison: The Treatment of Varicocele with a Report of 300 Cases, Urol, and 
Cutan. Review, 1921, xxv, 268-271. 
18. Bloodgood: A Warning Against Operations for Varicocele on Applicants for 
Enlistment, Registrants for Selective Draft and Soldiers, Jour. Am. Med. Assn., 1918, 
lxx, 409-410. 
19. Douglas: Results of Operation for Varicocele, Jour. Am. Med. Assn., 1921, lxxvi, 
716-718. 
20. Jacob: Du Varicocele- son traitement Chirurgical, Rev. de Chir., 1919, lvii, 352- 
365. 
21. Lerda: Contribution au traitement operatoire du Varicocele, Presse Med., Paris, 
1917, xxv, 284-287. 
22. Valle: A New Operation for the Treatment of Varicocele, Surg., Gynec. and 
Obst., 1916, xxii, 734-739. 
(See also modern text-books.) CHAPTER XIV. 
INFECTIONS OF THE TESTICLE. 
By J. DELLINGER BARNEY, M.D. 
Acute infections of the testicle as compared with those of the 
epididymis are relatively infrequent, for, as Smith32 well says: '‘It is 
only in recent years that differentiation has been made between 
processes affecting the epididymis and those affecting the testicle. 
Even today we frequently hear of ‘gonorrheal orchitis’ when epididy- 
mitis is the real disease.” 
But it must be borne in mind that infection of the testicle proper, 
although uncommon as compared with that of the epididymis, arises 
not infrequently as a complication of certain of the infectious diseases. 
These diseases are typhoid and paratyphoid fevers, smallpox, and 
mumps; tonsillitis, glanders, dengue, acute articular rheumatism, 
gout, scarlet fever, Mediterranean fever, pneumonia, diphtheria, 
influenza and typhus fever. Infections of the testicle are also reported 
during the course of malaria, and filariasis, and of course the effect 
of the Spirochsetse pallidum on the testis is well known. 
In the presence of a septic process anywhere in the body such as 
osteomyelitis, abscess of the testicle may occasionally arise, while a 
certain number of cases have been reported of infection by the colon 
bacillus, the Bacillus mucosus capsulatus, and the Staphylococcus 
aureus and albus whose source could not be determined. 
Etiology.—An inquiry into the frequency with which the testicle is 
attacked in the various infections already enumerated shows that in 
proportion to the number of cases of the disease these testicular 
infections are rare. 
Pike,26 in 1911, collected from the literature 102 cases of orchitis of 
typhoid origin. McCrae24 found only 4 in a series of 1500 cases (0.27 
per cent.), while in a total of 5500 cases of typhoid fever, the combined 
statistics of Osier,25 Liebermeister,23 Sorel,33and Holscher,14the testicle 
was involved but 14 times (0.25 per cent.). On the other hand, Pierre 
Do18 found no instance of epididymo-orchitis among 14,738 cases of 
typhoid fever collected from French and German sources. 
The severity of the typhoid fever has no relation to the incidence of 
orchitis. It usually arises early in the course of convalescence, may 
attack a patient of any age (usually the young adult), and in most cases 
involves both testicle and epididymis. Beardsley,3 in 102 cases, found 
both sides involved in 3; when unilateral, the right side was affected 
more often than the left. Suppuration occurred in 22 of the 102 cases. 518 
INFECTIONS OF THE TESTICLE 
In 13 suppurating testicles reported by Kinnicutt19 a pure culture of the 
typhoid bacillus was grown from the pus. Symptomatic hydrocele is 
not infrequent. 
More recently Cade, Yaucher and Huchon43 have studied infections 
of the testicle in typhoid and paratyphoid fevers. They report 5 
cases of their own of which 2 were due to the typhoid bacillus, and 
3 to the paratyphoid bacillus. These infections were always unilateral. 
Suppuration occurred in 2 cases, both paratyphoid infections. 
Syphilis of the testicle (gumma) is said to be uncommon and will 
probably become more so owing to improved methods of treating the 
disease. Keyes,17 in 2170 syphilitics found the testicle involved only 
67 times, of which but 10 were bilateral. While I have no definite 
statistics of these cases, I believe them to be more numerous than this. 
The testicle alone is affected in a small majority, in others the epi- 
didymis shares the infection. Suppuration of the gummatous testicle 
is rare, but necrosis may occur from endarteritis. 
Acute orchitis as a complication of smallpox (variola) and due to 
secondary pyogenic infection has long been recognized, but its incidence 
as given by different writers seems to vary widely. It seems to occur 
both before and after puberty. Thus, Roger30 found 48 infected tes- 
ticles out of 55 in patients dying from smallpox, while Quenu29 says that 
in severe forms of the disease the testicle is left intact only once in ten 
times. On the other hand, Hare and Beardsley13 observe that “ orchitis, 
single or double, and usually accompanied by an effusion of fluid into 
the tunica vaginalis, is a rare complication of variola.” Welch and 
Schamberg37 observed this complication but 8 times in 2000 cases of 
variola. It is probable that the virulence of the epidemic, the method 
of treatment, and the fact of vaccination are factors which would influ- 
ence the incidence of this complication. 
The orchitis of epidemic parotitis (mumps) is of frequent occurrence 
in the adult, and may occasionally occur before puberty. The well- 
known study of Laveran and Catrin21 shows that it is likely to occur 
once in every 3 cases of mumps. In 43 cases it was bilateral in 13, on 
the right side in 18, and on the left side in 12. Osier25 records 211 
instances in 699 cases of mumps. A recent exhaustive study of the 
literature of the testicular complications of mumps by Wesselhoeft50 
showed that orchitis occurred in 18 per cent, of all cases, with sub- 
sequent atrophy of the testicle in 55 per cent, of the cases in which 
orchitis occurred. Wesselhoeft states that he nowhere found mention 
of an eunuch resulting from mumps, a fact which would indicate the 
infrequency of orchitis before puberty. This author found only 2 
cases of male sterility as a result of mumps, suggesting that even in 
the case of a bilateral infection the spermatogenetic power of at least 
one organ remains intact. The frequency of orchitis in a disease 
which is so common and otherwise so comparatively mild, and the 
possible destruction of the spermatogenetic function of the organ 
warrants serious consideration. 
Such a complication in tonsillitis was long ago recognized by Ver- INFECTIONS OF THE TESTICLE 
519 
neuil35 and later carefully discussed by Lasegue.20 Joal,16 in 1886, 
reported 4 cases and went with great thoroughness into the relationship 
between tonsillitis and epididymo-orchitis. Occasional instances of 
this rare complication of tonsillitis are reported from time to time, 
by Prouty28 in 1912, and more recently by Benjamin and Quirk.39 
These authors describe a case of bilateral orchitis complicating an 
unusually virulent follicular tonsillitis and subsiding rapidly after 
tonsillectomy. 
Vecchia49 reports a case of orchitis arising during a very severe 
attack of malaria in a boy aged sixteen years. There was a history 
of previous attacks and the malarial parasite (type not stated) was 
found in the blood. Under the influence of quinine the orchitis and 
febrile attacks subsided. 
According to Lombard and Beg.uet46 orchitis complicates Mediter- 
ranean fever in 5 or 6 per cent. This complication was apparently 
first described by Duffey,44 in 1872, who reported 18 cases, while Lom- 
bard and Beguet report a personal case and mention 21 others in the 
literature. 
While he does not state the frequency of orchitis in pneumonia 
Mills47 has recently reported a study of 60 testes removed postmortem 
from pneumonia patients. It would appear, therefore, that testicular 
infections in this disease are not a rarity. 
Blechner and Stiassnie40 have reported a case of bilateral orchitis 
and epididymitis in a boy, aged seven years, arising during the course 
of a very severe diphtheria. While they did not demonstrate the 
B. diphtheria in this case they believe that this organism was respon- 
sible for the conditions noted. 
An intensive study of typhus fever by Wolbach, Todd and Palfrey51 
showed testicular lesions in the 16 cases studied histologically, but 
apparently there were few or no clinical manifestations. 
Howard45 states that “acute filarial orchitis and funiculitis is a 
common complaint” (in Zanzibar). Of 14 cases seen by him 7 resulted 
in abscess formation. These patients were all very ill but recovered 
promptly after the pus was evacuated. 
Septic foci, such as furunculosis and osteomyelitis may occasionally 
give rise to an acute epididymo-orchitis, a case of the former being 
reported by Quenu,29 while Biland5 records a similar complication in 
osteomyelitis of the acromion process. The rarity of an orchitis from 
this source may be judged from the fact that I have found no other 
cases of it in the literature. 
Finally, there are on record a very few cases of what may be called 
“idiopathic” orchitis with infection by a pyogenic organism in the 
absence of any demonstrable focus. Du Bois8 reports such a case of 
staphylococcus infection, and LeFur22 tells us of another. I1 have 
already reported 3 such cases and more recently have operated upon a 
fourth. My colleague, Smith, has also met with 1 within the year, 
at the Massachusetts General Hospital. In 2 of my own cases the 
colon bacillus was found in pure culture. In another the Bacillus 520 
INFECTIONS OF THE TESTICLE 
mucosus capsulatus was the offender, with a few streptococci sprinkled 
in. Cultures from the other cases were unsatisfactory. 
Bonner,42 in 1913, reported a case of suppuration of the testicle 
following heavy muscular effort, no other causative factor being found. 
B. coli was found in the pus. More recently Nash48 has reported 2 
similar testicular abscesses, both occurring without definite etiology 
and one containing B. pseudo-asiaticus of Castellani, the other show- 
ing B. coli and B. proteus. 
Acute orchitis is mentioned in the text-books as an occasional 
complication of glanders, influenza, dengue, acute articular rheuma- 
tism and scarlet fever. I have, however, seen no record of a definite 
case. 
It is therefore clear that almost any organism in the blood stream 
may enter the testicle and may, under favorable conditions for growth, 
produce its characteristic lesions. 
Pathology and Pathogenesis.—It is well known that the animal 
organism combats bacillemia by elimination of the bacteria in the 
circulating blood through the glands, chiefly kidneys, but we also know 
that the salivary glands (Quenu29), the seminal vesicles (Huet15), and 
other organs may share in this work. That the human testicle may also 
assume this excretory function has been shown by Belfield4 who says: 
“ While the kidney is provided with a new and private sewer, the ureter, 
the testis continues to use the frog’s old urinary duct, now called 
epididymis and vas deferens. This excretory function of the testicle 
and its duct illumines both its intimate alliance with the kidney and its 
frequent infection from the blood. The recognition of the testicle as 
an excretory organ illumines the frequent invasion of its tubules by 
mumps, typhoid and colon bacilli, Spirochseta pallida and other blood 
infections.” Be it further noted that the testicle and other organs may 
assume this excretory role without damage to their epithelium (von 
Biede and Kraus36), and when pathological changes occur, they must 
be regarded as an index either of an unusual virulence of the organisms, 
or of a lowered resistance on the part of the gland. 
While we have already seen that the testicular tissue is favorable for 
the growth of the typhoid bacillus, the Spirochseta pallida, and pyogenic 
bacteria, as well as for certain other, as yet unknown, organisms (e. g., 
that of mumps), it is common knowledge that the gonococcus rarely, if 
ever, finds lodgment in this organ, and the tubercle bacillus (with very 
rare exceptions) only after a primary invasion of the epididymis. For 
an explanation of this phenomenon we must ascribe to the testicle an 
excretory function; to the various bacteria a tendency to select one 
tissue rather than another in which to take up their residence. It is 
well established that organisms of various types may and do circulate 
in the blood stream at various times. It is clear that these organisms 
must find their way into the testis and epididymis as freely and as fre- 
quently as into other organs; perhaps more so, owing to their common 
blood supply, the spermatic arteries, which take origin from the aorta. INFECTIONS OF THE TESTICLE 
521 
Fig. 236. — Type I. 1, spermatic 
artery; 2, epididymal branch of the 
spermatic; 3, deferential artery; It, 
funicular artery; 5, epididymo-funiculo- 
deferential anastomosis in form of T. 
(From Picque and Worms, loc. cit.) 
Fig. 237.— Type II. 1, spermatic 
artery (main trunk); 2, internal sper- 
matic artery; 3, external spermatic 
artery; It, epididymal branch; 5, defer- 
ential artery; 7, spermato-funiculo- 
deferential anastomosis in form of T. 
Fig. 238.—Type III. 1, spermatic artery; 2, epididymal branch of spermatic artery; 
■3, deferential artery; funicular artery; 5, anastomosis between epididymal branch and 
deferential artery; 6, anastomosis between a testicular branch of spermatic and funicular 
artery. 522 
INFECTIONS OF THE TESTICLE 
This has been demonstrated by Pique and Worms27 in a large series of 
careful dissections of injected human specimens (Figs. 236, 237 and 
238). They have shown constant but slightly variable anastomoses 
between the spermatic, the deferential, and the funicular arteries (the 
latter running in the walls of the tunica vaginalis). It is thus seen 
that bacteria reach the testicle and epididymis with equal facility. 
While the comparative infrequency of orchitis as compared with epi- 
didymitis is undoubtedly due very largely to the fact that the testicle, 
as Belfield4 has shown, excretes the bacteria which enter it into the epi- 
didymis, there are two other factors which undoubtedly contribute to 
its comparative immunity from infection. These are: 
First, the tunica albuginea whose protective value was long ago 
recognized by Grendin.12 He says: “When the contiguous organ or 
adjacent part is of a different structure from that of the cellular tissue, 
the extension of the inflammation inward is checked. Thus in the case 
of the inflamed tunica vaginalis the cellular tissue readily transmits the 
morbid action to the epididymis, but the tunica albuginea arrests its 
progress to the body of the testicle.” 
Second, Testut34 and others have pointed out that the testicle is 
surrounded and permeated by a very rich lymphatic network, much 
greater than that enjoyed by the epididymis. 
Furthermore, the elaborate blood supply, already mentioned, while 
serving as a path along which bacteria can travel, undoubtedly serves 
at the same time as a highly efficient means of defense. 
In most testicular infections it is obvious that the organisms travel 
by way of the blood stream. This would hold true in general systemic 
diseases such as typhoid fever, or in pyogenic septicemia (from furuncu- 
losis or osteomyelitis, for example). In certain other cases the vas 
deferens or the lymphatics of the spermatic cord must be held account- 
able for the transmission of organisms. 
This hypothesis would apply particularly to the cases with preexist- 
ing inflammation of the organs at the bladder neck or of the urethra, 
as in a case recorded by Dalous7 and in two of my own cases. The 
researches of many, especially Baumgarten,2 have shown that infections 
travel usually with the stream of the secretion of the organ involved. 
While there are exceptions to this rule, with reversal of peristalsis in the 
vas deferens, it is evident that it furnishes, in most cases, ample ground 
for the elimination of this structure as a path along which organisms 
can travel. 
There is left, then, the possibility of a lympnangitis or of a phlebitis. 
While a retrograde lymphangitis is certainly an uncommon phenome- 
non, Dalous7 and Quenu29 are in agreement that it can occur, especially 
in the spermatic cord and testicle, and they further observe that it may 
take place without the usual clinical manifestations of its presence. 
Whether a phlebitis, transmitting its infection to the testicle, can be 
held accountable for these infections is open to argument. There 
appears to be no definite proof that it occurs. The fact remains that in 
gonorrheal epididymitis it is not unusual to observe pain, tenderness, 
and induration of the spermatic cord slowly progressing from groin to PATHOLOGY 
523 
epididymis, and Ivinnicutt18 describes a similar order of events in a case 
of typhoidal epididymo-orchitis. 
On the other hand, there are several examples of transmission of the 
infection from testicle to bladder and urethra, probably through the 
vas deferens. Thus in one of my cases the urine at first was clear and 
sterile to culture. Several days after orchidectomy there appeared a 
urethral discharge together with cloudy urine. Cultures showed the 
same organism as was found in the testicular abscess. This experience 
coincides with that of other observers. These data furnish additional 
proof of the excretory function of the testicle, which, by eliminating 
organisms through epididymis and vas deferens, infected the urethra 
and bladder neck. 
Pathology.—The pathology of testicular infections has been com- 
paratively little studied. Smith31 in a recent article describes a case of 
epididymo-orchitis of typhoid fever operated upon by Cabot. The 
former says: “ There was a small amount of free fluid within the tunica 
and a gelatinous exudate covered the testicle. The epididymis was 
enlarged to four or five times its normal girth, was tense and hard, and 
in color a reddish purple. The testicle was of normal size, and in its 
upper two-thirds of normal color. The lowest third, which was sepa- 
rated from the upper portion by a sharp line of demarcation, was slightly 
swollen and of a darker color. A nick was made through the tunica 
albuginea of this part of the testicle; the underlying tissue was dry 
and did not bleed. No pus was obtained (from the epididymis) but the 
serous fluid which oozed from the punctures showed a pure culture of 
the typhoid bacillus. The involvement of the testicle was caused 
by the occlusion of its arterial supply (the capsular artery, a branch 
of the spermatic, which pierces the tunica albuginea close to the 
epididymis).” 
There seems to be no good description of such infections of the testicle 
which have suppurated, but Girode10 has shown that the suppuration is 
between, not within, the canaliculi. 
The pathology of syphilitic infection of the testicle and epididymis is 
that of gumma, plus the changes wrought by interstitial sclerosis in the 
seminiferous tubules. These are destroyed to a greater or less extent 
by the sclerotic changes, but after an arrest of the syphilitic process 
show a marked recuperative power. 
For the pathology of the orchitis of mumps we are again indebted to 
Smith,31 who recently operated upon two such testicles. The tunica 
vaginalis was opened “ with escape of about one ounce of turbid yellow 
fluid. The testicle was three times the size of a normal testicle, firm and 
elastic on palpation. The color was more bluish than is usual, and 
throughout the tunica albuginea were scattered many minute reddish 
specks, probably punctate hemorrhages. The epididymis was defin- 
itely enlarged, soft, without induration, and of a deep red color which at 
the globus major became almost black. The cord was somewhat ede- 
matous, the vas normal.” A second case presented “an almost iden- 
tical picture.” Small sections of these testicles were examined by 524 
INFECTIONS OF THE TESTICLE 
Dr. S. B. Wolbach, now Shattuck Professor of Pathological Anatomy 
in the Harvard Medical School. He says: “The process does not 
affect the testicle tissue uniformly. There are groups of seminiferous 
(convoluted) tubules which are completely destroyed and distended 
with exudate, separated by areas of normal and slightly affected 
tubules which contain large numbers of mitotic sexual cells, though 
few mature spermatozoa. 
“The exudate in the destroyed tubules consists chiefly of poly- 
morphonuclear leukocytes and phagocytic endothelial leukocytes. The 
cells of the tubules have mostly undergone a hyaline degeneration and 
are taken up by phagocytic endothelial leukocytes, though there are 
occasionally perfectly preserved mitotic sexual cells scattered among the 
tightly packed exudative cells. 
“The intertubular connective tissue everywhere is edematous and 
between the tubules most affected contains coarse, meshed fibrin, small 
areas of hemorrhage and many polymorphonuclear leukocytes and 
endothelial leukocytes. 
“Among the groups of least affected tubules there are some with 
normal epithelium, but with lumina partly filled wdth polymorpho- 
nuclear and endothelial leukocytes, as if the process was spreading 
along the lumina. 
“ There are many more tubules, however, which show lesions involv- 
ing a small portion of the circumference, where it appears as if the 
process was extending from the intertubular connective tissue. In 
these places numerous leukocytes are found in the act of migrating 
through the basement membrane of the tubules. These small lesions 
contain deeply staining hyaline degenerated sexual cells, hyaline frag- 
ments, polymorphonuclear leukocytes and endothelial leukocytes. The 
immediately adjacent epithelium is usually full of mitotic sexual cells 
showing the various stages of spermatogenesis. 
“ The tunica albuginea is edematous, and there are small hemorrhages 
and zones of cellular exudate about bloodvessels. The cells about blood- 
vessels are polymorphonuclear leukocytes and endothelial leukocytes. 
“Mitotic endothelial cells in the lumina of capillaries occur in the 
tunica albuginea and intertubular connective tissue. 
“Liquefaction necrosis is not present either in the tubules or in the 
connective structures. 
“No bacteria or other parasites can be found in the sections and in 
film preparations made at the time of operation.” 
In both cases the blood cultures and the cultures from the hydrocele 
fluid and testicular tissue were bacteriologically negative. 
Thanks to Councilman,24 we have an admirable description of the 
pathology of the testicle in smallpox, which I quote at length. 
“Lesions most difficult of interpretation are those of the testicle. 
There is absence of spermatogenesis in the cases in which convalescence 
is established. Normal spermatozoa are absent in the lumina of the 
tubules, and there is degeneration of the spermatogenetic cells. This 
affects both cytoplasm and nuclei and the degenerating nucleus assumes PATHOLOGY 
525 
forms which present some similarity to certain of the intracellular para- 
sites in the epithelial cells of the skin. This degeneration is not peculiar 
to smallpox but may be found in typhoid fever. These lesions are 
absent in the undeveloped testes of children. 
“In addition to diffuse degenerative lesions there are focal lesions as 
characteristic of the disease as the skin lesions found in adult and 
child’s testes. Lesions begin as an infiltration of the intertubular tissue 
with both ordinary lymphoid cells and large mononuclear basophilic 
cells. The tubules in the foci are unaltered. From such lesions as 
these, which are best compared with small interstitial foci in the kid- 
neys, the process extends. The area enlarges, the cellular infiltration 
extends and finally there is complete necrosis in the centre, with fibrin 
and hemorrhage in the surrounding interstitial tissue. The necrotic 
tubules often contain numbers of phagocytic cells. The bloodvessels 
in the foci are obliterated in some cases by thrombi, but chiefly by the 
pressure of the cells. Acute endarteritis with accumulations of mono- 
nuclear cells is often found. 
“The lesions vary in number, some testicles showing large numbers 
of them, while in others they are found only after prolonged search. 
The smallest lesions and those best adapted for study are in the un- 
developed testes of children. They show a general relation to the 
duration of the disease, the most advanced cases occurring late in 
the course. 
“Notwithstanding its apparently specific nature no parasites were 
found in the testicular lesions of man.” 
Secondary infection of the smallpox testicle, at least in the suppura- 
tive cases is exceedingly common, for Esmonet,9 in a number of such 
cases, found streptococci, pneumococci, colon bacilli, and the Staphylo- 
coccus aureus alone or associated with the streptococcus. 
The pathology of suppuration of the testicle, when due to pyogenic 
infection, is not peculiar, but it is fair to say that there is little available 
material on which to base an opinion. In a case operated upon by me, 
with infection by the Bacillus mucosus capsulatus and the streptococcus, 
practically the whole testicle was occupied by an abscess cavity (Fig. 
239). Sections of this testicle, examined for me by Prof. S. B. Wolbach, 
showed that necrosis had “extended irregularly into the substance of 
the testicle, following the interstitial tissue.” In a second personal 
case, of colon bacillus origin, the abscess was found to occupy only the 
upper third of the organ, there being a fairly sharp line of demarca- 
tion between this and the rest of the testicle which was but little affected. 
In still a third case, only the lower third of the testicle was involved 
in the abscess. The normal-looking upper two-thirds of the organ was 
left behind, but became necrotic and sloughed out later. In a fourth 
orchidectomy (a recent case, unreported) I found a comparatively early 
stage of the infection. The whole testicle was riddled with abscesses 
of varying size, with tufts of seminiferous tubules sticking out here and 
there through holes in the tunica albuginea (Fig. 240). A testicle 
very similar to this, with Staphylococcus aureus infection, has been 
described by Dalous.7 526 
PATHOLOGY 
Fig. 239.—Abscess of testicle. Mucosus capsulatus. Author’s case. A, thick- 
ened tunica; B, remains of wall of testicle; C, abscess cavity in testicle; D, epididymis. 
Anterior view. 
Fig. 240.—Abscess of testicle. No culture. Author’s case. A, A, A, tufts of 
seminiferous tubules protruding through tunica albuginea; B, hydatid of Morgagni; 
C, epididymis. Lateral view. PATHOLOGY 
527 
The recent light thrown upon the testicle in typhus fever by studies 
of Wolbach, Todd and Palfrey51 are interesting. These authors say: 
“ Vascular lesions (thrombosis) are present in the testis or epididymis 
or both in all of the 16 male cases studied histologically. Perivascular 
accumulations like those of the skin of a proliferative nature are 
present in most of these cases. In 5 cases Rickettsia can be satis- 
factorily demonstrated in the bloodvessel lesions of the testis or 
epididymis.” 
“In 7 cases there was a considerable degree of azospermatogenesis, 
evidenced by absence of spermatozoa and diminution in the number 
or complete absence of mitoses. In 2 cases the aspermatogenesis is 
complete in some portions of the slides and is attended by slight 
hyaline thickening of the basement membrane of the tubules. These 
2 cases were not attended by severe vascular lesions. One was 
attended by severe bronchopneumonia. We regard this change in 
the testes to be independent of local lesions and to a general effect 
of the disease. Similar aspermatogenesis has been observed by one 
of us in epidemic influenza and by Mills in epidemic pneumonias 
caused by the streptococcus and pneumococcus.” 
The lesions in the guinea-pig’s testicle produced experimentally by 
these authors are comparable in most respects to those found in man. 
Thanks to Mills47 we have been presented with a very minute 
picture of the testicle in primary pneumonia and in that which is 
secondary to measles or influenza. Sixty testes were studied his- 
tologically. The pathological process seems to be a continuous one 
which Mills divides into six stages. He says that the edema may 
represent acute injury in another form, and round cell infiltration 
suggests that possibly other factors than toxins may have a part. 
In the absence of definite evidence to the contrary the cause of the 
lesions is assumed to be due to circulating toxins. This observation 
is of interest in the consideration of the testicular lesions of mumps, 
smallpox, diphtheria, malaria, filariasis and other conditions where 
the organism is either not demonstrable or unknown. Mills further 
states that the Streptococcus hemolyticus produced more extensive 
change, while measles and epidemic influenza had little apparent 
effect. The testicular changes in pneumonia are without apparent 
clinical manifestations, are non-specific, focal in character, independent 
of the infecting organisms or of the antecedent disease. 
I have been unable to find descriptions of the orchitis which is said 
to occur in influenza, glanders and other infectious diseases, but it 
seem unlikely that their pathology offers any peculiarities. 
From the foregoing consideration of the etiological factors, of the 
probable paths of infection, and of the pathology it is possible to state 
that acute orchitis can occur under three different conditions: 
1. As a localization of a primary infection (mumps, typhoid, syphilis, 
pyogenic septicemia, etc.). 
2. As a localization of a secondary infection in one of the above 
conditions. 528 
INFECTIONS OF THE TESTICLE 
3. As a propagation of a urethritis primary or secondary to a pyo- 
genic infection of the prostate, urethra, or bladder neck. 
It must not be forgotten, however, that a severe orchitis may be the 
result, not of actual bacterial invasion of the organ, but of a bacterial 
toxemia. The studies of Mills quoted above would seem to bear out 
this view. The possibility of this has been demonstrated by Esmonet,9 
who produced total necrosis of the testicle (in dogs) by the injection of 
15 drops of typhoid toxins. Also in 13 suppurating testicles of typhoi- 
dal origin Kinnicutt18 found a sterile culture in 6. Smith32 reported 
similar findings in mumps and Councilman6 in smallpox. 
Symptomatology and Diagnosis.—These two aspects of acute epi- 
didymo-orchitis can be considered together. 
In syphilis of the testicle the onset is gradual and generally symptom- 
less, the patient seeking advice largely because of the enlargement of 
the scrotum. The unilateral, wood-like hardness, involving chiefly the 
testicle, the complete absence of normal testicular sensation (an im- 
portant point), and lack of tenderness, the irregular contour, should 
suggest gumma at once. These findings, together with a positive 
Wassermann reaction in the blood or cerebrospinal fluid, or other 
evidences of syphilis, should make the diagnosis clear. The diagnosis 
is established occasionally only by exploratory incision. 
The symptoms of practically every other form of orchitis are those of 
acute inflammation localized to this organ or at least to the scrotum. 
The onset may be sudden and the pain intense, concentrating in the 
testicle or possibly radiating to the groin, back or perineum. In certain 
cases there is marked constitutional disturbance aside from that occa- 
sioned by the general infection from which the patient suffers. The 
temperature may be considerably elevated (102° to 103° F.) and nausea 
and vomiting may accompany the attack. In certain cases an accumu- 
lation of hydrocele fluid may make the differentiation between orchitis 
and epididymitis obscure; in others palpation will show a much en- 
larged, tender testicle, smooth and firm, with an epididymis more or 
less involved. In the later stages the skin of the much enlarged scrotum 
may be red, edematous, or in a state of phlegmon, with distinct fluctua- 
tion concentrated especially on its anterior surface. The whole sper- 
matic cord may be traced into the groin as a much enlarged conglomera- 
tion of vas, vessels, and cremaster muscle, indurated and tender to the 
touch. The prostate and vesicles may or may not be inflamed, and 
urethritis (in which organisms other than the gonococcus may be 
demonstrated) may exist. The urine may be clear and sterile to 
culture. It may, on the other hand, contain pus together with the 
organisms of either of the general infection (typhoid, for example) or of 
the scrotal infection (as in a case of infection with Staphylococcus aureus 
reported by Quenu29). Accompanying these phenomena there may be 
the symptoms of bladder irritability. 
A diagnosis of the cause of infection will depend upon circumstances. 
In the presence of parotitis (which incidentally may be easily over- 
looked), in the event of smallpox, typhoid fever, or any other definite 
general infection the nature of the orchitis will be clear. One also PROGNOSIS 
529 
would have suspicion aroused if the orchitis arose in the course of 
tonsillitis or of some localized pyogenic infection. 
On the other hand, one must not forget that orchitis may appear 
spontaneously in a previously healthy individual, as in the case of 
Du'Bois8 and of Le Fur22 and in those reported by the writer.1 
Some difficulty might be encountered at the onset in differentiating 
between a torsion of the testicle and an orchitis. What begins as a 
torsion may rarely become an orchitis, owing to the interference with 
the circulation of the testicle and its subsequent invasion by bacteria. 
Exploratory incision or the gradual decrease of symptoms under pallia- 
tive treatment, with atrophy of the testicle, will generally differentiate 
the two conditions. 
Prognosis.-—The prognosis in acute orchitis may be divided into 
that for the patient, and that for the testicle involved, with a pos- 
sible subdivision wffiich takes the other half of the scrotum into con- 
sideration. 
The outlook for the patient himself depends upon the nature of his 
infection. In typhoid fever, mumps, smallpox, syphilis or any other 
general infection, the mortality seems to be not at all influenced by the 
intervention of an orchitis. I have also seen no account of a death 
following orchitis when due to pyogenic organisms, whether primary or 
secondary. 
The chances of saving the testicle vary also w*ith the kind of infection, 
and must be considered from the stand-point of spermatogenesis, as well 
as from that of internal secretion. If extensive suppuration has taken 
place orchidectomy will be necessary. In certain cases evacuation of 
the pus by trocar or simple incision may suffice. It is to be expected, 
however, that the remaining portions of the testicle will eventually 
become so atrophied as to be of little or no value to the patient except 
possibly from a psychic stand-point. 
In typhoid fever the combined statistics of Kinnicutt18 and of Hare and 
Beardsley13 show an incidence of suppuration of 22.5 per cent. The 
percentage of bilateral orchitis is very small (Kinnicutt 0.42 per cent., 
and Hare and Beardsley 0.44 per cent.). When suppuration does not 
occur, atrophy, more or less complete, is to be expected, with a conse- 
quent destruction of the functional activities, especially spermato- 
genesis, of the organ. Smith31 has recently shown us that this is due 
to a destruction of the arterial supply of one or another portion of the 
testicle. His case also suggests the desirability of drainage at an early 
stage of the infection. 
In mumps we have seen that orchitis occurs once in about every 
three cases. Laveran and Catrin21 show a bilaterality of 30 per cent., 
and a subsequent atrophy of 60 per cent, of the testicles so affected. 
Secondary infection does not seem to be mentioned. Smith’s recent 
work32 in this affection suggests that the subsequent atrophy, which 
completely destroys the sexual function of the gland, may be obviated 
or lessened by early operation. It has been shown that the testicle is 
attacked by the Spirochseta pallida rather infrequently (67 times in 
2170 cases, Keyes17), and both sides are affected in 6.7 per cent. With 530 
INFECTIONS OF THE TESTICLE 
proper antisyphilitic treatment the future of the testicle seems to be 
bright, for we have the word of Gosselin11 that spermatozoa have been 
found in the semen after such treatment. Also in the words of Keyes,17 
“ Whatever part of the parenchyma has not been destroyed by sclerosis 
will continue to functionate, and the testicle which has been syphilitic 
for years may still secrete spermatozoa.” Secondary infection is not 
to be expected. 
There seem to be no actual figures at hand as to the frequency of 
suppuration in the orchitis of smallpox, but if we are to believe Es- 
monet,9 secondary infection is not uncommon. We are also left in the 
dark as to the probability of bilateral infection. The minute patholog- 
ical picture of these testicles painted for us by Councilman6 and the 
apparent frequency of suppurative processes make the prognosis of 
such an orchitis bad from every point of view. 
Pyogenic infection of the testicle, primary or secondary, apart from 
the diseases already enumerated, seems never to be bilateral. Destruc- 
tion of the gland is generally so complete as to require its removal. 
Even successful attempts at conservation will leave behind only a small 
mass of scar tissue. 
Treatment.—The physician must be guided in his treatment of the 
case by local and general conditions. 
In typhoid fever and mumps, early and thorough drainage of the 
tunical sac by incision, and of the epididymis and testicle by multiple 
puncture, may be considered and, in certain cases, may be necessary. 
Palliative treatment will probably suffice for most cases, and in the 
absence of actual suppuration the results may be as good as with 
drainage. 
In the far-advanced cases with free pus and much tissue destruction, 
orchidectomy is indicated. 
The recent studies of orchitis in mumps by Bonnamour and Bardin41 
throw some light on the possible prophylaxis of this complication. 
Sixty-five patients, admitted to their service with mumps, but with- 
out orchitis, were given an injection of 20 c.c. of diphtheria antitoxin. 
Among these patients only 5 per cent, developed orchitis and this 
was mild. Another group of 7 patients were similarly treated and 
none developed orchitis. These investigators think that the results 
are suggestive that the prophylactic injection of antitoxin may ward 
off or attenuate complications in a disease of which we do not know 
the cause, such as mumps. 
Ballenger and Elder38 have recently pointed out the danger to the 
testicle in mumps and describe a technic (longitudinal incisions through 
the tunica albuginea) for preventing atrophy. Three testes so oper- 
ated upon by them are now normal, 2 after three years, 1 after twenty 
months. 
In syphilis, arsphenamine or neoarsphenamine and mercury will pro- 
duce good, often brilliant results. The knife is indicated but rarely. 
In certain mild infections of the testicle the time-honored measures 
of rest in bed, an ice-bag, and support of the scrotum by a suspensory 
or an Alexander bandage may suffice. 
Combined with these measures, or with surgery, the patient should BIBLIOGRAPHY 
531 
be given some urinary antiseptic (preferably sandalwood oil or hexa- 
methylenamin), an abundant supply of liquids, a good cathartic, and 
a light diet. 
Meantime if he is suffering from one of the general infections already 
mentioned the treatment of this should go on as usual. 
1. Barney: Surg., Gynec. and Obst., March, 1914. 
2. Baumgarten: Yerhandl. d. deutsch. path. Gesellsch., 1905. 
3. Beardsley: Jour. Am. Med. Assn., March 28, 1908. 
4. Belfield: Jour. Am. Med. Assn., October 19, 1912. 
5. Biland: Cent, der Harn. und Sexualkrankheiten, 1905. 
6. Councilman: Osier and McCrae’s Mod. Med., 1913, 2d edition, i. 
7. Dalous: Ann. des Mai. des Org. Genito-urinaires, 1905, ii. 
8. Du Bois: Rev. Med. dela Suisse Romande, 1909, No. 11, 800. 
9. Esmonet: Thbse de Paris, 1903. 
10. Girode: Keen, The Surgical Complications of Typhoid Fever, 1898. 
11. Gosselin: Watson and Cunningham, Dis. and Surg. of the Genito-urinary System, 
1908. 
12. Grendin: Curling, Diseases of the Testis, 3d edition. 
13. Hare and Beardsley: Typhoid Fever and Exanthemata, Lea & Febiger, Philadel- 
phia, 1909. 
14. Holscher: Miinchen med. Wchnschr., 1891, Nos. 3 and 4. 
15. Huet: Cent. f. Bakt., 1909, lii. 
16. Joal: Arch. gen. de Med., 1886. 
17. Keyes: Syphilis, 1908. 
18. Kinnicutt: Med. Rec., 1901, lix. 
19. Kinnicutt: Med. Rec., 1901, lix, 801. 
20. Lasfegue: Traite des Angines, Paris, 1868. 
21. Laveran and Catrin: Bull, et mem. Soc. M6d. des hop., Paris, 1894, xi, 108. 
22. Le Fur: Bull. Assn, frangaise d’Urologie, Paris, 1909. 
23. Liebermeister: Ziemssen’s Handbuch d. spec. Path. u. Therap., 1874, ii, Bd. n, 
189. 
24. McCrae: Osier and McCrae’s Mod. Med., 1912, i, 2d edition. 
25. Osier: Pract. of Med., 1901, 4th edition. 
26. Pike: Am. Jour, of Dermat. and Genito-urinary Diseases, xv, 202. 
27. Pieque and Worms: Jour, de l’Anat. et de la Phys. norm, et path., 1909, i, 51. 
28. Prouty: Jour. Am. Med. Assn., 1912, viii, 1192. 
29. Qu6nu: Presse Med., 1909, xvii, 281. 
30. Roger: Esmonet, Th&se de Paris, 1903. 
31. Smith: Boston Med. and Surg. Jour., 1912, clxii, No. 10, 323. 
32. Smith: Tr. Am. Urol. Assn., 1912, vi. 
33. Sorel: Bull, et mfem. de la Soc. m§d. des hop., Paris, 1889, lvi, 236. 
34. Testut: Traite d’Anat. Humaine, Paris, 1897. 
35. Verneuil: Arch. gen. de M6d., 1857. 
36. Yon Biede and Kraus: Zeit. f. Hyg., 1898, xxvi, 353. 
37. Welch and Schamberg: Acute Contagious Diseases, 1905. 
38. Ballenger and Elder: Jour. Am. Med. Assn., November 6, 1920, Ixxv, 125. 
39. Benjamin and Quirk: U. S. Naval Med. Bull., April, 1921, xv, 406. 
40. Blechner and Stiassnie: Arch, de Med. d. enf., December, 1921, xxiv, 749-752. 
41. Bonnamour and Bardin: Presse med., December 22, 1920, xxviii, 929. 
42. Bonner: Lancet, October 4, 1913. 
43. Cade, Vaucher and Huchon: Progres Medicale, February 23, 1918, xxiii, 65. 
44. Duffey: Quoted by Lombard and Beguet. 
45. Howard: Jour. Trop. Med., March 15, 1918, xxi, 57. 
46. Lombard and Beguet: Presse med., September 21, 1921, xxix, 753. 
47. Mills: Journal of Exp. Med., November, 1919, xxx, 505. 
48. Nash: British Med. Jour., February 2, 1918, i, 149. 
49. Vecchia: Policlinico, January 5, 1920, xxvii, 6. 
50. Wesselhoeft: Boston Med. and Surg. Jour, October, 1920, clxxxiii, 425-520. 
51. Wolbach, Todd and Palfrey: Etiology and Pathology of Typhus, Harvard Uni- 
versity Press, 1922. 
BIBLIOGRAPHY. CHAPTER XV. 
GENITAL TUBERCULOSIS. 
By J. DELLINGER BARNEY, M.D. 
Introduction.—Tuberculosis of the genital tract in the male com- 
mences in the epididymis. Thence it spreads, at a fairly early date, 
to prostate and seminal vesicles, and, in some cases, attacks the testicle 
and the bladder. The vas deferens becomes involved to a greater or 
less extent in practically all cases. It is a characteristic of the disease 
to attack the opposite epididymis in over half the cases, within a year 
or two of the time of involvement of the first side. This catastrophe 
may occur unless proper means are employed to prevent it, but early 
excision of the epididymis first attacked will improve the chances for 
the escape of its fellow. 
Primary tuberculosis of the prostate, seminal vesicle, testicle, penis 
and urethra is occasionally reported. While there are a very few un- 
doubted examples of such lesions, most of those reported are open to 
criticism and can be disregarded. 
Genital tuberculosis in adults is found in from 2 to 5 per cent, of all 
tuberculous subjects. It is much less frequent in children. In over 
50 per cent, of cases there will be found old or active foci in other organs, 
especially the lungs. The urinary tract is often involved with the 
genital tract, but careful inquiry will show that involvement of the one 
system preceded that of the other. In my experience, when both are 
diseased, the genital tract has been first attacked. 
While proof is lacking of the exact mode of onset of the disease in the 
genital tract, it seems probable that the tubercle bacillus reaches the 
epididymis by way of the blood stream, and that the testicle and epi- 
didymis may possess an excretory function. The means of transmission 
of the disease to the other genital organs is still more in dispute. It 
seems probable that the lymphatics, especially those of the vas deferens, 
serve as a bridge between epididymis, prostate, and seminal vesicle. 
A similar route is probably taken from epididymis to testicle. Involve- 
ment of the second epididymis takes place in the same way as that of 
the first side, or by the transmission of the bacilli from the already in- 
fected prostate and seminal vesicle through the lymphatics of the second 
vas, but in a direction opposite to that of the normal flow. 
The pathological features of tuberculosis of the genital tract are not 
essentially different from those of the disease in other organs. Its 
characteristics are marked chronicity, a strong tendency to sinus forma- 
tion, and a gradual replacement of the normal structures by dense 
connective tissue. 
532 INCIDENCE OF TUBERCULOSIS 
533 
After the removal of one or both epididymes the tuberculous process 
in the prostate and seminal vesicles generally becomes quiescent and a 
clinical cure is established. 
While the tubercle bacillus is directly responsible for the disease, 
there are certain contributing factors of importance. Trauma, a pre- 
vious infection (generally gonococcal), and ectopia of the testicle may 
serve to reduce the local resistance. The young adult is most often 
attacked, but cases have been reported in infants on the one hand, and 
in men over 80 on the other. 
Most cases seek treatment within 6 months of the supposed onset of 
the disease, but its beginnings are generally so insidious that the onset 
is difficult to determine. Affections of the second epididymis occur in 
from 40 to 75 per cent, of all cases, while the prostate and seminal 
vesicles are attacked in at least 75 per cent. 
It will be found that most patients have lost weight, owing, no doubt, 
to the involvement of other organs which is so often found. Pain is to 
be expected at some stage in the disease, but like tenderness, it is inter- 
mittent and often mild. Bladder symptoms and a pathological urine 
are found in a considerable number. Scrotal fistula are seen in over 
three-fourths of the cases, while the testicle proper is invaded in about 
66 per cent. 
While the sexual desire and potency seem rarely to be impaired, even 
after double orchidectomy, azoospermia, due to occlusion of some 
portion of the genital duct, is found in a very large percentage. 
The diagnosis of a typical case of tuberculosis of the epididymis is 
easy. Differential diagnosis may be extremely difficult, and some- 
times can be settled only by exploratory incision. 
The prognosis is, on the whole, unfavorable. In our own cases up 
to about ten years ago, there was an operative mortality of 2.66 per 
cent., comprising 4 deaths, all of general miliary tuberculosis. During 
the past ten years we have had more than 100 such cases admitted 
to our service, in all but a very few of which either epididymectomy 
or orchidectomy, unilateral or bilateral, has been performed. Only 
1 of these cases has died (miliary tuberculosis) and he was unoperated. 
Over 27 per cent, of 113 cases, traced from one to twenty-five years 
after operation, have died of some form of tuberculosis. My experience 
shows that until at least ten years have elapsed after operation, no 
patient can be said to be cured of genital tuberculosis. 
If the technic of epididymo-vasectomy, now employed by us at the 
Massachusetts General Hospital, is done, and if it is performed, not 
under ether, but with novocaine local anesthesia or with gas-oxygen, 
operative mortality, postoperative sinuses in groin and scrotum, and 
the necessity of secondary orchidectomy will be practically eliminated. 
Treatment should consist of conservative surgery, combined with 
hygiene and tuberculin. The epididymis and accessible portion of the 
vas should be excised, together with the tunica vaginalis and other 
tuberculous tissues in the scrotum. The testicle may be freely explored, 
and, if tuberculous, the diseased portions may be removed by curette or 
knife. Orchidectomy is rarely necessary. 534 
GENITAL TUBERCULOSIS 
Incidence oi Tuberculosis.—The statistics of the world show tubercu- 
losis to be one of the most common and fatal of all diseases. Cornet25 
says that in 1894 in Germany the death-rate from tuberculosis was 25 
per 10,000, while in 1908 the number fell to 16.24. From 1896 to 1900, 
108,664 died of tuberculosis of the lungs, while in 10,000 this disease 
was found in other organs. 
From 1900 to 1909 the deaths in the registration area of the United 
States were 159.4 per 100,000 from lung tuberculosis alone, and 182.6 
per 100,000 from tuberculosis of all organs. In Massachusetts, for 1912, 
the deaths from lung tuberculosis alone were 131 per 100,000, and in 
Boston, for 1913, 144.7 per 100,000. Unfortunately, there seem to be 
no available national, State or municipal statistics which give satisfac- 
tory details of the distribution of the disease among the different organs 
and tissues. 
Incidence of Genito-urinary Tuberculosis.—Hesse26 has collected a large 
mass of statistics on the frequency of urogenital tuberculosis. In 
10,864 autopsies, lesions of the genito-urinary tract were found in 2.13 
per cent. Krzywicki,40 in 500 autopsies on tuberculous subjects, found 
5 per cent, with involvement of the urogenital tract. Fowler and 
Godlee72 found 5.27 per cent., and Reclus,62 many years before, reported 
12.8 per cent. 
Quite startling is the statement of Uchimura,67 that in 1830 autopsies 
on Japanese subjects, he found 629 cases of tuberculosis, the urinary or 
genital tract" being involved in 210, or 33 per cent. 
The above figures apply largely, if not entirely, to adults. In 
children the urogenital system is far less frequently attacked. 
Poissonnier,88 in a very complete review of the subject of infantile 
genital tuberculosis, collected 91 cases from various sources, the greatest 
number, 44, having been observed by Broca88 among 46,000 juvenile 
hospital inmates. Ritter,26 in 1909, found but 14 cases among 5000 
tuberculous children; Molliere and Augagneur,68 1 instance in 183 
cases of lung tuberculosis. The Massachusetts General Hospital 
has had 11 such cases from 1872 to 1920 among 401 admissions (includ- 
ing re-entries) for this condition, a percentage of 2.74. The figures 
from other sources give a proportion of urogenital tuberculosis in 
infants and children of about 1 in 200 cases of general tuberculosis. 
Tuberculosis of the Genital Organs.—The compilation of statistics is 
made a little difficult for the reason that the terms “genito-urinary” 
and “urogenital” tuberculosis are loosely used by almost all writers, 
and the general profession is only too apt to class under one of these 
names, an infection of the genital tract alone. While both the genital 
and urinary organs may be involved, careful inquiry will show infection 
of the one tract to be secondary to that of the other. While opinion is 
practically unanimous that the kidney is the first organ to be attacked 
in infections of the urinary system, there is less unanimity in the matter 
of the genital system. Most authorities now agree that the primary 
focus is in the epididymis, certain others still believe that the infection 
begins in the prostate, while a few put the burden upon the seminal 
vesicle. TUBERCULOSIS OF THE GENITAL ORGANS 
535 
In an analysis of 154 cases of epididymal tuberculosis from the Massa- 
chusetts General Hospital, the writer5 found tuberculosis of the kidney 
in 18. Of these, the genital lesion preceded the renal infection in 11, 
whereas in 7 the kidney was first involved. 
Keyes33 has reported 100 patients bearing 153 tuberculous epi- 
didymes. Among these renal tuberculosis had preceded the genital 
lesion in 11 cases, while extension of genital tuberculosis to the kidney 
took place 9 times. 
From our material and from the literature, I have gathered 1862 
cases of genito-urinary tuberculosis. Most of them are infections of 
the genital tract alone, in others the urinary organs are also involved. 
Certain valuable deductions can be made from so large a mass of 
material. 
Out of 821 cases in which the condition of the epididymis was 
described, 617, or 75.1 per cent., were tuberculous. 
The prostate and vesicles together were said to show tuberculosis in 
1169 out of 1675, or 69.7 per cent., while disease of the testicle was noted 
in 57.6 per cent, of 739 cases. 
It is therefore quite evident that next to the epididymis, the prostate 
and vesicles are most frequently attacked, a conclusion borne out by 
still further data. Hesse’s26 statistics comprise 815 cases of urogenital 
tuberculosis collected from 17 different authors. The prostate was 
tuberculous in 559, or 68.5 per cent. According to Burckhardt,25 the 
prostate is invaded in 73 per cent, of all cases of genito-urinary tuber- 
culosis, a statement based upon the investigation of much material. As 
the only clinical method of detecting foci in the prostate is by digital 
examination, there is a certain percentage of error, an observation which 
1 find agrees with that of Halle and Motz.25 This error lies generally in 
the detection of small, early, and centrally located lesions. 
Certain authors claim to have found isolated prostatic lesions in 
considerable number. Out of a possible 642 cases I find that the pros- 
tate alone was regarded as tuberculous in 21.6 cent On the other 
hand, Saxtorph,58 in a series of 205 cases of genito-urinary tuberculosis, 
has reported only 9 such lesions, and Sawamura,56 from various sources, 
collected but 11 more. After considering all the evidence, and with a 
large clinical and laboratory experience of his own, he thinks that the 
primary focus of genital tuberculosis may arise in the prostate, an 
opinion shared by K. M. Walker.71 
On the other hand, in 1911 George Walker,70 whose opinion is backed 
by much experimental work, has laid much stress on the rarity of pri- 
mary prostatic tuberculosis, and after reviewing the literature with great 
care, found only 3 cases in which the primary focus undoubtedly lay in 
the prostate. One was reported by Crandon,17 and 2 others by 
Krzywicki.40 I77 have recently been fortunate enough to have such a 
case of primary prostatic tuberculosis, which, strangely enough, was 
found to co-exist with adenomatous hypertrophy of the gland. A 
somewhat similar case was reported by Koll,84 and he, in turn, cites 
2 other apparently authentic examples of this rare and interesting 
lesion. Practically all the other authors mentioned above, who 536 
GENITAL TUBERCULOSIS 
claim to have found isolated prostatic tuberculosis, have based their 
conclusions either on clinical evidence, or upon the fact that although 
other foci were present in the genital tract, those of the prostate were 
further advanced and more extensive. I have already pointed out that 
clinical evidence is unreliable, and the consensus of opinion of experienced 
pathologists is that the apparent age of a tuberculous process does 
not necessarily determine its priority. I do not recall a single proved 
case in the genito-urinary clinic at the Massachusetts General Hospital, 
nor am I aware that the autopsy records of the hospital contain one. 
We have seen that the seminal vesicle, like the prostate, is invaded 
secondarily by tuberculosis with great frequency. Primary lesions, on 
the other hand, are apparently almost as rare as those of the prostate. 
This view is somewhat shaken by the fact that in 28.5 per cent, of 287 
cases, of the series of 1862, mentioned above, the seminal vesicle alone 
was said to be tuberculous. But what was said of the so-called isolated 
prostatic lesions applies to those of the vesicles, and careful scrutiny 
would undoubtedly eliminate most of the reported cases. 
Young,97 the most recent and most ardent advocate of the view that 
the seminal vesicle is the primary focus in genital tuberculosis, has 
collected much material from the literature to bear out his belief. 
He says, “Turning to the French literature, I find that Guyon, the 
father of modern urology, stated many years ago that the tuberculous 
process begins generally in the seminal vesicles. He cited 26 necropsies 
in which the seminal vesicles were found to be primarily the site of 
disease; in 2 cases only the seminal vesicles were involved and in 
10 cases the prostate was infected simultaneously with the vesicles. 
In 1 case, the prostate alone was involved. In 220 clinical obser- 
vations of patients suffering from urogenital tuberculosis which 
Guyon examined personally, 40 cases were isolated genital tuber- 
culosis, 74 were cases of tuberculosis of the urinary organs and 108 
were combined urinary and genital tuberculosis. In 127 clinical 
cases in boys suffering from urogenital tuberculosis before the age 
of puberty, Guyon found the prostate involved in 56, prostate and 
seminal vesicles in 11, epididymes in 2 and all of the genital organs 
in 58. Guyon asserted his belief that the tuberculous process begins 
most frequently in the seminal vesicles and that the involvement was 
from within outward, toward the external genitalia. 
“The statistics seem, therefore, to show conclusively that in the 
great majority of cases the primary involvement is in the seminal 
vesicles (or prostate), from which the epididymes or testicles are 
subsequently involved, the external disease being bilateral in from 
30 to 50 per cent., of the cases. In a probably larger percentage of 
the cases, the involvement of the seminal vesicles is bilateral (61 
per cent, of my cases in series B and probably higher).” 
That the seminal vesicle alone is not infrequently attacked by 
tuberculosis is shown in the investigations of Simmonds.91 He per- 
formed 40 autopsies in which the prostate alone was involved in 20, 
the seminal vesicles alone in 10, and the epididymis alone in 10. TUBERCULOSIS OF THE GENITAL ORGANS 
537 
From this he concluded that the primary focus in the genital tract 
proceeds from the seminal vesicle in one quarter of the cases. 
Primary tuberculosis of the testicle is conspicuous for its rarity. 
K. M. \\ alker and Hawes72 accept as authentic cases reported by 
Dufour,72 Langlet72 and Schmidt,72 while that of Barling,70 72 is 
vouched for by these authors, as well as by George Walker.72 
More recently Mark88 has reported in detail, a case of tuberculosis 
of the testis, apparently primary in that organ. It is, however, to 
be noted that a second and more careful examination of the excised 
specimen showed a single tubercle in the epididymis “which differs 
in no respect from those found in the testicle.” The pathologist 
also states that “ from the appearance of the lesion in the testicle and 
epididymis one is not able to say with certainty which may be the 
older. Histologically the processes in both are identical.” 
Tuberculosis of the glans penis may rarely occur: (1) as an isolated 
lesion, (2) in association with tuberculosis of the genito-urinary tract or 
elsewhere, (3) by direct infection (circumcision, coitus). George 
Walker70 has collected 5 cases in the first group, 3 in the second group, 
and says “ several (instances of infection from circumcision) have been 
noted in the Johns Hopkins Hospital.” He has collected some 31 
others from other sources. I have not seen an example of it. 
The question of infection from coitus has raised extensive discussion. 
Pinaud 1 cites 4 cases of tuberculosis of the penis from fellatio. Frank51 
and Kraemer51 regard tuberculosis of the penis from normal coitus as 
impossible; on the other hand, Senn,51 Oberndorfer51 and Williams51 
regard such an infection as possible. 
Although there seems to be no authentic case of primary urethral 
tuberculosis, a secondary infection is not infrequently seen in the 
course of tuberculosis of the genito-urinary tract. I have operated 
upon one or two such cases, and there have been several others, 
treated by dilatation, in the genito-urinary clinic at the Massa- 
chusetts General Hospital. Asch,1 Sawamura,56 Urchimura,67 Halle 
and Motz25 and others report several instances. Such strictures 
often accompany bilateral renal tuberculosis. 
Tuberculosis of the vas deferens is found sooner or later in practically 
all epididymal lesions, especially on the side first involved. Infections 
of the second vas are not so common and develop later in the disease. 
Tubercle bacilli have been found in human semen, and in that of 
animals, by numerous observers. In some cases there was tubercu- 
losis of the urogenital tract, in others tuberculosis of the lungs, but 
healthy genitalia. George Walker,70 after a careful review of all the 
literature of this subject, thinks that while tubercle bacilli may well find 
their way into the semen in the event of tuberculous genitalia, there is no 
positive proof that they can be secreted by healthy organs. The subject 
is of some importance, as undoubted examples of vaginal and cervical 
tuberculosis, arising apparently from sexual contact, have been reported. 
Cunningham79 states that in many clinical cases where the vesicles and 
prostate were typically tuberculous, smears of the material expressed 
show tubercle bacilli in less than 15 per cent, of the cases examined. 538 
GENITAL TUBERCULOSIS 
Tuberculosis of Other Organs—The frequency of a tuberculous 
infection of other organs, preceding or accompanying that of the 
genital tract, is well recognized. 
In my series of 154 cases of tuberculosis of the epididymis, tuber- 
culosis of organs other than those of the genito-urinary tract was found 
in 55.8 per cent. The lung was most frequently diseased, with a total 
of 35 cases, 22.7 per cent, of the whole. Kidney and bone infections 
came next, with 7 cases each. I have also shown elsewhere3 that the 
disease, quiescent or active, may be found in the joints, larynx, glands, 
meninges, middle ear, peritoneum and ischiorectal fossa. It will be 
found in many cases that these lesions have preceded, often for several 
years, the tuberculosis of the urogenital tract. 
Keyes33 found a previously existing process in 36 out of 100 cases; as 
he gracefully puts it, the disease is always “flitting between bone and 
lung and urinary tract.” Siinmonds26 in 35 cases of genito-urinary 
tuberculosis found lung infection in 27, Steinthal26 in 24 cases found the 
lungs involved 22 times, and Socin26 42 times in 52 cases of genito- 
urinary tuberculosis. In 37 cases of the latter, Oppenheim26 found 81 
per cent, of lung involvement, while in Iteclus’52 cases it was present in 
66 per cent. 
The percentage of tuberculous lesions outside the genital tract is 
therefore very high, and a lung process which has escaped the memory 
of the patient and the observation of the surgeon may not infrequently 
be uncovered by the unwise choice of ether as an anesthetic. 
Pathogenesis.—While two types of tubercle bacilli, human and 
bovine, may be found in man, a recent study by Eastwood and 
Griffith81 would appear to show that the human type is alone found 
in lesions of the genital tract. These investigators examined 17 cases 
affecting the genitals in 9 (7 testes, 1 salpinx, 1 prostate) and 8 in 
the kidney. The bacilli found were of the human type in 14, and of 
the bovine type in 3. The latter were all found in kidney lesions. 
In connection with this interesting and probably important question 
as to which type of bacillus is responsible for the lesions one occasion- 
ally sees a case in which both organisms might be present. I refer 
to the patient who has had tuberculous cervical adenitis in child- 
hood, and who in later life develops tuberculosis of the genital or urinary 
tracts. Was the adenitis of bovine origin? If so, is the later lesion 
due to the same type of bacillus? If not, is it due to a subsequent 
invasion by the human type of bacillus? The answer to this question 
can only be given by patient, careful research. The question as to 
how the tubercle bacillus reaches the primary focus in the genital 
tract is not yet definitely settled; still more in doubt is the path taken 
by the disease to its secondary foci. Recent literature throws no 
further light upon this interesting problem. 
I have shown that the relationship between genital tuberculosis and 
that of other organs, especially the lung, is very close, but there are 
occasional exceptions to this rule. 
Baumgarten,9 v. Bruns,69 Kocher,34 v. Braman,2 Durante2 and Zi gler2 PATHOGENESIS 
539 
have reported cases in which tuberculosis of the testis and epididymis 
was the only demonstrable focus in the body, while Kowalewsky37 and 
Ivraenzle37 have found isolated, primary tuberculosis of the testicle 
(epididymis?) in bullocks. These are the only instances I have found 
of isolated genital tuberculosis. 
I have no doubt that in the majority of cases the disease reaches its 
primary focus in the genital tract by way of the blood stream. Its 
attack upon the epididymis, the testicle or the seminal vesicle may be 
accounted for by the supposition that these organs have an excretory 
function, and that the disease gains a foothold upon a given organ at 
one time and not at another, because of either an overdose of the 
bacilli, or of a lowered resistance on the part of the gland involved. 
From an embryological stand-point, the testicle and the kidney are 
much alike, and there is ample proof that the latter may allow the 
passage of tubercle bacilli and other organisms without injury to itself. 
The filtration of bacteria through an apparently healthy kidney has 
been demonstrated by many observers, among them, Meyer,47 Heyn,72 
Kraemer,39 Budav,14 Wyssokowicz74 and Roily.53 More recently 
Brown13 has collected many instances of lung tuberculosis, some in his 
own practice, where tubercle bacilli were found in the normal urine, 
and where, later, the kidneys were shown to be free from disease. 
Some investigations by Cunningham,78 however, do not seem to 
bear out these findings. 
Belfield11 has shown that the testicle and epididymis are excretory 
organs. He says, “ While the kidney is provided with a new and private 
sewer, the ureter, the testis continues to use the frog’s old urinary duct, 
now called epididymis and vas deferens. This excretory function of the 
testicle and its duct illumines both its intimate alliance with the kidney 
and its frequent infection from the blood.” The writer6 has already 
shown in a study of infections of the testicle, that in certain cases the 
presence of organisms in both testicle and epididymis could be accounted 
for in no other way than by assuming that these organs had an 
excretory function. 
There seems to be also considerable evidence that the seminal vesicle 
can assume an excretory role, not only for tubercle bacilli, but for other 
organisms as well. 
Huet’s28 experimental work has showm not only that bacteria are 
present in the secretion of the seminal vesicles of healthy animals, 
but also that in animals dying of acute sepsis the specific organism may 
be found in this secretion. The seminal vesicle may thus be looked 
upon not only as a reservoir for spermatozoa, and a secretory organ, 
but also as an excretory organ. Ilueter,29 Simmonds2 and Spano61 
share this view. 
There seems to be some evidence that the prostate also plays the part 
of an excretory organ. Jani and Nakarai,56 in 1886 and 1898 respec- 
tively, found tubercle bacilli in the normal prostate of patients dying 
of lung tuberculosis. 
I have seen a number of cases of acute infection of the prostate with 540 
GENITAL TUBERCULOSIS 
the B. coli, there being no demonstrable focus of infection either in the 
kidneys, the bladder, or the external genitals. I have regarded this 
infection as hematogenous, but whether it is to be regarded as an 
excretory effort on the part of the prostate I am unable to say. 
Admitting that the epididymis is the primary focus, is the subse- 
quent prostatic infection of hematogenous, deferential, or lymphatic 
origin? 
While the tubercle bacillus may, in certain cases, be carried from 
epididymis to prostate by the blood stream, it is more likely that the 
more direct route offered by the vas deferens, or by the lymphatics is 
responsible. 
At first sight it would appear that the spread of the disease through 
the vas in the direction of the seminal stream, the descending, or, as 
some miscall it, the ascending route, offered an easy explanation for the 
early and frequent prostatic involvement. While this view has many 
proponents, it is strongly assailed by numerous competent observers. 
Baumgarten8 and his pupils, especially Ivraemer,38 have been the chief 
proponents of the descension theory, this opinion being based on much 
experimental and clinical observation. Among others who hold this 
view are Tylinski,66 Cholzoff,16 Sugimura,62 Sangiorgi,55 Sawamura56 and 
Gotzl.22 
While K. M. Walker71 regards genital tuberculosis as primary in the 
prostate, certain of his observations, both experimental and clinical, 
show that a flow of infected secretions through the lumen of the vas 
from the diseased epididymis may occur. This sets up a tuberculous 
process in the vas, most marked at its epididymal extremity, gradually 
shading off to normal tissue (unless the disease is of long standing) 
toward the external inguinal ring. My own observations and those of 
others have repeatedly borne out the truth of this observation. The 
only question is whether the advance of the disease has been intra- 
canilicular or intramural. 
Although in certain instances, the advance of the tubercle bacillus 
through the vas is possible, no positive proof can be shown, and the 
opponents seem to have the best of the argument. The fact that 
tuberculosis of the vas often obliterates its lumen near the epididymis 
before the upper part is involved, thus stopping the stream of secretion, 
at once places the proponents in an awkward position. Furthermore, 
how are they to account for the fact that even if the vas is ligated, the 
advance of the disease from epididymis to prostate may be delayed, 
but not stopped ? This phenomenon has been observed in a number of 
animals by George Walker.70 How also, are they to explain my observa- 
tions and those of Balliano,2 that the epididymis, prostate and vesicles 
may be tuberculous and the intervening vas perfectly normal? 
These observations can be explained only by discarding the idea that 
the disease spreads through the lumen of the vas, except in certain 
instances, and by adopting the view that the lymphatics of the vas itself 
are to be held accountable for the spread of the disease in most cases, 
for, according to Testut,63 the lymphatics of the vas are very rich and 
voluminous, extending throughout its course. PATHOGENESIS 
541 
This hypothesis explains the phenomena just cited, as for example, 
the invasion of the prostate by tuberculosis in the presence of a normal 
or of a ligated vas. The possibility of this is explained by K. M. 
Walker71 who says: “ The bacillus of tubercle does not always indicate 
its presence in the tissue by the production of a tuberculous lesion.” 
“Structures may be shown under the microscope to be absolutely 
free from signs of tuberculosis, and yet, nevertheless, have furnished 
the path along which the tuberculous invasion has progressed.” 
In certain cases of long duration, the whole spermatic cord may be 
involved, so that attempts to separate the vas from it may be either 
difficult, where there are dense adhesions, or impossible, where all the 
structures are imbedded in dense connective tissue. But in many 
early cases, one may find an involvement of the prostate and vesicles in 
the presence of a normal or but slightly affected spermatic cord. 
Although every argument presented here, for and against the vas and 
its lymphatics can be refuted, I think the evidence at hand favors the 
lymphatic transmission of tuberculosis from epididymis to prostate. I 
think the stream of secretions in the vas deferens is too scanty and slug- 
gish to be a factor in the passage of bacilli. In such an event, with 
organisms in contact with the entire length of the vas, we should find 
one end quite as much involved as the other. But such is not the case. 
The epididymal extremity is first and most seriously invaded, the patho- 
logical changes usually disappearing entirely as the inguinal canal is 
approached. To my mind this phenomenon is an evidence that the 
disease travels by way of the lymphatics. 
I have already pointed out that tuberculosis of one epididymis is 
followed sooner or later by an involvement of its fellow in a large per 
centage of cases. I have been unable to settle the question as to the 
manner of invasion of the second side in spite of much clinical observa- 
tion, nor do I find that the extensive experimental work of others throws 
much light on the matter. The paths of communication—vascular, 
deferential and lymphatic—are the same as before, but the infection is 
now undoubtedly influenced by the presence of an already tuberculous 
prostate and seminal vesicle. 
Many (Simmonds, Bungner, Kraemer, Bruns, Friedlander, Yolk- 
mann, Jordan and Zamurawkin, all quoted by Tylinski66) believe that 
the infection of the second side, like that of the first, is hematogenous. 
Cholzoff16 also inclines to this view. The possibility of it cannot be 
denied. 
While the ability of the tubercle bacillus to pass through the vas in 
the direction of its current has been shown to be doubtful, the chances of 
its proceeding against the current must be even less. Yet I find that 
Ziegler,2 Teutschlander,64 Kuhn,41 and Kocher35 consider this possible 
not only for the tubercle bacillus but also for the gonococcus and other 
non-motile organisms. A few of George Walker’s70 experimental results 
with tuberculosis and a few clinical cases cited by him seem to bear out 
this view. If the passage of these organisms through the vas from 
urethra to epididymis does occur it can be accounted for only by a re- 542 
GENITAL TUBERCULOSIS 
versal of the normal peristalsis of that structure, a phenomenon care- 
fully studied by Oppenheim and Low.49 It was observed in rabbits 
and guinea-pigs and in one or two humans, but did not occur in 
dogs. It was produced by stimulation of the hypogastric nerve or by 
irritation of the verumontanum. Its experimental production is evi- 
dently not constant; clinically, it is certainly rare. 
Epididymitis of gonococcal or pyogenic origin is occasionally seen, 
when the sudden onset, a few hours after some otherwise trivial injury 
(such as the passage of a sound) cannot well be accounted for in any 
other way. I have never seen a tuberculous epididymitis begin thus, 
perhaps because the organism develops so slowly. Moreover, if a 
tuberculous process can, as has been shown, obliterate the epididvmal 
end of the first vas, it can, by the same token, occlude the urethral end 
of the second vas by tuberculosis spreading from prostate or vesicles. 
Proof of this is offered by my observations3 4 and those of Keyes33 that 
a very large proportion of men with tuberculosis of even one epididymis 
have azoospermia, indicating an obstruction of the genital duct on both 
sides. The pathological studies of K. M. Walker71 bear out this belief. 
I should like to think with Konig,36 Lancereaux,66 Schmidt,59 and 
Sawamura55 that the infection of the second epididymis is a simple case 
of transmission through vas, urethra, and vas, but the evidence against 
it is unimpeachable. 
Unless one takes the view, as I am strongly inclined to, that the 
infection of the second epididymis occurs through the blood stream, 
possibly as an excretory phenomenon, the question narrows itself down, 
as in the case of the first epididymis, to the lymphatics as being the 
most probable bridge between prostate and epididymis. It is true that 
in such an event the infection must travel in a direction contrary to that 
of the normal lymph stream, but Balliano2 has shown that this can 
take place. 
The following case, seen (September 15, 1915) by my colleague, 
Dr. Hugh Cabot, furnishes apparently substantial proof of the sound- 
ness of this theory: 
A man, aged nineteen years, noticed a swelling of the right side of the 
scrotum about two years ago. In May, 1915, the right testicle wag 
removed by another surgeon for tuberculosis, the vas being divided at a 
point opposite the external ring. About two weeks ago the left side of 
the scrotum became swollen and tender. 
Examination showed the right testicle missing. A sinus led to the 
stump of the vas, which was surrounded by a mass of indurated tissue. 
On the left side the testicle and epididymis seemed normal, but at the 
top of the scrotum, close to the vas and evidently connected with it, 
there was a hard, nodular mass the size of an English walnut. The 
urine wTas clear, but contained a few shreds. 
Operation October 11,1915. Left epididymis and testicle apparently 
perfectly normal. The lower end of the vas near the epididymis not 
thickened. Near the top of the scrotum there was an indurated mass, 
adherent to the vas and spermatic cord as well as to the overlying skin, PATHOGENESIS 
543 
This was excised, together with the epididymis and vas, up to the exter- 
nal inguinal ring. An additional length of vas was then removed 
through a counter-incision opposite the internal inguinal ring. The 
inguinal portion of the vas showed two caseous nodules, one of which 
was removed. The vas was torn off (accidentally) at the second (distal) 
nodule, which could not be reached over the pelvic brim. 
The inguinal canal on the right side was then opened. The vas was 
isolated, drawn up over the pelvic brim, ligated and divided, thus 
removing the inguinal portion, together with the mass of inflammatory 
tissue surrounding its stump. 
The tissue excised from both sides is clearly shown in the accom- 
panying photograph (Fig. 241). 
Careful microscopical examination of the left epididymis shows no 
evidence whatever of tuberculosis or other inflammatory change. 
Sections of the left vas lying between the epididymis and the large 
tuberculous mass are likewise normal. Beyond this point the vas 
shows various tuberculous changes. 
The excised portion of the right vas also showed tuberculous changes. 
Fortunately for our purposes the patient was seen when the advance 
of the disease upon the second side was in its initial stages and before 
the epididymis was involved. 
Delli Santi19 injected tubercle bacilli into the urethra, and after three 
days demonstrated their presence in the testicle. Paladino-Blandini50 
obtained similar results. K. M. Walker and Hawes72 injected B. 
prodigiosus, Staph, aureus, and other organisms into the urethra of 
guinea-pigs. Eight to ten hours later they obtained cultures of these 
organisms from both epididymes, and got a scanty growth from the 
testicles and seminal vesicles. Especially important is the fact that 
positive cultures were obtained from the lymphatics of the vas deferens. 
Tubercle bacilli have also been demonstrated in the peridifferential 
lymphatics by Cholzoff.16 
Furthermore, it has been shown experimentally by Kappis32 and 
Baumgarten10 that the spread of tuberculosis in a direction opposite to 
the normal stream of secretion can occur only if that stream is stopped. 
These observations coincide with the fact already noted, that the vasa 
deferentia are very frequently obstructed on both sides early in the 
disease. 
When the prostate, testicle, or seminal vesicle is the primary seat of 
genital tuberculosis there is no reason to suppose that its origin is 
different from that of the epididymal process. 
In the event of renal tuberculosis, or of the filtration of tubercle 
bacilli through the healthy kidney, the prostate may be first invaded, 
with subsequent epididymal involvement, or the epididymis may be 
directly attacked. In either event the tubercle bacillus doubtless 
follows the same paths to the first epididymis which have been regarded 
as probable in infections of the second side. 
Tuberculosis of the testicle, secondary to that of the epididymis, 
may arise either by continuity, by spreading against the seminal 544 
GENITAL TUBERCULOSIS 
stream through the epididymal tubules or through the lymphatics. 
Here, again, the latter course seems to be the most likely, but actual 
proof is lacking. Yet it is significant that the most frequent site of 
secondary testicular involvement is the body of Highmore at which 
point the lymphatics of the testicle concentrate (Testut63). 
Fig. 241.—A, right vas; 1, proximal end with surrounding sinus; 2, distal end, divided 
at internal inguinal ring. B, left epididymis, upper pole 1, body l', lower pole 1". Mass 
of tuberculous tissue at upper part of scrotum, 2; caseous, spindle-shaped nodule, 3; 
lying within thickened vas, 4. 
Since the question of the primary focus and of the means by which 
the disease spreads from this focus to other organs is still open to ques- 
tion, I think the views of two authoritative students of the problem, 
although at variance, are none the less interesting. After many 545 
PATHOGENESIS 
years of study of this question and basing his opinion on the results 
of 200 necropsies of those dying with genital or genito-urinary tuber- 
culosis, Simmonds91 coines to the following conclusions: 
1. The primary focus in the genital tract proceeds from the pros- 
tate in one-half of the cases, while in one-quarter of the cases it arises 
in the seminal vesicle or in the epididymis. 
2. From these centres the process can proceed in the direction of 
the testicle or away from it. 
Ivraemer,87 on the other hand, believes that the spread of tuber- 
culosis with the natural secretory current within the male genital 
system holds true, and finds not only no evidence against this view 
in Simmond’s work, but even every evidence to support it. 
The recent views of Hugh Young98 still further complicate the 
problem. After an exhaustive study of the literature and of his own 
considerable personal material, he says, “The disease reaches the 
epididymis generally by the lymphatics of the cord from the seminal 
vesicles and first involves generally the globus minor. It is prob- 
ably erroneous to suppose that primary tuberculosis of the epididy- 
mis often occurs. It probably seldom occurs through blood-stream 
infections, as is so often asserted. The seminal vesicles are not 
only the primary focus from which the epididymes are involved, 
but from which also the prostate, bladder and the kidneys in many 
cases are involved. In fact, tuberculosis in the region of the pro- 
state and vesicles is far more dangerous to the entire human organism 
than tuberculosis of the epididymes and is probably responsible 
for the fearful mortality which is variously estimated at from 27 to 
60 per cent, in cases of genital tuberculosis.” 
Young98 concludes his argument as follows: “Statistics show con- 
clusively that in most cases of ‘genital tuberculosis’ the primary 
focus is in the seminal vesicles. Tuberculosis of the seminal tract 
is, therefore, the better name. 
“From the seminal vesicles, the globus minor of the epididymis is 
generally next attacked. 
“From the seminal vesicles, the prostate, urethra and bladder are 
often attacked later. 
“ From the seminal vesicles, more rarely, the kidney may be invaded 
through the lymphatics along the ureter. 
“From the seminal vesicles by the posterior line of lymphatics, 
the mediastinum and the lungs may be involved. 
“Tuberculosis of the seminal vesicles (ampullse and prostate, if 
involved) ranks first in importance when a curative operation is pro- 
posed for genital tuberculosis.” 
Having followed the subject of genital tuberculosis for several 
years with great interest and care I still find no occasion to change 
my original belief, in spite of much disconcerting evidence to the 
contrary, that the primary focus arises in the epididymis in the great 
majority of cases. I freely acknowledge that this focus may arise 
in the prostate or seminal vesical in a certain number of instances, 546 
GENITAL TUBERCULOSIS 
but the old argument still holds true that the removal of the tuber- 
culous epididymis produces clinical cure of the prostatic or vesicular 
process in the vast majority of cases. This being the case, is it reason- 
able to suppose that the primary focus lies in the one or the other of 
these organs rather than in the epididymis? 
Pathology.—-The microscopic picture presented by tuberculosis of 
the genital organs differs little from that seen in other tissues. Whereas 
elsewhere, notably in the lung, a tuberculous focus may often wall itself 
off and heal spontaneously, the tubercle bacillus seems never to cease its 
activity once it enters the genito-urinary tract. In certain cases it may 
remain quiescent for a long time (especially in the epididymis) bursting 
forth now and again with surprising violence, all the while replacing the 
normal tissues of the organ by a process of caseation and cicatrization. 
It has been my observation that the tuberculous process attacks first 
the lower pole or tail of the organ. Cholzoff,16 K. M. Walker,71 and 
George Walker70 report a similar experience. The early stages of 
epididymal tuberculosis have been well described by the latter in his 
experimental work. He says: “ The initial lesion begins just under the 
epithelial layer of the tubules. Soon there is an infiltration of the 
epithelium by small round cells, a few epithelial cells and leukocytes. 
This process progresses, the whole lining becomes disintegrated, and 
the lumen of the tubules is filled with exfoliated and adventitious cells. 
These soon die and are converted into tuberculous debris. The con- 
nective tissue framework becomes invaded secondarily, although there 
is an almost complete destruction of the epithelial lining before the 
connective tissue wall is affected.” 
The relation of the early stages of the tuberculous foci to the tubules 
(has also been pointed out by Cholzoff,16 but Tylinski,66 in tuberculous 
testicles of dogs, showed the tubercles to be in the interstitial con- 
nective tissue, especially in the neighborhood of blood effusions. An 
examination of a large amount of the material from our clinic has shown, 
generally speaking, that the tuberculous process was intertubular, 
involving only the surrounding connective tissue and leaving the 
tubules intact. In many sections the tubules were more or less com- 
pressed by the encroaching peritubular process, and in the later stages 
they showed evidence of complete destruction. The tendency of the 
tuberculous epididymis to form abscesses and sinuses is generally 
recognized. These will generally be found at the lower pole of the 
organ (Fig. 242), but in certain extensively diseased epididymes, puru- 
lent foci and even sinuses are to be seen at the upper pole as well, and 
occasionally in the intervening portion. 
It is apparently still unsettled whether the initial tuberculous process 
in the testicle begins in the canals or in the interstitial tissue. Many 
competent observers, Baumgarten,8 10 19 Cholzoff16 and others think it 
always commences in the canals or in their neighborhood, whereas 
Samuel,54 after a careful pathological study of human testicles, con- 
cluded that the disease spread by way of the interstitial tissue. George 
Walker’s70 experimental work throws light on this question. He says: Fig. 242.—Dissection of tuberculous epididymis. A, testicle; B, upper pole of epi- 
didymis; C, body, with tuberculous nodule; D, much enlarged lower pole, connected 
by a sinus with scrotal skin (E); F, nodular and thickened lower pole of vas; G, cut end 
of vas, slightly thickened. (Specimen from Warren Museum.) 
Fig. 243.—Longitudinal bisection of testicle extensively invaded with tuberculosis. 
The disease follows roughly the fibrous septa of the organ. The bisected upper and lower 
poles of the epididymis are seen above and below in the median line. (Specimen from 
Warren Museum.) (*,47) 
547 548 
GENITAL TUBERCULOSIS 
“In those cases in which the animals had received injections into the 
aorta and had been killed within a short time afterward, I found in 
one gland several small capillaries containing tubercle bacilli, and in 
another I observed very young tubercles close to the bloodvessels. It 
is presumable from this that the organisms penetrate the walls and 
form a tubercle in the immediately surrounding tissues. This process 
may occur in the intracanalicular connective tissue or just under the 
epithelium. As the process advances, the tubercles coalesce and form 
distinct nodules.” 
Balliano2 recognizes two forms of tuberculosis affecting the testicle 
and epididymis. The usual type is that which settles primarily in the 
epididymis, with the formation of single nodules. This soon goes on to 
caseation, abscesses and sinuses, and is to be regarded as of hematogen- 
ous origin. The disease arises primarily in the interstitial tissue. The 
second type, evidently rare, arises through the natural channels, 
urethra, prostate, and vas. It generally attacks epididymis and tes- 
ticle simultaneously, has its primary seat in the interior of the seminal 
canals, and gives rise to an increase of interstitial tissue with round-cell 
infiltration and general increase of sexual tissue. It somewhat resem- 
bles sarcoma. In advanced states there is caseation and destruc- 
tion of the organ. But if the resistance of the individual is high a 
clinical cure may occur, with induration of the organ (orchitis fibrosa) 
resembling the obliterated and scarred tuberculous foci of the other 
organs so often seen at autopsy. 
The question of spermatogenesis in a tuberculous testicle has 
received much attention. It may persist until late in the disease. 
Orth54 says that in a tuberculous human testicle, of which the centre 
showed complete caseation, one could recognize clearly the necrotic 
walls of the tubules, and in them, in the midst of caseous nodules, one 
could see many spermatozoa. Simmonds54 has seen spermatozoa, often 
in large numbers, in an extensively destroyed testicle. Baumgarten10 
observed that while the tubules were more and more compressed and 
squeezed together by the development of inflammatory connective 
tissue and infiltration, the epithelium itself still persisted and spermato- 
genesis was carried on by active karyokinesis. 
The macroscopical appearances of the testicle when removed at oper- 
ation may show an organ studded with miliary tubercles or it may 
present a caseous or necrotic focus near its junction with the epididymis 
(Fig. 243). All observers agree that the testicular invasion generally 
begins at the body of Highmore (Fig. 244), whence it spreads to other 
parts. In certain cases, even with a long-standing and extensive 
tuberculosis of the epididymis, the testicular tissue remains intact and 
will be found compressed by the slowly enlarging epididymis, as shown 
in Fig. 245. It not infrequently happens that a small and centrally 
located tuberculous process in the testicle will give no external sign of 
its presence. For this reason exploratory orchidotomy is to be recom- 
mended in doubtful cases. Yet in spite of careful macroscopical examina- 
tion our experience has shown that 66 per cent, of the testicles associ- PATHOLOGY 
549 
ated with tuberculous epididymes and removed showed microscopical 
evidence of tuberculosis. 
Before leaving the pathology of epididymis and testicle it may be 
observed that an actively tuberculous process of the tunica vaginalis 
is occasionally found. The serous coat is deeply injected, there are 
innumerable tiny ecchymoses, and small tubercles may dot its surface 
or that of the epididymis. In practically every case more or less 
hydrocele fluid escapes when the sac is opened, and its walls are adher- 
ent to a greater or less extent, especially at the lower pole. 
The 'pathology of the tuberculous prostate has been given much study. 
Experimental infections naturally show the earliest stages better than 
Fig. 244.—Longitudinal section of tes- 
tical and epididymis. Tuberculosis chiefly 
of the upper pole of the latter. Large 
tuberculous nodule in upper pole of tes- 
ticle in the body of Highmore, the favorite 
seat of testicular tuberculosis. (Specimen 
from Warren Museum.) 
Fig. 245.—Longitudinal section of 
testicle and epididymis showing 
compression of the testicle by exten- 
sive tuberculous involvement of the 
lower pole of the epididymis. (Speci- 
men from Warren Museum.) 
clinical specimens, especially as the latter are seen at autopsy when the 
disease is well advanced. The first changes begin just under the epithe- 
lial layer of the ducts. George Walker70 says of the subsequent changes: 
“ After the formation of a considerable subepithelial aggregation, the 
epithelium becomes invaded by the adventitious cells and the lumina 
of the ducts are encroached upon; later the lumina are filled with a mass 
of cells in which one can distinguish a large number of epithelioid, 
degenerated epithelial, small mononuclear cells, and polymorphonuclear 
leukocytes. Very soon after this stage, or in fact along with it, one 
sees a number of degenerated and dead cells; the nuclei are fragmented, 
and the protoplasm is granular and cloudy. As this advances, the cells 550 
GENITAL TUBERCULOSIS 
are converted into a granular mass without any definite cellular differ- 
entiation. In the ducts the epithelial lining disappears, leaving the 
walls made up solely of connective tissue. The prostate is converted 
into a number of cheesy, rod-like masses, interspersed among which is the 
connective and muscular tissue of the gland. This later breaks down 
and the wdiole gland is converted into tuberculous tissue.” 
Halle and Motz,25 with a large experience at the Necker Hospital, 
divide the tuberculous changes of the prostate into 
1. Small, primary tubercles. 
2. Large tubercles, which may present macroscopically a stage of 
softening, a stage of encystment, and a stage of fibrous induration. 
3. Encysted tuberculous abscesses. 
4. Tuberculous cavities, partly or wTholly open. 
5. A special form of massive infiltration, caseous or necrotic. 
The latter type seems to predominate. Careful pathological study 
shows that the tubercles are especially abundant in the middle lobe, 
but in more than half both lobes are attacked. Unilateral lesions are 
distributed without marked predilection for one or the other side. 
According to Ileclus52 and to Simmonds,25 the early lesions are often 
unilateral in the lobe corresponding to the diseased epididymis. 
Anatomical facts do not clearly confirm this, but in the early stages it is 
hard to confirm. 
Cholzoff16 says that tuberculosis of the prostate occurs in the form of 
cheesy, degenerated tubercles of different size and rarely the whole organ 
shows homogeneous, cheesy degeneration. Involution of the disease he 
regards as rare. 
Gotzl22 thinks the tuberculous prostate rarely, if ever, becomes 
encapsulated and calcified. 
Hesse26 classifies the changes in the prostate thus: 
1. The stage of tubercle formation. 
2. The stage of confluence of tubercles. 
(a) Caseation. 
(b) Abscess formation. 
3. The encroachment upon 
(a) The periprostatic tissues. 
(b) The whole organism, as an acute miliary tuberculosis. 
4. The stage of healing. 
Albarran1 recognized: 
1. Nodular infiltration. 
2. The cavernous type. 
3. The degenerative form. 
4. Prostatitis with periprostatitis. 
Many investigators, Hesse,26 Lowenstein45 and others, recognize a 
bacillary catarrh of the prostate as one of the earliest changes of tuber- 
culosis. Macroscopically, there is nothing to be seen, and even the 
microscope may find but little alteration. The prostatic secretion, 
however, is loaded wuth virulent tubercle bacilli. PATHOLOGY 
551 
In view of the scanty descriptions of the microscopical anatomy of 
tuberculosis of the prostate it may be of interest to quote that furnished 
me by I)r. F. B. Mallory, of the Boston City Hospital, in a case occur- 
ring in my own practice.77 
Dr. Mallory said: “It (the section of the prostate) shows a well 
marked, fairly chronic and typically tuberculous process, namely, 
miliary and conglomerate tubercles with giant cells and more or less 
extensive areas of necrosis surrounded by endothelial leukocytes 
with an occasional giant cell here and there. The process has invaded 
the lumina of the glands and ducts of the prostate in places and is 
extending along them ” 
Tuberculosis of the Seminal Vesicles.—For a good description of the 
tuberculous seminal vesicles we are again indebted to George Walker,70 
whose experimental investigations have been most thorough. The 
earliest specimen he found was five days after inoculation. There is 
at first a diffuse injection of the mucosa with a few pin-point tubercles. 
These gradually enlarge to pin-head size in about twelve days. They 
fuse and finally cover the whole mucosa, on which there are tiny 
ulcers. I.ater, there appears an exudate of a tough, fibrous, necrotic 
mass. This replaces the mucosa, and fills the lumen with semisolid 
grayish-yellow material. The walls become invaded and much thick- 
ened, and composed almost entirely of tuberculous tissue. In the 
advanced stages there is an extensive, adhesive, perivesicular tuber- 
culous process. In a few vesicles there were discrete, fair-sized 
tubercles here and there, with almost normal mucosa between. 
Microscopically the disease is seen to begin just under the epithelium. 
There is a small aggregation of epithelioid cells together with a few 
small, round cells; leukocytes are added to these and there is finally 
formed a small olive-shaped mass of cells which raise the epithelium, 
and shortly invade it. Sometimes there is an early invasion of the 
epithelium from the tissues below, and the tubercles appear to be formed 
in the epithelial layer. In other cases the tuberculous process pushes 
directly upward, invading the epithelial structures and protruding 
above the surface; there is no epithelial cap, and the whole of the 
minute papule is composed of tuberculous tissue. As the tuberculous 
process invades the epithelial layer, a break occurs in the surface and 
an ulcer is formed. This gives rise to fibrinous yellowish exudate which 
often covers the whole surface with a thick, diphtheroid membrane. 
The whole epithelium disappears and the membrane rests directly on 
the submucous tissues. In advanced cases the walls are thickened 
with caseous infiltration, and widespread destruction of muscle and 
fibrous tissue occurs. The process extends to the outside and in- 
volves the fascial covering. 
This invasion of the perivesicular and of the periprostatic tissues is 
especially important. As I shall point out later, it not only makes the 
removal of these organs difficult, or impossible, but it also makes the 
complete ablation of the disease a futile effort. As seen at operation 
or autopsy, the entire vesicle is generally found to be invaded by the 
disease, and in most cases both organs are involved. 552 
GENITAL TUBERCULOSIS 
Although many authors do not recognize the possibility of the sub- 
sidence of a tuberculous infection of the prostate and vesicles, such an 
event frequently takes place. My observations extending over a num- 
ber of years show a marked cessation in the activity of the infection of 
these organs (amounting to a clinical cure) after removal of the epi- 
didymes. Herein lies one of the strongest arguments of those of us who 
regard the epididymis as the primary focus of genital tuberculosis. 
Also Lapeyre42 has noted the tendency of the prostate to become 
encysted in fibrous tissue or to take on fibro-adipose changes. He 
found 19 such cures in 36 autopsies. Delore and Chalier80 note 
especially the retrogression of prostatic and vesicular lesions after 
epididymectomy. 
The condition of the vas deferens varies much. For a certain length 
of time it may show no tuberculosis at any point. Later the epididymal 
end becomes involved, the pathological changes gradually tapering off 
and finally disappearing as the inguinal canal is reached. Involvement 
of the entire vas from epididymis to prostate is evidently rare, if indeed 
it occurs at all. This statement is based upon many observations of 
my own and those of Iv. M. Walker and Hawes,72 and of Lapeyre.42 
The former, believing that the prostate is the primary focus of genital 
tuberculosis, have shown that the infection spreads centrifugally from 
the prostate along the lymphatics of the vas. Whether this also occurs 
in secondary tuberculosis of the prostate I am unable to say, but I see 
nothing against it. At any rate, we have the fact of a high percentage 
of azoospermia, even with a unilateral process, indicating pathological 
changes in, and obstruction of, the vasa. 
K. M. Walker and Hawes72 have shown that near the epididymis and 
for a certain distance beyond, sections of the vas show a ring of caseous 
material in the mucous lining, while the outer coats are intact. Farther 
up there may be no evidence of disease at all, while sections near the 
prostate will show infiltration, not in the mucous coat, but in the ad- 
ventia and more particularly in the lymphatics surrounding it. 
In well-developed cases the vas, especially its scrotal portion, may 
present numerous and fairly regular fusiform swellings along its course, 
resembling a chain of beads. The surrounding tissues and other ele- 
ments of the spermatic cord are stiffened and adherent, sometimes 
embedded in dense scar tissue. 
Microscopically, according to George Walker,70 the initial process 
“begins just underneath the mucosa and extends upward, invading, 
and finally completely replacing, the epithelium. In this manner the 
whole of the epithelial layer is disintegrated and separated from the 
underlying tissues. The lumen then becomes filled with tuberculous 
debris, similar to that seen in the prostatic tubules and the ducts of-the 
epididymis.” 
Tuberculosis of the urethra has been shown to be rare clinically, but it 
has been produced experimentally by a number of investigators. George 
Walker’s70 experimental work showed three stages of the disease: 
1. Very minute tubercles. 553 
PATHOLOGY 
2. Larger tubercles and ulceration. 
3. Caseous infiltration. 
As in all other tuberculous infections of the genital tract, the micro- 
scope shows the disease to begin “just beneath the epithelium, where 
there is seen a small cellular aggregation, which later invades the over- 
lying epithelium and forms the minute tubercle which can be seen with 
the* naked eye; an erosion of the epithelium soon occurs, and a tiny 
ulcer is formed. The organisms at the same time invade the submucous 
tissues, and finally the deeper tissues, with the formation of caseous 
infiltration more or less widespread.” 
The organisms do not seem to invade the mucosa directly, but it 
seems probable that the bacilli penetrate between the epithelial cells and 
lodge immediately under them. While trauma is certainly a predispos- 
ing factor, it does not seem to be essential in the production of stricture. 
Tuberculosis cf the Gians Penis.—I have already shown that tuber- 
culosis of the glans penis is occasionally seen, infection at the time of 
circumcision, and, as some believe, coitus, furnishing most examples. 
The disease takes the form of a chronic ulcer, as to the etiology of 
which all other organisms must be excluded. The microscope will 
reveal the nature of the lesion. 
A picture of the widespread havoc produced by the disease, once it 
has gotten outside of the genito-urinary tract, was presented by three 
of our patients who died of a general miliary tuberculosis following 
operation. 
In one, a boy aged six years, with a unilateral process of two months’ 
duration, practically every organ outside the genito-urinary tract was 
studded with miliary tubercles. The excised specimen showed tuber- 
culosis of the epididymis (there was no note on the testicle), but 
strangely enough bladder, prostate, seminal vesicles, and the remaining 
testis and epididymis showed no evidences of infection. There was a 
history in this case of an early tuberculosis of lung and meninges, and 
its remains were found at autopsy. 
The second case, aged thirty-five years, had a more or less active 
process in the spine, of six years’ duration. The epididymitis was right- 
sided, and of unknown age. Autopsy showed old tuberculosis of right 
kidney and ureter, bladder, pleura, peritoneum, bronchial lymph 
glands, spine, seminal vesicles, and prostate, with abscesses in the 
latter. Both testicles, and the remaining epididymis were healthy. A 
cover-glass preparation of the seminal fluid showed no tubercle bacilli. 
Our third case occurred in a man, aged twenty years. The process 
was again right-sided, its duration was said to be only a few days, and 
the pathologist reported an infection of testicle as well as of epididymis. 
Autopsy showed a general miliary tuberculosis, including the meninges. 
The bladder was uninfected, as well as the left seminal vesicle, and the 
left testicle and epididymis. But the prostate and right seminal vesical 
contained abscesses and caseous foci. 
I am now able to report76 a fourth autopsy occurring in a child, aged 
nine months, in the Children’s Medical Service at the Massachusetts 554 
GENITAL TUBERCULOSIS 
General Hospital. There was a bilateral epididymitis. The child 
died of tuberculous meningitis, unoperated. Autopsy showed tuber- 
culous ulcers of the intestines, of the mesenteric, retroperitoneal and 
bronchial lymph nodes, and miliary tuberculosis of the lungs, liver, 
spleen and kidneys. There was also meningeal tuberculosis. 
The epididymes were much enlarged and caseous throughout. 
The testicles showed no microscopical changes. The vasa deferentia 
were thickened to the size of a goose quill at the outer third of their 
length, whereas in the middle third there is no gross abnormality. 
The ampullae are enormously distended. Both seminal vesicles, 
especially the left, are several times their normal size and on section 
are extensively caseous, there being but little normal tissue left. 
The prostate is of essentially normal size and appearance. On section 
it shows caseous areas within and immediately around the ejacu- 
latory ducts throughout their entire course through the prostate. 
In one lateral lobe there is an ill-defined, partly caseous area occupy- 
ing about one-fourth of the lobe. 
Microscopical study of these organs was undertaken by our path- 
ologist, Dr. James Homer Wright. 
Prostate.—The opaque areas in the region of the ducts are typical 
ejaculatory tuberculosis, with much necrosis. The opaque area occupy- 
ing about one-quarter of the left lateral lobe shows small foci of 
necrosis in a cell-rich inflammatory tissue, in which are many epithe- 
lioid cells and some fibrous tissue. In the other lobe there are some 
small focal accumulations of epithelioid cells undergoing necrosis 
and constituting apparently recent tubercles. The microscopical 
appearance suggests a more recent process than in the ejaculatory 
ducts and in the epididymes. 
Epididymes.—The enlarged caseous epididymes show appearances 
of tuberculosis of more long standing character. But little of the 
original tissue remains. As indicated by the gross appearance the 
tissue is largely necrotic, but actively growing tubercles are present 
at the margin of the necrotic mass in the fibrous inflammatory tissue. 
The testicles are normal. 
Spermatic Cord.—Sections from the median portion show appear- 
ance of tuberculosis. 
It must be clear from this discussion of the pathogenesis and pathol- 
ogy of genital tuberculosis that many points are unsettled entirely, or 
are much in dispute. This ignorance and lack of agreement is due, not 
so much to a paucity of single or brief observations, clinical or experi- 
mental, as to a failure to study all the available material from beginning 
to end. The situation is well summed up by Halle and Motz.25 They 
say: 
“A detailed mass of statistics, patiently followed up, on pulmonary 
tuberculosis on the one hand, and on genito-urinary tuberculosis on the 
other, from the earliest clinical symptoms to the ultimate issue, will 
furnish sufficient and certain conclusions. We do not yet possess such 
a mass of statistics.” 555 
ETIOLOGY 
Etiology.—Although the tubercle bacillus is the organism responsible 
for the disease in question, certain conditions for its growth must 
generally be fulfilled before it can gain a foothold in the genital tract. 
These are: 
1. A lowered resistance on the part of the patient. 
2. A previously existing tuberculosis of some other part of the body. 
3. A lowered resistance on the part of the particular organ or organs 
attacked. 
The first condition may be assumed to exist in any individual acquir- 
ing tuberculosis. 
The second condition I have shown to be fulfilled in a very large 
percentage of cases. 
While a lowered resistance on the part of the organ first attacked 
cannot always be demonstrated, certain contributing factors can be 
shown to exist, or to have recently existed, in a considerable number of 
cases. 
First let us consider trauma. Tylinski66 and others have shown 
conclusively, in animals, that this has a distinct influence upon the 
localization of a tuberculous process in an organ. In our material a 
definite history of injury to the infected organ was obtained in 18 out 
of a possible 92 cases. In tuberculosis elsewhere, bone for example, the 
outbreak of the disease is very frequently preceded by an injury. 
Second, infections of the epididymis or other organs, generally 
gonorrheal, may be a predisposing cause in certain instances. Out of 
95 cases, of the series just mentioned, 34 (35 per cent.) had had an in- 
fection of the epididymis in the course of an attack of gonorrhea. A 
study of additional material has shown about the same percentage. 
Whether the initial epididymitis was of gonorrheal or tuberculous origin 
is hard to say. 
Under exciting causes we should include ectopia of the testicle. This 
in itself may lower the vitality of the organ or subject it to trauma. 
Ferron21 and Le Dentu43 have reported cases of tuberculosis of such an 
organ. 
Tuberculosis of the genital tract may attack the infant or the old 
man. One of my patients was eighteen months old; another was a 
man of seventy-three. Of 201 cases of genital tuberculosis collected 
by Hesse,26 2 occurred before the tenth year, 1 between seventy and 
eighty, and 1 after the eightieth year. Between the twentieth and 
fortieth years he found 118, or 58.7 per cent., and from forty to sixty 
years 49, or 24.3 per cent.; in other words, 83 per cent, were between 
twenty and sixty years old. In 120 patients (all with tuberculosis of 
one or both epididymes) I found 45 per cent, between the twenty- 
fifth and thirty-fifth years. Sixty-five of 96 cases reported by Keyes33 
were between twenty and forty years old. Vignard and Thevenot68 
have collected several cases of epididymal tuberculosis in infants. Two 
of their own patients were respectively fourteen months and eleven 
months old, each with a unilateral process. These authors cite a case 
in a patient of Cholmeley’s68 six months old; 1 of Hochsinger’s68 556 
GENITAL TUBERCULOSIS 
thirteen months old; 4 of Launois’s68 ranging in age from six to thirteen 
months; and 12 cases of Julien’s68 in patients under two years of age. 
No mention is made of the condition of the prostate or vesicles in 
any of them. I have found 1 case, reported by Davids,18 in a man 
aged eighty-five years. 
In a recent study of the question of “Gential Tuberculosis in Male 
Children”76 I said “various statements are made to the effect that 
the disease affects particularly very young children, decreasing in 
frequency as puberty approaches. Poissonnier, among 89 cases, 
found 42 occurring before the second year, 47 between the second 
and fifteenth year. Among our 11 cases the youngest child was 
aged nine months, the other children being, respectively, aged eighteen 
months, two years, two and a half years, five years, six years, six 
and a half years, seven years, eight years, twelve years and fourteen 
years. That the nursing infant is not spared is shown by 2 such 
patients reported by Swoboda,68 and we are even informed that a 
case of this disease in a fetus at term has been observed by Drechsfeld 
(quoted by Poissonnier).”89 
I have already indicated the frequency with which secondary tuber- 
culosis of the prostate and vesicles is found, but these figures apply 
chiefly to adults. All authors agree that before the age of puberty 
these organs are rarely attacked. Thus Kantorowicz,31 in 57 cases of 
epididymal tuberculosis in children, found the prostate involved but 
twice. In the cases under twelve to fourteen years of age (6 in all) 
coming under my own observation, I have seen no prostatic or vesicular 
tuberculosis. The combined experience of all observers shows that 
prostatic and vesicular tuberculosis is most frequent during the time 
of the greatest activity of these organs, i. e., from about the twentieth 
to the fortieth year. 
A study of juvenile genital tuberculosis which I reported in 192076 
is here quoted in the belief that the description of the findings in children 
is more complete than can be found elsewhere. 
“In our series of 11 cases both epididymes were found to be involved 
at the time of entrance in 1 case (an infant, aged nine months); in 
another case (a boy, aged eight years) the second side became involved 
twenty-seven months after removal of the epididymis first affected, 
while in a third case the involvement of the second side took place 
within three months after excision of its tuberculous mate (orchi- 
dectomy). These facts seem to be in accord with the views of other 
writers, especially Kirmisson83 and Poissonnier,89 the latter having 
collected only 7 bilateral infections out of 42 cases. Bilaterality of 
the disease in children is therefore far less common than in adults. 
“The remaining 8 cases in our series showed about an equal dis- 
tribution of the disease between the left and right sides. 
“Kirmisson83 states that in adults the testicle itself is often intact, 
whereas in children this organ is frequently diseased. On the other 
hand, Vignard and Thevenot68 assert that the testicle and epididymis 
are attacked simultaneously, a view which is shared by Poissonnier,89 ETIOLOGY 
557 
who states that the burden of infection is shared equally by these 
organs. 
“Our own experience shows that in only 2 instances was the testis 
itself definitely tuberculous, but it should be stated that the pathological 
reports, more particularly those of an earlier day, are very vague as 
to the differentiation between testicle and epididymis. I believe 
that there is much less frequently an involvement of the infantile 
than of the adult testicle, and that in most cases it is no more necessary 
to remove the testicle of a child than that of an adult. Indeed, it 
may be said that the removal of this organ from patients under the 
age of puberty should be done only as a last resort, with much less 
impunity than in the adult, owing to the demand made on its invalu- 
able internal secretion as puberty approaches. 
“ While the formation of a scrotal abscess with spontaneous rupture 
and the establishment of a fistula may occur in children as in adults, 
it certainly is a far less common phenomenon. I have already showed 
that such an event takes place in over 76 per cent, of adult cases, 
whereas in the children under discussion scrotal fistula was found 
only 3 times. 
“While it is unfortunate that our records definitely state that the 
vas deferens was involved in only 2 instances, there is no reason to 
believe that the seminal duct of children is less frequently invaded 
by tuberculosis than that of the adult. In the latter, such an involve- 
ment is found in the great majority of cases, and according to Poisson- 
nier89 the vas was definitely tuberculous in 18 out of 28 children in 
whom this point was noted. 
“It is unfortunate also that in so few cases is not only the con- 
dition of the vas deferens, but also that of the prostate and seminal 
vesicles recorded. Since so much hinges on the knowledge of the 
condition of the latter organs not only from the scientific, but also 
from the prognostic viewpoint, it is disappointing to find that no 
mention whatever is made of these organs by many observers. While 
it is true that in children rectal examination is not easy and may be 
productive of pain, the facts can readily be ascertained if and when 
the child is anesthetized for operation. 
“The records of our cases compare favorably with others in this 
respect, definite statements as to the condition of the prostate or 
seminal vesicles or both having been made in 6 cases, 2 at necropsy 
and in the other 4 either at or after operation. Of the latter, in a 
boy, aged eight years, the seminal vesicles were recorded as ‘pal- 
pable’ and ‘very tender’ before operation, whereas over two years 
later, tuberculosis of the second epididymis and of one kidney having 
meantime intervened, the record states that the ‘prostate is normal 
and the vesicles are not felt.’ In a boy, aged fourteen years, with 
unilateral epididymitis of short duration it is recorded that ‘nothing 
is felt in the prostate,’ and in a child aged five years, with a tuber- 
culous epididymitis of over two years’ duration on the one side, and 
of from three to four months’ standing on the other, we are told that 558 
GENITAL TUBERCULOSIS 
the rectal examination was ‘negative.’ Finally, a boy, aged seven 
years, having a unilateral orchidectomy, in 1905, was examined at the 
hospital, in 1911, and was found to have a normal prostate and seminal 
vesicles and the remaining testis and epididymis free from disease.” 
No statistics which I have seen give the incidence of marriage. 
Among our cases 66 per cent, were married. Not that this is strange, 
for matrimony usually claims this number. But as it has been stated 
that the disease may be conveyed by coitus, I note that in not one of 
this number was there anything to suggest that marital relations were 
the cause of contagion. 
The etiological factors already enumerated for tuberculosis of the: 
epididymis, will apply as well to that of any organ of the genital tract, 
whether primarily or secondarily involved. 
Clinical Signs and Symptoms.—The clinical picture of tuberculosis of 
the epididymis which I present, is based upon several studies of a group 
of cases from the Massachusetts General Hospital. They offer for 
consideration 210 tuberculous epididymes. 
Duration of the Disease.—Fifty-three per cent, of the patients noted 
the presence of the disease within the six months preceding their 
appearance at the hospital; in a few it was a matter of only days or weeks. 
In 72 per cent, the infection had begun within the previous year. 
Thence the time lengthens until from five to eight years have elapsed 
since the process began, and during which the smoldering fire has more 
than once broken into flame, only to be quenched with a poultice or a 
bag of ice. Moreover, nearly half of the patients acknowledged having 
submitted to more or less minor surgery in a vain effort to stamp out 
the disease. This interference was usually the tapping, often repeat- 
edly, of a hydrocele, which so frequently accompanies the tuberculous 
process. In a larger number than one would like to see, the family 
doctor had merely lanced the abscess, thus prematurely giving birth 
to the sinus which is so common. 
I would call attention to the fact that owing to the insidious nature of 
the disease, the patient can give, in most cases, no accurate answer as to 
the duration of his trouble. In this respect it is strikingly different 
from the epididymitis of gonorrhea, with its sudden onslaught. In a 
few instances the tuberculous process is ushered in with severe pain, 
tenderness and swelling, but even then one cannot be sure that the 
disease has not been going on for some time unknown to the patient. 
Side Involved.—The right side was affected in 59 (39.3 per cent.), 
the left side in 47 (31.3 per cent.), and both sides (at time of entrance) 
in 44 (29.3 per cent.). Sixteen patients (10.6 per cent.), after operation 
upon the first side, subsequently returned with tuberculosis of the 
second epididymis. There was, therefore, a total of 60 (40 per cent.) 
with bilateral disease, but it will be seen that the number of relapses 
was far less where the first epididymis had been previously removed. 
Keyes33 in a series of 87 cases has found a relapse upon the second side 
in 53 (60.9 per cent.). 
Konig36 noted bilaterality in 75 per cent., while Beck30 puts it at 27 CLINICAL SIGNS AND SYMPTOMS 
559 
per cent. v. Bruns69 found both sides involved in 38 per cent., while in 
111 cases from the Tubingen Clinic the percentage was 29. Thus the 
chances of escape of the second epididymis are seen to be slim, but the 
management of the first epididymis seems to influence the fate of its 
fellow. Keyes33 says: “Be the operation ever so slight or ever so 
radical” relapse upon the opposite side almost inevitably occurs. My 
figures show that relapse is less apt to occur if the first epididymis is 
operated upon. 
Time of Involvement of the Second Epididymis.—The time of involve- 
ment of the second epididymis, after the infection of the first side, 
varies considerably, but is usually not long delayed. In my series this 
point was ascertained in 49 patients. In 26.5 per cent, it took place 
within six months, while in the first twelve months 38.7 per cent, were 
so affected. In the remaining 44.8 per cent, the number of relapses 
dropped steadily after the first year, but took place in a few cases as 
late as the eighth year. Keyes’33 cases show that 46 out of 53 infections 
of the second side occurred within the first year. 
Eight of my cases (16.3 per cent.) experienced an apparently simul- 
taneous infection of both epididymes, ranging in duration from a few 
weeks to eight years before the patient sought relief. 
It is therefore clear that the damage to the second side is an early 
event in most cases, but the danger is not entirely eliminated until after 
the lapse of at least eight years. It is also quite possible that the infec- 
tion of the second epididymis may be so slight as to be overlooked at 
the time of operation upon the first side. This possibility is to be con- 
sidered in one’s statement to the patient of the condition and outlook 
of the second epididymis. 
Results of the Disease.—I have found that over 80 per cent, of those 
questioned on the subject have lost weight. In some, the depletion of 
flesh and strength was extreme, sometimes without demonstrable 
tuberculosis other than that in the genital tract. Per contra, a few 
individuals had.put on weight and appeared to be in the “pink” of 
condition. 
Pain.—This was noted in about 60 per cent, of my cases. It was 
usually mild, often trifling. Generally speaking, it was located in the 
diseased organ, but in certain instances was said to have extended 
upward to the groin or even into the lumbar region. Radiation 
upward was usually the result of more or less extensive involvement of 
the vas deferens and other structures of the spermatic cord. More 
often than not its presence in the scrotum could be accounted for by 
the pressure of hydrocele fluid upon an acutely inflamed epididymis or 
testicle. In spite of the high percentage of tuberculous prostates and 
vesicles, I have noted practically no pain located in these organs or 
their vicinity. Pain in the region of the bladder may, however, be 
experienced during, or at the end of micturition, and is found in cases of 
bladder tuberculosis of renal or prostatic origin. 
During one of the characteristic exacerbations of the disease, scrotal 
pain may be intense, abating with the rupture of an abscess and the 560 
GENITAL TUBERCULOSIS 
establishment of fistula, or by absorption of its products. Before such 
an outbreak of the disease there may be no pain at all. 
As an accompaniment there may be tenderness, not intense, barring 
always the very acute cases, but, generally speaking, of only a moderate 
degree, its intensity doubtless regulated by the same factors which 
produce pain. 
Fistula.—This is one of the most common “earmarks” of tubercu- 
losis of the epididymis, and is generally to be found in the skin at, or 
near, the lower pole of the organ. Fistuke at the upper pole are seen 
occasionally. 
Seventy-seven and three-tenths per cent, of 106 cases in my series 
had one or more fistula? in the scrotum. More often than not they were 
active; in others they showed a volcanic intermittency. The discharge 
is profuse at times, and is thin, purulent, and yellowish in color. 
In 22.6 per cent, of these 106 patients the scrotal skin was more or 
less adherent to the epididymis and in some cases marked the site of an 
ancient fistula, long since inactive. 
That fistulization is an early event is shown by an examination of the 
82 patients in this series presenting this condition. In exactly 50 
per cent, the abscess had formed, ruptured and established a fistula 
within six months after the onset of the disease, while within the first 
year this had taken place in 71 per cent, of the 82 cases. The progress 
of the disease is, therefore, not slow in most instances, but on the other 
hand, I have seen several epididymes, tuberculous for eight or nine 
years, with a fistula of only a few days’ duration. 
Fever.—An elevation of temperature before operation was noted in 
but 10 cases, the epididymes in these being in a state of acute 
inflammation. 
Condition of Prostate and Seminal Vesicles.—Owing to the proximity 
of these organs one to another, and to their close relationship, I believe 
that when the prostate is tuberculous, the seminal vesicles are also 
involved, or that they may be so regarded for clinical purposes. 
The effect of the disease upon these organs has already been dwelt 
upon at some length and I have shown that 76 of 101 rectal examina- 
tions in my series of cases revealed tuberculosis of the prostate and 
seminal vesicles. 
A more detailed study of these cases has shown that where prostate 
and vesicles were regarded as tuberculous, epididymitis was unilateral 
in 38 and bilateral in 38; while in the negative cases one epididymis was 
tuberculous in 16, and both were involved in 9. From which it follows 
that prostate and seminal vesicles become readily involved in the pres- 
ence of one tuberculous epididymis, and before infection of the opposite 
side has had time to take place. In substantiation of this point I have 
data as to the condition of the prostate and vesicles and the known 
duration of the epididymal infection in 99 cases. In the first six months 
of the disease prostate and vesicles were found to be infected in 40 and 
healthy in 15; in the period from six months to one year 14 were posi- 
tive and 3 negative. After the first year, and, in some cases, after a CLINICAL SIGNS AND SYMPTOMS 
561 
period of six or seven years, prostate and vesicles were tuberculous in 
20 and negative in 7. Thus in the first six months of the disease 30 
per cent, are infected, and in the first year 54 per cent. On the other 
hand, one must not lose sight of the 7 prostates which are said to have 
held the enemy at bay for periods ranging all the way from one to six 
or seven years. 
Bladder Symptoms and Condition of the Urine.—With so frequent 
and early an infection of prostate and vesicles, the bladder neck 
becomes irritable at an early date. In 45 patients (35 per cent.) urinary 
symptoms such as frequency, dysuria, and urgency were recorded, while 
43 per cent, of 104 urines contained pus, blood and albumin. Also, out 
of 10 urines with which the guinea-pig was inoculated, 8 showed the 
presence of the tubercle bacillus. As in the absence of symptoms point- 
ing to the kidney, cystoscopy and ureteral catheterization have seemed 
to us to be unwise, it is barely possible that some of these tuberculous 
urines were of renal origin. In this series there were recognized and 
operated upon, 18 cases of renal tuberculosis, occurring at some time 
or other in the course of the epididymitis. The 8 tuberculous urines 
already referred to include none of these cases. It is probable, there- 
fore, that the pathological urine and the bladder symptoms took origin 
from the prostate. This belief is substantiated by the observations of 
Lowenstein45 who, in 18 cases of epididymal tuberculosis, found tubercle 
bacilli in the urines of all. Renal tuberculosis was excluded as the 
source in every case and the prostate was regarded as accountable for 
the bacilli. 
Accompanying the bladder symptoms and the pathological urines in 
this series, prostate and vesicles were recorded as tuberculous in 28 and 
negative in 4. Furthermore, the relation of bladder irritability to the 
known existence of the epididymitis has been looked into in 43 cases. 
In 21, or 49 per cent., urinary symptoms were present in the first six 
months of the disease, whereas, in the first year the figures jump to 
27, or 62 per cent. 
Condition of the Testicle.—Sixty-six of the testicles in this series were 
found to be tuberculous. Forty-four occurred in unilateral cases, and 
only 22 where the process was bilateral. In other words, testicular 
infection is generally found in the early months of the epididymitis. 
Thus 60.6 per cent, of the total number had become tuberculous in the 
first six months of the disease, and 83.3 per cent, in the first year. That 
the testicle may resist invasion for a long period of time is illustrated by 
several cases in which the epididymal disease had existed for from five to 
eight years. These observations differ from those of Haas24 and 
Lapeyre42 who found the percentage of infected testicles to be progress- 
ively greater with the age of the epididymitis. 
Condition of the Vas Deferens.—It is unfortunate that physical ex- 
amination often overlooks an important and an interesting feature of a 
case. This has been true with the vas deferens. I have notes as to its 
condition (mostly macroscopic) in 46 instances, 26 of these being on 
the side last involved. Of the latter, 16 (61.5 per cent.) were thickened 562 
GENITAL TUBERCULOSIS 
for a greater or less distance upward from the epididymis, in some 
instances this being extreme. Fifteen out of 20 vasa (75 per cent.) of 
the first epididymis to be involved were regarded as tuberculous. 
While these figures are insufficient for accurate deduction, the fact 
that the vas of the epididymis last involved is less often diseased than is 
its fellow, would indicate that the tubercle bacillus reached the second 
side by the blood stream, or by the lymphatics. 
Sex Function.—I have mentioned elsewhere that 85 per cent, of the 
patients whose semen has been examined have shown azoospermia, 
even with only one epididymis involved, an observation supported by 
the experience of Keves.33 Further studies confirm this view. This 
condition is probably accounted for by an obstruction of the vasa 
deferentia, that on the still healthy side being doubtless involved at its 
urethral extremity by extension of the disease from the prostate. 
Masculinity does not seem to be impaired even after double orchi- 
dectomy. Several of our cases bear out this statement, and Simon60 
says the sex function remained normal for from ten to twenty years 
in 29 of his cases of double orchidectomy for tuberculosis. It has also 
been shown that spermatogenesis is persistent, even in a testicle riddled 
with tuberculosis. 
The symptomatology of primary prostatic tuberculosis is little differ- 
ent from that which is secondary to epididvmal disease. The bladder 
irritability, the character of the urine and the course of the disease 
present no striking differences. 
Difficulty of urination, or possibly retention, plus the evidences of 
tuberculosis, would characterize a tuberculous stricture of the urethra. 
It has been my experience to find this lesion accompanying renal 
tuberculosis. 
A chronic ulcer of the glans penis, not associated with venereal 
disease, might lead one to suspect tuberculosis. Microscopic examina- 
tion would confirm the suspicion. 
Diagnosis.—The diagnosis of a typical case of tuberculosis of the 
epididymis may not be difficult. Induration, enlargement, and 
nodularity of the organ, especially at its lower pole, associated with 
little or no pain or tenderness, is the usual clinical picture. If, in 
addition, one finds the corresponding vas deferens enlarged and 
irregularly thickened, especially at its epididymal end, and if the 
prostate and the seminal vesicles (particularly on the same side as 
the diseased epididymis) are likewise affected, the case is undoubtedly 
one of tuberculosis. The ehronicity of the disease, or its bilaterality 
would help to confirm this diagnosis. If, also, there is bladder irrita- 
bility and a hazy urine containing pus and tubercle bacilli, all doubt 
is removed. The diagnosis is equally certain in the presence of an 
active fistula or the dimpled scar of one long healed. 
In certain cases where there is more or less hydrocele, it may be 
worth while to withdraw this fluid through a sterile needle, and examine 
its sediment after staining for tubercle bacilli. I have seen these organ- 
isms in at least one case where the diagnosis had been under active 
discussion in the clinic. DIAGNOSIS 
563 
In the hope that chemistry might throw some light on the diagnosis 
of obscure cases I have withdrawn the fluid from the tunical sac in 
a number of instances and had it examined both qualitatively and 
quantitatively. This work is not yet completed but thus far there 
is no evidence that chemistry will enable us to distinguish between 
the hydrocele fluid of tuberculosis and that of gonorrhea. 
At other times the diagnosis must be in doubt until one or more of 
the features enumerated above comes to the rescue, or until removal of 
the epididymis and microscopical examination reveals the truth. The 
acute tuberculous epididymis may well be mistaken for that of gonor- 
rhea or a pyogenic infection. Only a careful history, painstaking 
examination, and adequate observation will solve the problem. 
But it should not be forgotten that an attack of gonorrhea which has 
escaped the patient’s memory, an unobserved syphilitic infection of 
long ago, an infection of the epididymis in the course of a colon bacillus 
cystitis, or with a pyogenic organism from some septic focus elsewhere 
in the body, may each produce a picture not unlike that of tuber- 
culosis. 
Lesions of the scrotum are impossible to diagnose accurately at 
times by the most expert. In this connection I wish to mention two 
cases both occurring in my own practice which have forced me to the 
conclusion that when in doubt it is best to operate and give the 
patient the benefit of that doubt. 
The first case was that of a man, aged thirty years. For years he 
had been regarded as tuberculous and so treated, although bacilli 
had never been found in the sputum. I was asked to see him in con- 
sultation with a well-known surgeon who thought the patient had 
genital tuberculosis. My opinion coincided with that of the surgeon 
that there was tuberculosis of the left epididymis. I advised oper- 
ation but this was rejected by both the surgeon and the patient and 
hygienic measures instituted. While this treatment improved the 
general condition, that of the scrotum grew worse. The surgeon 
finally operated, removing a mass about the size of a tennis ball which 
the pathologist reported to be sarcoma. The patient died about 
three years later of metastases. 
The second case occurred in a boy, aged nineteen years. After 
an attack of measles, acute epididymitis developed and this was 
followed shortly by appendicitis for which an operation with drain- 
age was performed. At this operation the mesenteric lymph glands 
were found to be greatly enlarged. As the epididymis did not sub- 
side, the boy consulted a well-known urologist who made a diagnosis 
of tuberculous epididymitis and advised expectant treatment. With 
a view to confirming this opinion I was asked to see the boy. I 
agreed in the diagnosis, but advised operation. This was refused. 
As the process did not subside the boy consulted a third surgeon who 
advised and later performed orchidectomy. Here again the pathol- 
ogist reported sarcoma. As this occurred over three years ago 
and as the boy is in splendid health, it seems probable that metastases 
have not occurred. 564 
GENITAL TUBERCULOSIS 
While my diagnosis was wrong in each instance my advice was 
correct and if taken it seems possible that the first patient might now 
be alive. 
One can never be certain of the condition of the testicle. An 
increase in the size of the organ, with nodularity of its surface, may 
mean disease, or may signify only an invasion of the overlying tunica. 
If the evidence is in favor of tuberculosis, or if the disease is clearly 
progressing, an exploratory operation should be advised. The diag- 
nosis of lesions within the scrotum are so uncertain, even when made by 
the most expert, that the patient shoul d be given the benefit of the doubt. 
If he has tuberculosis he is entitled to the earliest treatment; if he has 
not tuberculosis he is entitled to the joy which that knowledge brings. 
Prognosis.*—I have already pointed out the disastrous results of 
genital tuberculosis and their rapidity of occurrence. It has been 
shown that the second epididymis is attacked in 26.5 per cent, within 
the first six months after the involvement of the first side; that the 
disease invades prostate and vesicles in 30 per cent, within the same 
time; and that testicular tuberculosis within this period is found in 
60.6 per cent. If one adds to these misfortunes the annoyance of blad- 
der irritability, and the affliction of sterility, the outlook is indeed 
gloomy. It is also to be remembered that a very large proportion of 
patients have the proverbial axe hanging over them in the form of 
tuberculosis of other organs. 
Let ns now see what encouragement can be held out to the patient 
with tuberculosis of the epididymis. I have traced 113 patients from 
one to twenty-five years after operation. Over 27 per cent, have died 
of some form of tuberculosis. Within a period of six years after opera- 
tion 41 per cent, of 58 patients have died of this disease. Of the 
deaths from tuberculosis, 14.2 per cent, occurred within one month, 
32.1 per cent, within six months, and 50 per cent, within one year 
after operation. During the first six years 85 per cent, died, while 
between the ninth and eleventh years 10.7 per cent, succumbed. 
Miliary, renal and lung tuberculosis were, in order, the final types of 
the disease. A large majority of those dying of tuberculosis had had 
one or more outbreaks of the disease both before and after operation. 
My experience warrants the conclusion that until at least ten years 
have elapsed after operation, no patient can be said to be cured of 
genital tuberculosis. The high percentage (14.2) of the total deaths 
from tuberculosis within a month after operation, in the hospital, 
deserves a word of explanation. There were actually four deaths within 
this period, giving an operative mortality of 2.66 per cent, for the 
total number of 150 cases. Operation was performed in all under 
ether, an anesthetic which is generally recognized as likely to stir up 
an otherwise quiescent focus of tuberculosis in the lung. I am con- 
vinced that the employment of a local anesthetic (novocain) or of 
gas-oxygen anesthesia, as is at present usually done, will eventually 
reduce this high operative mortality. 
* For the views here expressed I shall quote freely from my paper on “The Ultimate 
Results of Genital Tuberculosis in the Male.”5 PROGNOSIS 
565 
The records of the 60 patients now living (53 per cent.) show a much 
smaller percentage of other tuberculous processes before operation 
than do those of the dead, but many of them have since developed 
other foci. As 81 per cent, of those examined and 28.5 per cent, of 
those reached only by letter are still within the six-year period, in which 
I found that 85 per cent, of deaths occurred, it is to be expected that the 
deaths from tuberculosis in this group are not yet at an end. The long 
life and good general condition of many of the patients, even though 
suffering from repeated outbreaks of the disease, shows that the sur- 
vival of the patient depends largely upon his ability to immunize 
himself to the disease. Taken all in all, the odds are against the 
patient. The longer he can live and fight down any particular outburst 
of the disease the better able he is, in most instances, to overcome the 
next exacerbation. 
The facts here presented are somewhat different from those of other 
writers. Lapeyre42 says that 75 per cent, of his cases are cured, and that 
a survival of the patients of from four to ten years after operation is to 
be expected. 
Simon60 has followed 92 cases from the Heidelberg Clinic. Fifty-four 
were found to be alive and free from tuberculosis, but this disease had 
claimed 26 of the 33 who had died. Lung tuberculosis figured largely 
in the latter, and was frequently found in those still alive. 
v. Bruns69 found bilateral epididymal tuberculosis in 38 per cent, of 
his cases. Of those having operation on one side, 23 per cent, returned 
within three years for the removal of the second testicle. Of the single 
castrations, 12 per cent, died of urogenital tuberculosis, and 15 per cent, 
died of tuberculosis of other organs, especially the lungs. Forty-six 
per cent, of the unilateral cases were cured after three to thirty-four 
years. 
Of the double castrations, 15 per cent, died of urogenital tuberculosis, 
and 25 per cent, of tuberculosis of other organs, the lungs again being 
most often attacked. Fifty-six per cent, of this group were cured after 
three to thirty years. 
Berger12 has reported 60.4 per cent, of cures after single or double 
castration, but does not state the time elapsing after operation. 
Among the cases analyzed here, epididymectomy, partial or complete, 
single or double, was performed 78 times. I have stated elsewhere on 
several occasions, as evidence of the efficacy of this operation, that 
not one of these patients had been obliged to submit to subsequent 
orchidectomy. Since this statement was made I have had 2 cases, 
from whom it was deemed necessary to remove the testicle within 
one month and two months respectively after epididymectomy. 
The pathologist reported tuberculosis of one gland; the other showed 
only a round-cell infiltration, and its removal was probably an error of 
surgical judgment. At the first operation there was no evidence in 
either case that the testicle was diseased. More recently I have seen 
1 or 2 other similar cases but in these the testis was definitely tuber- 
culous and should have come out at the first sitting. Only the strong 566 
GENITAL TUBERCULOSIS 
desire of the patient to preserve his organs led me to leave behind a 
testis which was obviously doomed. None the less it is amazing how 
much diseased tissue one can remove and how little healthy tissue 
one can leave behind with every reasonable assurance that it will 
become quiescent. What better proof is there of the efficacy of 
epididymectomy, even though we know that in certain of them a 
more or less infected testicle is allowed to remain? 
I find that this experience agrees with that of Lapeyre,42 Keyes33 and 
Marinesco,46 although the latter has had 6 of his unilateral epididy- 
mectomies return within two months for a secondary castration. The 
size, shape, consistency, and, in most cases, the sensation of the testicle 
are unaffected, and the benefit to the patient morally and physically is 
well worth the very slight chance of the necessity of a secondary orchi- 
dectomy. I think we are apt to regard altogether too lightly the great 
value of the internal secretion of the testicle. 
In this connection it may be mentioned that a tuberculous tunica 
vaginalis may assume an unexpected activity after epididymectomy. 
The clinical picture is very like that of an orchitis, and in this belief 
orchidectomy may be advised or even done. There have been 3 such 
in my series, but in each a careful investigation of the situation, and the 
free use of the curette has saved the testicle. 
The very great incidence of sterility, even with unilateral epididymal 
tuberculosis, has been pointed out. I have no evidence that this con- 
dition is done away with, in spite of an otherwise successful issue of the 
case. An involvement of one or both testicles does not seem to affect 
potency, and this may continue even after bilateral orchidectomy. 
Postoperative sinuses of the groin or scrotum are now a negligible 
factor in our experience. If the vas is divided in the region of the 
external ring, where it has been shown to be tuberculous in many 
cases, a sinus of several weeks’ or months’ duration is not unusual. By 
dividing the vas well over the pelvic brim, at a point where, with few 
exceptions, it is free from disease, no sinus will occur. Since the 
introduction of the technic of epididymovasectomy, to be described 
later, I know of no case in which even a temporary sinus from the 
stump of the vas has occurred. In a few instances there have been 
small and short-lived sinuses of the scrotum, but they have readily 
yielded to time, tuberculin and hygiene. 
In 69 of the 113 patients whom I have followed, the prostate and 
seminal vesicles were found to be tuberculous at the time of entrance to 
the hospital. I have since examined many of them at various intervals 
of time after operation. In most instances the induration, nodularity, 
and tenderness, present before operation, has subsequently disappeared 
entirely or much decreased. In a few, the condition is the same as 
before operation. In 2 instances an abscess subsequently formed and 
opened spontaneously, with the establishment of a perineal fistula, 
from which urine has leaked at times. 
The tuberculous stricture has a habit of closing down rapidly after 
dilatation or division, much more than is the case with one of gonorrheal 
origin. RESUME 
567 
The facts here presented are based upon operated cases. They 
demonstrate beyond question that, taken all in all, the odds are against 
the patient. 
Since the above statements were made Young98 has taken the matter 
up in a thorough survey of the literature and in a study of his own 
cases. He asserts positively that the seminal vesicle is so frequently 
and so definitely the primary focus in genital tuberculosis that he 
now speaks of the lesions as “tuberculosis of the seminal tract.” I 
quote some of his observations: 
“In an interesting paper, in 1910, Whiteside94 called attention to 
the fearful ravages of testicular tuberculosis and to the ineffective- 
ness of resection of the epididymis. He stated that from necropsies 
and from his own clinical experience, he believed involvement of the 
entire genital tract to be frequent and that epididvinectomy was 
entirely inadequate. He stated that he had recently practiced a 
radical operation in such cases and cited the case of a man in a de- 
plorable condition with involvement of both testicles, epididymes, 
prostate, seminal vesicles and bladder, in which a wonderfully satis- 
factory result was obtained by extirpation of the seminal vesicles as 
well as the external foci of involvement. Whiteside95 has recently 
published another article on this subject, reciting several remark- 
able results in apparently desperate cases and calling attention to 
the value of a radical operation. In reponse to a personal letter of 
inquiry, he states that he is unable to get exact statistics of the number 
of cases or results, but he says: 
“ ‘ My remote results, quoting from memory, are that those patients 
who have survived are well. They even tell me that they are sexually 
able to perform coitis. Those with good resistance to the disease 
have complete healing of all operative wounds and resultant sinuses 
before six months after operation. Those that are tuberculous else- 
where than in the genital tract have one or more sinuses in the perineum 
or groins for a year or more. These cases for which I advocate radical 
removal of everything tuberculous are advanced cases. Consequently, 
a large percentage of these have, or soon suffer from, further tuber- 
culosis (lungs, kidneys, etc.) and many died within five years after 
operation.’ 
“Resume.—Of 63 patients, 53 were operated on. Of these 18 are 
dead. Eighteen have not been heard from, and of the 45 patients 
heard from 13 have been operated on less than three years and 9 
less than two years. There remain, therefore, out of 63 patients, 
only 27 who are known to be or have been alive three years or more 
since admission. Of these, only 22 are known to be well and improved. 
When we consider also that, with the exception of about 24 cases, the 
urinary tract was not involved and that the cases were, therefore, 
fairly early cases of tuberculosis of the seminal tract, the results 
obtained by epididymectomy or castration are, indeed, very poor. 
In many of these cases, the seminal vesicles were injected through the 
vas from one to four times during and after operation, either oil 
containing iodoform or pure phenol being employed. 568 
GENITAL TUBERCULOSIS 
“Results.—Only 1 of these patients is said to be well. He had 
tuberculosis of the prostate, bladder and both seminal vesicles and 
no operation was performed. Seven years have elapsed since he 
was here. He has not been examined personally. Four are said to 
be improved and have been followed six, seven, eight, and thirteen 
years, respectively. In all of these 4 the prostate was involved, in 2 
the seminal vesicles, and in 2 the bladder. The kidney was involved 
in 1 case, and in the latter case nephrectomy was performed. In 
the other 3 cases no operation was performed. Repeated question- 
naires have been sent out and 5 patients are knowm to have died. 
In 18 cases, no information can be obtained and it is probable that 
in many of these the patient has died.” 
Young then continues, “We have next collected the statistics as 
regards cures which have been effected by castration or epididy- 
mectomy. In most instances, it is not possible to determine whether 
a single or double operation was performed, nor have the epididy- 
mectomies been separated from the castrations. There is also con- 
siderable variation as to what is considered a cure—a cure of the 
lesion in the scrotum is quite different from the entire disappearance 
of the disease from the whole genital tract. In my statistics I have 
included also cases of patients that were improved. If cures only 
were included, the percentage would be only 19 per cent.” 
In order that there may be no mistake about his beliefs Young 
further says, “The seminal vesicles are not only the primary focus 
from which the epididymes are involved, but from which also the 
prostate, bladder and the kidneys in many cases are involved. In 
fact, tuberculosis in the region of the prostate and vesicles is far more 
dangerous to the entire human organism than tuberculosis of the 
epididymes and is probably responsible for the fearful mortality 
which is variously estimated at from 27 to 60 per cent, in cases of 
genital tuberculosis. Therefore, it is the duty of the surgeon to attack 
the most dangerous focus of involvement, namely, that of the vesicles 
and prostate. Therefore, in tuberculosis of the seminal tract in the 
great majority of cases radical operation not only should be the oper- 
ation of choice but also should be practically imperative.” 
Since Young’s article appeared I have made a careful study of the 
question of genital tuberculosis with particular reference to male 
children. In conclusion I said:76 
“In an experience of several years in the study of this problem I 
have found the most perplexing and conflicting evidence, both clinical 
and anatomical. While I still believe that the great weight of evidence 
favors the origin of genital tuberculosis in the epididymis, I am willing 
to believe that in certain instances the primary focus may lie in the 
prostate, possibly even in the seminal vesicle. It is impossible to 
take up and discuss seriatim and ad infinitum the argument of the 
various proponents of each point of origin, more especially those of 
Young.98 One can only make generalizations. 
“If genital tuberculosis arises in the prostate or even in the seminal RESULTS 
569 
vesical why is it that this disease is practically unknown clinically 
or post mortem? It is only reasonable to suppose that tuberculosis 
of either of these organs would produce symptoms for which relief 
would be sought and treatment given. Furthermore, prolonged 
observation of such cases would undoubtedly reveal the actual con- 
dition sooner or later. It is also true that in not a few instances 
necropsy has shown tuberculosis of almost every organ in the body, 
the prostate or seminal vesicles alone being spared. 
“If the prostate or seminal vesicle is the starting point of epididymal 
tuberculosis why is it that the removal of the epididymis has such a 
salutary effect on the other organs of the genital tract? I have 
followed many cases for a long period of time both before and 
after operation. While there have been occasional exceptions, as 
is to be expected, the prostate and vesicles which were nodular, indu- 
rated and enlarged before epididymectomy have eventually returned 
to an essentially normal condition. It is probably true that while 
the microscope would still show evidence of tuberculosis in some, it 
is equally true that fibrous changes eventually occur and a clinical 
and permanent cure is established. This statement is not a case of 
the wish being father to the thought, but is an actual statement of 
fact. 
“In this connection one cannot avoid touching on the subject of 
treatment. The results just mentioned have occurred after epididy- 
mectomy or orchidectomy, yet there are those, of whom Young is 
the most recent and ardent, who urge the desirability of and the 
necessity for the removal of the entire genital tract. While this 
operation certainly gives free scope to the skill, patience and ingenuity 
of the surgeon, it apparently does not seem to afford an equal amount 
of satisfaction to the patient and after all, surgery should have this 
as one of its objects. If the prostate will quiet down spontaneously 
by a simple procedure why remove the prostate ? Also is it not against 
all surgical principles for a primary focus to subside after the removal 
of a secondary focus. Why not remove the entire ureter and the 
bladder as well as the kidney in treating renal tuberculosis? The 
procedure would be quite as logical. Or why not cure cancer of the 
breast by dissecting out the glands in the axilla? 
“If the primary focus lies in the prostate or seminal vesicle why 
are these organs less frequently attacked in children than in adults? 
Yet this seems to be the fact judging from my own experience and 
from reports in the literature. 
“The radical operation of removing the entire genital tract is 
thought to reduce the immediate as well as the ultimate mortality. 
Does it do so? In the past ten years more than 100 cases of genital 
tuberculosis have been admitted to the genito-urinary service of the 
Massachusetts General Hospital. All but a few patients have had 
either epididymectomy or orchidectomy performed. There has been 
one death in the hospital in this time, and this patient was not oper- 
ated on. It would not appear, therefore, that conservative surgery 570 
GENITAL TUBERCULOSIS 
involved a high death rate. It is true that the ultimate deaths from 
tuberculosis are high and that at least ten years must elapse before 
the danger of dying from tuberculosis is past. Many of the deaths 
are from lung or general miliary tuberculosis. The radical surgeons 
claim that this high mortality is due to the tuberculous genitals which 
the conservative surgeons leave behind, yet they have presented no 
evidence that this mortality did not arise quite as much from the 
original process in the lung or other organs which induced the genital 
tuberculosis, as from the genital tuberculosis itself. Furthermore, 
few, if any, of their cases have been followed a sufficient length of 
time to show what the outcome will be. Certainly the results reported 
by Whiteside are far from encouraging,” and the results so far reported 
by Young are by no means convincing that he has solved the pro- 
blem by his radical procedures. 
I have but few data of patients who have had no operative treat- 
ment. There were 11 such cases in the material that I have studied, 
which were not operated upon for one reason or another. None, 
so far as I am aware, were given tuberculin or any special hygienic 
care. Six died from tuberculosis, 1 three months later, 1 after ten 
years; 1 was “well” a year later; 1 died of “apoplexy” shortly after; 
3 cannot be traced. While these figures are too small to be of much 
value, they show that the outcome was not brilliant. Keyes33 found 
30 per cent, of “cures” in 34 cases without operation and watched 
for more than three years. He says, “They would not be verified 
if the cases were more numerous,” and I am inclined to agree with 
him. 
While we have a high opinion of tuberculin as an adjunct to the 
postoperative care of genital tuberculosis, we have advised strongly 
against it as a substitute for operation. Some of the French writers, 
on the other hand, have much to say in its favor in the expectant treat- 
ment of the disease. Lelongt44 quotes the statistics of Mantoux, based 
on 70 cases of genital tuberculosis treated in this way. He thinks they 
are encouraging when one considers that they had no hope of improve- 
ment by surgical treatment. These cases showed cure in 33 per cent., 
much improvement in 48 per cent., no change in 11 per cent., and 
deaths in 8 per cent. 
No details are given, especially of the time during which the cases 
were observed. Without definite facts one hesitates to accept the 
claims. 
Treatment.—This may be divided into expectant, conservative, and 
radical, tuberculin being an important adjunct throughout. 
Expectant treatment should be undertaken only in those cases where 
operative measures are refused or, for some reason, impossible. It 
means putting the patient under the very best of hygienic conditions as 
regards fresh air, sunlight, food, work and sleep. Tuberculin should be 
given regularly and intelligently. It means the tapping, when indi- 
cated, of the hydrocele which so often accompanies the tuberculous 
epididymis, and, to those who have a pathological urine or bladder TREATMENT 
571 
symptoms, sandalwood oil should be administered (10 minims thrice 
daily).* If abscesses of the scrotum occur they should be incised and 
properly drained. 
In addition to the methods of expectant treatment outlined above 
there have appeared a few articles on the value of heliotherapy and 
radiography in genital tuberculosis, von Schmieden93 comes out in 
favor of the hygienic and climatic treatment of these lesions, but 
acknowledges that conservative surgery must at times be employed. 
Among other things he brings out the point, which I believe to be 
well taken, that patients with discharging sinuses and tuberculous 
bladders should be as careful of the disposition of the pus and of the 
urine, and incidentally, of the semen, as is the lung patient of his 
sputum. 
Wildbolz96 has tried the effects of heliotherapy in 13 cases from 
eight months to two years under the best conditions. Microscopical 
examination of the organs removed at a later time showed not the 
slightest evidence of reparative processes. 
Antonio75 discusses the value and technic of the local injection 
of iodine in genital tuberculosis as described by Durante.75 He 
describes a case which was so treated with apparently satisfactory 
results. 
Freund82 has recently described his experience with 15 adult cases 
of genital tuberculosis, of whom fistula was present in 7, treated by 
roentgen ray. He states that tuberculous tissue is not especially 
sensitive to the roentgen ray; its favorable effect on tuberculosis is 
to be found in its stimulating effect on normal granulations. This 
effect is best brought about by small doses. He concludes that 
roentgen ray can be relied upon to accomplish a radical cure if the 
process is confined solely to the testis and epididymis. If, on the 
other hand, the process has spread to the vesicles, prostate, bladder 
or kidney, roentgen ray may at least check further development, 
close up fi strike, and prevent its spread to the opposite side. He 
wisely adds, however, that in certain cases partial resection of local 
foci may well precede roentgen irradiation. 
By conservative treatment I refer to the removal of the epididymis, 
together with as much of the vas as is easily accessible, and, where 
necessary, the testicle. 
The history of operations upon the epididymis has been written by 
Marinesco.46 Recognizing the evil effects, mental and physical, of 
castration, especially when bilateral, and acknowledging the impor- 
tance of the epididymis in genital tuberculosis, Berard,46 in 1834, 
performed the first partial epididymectomy. In 1851 Malgaigne,46 as 
well as Jobert46 and de Lamballe,46 were performing a complete and 
extensive excision of the epididymis. Bardenheuer,46 in 1880, is credited 
* A very efficient substitute for sandalwood oil is a capsule composed of guaiacol 
carbonate gr. iij, powdered pepsin (1 to 3000) gr. j, calcium carbonate (C.P.) gr. x. 
This is given thrice daily after meals. All preparations containing hexamethylenamin 
are likely to aggravate bladder symptoms. 572 
GENITAL TUBERCULOSIS 
with the first real description of epididymectomy, and he showed its 
value in a series of 34 cases. 
Villeneuve46 did the first epididymectomy in France in 1889, and 
emphasized the great value of the testicle for its internal secretion, as 
well as for its psychic effect. 
While the French surgeons were doing their utmost to preserve the 
testicle, the Germans, with one or two exceptions, continued their habit 
of promiscuous castration. Unfortunately their example has been 
copied all too widely and even today the general surgeon, otherwise 
sound and conservative, removes the testicle, when by a simple opera- 
tion this valuable organ can be preserved to the patient. 
For the technic of epididymectomy, better called epididymovasec- 
tomy, we are indebted to Cabot,15 whose description of the operation 
I quote. This procedure can be done in most cases with novocain 
local anesthesia, but in a few patients, with an acutely inflamed 
scrotum, or of neurotic temperament, gas-oxygen anesthesia is prefer- 
able. The use’of ether is strongly condemned. 
“ The local preparation of the patient should involve the skin of the 
scrotum and the groin of the corresponding side if the disease is unilat- 
eral. An incision is made over the epididymis about twro inches long. 
If sinuses are present they should be circumscribed by the incision. 
This is carried down to and opens the tunica vaginalis, which will in 
many cases be found adherent to the testicle and must be separated by 
dissection. The testicle and epididymis are delivered from the wound. 
The epididymis is then separated from the testicle by a scissors dissec- 
tion, as in this way the vessels which lie behind the epididymis are less 
likely to be destroyed. The separation should be begun at the upper 
pole and carried downward, the epididymis being separated from 
within outward. When it is free.the lower inch or two of the vas should 
be stripped up by blunt dissection from the structures of the cord. A 
curved clamp is then applied to the vas and the epididymis and the 
lower inch or two of the vas cut away. The vas is then stripped up by 
blunt dissection with the fingers so as to free it from the structures of 
the cord up to the external inguinal ring. Guided by the finger, the 
clamp on the lower end of the vas is then passed up to the external 
ring and carefully inserted into the canal, care being taken to avoid 
pushing it in front of the canal between the fascia and the fat. The 
clamp is then pushed upward and outward, following the line of the 
inguinal canal until its tip lies directly beneath the fascia at the level of 
the internal inguinal ring. The handle of the clamp is then strongly 
depressed, bringing the point snugly against the skin. An incision 
not over half an inch in length is then made on the point of the clamp, 
which is then pushed out through this incision carrying with it the 
distal end of the vas (Fig. 246). The vas is then picked up, the traction 
is made so as to pull out the portion lying in the canal so that the 
remaining portion dives vertically into the wound and over the brim of 
the pelvis. The finger is then inserted into the little wound, as shown 
in Fig. 247, and the vas is freed as far as the finger can reach, making TREATMENT 
573 
steady traction during this process. A right-angled clamp is then 
applied to the vas at the lowest accessible point. It is divided, cauter- 
ized with phenol (carbolic acid) and dropped back. The wound in the 
Fig. 246.—Vas held in curved clamp which has been passed up into the inguinal 
canal and is making its exit through a small incision opposite the internal inguinal 
ring. 
Fig. 247.—Tension is made on the vas by the operator’s left hand, while with his 
right index finger in the inguinal incision, he frees the vas over the pelvic brim. 574 
GENITAL TUBERCULOSIS 
groin is closed with one catgut suture in the fascia, with a silkworm-gut 
stitch in the skin. The operation is completed by the careful ligation 
of any bleeding-points in the scrotum. Any apparent foci in the testicle 
are eradicated with a curette. The wound is painted with tincture of 
iodine and closed with a subcuticular suture of silkworm gut, leaving 
a small protective-tissue drain at the lower angle. This drain has been 
found to shorten convalescence by giving free exit to the serum which 
necessarily oozes from the raw surface, the amount of which is con- 
siderably increased by the application of iodin. The dressing is held in 
place by the application of an Alexander bandage, one of the many 
devices of the late Samuel Alexander, which has been a boon to the 
genito-urinary surgeon. The drain can generally be removed in forty- 
eight hours and the patient may be up and about in two or three days. 
The after-treatment should include all of the general hygienic measures 
suitable for patients with tuberculosis, including the routine use of 
tuberculin and the routine use of sandalwood oil in cases in which there 
is involvement of the prostate.” 
As regards the testicle, I would add that in suspicious cases I am in 
accord with Lapeyre,42 that an exploratory orchidotomy, partial or 
complete, is not only justifiable, but harmless. 
Sinuses at the point of division of the vas deferens do not occur, and 
those of the scrotum are insignificant and infrequent. I do not hesi- 
tate to say that this operation marks one of the most important ad- 
vances in the surgery of the genital tract. 
Our attitude toward the second epididymis, even though it be healthy, 
should be carefully considered. I said in 1911,3 “knowing the life 
history of the disease, and finding the patient already sterile, as we shall 
in a very large number of cases, we feel justified in advocating the 
removal of both epididymes and vasa at one sitting.” 
While this may appear to be a radical policy, it rests upon a firm 
basis of surgical pathology. The beneficial effects of double section of 
the vas, upon vesicular and prostatic lesions has been shown by 
Lapeyre42 and Israel.42 
According to Legueu,42 “in the presence of bilateral vesicular disease 
the second vas should be systematically ligated in the course of a uni- 
lateral operation. We then avoid at once the infection of the healthy 
testicle and serious involvement of the prostate.” Lapeyre,42 on the 
other hand, takes the more radical view. He has resected the healthy 
vas for 3 years as a routine practice and says that “after double 
section of the vas, as after double castration, the cure of vesiculoprosta- 
titis is more frequent than after a unilateral operation.” If it is proved 
that the patient is already sterile, I regard this procedure as desirable. 
It is acknowledged by practically all investigators of the subject 
that tuberculosis of the prostate and vesicles is present in a very large 
percentage of cases of epididymal tuberculosis. Furthermore many 
surgeons have reported the frequency with which fistula has formed 
at the stump of the divided vas. While this has not been the case 
in my experience after the use of the technic described by Cabot,15 TREATMENT 
575 
it none the less may occur. In order to obviate this difficulty and 
in the hope of eradicating earlier and more completely the lesions 
of the vesicle, Cunningham79 has injected the stump of the vas after 
epididymectomy or castration with crude carbolic acid. For the 
technic of this procedure the reader is advised to consult the original 
article. Cunningham says that “the reaction from this method of 
treatment while severe in some cases is slight or absent in others, and 
whatever immediate discomfort there may be is of only passing inter- 
est if we can free the genital tract of so severe a disease. 
“The examination of the vesicles and prostate months following 
operation usually shows the vesicles to be small, fibrous bodies, if 
palpable at all, and the prostate quite normal but often sclerotic; 
the material expressed by massage is small in amount. In no instance 
has the massage fluid following operation shown the tubercle bacillus 
in smears and in no instance has a contracture taken place in the 
urethral canal. Following the healing of the wound. . . the 
patients are given tuberculin.” 
Radical treatment involves the removal, not only of the epididymis, 
but also of the prostate and seminal vesicles, but we have seen no case 
in which this extensive operation was deemed necessary or wise. In 
fact, we cannot condemn too strongly this extremely radical step. 
European surgeons have been more favorable to the radical operation. 
Ullmann,42 in 1889, performed epididymo-vaso-vesiculectomy, but 
the operation met with little favor on account of its dangers and 
difficulties. Baudet7 has since popularized it by making use of the 
inguinal route. In his hands the mortality has been practically nil, 
and he has reported 46 cures, out of 58, after the lapse of from four 
to six years. 
Interference with the prostate, either alone or in conjunction with 
the other genital organs seems to be generally regarded as a serious 
matter and productive of bad results. Enucleation is exceedingly 
difficult or impossible owing to adhesions. Incision and drainage 
of an abscess gives only temporary relief, and is generally productive 
of a permanent fistula. I agree with Lapeyre42 that operations upon 
the prostate are inadvisable; mild affections will heal after the removal 
of the epididymis, and extensive lesions had best be let alone. In 
my opinion, the same may be said of the seminal vesicle. 
The most enthusiastic champion of the radical operation in this 
country is undoubtedly Young. In 1918,97 he presented his de- 
scription of the operation performed by him, this being given in great 
detail and splendidly illustrated. Again in March, 1922, Young 
published another article98 confirming his views as to the desirability 
of this procedure and again setting forth in word and picture every 
step of the operation. The reader is referred to these two articles 
in the event of his desire to follow in Young’s footsteps. The article 
is a remarkably able and complete summary of the entire literature 
of the subject. 
Young98 reports 15 cases so treated and in these cases be removed 576 
GENITAL TUBERCULOSIS 
the epididymis, the testicle, the entire vas deferens and the seminal 
vesicles on one or both sides in all and one or both lobes of the prostate 
In all but 3 cases. He says, '‘The pathological study of these 15 eases 
shows conclusively the preponderant importance of the seminal 
vesicles as the primary seat of the disease, and the urgency to remove 
them if radical cures are to be uniformly expected, and the present 
disgraceful mortality in genital tuberculosis is to cease. 
“The operation has not been reserved entirely for patients in good 
general condition as shown by the fact that 7 patients had fairly 
definite evidence of tuberculosis of the lungs previous to operation 
and 5 patients had tuberculosis of the kidney, 3 requiring nephrectomy. 
Regardless of this fact, there has been only 1 death so far recorded, 
going back as far as seven years; and all but 1 of the cases have been 
followed almost a year at least. Perineal urinary fistula, that sup- 
posedly great bugbear of operations on the tuberculous prostate and 
vesicles, is present in only 1 case; and in this, only a few drops of 
urine escape during urination, so that the condition is not serious. 
Discharging sinuses are present either in the scrotum, groin or perineal 
wound in 6 cases. Most of these are recent cases and statistics show 
that they usually cease spontaneously with time. At any rate, they 
are not really annoying and compare favorably with statistics follow- 
ing epididymectomy or castration in which a much higher percentage 
of, and more annoying, discharging sinuses are recorded in the liter- 
ature. Another most interesting demonstration is the fact that the 
sexual powers are not usually impaired in any way except that the 
amount of ejaculatory fluid is much lessened. We have no direct 
evidence that any case has been impaired, though 10 patients have 
not answered this question either before or after operation. Other 
operators, however, have shown that the removal of both seminal 
vesicles and vasa does not impair the sexual appetite or act. In 3 
cases in which the vas, vesicle and epididymis on one side only were 
removed, the opposite epididymis became involved in the course of 
a year and required removal; and 1 patient died after the second 
operation (epididymectomy) one year later. It may be found with 
time that it is wise always to remove both vesicles and ampullae and, 
if this is not done, either to ligate and divide the supposed healthy 
vas, which is not removed, or to remove the ampulla on that side, or 
to ligate the vas through an incision in the scrotum so as to avoid 
involvement of the second epididymis. 
“Two patients refuse to answer letters and questionnaires, which 
are not returned, indicating that the patients are still alive. I believe 
the results obtained in both of these cases were good. 
“Of the 12 cases in which the ultimate results have been obtained 
up to date, the radical operation has been eminently successful in 
improving the general health. One of these patients developed tuber- 
culosis in the remaining epididymis and required epididymectomy. 
In all cases, there has been ultimately an excellent local result, with 
improvement in micturition even in those cases with tuberculosis of 
the bladder and kidney (3 of which were removed). TREATMENT 
577 
“ Considered, therefore, from every standpoint, the results obtained 
by the radical operation in these 15 cases have been eminently satis- 
factory and far better than we have obtained by mere excision of the 
epididymis or testicle.” 
In 1910, Whiteside94 reported 2 cases in which he had removed 
the entire genital tract with “excellent results.” In 1914,73 he reported 
22 cases so operated, but his own comments on the results are far 
from encouraging, perhaps, because he employed it in “only the old 
and apparently hopeless cases,” the very ones which it seems to me 
good surgical judgment would prompt one to avoid. Again, in 1919, 
Whiteside95 published a report of his progress with the operation and 
regrets “that this first case is the only one of which I have certain 
knowledge that the remote result was successful. Several others 
have been under observation for months, but none for more than 
two years.” 
Quinby,90 in 1918, detailed 7 cases of radical excision of the seminal 
tract for tuberculosis according to Young’s technic without an oper- 
ative death and with excellent immediate results. After reviewing all 
this one cannot but feel that while time may prove the wisdom of these 
radical procedures there is as yet not enough evidence as to their 
actual and ultimate value to make the average man desire to go 
through this ordeal himself. 
The treatment of tuberculous stricture of the urethra had best be 
conservative. Dilatation, under the influence of a local anesthetic in 
the urethra is usually successful; in other cases, internal urethrotomy 
may be necessary, but should be done only on strictures anterior to 
the bulbous urethra. External urethrotomy should be avoided on 
account of the danger of establishing a permanent urethral fistula. 
Whichever is done, dilatation or urethrotomy, a tuberculous stricture 
will close down rapidly and require constant attention. 
Most authorities are now agreed that tuberculin is a valuable 
adjunct in the treatment of genital tuberculosis, especially after 
operation. We have used it for a number of years in the after-treat- 
ment of both genital and urinary tuberculosis. Our opinion of it 
and the details of its use have been set forth by O’Neil and Hawes.48 
“Tuberculin injections are used in conjunction with other measures, 
but in few if any cases would we be willing to attribute to tuberculin, 
all or nearly all of the improvement. In some of the genito-urinary 
cases it has seemed as if tuberculin was an important factor in the 
treatment; in the great majority of cases, however, while a factor, it 
is by no means the most important one in producing results. The 
tuberculin used is a bouillon filtrate (or bacillary emulsion) supplied 
by the Saranac Lake Laboratory. It is administered once a week 
according to the rules of Trudeau, the initial dose being from 0.0001 
mg. to 0.0005 mg., rarely 0.001 mg. This is gradually increased to 
50 to 100 mgs. The increase in dosage is gauged by careful obser- 
vation of clinical signs of reaction, local, focal or constitutional. 
Constitutional reactions have been rare and no untoward results 578 
GENITAL TUBERCULOSIS 
have followed such as have occurred. Occasionally benefit has 
seemed to follow a mild constitutional disturbance. It is the aim, 
however, to avoid all such, and as a rule it has been possible to carry 
patients up to large amounts without discomfort. ... As the 
local and general conditions improve the patients are allowed to come 
once in two weeks, and when the process is arrested, to report once a 
month or once in two months.” 
As I have stated elsewhere,6 “it all comes down to a question of 
immunity. Once fortified in this manner a patient can ward off an 
onslaught of the tubercle bacillus, which, under other circumstances, 
would get the upper hand in a short time. While we have all seen 
patients with surgical tuberculosis, who have fought single-handed a 
winning battle for many years, we should not hesitate to bring to their 
relief the best of hygienic treatment, the regular and continuous 
administration of sandalwood oil, and the use of tuberculin. . . . 
Under these conditions whatever natural immunity the patient may 
possess, or has acquired, will be raised to the highest possible point, a 
factor which I believe will give the victims of this disease a better 
outlook in the future than they have had in the past.” 
1. Asch: Zeit. f. Urol., 1909. 
2. Balliano: Beit, zur Klinik der Tuberkulose, 1912. 
3. Barney: Am. Jour. Urol., 1911; Boston Med. and Surg. Jour., clxviii, 1913. 
4. Barney: Boston Med. and Surg. Jour., 1912, clxvi, No. 11. 
5. Barney: Jour. Am. Med. Assn., December 31, 1914. 
6 Barney: Surg., Gynec. and Obst., March, 1914. 
7. Baudet: Rev. de Chir., 1901, i. 
8. Baumgarten: Arch. f. klin. Chir., 1901, Ixiii. 
9. Baumgarten: Langenbeck’s Arch., 1901, Bd. Ixiii, H. 4. 
10. Baumgarten: Verhandl. der deutsch. path. Gesellschaft, 1905; Arbeiten aus 
dem path.-anatom. Inst, zu Tubingen, 1906, v. 
11. Belfield: Jour. Am. Med. Assn., October 19, 1912. 
12. Berger: Arch. f. klin. Chir., 1902, lxviii. 
13. Brown: Jour. Am. Med. Assn., 1915, lxiv, No.. 11. 
14. Buday: Virchows Archiv, 1906. 
15. Cabot and Barney: Jour. Am. Med. Assn., 1913, lxi. 
16. CholzofT: Folia Urologica, 1908-09, iii. 
17. Crandon: Boston Med. and Surg. Jour., 1902, cxlvii. 
18. Davids: Inaug. Dissert., Gottingen, 1898. 
19. Delli Santi: Riforma Medica, 1903, No. 34. 
20. Dreyer: Inaug. Dissert., Gottingen, 1891. 
21. Ferron: Jour. d’Urol., June 15, 1913. 
22. Gotzl: Folia Urologica, 1912-13, vii. 
23. Guisy: Ann. des Mai. des Org. Genito-urinaires, 1906. 
24. Haas: Beit, zur klin. Chir., 1901, xxx. 
25. Halle and Motz: Ann. des Mai. des Org. Genito-urinaires, 1903. 
26. Hesse: Cent. f. der Grenzgebiete der Med. und Chir., 1913, xvii. 
27. Heyn: Virchows Archiv, 1901. 
28. Huet: Centralbl. f. Bakt., 1909, lii. 
29. Hueter: Ziegler’s Beit., 1904. 
30. Jannsen: Sammlung klin. Vortrage, 1910-11. 
31. Kantorowicz: Inaug. Dissert., Berlin, 1893. 
32. Kappis: Inaug. Diss., Tubingen, 1905. 
33. Keyes: Ann. Surg., June, 1907. 
34. Kocher: Deut. Chir., 1887, Bd. 1. 
35. Kocher: Deut. Chir., 1887, 1. 
36. Konig: Deut. Zeit. f. Chir., 1898, xlvii. 
BIBLIOGRAPHY. BIBLIOGRAPHY 
579 
37. Kowalewsky: Jahresb. der ges. Medizin, 1907. 
38. Kraemer: Wien. med. Wchnschr., 1900, 1; Deut. Zeit. f. Chir., 1903, lxix. 
39. Kraemer: Ziegler’s Beit., 1904. 
40. Krzywicki: Ziegler’s Beitr., 188, iii. 
41. Kuhn: Jahresb. der ges. Med., 1906. 
42. Lapeyre: Arch. gen. de chir., 1912, viii. 
43. Le Dentu: Bull et mem. Soc. de chir. de Paris, 1912, xxxviii. 
44. Lelongt: Thfese de Paris, 1911. 
45. Lowenstein: Deut. med. Wchnschr., 1913, xxxix. 
46. Marinesco: Jour. d’Urol., 1912, i. 
47. Meyer: Virchow’s Archiv, 1895. 
48. O’Neil and Hawes: Tr. Am. Assn. Genito-Urin. Surg., 1913, viii. 
49. Oppenheim and Low: Vichows Archiv, 1905, clxxxii. 
50. Paladino-Blandini: Ann. des mal. des Org. Genito-urinaires, 1900. 
51. Pinaud: Seifert, Dermatologische Studien, 1903-1910. 
52. Reclus: Th&se de Paris, 1876. 
53. Roily: Jahresb. f. ges. Med., 1909. 
54. Samuel: Wiener klin. Rundschau, 1911, No. 47. 
55. Sangiorgi: Cent. f. allg. Path, und path. Anat., 1909, xx. 
56. Sawamura: Deut. Zeit. f. Chir., 1909-10, ciii. 
57. Sawamura: Folia Urologica, 1910, Bd. iv. 
58. Saxtorph: Cong. Internat. de Chir. Urin., 1900. 
59. Schmidt: Inaug. Dissert., Tubingen, 1896. 
60. Simon: Deut. Gesellschaft f. Chir., 1901, xxx. 
61. Spano: Rev. de la Tuberculose, December 31, 1903. 
62. Sugimura: Arbeiten auf dem Gebiete der path. Anat. und Bakt., 1912, viii. 
63. Testut: Traite d’Anatomie Humaine, 1897. 
64. Teutschlander: Beitr. zur Klinik der Tuberkulose, 1905. 
65. Teutschlander: Beitr. zur Klinik der Tuberkulose, 1906. 
66. Tylinski: Deut. Zeit. f. Chir., 1911, cx. 
67. Uchimura: Sei-I-Kwai Med. Jour., 1914, xxxiii. 
68. Vignard and Thevenot: Ann. de Med. et Chir. Infantiles, 1911, xv. 
69. von Bruns: Deut. Gesellschaft f. Chir., 1901, xxx. 
70. Walker, George: Johns Hopkins Hosp. Rep., 1911. 
71. Walker, K. M.: Lancet, 1913, i. 
72. Walker and Hawes: St. Bartholomew’s Hosp. Rep., 1911, xlvii. 
73. Whiteside: Tr. Am. Assn. Genito-urinary Surg., 1914, ix. 
74. Wyssokowicz: Zeit. f. Hyg. und Infectionskrankheiten, 1908. 
75. Antonio: Policlinico, 1917, vol. xxiv. 
76. Barney: Am. Jour. Dis. Children, December, 1921, vol. xxii. 
77. Barney: Jour. Urology, July, 1923. 
78. Cunningham: Tr. Am. Assn. Genito-urin. Surg., 1911, vol. vi. 
79. Cunningham: Surg., Gynec., and Obst., 1916, xxiii, 385. 
80. Delore and Chalier: Lyon med, 1921, vol. cxxx. 
81. Eastwood and Griffith: Jour. Hygiene, 1915-1917, xv. 
82. Freund: Wien klin. Wchnschr., October 20, 1921, xxxiv, No. 42. 
83. Kirmisson: Rev. gen. de clin. et de Therap, 1918, xxxii, 641. 
84. Koll: Ann. Surg., October, 1915. 
85. Kraemer: Beitr. z. Klin. d. Tub., 1914, xxxiii, 259. 
86. Kraemer: Beitr. z. Klin. d. Tub., 1915, xxxv, 119. 
87. Kraemer: Deutsch. med. Wchnschr., 1920, xlvi, 435. 
88. Mark: Jour. Urol., 1921, v, No. 2. 
89. Poissonnier: Gaz. des hop., 1907, pp. 375-380. 
90. Quinby: Jour. Am. Med. Assn., November 30, 1918, lxxi, 1790. 
91. Simmonds: Beitr. z. Klin. d. Tub., 1914, xxxiii, 35. 
92. Simmonds: Beitr. z. Klin., 1915, xxxiv, 173. 
93. von Schmieden: Munchen. med. Wchnschr., December 2, 1921, vol. xlviii. 
94. Whiteside: Calif. State Jour. Med., 1910, viii, 88. 
95. Whiteside: Northwest Med., May, 1919, xviii, 83. 
96. Wildbolz: Schweiz, med. Wchnschr., June 17, 1920. 
97. Young: Surg., Gynec. and Obst., April, 1918. 
98. Young: Arch. Surg., 1922, iv, 334, 419. CHAPTER XVI. 
TUMORS OF THE TESTICLE. 
By FRANK HINMAN, M.D. 
Introduction.—Tumors of the testicle present two considerations 
not found to a like degree in tumors elsewhere. The first relates to 
their pathology, which is so very complex and diverse as to have 
aroused considerable difference of opinion as to its nature, some con- 
sidering all tumors teratomatous, in origin at least, while others 
recognize various homologous and heterologous types. The subject 
is very much confused by the inclination of so many to call a testicular 
tumor “sarcoma,” when probably a true sarcoma of the testicle is 
a very rare type of tumor. 
Secondly, embryological and anatomical peculiarities render the 
surgical treatment of the condition in one way very easy, in another 
way very difficult. Orchidectomy is so simple and practically with- 
out risk that it appears the obvious procedure, but the fact that 
metastases occur primarily to the remote retroperitoneal lymphatic 
neighborhood of embryological origin, alongside and upon the vena 
cava and aorta, permits simple removal of the testicle and its tumor 
to cure relatively few sufferers. 
Incidence.—Tumors arising in the testis are not frequent. Rela- 
tive to male admissions in general hospitals, teratoma testis occurs 
less often than 1 to every 1500. The incidence in animals is some- 
what higher, 1 to 1000. Among malignant tumors in men the testicle 
has been found relatively and primarily involved in 0.57 per cent. 
Statistics show that these tumors are relatively more common in 
undescended than in normally placed organs. Thus, of 649 testicular 
tumors variously reported, 78, or 12.2 per cent., were in undescended 
testicles. There is no evidence that one side is more subject to the 
disease than the other. Of 222 cases analyzed, the right was involved 
123 and the left 99 times. Seventeen instances of bilateral involve- 
ment, mostly in cryptorchids, have been reported. An analysis of 
statistical figures is given in Table I. 
Etiology.—The cause of testicular tumor is unknown. Trauma 
may be a factor. Testicles retained in the inguinal canal are peculiarly 
exposed to injury, and Bulkley’s statistics would seem to show that the 
inguinal!y retained testicle is more likely to become malignant than 
either the normally placed or the abdominal organ. About 1 in every 
1500 male admissions has teratoma as compared to 1 malignant 
abdominal cryptorchid in every 60,000 admissions of cryptorchid, but 
the normally placed testicle occurs 600 (Rennes) to 1000 (Marshall) 
580 ETIOLOGY 
581 
Author. 
Hospital. 
Number 
of 
cases. 
Male. 
Number 
of 
testicular 
tumors. 
Percent- 
age. 
I. Relative frequency 
Howard 
General 
110,000 
All 
65 
0.05 
among general 
Eccles 
hospital admis- 
(Coley) 
London 
60,000 
All 
38 
0.06 
sions 
Bulkley 
Presbyterian, N. Y. 
12,729 
13 
0.10 
182,729 
116 
0.063 
II. Frequency in animals 
Slye 
Mice 
19,000 
9,500 
28 
0.29 
McCoy (Slye) 
Rats 
100,000 
Not stated 
103 
Kimura (Slye) 
Horses 
77,224 
“ 
49 
III. Relative frequency 
Gurlt (Kober) 
Vienna 
16,637 
Not stated 
(109) 
among malig- 
Corner 
St. Thomas 
1,080 
1,080 
6 
0.88 
nant tumors 
Slye 
U. S. Census Rept. 
52,420 
21,282 
121 
0.58 
70,137 
22,362 
127 
0.57 
IV. Relative frequency 
Number of cases of 
in undescended 
undescended testicle. 
testicles 
A. Among unde- 
Eccles 
859 
0 
scended tes- 
Coley 
Hospital for Rupt- 
tides in gen- 
ured and Crippled 
eral 
Children 
1357 
0 
Kocher 
1000 
1 
Brenner 
Eiselberg’s Clinic 
75 
0 
Hoffstatter 
181 
4 
Goeritz 
57 
1 
3529 
6 
0.17 
B. Among testicu- 
In undescended 
lar tumors in 
Testicular 
testicle. 
general 
tumors. 
Ing. 
Abd. 
Total. 
Howard 
General 
57 
9 
15.7 
Chevassu 
128 
10 
5 
15 
11.7 
Odiorne and 
Simmons 
54 
2 
6 
11.1 
Coley 
64 
12 
18.7 
Kober 
114 
18 
15.8 
Hinman 
Johns Hopkins 
32 
7 
21.7 
Von Kalhden 
41 
5 
12.1 
Ufferduzzi 
159 
6 
3.7 
649 
78 
12.2 
V. Relative frequency 
Hinman, Gib- 
57 (radical 
Right. 
Left. 
on two sides 
son and Kutz- 
op.) 
man (unpub- 
33 
24 
lished) 
Chevassu 
106 
56 
50 
Cunningham 
59 
34 
25 
222 
123 
99 
VI. Relative frequency 
Crypt- 
of bilateral in- 
orchids. 
volvement 
Chevassu 
128 
1 
1 
0.78 
Kober 
93 
5 
Not stated 
5.3 
Shubert 
15 
3 
“ 
“ 
20.0 
Cunningham 
67 
3 
67 
4.6 
Kaiser 
i 
1 
Smith 
i 
1 
Butt and Arkin 
i 
1 
Oraison 
i 
1 
Rogers 
i 
1 
■ 303 
17 
TABLE I.—ANALYSIS OF STATISTICS RELATIVE TO INCIDENCE. 582 
TUMORS OF THE TESTICLE 
times to every single cryptorchid, and inguinal retention is much more 
frequent than abdominal. Statistics are very difficult to interpret 
correctly. Coley, for instance, in 59,235 cases of inguinal hernia, in 
the Hospital for Ruptured and Crippled Children, from 1890-1907, 
encountered malignancy of the undescended testicle 737 times—1 in 
every 80—an unbelievably high incidence in view of the fact that 
testicular tumors do not attain their maximum frequency until after 
the third decade. Testicular tumors in infants and children are 
comparatively rare (Phillip). Trauma, of the nature of a chronic 
irritation of an undescended testis, may well prove an etiological factor, 
just as it seem to be of importance elsewhere. It is doubtful, however, 
whether single injuries to the normally placed organ do more than 
call attention or act as a stimulus to an already existing growth. 
Pathology.—The complexity of tumors of the testicle has led to the 
most diverse opinions concerning their nature. Indeed, there is 
probably no other field in pathology where so many views have been 
and still are current. In the literature, are found cases reported as 
adenoma, adenocystoma, adenomatous teratoma, chondroadenoma, 
chondrocystoma, adenosarcoma, sarcocareinoma, carcinoma, chondro- 
carcinoma, enchondroma, sarcoma, fibroma, myomastriocellulare, 
myxoma, osteoma, dermoid, seminoma, lymphosarcoma, alveolar 
sarcoma, endothelioma, lipoma, chorioepithelioma, globo-cell sarcoma, 
angiosarcoma and so on without end, so that one is forced to wonder 
at the extreme versatility of the organ. It is astonishing how fre- 
quently the diagnosis of sarcoma occurs. 
Some semblance of order out of this chaos has been achieved by 
the epochal papers of Johnson (1856), who was the first to recognize 
the tridermal constitution of testicular tumors, and Langhans, who, 
together with Kocher (1887), laid the basis for an accurate classifi- 
cation of tumors according to microscopical structure. They were 
the first to suspect that the group of teratomata embraced a large 
proportion of all tumors of the testicle; and Wilms, in 1896, demon- 
strated the fact that most tumors of the testis are teratoid in nature. 
In 1911, Ewing presented an excellent review of the literature, with 
a pathological study of a series of cases, and came to the conclusion 
that practically all tumors of the testis are of teratomatous origin. 
“ In the testis more notably than in any other organ it is possible to 
maintain a single embryogenic origin of the great majority of tumors. 
It appears that all the common and nearly all the rarer tumors of this 
organ arise from toti-potent sex cells, and that the monodermal forms 
of these growths represent one-sided development of tridermal tera- 
tomas. A ery rarely the stroma, duct cells and adult seminiferous 
tubules give origin to characteristic growths. Whether any of the 
malignant epithelial tumors may originate from fully differentiated 
cells of rete, epididymis or testis it remains for future observations 
to determine.” 
Ewing thus challenged the contention of Chevassu, whose exhaus- 
tive thesis was published in 1906, and that of Debarnardi, appearing PATHOLOGY 
583 
the same year. Chevassu demonstrated that a large proportion of 
tumors of the testicle are of the solid, medullary, large cell type, the 
cells being identical in morphology and staining reactions with those 
of the spermatogenic cycle. He, therefore, derived a large propor- 
tion of testicular tumors from the spermatocytes and called them 
“seminomes.” Tizzone (1876), Birch-Hirschfeld (1877), Talavera 
(1879) and Langhans (1887) thought they were able to trace the 
transition from the cells of spermatic tubules to the so-called “sem- 
inome.” Chevassu, however, was unable actually to demonstrate 
this transition. 
The fundamental difference of these two views is well expressed in 
the respective methods of classification of testicular tumors. Ewing 
recognizes but one type, which he divides simply into three groups: 
1. Adult embryomas or teratomas—rare cases in which the rudi- 
mentary organs of a parasitic fetus may be found. 
2. Embryoid, teratoid or mixed tumors—cases in which deriva- 
tives of all three germ layers are found, but in such confusion as to 
eliminate any resemblance to a fetus. 
3. Embryonal malignant tumors, a monodermal teratomatous 
derivative (corresponds with the seminome of Chevassu, and the 
spermacocytoma of Schultz and Eisendrath). 
A much more comprehensive classification, and one which embraces 
the opposite viewpoint of two distinct types of tumors, has been 
presented by Schultz and Eisendrath, and is as follows: 
I. Homologous tumors: 
A. Benign: 
1. Epithelial: 
(a) Adenoma of the seminal tubules (the tumors 
of Chevassu and of Pick [Ewing]). 
2. Mesoblastic: 
(a) Fibroma (arising in the tunics; the tumors of 
Lardennois and Lecene; Makins, and Boyer). 
(b) Leiomyoma (arising in the epididymis); Ewing 
accepts the tumors of Trelat, Rindfieisch and 
Hericourt; Schultz and Eisendrath report a 
similar case. 
(c) Vascular tumors (lymphangioma; hemangioma). 
(d) Interstitial cell tumors (a specimen in his own 
laboratory and the case reported by Che- 
vassu, Ewing considers examples of hyper- 
plasia rather than neoplasia). 
B. Malignant: 
1. Epithelial: 
(a) Syermatocytoma (seminome of Chevassu). 
2. Mesoblastic: 
(a) Sarcoma (extremely rare; possibly Sakaguchi’s 
case and 3 of Miyata’s cases arising in the 
tunics may be accepted). 584 
TUMORS OF THE TESTICLE 
II. Heterologous tumors: 
A. Benign: 
1. Cystic dermoid. 
B. Malignant: 
1. Embryonal carcinoma (heterologous tissue may be 
present or may have been overgrown; the 
atypical tissue may be): 
(a) Trophoblastic (chorioepithelioma). 
(b) Hypoblastic (the usual adenomatous tumor). 
(c) Epiblastic (solid alveoli of basal-cell type, or 
tumors of neurocytoma type). 
2. Sarcomatous mixed tumor (true sarcoma in a tera- 
toma appears to be rare). 
Thus, two schools, differing more upon theoretical than practical 
grounds, have arisen. The one maintains that there exists only one 
malignant tumor of the testis, namely, a teratoma (Wilms, Pick, 
Itibbert, Ewing, Wilson, O’Crowley and Martland). The other main- 
tains a belief in a second group, other than teratomatous, of pure 
tumors originating from the cells of the seminiferous tubules (Chevassu, 
Frank, Sakaguchi, Schultz and Eisendrath, Yecchi, Birch-Iiirschfeld, 
Tizzone, Langhans, etc., and practically all French authors). Whether 
one favors the first or the second explanation of their nature is in 
practice unimportant. The very occasional exception of a benign 
tumor, not more than a few dozen reliably existing, make it wise to 
consider clinically all testicular tumors as malignant. Of these, it 
is important to recognize that two main groups exist: (1) Mixed 
tumors, and (2) pure one-celled type of solid medullary tumors. 
Teratoma designates satisfactorily the first; seminoma is peculiarly 
expressive of the second. And there would seem to be no valid objec- 
tion to the retention of these two terms limited strictly in meaning 
to define respectively mixed and single-cell types of tumor until more 
of the pathology of these tumors is known. 
Tumors of the testicle, irrespective of type, appear to have their 
origin in the rete testis (Ewing), and from that point quickly involve 
the whole organ without any change in its shape or, at first, in its 
size. At operation, one rarely sees any normal gland tissue remain- 
ing. It is completely replaced by the growth which distends the 
albuginea throughout, but rarely escapes beyond its bounds. Bar- 
ringer and Dean report an unusual case in which the epididymis 
was principally involved by a teratoma, and the testicle showed very 
little encroachment upon its substance. In one of Young’s cases, and 
likewise in one of the author’s (Case VIII), Fig. 248, a thin layer of 
glandular tissue still remained at a point opposite the attachment of 
the epididymis. 
Externally, teratomata and seminomata present a similar appear- 
ance, but on section the difference is often striking. The seminoma 
presents a grayish-white, solid, opaque picture, characteristic of a 
medullary type of growth (Fig. 248). The teratoma, on the other PLATE IX 
Successfully removed (October 16, 1922) by radical operation from a man 
aged thirty-three years, together with unusually large metastatic lumbo- 
aortie glands. The onset of the tumor followed immediately upon severe 
trauma sustained ten months previously. The patient made an uneventful 
recovery following the operation and was discharged from the hospital in 
three weeks. Note the variegated cystic structure of the cut surface charac- 
teristic of teratoma which usually enables one to distinguish it grossly from 
the smooth solid homogeneous structure of the unicellular “seminoma.” 
(Courtesy of Dr. Hugh H. Young, Baltimore, Md.) 
Mixed Tumor (Teratoma) of Left Testicle. PATHOLOGY 
585 
hand, presents a varied picture, depending upon the proportions of 
cysts, cartilage, cellular areas, hemorrhage, necrosis, etc., present 
(Figs. 249, 250 and Plate IX). However, this differentiation is not 
always easy, as areas of necrosis and liquefaction may occur in the 
seminoma, due to poor blood supply (Fig. 251). 
The microscopical characteristics of the two groups are well illus- 
trated in the accompanying microphotographs (Figs. 252, 253, 254 
and 255). The tendency of one element to dominate the histological 
picture (Wilms, Pick, Ewing) is confusing, and many supposedly pure 
seminomata are found from more careful study of serial sections to 
present small areas of cartilage, gland tissue, etc., thus demonstrating 
their tridermal constitution. In view of this pathological confusion, 
Fig. 248.—Photograph of single cell type tumor, a seminoma. At the inner edge of the 
left half of the specimen is seen a small compressed remnant of the testicle. Usually no 
normal testicular tissue can be found. The tumor measured 5 x 7.5 cm. 
it is surprising how nearly uniform teratoma and seminoma occur. 
In 128 cases, Chevassu found 59 seminomas and 62 teratomas. In 
22 cases of the Johns Hopkins series, personally examined by the 
writer, 12 were pure sihgle-cell tumors and 10 typically teratomatous. 
Often the area of cartilage, glandular or other mixed tissue is so 
minute in what otherwise appears to be a single-cell type that it might 
easily have been overlooked, and this gives force to the argument 
that the predominate cell has outgrown less viable tridermal structures. 
Metastases usually occur primarily by way of the lymphatics. The 
primary lymph zones of the testicle were anatomically demonstrated 
by Most, in 1899, and his findings since confirmed by Cuneo, Jamie- 
son and Dodson and others, to lie in the neighborhood of embry- 
ological origin, as would be expected. Lymph vessels follow the course 586 
TUMORS OF THE TESTICLE 
of the spermatic vessels and drain into four to six retroperitoneal 
lymph nodes which lie alongside and upon the vena cava for the right 
and the abdominal aorta for the left testicle (Fig. 256). Secondary 
glands lie along the internal and external iliac vessels and deeply 
between and beneath the vena cava and aorta. It is an easy matter 
Fig. 249.—External aspect of teratoma testis (see Fig. 248). Characteristic of 
testicular tumors in general, the tumor retains closely the normal shape of the testicle. 
The tunica vaginalis surrounding the mass is thickened and distended with fluid, but 
not infiltrated by the neoplasm. 
to force the injection fluid used to demonstrate these primary nodes 
through them to the deeper lumbar and bronchial glands, and even 
on up through the thoracic duct into the subclavian vein. It is more 
than likely that many visceral metastases occur by this secondary 
lymphatic route rather than by a vascular one directly from the PATHOLOGY 
587 
testis. Venous extension undoubtedly does occur, however, with 
metastases to the lungs, liver, spleen, intestines, kidneys, long bones, 
Fig. 250.—Photograph of a mixed cell type of tumor, a teratoma. No normal testic- 
ular tissue is seen. Multiple dissimilar areas characteristic of different types of tissue, 
such as cartilage, gland and single cell masses, give a totally different picture from that 
of Fig. 248. The size of the tumor was 9 x 10 cm. 
Fig. 251.—Drawing of the cross section of a seminoma, which shows areas of softening 
and cystic appearance suggestive of teratoma. Careful microscopical study revealed only 
one type of cell. 
spinal cord, etc. The predominence of the involvement of these 
respective retroperitoneal, precaval and preaortic zones as the primary 588 
TUMORS OF THE TESTICLE 
Fig. 252.—Microphotograph (low power) of a seminoma, a uniform picture of large, 
round vesicular cells resembling the spermatoblasts. This is the type of tumor which 
probably has been so frequently wrongly diagnosed as sarcoma. 
Fig. 253.—Microphotograph (high power) of a seminoma. The uniform, round 
vesicular cells distributed in a lymphoid stroma is characteristic. The nucleus is large 
and shows fine stippling as seen in spermatoblasts and generally one or two large nucleoli. PATHOLOGY 
589 
Fig. 254. Microphotograph (low power) of a teratoma showing area of cartilage 
and three cystic spaces, each lined with a different type of epithelium—cuboidal, short 
columnar and high columnar. 
Fig. 255.—Microphotograph (high power) at the edge of the area of cartilage in Fig. 
252, with a small epithelial lined cyst surrounded by connective tissue stroma invaded at 
portions of the outer rim of the cyst wall by malignant tumor cells. 590 
TUMORS OF THE TESTICLE 
route is further fixed by the operative findings of early metastases 
here where radical surgery has been employed. Anatomical, patho- 
logical and surgical facts all concur in establishing the significance and 
importance of this primary mode of extension. Inguinal glands are 
not invaded except in rare instances of direct extension of the tumor 
cells to scrotal tissues or skin. 
Fig. 256.—Diagrammatic representation of the primary lymph zones of the testicles. 
The lymph flow from the right testicle drains first into 2 to 5 nodes situated in the groove 
between the vena cava and aorta. Occasionally a primary gland occurs at the brim of 
the pelvis on the external iliac vein, where it is crossed by the ureter, and rarely on the 
ventral surface of the aorta at its point of bifurcation; from the left testicle, into a variable 
number of nodes at the left side of the aorta, frequently in a cluster behind the inferior 
mesenteric artery. There is considerable variation in their exact location hut the glandu- 
lar zone is limited above by the renal pedicle and below by the aortic bifurcation except 
from the occasional node on the external iliac. 
Clinical Picture.—There are no characteristic features in the clinical 
picture. It may attack infants, boys or grown men. The accom- 
panying Fig. 257 is reproduced from Chevassu, showing that 
men between the ages of twenty and fifty are most subject to the 
disease, and that the greatest frequency is between twenty and thirty CLINICAL PICTURE 
591 
for teratoma and between thirty and forty for seminoma. Kober 
collected 10 cases between the ages of three months and ten years, 
and Phillips (1909) found 42 case reports of the condition in infants. 
Mixed tumors are the rule in infants, the seminoma being very rare, 
1 case of which is reported in a child, aged seven years, by Hardouin 
and Patel, and another in a boy, aged ten years, with unusual and 
extensive metastases, by Kutzmann and Gibson.* 
Symptoms are commonly absent, the patients first noticing, as a 
rule, a gradual but painless enlargement, accompanied by a sense of 
weight or fulness in the scrotum. The absence of pain in the begin- 
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 
Years 
Fig. 257.—Chart (reproduced from Chevassu) showing age incidence of seminoma 
and teratoma. The optimum period for teratoma is in the third decade; for seminoma, 
in the fourth. Chevassu had no seminoma in boys under twenty years, and only 1 
under twenty-seven years, but 5 teratomas under five years of age. 
Seminoma (58 cases) 
Teratoma (61 cases) 
ning is notable, though it occasionally becomes severe in late stages. 
Local tenderness also, as a rule, is absent. An initial enlargement, 
with a period of quiescence, and then after trauma, or for no apparent 
reason, rapid growth, is a not uncommon history, as typified by the 
following instance: 
The patient noticed seven years ago, shortly after having struck 
his left testis against the horn of a saddle, a small painless lump, 
which gradually grew within a year to twice the size of a normal 
testicle and then remained unchanged for six years, when it became 
* Malignant Tumors of the Testicles in Children, with report of a case in a boy 
aged ten years. Ann. Surg. (in course of publication). 592 
TUMORS OF THE TESTICLE 
painful, apparently after rowing a boat, and gradually increased in 
size up to the time of operation, nine months later (Hinman, Case 
III). This insidious onset, with periods of latency, renders an esti- 
mation of duration uncertain and quite variable, but, as a rule, testic- 
ular growths have a short duration and course. In an analysis of 96 
cases, Chevassu found 71 had existed less than a year, and 45 of these 
less than six months. Sixty-six of Kober’s 94 cases had a duration 
under two years. In an analysis of 72 cases of radical operation, we 
find that onset antedated operation twelve months or less in over 40. 
On the other hand, an occasional report of such a prolonged duration 
as twenty-six years (Kober) is found. 
The course of the disease beyond the stage of testicular enlarge- 
ment varies with the type and extent of metastases. Local develop- 
ment is usually progressive, but may show periodic activity. Rarely 
is it so rapid as to simulate an acute orchitis or inflammation of the 
tunics, with pain, redness and edema, which may be due to transitory 
secondary infection. Symptomatic hydrocele may complicate the 
picture. Inflammatory enlargement of the inguinal and iliac glands 
may occur. 
The period of primary lymphatic involvement is most variable. 
Extensive metastases have been found with tumors of recent onset, 
and vice versa. Autopsy and operative findings indicate that the 
mixed type of tumor (teratoma) spreads more rapidly than the uni- 
cellular (seminoma). An analysis of 77 cases subjected to radical 
operation shows that no inference as to the presence or extent of 
metastases can be had from a knowledge of the duration of the testic- 
ular enlargement. Unfortunately, primary extension to the retro- 
peritoneal lymph area gives no clinical evidence other than palpatory, 
and when these glands are large enough to be palpable, a late stage, 
probably with generalized metastases, is reached. 
Diagnosis.—The clinical recognition of testicular tumor is largely a 
matter of exclusion. They present no pathognomonic signs or symp- 
toms. They may vary markedly in size, sometimes being little 
larger than the normal testicle, at other times reaching huge propor- 
tions. Heydenreich reports a case in which the tumor extended to 
the level of the knees. Usually such enlargements are complicated 
by hydrocele, as in this case, in which the tunica vaginalis contained 
10 liters of fluid. As a rule, the tumor preserves the shape of a nor- 
mal testicle and has a smooth, regular surface. Nodulation and 
irregularities, however, may occur, but are usually late. The con- 
sistency is ordinarily one of uniform hardness, although early smooth 
tumors may have considerable elasticity. Occasionally, there may 
be found areas of fluctuation, due to localized necrosis or cystic degen- 
eration (Fig. 249). The epididymis is ordinarily easily recognizable, 
but in advanced cases becomes completely obliterated. The cord 
may be somewhat enlarged, but rarely either indurated or nodular. 
The skin of the scrotum is commonly uninvolved and found to be 
freely movable over the mass. It may appear red and shiny from DIAGNOSIS 
593 
being stretched, or present a congested appearance from increased 
vascularity, large bluish veins showing through. Exceptionally is it 
manifestly adherent to the mass or presents an area of gangrene or 
ulceration. 
Syphilis, hematocele (hydrocele) and tuberculosis present prob- 
lems of differentiation. Gumma simulates tumor more often and 
closely than any other condition, and it is well never to forget that 
generalized lues and testicular malignancy may coexist. A positive 
Wassermann or antiluetic therapy should not be a cause for too long 
delay. It is preferable to remove gumma, as has been frequently 
done, than to delay in the removal of a malignant tumor. 
Some cases of hydrocele and hematocele present great difficulties 
in differentiation. The pathognomonic signs of transillumination and 
fluctuation may fail in hematocele and certain teratomas in which 
cartilage and mucoid material preponderate may transmit light and 
be fluctuant. Trauma, as the important factor in hematocele, may 
have been absent, and its significance relative to tumor is about as 
great anyway. Hydrocele in conjunction may completely mask the 
presence of tumor and, on the other hand, simple hydrocele may 
present hard indurated areas, due to organization and absorption. 
Of considerable help often is puncture drainage of the vaginalis, which 
enables more accurate palpation of the testicle. Significant of this 
is the frequency in the history of tumor cases of the occurrence of 
numerous tappings before the true condition was even suspected. 
Tuberculosis more rarely presents difficulties, and only in those 
rare instances of massive tuberculous epididymoorchitis. The epi- 
didymis is the seat of primary election to tuberculosis, and the disease 
produces characteristic nodulation as it progresses. Mistaken diag- 
noses are possible, however, as the writer can testify, having both 
performed a radical operation for tuberculosis and delayed another 
in seminoma, thinking it was tuberculosis. Mistakes occurred in 
both cases after gross inspection following orchidectomy and in con- 
sultation with an expert pathologist. It was only after careful micro- 
scopical study later that an exact diagnosis was made. The photograph 
shown in Fig. 258 demonstrates the unusual nature of massive tuber- 
culosis of epididymis and testicle. 
The recognition of malignancy in cryptorchism is difficult. Inguinal 
ectopy is more apt to give early evidence because the anatomical posi- 
tion emphasizes pain and tumor. In abdominal retention, however, 
suspicion of the disease may be long delayed and only aroused by 
the appearance of an abdominal tumor, or by such secondary mani- 
festations as neuralgia or edema of the extremities from pressure on 
nerve or bloodvessels. In these cases, the congenital absence of a 
corresponding testicle in the scrotum is of great significance. The 
relative greater frequency of malignant change in cryptorchids has 
an important bearing upon the surgical correction of this deformity. 
Most surgeons recognize that spontaneous descent will not occur 
after puberty and advise orchidopexy at or before this period. Had 594 
TUMORS OF THE TESTICLE 
orchidectomy been done before puberty in all of Bulkley’s 59 cases 
of tumor in intra-abdominal eryptorchids, 31 would have been saved. 
In view of the difficulties in diagnosis, the extreme malignancy of 
these growths and the simplicity of exploratory examination, the 
interest of the patient demands that every testicular enlargement 
which is in any way suspicious should be immediately inspected surgi- 
cally and, when necessary, its exact nature determined by microscopical 
study. Delay in these cases proves fatal. 
Prognosis.—The extremely poor outlook for patients suffering with 
tumors of the testicle is well recognized. Orchidectomy, even with 
early diagnosis, is a dismal failure. There is sufficient statistical 
evidence to prove the inadequacy of simple castration (see Table II). 
Obviously, the procedure in order to cure must antedate extension 
outside the testicle, and this it has done in less than 15 per cent, of 
the cases. A mortality after surgery of over 80 per cent, is appalling, 
and that castration must be supplemented by radium, roentgen ray or 
more radical surgery is apparent if any considerable improvement in 
treatment is to be gained. 
The results of Barringer and Dean in a four years’ systematic use 
of radium are far from encouraging (see Table II). They report one 
remarkable case, in which a large abdominal metastasis was palpable 
in the right pelvic region. Radium packs were placed over this 
mass before and after castration, and within a month it had melted 
away so that it could no longer be felt. Examination of the testicular 
tumor proved it to be a teratoma (Ewing). The patient reports that 
he is entirely well now—three years and five months after he was first 
seen. 
In Beclere’s case of seminoma treated by castration and followed 
two years later by a large tumor filling two-thirds of the abdomen, 
it does not seem likely that the mass was a recurrence but rather a 
splenic enlargement, since, as a result of radium treatment, the patient 
has been living and well for five years. 
Taylor, in England, reports a striking instance of the result of 
radium in the case of a physician, aged thirty-three years, who was 
an inguinal cryptorchid (left). He had been operated for hernia at 
the age of thirty years, and the testicle was brought down into the 
scrotum. A year later, he developed a malignant tumor of that 
testicle and simple castration was done. Eight or nine months 
later, he developed a recurrence in the left iliac fossa, which was 
deemed inoperable. This mass was about the size of a cocoanut and 
compressed the vessels, causing edema of leg and steadily increasing 
pain so that he was confined to bed and kept under the influence of 
morphine. On two occasions (six to seven weeks apart) radium 
was introduced by open operation into the mass, and on the first 
occasion a bismuth salt was introduced as well, so that the tumor 
might be subjected to the secondary rays given off by the bismuth 
as a result of its exposure to radium. The tumor decreased markedly 
in size; the patient recovered his health and was able to walk, dance, PROGNOSIS 
595 
Number of 
cases dead. 
Number of cases living. 
Number 
Number 
Time 
With 
4-yr. 
Author. 
of cases. 
lost from 
not 
metastases 
Total. 
observa- 
stated. 
clinically. 
Time 
Less 
Longer 
per cent. 
tion. 
Within 
In 1 to 
After 
not 
than 
1 to 3 
3 to 4 
than 
1 yr. 
4 yrs. 
4 yrs. 
Total. 
stated. 
1 yr. 
yrs. 
yrs. 
Total. 
4 yrs. 
Chevassu 
100 
15 
38 
27 
1 
81 
4 
4 
15 
19 
19 
S.i 47 
8 
23 
31 
4 
12 
16 
34 
T. 50 
7 
28 
11 
1 
47 
3 
3 
6 
Kober. 
76 
40 
All died 
within 
1 
41 
is 
6 
2 
26 
8 
34 
13 
3 ye 
ars 
(6 yrs.) 
Nicholson 
18 
12 
12 
6 
(1 to 5 
6 
0 
yrs.) 
Howard . 
57 
21 
27 
6 
2 
8 
0 
(all less 
than 3 
yrs.) 
r 
24 
20 
1 
3 
Hinman . . j 
S. 9 
T. 9 
V 
2 
Coley 
52 
ii 
is 
9 
3 
3 
3 
(orchidec- 
tomy and 
“Coley’s 
serum”) 
Barringer and 
Dean: 
Group II2. 
8 
2 
3 
8 
2 
1 
3 
0 
Group III3. 
19 
6 
8 
19 
2 
3 
5 
0 
Group IV4. 
6 
2 
2 
2 
0 
1 S., seminoma- 
-T., teratoma. 2 No 
surgery— 
-“primary inoperable.” 
3 Castration plus radium— 
“recurrent.” 
4 Castration plus radium- 
—“prophylactic.” 
TABLE II.—RESULTS FOLLOWING SIMPLE ORCHIDECTOMY. 596 
TUMORS OF THE TESTICLE 
fish and play golf. He was surgeon on the Lusitania for a time and 
remained perfectly well for eighteen months. Then he developed 
glands in the neck, had hemoptysis and a rapidly fatal issue super- 
vened. The growth was carcinoma microscopically. 
Cacciatore (Buenos Aires) reports a case of local recurrence shortly 
after castration treated with radium, with temporary relief. Three 
applications of radium were given. Abdominal metastases occurred 
and the patient died six months after operation. Diagnosis: “Angio- 
myxo-sarcoma.” 
Levin states that the highly specific action of radium on the testicu- 
lar cells undoubtedly explains the remarkable beneficial effect of 
radium on malignant tumors of the testicle. The rays destroy the 
spermatogenic elements without apparent injury to the other elements. 
French authors advocate radiotherapy upon this theoretical consid- 
eration. Accordingly, the seminoma derived from the spermatoblasts 
is regarded as especially amenable to radiotherapy, while the mixed 
tumors may not be necessarily more susceptible than other tumors 
(Sebileau and Descomps). Barringer and Dean state that the more 
embryonal types of teratoma (regarding all cases as teratoma, accord- 
ing to Ewing’s classification) react most favorably. This statement 
is not at variance with the French view, since, according to Ewing, 
the seminoma falls in the class of teratoma of embryonic type (embry- 
onal carcinoma). 
The roentgen ray has also been used in the attack of these tumors. 
Orbaan’s is the only systematic study available. He reports 9 cases 
treated before and after castration. Eight of these showed clinical 
evidence of recurrence when roentgen-ray treatment was instituted. 
Six cases have died and 3 are living twenty-four, twenty-five and 
thirty months, respectively, after starting roentgen-ray treatments, 
and the patient living twenty-five months still shows clinical evi- 
dence of metastases. Metzmacher cites a temporary check in the 
progress of a recurrence after castration by the use of roentgen-ray, 
although the patient died. One case in the writer’s series of radical 
operation is of interest here. Large masses, which were not palpable 
through a thick muscular abdominal wall, were discovered upon 
retroperitoneal exposure. Several roentgen-ray treatments have kept 
them stationary at least, as the patient, only recently examined, 
shows no palpable nodules and is active and in good health nineteen 
months after castration. 
While the reports of radiotherapy are too few to prove or disprove 
its value, its use as a palliative measure and in conjunction with 
surgery as curative seems justified by the few apparently brilliant 
results recorded. 
The poor results following simple castration for teratoma testis 
have stimulated surgeons to apply the well-recognized principle in 
the treatment of cancer elsewhere to this condition, and attempt a 
radical removal of the primary lymph zone with the testicle. An 
analysis of the findings and results of this extensive procedure in 79 PROGNOSIS 
597 
cases has recently appeared.* A period of four years or longer has 
passed after the performance of the operation in a sufficient number 
of cases to give an estimation of its merits. Obviously, those patients 
from whom lumbar lymph nodes with metastatic cancer were removed 
at operation, who have survived four years or longer, may be regarded 
as cured by reason of the radical treatment. Simple orchidectomy 
would have been of no avail in any one of these cases. In another 
group, however, careful microscopical study of the preaortic lymph 
area removed at operation failed to show any evidence of metastases, 
and it might appear that the radical operation was unnecessary 
were it not for the fact that 4 of these cases have since died with 
postoperative metastases to this same lymph area, a result which 
clearly indicates that the original operation, rather than being unneces- 
sary because of the failure to find metastases, was insufficiently radi- 
cal, because failure completely to remove the wdiole lymph area is 
the only possible explanation of the subsequent appearance of metas- 
tases here. It is admittedly possible that a negative finding of 
glandular invasion of the lymph area removed in those who survive 
is an error either of microscopical recognition in the case of very early 
involvement, or of incomplete search, and that simple removal of 
the testicle would have failed to cure some of these. Nevertheless, a 
certain number of patients (15 per cent.) will be cured by simple 
orchidectomy, as statistics show, and in these the radical operation 
is theoretically unnecessary. But the recognition of this small group 
is impossible clinically, and it is absolutely necessary to sacrifice 
them to radical treatment in the interest of the majority. 
The results and findings in the 77 cases of attempted and successful 
radical resection are indicated in the accompanying table (Table III). 
There were 22 inoperable cases, Group I, in which the disease was so 
far advanced as to render them unsuitable for radical treatment. In 
9, large lumbar masses were palpable clinically before operations, and 
in 13, metastatic nodes too extensive for surgical removal were found 
at operation. All but 5 have died, and these are doomed, the average 
period since operation that they have been followed being only seven- 
teen days. Six of the 22 died in the hospital as a result of the opera- 
tion (shock, 3; pneumonia, 1; embolism, 1; peritonitis, 1). The mor- 
bidity of this group is 100 per cent. 
In 49 cases, Group II, more or less successful removal of the lym- 
phatic drainage system was accomplished. Five of these failed to 
survive operation—an operative mortality of 10.2 per cent. Four- 
teen cases have since died of metastases, and 11 of these are known 
to have died within one year. Twenty-eight cases are reported as 
living and well for two months to ten years since radical operation, 
and it is worthy of emphasis that 6 of the 28 have outlived the four- 
year-time period for cure. Four of these 6 cures had metastatic 
* Hinman, Gibson and Kutzmann: The Radical Operation for Teratoma Testis: 
An analysis of 79 cases—10 of which are personal. (Paper in course of publication, 
Surgery, Gynecology and Obstetric.) 598 
TUMORS OF THE TESTICLE 
invasion of the lymph tissue removed and all 4 are alive directly by 
virtue of the clean, complete removal of this metastatic lymph area. 
(Chevassu, I, living and well, four years and ten months; Descomps, 
I, living and well, eight years; Hinman (Eloesser), I, living and well, 
eight years; Hinman, III, living and well, four years and seven months). 
Consideration of these findings in comparison with what simple 
orchidectomy alone might have accomplished in this same series of 
77 cases is favorable to radical surgery. Orchidectomy could have 
been curative only when applied in the 25 cases of A, Group II, in 
which no invasion of the lymph area was demonstrable. Eight of 
these cases have since died of metastases, and they would not have 
survived after simple castration. Even granting that castration cured 
the remaining 13 cases, which is granting too much, it would only 
cure about 16 per cent, of the 77 cases. The large group of 24 cases 
(B, Group II), which had early metastases to the primary lymph 
zone, would have received no benefit by orchidectomy alone, whereas 
the statistics show that at least 4 of these have been cured by the 
radical and clean removal of this area (living and well over four years), 
that 15 others are still living and well—8 for almost three years— 
and that it is, therefore, reasonable to expect a fair proportion of the 
15 also to be cured, inasmuch as the great majority of those which 
die of metastases die within one year (11 of 14). Radical operation 
even at this early date of its application is seen to have improved the 
results of treatment of teratoma testis over orchidectomy 100 per 
cent, or more, and by its use in suitable cases we can expect a cure of 
30 per cent, instead of the appalling 15 per cent, as formerly. 
Treatment.—Present knowledge of the clinical course, diagnosis and 
prognosis of teratoma testis emphasizes the following points of 
treatment: 
An early and accurate diagnosis of every testicular enlargement is 
essential, and in every case of reasonable doubt there should be no 
hesitation in exposing the tumor to surgical inspection, and when- 
ever necessary performing castration and subjecting the tissue to 
immediate microscopical examination. Hematocele and massive tuber- 
culosis require surgery, so that the only possible sacrifice, by adopt- 
ing such a policy, is that of an occasional gumma of the testicle. 
Too many malignant growths have been neglected through uncer- 
tainty in diagnosis. Repeated tappings and prolonged observation 
are inexcusable in view of the simplicity of exploration. 
Once the diagnosis is established, one of two lines of procedure is 
indicated: Either a palliative course of treatment by orchidectomy 
with radium or roentgen-ray therapy, or an attack, more commen- 
surate with the extreme seriousness of the disease, by radical resec- 
tion of the growth and its primary lymphatic area. A certain num- 
ber of cases that come for treatment will have clinical evidence of 
abdominal metastases. Radical resection should never be attempted 
in these cases. They are inoperable. Radium packs and roentgen- 
ray therapy, as used by Barringer and Dean, or Orbaan, may check TREATMENT 
599 
Dead. 
' 
Living. 
Author. 
Dead. 
Living. 
Author. 
Time. 
Visceral. 
Local. 
Lumbar. 
Time. 
Metastases. 
Time. 
Visceral. 
Local. 
Lumbar. 
Time. 
Metastases. 
1. Gregoire123 II 
3 mos. 
1. Gregoire12 
34 I 
31 mos. 
Yes 
2. Gregoire12 3 III 
5 mos. 
Yes 
Yes 
2. Mauclaire1 
III 
3. Fredet13 
5 mos. 
Yes 
3. Mauclaire1 
IV 
Yes 
Yes 
4. Andr6 
Yes 
Lost fro 
m observa- 
4. Barbier4 
3 mos. 
Yes 
tion aft 
er 2 weeks 
5. Pillet 
1 yr. 
Yes 
5. Duval4 
I 
4 mos. 
6. Georgesco and 
15 days 
Lung 
Yes 
6. Duval4 
II 
3 to 4 mos. 
Yes 
Yes 
Savesco II 
7. Descomps V 
(pneumonia) 
48 hours 
Spleen 
Yes 
7. Picot4 3 
18 days 
Yes. 
(shock) 
48 hours 
Yes 
8. Patel 
I 
8. Descomps VI 
(shock) 
1 mo. 
Yes 
9. Georgesco 
and 
9. Descomps VII 
Savesco 
III 
15 days 
Yea. 
10. Descomps 
IV 
13 days 
(embolism) 
11. .Roberts 
6 weeks 
peritonitis) 
12. Hinman5 
VIII 
18 mos. 
None 
13. Young6 
palpable. 
V 
2 mos. 
Roentgen- 
ray shows 
metastases 
to lung. 
Summary of A: 
Summary of B.: 
Summary of 22 cases, Group I: 
Operative deaths, 3 
Operative deaths, 2 
Operative mortality, 22.7 per cent. 
Died of metastases, 5 
Died of metastases, 5 
Morbidity to date, 75.0 
“ 
Living, 
1 (for 2 weeks) 
Living with metastases, 4 
Probable morbidity, 100.0 
“ 
— 
Incomplete data, 2 
Tota 
. . 9 
— 
Total 
. . 13 
1 Cited by Delbet. 
Cited by Chevassu. 
3 Cited by Sebileau and Descomps. 
4 Cited bv Mascarenhas. 
5 Hinman, Gibson and Kutzmann: The Radical Operation for Teratoma Testis: 
An analysis of 
79 Cases (10 of which are personal) (paper in course of publication-). 
Surgery, Gynecology and Obstetrics. 
6 Personal communication. 
TABLE III—ANALYSIS OF CASES OF RADICAL OPERATION. 
Group I.—Inoperable Cases. 
A. ABDOMINAL MASSES PALPABLE BEFORE OPERATION. B. INOPERABLE MASSES FOUND AT OPERATION. 600 
TUMORS OF THE TESTICLE 
Dead. 
Living. 
Dead. 
Living. 
Author. 
Time. 
Visceral. 
Local 
Lumbar. 
Time. 
Metastases 
Author. 
Time. 
Visceral. 
Local. 
Lumbar. 
Time. 
Metastases. 
1. 
Mauclaire1 
I 
8 yrs. 
In scar 
after 5 
and 8 yrs. 
i. 
Cuneo2 3 
I 
3 yrs. 
None. 
2. 
Chevassu 
II 
5 yrs. 
7 days 
Lung 
2. 
Gregoire4 
IV 
8 mos. 
Lung 
None 
clinically 
3. 
Chevassu2 
III 
None 
3. 
Gosset14 
None. 
(peritonitis) 
4. 
Morestin1 
I 
48 hours 
4. 
Chevassu5 
I 
None. 
(pneumonia) 
5. 
Morestin2 4 
II 
7 mos. 
Left 
Yes 
5. 
Bland Sutton 
2 yrs. 
None. 
kidney 
Vautrin 
7 mos. 
6. 
Jacob2 4 
2 mos. 
None 
6. 
1 mo. 
Probably 
spleen 
7. 
Gregoire 
V 
10 yrs. 
None 
7. 
Michon2 4 
II 
8 mos. 
None. 
8. 
Gregoire 
VI 
18 mos. 
Probably 
8. 
Gayet 
25 days 
None 
lung 
(pneumonia) 
9. 
Duval2 
III 
9 mos. 
Yes 
9. 
Howard 
1 yr. 
Yes 
Yes 
10. 
Duval2 
IV 
18 days 
None 
10. 
Davis 
9 mos. 
Yes 
11. 
Delbet 
2 yrs. 
4 mos. 
None 
11. 
Maragliano4 
10 mos. 
None. 
12. 
Michon1 4 
I 
2 yrs. 
4 mos. 
None 
12. 
Descomps 
I 
8 yrs. 
None. 
13. 
Michel4 
2 mos. 
None 
13. 
Descomps 
II 
Accidentally 
None 
(pneumonia) 
killed in 8 
14. 
Pringle5 
Liver 
None 
2 yrs. 
None 
14. 
Descomps 
III 
15. 
Lapointe and 
6 mos. 
None 
15. 
Lister 
3 wks. 
None. 
Alberstadt4 
Lungs 
16. 
Georgesco and 
9 mos. 
Symptoms 
16. 
Matas 
4} mos. 
Lung 
Savesco 
Barringer5 
I 
of hydro- 
nephrosis 
17. 
I 
22 mos. 
None 
17. 
Mauclaire 
V 
18. 
Barringer5 
II 
Not stated 
Lung 
18. 
Y oung5 
II 
2 yrs. 
None. 
19. 
Barringer 
III 
Lost fr 
om observa- 
19. 
Y oung5 
IV 
6 mos. 
21 mos. 
None. 
ti 
on 
TABLE III.—ANALYSIS OF CASES OF RADICAL OPERATION.—{Continued.) 
Group II.—Successful Resection of Primary Lymph Area. 
A. NO INVASION OF LYMPH GLANDS. B. METASTATIC EXTENSION TO LYMPH GLANDS. TREATMENT 
Author. 
Author. 
Diagnosis. 
Dead. 
Living. 
1. Guyot 
2. Patel 
3. Mauclaire2 II 
4. Pauchet 
5. Marion II 
6. Masini 
Radical operation followed by radiotherapy, with recovery 
Radical removal of tumor and glands 
Radical; metastases to both humeri and death in nine months 
Radical removal of glands which were not examined 
Radical removal of enlarged lymph glands 
Radical for seminoma, living and well, two years 
1. Cuneo1 II 
2. Marion1 I 
3. Mercade1 
4. Hinman3 VI 
Lues 
Lues 
Lues 
Tuberculosis 
Yes 
Yes 
Yes 
Summary of 77 cases: 3 Hinman, Gibson and Kutzmann: The Radical Operation for Teratoma Testis: An 
Operative deaths, 10-12.03 per cent. Analysis of 79 Cases (10 of which are personal) (paper in course of publication). Surgery, 
Died of metastases, 25 Gynecology and Obstetrics. 
Living with metastases, 5 
Living and well, 33 
Killed or lost, 4 
Total .... 77 
1 Cited by Mascarenhas. 
2 Cited by Delbet. 
601 
20. Young® I 
21. Young® III 
22. Hinman II 
23. Hinman6 IX 
24. Hinman6 X 
(Hepler) 
25. Lipschutz 
2 yrs. 
9 mos. 
Lung 
Yes 
Yes' ’ 
2 yrs. 
2 mos. 
2 mos. 
10 mos. 
None 
None 
None 
None 
20. Hinman I 
(Eloesser) 
21. Hinman III 
22. Hinman IV 
23. Hinman V 
24. Hinman6 VII 
18 mos. 
(cardiac 
dilatation) 
Right 
kidney 
Yes” 
8 yrs. 
4? yrs. 
2 mos. 
None. 
None. 
None. 
Summary of A: 
Operative deaths, 3 
Died of metastases, 8 
Living, 13 (over 4 yrs., 2) 
Lost after discharge, 1 
Total ... 25 
Summary of B: 
Operative deaths, 2 
Died of metastases, 6 
Living, 15 (over 4 yrs., 4) 
Accidentally killed, 1 
Total . . 24 
Summary of 49 cases, Group II: 
Operative mortality, 10.2 per cent. 
Morbidity to date, 38.7 “ 
Living 4 yrs. or longer, 6 cases 
Living over 3 years, 14 cases 
1 Cited by Delbet. 
2 Cited by Mascarenhas. 
3 Cited by Chevassu. 4 Cited by Sebileau and Descomps. 
6 Personal communication. 
6 Hinman, Gibson and Kutzmann: The Radical Operation for Teratoma Testis: 
publication). 
An Analysis of 77 Cases (67 in the literature and 10 personal) (paper 
in course of 
Group III.—Incomplete Data and Mistaken Diagnosis, 
a. data insufficient for analysis. b. mistake in diagnosis. 602 
TUMORS OF THE TESTICLE 
the progress of the malignancy and prolong life. In all other cases, 
metastases not demonstrable clinically, the attack should be whole- 
hearted. A certain number of these, unfortunately, will have inop- 
erable masses revealed after retroperitoneal exposure, and these cases 
will necessarily be condemned to the above palliative methods of 
radium and roentgen ray. Radiation of the open wound at the 
operating table is a commendable procedure for these as well as cases 
of successful resection. In a larger group, which will increase with 
earlier and more accurate diagnosis, radical surgery is indicated. A 
small number of these cases might be cured by simple castration, 
inasmuch as metastases have not yet occurred, but in the interest 
Fig. 258.—Photograph of solid testicular tumor due to massive tuberculosis. The 
uniform smooth surface, absence of tubercles and of suppuration may lead to difficulty 
in diagnosis upon gross inspection and illustrate the need and importance of diagnosis 
by microscopic study of frozen sections in every case of doubt. Tumor measured 9 x 10 
cm., the same size as the teratoma shown in Fig. 249. The line of separation appeared 
after hardening in formalin. 
of the majority they should unhesitatingly be exposed to the risk of 
a radical operation. This surgical risk is not great, less than 10 per 
cent., and will undoubtedly diminish as greater knowledge and 
experience with the operation is obtained. 
The technical steps of radical operation for teratoma testis are 
illustrated in Fig. 258 and Fig. 260. The patient is better turned 
a little to the opposite side, with a small pad under the back. The 
cord is exposed through an inguinal incision and clamped so that 
subsequent pressure and manipulation in delivering the testicle will 
not spread cells into the blood stream. If, upon delivery of the 
scrotal mass, a solid testicular tumor is found, castration should be TREATMENT 
603 
completed by severing the cord below the clamp with cautery. The 
tumor mass is immediately sectioned by a pathologist or assistant 
in order to confirm the diagnosis. Too many radical resections of 
Fig. 259.—Drawing in illustration of the technical steps of radical resection of the 
primary lymph zone; a, shows two types of incision. The one following the outer edge 
of the rectus for some distance and then curving out along the lower side of the twelfth 
rib gives a better exposure; b, shows the vertical inguinal incision, exposing the cord, 
which is clamped before delivering the tumor mass from the scrotum; c, cautery division 
of the cord after gross inspection has confirmed the diagnosis; d, shows the method of 
stripping back of the peritoneum, beginning in the iliac fossa. The ureter and spermatic 
vessels strip up with the peritoneum. The vas deferens is seen crossing the ureter and 
is divided low down behind the bladder. 604 
TUMORS OF THE TESTICLE 
retroperitoneal glands for tuberculosis or syphilis have been per- 
formed (4 are reported) to warrant the omission of this necessary 
diagnostic step. In case of malignancy the inguinal incision is extended 
Fig. 260.—Drawing to show completion of the operation. The spermatic vessels at 
their point of juncture with the abdominal vein and artery have been isolated, ligatured 
and divided before resection is attempted, which may then be carried out from above 
downwards or from below upward. 
to the twelfth rib, which it then parallels (Fig. 259-a). Muscle and 
fascia are divided in the line of this skin incision down to the peri- 
toneum. Beginning in the iliac fossa (Fig. 259-d), the peritoneum is 
stripped back to and beyond the large abdominal vessels. The ureter TREATMENT 
605 
and spermatic vessels with lymphatics strip lip with the peritoneum, 
but the lymph nodes remain upon, sometimes being quite adherent, 
to the vena cava and aorta. Theoretically, the lymph area should 
Fig. 261.—The spermatic sheath and metastatic lumbo-aortic lymph nodes (actual 
size, removed by radical operation together with tumor. The unusual size of these glands 
is particularly noteworthy in view of their successful surgical removal. 606 
TUMORS OF THE TESTICLE 
be removed from above downward, but practically its clean and 
complete removal is more difficult in this way than by resection from 
below, for the reason that traction on the cord greatly facilitates 
following it and making a clean dissection. It is probable that the 
cleaner, more complete removal permitted by dissecting from below 
upward offsets the theoretical advantage of peripheral attack. It 
would seem advisable, therefore, to combine the methods by first 
isolating, ligating and dividing the spermatic vessels at their points 
of union with vena cava, aorta or renal vein and then proceeding 
with resection of the area from below upward (Fig. 261). After com- 
pletion of the resection immediate exposure on the operating table 
of the retroperitoneal and iliac area to roentgen radiation is an added 
protection against recurrence because of possible isolated cells or 
metastatic areas left behind. The placement of rubber tubes for 
drainage of the serous discharge, with exit at the back or upper end 
of the wound, as after kidney operations, is advantageous, and these 
tubes may be used, or additional ones if advisable, to carry radium 
for radiation of the resected area for twelve to twenty-four hours 
postoperative. 
BIBLIOGRAPHY. 
Andre: Cancer due testicule avec extirpation des ganglions lombo-aortiques, Rev. 
med. de l’est, 1912, xliv, 420. 
Barringer, B. S., and Dean, A. L.: Radium Therapy of Teratoid Tumors of the 
Testicle, Jour. Am. Med. Assn., 1921, lxxvii, 1237. 
Biiclere: La radiotherapie des neoplasmes intra-abdominaux d’origine testiculaire, 
Bull, de l’Acad. de med., Paris, 1916, lxxvi, 72-81. 
Beckerich, Louis-Achille: De 1’ablation des ganglions lombo-aortiques comme com- 
plement ala castration pour neoplasme testiculaire, Thesis de Nancy, 1911 (see 
Mascarenhas). 
Bland-Sutton: An Improved Method of Removing the Testicle and Spermatic Cord 
for Malignant Disease, Lancet, 1909, ii, 1406; The “Radical” Operation for Malignant 
Diseases of the Testicle, Lancet, 1912, i, 606. 
Brenner: Zur Frage der Behandlung des Leistenhodens zum Sechzigsten Geburtstag 
Prof. Eiselbergs, Wien. klin. Wchnschr., 1920, xxxiii, 1062-1066. 
Bulkley, K.: Malignant Disease of the Testicle Retained within the Abdominal 
Cavity, Surg., Gynec. and Obstet, 1913, xvii, 703. 
Butt, A. P., and Arkin, A.: Malignant Diseases of the Retained Testicle, Surg., 
Gynec. and Obstet., 1914, xix, 419. 
Cacciatore, C.: Tumor del testiculo consecutivo a un traumatismo, Semana m6d., 
Buenos Aires, 1920, xxvii, 850. 
Calin, Paul: Du Traitement chirurgical du cancer du testicule (extirpation des 
ganglions ilio-lombaires). Thesis de Lyons, 1911. 
Chevassu and Picque: Teratome du testicule, Bull, et mOn. Soc. de chir., Paris, 
1898, pp. 24-60. 
Chevassu, M.: Tumeurs du testicule, Thesis de Paris, 1906; Le diagnostic clinique 
des cancers du testicule, Presse med., 1910, xviii, 363; Le traitement chirurgical des 
cancers du testicule, Rev. de chir., 1910, xli, 628, 886; Deux cas d’epitheliome du testi- 
cule traites par la castration et 1’ablation des ganglions lombo-aortiques, Bull, et mem. 
Soc. de chir., 1910, xxxvi, 236. 
Codman, E. A., and Sheldon, R. F.: The Prognosis of Sarcoma of the Testicle, 
Boston Med. and Surg. Jour., 1914, cixx, 267. 
Coley, W. B.: Cancer of Testis: Report of 64 Cases, Ann. Surg., 1915, lxii, 40-73; 
The Treatment of the Undescended or Mal-descended Testis, with Particular Refer- 
ence to End-results: A Report of 415 Cases, Trans. South. Surg. Assn., 1918, 1919, xxxi, 
79-101. 
Corner, E. M.: Diseases and Defects of Testicles, Med. Press and Circ., London, 
1915, n. s., c, 274-277. BIBLIOGRAPHY 
607 
Cuneo, B.: Note sur les lymphatiques du testicule, Bull, et mem. Soc. anat. de 
Paris, 1901, lxxvi, 105. 
Cunningham, J. H.: New Growths Developing in Undescended Testicles, Jour. 
Urol., 1921, v, 471. 
Dardel, G.: Klinische Erfahrungen iiber Kryptorchismus, Deutsch. Ztschr. f. Chir., 
1917, cxlii, 1-50. 
Davies, H. M.: Malignant Disease of the Testicle, and the Treatment of It by 
Radical Operation, Lancet, 1912, i, 418-421. 
Debarnardi: Beitr. z. Kenntniss d. Malig. Hodengeschwiilste, Beitr. z. path. 
Anat., 1906, xl, 534. 
Del bet, P.: Epithelioma testiculaire gauche; ablation de la tumeur et des ganglions 
lombo-aortiques (Guerison), par M. A. Gossett; Epithelioma du testicule; ablation de 
la tumeur, du cordon, des vaisseaux spermatiques, des ganglions iliaque et juxta-aortique, 
par M. Pierre Fredet; Deux cas d’epitheliome du testicule traites par la castration et 
l’ablation des ganglions lombo-aortiques, par M. Chevassu; Bull, et mem. Soc. de chir. 
de Paris, 1910, xxxvi, 236. 
Descomps, P.: Sept cas de chirurgie du cancer testiculare, Bull, et mem. Soc. de 
chir. de Paris, xlvi, 849-857; Discussion, pp. 917, 989. 
Dezarnaulds: De 1’extirpation des ganglions lombaires dans la Guerison du cancer 
du testicule, Thesis de Paris, 1906. 
Eccles: On the Anatomy, Physiology and Pathology of the Imperfectly Descended 
Testis, Lancet, London, 1902, i, 569, 722. 
Ewing: Teratoma Testis and Its Derivatives, Surg., Gynec. and Obstet., 1911, xii, 
230. 
Ewing: Neoplastic Diseases, 5922, Chap, xl, Tumors of the Testis. 
Frank: Die histogen. ableitung der Hodentumoren, Franfurt Ztschr. f. Path., 1911, 
ix, 206. 
Fredet, Pierre: Epitheliome du testicule; ablation de la tumeur, du cordon, des 
vaisseaux spermatiques, des ganglions iliaque et juxta-aortique (Rap. de P. Del bet), 
Bull, et mem. Soc. de chir. de Paris, 1910, xxxvi, 236; Obs. in Bull, et mem. Soc. de 
chir., 1910, p. 245; Rev. de chir., 1910, xli, 661; Maladies des org. gen. de l’homme par 
Le Dentu et Del bet, 1916, xxxii, 580. 
Gayet: Obs. in Calin, Thesis de Lyons, 1911. 
Georgesco, G., and Savesco, V.: Etude anatomique et chirurgicale sur trois cas 
de cancer du testicule, Jour, de chir. de Bucarest, 1914, iv-vi, 226. 
Goeritz: Arch. f. klin. Chir., 1919, iii, 4. 
Gosset, A.: Epithelioma testiculaire gauche; ablation de la tumeur et des ganglions 
lombo-aortiques; guerison (Rap. de P. Delbet), Bull, et mem. Soc. de chir. de Paris, 
1910, xxxvi, 236-262. 
Gregoire, R.: A propos de la communication de M. Pierre Descomps: Sept cas de 
Chirurgie du cancer testiculaire, Bull, et mem. de la Soc. de chir. de Paris, 1920, xlvi, 
917; Considerations sur l’etat des ganglions dans le cancer du testicule, Arch. gen. 
de chir., 1908, ii, 1; Obs. in Thbsis of Chevassu, 1906, p. 182 and in Rev. de chir., 1910, 
xli, 648, 654, 656. 
Gregoire, R.: Considerations sur l’etat des ganglions dans le cancer du testicule, 
Arch. gen. de chir., 1908, ii, 1; Obs. in Thesis of Chevassu, 1906, p. 182; in Rev. de 
chir., 1910, xli, 646, 654, 656. 
Guyot: Seminome du Testicule, Jour, de med. de Bordeaux, 1921, li, 326. 
Guyot and Villar, F.: Seminome du Testicule, Gaz. hebd. d. sc. med. de Bordeaux, 
1921, xlii, 425. 
Hardouin and Patel: Deux observations de tumeurs du testicule chez l’enfant, 
I. A. S. (by Jour, de chir., G. Masson). 
Hardouin, P., and Patel, G.: Deux observations de tumeur du testicule chez l’enfant, 
Bull, et mem. Soc. anat. de Paris, 1914, lxxix, 150. 
Heydenreich: Un cas de tumeur enorme du testicule, Congres frangaise de chirurgie, 
October, 1895, pp. 827-832. 
Hinman, F.: The Radical Operation for Teratoma Testis, with Report of Five 
Cases, Surg., Gynec. and Obst., 1919, xxviii, 495; The Operative Treatment of Tumors 
of the Testicle, Jour. Am. Med. Assn., 1914, xliii, 2009-2014. 
Hinman, Gibson and Kutzmann: The Radical Operation for Teratoma Testis, an 
Analysis of 79 Cases, 10 of which are Personal, Surg., Gynec. and Obst. (In course of 
Publication). 
Hoffstatter: Klin. Jber., 1912, p. 26. 
Howard, R.: Malignant Disease of the Testis, Practitioner, 1907, lxxix, 794-810; 
A Radical Operation for Malignant Disease of the Testis, Lancet, 1910, ii, 1406; A 
Lecture on Malignant Disease of the Testis, Clin. Jour., London, 1910, xxxvii, 6-14. 608 
TUMORS OF THE TESTICLE 
Jamieson and Dodson: The Lymphatics of the Testicle, Lancet, London, 1910, i, 493. 
Kaiser, H.: Ein Fall von Bilateralem Hedensarkom, Wien. klin. Wchnschr., 1920, 
xxxiii, 1066-1068. 
Kober, G. M.: Sarcoma of the Testicle, Am. Jour. Med. Sci., 1899, cxvii, 535. 
Krompecher: Ueber die Geschwulste, in besondere die Endotheliome des Hodens, 
Arch. f. path. Anat., Berlin, 1898, ci, 1-65. 
Kocher: Karnkheiten d. Mannl. Geschlechtsorganen, Deutsch. chir. Lief., 1887, 
1, 414-532. 
F.utzmann and4Gibson: Tumors of the Testicle in Children, Am. Surg. (In course of 
Publication). 
Langhans: Deutsch. chir. Lief, 1887, 1, 414-532. 
Lapointe and Alberstadt: Cancer due testicule; castration avec extirpation de la 
chaine ganglionnaire; mort par recidive cinq mois apr&s 1’operation, Bull, et mem. de 
la Soc. anat. de Paris, July, 1913, p. 400. 
Lardennois and Lec&ne: Fibrome de l’albuginee, Bull, et mem. Soc. anat. de Paris, 
1911, lxxxvi, 712. 
Levin, I.: Scope of Radium Therapy in Diseases of the Genito-urinary Organs, 
Urol, and Cutan. Rev., 1918, xxii, 6-9. 
Lipshutz, B.: Malignancy of the Undescended Testis, Associated with Hydrocele, 
Ann. Surg., 1922, lxxvi, 260. 
Lister, C. R.: A Case of Sarcoma of the Undescended Testis, Med. Jour. Australia, 
1915, i, 31. 
Makins: Multiple Fibromata of the Tunica Vaginalis, Proc. Royal Soc. Med., 1911- 
1912, v, 155. 
Maragliano: Radical Cure of Malignant Tumors of the Testicle by Extirpation of 
the Juxta-aortic Glands, Riforma med., Naples, 1913, vol. xxix, Nos. 33-34. 
Marion: Bull, et mem. de la Soc. de chir. de Paris, 1910, xxxvi, 1367. (See Mas- 
carenhas.) 
Marion, M.: Tumeur du testicule, Bull, et mem. de la Soc. de chir. de Paris, 1920, 
xlvi, 1273. 
Mascarenhas, C. O.: Contribution a l’etude du traitement du cancer du testicule, 
Thesis, Paris, 1912. 
Masini: Seminome du testicle et operation de Chevassu, Marseille med., 1921, lviii, 
519. 
Matas, R.: Clinical Reports of Cases Presenting Features of Unusual Surgical 
Interest, New Orleans Med. and Surg. Jour., 1915, lxviii, 327. 
Mauclaire, P.: Ablation d’un epithelioma du testicule avec toute la gaine des vais- 
seaux spermatiques, Tribune Med., Paris, 1905, n. s., xxxvii, 373-375; Embryome intra- 
testiculaire k evolution maligne tr&s lente, Bull, et mem. de la Soc. de chir. de Paris, 
February, 1922, No. 4, p. 163. Resumed by Dore: Jour, d’urol. med. et chir., May, 
1922, No. 5, p. 408. 
Metzmacher, Karl: Beitrlige zur Kasuistik der Malignen Hodentumoren. Diss., 
Wurzburg, 1913. 
Michel: Cancer du testicule; extirpation avec ablation des ganglions lombo-aortiques 
par la precede de Chevassu, Bull, etmem. Soc. de chir. de Paris, 1910, xxxvi, 1361-1367. 
Michon: Soc. de chir. de Paris, 1910. 
Miyata: Zur Kenntniss. Hodengeschwulste und die Bedeutung des Traumas fur 
ihre Entstehung, Arch. f. klin. Chir., 1913, ci, 426. 
Morestin, H.: Tumeur maligne du testicule, Bull, et mem. Soc. anat. de Paris, 
1899, lxxiv, 1018-1021. 
Most: Ueber maligne Hodengeschwiilste und ihre Metastasen, Arch. f. path. Anat., 
Berlin, 1898, xliv, 138-177. Ueber die Lymphgefasse und Lymphdriisen des Hodens, 
Arch. f. anal. u. Entwchl., 1899, p. 113. 
Nicholson: New Growths of the Testicle, Guy’s Hosp. Gaz., 1907, lxi, 249-321. 
O’Crowley, C. R., and Martland, H. S.: New Growths of the Testis, Their Symp- 
tomatology, Pathology, Diagnosis and Treatment, Surg., Gynec. and Obst., 1919, 
xxviii, 486. 
Odiorne and Simmons: Undescended Testicle, Ann. Surg., 1904, xl, 962-1004. 
Oraison, J.: Cancer simultane des deux testicules, Gaz. hebd. d. sc. mod. d. Bordeaux, 
1919, x, 32. 
Orbaan, C.: Roentgen-ray Treatment of Cancer of Genitals, Nederlandsch Tidjschr. 
u. Geneesk., 1920, ii, 695; ab., 1920, lxxv, 1301. 
Pauchet, Victor (d’Amiens): Cancer of the Testicle, Castration, Extirpation of the 
Spermatic Cord and the Iliac Glands, Arch. Provinciates de chir., 1910, xix, 239. 
Philipp: Ueber maligne Mischgeschwiilste des Kindlichen Hodens, Zeitschr. f. 
Krebsforschung, 1909. BIBLIOGRAPHY 
609 
Pillet: Cancer due testicule avec extirpation des ganglions pelvicus etlombaires, 
Normandie med., Rouen, 1913, xxix, 36-38. 
Pringle, Seton: Radical Operation for Malignant Disease of the Testis, Lancet, 
1913, i, 21. 
Ricard: Plurality des neoplasmes, Thesis de Paris, 1885. 
Roberts, J.: Excision of the Lumbar-lymphatic Nodes and Spermatic Vein in 
Malignant Diseases of the Testicle, Ann. Surg., 1902, xxxvi, 539-549; also Trans. Am. 
Surg. Assn., Philadelphia, 1902, pp. 297-307. 
RoullRs: (Cit. Case I, Descomps), Thesis, Paris, 1919. 
Saint Donat: Nouvelles Observ. sur la pratique des Accouchments (Pierre Amand), 
Paris, 1715, p. 79; cit. by Verneuil. 
Sakaguchi: Zur Kenntniss der Malignen Hodentumoren, vor allem der epithelialen, 
Deutsch. Zeitschr. f. klin. Chir., 1913, pp. 125-294. 
Sakaguchi, J.: Contribution k l’etude des tumeurs malignes due testicule, special- 
ment des formes epitheliales, Arch. gen. de chir., 1914, viii, 513, 641. 
Salabert, A. R.: Methode rationnelle pour pratiquer la castration dans les cas de 
tumeurs malignes du testicule (methode de M. Villar), Thesis de Bordeaux, 1901. 
Schulz and Eisendrath: The Histogenesis of Malignant Tumors of the Testicle, 
Arch. Surg., 1921, ii, 493. 
Sebileau, P., and Descomps, P.: Maladies des organes Genitaux de l’homme (vol. 
xxxii); Nouveau traite de chirurgie, by A. C. Dentu and P. Delbet, 1916, pp. 518-602. 
Slye, Maud; Holmes, Harriet F. and Wells, H. G.; The Comparative Pathology of 
Tumors of the Testis, Jour. Cancer Research, 1919, iv, 53. 
Smith, O. C.: Bilateral Sarcoma of Undescended Testes, Boston Med. and Surg. 
Jour., 1914, clxx, 839. 
Stimson, J. C.: A New Operation for Malignant Disease of the Testicle; the Necessity 
of a More Radical Operation than Castration for Carcinoma, Sarcoma, etc., of the 
Testicle, Med. Rec., New York, 1897, lii, 623; see also Albany Med. Herald, 1897, xvii, 
537. 
Symmers, D.: Metastasis of Tumors; Study of 298 Cases in 5155 Autopsies, Am. 
Jour. Med. Sci., 1917, cliv, 225-240. 
Talavera: Lymphadenome du testicule, Thfese de Paris, 1879; Recherch. histol. surg. 
tumeurs du testicule, Paris, 1879. 
Taylor, G.: The Aberrant Testicle; a Plea for Castration, Clin. Jour., London, 1918, 
xlvii, 26-28. 
Tizzone: Contrib. alio studio dei tumoro del testicolo, Rivista clin. di Bologna, 
1876, vi, 145. 
UfTerduzzi: Die pathologie der Hodenretention, Arch. f. klin. Chir., Berlin, 1913, c, 
115; ci, 150. 
Vautrin: Le traitement actuel du cancer du testicule, Rev. med. de l’est, Nancy, 
1910, xlii, 633-635. 
Verneuil: Tumeurs du testicule, Bull. Soc. chir. d. Paris, 1867, 2d s., vii, 355; (Mem. 
sur l’inclusion scrotale et testiculare), Arch. gen. de med., 1855, i, 641; ii, 191, 299. 
Violet: Cancer du testicule avec envahissement clinique des ganglions lombaires; 
du testicule; radiotherapie des masses ganglionnaires; guerison maintenue 
depuis un an, Lyon med., 1912, cxviii, 929-932. 
Von Foth: Ueber abnorme Lagen der Miinnlichen Keimdrusen mit besonderer 
Beriicksichtung der Kryptorchism, Leipzig, 1910. 
Von Patel: Deux cas du cancer du testicule, Soc. de chir. de Lyon, 1913, iv, 17; 
Lyon med., 1913, xxxvi, 394. 
Williams, W. R.: Malignant and Non-malignant Tumors of Bilateral Origin, Lancet, 
1910, i, 426. 
Wilms: Die Mischgeschwiilste, Berlin, 1902; Embryome u. embryoide Tumoren d. 
Hodens, Deutsch. Zeitschr. f. Chir., 1898, xliv, 1; Die teratoiden Geschwiilste d. Hodens, 
Beitr. z. path. Anat., 1896, xix, 233; Die rudimentaren Parasiten und embryoiden 
Tumoren der Geschlechtsdrusen, Centralbl. f. Allg. Path, und Path. Anat., 1897, viii, 861. SECTION IV. 
THE PROSTATE AND SEMINAL 
VESICLES. 
CHAPTER XVII. 
ANATOMY AND PHYSIOLOGY OF THE PROSTATE AND 
SEMINAL VESICLES. 
By WM. C. QUINBY, M.D. 
PROSTATE. 
Definition.—The prostate is the most important of the male accessory 
genital glands. It is a musculoglandular organ lying between the 
outlet of the urinary bladder and the triangular ligament, and enclosing 
within its substance the first, or prostatic, portion of the urethra and 
ejaculatory ducts. It shows a somewhat different morphology at the 
three periods of life: infancy, puberty and old age. 
Embryology.—For a clear understanding of the anatomy of the pros- 
tate a knowledge of its embryological development is most important. 
Indeed, it is only since the relatively recent studies on the formation of 
this organ, by Weski, Pallin,9 Porosz,12 and Lowsley,7 that there has 
existed any unanimity of opinion among anatomists and surgeons as to 
the relative importance and significance of the various lobes which 
together constitute the gland.* 
At about the third month of intra-uterine development the walls of 
the urethra, just below the bladder proper, show two small longitudinal 
depressions—the so-called prostatic furrows; and at the same time 
there are seen clumps of cells lying in the wall of the urethra, which in a 
short time, by a process of budding, become differentiated into glan- 
dular masses and tubules. These glandular elements penetrate the 
surrounding muscular and embryonic connective tissue in five distinct 
groups. One group takes its origin from the posterior midline of the 
urethra, just above the openings of the ejaculatory ducts; one on either 
side from each prostatic furrow and lateral urethral wall; one from a 
point just below the ejaculatory ducts, and one from the anterior wall of 
* Of these studies by far the most important are those of Lowsley, to whom the 
writer is indebted for many of the points brought forward in this present account. 
611 612 
ANATOMY AND PHYSIOLOGY OF THE PROSTATE 
Fig. 262. —Arteries of the pelvis. 
Fig. 263.—Sagittal view of a wax model of the prostate of a newborn infant. X 14. 
(From Lowsley.) Lai., anterior branches of lateral lobes; P.L., posterior lobe; E.J., 
ejaculatory duct; <S.F., seminal vesicle; A.L., anterior lobe tubule; U., urethra; UP., 
utriculus prostaticus; A.G., subcervical glands of Albarran; M.L., middle lobe tubules; 
L.Ur., left ureter; Bl., bladder; P.Gl., prostate gland. PLATE X 
Rectum drawn. 
Peritoneum of 
Douglas' pouch 
Ampulla of Vas def 
and 
'■ seminal vesicle 
Denonvillier's fascia ' 
over posterior surface 
of prostate 
Dissection of Prostate and Seminal Vesicles from Behind, to Show Fascia of Denonvillier’s. Note also 
the Location of the Peritoneum between the Two Ampullae of Vasa Deferentia. The Sacrum and 
Coccyx have been Removed. PROSTATE 
613 
the urethra, opposite the others. These form respectively the middle, 
two lateral, posterior and anterior lobe glands. The middle lobe 
tubules grow posteriorly between the ejaculatory ducts and the urethra. 
Those of the two lateral lobes also grow backward, and later form 
almost the whole of the base of the organ. They are not separated from 
the middle lobe by an intraglandular capsule. The tubules of the pos- 
terior lobe, arising below the ejaculatory ducts, grow backward behind 
these structures and are definitely separated from the lateral lobes by a 
fibrous intraglandular partition. The anterior lobe tubules, few in 
number at any stage, gradually disappear, until at birth the lobe is 
represented only by two or three glandular masses. As a rule this lobe 
remains insignificant, or it may even disappear entirely. 
Two other small groups of glands remain to be mentioned—the so- 
called subcervical and subtrigonal. The first of these, also called the 
group of Albarran—who was the first to call attention to its importance 
—appears to be constant after the sixteenth week, while the subtrigonal 
group makes its appearance at about the twentieth week. These two 
glandular masses lie closely underneath the urethral and bladder 
mucosa and are of importance only because of their ability easily to 
cause obstruction to urinary outflow if they become enlarged. 
The ejaculatory ducts run from above downward and forward 
obliquely through the substance of the prostate. They penetrate the 
posterior wall of the prostatic urethra on both sides of the utricle. This 
structure, the remains of the fused Mullerian ducts—an analogue of 
the vagina in the female—is seen as a blind tube running for a shorter 
or longer distance backward into the substance of the prostate. The 
prominence known as the verumontanum, on the posterior wall of the 
urethra, is composed of the utricle with the ejaculatory ducts and their 
envelopes. 
Gross Anatomy.—The shape of the prostate is somewhat that of a 
truncated cone with apex downward, flattened anteroposteriorly. The 
average dimensions of the adult gland are 3.4 cm. in length, 4.4 cm. in 
width, and 2.6 cm. in thickness. In consistency it is firmly elastic. 
A base, apex, anterior, posterior, and two lateral surfaces are described. 
The base is about one-third wider laterally than anteroposteriorly. 
It is concave and is directly apposed to the neck of the bladder and to 
the tips of the seminal vesicles. It is pierced by the urethra, and behind 
this in a short transverse groove by the entrance points of the two 
ejaculatory ducts. This groove divides a posterior from an anterior 
area. 
The apex is in relation with the triangular ligament, and gradually 
becomes merged with the musculature of the membranous urethra. 
The anterior surface of the gland, flat centrally and becoming convex 
laterally, looks toward the symphysis pubis, from which it is separated 
by cellular tissue and by the liberal plexus of veins known by the name 
of Santorini. 
The two rounded lateral surfaces are closely related to the fibers of 
the levator ani muscle. 614 
ANATOMY AND PHYSIOLOGY OF THE PROSTATE 
The posterior surface is that part of the gland which can be palpated 
by rectum. It is broader above than below, and in the midline shows a 
shallow vertical groove, which fades out toward the apex. 
On the posterior wall of the initial portion of the urethra contained 
within the substance of the prostate is seen a longitudinal elevation, 
known as the verumontanum. On both sides of the midline of this are 
the openings of the ejaculatory ducts, while in the middle and slightly 
above there occurs the slit-like opening of the utricle. On each side 
and below the verumontanum are seen the minute openings of the 
prostatic ducts. 
The fascial planes surrounding the prostate are important, although 
their description, as found in various anatomical works on the subject, 
differs considerably. This seems to be largely due to the well-known 
variations in development of the levator ani muscle, some subjects 
showing a marked increase over others in actual muscular fibers. Ac- 
cordingly this so-called pelvic diaphragm has no absolutely constant 
Anterior lole 
Middle lol>e 
I/dcr/ial spliacter Svlcereicalglands 
Utricle and 
E/amtaton,y duets 
Rsteriorlole 
Lateral I ole 
Utricle 
jEjaci/Jato/y duct 
Fig. 264. — The prostate in cross- 
section. Semidiagrammatic camera- 
lucida sketch. 
Fig. 265.—The prostate in sagittal 
section. Semidiagrammatic camera- 
lucida sketch. 
amount of fibrous expansion. For practical purposes, however, the 
description of Denonvilliers,3 one of the first to study the subject, is 
sufficiently accurate. He describes a puboprostatic aponeurosis, run- 
ning anteriorly from the prostate to be inserted into the posterior surface 
of the symphysis pubis. This is made up of two resistant fibrous layers 
on each side of the middle line, which sometimes bear the name of 
anterior ligaments of the bladder. Between these there is a space of 
about a centimeter, filled by a delicate but quite resistant fibrous tissue, 
pierced by numerous holes, through which run the dorsal veins of the 
penis to reach the venous plexus at the neck of the bladder. 
At its apex the prostate is supported by the deep layer of the tri- 
angular ligament—the trigonum urogenitale of the newer nomenclature. 
On each side is found the so-called lateral aponeurosis of the prostate. 
This runs from the descending rami of the pubis, backward to join the 
rectum; and by it the prostate is separated from the median margins of 
the levator ani muscle. It is closely applied to the sides of the gland PROSTATE 
615 
and is united to it by the cellular tissue containing the vesical plexus 
of veins. 
Behind the prostate, separating it and the seminal vesicles from the 
rectum, there is a transverse aponeurosis, known commonly as the fascia 
of Denonvilliers, but which he calls the prostatoperitoneal fascia. He 
describes this layer as attached below and anteriorly to the tip of the 
prostate and triangular ligament, and united above to the peritoneum, 
which descends between the bladder and the rectum. “ This last union 
is as marked as though there existed continuity of tissue, and explains 
the constancy of the rectovesical cul-de-sac” (Douglas’s fossa). On 
each side this fascia is attached to the lateral aponeurosis described 
above. By its posterior surface it is but loosely attached to the rectum, 
Fig. 266. —Microscopic section of prostate. (X 90.) Branching tubular glands 
surrounded by smooth muscle fibers and connective tissue. 
but by its anterior surface it is quite firmly attached to the seminal 
vesicles and to the true capsule of the prostate gland. The texture of 
this membranous layer is said to resemble that of the dartos. It is 
probably a fascia resulting from the obliteration of the embryonic 
urorectal septum. 
All these surrounding prostatic fasciae make up the prostatic bed— 
the loge prostatique of the French writers—and thus serve to control the 
direction and spread of suppurations in this area. The posterior fascia 
of Denonvilliers is also of surgical importance, because only by incising 
it can access to the gland be had in the operation of prostatectomy by 
the perineal method of Young. 
Besides these aponeuroses described above the prostate has a true 
capsule of its own which sends prolongations between the gland lobes. 616 
ANATOMY AND PHYSIOLOGY OF THE SEMINAL VESICLES 
Bloodvessels, Lymphatics and Nerves.—The arteries of the prostate 
are branches of the middle hemorrhoidal, of the inferior vesical, and of 
the internal pudic. The veins become grouped on the lateral and 
anterior surfaces of the gland, whence, after receiving the dorsal veins 
of the penis, they eventually empty into the internal iliacs. The 
lymphatics begin about the gland acini, and following the bloodvessels, 
drain into the lymph nodes situated on the hypogastric and iliac 
arteries. They are very numerous. 
The nerves of the prostate are derived from the hypogastric plexus 
of the sympathetic and also from the anterior roots of the third and 
fourth sacrals. These show many ganglion cells and variously con- 
structed end-organs, situated chiefly at the periphery of the organ. 
From the elaborate studies of Timofeew15 it is known that these nerves 
are medullated as well as non-medullated, some of them showing 
structures resembling the Pacinian corpuscles. 
Normal Histology.—The microscopic picture presented by the 
prostate is that of a gland of the compound tubular type. Each tubule 
is surrounded by smooth muscle fibers arranged in a circular fashion. 
Cylindrical cells with a basal nucleus line these tubules in a single layer. 
Occasionally a round or conical cell is interposed between them. The 
gland ducts are quite short and are lined by a single layer of cuboidal 
cells, which gradually become identical with those lining the urethra. 
The smooth muscle surrounding the ducts is laid down in a longitudinal 
rather than circular arrangement. Beginning just above the veru- 
montanum there is a thick mass of circular smooth muscle fibers laid 
down in a ring about the urethra. These form the internal vesical 
sphincter. Superiorly the fibers are continuous with the middle cir- 
cular coat of the bladder. Elastic and connective-tissue fibers are 
quite numerous throughout the gland, and an occasional area of lym- 
phoid tissue may also be seen. The relative amount of glandular tissue 
to muscular and supporting structures throughout the gland is about as 
five to one in the adult prostate. 
Definition.—The seminal vesicles may be described as a pair of con- 
voluted organs lying at the base of the bladder, between it and the 
rectum, and converging diagonally toward the midline, to empty into 
the ejaculatory ducts. 
Embryology.—Together with the ejaculatory ducts the seminal 
vesicles appear at about the third month of intra-uterine life as lateral 
evaginations of the Wolffian duct. At the fourth month the vesicles 
begin to show diverticula, and soon after this assume the general topog- 
raphy which they retain until puberty. At this period there is a 
marked increase in the size of these organs, as well as an addition to the 
number and diversity of their diverticula. 
Gross Anatomy.—The adult seminal vesicle shows an extreme indi- 
vidual variation in size as well as in the number and kind of diverticula, 
SEMINAL VESICLES. SEMINAL VESICLES 
617 
both in the filled and empty condition. Its cubic volume ranges from 
one to three, or even eleven, cubic centimeters in the single vesicle. 
The average length is from forty-five 
to fifty-five millimeters; the average 
breadth from fifteen to twenty milli- 
meters, and the average thickness 
about ten millimeters. Also in a 
single individual, one vesicle may 
be of different size and shape from 
its fellow. On external view the 
vesicles appear as somewhat long 
Fig. 267.—Left seminal vesicle and 
ampulla of vas deferens in section, seen 
from behind. (From Eberth: Mann- 
liche Geschlechtsorgane.) 
Fig. 268.—Simple convoluted type of seminal 
vesicle. (From Picker; Type C.) 
organs, flattened anteroposteriorly and with an irregularly corrugated 
surface, which has been likened to an area of varicose veins. 
Fig. 269.—Radiograph of injected vesicles and vasa deferentia. (From Picker; Type B.) 
The inner surface of the vesicles is in relation with the vas deferens 
and its ampulla, with which the vesicles are united by an embracing 
fascia. By their anterior surfaces they are closely approximated to the 618 
ANATOMY AND PHYSIOLOGY OF THE SEMINAL VESICLES 
posterior surface of the bladder wall. The upper portion of their outer 
surfaces (upper pole) lies against the ureter just at the beginning of its 
intravesicular portion, while on the posterior surface the vesicles are 
separated from the rectum by the peritoneum of Douglas’s fossa in their 
upper third, and by the fascia of Denonvilliers in their lower two-thirds. 
Fig. 270. —The vesicles, ampullae of vasa deferentia, and initial portion of ejaculatory 
ducts shown by the corrosion method. (From Pallin.) 
The varieties of diverticula have been carefully studied by Pall in,9 
by the corrosion method. He groups the vesicles under two main 
Fig. 271.—Microscopic section of seminal vesicle. (X90.) Very tortuous glands 
filled with secretion and spermatozoa, and surrounded by a thick muscular wall. 
headings; (a) those with slightly convoluted main channels, and (b) 
those with the main channel markedly convoluted. Under each divi- 
sion he makes two subheadings, according as the diverticula are short 
and uniformly developed, or irregularly developed and themselves con- 
voluted. A still more comprehensive study has been made by Picker,10 PHYSIOLOGY 
619 
who injected collargol or bismuth paste into the vesicles in 150 subjects 
and then examined them by radiographs. He divides his material as 
follows: 
Vesicles showing: 
Per cent. 
A. 
Simple straight tubes 
. 3.5 
B. 
Thick, twisted coils with or without very small diverticula . 
. 15.0 
C. 
Thin, twisted tubes with or without diverticula 
. 15.0 
D. Straight or twisted main channel with large bulbous diverticula 
. 33.0 
E. 
Short main channels; large branched, irregular accessory channels 
. 33.0 
F. 
Varia 
0.5 
Bloodvessels.—The blood supply of the seminal vesicles is large. It is 
derived from the middle hemorrhoidal and inferior vesical branches of 
the internal iliac artery. The main point of entry of these arteries is at 
the upper outer border of each vesicle. This fact has been emphasized 
by Barnett, who calls it the vessel pole, and who advises its careful 
ligation before enucleation of the organ. The veins are similar to the 
arteries. The nerves are derived from the pelvic plexus of the auto- 
nomic system and are present in considerable number. The lymphatics 
drain into the glands on the common and internal iliac vessels. 
Normal Histology.—The wall of the seminal vesicle is composed of 
three layers of smooth muscle fibers; the inner and outer coats running 
longitudinally, while the middle coat is circular. These enclose many 
multil-ocular cavities, lined by high, cylindrical epithelium. The cavi- 
ties are surrounded by many elastic tissue fibers, and show also in their 
periphery numerous sympathetic nerve ganglia. 
PHYSIOLOGY. 
The prostate is best examined physiologically from three aspects: as 
a secreting gland, as a muscular organ, and as an organ of special 
function represented by the great variety of nerve structures within 
its substance. 
Secretion.—With the advent of puberty the prostate and seminal 
vesicles assume an active growth which mostly involves their glandular 
elements, although there is some general increase in size and amount 
of the supporting structures. This activity is synchronous with the 
appearance of spermatozoa; and the combined secretions of the testes, 
prostate, seminal vesicles, and Cowper’s glands constitute the semen. 
This is a glairy, semimucilaginous fluid, of uneven consistency, giving 
off a characteristic odor. It is probable that these combined secretory 
products of the accessory genital glands act to preserve the life and 
motility of the spermatozoon, though the role played by any individual 
gland is still quite uncertain. We do know, however, that the seminal 
vesicles act as reservoirs for the spermatozoa, besides furnishing a 
secretion to the semen. 
From the many and diverse observations on this subject it seems 
probable that the prostatic and vesicular secretion acts on the sper- 
matozoa in a physical as well as in a specific physiological manner. In 620 
ANATOMY AND PHYSIOLOGY OF THE SEMINAL VESICLES 
the case of human spermatozoa it has been shown that the duration of 
their activity outside the body depends in a large measure on the re- 
action of their surrounding medium. An acid medium slows their 
motility, or entirely suspends it, while a weakly alkaline one seems most 
favorable. Analogous results are shown clinically in some cases of 
chronic prostatitis and vesiculitis, in which, though many spermatozoa 
are found, they are all without motion. And in such cases their 
motility is regained on subsidence of the infection. Such findings are 
best explained by a change in the reaction of the semen caused by the 
bacterial invasion. 
It has further been shown that spermatozoa placed in a physiological 
salt solution do not live as long as do those in the semen. But the view 
expressed by Fiirbringer,5 that the prostatic and vesicular secretion 
causes the spermatozoa, normally motionless, to assume motility, ap- 
pears at present untenable. For, in man, motile spermatozoa have 
been found frequently in the fluid of spermatoceles; and in exploratory 
revision of the epididymis in cases showing sterility, the writer has re- 
peatedly demonstrated motile spermatozoa in the globus major. But 
though spermatozoa obtained from the epididymis do show motion, 
it is probable that this is much better maintained in the midst of the 
normal secretions of the accessory glands. 
The physical properties of the semen in respect to its viscosity seem 
also to play a part, it being well-known that human semen becomes 
more limpid and homogeneous after standing than when it is first 
ejaculated, even though the normal temperature is maintained. It is 
probable that the more fluid portion of the semen, coming from the 
prostate, has a dissolving action on the globular masses which come 
from the seminal vesicles. This would tend to facilitate motion in 
those spermatozoa held in the vesicles. 
Attempts have been made to gain light on the physiology of these 
organs through experimental extirpation in animals, and though it is 
very unsafe to draw parallel deductions in such a highly specialized 
biological phenomenon as that of procreation, these experiments seem 
to be followed by sterility, though potency is retained. 
The intimate physiological relation between the prostate and the 
gonads is well shown in the marked glandular shrinkage following 
orchidectomy; or if carried out before puberty, in the complete failure 
of the prostate to take on its adult character. 
That the prostate has also an internal secretion—at least in dogs—* 
would seem to be quite well established by the work of Serrallach and 
Pares.13 Following a complete prostatectomy these investigators 
obtained atrophy and diminution in volume of the testes, with suspen- 
sion of spermatogenesis. In these animals intravenous injection of a 
glycerin extract of the prostate caused the reappearance of spermato- 
zoa, as did also a subcutaneous graft of prostatic tissue. 
Muscular Apparatus.—The musculature of the prostate takes part ir 
two physiological functions—those of micturition and of ejaculation 
In the latter the seminal vesicles also play a part. PHYSIOLOGY 
621 
In micturition the internal sphincter of the bladder is brought into 
play. This group of smooth muscle fibers forms the involuntary por- 
tion of the mechanism controlling bladder closure. Between the acts of 
urination this muscle is in constant tonus. It is still not entirely clear 
at what moment in the chain of events leading to urination it receives 
its stimulus to relax, or what the degree of bladder distention must be to 
call forth this stimulus. Indeed, writers on the physiology of micturi- 
tion are not at present in entire agreement on the subject. This is a 
matter, however, which falls outside the scope of the present article. 
It is important to note only that the sphincter internus is definitely a 
part of the prostate, and that it is dependent on an efficient connection 
with its nervous centres for its constant tonus. 
The arrangement of the muscle fibers about the prostatic follicles in 
a circular fashion, while they are longitudinally placed about the ducts, 
permits forcible and quick extrusion of the contents of the gland at the 
period of ejaculation. The same is true of the musculature of the 
seminal vesicles. In certain animals stimulation of the appropriate 
nerves calls forth a contraction of the vesicle, in which the organ be- 
comes shorter, while at the same time its circumference is narrowed 
by a wave of constriction beginning at the upper pole and travelling 
downward. Thus the contents of both prostate and vesicle reach the 
urethra quickly, where by the direction of the openings of the prostatic 
and ejaculatory ducts they are intimately mixed. 
It has been held by some that the semen is prevented from entering 
the bladder by a swelling of the verumontanum which takes place be- 
fore ejaculation occurs. The weight of evidence is against this view, 
however. Complete closure of the vesical sphincter, which is present 
during erection, is undoubtedly sufficient to meet this need. That such 
closure is of considerable intensity is well demonstrated by the unusu- 
ally marked voluntary efforts which must be made to secure relaxation 
of the sphincter and subsequent urination in the presence of erection. 
Nerve Supply.—Much has still to be learned concerning the function 
of the very complex nervous mechanism of the prostate and seminal 
vesicles. From the investigations of von Zeissel it would seem that 
the hypogastrics are the true secretory nerves of these organs. Motor 
nerves also exist; some in the hypogastrics, some in the nervi erigentes 
coming from the anterior sacrals. The significance of the ganglion 
cells and of nerves showing special end-organs is entirely unknown, 
though for the latter it may be surmised that they have to do with the 
sensual phase of the act of coitus. The importance of the nerve supply 
in the region of the verumontanum is undoubtedly great, though here 
again clear-cut data are lacking. Clinically, many abnormalities have 
been ascribed to inflammation located here, some justly, others without 
any clear evidence. Diminished sexual sensation, impotence, pre- 
mature ejaculation, among others, as well as psychic disturbances such 
as sexual neurasthenia, are sometimes said to be due to lesions of this 
area. However this may be, it is certain that the nerves situated here 
play a large part in the sensory side of the act of coition. 622 
ANATOMY AND PHYSIOLOGY OF THE SEMINAL VESICLES 
BIBLIOGRAPHY. 
1. Aversenq and Dieulafe: Aponevroses et espaces periprostatiques, Ann. d. mal. 
d. org. gcnito-urin., 1911, xxix-1, 1. 
2. Cosentino: Sulla distribuzione del tessuto elastico nella prostata dell’ uomo e 
degli animali. Anat. Anz., 1905, xxvi, 293. 
3. Denonvilliers: Propositions d’anatomie de physiologie et de pathologie. Paris 
Thesis, 1837. 
4. Fischel and Kreibich: Ueber Prostatasekretion, Wien. klin. Wchnschr., 1911, 
xxiii, 901. 
5. Fiirbringer: Ueber Prostatafunktion und ihre Beziehung zur Potentia generandi 
der Manner, Berl. klin. Wchnschr., 1886, xxiii, 476. 
6. Luna: Ueber Anordnung und Struktur der sympatischen Ganglien in der men- 
schlichen Prostata, Folia neurol., 1908, ii, 220. 
7. Lowsley: Gross Anatomy of the Human Prostate Gland and Contiguous Struc- 
tures, Surg., Gynec. and Obst., 1915, xx, 183. The Development of the Human Prostate 
Gland with Reference to the Development of Other Structures at the Neck of the Urinary 
Bladder, Am. Jour. Anat., 1912, xiii, 299. 
8. Muller and Dahl: Die Innervierung der mannlichen Geschlechtsorgane, Deutsch. 
Arch. f. klin. Med., 1912, cvii, 113. 
9. Pallin: Beitrage zur Anatomie und Embryologie der Prostata und der Samen- 
blasen, Arch. f. Anat. u. Physiol., 1901, i, 135. 
10. Picker: Studien iiber das Gangsystem der menschlichen Samenblase, Berlin, 
1911. 
11. Pousson and Desnos: Encyclopedie franpaise d’urologie, Paris, 1914, vol. i, O. 
Doin. 
12. Porosz: Daten zur Anatomie der Prostata, Arch. f. Anat. u. Physiol., 1913, Sup. 
vol., 172. 
13. Serrallach and Par&s: La secretion interne de la prostate, Ann. d. mal. d. org. 
genito-urin., 1911, xxix-1, 625. 
14. Stohr: Bemerkungen iiber die Verbindungen der Lymphgefasssystem der Prostata, 
Anat. Anz., 1899. 
15. Timofeew: Ueber ein besondere Art von eingekapselten Nervenendigungen in 
den mannlichen Geschlechtsorganen bei Saugethieren, Anat. Anz., 1896, xi, 44. 
16. Voelcker: Chirurgie der Samenblasen, Neue Deutsch. Chir., 1912, ii. 
17. Walker: Beitrage zur Anatomie und Physiologie der Prostata neben Bemerkungen 
fiber den Vorgang der Ejakulation, Arch. f. Anat. u. Physiol., 1899, 313. 
18. Wilson and Magrath: Surgical Pathology of the Prostate, Surg., Gynec. and 
Obst., 1911, xiii, 647. CHAPTER XVIII. 
PROSTATIC OBSTRUCTIONS. 
By JAMES A. GARDNER, M.D. 
The history of the treatment of obstruction at the bladder neck 
is a most interesting one. It shows the gradual development of skill 
and ingenuity by men who have been handicapped by the lack of 
anatomical knowledge and instruments by which they might make 
accurate examination. The early recognition and treatment is only 
interesting from a historical point of view and has been so thoroughly 
reviewed by Deaver6 that it will be unnecessary to take space here for 
any extended review. 
The early methods, beginning with tunnelling of the prostate, and 
later making a permanent fistulse, were improved by Merrier, who, 
in 1837, developed an instrument to incise the prostate in the same 
way that internal urethrotomy was performed. This method was 
improved by Bottini in 1873. This form of relief was very popular 
abroad, and in this country was used by Keyes, Chetwood, Willy 
Meyer and others. It was not until the birth of the cystoscope in 
1879, that prostatic surgery began to advance by regular steps. It 
is to Nitze that urology owes so much. As the cystoscope has been 
improved and diagnosis made more accurate so has prostatic surgery 
advanced. 
Perineal prostatectomy is an outgrowth of prostotomy by the open 
method and was practised by various men. Goodfellow in 1891, 
performed it through a straight median incision. He was able to 
enucleate the entire growth. He was one of the pioneers and followed 
this procedure for many years. The method was blind and the 
sphincter was frequently injured. It was not until Proust, (1901),23 
advocated an open operation where the removal of the prostate was 
performed under sight that a satisfactory method was suggested. 
Young36 improved and amplified this operation. The incision of 
the perineum and the exposure of the field was made possible by 
instruments which he introduced. 
To McGill, in 1887, credit is given for the first report of removing 
the obstruction suprapubically, not that he was the first to remove 
the obstruction by this method, but he was the first to advocate this 
method as a routine procedure. In 1901, Freyer, of London, advocated 
the suprapubic operation that bears his name and claimed that with 
his finger he could enucleate the entire prostate. It is now realized 
that he removed only the adenomatous growth. The operation, in 
his hands, became very popular, and as time passed he reported a 
large series of cases with a low mortality. He had many followers. 
623 624 
PROSTATIC OBSTRUCTIONS 
Fuller, in this country, in 1892, was the first to advocate combined 
suprapubic and perineal prostatectomy and did much to advance 
prostatic surgery. 
Perineal prostatectomy likewise had been accomplished many times 
by various men, notably Albarran and Proust in France, but it 
remained for Young, of Baltimore, in 1903 to work out a satisfactory 
technic for its performance. He published a large series of cases 
operated by this method and showed a remarkably low mortality rate. 
There still remained much to be desired. The methods, both supra- 
pubic and perineal, while reasonably safe in the hands of a few experts, 
when attempted by the general surgeon, as was often necessary, 
resulted in a relatively high mortality. The combined work of many 
urologists resulted in the general adoption of a period of preliminary 
treatment in all cases of urinary stasis. Periodic catheterization, 
continuous drainage of the bladder, renal decompression, became 
recognized preliminaries to prostatectomy. Finally the two-stage 
transvesical prostatectomy, which is an operation that is reasonably 
safe in the hands of the general surgeon, was established. 
ANATOMY OF THE PROSTATE. 
The anatomy of the prostate has been given in detail in a previous 
chapter, so the details need not be repeated here. Surgically we have 
come to recognize that the prostate is divisible into five lobes: the two 
lateral lobes, the middle lobe, the posterior lobe, and the anterior lobe.6 
The fact is that the prostate is described as divided into lobes only 
because it consists primarily of five buds jutting out from the posterior 
urethra. Each bud represents a collection of tubules which later 
develop into secreting glandular masses which finally fuse and form into 
a single body called the prostate gland. If one were to attempt 
division of the normal prostate into lobes basing his judgment on the 
gross appearance of the gland in its normal state it would be very diffi- 
cult. Therefore, to my mind, it is of very little moment whether we 
recognize certain definite subdivisions of the gland, or not, if we but 
keep in mind the fact that the gland develops from five distinct buds, 
and we may designate their end-development as we will. 
PATHOLOGY OF THE PROSTATE. 
The vast majority of enlarged prostates which cause obstructive 
symptoms show both microscopically and macroscopically, circum- 
scribed nodular growths, to which various names have been given, 
viz., hypertrophied prostate, adenomatous hyperplasia, benign 
adenoma, multiple adenoma, etc. The histological picture is per- 
fectly definite and no controversy exists in regard to the pathological 
diagnosis, but there is still much uncertainty as to the etiological 
factor, and the origin of these nodular growths. Some hold that 
the condition is a pure hyperplasia of the constituent gland cells, PATHOLOGY OF THE PROSTATE 
625 
Fig. 272.—Low-power photomicrograph of a cross-section of one-half of a normal 
prostate gland of a young adult, showing normal symmetrical distribution of ducts 
and lobules. 
Fig. 273.—Low-power photomicrograph of a cross-section of an entire prostate gland, 
showing multiple adenoma in the neighborhood of the urethra. Periphery shows non- 
adenomatous prostatic tissue. (Section kindly loaned by Dr. J. T. Geraghty.) 626 
PROSTATIC OBSTRUCTIONS 
while others believe that isolated lobules undergo a hyperplastic 
change; still others, including the writer, believe these nodules to 
Fig. 274.—Low-power photomicrograph of a cross-section of an entire prostate, aged 
thirty-four years, showing at A a single early adenoma. 
Fig. 275.—Low-power microphotograph of an adenoma impinging on the urethra. 
Note the contrast between the normal prostatic structure in the lower portion of the 
section. PATHOLOGY OF THE PROSTATE 
627 
be new growths springing either from remnants of undeveloped ducts 
or embryonic rests. 
While, as said above, the majority of hypertrophied prostates are 
Fig. 276.—Low-power photomicrograph of a cross-section of one-half of a prostate, 
showing at L a leiomyoma, impinging on the urethra, at A several adenomata and 
at N atrophic prostatic tissue. 
Fig. 277.—Low-power photomicrograph of an isolated adenoma. 628 
P ROST AT IC OBSTRUCTIONS 
caused by nodular growths, still occasionally, one meets with obstruc- 
tive symptoms, in which there occurs other pathological pictures, 
viz., diffuse hyperplasia or smooth muscle tumors. 
Fig. 278.—Higher-power photomicrograph of the nodule A seen in Fig. 274, 
Wilson and McGrath31 in an analysis of 468 prostates removed 
surgically at the Mayo Clinic, found that 387 or 83 per cent, showed 
hypertrophy. The remaining 81 prostates showed either malignancy 
Fig. 279.—Medium-power photomicrograph of an isolated adenoma in a lateral lobe. 
Note beginning of capsule formation. 
or tuberculosis. In this chapter, we will deal only with the pathology 
of chronically enlarged prostates which cause urinary obstruction. 
Normally the weight of the prostate gland gradually increases 
from the twentieth year, at which time its average weight is about PATHOLOGY OF THE PROSTATE 
629 
15 gm., up to the fiftieth year, when it reaches its maximum normal 
weight, viz., in the neighborhood of 20 gm. At this period the 
functional activity begins to wane, and this gland like some other 
Fig. 280.—Medium-power photomicrograph of an adenomatous nodule, showing 
atrophic remnants of prostatic glands. 
Fig. 281.—Low-power photomicrograph of a cross-section of the lower left quadrant 
of a hypertrophied prostate. Note multiple adenomata. At the centre the alveoli 
are dilated and the epithelium flattened. Note small adenoma in the capsule. Also 
atrophic remnants of prostatic glands in the capsule. 
glands of the body undergoes a natural atrophy corresponding to 
the gradual decrease of functional demand. But unfortunately, 
this normal process does not take place in all cases, for about 30 630 
PROSTATIC OBSTRUCTIONS 
per cent, show pathological changes that may give rise to obstructive 
symptoms, and are characterized by irregular nodular enlargements 
of one or more of the constituent lobes. 
The acute conditions in which the prostate gland becomes enlarged 
and thus may give rise to obstructive symptoms are acute prostatitis 
and prostatic abscess. These conditions will be considered in another 
chapter. 
Fig. 282.—Sagittal section through the pelvis, showing the prostate hypertrophied. 
(Tandler and Zuckerkandl.) 
Chronic enlargement of the prostate gland may be due to the 
following conditions: 
1. Diffuse parenchymatous or interstitial hyperplasia. 
2. Leiomyoma. 
3. Multiple adenomata (hypertrophy). 
4. Malignant neoplasms. MULTIPLE ADENOMATA 
631 
DIFFUSE HYPERPLASIA. 
The diffuse hyperplasia may affect either the parenchyma cells 
or the interstitial connective tissue and is characterized by a pro- 
liferation of either of these elements. As a usual thing, both are 
affected, but one or the other usually predominates and therefore 
leads to the classification, interstitial or parenchymatous hyper- 
plasia. In some cases, the process, may be limited to one of these 
elements, while the other seems to be little affected. 
These pathological conditions may be compared to that which 
occurs in the breast of females, especially around the time of the 
menopause and designated as chronic interstitial or chronic cystic 
mastitis. The etiological factor is long continued chronic inflam- 
mation, due to a previous infection. 
In the parenchymatous type, we find histologically a diffuse pro- 
liferation of the epithelial cells often occurring in folds or papilli 
containing two or more layers of cells. 
The alveoli are often dilated and may contain corpora amylacea 
and desquamated epithelium. The stroma shows infiltration of 
lymphocytes and often plasma cells and an occasional leukocyte. 
Grossly these prostates are more or less symmetrical in outline, and 
examination of a microscopical section with a simple magnifying 
glass fails to show circumscribed isolated nodules. 
The interstitial type shows a proliferation of the connective tissue 
often at the expense of the smooth muscle cells and a diffuse infil- 
tration of round cells. The gland is not markedly enlarged and in 
the latter stages, the connective tissue may contract producing a smooth, 
hard, irregular prostate; simulating clinically scirrhus carcinoma. 
Enlargement due to either parenchymatous or interstitial hyperplasia 
constitutes only a very small proportion of the prostates causing 
obstructive symptoms. 
LEIOMYOMA. 
Organs containing smooth muscle cells are always liable to be the 
seat of smooth muscle tumors, viz., leiomyomata. This is markedly 
true of the uterus, which is the seat of these benign neoplasms in 
nearly 50 per cent, of women in middle life. Leiomyomata are also 
found not infrequently in the ovaries, broad ligaments, the walls of 
the hollow organs, and in the prostate gland. In the latter organ, 
these are usually single and vary in size from a pin-head to a hazel 
nut. They rarely cause obstructive symptoms except when they 
are situated in the neighborhood of the prostatic urethra. This was 
the case in the specimen which is shown in Fig. 276. 
These tumors are composed of smooth muscle cells with very little 
stroma and undoubtedly originate in misplaced embryonic cells. 
MULTIPLE ADENOMATA (HYPERTROPHY). 
In the opinion of the writer, the vast majority of enlarged prostates 
are the result of true tumor formation, that is the benign adenoma. 632 
PROSTATIC OBSTRUCTIONS 
While these tumors may occur singly, the usual finding shows them 
to be multiple. 
While Virchow29 speaks of myomata and glandular tumors in con- 
nection with enlarged prostate glands, it is to Socin24 that the credit 
must be given for having definitely stated that the common cause 
of enlargement of this gland was due to true tumor formation. 
The tendency of American urologists and pathologists is to con- 
sider the usual enlargement of this organ as inflammatory hyper- 
plasia. Ewing, in his new book, “Neoplastic Diseases,” admits 
that the inflammatory theory is distinctly in need of further support, 
but on the other hand, he writes that several features stand against 
Fig. 283.—Cross-section of specimen, showing multiple adenoma. 
the neoplastic theory. The majority of French and German path- 
ologists accept this lesion as a manifestation of a benign tumor growth 
and Aschoff states definitely that the circumscribed nodular structures 
commonly the cause of enlargement of this organ, are true adenomata. 
Multiple adenomata of the prostate may be compared to a similar 
condition which occurs in the thyroid gland. Up to a certain age, 
both organs are free from this tumor formation. Then isolated ones 
begin to occur and in the course of time, new ones spring up in other 
parts of these glands until their presence begins to produce signs and 
symptoms, and we recognize them at this time on that account. 
Examination of cross-sections of prostates which are the seat of MULTIPLE ADENOMATA 
633 
multiple adenoma will nearly always show areas of non-adenomatous 
prostatic tissue which especially in older men show evidence of atrophic 
changes. This fact was observed and pointed out by Tandler and 
Zukerkandl27 in their extensive monograph on Prostatic Hyper- 
trophy. It would seem difficult to explain why certain areas in the 
same lobe should undergo hyperplasia, while others would show 
atrophic changes, unless one were to consider these nodules as true 
adenomata. 
Gardner and Simpson7 studied 80 prostates removed from consecutive 
autopsy cases, the ages ranging from one to eighty-five years. The 
first prostate to contain an adenoma was found in a man, aged thirty- 
four years. This was a small isolated adenoma in one of the lateral 
lobes.* In the next decade, that is from forty to fifty, 5 out of 19 
Fig. 284.—Showing multiple adenoma. 
prostates showed adenomata. Between the ages of fifty and sixty, 
there were 7 out of 14 which showed multiple adenomata, and in the 
next decade, that is between the ages of sixty and seventy years, we 
found 5 out of 18. In the majority of these cases, the prostates were 
not exceptionally enlarged and there was no marked evidence of 
inflammatory reaction in other portions of the organ. The glands 
in individuals between the ages of sixty and eighty-five years that 
did not adenomatous growths gave a histological picture of a 
general atrophy. It would seem that these findings give a decided 
support to the neoplastic theory. A study of 50 prostates removed 
at operation to relieve obstructive symptoms showed numerous 
isolated circumscribed nodules of various sizes, comparable to those 
found in the autopsy series. 
The fact that these tumors may originate from any area of the 
* Hada,9 in his extensive studies of the prostate, was able to find the early stages 
of adenomata formation. In a series of autopsy cases he found isolated nodules 6 times 
in the right lateral lobe, 4 times in the left lateral, twice multiple nodules confined 
to the right lobe and in 2 cases he found isolated nodules in the anterior lobe. 634 
PROSTATIC OBSTRUCTIONS 
commonly affected lobes, vary in size, and are circumscribed nodules, 
would appear to militate against the theory that prostatic enlarge- 
ment is commonly due to inflammatory hyperplasia. In the his- 
tological study of cases of infected hypertrophied prostates removed 
at operation, it is very illuminating in this connection, to find the 
adenomata free from infiltration of leukocytes, while the ducts and 
alveoli of the non-adenomatous portion showed the presence of these 
cells to a marked degree, thereby showing that the adenomata are 
without communicating ducts. 
The new growth starts as a small isolated group of cells wdiich 
soon arrange themselves to form alveoli. These alveoli resemble 
very closely normal prostatic structure. As these nodules increase 
in size, they compress the adjacent prostatic tissue which becomes 
atrophic and often forms a capsule for the neoplasm. The exami- 
nation of a microscopical section of one of these enlarged prostates 
with a simple lens shows these nodular structures very nicely. 
While the great majority of adenomata occur in the lateral lobes, 
and are frequently bilateral, one sometimes meets with a case in which 
they are confined to a single lobe, even rather small nodules situated 
in the middle lobe, may give rise to serious obstructive symptoms. 
Apparently the cells often take on a secretory function, for it is 
common to find the alveoli dilated and filled with fluid contents. 
Geraghty37 holds that the hypertrophy nearly always takes origin 
from the glands in the vicinity of the urethra and is practically limited 
to the lateral and middle lobes. 
Lowsley16 reports finding 2 prostates showing hypertrophy of the 
anterior lobe in a series of 97 cases which he studied. The posterior 
lobe, while frequently the seat of carcinoma, seems to be rarely affected 
in the hypertrophic process, as was shown by Geraghty in his path- 
ological studies of the prostate, and this fact is borne our in our experi- 
ence. 
The histological origin of these nodular growths may be from cells 
of the lobules that remain biologically more active than others, and 
respond to a demand for compensatory growth due to a waning inter- 
nal secretion which might explain their circumscribed structure. 
Ilada,9 in his study of prostates removed at autopsy, found in nearly 
all cases in men over forty years of age certain lobules showing hyper- 
plasia, while neighboring lobules showed atrophy. He believes that 
the hyperplasia is compensatory and that later the adenomatous 
hypertrophy takes its origin in these hyperplastic lobules. It is not 
altogether improbable that these nodules might take their origin 
from undeveloped tubules which were formed in embryological develop- 
ment. 
Lowsley16 has shown that in the early embryo, the anterior lobe is 
represented by an average of 13 tubules, while at birth the majority 
have disappeared, often only 2 persisting. It is not unreasonable 
to believe that this may occur in the other lobes, and also that rem- 
nants of these tubes may persist. That functional demand has its SUBCERVICAL GLAND HYPERTROPHY 
635 
influence upon the stimulation of the cells to take on growth char- 
acteristics is borne out by the fact that enlargement occurs usually 
past middle life. Another clinical observation is also of value along 
these lines, that is, hypertrophy of the prostate is rarely, if ever 
observed in Catholic priests. 
Fig. 285.—Hypertrophy of both lateral and the median lobes. The Y-shape taken 
by the prostatic urethra as it passes on either side the median enlargement to enter 
the bladder is well shown. Reduced -5. (Watson.) 
SUBCERVICAL GLAND HYPERTROPHY. 
While these glands do not belong to the prostate proper, they should 
be considered in connection with obstruction in this region. Jores12 
was the first to call attention to hypertrophy of these glands, and 
believed that all enlargement in this region was due to their hyper- 
trophy. We know now* that it is the true middle lobe which is com- 
monly the seat of these new growths in this location. 636 
PROSTATIC OBSTRUCTIONS 
Lowsley19 found in his studies of the prostate that 25 per cent, of 
men over thirty years of age, show hypertrophy of the subcervical 
glands and calls attention to the fact that this pathological condition 
Fig. 286.—Bilateral hypertrophy. The two lateral lobes joined by a bridge or median 
bar, the so-called bar at the neck of the bladder. Reduced ;. (Watson.) 
may occur without definite change in the prostate gland itself. A 
slight hypertrophy of the subcervical gland may give rise to serious 
obstructive symptoms. SUBCERVICAL GLAND HYPERTROPHY 
637 
Malignant neoplasma are to be treated in a subsequent chapter 
and will not therefore, be considered here. 
Fig. 287.—Hypertrophy of median lobe only. (Watson.) 
Fig. 288.—Gross specimen of hypertrophied prostate, showing enlargement of both 
lateral lobes and especially M, middle lobe. 
Secondarily Changes in the Urinary Organs.—These are due primarily 
to obstruction at the outlet of the bladder and later to infection. 
Deformity at the outlet of the bladder involving also the trigonum 638 
P ROST AT IC OBSTRUCTIONS 
Fig. 289.—Gross specimen of hypertrophied prostate. M, middle lobe; R L, right lateral 
lobe (note nodule at lower pole); L L, left lateral lobe. 
Fig. 290.—Cross-section of hypertrophied middle lobe, showing grossly, multiple 
adenoma. 
Fig. 291.—Cross-section of hypertrophied lateral lobe, showing grossly multiple adenoma. SUBCERVICAL GLAND HYPERTROPHY 
639 
Fig. 292.—Gross specimen of hypertrophied prostate, only lateral lobes affected. 
Middle lobe free. 
Fig. 293.—Same as Fig. 292, showing prostate cut open. 
Fig. 294.—Gross specimen of hypertrophied prostate, showing both lateral lobes 
symmetrically enlarged with no involvement of the middle lobe. 640 
PROSTATIC OBSTRUCTIONS 
corresponds to the extent and direction of the hypertrophy of the pros- 
tate. As a rule the gland enlarges, forces its way through the sphincter 
vesicle, gradually dilating it. In the cases of massively hypertrophied 
Fig. 295.—Photograph of prostate that was not markedly enlarged, but was com- 
posed almost entirely of circumscribed nodules, with very little prostatic glandular 
structure left. 
gland the sphincter is so widely dilated that it becomes functionless. 
At the same time the urethral orifice is raised, being displaced by the 
enlarging gland. Its form depends upon the character of the glandular 
hyperplasia, especially the size and shape of the middle lobe. 
Fig. 296.—Gross specimen of hypertrophied prostate, showing enlargement of both 
lateral lobes. The left lobe is more markedly affected. Note the nodular character. 
In the cases where the prostate is small and fibrous the orifice is 
displaced less, but the opening is much less flexible, as is true also of 
the cases of bar formation. In all of these cases the orifice is held high 
up and the trigonum drops down nearly vertically, so that the bladder PLATE XI 
Extreme Backward Pressure Produced by Prostatie 
Hypertrophy. 
Note extreme dilatation of both ureters and renal pelves and extreme 
atrophy of renal secreting tissue. (Wade.) URINARY OBSTRUCTION WITHOUT ENLARGEMENT 
641 
tends to sag at this point and form a so-called pouch below the level 
of the orifice, which makes it difficult to entirely empty the bladder. 
The increasing obstruction in the urethra, the lack of flexibility of the 
sphincter, the unnatural high position of the orifice and the sagging 
posterior wall of the bladder, all favor incomplete emptying of the 
bladder which gradually results in urinary stasis of varying degrees, 
influenced by the changing condition of the prostate. Retention of 
urine produces its own train of symptoms and, as the amount increases, 
the pathological changes extend, affecting the bladder itself, the ureters, 
the kidney and finally the general system. (Plate XI.) 
The bladder is affected first. The obstruction to the outflow of urine 
is partially compensated for by an increase in the thickness and strength 
of the muscular walls. The muscle bands increase very markedly in 
size and, as the obstruction increases, the individual muscle columns 
hypertrophy to such an extent that they stand out on the inner wall of 
the bladder, forming an interlacing network of bands or trabeculations. 
As the obstruction increases and the force exerted continues, the section 
of the bladder wall between the muscle bands bulges and numerous 
false diverticula are produced. The ureter openings are usually not 
affected until a late stage of the disease. With the incidence of infection, 
the mucous membrane becomes inflamed, mucus and phosphatic mate- 
rial deposits between the trabeculae and calculi form. In our own 
series calculi were found in about 20 per cent, of the cases. If the 
cystitis is of long standing, the inflammation extends more deeply 
into the bladder wall and further impairs its utility. 
The ureters and finally the kidneys gradually become affected, first 
from mechanical obstruction and second through infection. 
Aside from the clinical evidence of renal infection and renal insuf- 
ficiency, the most striking evidence of renal injury due to prostatic ob- 
struction is presented in those patients dying from the disease. Autopsy 
shows a variety of conditions existing in the kidney, the lesion most 
common to all being a dilatation of the ureter beginning immediately 
above the bladder, resulting in various degrees of hydro-ureter and 
hydronephrosis and destruction of the kidney parenchyma. This in 
turn is influenced by the degree and duration of the obstruction and in 
more advanced cases is accompanied by infection, formation of renal 
calculi, and in some by actual infection and destruction of the kidney 
parenchyma. 
Urinary Obstruction without Enlargement of the Prostate.—This 
subject should occupy a chapter by itself, but is so closely allied with 
the subject of enlargements of the prostate that it must be mentioned 
here. We recognize a number of lesions entirely distinct in etiology 
and histological formation. 
First Type.—A submucous fibrosis. The most prominent change 
found, according to Young, is the occurrence of a newly formed con- 
nective-tissue layer immediately beneath the mucous membrane, 
forming a firm fibrous ring associated with an elevation of the median 
portion of the prostate. There is no underlying prostatitis, no infiltra- 642 
PROSTATIC OBSTRUCTIONS 
tion of the sphincter muscle, or hyperplasia of gland tissue. It is 
essentially a submucous fibrosis. 
Second Type.—Hardly less frequent are those cases of deformed 
orifice due to chronic inflammatory change in the glandular tissue with 
round-cell infiltration occasionally extending into the muscle. This 
is undoubtedly due to previous prostatitis. 
Third Type.—That due to hypertrophy, or proliferation of the sub- 
urethral or subtrigonal group of gland acini. This produces retention 
by mechanical obstruction precisely as do enlargements of the prostate. 
Symptoms.—The most characteristic symptom of obstructive pros- 
tatic disease is the gradual development of frequent urination, with a 
gradually increasing urgency of urination, and in many cases an 
increase in the amount of urine passed. 
Around these symptoms are grouped various classes of cases which 
may be described as different types, nearly all of which either early in 
the disease, or later, present the symptom of frequency of urination as 
its most prominent feature. 
It has been the writer’s experience that the particular symptom- 
complex is not dependent upon any one form of prostatic enlargement. 
Naturally, the symptoms are dependent upon the degree of pathological 
change present along the urogenital tract. Nephritis, pyelonephritis, 
stone in the kidney, ureter, or bladder, purulent cystitis, diverticulitis, 
increasing degrees of residual urine, all influence the symptom-complex. 
Stone in the bladder especially affects the symptoms, for its presence 
causes a congestion and pseudo-enlargement of the prostate, the 
obstruction, however, decreasing upon the removal of the stone. 
The primary symptoms are due chiefly to the obstruction to urination 
caused by the changes in and about the prostate, and in addition to 
congestion of the mucous membrane and morphological irregularities 
in the prostatic portion of the urethra. Frequency and urgency of 
urination are dependent on these factors, while the symptoms of painful 
urination and distress after urinating usually are associated with 
inflammatory conditions of the prostate and the more infrequent forms 
of obstruction due to fibrous hyperplasia. 
The usual story is that of increasing frequency of urination, first 
noticed at night; later a certain amount of urgency when the desire to 
urinate is present; slight difficulty in starting the stream, some 
diminution in the force and size of the stream as it is ejected; a certain 
amount of distress in the perineum; also, under stress of nervous excite- 
ment, or after exposure to cold, there is often a marked inability to 
urinate voluntarily, and the impossibility of checking the stream as 
quickly and fully as was formerly possible. The symptoms are quite 
irregular as a rule, there being periods of well-being during which time 
the patient does not notice anything unusual other than the slight 
increased frequency of urination, and again, the symptoms will be 
increased by various indiscretions of diet or exercise, and there will 
exist considerable difficulty in urinating and a sense of pressure and 
incomplete evacuation of the bladder with more or less continued desire URINARY OBSTRUCTION WITHOUT ENLARGEMENT 
643 
to urinate after the act has been completed. Even in the early stage 
we may have a period of temporary complete retention of urine coming 
on after undue exposure. This may last for a few days and then pass 
off entirely. If the obstruction is due to an irregular form of enlarge- 
ment, such as a submucous fibrosis or small nodular hyperplasia, with 
only partial obstruction of the canal, we usually have in addition to the 
ordinary symptoms vague pains referred to the perineum, to the back 
and to the legs, and in addition painful urination. If at any time a 
catheter is used, infection may take place and the entire picture may 
change to one of cystitis with urinary stasis. Later in the early stage 
there may be enuresis and slight dribbling of urine during the day. At 
a later period in the development of the enlargement the symptoms are 
mostly those of obstruction and pressure, with the symptoms localized 
in the bladder and urethra. It is a period of incomplete chronic 
retention. The bladder at no time is entirely empty unless a catheter is 
passed. The urine frequently does not change its character except 
in the lowering of the specific gravity and an increase in the 
actual amount of the urine passed. The symptoms here are variable, 
depending upon the amount of dilatation of the bladder. There is an 
increase in the dysuria, the urinary stream is smaller and it may even 
decrease in size until the patient urinates intermittently in very small 
amounts. Dull pain in the bladder region extending downward to the 
legs is frequently complained of at this stage of the disease. There is 
some difficulty at stool and the patient begins to strain and exert con- 
siderable muscular effort to empty his bladder. During this period of 
mechanical obstruction, calculi frequently form in the bladder. In our 
own series of cases it occurred in about 10 per cent, of the cases. The 
calculus tends to increase the disturbing symptoms and invites infection. 
At this time also, secondary changes begin to take place in the kidney 
and the reflex disturbances make their appearance, especially those of 
the gastro-intestinal tract. Hematuria may occur at any time, but is 
evidence of either a complication or an advanced stage of hyperplasia. 
The kidney becomes more and more affected by the chronic retention 
and expresses itself in an increased secretion of urine of a low specific 
gravity. In addition, changes in the stability of the renal function 
become evident. 
The patient’s general condition begins to suffer markedly. There 
are evidences of loss of sleep, the loss of appetite, lack of food and 
increasing mental unbalance resulting in a condition of chronic inva- 
lidism. The patient becomes an object of pity, his linen is saturated 
with urine and he always carries with him the unmistakable odor of 
decomposing urine. Gradually as time goes on his entire attention is 
given to emptying his bladder. If the case still remains untreated, the 
patient passes on to a stage of chronic complete retention of urine with a 
guttatim overflow. The constant straining often produces inguinal 
hernise, hemorrhoids and prolapsus ani. Efforts to empty the bladder 
become more and more ineffectual and the use of a catheter is resorted 
to. Sooner or later cystitis develops which adds its distressing symp- 644 
PROSTATIC OBSTRUCTIONS 
toms. Later the ureters and kidneys share in the infection and death 
results. 
The complications and sequellse of infection and calculus formation 
along the urinary tract are the same in their terminal stage, whether due 
to prostatic obstruction or to other obstruction in the urethra, or at the 
neck of the bladder. 
It is impossible to give a complete word picture of the symptoma- 
tology of this disease because of the diversity of the pathological 
changes which take place. For example, some patients will present 
symptoms of the early stages of the disease and remain without change 
for years, while other patients will rapidly pass from one stage to the 
other and unless properly treated will find their lives intolerable in a 
short period of time. It is well known, also, that some men will go 
about suffering from a chronic overdistention of the bladder without 
ever having suffered urinary symptoms to call their attention to the 
fact. 
The main features, however, are the same. That is, the gradual 
development of an obstruction at the outlet of the bladder, causing 
incomplete evacuation of the urine, resulting in far-reaching patho- 
logical changes, and terminating in death from uremia or sepsis. 
Diagnosis.—History.—It is important in every case to take a com- 
plete history of the patient. This includes the usual data concerning the 
early life and habits of the patient, as well as a detailed record of the 
diseases and accidents suffered by him. The special points worthy of 
note in all patients suffering from urinary disturbances have already 
been stated in previous chapters. In these cases we wish to know first 
the age of the patient, his social status, his venereal history and whether 
or not he has at any time suffered from infection of the kidney or 
bladder, has passed calculi, or has been subject to attacks of renal colic. 
We should ascertain, if possible, whether pus or blood has ever been 
found in his urine. It is especially important to know if there have 
ever been any periods when he was unable to voluntarily evacuate' his 
bladder. If so, has it been necessary to pass sounds or catheters to 
withdraw the urine? In fact, it is always best to obtain all the data 
possible concerning the urinary organs of the patient previous to his 
present trouble. 
Next, it is important to question the patient concerning the develop- 
ment of the disorder for which he seeks relief. The duration of his 
symptoms, the order of their occurrence, the extent of the disability 
resulting, and the effect upon other organs and systems of the body. 
Usually the patient’s attention will centre about the act of urination, 
the increasing frequency at night and during the day, the difficulty of 
starting the stream, the smallness of the stream and the lack of force in 
ejecting it, and the soiling of his linen afterward. Such a history 
given by a man of advanced years immediately makes one think that he 
is suffering from obstructive enlargement of the prostate. There are, 
however a number of other pathological lesions which may give rise to EXAMINATION 
645 
these same symptoms. Therefore a detailed history should be taken 
and a careful examination of the patient made. 
Examination.—A general physical examination of the patient should 
first be made. It is unnecessary to reiterate the details of this pro- 
cedure, but special care should be directed to the condition of the lungs 
and heart and the general arterial and venous systems. It is important 
to know the condition of the heart muscle and the condition of the 
walls of the arteries; and in addition, to record the blood-pressure. An 
examination of the blood should be made to ascertain the percentage 
of hemoglobin which is present, and to determine when possible, the 
blood urea and blood creatinin content as an index of the renal 
efficiency. 
The soft-rubber catheter. 
Mercier coude catheter. 
Mercier bicoude catheter. 
Bougie catheters. 
Fig. 297.—Various forms of catheters. 
A detailed examination of the abdomen should be made, noting 
especially the condition of the stomach and intestines, palpating for 
tumors, and percussing for the bladder, if it is distended. Frequently 
the examiner will note the presence of inguinal hernise. 
Next, the legs are examined, searching especially for edema and 
varicosities. 
With a knowledge of the general condition of the patient, the phy- 
sician then turns to an examination of the urethra and bladder. At 
this point a divergence of opinion arises. The expert in urethral 
catheterism needs no advice. The ordinary physician is advised to 646 
PROSTATIC OBSTRUCTIONS 
use the instruments which can do the least harm. If one is not 
experienced in the use of a cystoscope, it is wiser to employ the older 
methods of diagnosis, preferably a medium-sized soft-rubber catheter, 
or, if this cannot be passed, a Mercier coude catheter which is stiffer 
and is especially molded so that the end tends to pass up over the 
obstructing prostate and enters the bladder. If one is not successful 
with the Mercier coude catheter, the bicoude or the bougie catheters 
should be tried (Fig. 297). 
The operator must employ every precaution to protect the urethra 
and bladder from infection. 
Technic.—The patient first passes as much urine as possible. Then 
with the patient in the recumbent position, the glans penis is carefully 
cleansed, the instrument lubricated and introduced slowly. Great 
care must be exercised when the prostatic urethra is reached. Too 
great force exerted at this point will easily cause laceration of the tissues 
which causes hemorrhage and invites infection. If the obstruction 
cannot be overcome after trying various catheters, the operator should 
desist. The beginner should be warned against using small, stiff 
instruments for two reasons. First, they are more apt to cause injury, 
and second, because a large one usually passes more easily into the 
bladder. 
If the catheter enters the bladder, the urine is allowed to flow out. 
If the bladder is over distended, it should never be entirely emptied, as 
fatal hemorrhage into the bladder has been known to follow this 
procedure. The amount of urine withdrawn (after the patient has 
passed as much as he could voluntarily) constitutes the residual 
urine. This is saved for laboratory examination. 
During the passage of the catheter or metal instrument through the 
prostatic urethra, the length of this portion of the tract can usually 
be estimated and frequently its tortuosity can be appreciated. 
Rectal Examination.—1This is always of importance. The finger in 
the rectum will easily detect any marked enlargement of the lateral 
lobes. If malignant disease exists, it is usually most marked in the 
posterior lobe, and one feels varying degrees of induration and hardness 
here which leads one at least to suspect cancer. Often intravesical 
enlargements of the prostate are present which cannot be determined 
by the finger. 
The Use of the Cystoscope.—No instrument which has been devised for 
estimating the size, conformation, and relations of a diseased prostate 
has proved more useful than the simple prismatic or correct-vision 
cystoscope in the hands of an experienced operator. 
The cystoscope is quite accurate for determining the size and contour 
of an intravesicallv hypertrophied prostatic lobe. The thickness of an 
intravesical glandular hyperplasia may be measured, and the prostatic 
urethra may be explored. 
For these uses it is necessary to have an instrument in which the 
reflecting prism is so constructed that objects, even though they may be 
almost touching the surface of the prism, may be distinctly seen. One EXAMINATION 
647 
must, however, always make proper allowance for the magnification 
and possible distortion. In the ordinary case, in order to complete 
our examination, we first have the patient pass his urine and then we 
immediately introduce the small bladder cystoscope, measure the 
residual urine, wash out the bladder through the cystoscope, rein- 
troduce the telescope, and make a further examination of the bladder. 
The essential points in the technic of the examination are as follows: 
Technic.—The anterior urethra is made insensitive by the use of a 
4 per cent, novocaine solution. If the patient is supersensitive, two 
grains of alypin are deposited in the posterior urethra. The bladder 
cystoscope is then introduced as previously described. The bladder 
is filled with 200 to 500 c.c. of sterile water, or a 2 per cent, boric 
acid solution, and a thorough examination is made. 
Fig. 298.—Cystoscopic picture showing false diverticula in a trabeculated bladder—the 
result of disease. 
Conducting the Examination.—The base of the bladder and the ureter 
openings are first examined. This is essential, because there is fre- 
quently some bleeding caused by the instrumentation and the base of 
the bladder becomes quickly obscured. The urinary efflux is studied, 
diverticula, calculi, tumors, scars, and other pathological conditions 
looked for, especially noting the presence and degree of trabeculation. 
This will give some idea of the effect of the obstruction on the bladder. 
Sometimes we find distortion of the ureter openings, but there is 
seldom interference with the urinary efflux unless the disease has 
progressed to the stage of involvement of the ureter and kidney. 
Diverticula occur most frequently near the ureter openings and at 
the vertex of the bladder. If there is an insufficient quantity of 
fluid in the bladder, the base sinks down and it is difficult, and often 
impossible, to examine thoroughly the pouch which is formed below 
the prostatic bar or median enlargement of the prostate. This dif- 
ficulty may be overcome by introducing more fluid, wrhich will tend 
to elevate the base of the bladder so that the trigone will come more 
fully into view. It is in this pouch, which forms mainly posterior 648 
PROSTATIC OBSTRUCTIONS 
to the interureteric band, that phosphatic concretions, diverticula, 
and stones are found. 
As a result of chronic obstruction the muscular structure of the 
bladder wall becomes greatly hypertrophied and thickened. In the 
earlier stages of prostatic obstruction only a few of these bundles are 
seen crossing the wall; but as the obstruction becomes more complete 
they appear as innumerable, well developed, interlacing columns, 
resembling a lattice-work, with larger and smaller branches, much 
like the muscular structure seen on the inside of the ventricles of the 
heart (Fig.' 298). The spaces between these bundles frequently 
show the openings of diverticula, which vary greatly in size and 
depth; sometimes stones are found within them. Such pockets, 
when infected, give rise to an intractable cystitis. The superior sur- 
face and sides of the bladder do not share equally with the posterior 
surface in this change. 
In many cases of prostatic disease there is present in the bladder 
some evidence of inflammation. It varies from a simple hyperemia 
of the base to a severe general involvement of the viscus. In the 
chronic forms the mucous membrane is swollen and pale; with acute 
exacerbations portions of the bladder appear more acutely inflamed, 
especially the trigone, but, as a rule, the rest of the bladder remains 
unchanged. This naturally depends upon the intensity of the cystitis. 
In the old chronic forms the bladder will be found covered with shreds 
of muco-pus and phosphatic concretions which are difficult to detach. 
If a stone of large size is present, a satisfactory examination cannot 
always be made. 
Examination of the Prostate.—It must be remembered that in using 
the ordinary prismatic cystoscope, without the correct-view lens, the 
picture seen is inverted and considerably magnified. The newer lenses 
give a correct view with a magnified picture. 
As the instrument is drawn back toward the urethra, after a thorough 
examination of the bladder has been made, the prostate will come into 
view and that portion of the organ covered by bladder mucosa can be 
carefully studied. Only a small portion can be viewed at one time. 
The operator should first view the entire orifice by turning the cysto- 
scope through a complete circle. This gives an idea of the prostatic 
mass; any abnormalities may be noted, to be studied later in detail. 
The size and position of the median enlargement and its relation to the 
trigone and the ureter openings should be studied. 
The normal prostatic orifice appears circular except at its posterior 
margin, which is flattened or slightly raised. 
In bilateral enlargement of the prostate the anterior and posterior 
views show sulci of varying depths. As the instrument is turned 
around, the lateral lobes are seen to come together and project into the 
bladder. 
In marked median-lobe enlargement the position of the cystoscope as 
it enters the bladder may be so influenced that it will lie in a sulcus 
between the median lobe and a lateral lobe, and it is only by raising or EXAMINATION 
649 
depressing the shaft of the instrument that a correct idea of the true 
conditions can be obtained. 
The picture presented by a cleft formed by two hypertrophied lobes 
depends upon the position of the cystoscope. If the cystoscope is 
pressed up into the sulcus, the lobes are separated and no cleft is seen. 
But as the beak is lowered, the lobes press together and the cleft can be 
seen. 
In this way the prostatic orifice may be studied, and a fairly exact 
idea of the degree and character of the prostatic enlargement be 
obtained. 
Of what Value is the Cystoscope in the Diagnosis of Obstructive Pros- 
tatic Hypertrophy f—By the use of the instrument all the necessary 
intra-urethral instrumentation can be carried out; the presence of 
strictures determined; the length of the urethra measured; the amount 
of resistance in the prostatic urethra accurately felt by the hand; the 
amount of residual urine measured, and, in the great majority of cases, 
the presence of new growth or other obstructing intravesical conditions 
be excluded. The presence or absence of a calculus is always important 
to know beforehand, and this can be diagnosed with the greatest 
accuracy by the cystoscope. Oftentimes the presence of a stone in the 
bladder will cause sufficient congestion of a prostate to create obstruc- 
tion. Furthermore, the exact position of the obstructing mass, be it a 
prostatic bar or a single ball-valve median-lobe enlargement, or a lateral- 
lobe encroachment, or an anterior-lobe obstruction, may all be deter- 
mined before operation is undertaken. This knowledge may have an 
important bearing upon the character of the operation. 
Before withdrawing the cystoscope the lamp should be extinguished, 
and with the instrument still in the bladder and one finger in the rectum 
the thickness of the prostatic bar can be determined by drawing the 
beak of the instrument down and engaging the prostatic urethra 
between it and the examining finger. 
X-ray Examination.—This is seldom employed as a routine method of 
examination in the diagnosis of urinary obstruction. It is of value, 
however, in those cases where the diagnosis is doubtful, especially where 
we know or suspect that a stone is present in the bladder. Occasionally 
a calculus is hidden in a diverticulum, and the ordinary examination 
with the finger does not always discover it. Frequently there are small 
stones which form in the substance of the prostate, but it has been our 
experience that they do not always register on the x-ray plate. 
The x-ray examination is especially valuable in the cases in which 
there is a recurrence of the dysuria following prostatectomy. The pic- 
tures are taken, first with the bladder empty and second with the bladder 
filled with an opaque solution. The presence of calculi, diverticula, 
and irregularities at the outlet of the bladder can sometimes be 
demonstrated. 
How Far are We Justified in Insisting on a Complete Diagnosis 
before Operationf—fill is depends to a certain degree on the condition of 
the patient and the stage of the disease. When a man between the ages 650 
PRO STATIC OBSTRUCTIONS 
of fifty and sixty years comes to the physician suffering from some 
increasing disorder of the bladder, and is still in good physical condition, 
great care should be taken to make as complete a diagnosis as possible 
before operation is advised. Frequently a stone in the bladder is the 
cause of the symptoms. Sometimes a neglected stricture of the urethra 
is found and, in fact, there are a number of diseases other than an 
enlarged prostate any one of which might be the cause of the symptoms. 
We feel that many disasters and incomplete operations would be 
avoided if more care were taken to make an exact diagnosis. The same 
rule should apply to the older patients who are not in the advanced 
stages of the disease. On the other hand, where the patient is weak 
and infirm, and where the patient has been subjected to proper methods 
of treatment to overcome his urinary stasis without success, we are 
justified in operating at once to relieve the retention of urine without 
waiting to make a complete and often exhausting examination. 
Differential Diagnosis.—If attempting to determine the type of 
change presented in a given case of obstruction at the neck of the bladder, 
it is important to remember that the same degrees of obstruction may be 
caused either by the large glandular hyperplasia of the prostate or the 
less apparent fibrous deformities. The former is much more frequent 
in men past sixty, while the latter is more often encountered in men who 
are younger. With regard to the clinical symptoms there is consider- 
able difference of opinion. Some observers believe that the bladder 
symptoms are more distressing when fibrous changes are present, espe- 
cially those which are the sequelke of inflammation, while on the 
other hand we do not see some cases of glandular hyperplasia until after 
infection has taken place and our clinical picture is obscured. In fact 
many patients of the latter type suffer from as marked dysuria as those 
of the former. Therefore we cannot depend on the symptoms alone, 
but each case, when doubt arises, must be judged on the evidence 
obtained from a confined urethral, rectal, and cystoscopic exami- 
nation. 
Chronic Prostatitis.—There is usually a previous history of acute 
prostatitis. The clinical symptoms are often very slight and are not 
characteristic. There is usually an uneven enlargement of the prostate 
appreciable by rectal examination. The prostatic secretion, expressed 
by massage of the gland, and examined, contains pus cells. When the 
disease is of long standing, and has invaded the interglandular struc- 
tures, more lasting changes take place and chronic obstruction may 
become established. 
As a rule the cystoscope is not of great value here. It may, how- 
ever, serve to differentiate between a chronic prostatitis and a median- 
lobe enlargement of the prostate. Where the median lobe is enlarged, 
the obstruction at the vesical neck is found to be caused by a smooth, 
rounded swelling which overlaps but does not necessarily encroach 
upon the trigone. With chronic prostatitis, the posterior segment of 
the prostatic urethra appears hyperemic, swollen, and infiltrated, so 
that when the instrument is pressed against it, it does not yield as easily DIFFERENTIAL DIAGNOSIS 
651 
as does the median-lobe enlargement. The swelling and infiltration 
may cause a slight bar formation with a pouch behind it, and the 
trigone itself may also be infiltrated and thickened. 
Tuberculosis of the Prostate.—If tuberculous disease of the prostate, 
without involvement of the bladder, is suspected, the passage of a 
cystoscope or other instrument for examination is usually contra- 
indicated. In the presence of severe bladder symptoms, it is justifiable 
to use the cystoscope. The prostate will be found to be irregularly 
enlarged and its surface hyperemic and granulated. The hyperemia 
and irregularity of the surface and the lack of extensive hypertrophy 
will often give a clue to the true condition of the prostate. In the more 
advanced cases ulceration may be present, and if so, bleeding takes 
place very easily. Rectal examination in combination with visual 
examination of the organ and the almost invariable presence of tubercle 
bacilli will make the diagnosis easy. 
Carcinoma of the Prostate.—The question of the diagnosis of this con- 
dition has been fully reviewed in a subsequent chapter. It may be well 
to emphasize the fact that it is sometimes very difficult and sometimes 
impossible to make a definite diagnosis of carcinoma of the prostate. 
The disease usually begins in the posterior lobe and extends toward the 
trigone of the bladder without, as a rule, involving the mucous mem- 
brane covering it. Rectal examination reveals the prostate with areas 
of dense induration, in places as hard as a stone. If the glandular 
elements have become involved, the entire lobe may feel like a calculus, 
but, as a rule, it is not very greatly enlarged. With a cystoscope we 
find that although there has been considerable residual urine still there 
is no considerable hypertrophy or overgrowth of the prostate extending 
into the bladder. Secondly, the trigone is lifted and is decidedly 
more prominent than normal, and does not shift its position with the 
filling or emptying of the bladder. We can see, at the same time, 
whether or not there is any involvement of the bladder mucous mem- 
brane. 
Conditions Simulating Prostatic Disease.—1. Retention of Urine Due 
to Spinal Disease.—Diseases of the spinal cord affect the bladder by 
causing incomplete muscular control, resulting in partial or complete 
loss of its power of expelling the urine. The patient passes urine fre- 
quently day and night, but never empties the bladder completely. 
Cystoseopic examination shows no hypertrophy of the prostate or 
median-bar formation. Young states that when disease simulating 
prostatic obstruction comes on late in life, and both rectal and cysto- 
scopic examination show no hypertrophy or median-bar formation, 
with a large residual urine, we should suspect spinal disease. 
In addition to the ordinary means of detecting spinal-cord lesions, the 
laboratory tests of the blood and spinal fluid will help to establish a 
correct diagnosis. 
2. Vesical Tumors Simulating Prostatic Disease.—To differentiate 
between a vesical tumor and prostatic enlargement is not, as a rule, 
difficult inasmuch as the clinical symptoms are usually quite distinct. 652 
PROSTATIC OBSTRUCTIONS 
Some neoplasms, however, arising from or near the prostate are impos- 
sible of differentiation. If, however, we make an examination of the 
prostate and find that the prostatic body itself is not enlarged, or only 
slightly enlarged, and that at one point there is a decided outgrowth of 
new tissue, a vesical tumor may be suspected. As a rule, however, 
the tumor arises independent of the prostate, and by careful exami- 
nation we are able to see a lack of continuity between the prostate 
and the growth, with a distinct area of normal vesical mucosa inter- 
vening. The ordinary papillomatous and ulcerating types of car- 
cinoma are not difficult to differentiate. But a carcinoma involving 
the base of the bladder, or a carcinoma infiltrating the base without 
ulceration, are extremely difficult to recognize. 
3. Vesical Calculus Simulating Prostatic Disease.—In patients over 
sixty-five years of age a calculus may form so gradually that it is not 
suspected, the symptoms at no time being very severe. The first 
evidence of its presence may be due to the congestion of the prostate 
caused by a stone pressing against it. The first symptoms are 
usually frequency of urination during the day. Many such cases 
have been operated upon and the prostate removed, leaving the stone 
in the bladder, with the recurrence of the symptoms and the necessity 
of another operation. Cystoscopic examination will, of course, clear 
up the diagnosis, and a suitable operation will relieve the patient of his 
prostatic and vesical symptoms. Vesical calculi are present in about 
10 per cent, of all cases of prostatic hypertrophy. The stone may be 
found in the postprostatic pouch or it may occupy a diverticulum. If 
a stone is found occupying a fixed position on the base of the bladder, 
it is extremely important to make a rectal examination in order to 
ascertain whether or not a portion of the stone is hidden in a diver- 
ticulum. 
Treatment.—In considering the treatment of obstructions due to en- 
largements of the prostate or their associated lesions—deformities of the 
prostate—one must realize that we are dealing with lesions which are 
almost without exception progressive. The seeming recessions are not 
due to actual tissue changes in the prostate, but are the result simply of 
a lessened congestion, or removal of some irritating substance, causing 
edema of the prostate and its surrounding structures. As age 
advances the hyperplasia increases and in this wray differs from the 
ordinary diseases of the body which frequently are associated with 
atrophy of the tissue after a certain age. Therefore we cannot employ 
palliative measures in the hope of carrying the patient over a certain 
period of advancing enlargement, but must face the fact that eventually 
the case will come to operation if it is a true hypertrophy, or death will 
result when our operative means fail to relieve the retention of urine 
and the infections of the urinary tract. 
Hygienic Considerations.—The same general rules of hygiene apply 
to these elderly patients as apply to any condition of ill health in a man 
of mature years. It is especially important that the diet at all 
times should be mild; fruit juices are distinctly beneficial. Chilling TREATMENT 
653 
of the body, wetting the feet, violent exercise, and in fact anything 
which would tend to increase congestion of the pelvic organs, will 
cause an increase of the distressing'symptoms. In the earlier stages 
the patient often is tempted to hold his urine longer than he should. 
This has very frequently been followed by acute retention and has 
led to the first introduction of a catheter. Out-of-door life, moderate 
exercise, a bland diet, regularity of the bowels, regularity of meals, 
abstinence from alcohol, regular hours of sleep, a constant protection 
of the abdomen and pelvis from sudden chilling—these are the most 
important details in the life of the patient with an enlarging prostate. 
The treatment of the early stages of enlargements of the prostate 
resolve themselves almost entirely into treatment of urinary stasis. 
Later, infections of the bladder and kidney appear and need to be dealt 
with. 
When the symptoms in the early stage are intensified by the incidence 
of congestion or inflammation of the prostate they may be dealt with by 
non-operative methods. This consists of relieving the congestion of the 
pelvic organs as much as possible, by administering enemata to empty 
the bowel, by repeated sitz baths, by hot rectal irrigations, by pros- 
tatic massage, and by the exhibition of such drugs as urotropin, 
benzoate of soda, santal oil and the various balsams. 
Treatment of Acute Retention of Urine.—If possible, the introduction 
of a catheter by the urethra under these conditions is to be resorted to 
only after all other means of relieving the patient have failed. Water 
and fluids by mouth should be restricted, rest in bed should be insisted 
upon. The patient should try to empty his bladder while sitting in 
a tub of hot water, and should be given various narcotics to diminish 
the reflex spasm of his internal sphincter muscle. If all these measures 
fail, then a relatively stiff silk-webbing catheter of the bougie or Mercier 
coude type, preferably 18 to 22 of the French scale in size, should be 
slowly and carefully introduced. It is our belief that less harm is done 
with a silk catheter than with a soft-rubber catheter , which easily bends 
upon itself when it reaches the posterior urethra and sometimes causes 
very considerable injury. With acute retention, if a catheter has 
entered the bladder, the urine is allowed to escape slowly and, if the 
bladder does not contain more than 20 ounces or thereabouts, it may 
be entirely emptied. If there is an enormous distention of the bladder, 
not more than 20 ounces should be withdrawn at one time and a catheter 
should be left in place, properly stoppered, and the urine allowed to 
flow out from the bladder at intervals of from fifteen to twenty minutes 
until it is emptied. Then a non-irritating solution should be injected 
into the bladder and left there. The patient should be placed on a 
restricted diet of milk, should be kept perfectly quiet, should have his 
pelvis carefully protected and heat applied, and it will usually be found 
that it is unnecessary to pass the catheter more than once in this 
manner. If repeated catheterism is necessary, the same precautions 
must be observed each time. 
Treatment of Cystitis with Urinary Stasis.—If infection of the bladder 
has taken place, the bladder should be catheterized each day, carefully 654 
PROSTATIC OBSTRUCTIONS 
washed out and injected with sterilized oil or some silver salt. Two 
ounces of 0.5 per cent, solution of silver nitrate is probably the best 
solution to use in these cases. It should be allowed to remain in 
the bladder for from five to ten minutes and then withdrawn. This 
treatment should be continued until the cystitis is overcome. 
It is not our province here to discuss the treatment of inflammatory 
conditions of the prostate, and the reader is referred to the chapter 
dealing with this subject. 
Catheter Treatment of Cases of Urina ry Stasis Due to Prostatic Enlarge- 
ment.—Increasing experience has more than ever demonstrated that the 
safest method of treating urinary retention due to obstructive enlarge- 
ment of the prostate is by suprapubic drainage. This conclusion, of 
course, applies only to the cases that have reached the stage of chronic 
retention of urine. The fact that a man has an hypertrophied prostate 
is no argument for its removal unless it is causing active symptoms. 
The dictum does not apply to the beginning stages of hypertrophied 
prostate where we are called upon to treat active congestions from 
irritations of an enlarging prostate. But when enlargement of the 
prostate is causing sufficiently grave symptoms to demand some 
artificial means of emptying the bladder, the better procedure is through 
an opening above the pubis. 
The statistics compiled by various urologists have demonstrated 
again and again that sooner or later within a relatively short period of 
time death from sepsis results from the initiation of catheter treatment. 
In a work of this kind it is not our purpose to repeat the instructions 
for the choice of catheter, the methods of its sterilization and its means 
of introduction which have been so carefully worked out and written 
down by many previous writers. The same catheters and instruments 
are indicated in those cases where catheter treatment is insisted upon 
as are used for the purpose of diagnosis in cases of advanced prostatic 
disease. 
We believe that there are very few cases, indeed, where one is justi- 
fied in advising catheter life. In those exceptional cases where the 
condition of the patient will not permit of operation, the physician 
should himself select a catheter and instruct the patient in its use. He 
should advise the patient to empty his bladder by means of a catheter 
regularly night and morning and should tell him that more frequent 
catheterism is undertaken at the patient’s own risk. It is manifestly 
more dangerous for any patient to have the catheter passed through 
his urethra four or five times a day than it is to have a suprapubic 
cystostomy performed under local anesthesia. 
Intra-urethral Methods of Treatment.—As a palliative measure in 
enlargements of the prostate due to congestion and inflammatory pro- 
cesses, the catheter is frequently employed. Its uses in the early stages 
of a true hypertrophy of the prostate have already been referred to. 
There are, however, a set of cases in which intra-urethral methods of 
treatment should be the methods of choice. These methods range PALLIATIVE TREATMENT 
655 
from minor surgical procedures carried out through an endoscope, 
including the application of the high-frequency spark, to the more 
radical punch operation of Young and the more dangerous galvano- 
cautery operation of Bottini and the modification of this method 
advised by Chetwood. The cases in which these methods of treatment 
are called for are those which fall into the class already described under 
Urinary Obstruction without Hypertrophy of the Prostate, i. e., sub- 
mucous fibrosis, deformed orifice due to inflammation, and hyperplasia 
of the suburethral and subtrigonal group of glands. 
The contra-indications to the more radical operation of pros- 
tatectomy are practically the same as those governing any major 
surgical operation in a patient of the same age. 
We divide then our recommendations for treatment into four classes: 
1. Palliative treatment in the prostatic enlargements due to congestive 
or inflammatory causes, also in the cases in which surgical operation is 
contra-indicated. 
2. Intra-urethral surgical treatment in the cases of urinary obstruction 
without hypertrophy of the prostate. 
3. Suprapubic as a preliminary step to prostatectomy, 
and as a permanent means of relieving retention of urine in cases in 
which prostatectomy is contra-indicated. 
4. Prostatectomy, either perineal or suprapubic transvesical, in all 
cases of true hypertrophy of the prostate. 
Palliative Treatment.—Why is this not justifiable in the cases of 
true prostatic hypertrophy ? It may be tried as a temporary expedient, 
and then only in the early stages of the disease; but in the light of our 
present experience always under protest rather than as a measure 
possessing the full recommendation of the surgeon. 
Doubtless in many cases operation on the first'appearance of serious 
obstructive symptoms will be impracticable, either through the disin- 
clination of the patient to submit to such an operation as prostatectomy, 
or his inability to give up from his occupation the time required for its 
performance and recovery thereupon. The catheter may be employed, 
provided its use is found to be unattended with any special trouble or 
discomfort. 
Intermittent Catheterism.—As a temporary expedient to relieve an 
obstruction which may be expected to shortly disappear, intermittent 
catheterism is simple and efficient. It has its dangers, which consist, 
first, of possibilities of septic infection, which, while they may be reduced 
to a minimum by extreme care, are nevertheless always present, and in 
the peculiar conditions which surround patients suffering from urethral 
obstruction the necessary precautions are usually sooner or later im- 
perfectly observed, and the introduction of sepsis takes place. It is a 
matter of occasional observation, however, that certain individuals 
exhibit a marked immunity to the results of such infection, indeed in 
some cases the use of an unclean catheter is persisted in for years with 
the production of only a very moderate amount of septic infection in 
the bladder. These cases, however, are so rare as to make more 656 
PROSTATIC OBSTRUCTIONS 
emphatic the statement that the continued use of a catheter is sure to 
result in a train of septic consequences of the most serious character. 
The majority of patients who elect to depend upon the continued use 
of the catheter for urinary relief enter upon a course which in itself 
progresses steadily to fatal termination within a brief period. 
The second danger attending the use of a catheter is the immediate 
constitutional reaction which in occasional instances has been observed 
to follow its use, a reaction so profound in some cases as to terminate 
in death within a very few hours. 
The third danger is referable to the local irritation, or traumatism, 
with which its introduction is attended. As the result of this 
there is pain and constitutional disturbance, though of a lesser 
degree than has already been mentioned, which follows each 
attempt at the introduction of the catheter. In those conditions 
of obstruction due to prostatic enlargement in which the question 
of catheter relief comes up for consideration, the character of 
the obstruction is such as frequently to insure and accentuate the 
pains and difficulties just indicated. These difficulties may often 
be very greatly lessened or modified by the choice of the best model 
of an instrument or by skill in its introduction, but in many cases 
even with the highest degree of skill and the best of instruments 
the local irritation incident to persistent attempts at the use of a 
catheter becomes so great as to be a serious element in the dangers 
of the case. 
The Catheter a demeure.—As a substitute for intermittent catheterism 
the permanent tying in place in the bladder of a catheter is to be con- 
sidered. Its value has received the commendation of men of the high- 
est authority. Practically, however, it is found that marked differences 
exist in individuals as to their ability to tolerate the presence in the 
urethra of the instrument. When it can be tolerated, its use is free 
from the special difficulties and miseries incident to the continued fre- 
quent introduction of an instrument, especially in those cases in which 
the introduction of an instrument is difficult. In the best of cases, 
however, there is a certain amount of irritation of the urethral mucosa 
which attends its presence in the urethra; a moderate urethritis is 
produced. The irritation of the deep urethra is of special consequence 
in this connection, if, as seems to be well substantiated, there is any 
special nervous relation between this portion of the urethra and the 
secretory apparatus of the kidneys. One of the alarming results which 
attend the second group of dangers connected with the use of the 
catheter, already alluded to, is anuria directly dependent upon the 
irritation of the deep urethra, caused by the use of a catheter. This 
reflex effect upon the renal secretory apparatus must be kept in mind in 
determining the propriety of introducing or maintaining a permanent 
urethral catheter. This must be of special importance in those cases in 
which reflex renal disturbances dependent upon urethral and bladder 
conditions have already been demonstrated. It is in this last group of 
cases more particularly that, as a substitute for a permanent urethral WITHDRAWAL OF RESIDUAL URINE 
657 
catheter, the opening of the bladder above the pubis and the securing 
within the opening of a suitable drain to relieve the urethra entirely 
suggests itself. 
The Gradual Withdrawal of Residual Urine.—An ingenious method 
described by Van Zwalenburg,28 has been used at the Mayo Clinic 
since January 1, 1921. 
Fig. 299.—Simple method of gradually emptying a chronic distended bladder. 
Method of Application.—The patient is placed in a hospital and made 
comfortable in a warm bed. A soft rubber catheter is introduced 
with all aseptic precautions and fastened in place without permitting 
the escape of any urine. This procedure is possible except in occasional 
cases in which the catheter has to be passed on a metal guide. In 658 
PROSTATIC OBSTRUCTIONS 
these cases a minimum loss of urine occurs, usually from 10 c.c. to 
15 c.c. The catheter is then connected to a 6-foot rubber tube, which 
at its distal end, is connected with one arm of a Y-glass tube. The 
other arm of the Y-tube is hooked over the edge of a receptacle hung 
at the foot of the bed. When all is connected the clamp is removed 
from the catheter and the height of the urine receptacle is adjusted 
to a level at which the urine will just trickle over into it on deep inspi- 
ration. The tube is clamped when the patient is fed, bathed, or when 
any movement is to be undertaken which will disturb the relative 
level of the bladder and the outlet. An ordinary douch pail makes a 
good receptacle, since the accumulated urine may be removed by 
removing the stopper from the outlet, without disturbing its level. 
The receptacle is lowered 2.5 cm. each day until the bladder has emptied 
itself or until the level of the outlet is approximately that of the bladder. 
When this level is reached the bladder is usually almost, if not quite 
empty. However, if 200 or 300 c.c. of urine remain the intravesical 
pressure is reduced to nil and there is no danger in completing the 
emptying of the bladder. 
Suprapubic Cystostomy.—Suprapubic cystostomy is a surgical pro- 
cedure that has its own perils and requires the most careful attention 
to details of technic to reduce its dangers to a minimum. It commends 
itself especially in those cases in which a temporary relief to urinary 
prostatic obstruction is desired while the best general and local con- 
ditions are being secured for the later radical removal of the obstruc- 
tion itself. It is free from any of the reflex effects which attend the 
introduction or retaining of a catheter in the urethra. It has still 
further the advantage not only of easy and adequate urinary drainage, 
but also of placing at rest the urethral tract and of being the most 
powerful agent in overcoming any reflex influence which the irritation 
of that tract may previously have been producing. 
It is impossible to emphasize too strongly the great dangers of cathe- 
ter life, and the lessening of the chances of complete recovery which 
delay and the inevitable infections of the bladder and kidney entail. 
Moullin8 in his work on the prostate states, “ I have more than once 
known suppression of urine to be caused by the introduction of a cathe- 
ter into the urethra.” And later, “Tying in a catheter must be 
regarded as a measure that should only be adopted w hen nothing else 
can be done.” Likewise Wallace30 in his book says: “The fact must 
be faced, that a patient practising self-catheterization is almost sure 
to fall a victim to septic infection of the urinary tract.”* 
Figures sometimes emphasize a fact better than argument. From 
a series of thirty cases not subjected to operation and observed by 
Squier25 the following conclusions were drawn: 
Fifty per cent, of unoperated cases will die within five years from the 
* The fact remains that constant drainage with an inlying catheter as a method of 
preparing patients for operation is extensively used by most experienced surgeons with 
excellent results.—Ed. 659 
SUPRAPUBIC CYSTOSTOMY 
onset of obstructive symptoms, where catheter life is not employed. 
The beginning of catheter life shortens this expectation of life almost 
50 per cent, (two years and ten months) and increases the mortality 
66.67 per cent, within the shortened period. Fourteen of the seventeen 
patients who took up catheter life died with an average duration of life 
of two years and ten months. 
On the other hand, the immediate mortality following prostatectomy 
when properly performed is about 5 per cent, and the expectation of 
complete relief is over 80 per cent. 
Surgical Indications.—The satisfactory establishment of surgical 
efforts for the radical removal of urinary obstruction, caused by 
enlargements of the prostate gland, must be accepted as now thor- 
oughly accomplished. 
It is of interest to note, in surveying the literature of the subject, 
that among the many different methods of attacking the prostate that 
have been proposed by different surgeons, practically equally good 
results are reported to have been secured by the most diverse methods 
by men who have become specially skilled in their application. It 
cannot be, however, that the choice of a method is a matter of indiffer- 
ence, a question of chance or prejudice. In view of the frequency of 
the malady, the general recognition of the possibilities of operative 
relief will prompt the surgeon to supply it. So the question is no 
longer what is possible in the hands of the expert, but what, in the 
light of our present knowledge of the anatomical relations and the 
pathological changes of the prostate gland, will in the hands of the 
average surgeon most certainly and safely, wholly and permanently, 
relieve the obstructive dvsuria that the prostatic disease had produced. 
The question of mortality naturally takes precedence in the con- 
sideration of any operative proposition. There must of necessity be 
some mortality in any and every kind of surgical intervention in pros- 
tatic patients. Sepsis, renal insufficiency, and the multiple degenera- 
tions incident to old age are complications in varying degrees of com- 
bination, that have to be reckoned with in many instances, and which 
must determine a fatal exit inevitably in a certain proportion. The 
proper selection of cases and the due preparation of them for the 
hazards of operation will always engage the earnest attention of 
the surgeon, and by these means the mortality will be kept at a 
minimum. With the demonstration of the comparative safety and 
certain benefits of operation will come a resort to it much earlier in 
the course of the disease than has hitherto been the case, and with this 
will come a marked diminution in its hazards and a corresponding 
lowering of its death-rate. 
The greatest advance made in prostatic surgery in the last decade 
has been the appreciation of the value of treatment preliminary to 
removal of the prostate. This has not only lowered the mortality rate 
in the total number of cases operated upon, but in addition has made 
it possible to offer operative relief to a class of patients who previously 
were denied operation. 660 
PROSTATIC OBSTRUCTIONS 
In a word the chief object of preliminary treatment is the relief of 
the urinary stasis through drainage of bladder. 
The primary effect of the drainage is decompression of the kidney; 
continuance of the drainage means a readjustment of the renal function. 
Before discussing the relative value of the various methods of accom- 
plishing this decompression it will be well to review the evidence at 
hand showing the cycle of renal functional adjustment in urinary 
obstruction. 
Clinical Evidence.—The clinician will observe, in cases of prostatic 
disease in which there is considerable retention of urine, that there 
will be evidences of intestinal stasis, loss of appetite, loss of sleep, 
changes in temperament, mental degeneration, loss of weight and a 
general deterioration of the entire organism. Aside from this, further 
examination may show various phases of uremic poisoning; in many 
cases a very marked increase in the secretion of urine with low specific 
gravity. Frequently the amount of urine will reach 150 ounces in 
twenty-four hours and its specific gravity be as low as 1.002. In 
one case the twenty-four-hour record was over 300 ounces. This, of 
course is an indication of functional derangement of the kidney. The 
rapid disappearance of all these clinical evidences of disturbed renal 
function, which frequently follows drainage of the bladder, shows the 
direct relation of cause and effect. 
We have both acute and chronic, partial and complete forms of 
obstruction. 
In the cases of chronic partial obstruction it has been noted in general 
that the amount of urine secreted is increased, providing the bladder 
is strong enough to regularly overcome the partial obstruction, and 
partially empty the bladder so that at no time the back pressure from 
the viscus is continually great. Where the musculature of the bladder 
is not so strong, and there is a chronic retention of a considerable 
amount of urine with very little overflow, the quantity secreted will 
often average as high as 120 to 150 ounces in twenty-four hours with 
a low specific gravity. 
Where we have a contracted bladder with greatly thickened walls, in 
which there is only a small amount of urine retained, and its 
quantity almost entirely fills the contracted bladder, the urine is 
passed very frequently and in small amounts. Such a bladder may 
contain only two or three ounces and is almost continuously full. Under 
such conditions the kidney diminishes its secretion. The total amount 
secreted in twenty-four hours may be very little, finally resulting in 
complete anuria. 
The other cases are those of acute retention of urine, in which the 
kidneys act freely until the bladder is filled to its capacity, at which 
time they stop acting entirely. 
Aside from the clinical evidence of renal infection and renal insuffici- 
ency already presented, the most striking evidence of renal injury due 
to prostatic obstruction is presented in those patients dying from the 
disease. Autopsy shows a variety of conditions existing in the kidney, SUPRAPUBIC CYSTOSTOMY 
661 
the most common lesion being a distended ureter beginning immedi- 
ately above the bladder, resulting in various degrees of hydronephrosis 
and destruction of the kidney parenchyma. This in turn is influenced 
by the degree and duration of the obstruction and in many of the 
advanced cases is accompanied by infection, the formation of renal 
calculi, and, in some, by almost total destruction of the kidney 
parenchyma. 
Operative Proof.—From a careful study of a series of cases in which a 
preliminary cystostomy was done, certain phenomena were repeatedly 
observed which seemed to justify us in dividing the results of advanced 
prostatic obstruction into three forms. It has further emphasized in 
our minds the peculiar balance existing between the heart, kidney, 
secretion of urine, and the nervous control of these in the patient who 
has gradually become used to overdistention of the bladder. 
We have learned not to rely upon any one clinical sign or symptom in 
judging the fitness of the patient for operation. We have learned that 
the balance between the various elements of the system is so adjusted 
that a disturbance of one of them will bring to light weakness in some 
of the others which has not been suspected, for example, as may appear 
in the phthalein excretion by the kidney. This may be very deceptive. 
The patient may show 50 to 60 per cent, of excretion of phthalein in two 
hours before anything has been done to relieve the retention of urine. 
Drain the residual urine from the bladder and all of the other elements 
of the system are thrown into confusion. The back pressure is relieved; 
decompression of the kidney follows; swelling and congestion of the 
organ take place; and its functional capacity immediately drops to a 
very low point. The outward signs of this derangement are very 
evident. This is the second phase. It is our belief that in the case of 
many of the patients who have died following operation, death has 
resulted from a lack of appreciation of this second phase of renal dis- 
turbance. Many deaths have been reported on the third to the fifth 
day following a one-step prostatectomy, when the patient was seem- 
ingly doing well; but when we take into account the phenomena 
of the second phase in addition to the shock of the major operation 
with its loss of blood and the depressing effect of the general anes- 
thetic, it can be easily appreciated why these deaths take place, and 
many will agree that the overtaxed heart and the system overloaded 
with toxins which the kidneys should, but cannot, separate from the 
blood are the cause of the death. Extended observations have 
shown that nearly every prostatic will present these three phases, 
and this fact has influenced us very greatly in favor of the two-stage 
operation in every case of benign hypertrophy. 
The Three Phases.—The results of our observations are graphically 
shown on the accompanying chart (Fig. 300) which shows the average 
condition which prevails in many advanced cases of obstructive 
hypertrophy of the prostate. 
The First Phase.—For the first day, the day on which the suprapubic 
cystostomy is done, the blood-pressure frequently registers from 200 to 662 
PROSTATIC OBSTRUCTIONS 
220 mm. of mercury; the urinary output for twenty-four hours will 
average from 70 to 120 ounces; the phenolsulphonephthalein test will 
frequently average above 50 per cent, in two hours and the urine 
will show only a trace of albumin. If these conditions are considered by 
themselves, they will give us a false impression of the actual condition 
of the patient. For example, if the patient’s blood-pressure registered 
200 mm. and he was passing 90 ounces of urine in twenty-four hours 
URINARY - 
OUTPUT - 
BLOOD 
UREA 
ALBUMIN 
SPECIFIC 
GRAVITY 
DAYS 1234 5 6 7 8 9 10 11 12 
1ST PHASE 2ND PHASE 3RD PHASE 
Fig. 300.—Chart showing changes taking place in the urine following operation. 
with low specific gravity and wTith only a trace of albumin, we would be 
rather suspicious of the functional capacity of the kidneys. But 
when we make a phenolsulphonephthalein test, and find that the out- 
put in two hours is 60 per cent, or more, it might lead us to believe 
that the actual functional capacity of the kidneys is greater than the 
specific gravity would indicate. 
The Second Phase.—A second glance at the chart will show a very SUPRAPUBIC CYSTOSTOMY 
663 
different condition existing on the third or fourth day after the bladder 
has been opened and drained. Here we see a lowered blood-pressure, 
probably between 170 and 180. The urinary output has suddenly 
dropped 15 to 20 ounces; the amount of albumin in the urine has 
increased enormously. On the third or fourth day the phenolsulphone- 
phthalein test shows the functional capacity of the kidney at this most 
critical time to be only 15 per cent. This, then, is the change that has 
taken place simply following a drainage of the bladder without any loss 
of blood or other surgical shock due to anesthesia or prolongedmanipula- 
tion. If to the shock of a prostatectomy with its general anesthesia a 
very considerable loss of blood and the shock consequent to pain had 
been added, one does not wonder that so many patients have died 
on the third, fourth and fifth day from no apparent cause. 
The Third Phase.—Passing to the third phase of the condition 
following drainage of the bladder, we find in the average case that 
on the seventh to tenth day the blood-pressure has decreased to 
160 to 170 mm., the urinary output has increased to 40 to 50 ounces 
in twenty-four hours, the phthalein test shows a reaction of the 
kidney from a 15 per cent, output to one of 50 per cent., and the 
amount of albumin has decreased very markedly, it being still a little 
more than before the cystostomy and very much less than was found 
on the third or fourth day. 
If the prostatectomy is performed now, the effect upon all these 
phenomena is quite different from that after a preliminary cystostomy. 
In the latter case the blood-pressure falls still lower, the urinary output 
decreases very little; the functional capacity of the kidney does not 
fall more than ten points; it is difficult to ascertain the amount of 
albumin present in the urine on account of the presence of the wound in 
the bladder, but at no time is it as great as was found on the third or 
fourth day after the cystostomy was performed. 
By following this method we entirely avoid the second phase after the 
prostatectomy. 
Hugh Cabot3 in studying the mechanism of the protection afforded 
by the drainage of prostatics as a preliminary to operation has observed 
certain phenomena which lead him to conclude that “the relief appears 
to be the result of two factors: (1) Relief of the so-called “ back pres- 
sure” with the equalization of the kidney circulation thus resulting, and 
(2) lessening of infection which though long believed to be chiefly a 
cystitis, is now generally regarded as in fact a pyelonephritis.” He states 
further: “No discussion is necessary to establish the now generally 
accepted view that the custom of preliminary drainage before operations 
for prostatic obstruction has been an important factor in reducing the 
mortality. Much obscurity, however, surrounds the reasons for the 
benefit thus produced and it is with this subject that we are here con- 
cerned. The importance of preliminary drainage is by no means equal 
in the various classes of cases presenting themselves for operation. It 
will probably be generally admitted that preliminary treatment, of 
which drainage is the most important constituent, is most essential in the 664 
PROSTATIC OBSTRUCTIONS 
class of patients who come to us with largely overdistended bladders, 
sometimes stretched to the point of overflow but in whom infection has 
not yet occurred. We all remember the dreadful mortality which 
accompanied the attempt to empty the bladder and remove the 
obstruction immediately upon coming under observation. It is notori- 
ous that these cases did badly from the start and died generally with the 
symptom-complex which we somewhat loosely call uremia. Perhaps 
the next most lethal proceeding was to operate at once upon those cases 
with a moderate residual of from 6 to 12 ounces and a still uninfected 
urine, while immediate operation was least hazardous in those cases 
with a moderate residual thoroughly infected and best typified by the 
patients who had for some time be«n leading the so-called catheter life. 
The extremes are represented by the overdistended uninfected bladder 
and the thoroughly infected but regularly emptied bladder enjoying a 
catheter life.” 
Treatment Preliminary to Prostatectomy.—It is quite evident then 
that a certain amount of preliminary treatment is indicated in every 
case before the final prostatectomy is attempted. The requirements in 
the given case must be judged by the individual surgeon. In the 
majority of cases one of three methods should be adopted. (1) The 
repeated use of a catheter to empty the bladder at regular intervals, or 
(2) The use of a catheter a demeure, or (3) The establishment of 
suprapubic drainage. The relative values of these methods and their 
indications have already been discussed under the heading of Palliative 
Treatment. While in most cases the surgeon may employ any of these 
methods with safety to the patient, still there are cases in which 
definite precautions are necessary. Although their variety is great, there 
are certain distinct types which represent those most commonly seen. 
1. Patients who present themselves with enormously distended 
bladders, as yet uninfected, passing from 70 to 150 ounces of urine in 
twenty-four hours, with a low specific gravity and a trace of albumin, 
but with a relatively large percentage of blood urea. These cases call 
for a very gradual reduction in the amount of residual urine which can 
best be accomplished by the use of a catheter a demeure with gradual 
withdrawal of the urine, not emptying the bladder completely for 
two or three days; or, in the hands of the expert, the introduction of a 
button drainage tube through a cystostomy opening and gradually 
withdrawing the urine from the bladder in this way. If it is not pos- 
sible to introduce a catheter, the patient should be kept as quiet as 
possible spending most of his time in bed, the bowels moved properly by 
salines and the amount of liquid given reduced to a minimum. At a 
favorable moment the suprapubic cystostomy should be done under 
local anesthesia and bladder drainage established. 
2. Patients with very frequent urination or painful dribbling of urine 
due to partial retention complicated by a foul cystitis with or without 
the presence of a calculus. Where such a cystitis is present there is 
usually no contra-indication to the use of a catheter, but the greatest 
amount of relief will be afforded by a preliminary suprapubic cystostomy TREATMENT PRELIMINARY TO PROSTATECTOMY 
665 
which provides for bladder drainage and then, depending upon the 
special training and aptitude of the operator, he will do a perineal or 
suprapubic prostatectomy. In all cases where suprapubic cystostomy 
has already been done, transvesical enucleation of the prostate can be 
accomplished more quickly and with less shock than is possible if a 
perineal operation is attempted. 
3. Patients presenting themselves with complete retention of the 
urine, hemorrhage into the bladder, bladder distended, patient in 
shock. Unquestionably the safest procedure in such a case is an 
immediate performance of a suprapubic cystostomy under local 
anesthesia and simple drainage of the bladder. 
4. Patients who have suffered for a long time from urinary stasis due 
to prostatic obstruction, who come to the surgeon as a last resort who 
are already suffering from uremic symptoms and suppression of urine. 
Some of these are beyond help, while others may be brought safely 
to operation and recovery. It is in this type of cases that we must 
expect some mortality. If we refused to operate upon them our 5 
per cent, mortality record would be reduced to 1 or 2 per cent.; but 
even in this type many brilliant results are secured. Here preliminary 
treatment is absolutely essential and should be continued for two 
or three months before it is safe to enucleate the prostate. It is in these 
cases especially that the work of the surgeon should be supplemented 
by that of a physician to regulate the diet, to sustain the heart muscle 
and promote the well-being of the patient. 
1low shall the surgeon he guided in selecting the time to perform the 
prostatectomy in a given casef 
First, his judgment should be based on the general condition of the 
patient. When the patient’s appetite returns and his sleep becomes 
normal, when his temperature, pulse and respiration become normal, 
and when the renal output has returned to its normal limits, he 
should consider these a fair index of the general physical well-being of 
the patient. 
Second, prostatectomy is not safe until all the uremic and renal 
symptoms have disappeared. A moderate amount cf albumin in the 
urine is no contra-indication. The condition of the blood-pressure 
is a valuable index. 
Third, the phthalein test is of value only as taken in connection 
with other signs. In the first place one must consider the results of the 
phthalein test before the preliminary drainage; then the phthalein test 
taken on the second, third or fourth day, and again, the functional 
reaction of the kidney to this test at the end of a week or ten days. It is 
a mistake to rely solely upon this test, especially before the drainage 
has been instituted. For example, the test may show excretion of 
more than 50 per cent, of phthalein in the first two hours before the 
preliminary cystostomy, but the reaction may drop on the second or 
third day after relief of the retention of urine to below 15 per cent, or 
even lower, which is a true indication of the functional capacity. When, 
however, the period of depression is passed and the output returns to 666 
P ROST AT IC OBSTRUCTIONS 
50 per cent, after the retention of urine has been relieved, this then 
becomes a fair index of what we can expect the kidney to do after the 
prostate has been removed. Meyers states that26 “Blood urea is 
the most valuable of the blood tests. Since creatinin is normally 
the most readily eliminated of the nitrogenous waste products, its 
retention does not occur until after the urea has doubled the normal. 
For this reason ceratinin is significant only in those cases which show 
a definite urea retention.” 
Phthalein shows the amount of excretion, while urea nitrogen and 
creatinin show the amount of retention. As a rule these tests balance 
fairly well, but if a patient shows a retention of 25 mg. or over, with 
a fairly good phthalein output of 50 per cent, in two hours, one should 
be cautious in operating. A high creatinin retention is a counter- 
indication of any operative interference. The surgeon should not 
rely upon any one test. The general appearance of the patient, the 
amount of urine in twenty-four hours, specific gravity, both retention 
and excretory tests together with blood-pressure, go to make up a 
picture which should be carefully studied. 
Expectation of Cure.—The primary indication is the reestablishment 
of the ability of the individual to readily, fully and painlessly evacuate 
his bladder. With regard to the restoration of normal function it must 
not be forgotten that the statements both of patients and of surgeons 
should always be considered as relative. Prepossession and enthusiasm 
often lend a rose color to the reports of results, and a more close scrutiny 
of the conditions may often elicit information as to attendant infirmities 
which modify the conclusions. Nevertheless, even with these modi- 
fications, the fulfilment of the supreme indication, viz., the removal of 
the urinary obstruction, is a sufficient achievement to compensate 
for the presence of many lesser evils. 
The patient who comes to us in the early stages of the disease before 
infection has taken place can be assured today that the result of removal 
of his prostate will be a full restoration of the bladder to its normal 
function, with full control of his urine and the ability to completely 
empty his bladder. When marked deformity of the outlet has taken 
place as a result of fibrous changes, the end-result is usually not as 
satisfactory, but even in these cases, which are relatively few in 
number, marked improvement in the obstructive symptoms results. 
The patients wTho present themselves in the advanced stages of the 
disease, often surprise the surgeon by the completeness of their return to 
the normal condition. The extensively trabeculated bladder, with its 
hidden recesses the seat of chronic inflammatory changes, can never be 
expected to return to its normal state again, but aside from the evi- 
dences of a low-grade chronic cystitis, the patient is freed from his 
frequent painful urination and his urinary stasis. Wherever it is pos- 
sible to remove the obstruction completely the percentage of failure is 
almost nil. The so-called failures recorded are in the opinion of the 
writer due to incomplete operation. 
The infirmities which sometimes mar the results are impotence, TREATMENT PRELIMINARY TO PROSTATECTOMY 
667 
urinary inccntinence, epididymitis and orchitis, fistulas, stricture of the 
urethra. 
Impotence.—This results from injury to or removal of the ejaculatory 
ducts. It is less likely to occur when the operation is done from above, 
but with proper care the segment carrying these ducts and terminating 
in the verumontanum can usually be preserved during a perineal enucle- 
ation. It is a surprising fact that the sexual vigor, if present before 
the operation, is very little impaired by removal of the hyperplastic 
portions of the gland. 
Urinary Incontinence.—This is of rare occurrence as a result of pros- 
tatectomy. A slight defect in the ability to retain urine in the bladder 
may be present during the first weeks following operation, but the 
sphincters rapidly regain their tone and full control of the urine is 
established. 
In our own series of cases we have never seen incontinence following 
a perineal or suprapubic prostatectomy. I believe this to be due to the 
fact that iu every case the compressor urethrae muscle has been care- 
fully preserved. It is our belief, further, that in the majority of cases 
in which incontinence of urine has followed an operation, it has been 
the result of an attempt to remove a prostatic obstruction where the 
hyperplastic masses were not easily enucleatable. In other words, it is 
only apt to occur in those cases where there is no distinct defining 
capsule and the overzeal of the operator makes him pass beyond the 
confines of the prostate, in doing which he injures or removes a portion 
of the muscle which controls urination. The injury or removal of the 
internal sphincter does not have any effect upon the actual muscular 
control of urination, as has been frequently proved practically where 
operations have involved the removal of the internal sphincter, and a 
full control of the urine has resulted. 
Epididymitis and orchitis are seldom seen unless instrumentation of 
the urethra is employed after prostatectomy. Rarely does epididymitis 
follow the operation alone. In our own series of cases epididymitis 
occurred much more frequently in the perineal than in the suprapubic 
sections. In a few cases the inflammation extends and may involve the 
loss of a testicle, and may cause extensive sloughing of the tissues 
resulting in an urethrorectal fistula. 
Fistulas.—Suprapubic fistula;, perineal fistula and recto-urethral 
fistula are among the occasional sequela of operation for the removal of 
the prostate. They occur with sufficient frequency to make their 
mention necessary in any complete consideration of the subject of 
prostatectomy, but yet so rarely as to have very little practical bearing 
on the prognosis of a given case. In the absence of great loss of sub- 
stance in the original wound, the failure of a suprapubic or perineal 
opening to close is usually due to some contraction in the anterior 
urethra, and, as a part of the treatment in any given case, the surgeon 
should secure perfect freedom of the urethral lumen throughout its 
whole extent. 
Recto-urethral fistula' may result either from an accidental tear 668 
P ROST AT IC OBSTRUCTIONS 
through the anterior wall of the rectum in the course of the efforts to 
expose the prostate or from later sloughing consequent upon intense 
local infection, or from drainage tube, or tampon pressure. The very 
close relation of the prostate and the rectum at once suggests the 
difficulty of separating them without injury to the rectum, and the 
possibility of such injury doubtless had much to do in discouraging 
earlier attempts on any general scale to attack the prostate. Fortu- 
nately, however, between the capsule of the prostate and the underlying 
musculofibrous external coat of the rectum there is an appreciable 
layer of loose connective tissue which forms a line of easy cleavage, so 
that when the capsule of the prostate has been exposed, the further 
stripping back of the rectum to any degree that may be necessary is 
comparatively free from danger of injury to the bowel. It is that 
portion of the rectum which is anterior to the prostate, and which is 
pulled forward toward the membranous urethra by the recto-urethralis 
muscular fibers, which is most likely to be the seat of injury when the 
prostate is approached from the perineum. With care and due atten- 
tion to the anatomical relations of the structures involved, this point of 
danger may usually be avoided; but it is quite conceivable that in 
occasional instances the relations and texture of the perineal structures 
may be so altered by fibrous or inflammatory changes as to make the 
desired detachment and pushing back of the rectum without injury very 
difficult to accomplish. That such injury has occurred at the hands of 
many able surgeons is a matter of record, and it is not unreasonable to 
believe that not all the instances in which it has occurred have been 
published. 
Urethral stricture does not seem to have followed to any serious 
degree the extensive lacerations and removals of the prostatic urethra 
which have marked many of the operations upon the prostate. It has 
been frequently the case that the entire prostatic urethra has been taken 
away with no subsequent disturbance of the urinary functions. 
Extensive tearing away of the prostatic urethra has accompanied 
certainly some, and probably all, of the extensive enucleations done 
by the suprapubic route; a varying degree of injury to the floor 
and lateral walls of the prostatic urethra attends most of the perineal 
methods of operation. The claims of many operators who remove 
prostatic masses guided by the sense of touch alone, that very limited 
injury of the urethra results from their manipulations, are not sustained 
by our knowledge of the anatomical conditions of the parts. The 
urethra in its course through the prostate does not present such distinct 
layers in its walls as are found in its membranous and penile portions; 
nor does it present any such recognizable layers as does the capsule of 
the gland from which the adenomatous masses of an enlarged organcan 
be readily peeled away. It consists of a few layers of columnar epithe- 
lium resting on a base composed of connective tissue and muscular 
fibers which are directly continuous with the stroma of the gland 
itself, and surround and support the score and more of ducts to 
which the primary lobule outlets converge, and which open upon the TREATMENT PRELIMINARY TO PROSTATECTOMY 
669 
floor of the urethra, and which are also lined by an extension of the 
urethral epithelium. In other words, the submucous and muscular 
coats belonging to the urethra in other parts of its course are here 
replaced by prostatic substance. It seems to the writer that the 
laceration of the urethral wall by attempts to tear out more or less 
of the glandular substance external to it can be prevented only by 
the most delicate manipulation, conducted in full view and with 
the assistance of careful dissection as the enucleation approaches the 
vicinity of the urethral wall. The periphery of these prostatic masses 
can readily be enucleated from the capsule with a blunt dissector or 
with the finger-tip; but upon the urethral side of the mass the condition 
is different. These masses can be readily torn away, it is true; but the 
operator who thinks that in effecting this he leaves the prostatic urethra 
intact is probably mistaken. More emphatically is this the case in the 
presence of the hard, fibrous prostate. 
It may be well therefore to accept as one of the usual accompani- 
ments of prostatectomy, a very considerable laceration and loss of 
substance of the prostatic urethra. In view of this the fact of its 
regeneration has decided surgical interest. When the roof and a con- 
siderable portion of its lateral wall is left after the enucleation is 
completed, it is natural to expect that the conditions insure a patent 
mucous-lined canal as wound healing progresses; in those other cases in 
which nearly complete enucleation of the whole gland en masse, bringing 
with it a considerable segment of the whole circumference of the urethra, 
is effected by attack from within the bladder, there remains an irregular, 
but in general a funnel-shaped, cavity, into which the bladder mucosa 
must prolapse, and as the process of repair progresses, furnishes an 
advancing line of epithelium to cover the raw surface. From the end of 
the membranous urethra likewise a similar epithelial growth may con- 
tribute to the ultimate result; from the ducts and lumina of any of the 
gland substance that may have escaped the surgical attack an addi- 
tional source of epithelium may be supplied. This may explain’why 
speedy regeneration of an adequate epithelium-lined canal through the 
area formerly occupied by the prostate has been demonstrated by abun- 
dant clinical experience. The very natural apprehension entertained 
by many that intractable stricture would be a common sequel to these 
operations has not been realized. In order to secure this immunity 
from later stricture, it would seem that the urethral injury must be 
restricted to the prostatic portion of the urethra. It would seem also 
a sound surgical procedure in all cases to place a good-sized rubber 
drainage tube in the bladder through the prostatic hiatus during the 
early days after the operation, to be replaced later, possibly for a week 
or more, by a catheter a demeure; this, in addition to the advantages of 
drainage, answers the purpose of favoring and controlling the formation 
of a suitable channel, along which the process of epithelial proliferation 
should extend. The occasional use of a full-sized sound may be adopted 
as a substitute for the catheter for a time in the subsequent treatment. 
The Surgical Problem.—To state the case in its simplest terms the 
problem presented in obstructive lesions of the prostate is: 670 
PROSTATIC OBSTRUCTIONS 
1. To provide a free exit for the urine from the bladder. 
2. To permanently remove the obstruction at the neck of the 
bladder. 
3. To preserve the sphincter vesica', and if possible, the ejaculatory 
ducts. 
4. To prevent postoperative shock and hemorrhage. 
5. To prevent infection and sloughing. 
6. To secure rapid healing of wound and the reestablishment of the 
normal functions. 
The Choice of Operation.—Intra-urethralmethodsof operation are indi- 
cated in the cases of obstruction due to submucous fibrosis; bar forma- 
tions of inflammatory origin, and obstructions due to hyperplasia of the 
suburethral and subtrigonal glands. In the remaining cases there are 
but two methods of operation to be considered, namely, perineal and 
suprapubic-transvesical prostatectomy. So much has already been 
written concerning the relative merits of each that a full discussion 
of the subject is not necessary. It is safe to say that the majority of 
surgeons have adopted the suprapubic transvesical method. In the 
hands of a few specially trained men there is practically no choice 
between the two methods, judging from the mortality records, and 
the character of the end-results. But this does not hold good when we 
consider the results of the operation in the hands of the general surgeon 
to whom the major portion of the work comes. 
Perineal prostatectomy is an operation for the expert only. Supra- 
pubic prostatectomy is an operation per se which can be easily per- 
formed by the majority of surgeons. In the latter operation the chances 
of accident are less and the certainty of completely removing the 
obstruction is greater than when perineal prostatectomy is attempted 
by a surgeon who is not specially trained in the surgery of this region. 
Many men encouraged by the brilliant results of a few who popu- 
larized the perineal operation, attempted the operation and brought 
discfedit to it by their failures. The same is true to a lesser degree 
of the suprapubic operation. The fact is that success in remov- 
ing prostatic obstructions depends upon a fundamental knowledge of 
the pathology of the disease, not only as it affects the prostate itself, 
but more especially as it affects the bladder and ureters and kidneys. 
The mortality percentage in a given series of cases does not depend 
upon the particular type of operation employed, but it does depend 
upon the individual surgeon who performs the operation, his pre- 
operative study of the case, his ability to anticipate the dangers before 
they arise, and his skill in meeting the emergencies as they occur. 
Some expert urologists who operate upon the majority of their cases 
by the suprapubic route still employ the perineal route in those cases 
where the obstruction is caused by a small fibrous prostate. Practically 
all surgeons agree that the suprapubic operation is preferable in those 
cases in which there is a massive intravesical overgrowth of the gland. 
Many surgeons perform suprapubic prostatectomy in two stages, the 
first operation consisting of a cystostomy with drainage of the bladder; THE PUNCH OPERATION 
671 
the second operation, enucleation of the prostate through the existing 
cystostomy opening. Other surgeons complete the operation in one 
stage. Experience and a proper consideration of the individual case 
should always guide the operator. 
Removal of Obstructing Growths per Urethram. *—Attempts to remove 
the obstruction at the neck of the bladder by means of instruments 
introduced and operated through the urethra date back for over a cen- 
tury. The sum total of the experience gained during that period and 
especially during the past twenty years is, that no permanent relief 
can be gained excepting in the cases of the irregular forms of obstruc- 
tion which we have described under the headings, Submucous Fibrosis, 
Bar Formations Due to Chronic Inflammatory Changes, and Obstruc- 
tions Due to Hyperplasia of the Suburethral and Subtrigonal Glands. 
In dealing with these types we have a choice of various methods: 
Destruction of the obstruction by means of the galvanocautery knife, 
or the high-frequency spark, or actual removal of the tissue by means 
of an instrument which punches out the tissue. Mercier, in 1839, 
devised the first instrument for actually excising portions of the growth, 
improving his technic and adding a blade for simply cutting through a 
median obstruction. Bottini, in 1874, introduced his method of 
division and incision of the prostatic obstruction by means of a gal- 
vanocautery instrument, hoping by this method to avoid the hemor- 
rhage which was so dangerous a complication of the Mercier method. 
These surgical procedures were extensively tried, modified, and 
improved, and were the methods of choice until the present technics 
of perineal and suprapubic prostatectomy were introduced; then it 
was demonstrated that the operation of complete removal of the 
diseased portion of the prostate was just as safe as these partial 
expedients, and the results were far more satisfactory and lasting. 
The result has been that most of these operations conducted per 
urethram have been discarded in the cases of true hypertrophy of 
the prostate. There still is a limited field, i. e., in the irregular forms 
of obstruction, for the partial excision and electric-spark destruction. 
Punch Operation.—In 1909, Hugh H. Young33 devised an instrument 
which he calls The Punch, by means of which the prostatic bars, 
(Fig. 301) can be removed through the urethra under local anesthesia. 
The first instrument presented was a urethroscope, with light holder 
and attempts were made to remove the median bar, or other structures 
at the vesical neck, under visual direction, but experience showed that 
while it was possible to see the bar which was entrapped in the fenestra 
of the instrument, and to observe the first cut, the hemorrhage which 
followed effectually prevented observation of the succeeding cuts. 
As subsequent experience has shown that the operation can be very 
efficiently and accurately performed without visual direction the 
light carrier has been dispensed with. As at present carried out the 
operation is as follows: The instrument consists of an outer tube 
* For an extended history and description of this method see Deaver’s “Enlargement 
of the Prostate.” P. Blakiston’s Son & Co., Philadelphia, 1905, p. 176. 672 
PROSTATIC OBSTRUCTIONS 
with a fenestra on the side (see Fig. 302) and an inner tube with a 
sharp cutting end which fills the fenestra entirely until it is partially 
withdrawn, which is used to excise tissue that may drop into the 
fenestra. An obturator is also provided but not often employed. 
Fig. 301.—Longitudinal section showing a typical median bar elevated above the trigone 
without enlargement of the prostate. 
The technic of operation is as follows: Local anesthesia is usually 
employed, 4 per cent, novocaine in urethra and bladder inserted 
with a catheter which is later used to fill the bladder with fluid. 
The patient also receives \ gr. of morphia hypodermically, and 
under this anesthesia the operation can usually be carried out with 
little pain. The instrument which is of No. 29 French calibre and 
Fig. 302.—Young’s prostatic bar excisor or “punch.” A, outer tube and fenestra; 
C, obturator; B, inner cutting tube. 
provided with a short curved beak, can usually be introduced without 
difficulty. It is carried well into the bladder (Fig. 303) and the 
inner cutting tube withdrawn about 1 inch, thus uncovering the 
fenestra and allowing the fluid to escape from the bladder. The 
instrument is then rapidly drawn outward and as the fenestra comes THE PUNCH OPERATION 
673 
into the urethra and the prostatic bar or contracture immediately 
drops into the fenestra (Fig. 302), the operator then simply pushes 
home the sharp inner cutting tube which excises the bar which is 
Fig. 303.—The “punch” instrument has been introduced well into the bladder and 
the inner tube drawn upward, thus opening the fenestra through which urine begins to 
escape. The median bar is seen depressed by the shaft of the instrument. 
within the fenestra (Fig. 304). With alligator forceps the tissue excised 
is quickly withdrawn from the interior of the instrument (Fig. 305) 
and inspected. As a rule more than one cut is desirable and the 
operator turns the instrument in the desired direction and, following 
Fig. 304.—The cutting inner tube is seen excising the median bar. 
the technic above described, promptly entraps and excises the tissues 
at the vesical neck in the desired directions. 
In the majority of instances the posterior portion of the prostate 
is alone involved and consists of a fibrous or inflammatory glandular 
enlargement of small size, which is easily caught by the fenestra of the 674 
P ROST AT IC OBSTRUCTIONS 
instrument, which is about If cm. in length. One cut posteriorly 
is usually made first. The effects of the removal of this section 
(Fig. 306) is that the instrument immediately drops to the bottom 
of the cut, and, as it is desirable to excise more of the median bar on 
Fig. 305.—Sectional view, showing the removal of the excised mass of prostatic tissue 
with urethroscopic clamps. 
each side, this is done by turning the instrument directly to the left 
and then to the right, and by repeating the procedure above described, 
thus excising the left and right ends of the median bar which was 
Fig. 306.—Sagittal section of prostate after excision of median bar. 
partly removed by the posterior median cut. In some instances 
anterior valves or bars are seen with the cystoscope, and if present 
should be removed first. If the posterior cut is made first and the 
instrument drops into it, greater difficulty is experienced in entrapping THE PUNCH OPERATION 
675 
an anterior bar or valve. It is desirable occasionally to remove the lateral 
margins of the prostate. This was particularly true in cases where 
there was a general contracture but Young nowT thinks that such exten- 
sive excision is not necessary and that as a rule the removal of the 
median portion with three cuts is sufficient. There is usually fairly 
acute hemorrhage for a time and this is evacuated best through the 
punch instrument by means of a large syringe, with which the bladder 
is filled several times with fluids and the clots evacuated. A single 
large coude gum catheter is then inserted into the bladder (Fig. 
307) which is again washed free from blood and the catheter fastened 
in place with strips of adhesive. Young’s “Punch” operation can 
usually be done in a very few minutes and the actual cutting causes 
Fig. 307.—Drainage of bladder with large catheter, No. 28, after removal of the 
prostatic bar or contracture. 
very little pain owing to the speed with which it is accomplished, 
and as a considerable amount of tissue is removed the operation is 
really very radical, and thoroughly adequate for the type of case for 
which it should be reserved, namely, fibrous contractures of the 
vesical orifice, bars or small rounded posterior lobes consisting of 
fibrous or inflammatory glandular enlargement of the median portion 
of the prostate. 
In the presence of lateral lobe or definite median lobe hypertrophy 
this operation should not be done, as removal of the median ob- 
struction leaves the lateral lobes to continue the obstruction in 
generally increased amounts, so that careful study should be made 
with the cystoscope, and particularly with examination of the median 
and lateral portions of the prostate by finger in the rectum while the 
cystoscope is in the urethra to determine the presence of an. hyper- 
trophied collar or definite median and lateral hypertrophy of the 
prostate. 676 
PROSTATIC OBSTRUCTIONS 
Young has also modified the instrument by introducing a small 
motor with which the inner cutting tube is revolved with great speed 
while the cuts are made. This seems to remove definitely larger 
masses of tissue with greater speed and with less pain but it is prob- 
ably unnecessary. 
Young had also constructed a cautery punch, in 1911, which was 
supplied also with a stream of water to prevent overheating the 
outer tube. (See Fig. 308, photograph of instrument made in 1911.) 
As seen here the inner cutting tube consists of iridoplatinum which 
is superheated by an electric current. When the prostatic bar has 
been entrapped the electric current is turned on and after waiting a 
few seconds the cautery tube is slowly carried home by turning the 
outside screw mechanism. The effect is to burn away a block of 
tissue which fills the fenestra of the instrument, and this is done quickly 
and absolutely without hemorrhage. There remains, of course, a 
small area of charred tissue at the prostatic orifice and this must 
naturally separate and crumble away with the patient’s convalescence. 
Fig. 308.—Photographic side view of cautery punch with water-cooling device, which 
was designed by Young and made by Loewenstein, in Berlin, in 1911. 
A similar number of cuts.can be made with this instrument as with 
the simple cutting punch instrument, and has this distinct advantage, 
namely, in that hemorrhage is entirely absent and a urethral catheter 
is not necessary. 
In 1920, J. R. Caulk presented a simpler form of cautery punch 
which he had independently devised and used. This is not provided 
with an irrigation to keep the outer tube cool, as he has demonstrated 
that this is unnecessary. His article strongly urges the use of the 
cautery punch instead of the simple punch and has forcibly called 
attention to this modification of the original operation. A personal 
report from McKim states that the use of the cautery punch has in 
some instances led to the deposits of urinary salts and small calculi 
upon the eschar at the site of the cautery burns in the prostatic orifice. 
Subsequent treatment of the simple punch operation consists in 
maintaining a catheter drainage for several days, during which time 
the patient is given water in large quantities and if the catheter becomes 
plugged with blood clots, as it often does during the first two or three 
days, these are removed by means of suction with a large syringe 
accompanied by introduction of water to wash out the bladder. THE HIGH-FREQUENCY SPARK OPERATION 
677 
Occasionally rather severe hemorrhages are encountered, but in a series 
of over 200 cases Young had no deaths and the hemorrhage has 
always been taken care of by evacuation of the clots, occasional 
instillation of adrenalin into the bladder and the use of infusions and 
transfusions if necessary. In two instances other surgeons have 
found it desirable to carry out suprapubic drainage and pack at the 
prostatic orifice on account of hemorrhage. One of these was a case 
of tuberculosis of the bladder and the other of cyst at the vesical 
orifice. But even if suprapubic drainage is occasionally desirable 
or necessary it adds very little to the gravity of the operation and 
without the punch operation it would probably always have to be 
employed in removal of the median bar. * 
As to results obtained, a careful study of cases has shown that this 
simple operation is really very radical and entirely satisfactory in 
removing the difficulty of urination, the hesitation, the small stream 
and the frequency of urination which is so often present in these 
cases. In some instances complete retention of urine was present 
but this was rare and in the majority of cases the residual urine was 
from 25 to 100 c.c. in amount, and was usually associated with con- 
tracture of the bladder, which almost always completely disappeared 
as the obstruction to urination and the consequent hypertrophy of 
the bladder muscles disappeared. 
Because of the difficulty in making a differential diagnosis, between 
median bar and median lobe, and inasmuch as the punch is only 
applicable for the median bar type of cases, many surgeons have 
performed a two-step operation and at the time of the suprapubic 
cystotomy, and if the operator on examination with his finger in the 
bladder finds a bar he uses the punch, under the guidance of his fingers. 
Performed under these conditions there is no danger of hemorrhage. 
The High-frequency Spark Operation.—This form of treatment is 
applicable in the same class of cases as the Young’s punch operation. 
The spark operation is less trying for the patient, and eliminates almost 
entirely the danger of hemorrhage. The patient is prepared as for a 
cystoscopic examination. A catheterizing cystoscope of small size, or a 
cysto-urethroscope is used. With the instrument in place, the obstruct- 
ing mass is brought into view and the electric wire is advanced until 
it engages the tissue. Then the spark is applied for a period of from 
twenty to thirty seconds, or until the tissue shows destructive effect of 
the spark, dependent, of course, on the strength of the current. The 
spark is applied along parallel lines, reaching well across the obstruc- 
tion. It is best to be cautious with the first application, doing too 
little rather than too much. After a period of two weeks, the cysto- 
scope is again introduced, the effect observed, and further treatment 
applied. Considerable improvement should follow after the fourth 
or fifth treatment. 
* In my experience bleeding has been a serious handicap to this operation with the 
“cold knife.”—Ed. 678 
PROSTATIC OBSTRUCTIONS 
Bugbee,1 who has treated a number of cases by this method, has 
published the following conclusions: 
The residual urine has been eliminated in all cases of median-bar 
obstructions, as well as those due to cicatrix and chronic inflammation 
of the vesical neck. 
Partial relief was obtained in cases of incomplete prostatectomies 
with nodules of prostate remaining about the vesical neck. 
Of the patients with glandular hyperplasia, nine in number, three 
have died of intercurrent disease; two are symptomatically relieved; 
three are still under treatment. In eight of the nine treated, the 
residual urine was lessened. In one case there was no improvement. 
The cases of lateral-lobe enlargement have shown little improvement. 
These results bear out the belief of the writer that the high-frequency 
current should be reserved for the cases of submucous fibrosis and 
enlargements due to chronic inflammatory changes alone. 
Transvesical Prostatectomy.—Transvesical prostatectomy has been 
employed for many years with varying degrees of success. Its uni- 
versal acceptance as a method for enucleation of the prostate has 
been delayed by several unpleasant, and often dangerous, features 
which have resulted from imperfect technic. Chief among these 
factors have been: 
1. The discomfort of the patient due to continuous urinary leakage 
from the suprapubic wround. 
2. The sloughing and infection of the wound. 
3. Incomplete control of hemorrhage. 
4. Confinement in bed. 
5. Prolonged urinary leakage. 
6. Long-continued urinary fistula. 
Since these objections have been overcome by the employment 
of a special technic, transvesical prostatectomy has become more 
popular than perineal prostatectomy. Since a suprapubic cystostomy 
is usually done as the first step of a transvesical prostatectomy, 
division of the operation into two stages has naturally suggested itself 
and is now employed by many surgeons in preference to preliminary 
catheterism and later transvesical prostatectomy. A discussion of the 
merits of these steps has already been given. 
In those cases in which the operation of transvesical prostatectomy is 
completed in one stage the technic of the cystotomy is exactly the same 
as when a cystostomy is performed, with the exception of the closure 
of the wound. Therefore the two will be described together. 
Pilcher prefered the two-stage operation in practically every case 
of glandular hyperplasia of the prostate for the following reasons: 
1. It permits of renal decompression with the least risk.21 
2. It provides complete urinary drainage without any urinary leak- 
age. The result is a dry wound and allows the patient to be out of 
bed within twenty-four hours after the cystostomy. 
3. Primary union of the suprapubic wound is secured around the 
opening into the bladder through which the prostate may be enucleated, TRANSVESICAL PROSTATECTOMY 
679 
thus excluding the tissues of the prevesical and perivesical spaces from 
the operative field and preventing infection and extravasation of urine. 
With the drainage tube in place and the urine entirely controlled, an 
indefinite period may be allowed for the patient to recover from his 
stage of depression and a time may be chosen for the prostatectomy 
which is most favorable for the patient. Often without further incision 
for the use of any instrumentation the enucleation of the prostate may 
be accomplished through the opening already provided, thereby 
Fig. 309.—Infiltration of bladder with novocaine. (Lower.) 
greatly diminishing the possibilities of surgical shock and limiting 
the area in which infection may develop. 
Suprapubic Cystostomy.—Cystostomy is employed either as a first 
stage of the two-step operation, or as a preliminary to transvesical 
prostatectomy. The operation is performed under local anesthesia. 
Preparation of the Patient.—The usual catharsis is given forty-eight 
hours previous to the day of operation. No catharsis or enema is 
given within twenty-four hours of the operation. The field of opera- 
tion is prepared by shaving the parts and cleansing them with soap 
and water the day before operation. Just before the operation is 
commenced iodine is applied to the skin. 680 
PROSTATIC OBSTRUCTIONS 
In emergency cases the area is shaved, Harrington’s solution is 
applied, followed by washing with alcohol. 
Special efforts are made to inspire the confidence of the patient before 
the operation. Examinations are made with the utmost gentleness. 
The night before operation the patient is given 30 grains of sodium 
bromide and this is repeated on the morning of the operation. In many 
cases morphine, \ grain, combined with atropine, grain, is given 
by hypodermic injection half an hour before the operation. Panto- 
pon, grain, given one hour previous to the operation has been very 
Fig. 310.—Deep infiltration along edges of capsule of prostate before removal. (Lower.) 
satisfactory. Many urologists object to the use of morphine in these 
cases, but the writer feels that their objections are not sustained. 
Wherever possible the principles of anoci-association are employed 
during the performance of the operation. 
This is advocated both during the cystotomy and later in enucleat- 
ing the prostate. Lower’s14 technic is as follows: 
1. An hour before the operation the patient is given a hypodermic 
injection of morphine and scopolamine, the seize of the dose depending 
upon the age of the patient. TRANSVESICAL PROSTATECTOMY 
681 
2. Immediately before the operation the bladder is irrigated and 
60 to 90 c.c. of a 5 per cent, solution of alypin is injected through the 
catheter. The catheter is clamped and both catheter and solution are 
allowed to remain. 
3. The bladder is approached in the usual way except that the skin 
incision and every division of tissue is preceded by a thorough infiltra- 
tion with nocovaine in solution. 
4. When the bladder is exposed it is elevated with curved hooks 
and thoroughly infiltrated with novocaine solution (Figs. 309 and 310). 
Fig. 311.—Showing the surgical problem. Special attention should be directed to 
A, the fold of peritoneum in its relation to the symphysis when the bladder is con- 
tracted. B, the raising up of the peritoneal fold when the bladder is dilated. The 
relation of A and B to the symphysis is quite variable and in some instances is fixed at 
the level of the symphysis. 
Technic of Suprapubic Cystostomy.—The skin incision begins about 
one inch above the symphysis and is continued in a vertical direction 
toward the umbilicus for about four inches. The fat and fascia are 
divided with a knife and the recti muscles are separated by the 
finger; the remaining fascia and prevesical tissues are easily separated. 
At this point the bladder is well filled with sterile water through a 
catheter introduced by the urethra. If it is not possible to introduce 
a catheter without undue force, it is not attempted. 
With the bladder full the finger is introduced into the wound until the 
under surface of the symphysis pubis is reached; then the finger covered 682 
P ROST AT IC OBSTRUCTIONS 
with gauze is slowly swept upward, gradually lifting the tissues away 
from the anterior surface of the bladder, at the same time forcing the 
Fig. 312.—Second step, freeing anterior wall of the bladder, preparing it for incision. 
Finger has been swept upward from symphysis along anterior face of the bladder 
carrying with it peritoneal fold P. If finger is removed from the wound at this point, the 
peritoneal reflexion will be seen forcing its way downward with each respiration of the 
patient. 
Fig. 313.—The bladder wall is seen exposed and the position of the incision is indi- 
cated near the fold of the peritoneum. The two stay sutures are in place and hold the 
bladder wall up. As soon as these sutures have been introduced the fluid is withdrawn 
from the bladder. 
peritoneal fold upward. This is of great importance because the peri- 
toneal fold frequently descends low and lies over the anterior wall of SUPRAPUBIC CYSTOSTOMY 
683 
the bladder where it is desired to expose it (Figs. 311 and 312). After 
the bladder wall has been cleared it will be recognized by the tortuous 
dilated veins presenting on its surface, extending upward in a fan shape. 
Also the appearance of the thick muscle bundles of the bladder wall is 
characteristic. When the finger is removed the peritoneal fold will 
bulge downward. Great care must be exercised in pushing back the 
peritoneum, for it is easily torn. This accident has occurred to the 
writer, but no untoward symptoms follow the injury if the wound is 
immediately closed. 
When the bladder wall is properly bared, retractors are introduced, 
two lateral ones to hold back the muscles, and one in the upper angle 
of the wound to hold back the peritoneal fold. When all is in readi- 
ness, two retaining sutures are introduced into the bladder wall (Fig. 
313), about an inch apart on either side of the point where the bladder 
is to be incised. This point is chosen at the uppermost limit of the 
Pi Ic'K er 
button 
drainagetube 
Fig. 314.—de Pezzer catheter 
Fig. 315.—The Pilcher modification. 
bladder near the peritoneal fold. Before the bladder is opened the 
fluid is allowed to flow out through the urethral catheter. The 
button drainage tube (Figs. 314 and 315) is held ready for use. Then 
the bladder is held up and steadied by the stays, or clamps if preferred, 
and an opening is made at the point chosen. The finger is inserted 
through the opening, the anterior of the bladder explored, foreign 
bodies, calculi, etc., are removed and the character and size of the 
prostate is determined. When the finger is withdrawn the button 
drainage tube is immediately inserted and fixed in place either by a 
purse-string suture of chromic gut or silk or by tying the stay sutures 
around the tube (Fig. 316). If it is undesirable to empty the bladder 
the tube is plugged with a cork; otherwise it is allowed to drain as 
it will. At times small vessels in the bladder wall are injured. These 
should be clamped or ligated. 684 
PRO STATIC OBSTRUCTIONS 
The Convalescent Period.—Management of the Urinary Drainage.— 
As soon as the patient reaches his room the stopper is removed from 
the drain pipe and the bladder emptied. If there has been only a 
small amount of residual urine continuous drainage is allowed. If 
Fig. 316.—Shows the way in which the button drainage tube is fixed into the bladder 
wound—the stay suture from one side being tied on the opposite side of the tube includ- 
ing some of the bladder wall, and the one from the other side tied in a similar manner. 
These will hold the tube firmly in place. A purse-string suture is used for the same 
nurpose. 
Fig. 317.—Method of securing button drainage tube in abdominal wound to prevent 
its slipping out or in, and consists of a simple strip of adhesive plaster one piece of which 
crosses the abdomen and the other piece encircles the drainage tube and then is attached 
to the abdomen. The condition finally secured is shown in Fig. 318. TRANSVESICAL PROSTATECTOMY 
685 
there has been a marked and long-standing distention of the bladder, 
continuous draining should be avoided, the stoppered drain being 
opened at intervals of one or two hours as the case demands. 
No attempt is made during the first three or four days following the 
operation to wash or medicate the bladder. 
The most marked reaction which follows the operation will become 
evident from the second to the fifth day after suprapubic cystostomy. 
The patient, however, is in the best possible condition to withstand this 
depression, for there has been practically no loss of blood, no general 
anesthetic, and no special pain, all of which factors tend to decrease 
the resisting powers of the organism. 
Fig. 318.—de Pezzer catheter in place after suprapubic cystostomy. Button of the 
catheter fits snugly and is far superior to the ordinary drainage tube inasmuch as it 
does not permit any rough or sharp surface to irritate the prostate or the bladder wall. 
This idea was first suggested to Pilcher by Rovsing and is the method which he follows. 
If the technic of the operation has been carefully followed, there will 
result a cystostomy opening in which the button drainage tube fits 
snugly, and being securely held in place prevents any leakage around 
the tube and at the same time completely empties the bladder. 
It has been the experience of Pilcher in employing this technic that 
primary union of the wound is secured in practically every case, even 
where an extensive infection of the bladder exists. The special features 
which recommend the adoption of this technic, as first described 
by Pilcher,22 are that primary union of the wound is secured with 
complete control of the urine; further, that the prevesical and peri- 686 
PROSTATIC OBSTRUCTIONS 
vesical spaces have been eliminated from the surgical problem and half 
of the operation of transvesical prostatectomy has been completed 
without the employment of general anesthesia and with freedom from 
surgical shock. 
Enucleation of the Prostate.—Many surgeons still proceed with enucle- 
ation of the prostate at the time of the primary operation and the 
method of its accomplishment is practically the same whether it is 
employed as a primary operation or as a second step following recovery. 
Preparation for the Second Stage.—When the time for removing the 
prostate has arrived, the patient is prepared for operation as before. 
All unnecessary catharsis, etc., on the previous day is avoided. The 
patient is placed on the table and iodine is applied to the skin around 
the drainage tube. 
Anesthesia.—Ether by the drop method and nitrous oxide are the 
anesthetics most commonly used. Lower, in addition, through the 
suprapubic opening, injects into the prostate and capsule novocaine 
to relieve the shock (Fig. 310). 
Spinal anesthesia has been used in Boston and its vicinity for a 
number of years. Chute was one of its early advocates and has had 
a large experience in its use. He finds that this form of anesthesia 
reduces the risk. Labat,13 at the Mayo Clinic, devised a technic 
which it is claimed eliminates headache and nausea, which he de- 
scribes as follows: 
“The patient is injected in the upright position as usual. The 
puncture is made at any level between the twelfth dorsal and the 
fifth lumbar vertebrae, according to the height of the anesthesia desired. 
No attempt is made to produce anesthesia higher than the line of the 
nipples. After making the puncture, the first few drops of cerebro- 
spinal fluid are allowed to flow' out, so as to obtain a clear fluid, which 
is allowed to fall in a special ampoule containing the anesthetic drug. 
More fluid is withdrawn varying betw een 10 c.c. and 25 c.c., according 
to the condition of the intraspinal pressure, which very often agrees 
w ith the blood-pressure. The appearance of headache should prompt 
the cessation of further withdrawal of fluid. The solution thus made 
is aspirated into any kind of syringe by means of a spare needle, the 
syringe is then adapted to the spinal puncture needle and as much 
new fluid is brought into the syringe as it now contains solution. Half 
of this is injected very slowly, more new fluid is aspirated, the syringe 
is discharged in the same way, leaving less and less fluid in it, and at 
the end of four or five injections it is emptied. There is no hurry in 
placing the patient in the recumbent position, but there is also no 
reason for keeping him in the erect position. He is, therefore, placed 
on his back, and by the time the operative field is prepared, he can 
be placed in the Trendelenburg position and stay there until sen- 
sibility returns wdthout prejudice to his respiratory function. As 
is usual with spinal anesthesia the blood-pressure falls in the majority 
of cases very rapidly, affecting only the maxima, and comes back 
to normal later, sometimes during the operation and sometimes only 687 
TRANSVESICAL PROSTATECTOMY 
in the afternoon, without changing the clinical aspect of the patient 
whose condition he, himself, considers to be very satisfactory. A 
nauseated condition sometimes exists, especially v7ith the Trendelenburg 
position, which disappears rapidly by deep breathing. No special 
post anesthetic care nor position is especially indicated in the patients 
thus anesthetized.” 
As the prejudice is overcome this form of anesthesia will probably 
be used more and more. It has many advantages in this class of 
surgery, one of which is the relaxation of the abdominal muscles. 
Fig. 319.—Enlarging the suprapubic opening after cystostomy where a nearer 
approach to the prostate is desired. Note that there are two lateral incisions and one 
toward the pubis extending only through the fat layer. In doing an enucleation of the 
prostate the skin sutures remain in place. The wound is not enlarged upward because 
of the danger of opening the peritoneal cavity. 
In cases in which the period of depression following the first opera- 
tion is short, i. e., from one to two weeks, it is not necessary to use 
any instruments to enlarge the drainage opening; the silk skin sutures 
are still in place and should remain. Where the skin sutures have cut 
through it is sometimes wise to reinsert heavy silk stay sutures to 
splint and keep the wound from tearing open during the manipula- 
tions necessary for enucleating the prostate. Where a long interval is 
necessary between the first and second operation, it is frequently of 
advantage to enlarge the opening. 
Enlarging the Suprapubic Opening.—This is done as shown in Fig. 
319 by three radiating incisions extending on each side of and down- 
ward from the opening. These incisions are not necessarily more than 
an inch in length and are all carried through the subcutaneous fat to 
the sheath of the rectus muscle. 688 
PROSTATIC OBSTRUCTIONS 
Making the Approach to the Prostate Easier.—If the patient is very 
stout and the thickness of the abdominal wall leaves the prostate out of 
our reach, it is desirable to remove sufficient subcutaneous fat to allow 
Fig. 320. —Tip of index finger introduced into vesical portion of the urethra. 
Fig. 321.'—After beginning enucleation of the urethral aspect of the lobe the finger 
follows the sphincter muscles around the prostatic mass until the prostate is entirely 
free from it. If this is done before the prostate is removed, the sphincter can be entirely 
freed from all prostatic tissue and there will consequently be less bleeding. 
the hand to rest directly against the sheath of the recti muscles. This 
reduces the intervening space between the hand and the prostate and 
makes the distance for the finger within the bladder about the same in TRANSVESICAL PROSTATECTOMY 
689 
all cases. In cases where the approach is still too constricted to allow 
of complete control of the field of operation, the wound is enlarged by 
carrying the two lateral incisions deeper through the sheath of the 
recti muscles. Thus, any degree of exposure can be obtained with- 
out reopening the prevesical spaces. The incisions are not extended 
upward on account of the danger of injury to the peritoneum. 
The Enucleation.—With the approach to the prostate provided for, 
the enucleation of the enlarged portions of the gland is accomplished by 
entering the index finger of the one hand (or in difficult cases the index 
and second finger) into the vesical portion of the urethra, slowly dilating 
it and seeking, if possible, the band-like sphincter vesicse (Fig. 320). 
Having located this an effort is made first to separate the gland from 
the encircling sphincter by entering the natural line of cleavage which 
exists between the hyperplastic glandular masses and the muscular 
fibres (Fig. 321). 
This is of advantage because, if the internal sphincter is preserved, 
the patient will gain control of his urine more quickly and the con- 
trol will be more perfect; and in the second place, where this muscle 
is preserved, one seldom has any troublesome hemorrhage following 
the enucleation, probably because a rapid contraction of the surround- 
ing tissues takes place. In the case of fibrous or muscular hyper- 
plasia this separation of the sphincter is more difficult. In every 
case all prostatic tissue should be cleared from the sphincter muscle. 
Having accomplished this, the finger is passed farther into the 
urethra until the most distant part of the enlarged gland is reached. 
Here the lines of cleavage are sought and the enucleation accom- 
plished slowly, gently and completely. 
The work of enucleation will be greatly facilitated if the operator 
introduces one or two fingers into the rectum to lift up and steady the 
prostate while the enucleation is being accomplished. 
Details of the Prostatic Enucleation.—With the finger in the prostatic 
urethra, the point of least resistance in the mucous membrane of the 
urethra is sought. Usually this will be found on the lateral wall of 
the urethra. At this point the division between the prostate and the 
urethra is usually quite easily broken through. The finger after enter- 
ing the line of cleavage sweeps, first, slowly around the distal portion 
of the growth, and then up over the anterior surface of the growth, 
separating it from the prevesical tissue. The finger is then passed 
across the urethra to the other side with a sweeping motion and the 
opposite lateral lobe is freed (Fig. 322). The finger is now passed over 
the two loosened lateral lobes, then beneath and between them and 
the rectum, and then the finger is pulled toward the bladder so that 
the growth will be pushed into the bladder. 
The point which is most difficult to free is that which is most distant 
from the bladder, at the junction of the prostatic and membranous 
urethra, or at the point of the attachment of the atrophied middle 
lobe distal to the ejaculatory ducts, which part of that lobe probably 
is not removed in the majority of cases. Those cases in which the 690 
PROSTATIC OBSTRUCTIONS 
prostate does not shell out easily should be carefully examined for 
evidence of malignancy. 
A peculiar type of prostate which is occasionally encountered is that 
in which the gland is enormously hypertrophied in all its parts except 
the median lobe. In removing such a prostate it may often be more 
easily done by passing the finger between the sphincter vesica? and the 
growth and sweeping the finger around the latter, as recommended by 
Freyer. It will quickly fall out into the bladder. However, in the 
majority of cases the intra-urethral enucleation is to be preferred. It 
is quite essential for the welfare of the patient that all of the prostatic 
tissue as far as possible should be removed. The operator should not 
be satisfied with removing the larger adenomatous mass alone, but an 
Fig. 322.—Prostate elevated by finger in the rectum; index finger in urethra enucleating 
the prostate. 
attempt should be made to bring away all the prostatic tissue unless 
there is a diffuse carcinomatous involvement. If fragments remain, 
they retard the healing of the cavity from which the prostate has been 
removed and are apt to necrose and cause a delay of the healing process. 
Following the Enucleation.—Remove all foreign material from 
bladder, i. e., blood clots, the enucleated prostate, loose pieces of tissue, 
and most important of all, any small prostatic calculi which have been 
forced into the bladder during the enucleation. Frequently these 
calculi are overlooked and they may remain and later cause distressing 
symptoms. 
A small gauze sponge is the best instrument with which to remove 
such calculi. TRANSVESICAL PROSTATECTOMY 
691 
The Control of Hemorrhage.—1. By removing all the glandular 
masses. This allows the cavity to contract, just as the pregnant 
uterus does after being emptied. 
2. By direct pressure, one finger in the rectum and one in the bladder, 
placing all torn bits of attached tissue over the lacerated area. Fresh 
muscle fibers will often seal the opening in a torn vessel. 
3. By the bag hemostat. We no longer use gauze packing to control 
hemorrhage in these cases, because of the large amount of material 
necessary to secure absolute control of the bleeding, the sloughing of 
Fig. 323.—The hemostatic bag of Hagner. 
the bladder and wound which may follow its use, the pain and unneces- 
sary disturbance of the healing surface caused by its removal. The 
hemostat of Hagner10 provides direct pressure on the bleeding surface 
by means of an inflatable rubber bag placed within the bladder, the 
degree of pressure being controlled by a rubber tube which passes 
down through the urethra, by means of which the bag is inflated and 
held in contact with the lacerated surface (Fig. 323). 
Pilcher has devised a hemostatic bag of this type which embodies 
some new features, the object being to increase the comfort and to 
secure the safety of the patient. In addition, this bag provides for 
the drainage of the urine through the urethral tube (Figs. 324 and 325). 
To place the bag, a well-curved sound with nub on the end is 
passed through the urethra into the bladder, after the prostate has 
been removed until its tip projects through the suprapubic opening. 692 
PROSTATIC OBSTRUCTIONS 
The open end of the urethral tube of the bag is threaded over the 
end of the sound and tied. The sound is then withdrawn, bringing 
with it the rubber tube attached to the bag. This tube is then secured, 
Fig. 324.—The Pilcher hemostatic bag. The device is a simple inflatable rubber bag 
fashioned about a large size catheter. Cross-section in figure below shows structure of 
bag. The open tube catheter is entered first through the suprapubic wound over a 
silver catheter and drawn down through the urethra. When the bag is in the bladder 
with the tube in the urethra, the bag is inflated through the inflating tube and the 
inflated bag is used for pressure against the bleeding surface from which the prostate 
was removed. When pressure is desired the catheter attachment is pulled upon which 
brings the bag more tightly in contact with the bleeding surface. This pressure may be 
maintained by attaching the catheter tube to the leg. The catheter tube also acts as an 
avenue for the escape of the urine from the bladder. 
Tube for inflecting bag 
Air space 
Opeg -tube 
"Through urethra 
Air space 
Fig. 325.—Diagram of the Pilcher hemostatic bag. 
the bag distended with water through the other tube provided for that 
purpose, and with one finger in the bladder, the urethral tube is pulled 
upon, drawing the bag down into the area from which the prostate 
has been removed; at the same time all tags of tissue and torn muscle 
fibres are tucked in front of the bag and are brought in contact with 
the lacerated area (Fig. 326). The urethral tube is attached to the TRANSVESICAL PROSTATECTOMY 
693 
cage by a cord, one end consists of a sailor’s slip knot fastened close 
to the meatus, the other to the ring on the cage. Tension on the cord 
holds the cage in place and likewise makes any desired pressure at the 
Fig. 326.—Sketch showing complete drainage of bladder with hemostatic bag in 
place after enucleation of the prostate, inflating tube passing up through or beside 
large drainage tube. In two or three hours the bag is allowed to deflate and the 
pressure is relaxed. If bleeding recommences, the bag is reinflated and pressure 
reestablished. This bag is removed through the suprapubic wound in twenty-four 
hours. 
Fig. 327.—Barone modification of the Hamer cage. The cage permits the patient to 
move, but keeps steady tension on the rubber-drainage tube. 694 
P ROST AT IC OBSTRUCTIONS 
vesicle neck. It also permits the tube to drain into a urinal (Fig. 
327). By this means we have a safe and positive means of controlling 
hemorrhage, which can be removed within an hour, if desired, and 
reapplied at will, without disturbing the patient. Its removal at 
the same time that the drainage tube is changed is accomplished with 
relatively little discomfort to the patient. 
Drainage of the Bladder.—This we consider necessary in every case 
of transvesical prostatectomy. A large size rubber tube is used, pre- 
ferably about an inch in diameter. The tube extends only half an inch 
within the bladder and is fastened to the skin by a silk suture (Fig. 328). 
If a hemostat bag has been used, the air tube is brought out through the 
Fig. 328.—Surface view of drain and dressing following suprapubic cystostomy 
in which bag hemostat has been used, the smaller tube being the inflating tube of the 
hemostatic bag. 
drainage tube or beside it (Fig. 328). A large size glass connecting 
tube is attached to the drainage tube and a second rubber tube is 
attached to it, whereby the secretions from the bladder are collected in 
a bottle at the bedside. In most cases this will be most satisfactory 
and the patient will be kept dry for the first twenty-four hours following 
the enucleation. 
Management of the Bag Ilemostat.—With the bag inflated with 
water and in position, we have an absolute control of the hemorrhage. 
The amount of tension exerted on the urethral tube controls the degree 
of pressure exerted on the torn periprostatic tissues. It is our practice 
to exert a considerable amount of pressure for two hours after pros- 
tatectomy. At the end of this time the bleeding has usually stopped. 
The cord is untied from the ring of the cage and the cage is removed. 
The bag is left inflated for eight hours after the operation. If there 
is any active bleeding, the nurse can easily replace the cage. When 
the bag is deflated it remains in place but exerts no pressure. The TRANSVESICAL PROSTATECTOMY 
695 
urethral tube in the meantime is functionating as a catheter and is 
draining the urine from the bladder into a bottle. In other words, 
we have provided a double exit for the urine, and the result is added 
comfort to the patient, a dry clean wound, and a great reduction in 
the dressings. If any bleeding should start again it is a simple matter 
to dilate the bag and reapply the pressure. The bag is removed in 
from twenty-four to forty-eight hours. 
First Twenty-jour Hours after Operation.—If the patient is comfort- 
able and dry and the draining tube is not causing pain or spasm of 
the bladder, he is not disturbed in any way. If desired, he is allowed 
to sit up in a chair the day following operation. 
If the bag hemostat is causing trouble it may be removed together 
with the suprapubic drainage tube at the end of twenty-four hours, 
otherwise it is left in place for forty-eight hours. 
Forty-eight Hours after Operation.—We now have the choice of two 
methods of after-care. If the patient bears an indwelling catheter 
well—and many who could not tolerate one before the first step, will 
wear it subsequently with comfort—we attach a soft-rubber catheter, 
size 20 F., by a stitch to the urethral tube. The suture holding the 
drainage tube is cut and the tube and bag are gently withdrawn from 
the suprapubic wound. The urethral tube having been cleaned and 
covered with vaseline is easily drawn through the urethra, bringing 
with it the soft-rubber catheter. When the catheter appears in the 
suprapubic wound it is detached from the tube and a silkworm suture 
through the skin holds it in place. If the catheter becomes plugged 
at any time, it is easily pulled into sight by the suture. The wound 
is packed with gauze and the abdomen strapped. This method, when 
it can be used, gives ideal drainage. If an indwelling catheter is not 
feasible, drainage above is made as follows: Depending upon the 
character of the wound we choose a specially made de Pezzer or 
Pilcher catheter, or a button tube. Grasping the enlarged end of 
the tube with a pair of dressing forceps it is passed along the groove 
of the narrow retractor until the end enters the bladder. Then the 
forceps and retractor are withdrawn, leaving the button end of the 
tube in the bladder. In most cases the bladder wall will immediately 
contract and hold the tube in place. In some cases this will take 
three or four hours. When the tube is in place it is carefully tested 
by a small amount of irrigation to make sure that it drains the bladder. 
Frequently some of the irrigating fluid returns around the tube, but 
in practically every case the greater part returns through the tube, 
if it is properly placed. When satisfied that the tube is in proper 
position it is fastened by an adhesive strip (Fig. 328) and attached 
to an extension tube which is lead to the bottle. In most cases this 
tube, if correctly placed, will drain all of the urine from the bladder, 
and after a period of a few hours will keep the patient perfectly dry. 
This we consider a great advantage to the patient. 
Barringer1 uses a sponge holder (Figs. 329 and 330) with sufficient 
packing of a 2-inch width to fill the prostatic cavity One end of Fig. 329.—Barringer’s method of using sponge holder to hold gauze which exerts pressure 
in the prostatic cavity. 
Fig. 330.—Barringer’s method of applying dressing when sponge holder is used. 
696 TRANSVESICAL PROSTATECTOMY 
697 
the gauze is brought out through the wound, no drainage tubes are 
used, pressure is made on sponge holder by a strip of adhesive plaster. 
As a rule, three hours following the operation, when the dressings are 
first changed, the pressure with the adhesive strip is discontinued. 
Ten hours after operation forceps are unclamped and a few hours 
afterward are removed. Twenty-four hours after the operation that 
part of gauze which is loose is removed, and each time the dressing 
is changed more is pulled out. Following the removal of the gauze 
a de Pezzer catheter is placed in the wound and the wound strapped 
with adhesive plaster. This usually keeps the patient dry. 
At the end of twenty-four hours, some patients, and after forty-eight 
hours, most of them are allowed to get out of bed. Common sense 
and not rule governs this phase of the subject. 
Control of the Bladder. — One Week after Operation.—By this time 
the healing at the neck of the bladder is well advanced, and it is 
time to think of using the urethra again. (In one of our cases 
the suprapubic wound healed in four days.) At the end of a week 
the button .drainage tube is still in place, and in most cases the 
patient is dry. In some cases there will still be leakage beside the 
tube. When the patient is dry we encourage the use of the urethra. 
We temporarily close the drainage tube and allow the bladder to 
partially fill. Then the patient is told to try and void per urethram. 
It is surprising to note how many will succeed. The majority begin by 
passing a dram or two each time, every hour a little. At the end of 
twenty-four hours the patient will be passing an ounce or so every 
hour and gradually he resumes his natural habit. All of this time we 
have the drainage tube as a safety valve. In a few days we find that 
most patients no longer need the tube, and it is removed. Some 
suprapubic leakage will occur for a day or so, but in many cases there 
will be very little after twenty-four hours. This depends, however, to a 
considerable extent on the care and exactness with which the first stage 
of the operation has been carried out. This refers especially to the 
placing of the opening in the bladder and the healing of the wound. 
The suprapubic opening heals rapidly and, as a rule, is entirely free 
from the necrotic, phosphate encrusted tissues. 
The technic above described is applicable in the majority of cases of 
prostatic hypertrophy, and when followed will give the patient the 
maximum of security with the minimum amount of suffering. 
Control of Hemorrhage.—In addition to the methods already described 
for controlling hemorrhage the follow ing means have been employed. 
Fenwick Method by Clamp and Ligature.—Fenwick has devised a 
series of three specula of different sizes wThich may be introduced 
through the suprapubic wound, bringing the area from wrhich the pros- 
tate has been removed directly into view. The use of one of these 
specula is illustrated in Fig. 331. The headlight is used to illuminate 
the cavity. With the lacerated oozing area in view and properly illumi- 
nated, the area is sponged as dry as possible and it will be found, as a 
rule, that bleeding does not come so much from the cavity from which 698 
PROSTATIC OBSTRUCTIONS 
the prostate has been removed, but usually from the free edges of the 
lacerated tissue which covers the surface of the prostate on its vesical 
aspect. The area from which the prostate has been removed flattens 
out very quickly and does not remain as a cavity, but contracts and, 
usually, does not allow space for the accumulation of blood clots. 
Through the speculum the bleeding points are caught with specially 
devised hemostats. In this way the bleeding can be entirely con- 
trolled. In most cases after a few minutes’ crushing with the hemo- 
stats they may be removed and no further bleeding will occur. The 
hemostats are so constructed that the handles may be removed, if 
necessary, and the instruments may be left in situ for twenty-four hours. 
Fig. 331.—The Fenwick bladder speculum in place. 
As a modification of this method the writer would suggest the use of 
the actual cautery through the speculum to control any bleeding-point 
which might come into view. 
Control by Suture.—A number of prominent operators complete 
their prostatectomies by surrounding the area from which the prostate has 
been removed by a continuous or by interrupted catgut sutures. This 
necessitates a large suprapubic wound and consumes considerable time 
and, in the experience of the writer, has never been found necessary. 
Control of Secondary Hemorrhage from the Bladder.—Hemorrhages 
occurring within twelve to twenty-four hours after the prostatectomy 
are best controlled by packing the prostatic pouch around a catheter 
introduced through the urethra. In one case the writer passed a silk TRANSVESICAL PROSTATECTOMY 
699 
suture through the perineum, placed a gauze packing over the pros- 
tatic pouch and fastened the silk suture to this gauze packing, tying the 
same on the outside of the perineum. Secondary hemorrhage which 
occurs a week or so after the operation may be either from the wound 
itself which calls for its reopening and suture, or it may be from the 
vesical neck or the prostatic pouch itself. Such an occurrence calls for 
reopening of the bladder, exposure of the bleeding-point and securing 
it either by suture or touching it with the actual cautery or the 
high-frequency spark generated from the D’Arsonval current. In one 
case of my own it was necessary after the second week to reopen the 
bladder widely and cauterize the entire area of the vesical neck before 
the hemorrhage could be stopped. 
Variations in Technic.— The Trocar and Cannula for Suprapubic 
Drainage of the Bladder.—This technic has been recently worked out 
by Lower,5 of Cleveland. He describes it as follows: 
Using a local anesthetic, or without any anesthetic even, the trocar 
and cannula may be forced into the bladder at a point sufficiently 
distant from the pubis to avoid puncturing the plexus of veins which 
lies just behind the pubic bone. The trocar is then withdrawn, and a 
sterile No. 14 soft-rubber catheter is inserted through the cannula into 
the bladder. The cannula is withdrawn and the bladder emptied 
Fig. 332.—Trocar and cannula with metal collar. (Lower.) 
through the catheter, which is allowed to remain. The retained 
catheter can be held in place by adhesive plaster, the end being plugged 
or compressed until relief is again needed. The catheter may remain 
in place for days, if necessary, without doing any harm and in the 
meantime the patient can be made ready for operation or further 
treatment. It may happen that after several days of suprapubic 
drainage the patient will again be able to void urine. This method 
often is a more comfortable way of securing continuous drainage of the 
bladder as a preparation for prostatectomy than is the insertion of a 
catheter through the urethra, as the latter method is generally irritat- 
ing and disturbs the patient greatly. 700 
PROSTATIC OBSTRUCTIONS 
If no soft catheter of the proper size is available the cannula itself 
may be retained, if it is fastened with tape inserted through the 
small slits in the collar. The writer has never seen a permanent 
fistula follow the use of the trocar. 
This method is not recommended to replace the preliminary cystos- 
Fig. 333.—Cavity left after removal of prostate and bladder caught preparatory to 
suturing. (Judd.) 
tomy, for two reasons: First, the opening in the bladder is too low 
down; and second, because the opening is not large enough to permit 
removal of the prostatic growth. 
The bladder should be full when the trocar is inserted into it. 
Transvesical Prostatectomy by the Open Method.—Many operators 
still prefer to complete the operation of transvesical prostatectomy in 
one stage, always, however, preceded by a period of preliminary treat- 
ment of intermittent catheterism or permanent bladder drainage 
through the urethra. Our objections to this have already been noted. TRANSVESICAL PROSTATECTOMY 
701 
There are those also who prefer the open method of prostatectomy 
even after preliminary suprapubic drainage, either by the method of 
cystostomy, or the introduction of a suprapubic tube through a trocar 
opening. 
Either through a primary incision or by enlarging the opening which 
already exists, the interior of the bladder is exposed. The bladder wall 
is cut sufficiently to give a good exposure of the vesical neck, care 
Fig. 334.—a, prostatic capsule partially closed by interrupted suture; b, sutures in 
place investing mucous coat. (Judd.) 
being exercised not to carry the incision too near the urethral opening. 
Suitable retractors are introduced. Then using a large syringe, a 
solution of novocaine 0.25 per cent, containing a small amount of 
adrenalin is injected into the prostate especially at its periphery. This 
tends to block the nerves and the enucleation may then be done in a 
number of different ways. Some operators prefer to incise the mucous 
membrane over the more prominent portions of the gland and the 
separation of the mass is started with a blunt dissector or the gloved 702 
P ROST AT IC OBSTRUCTIONS 
finger. The technic of Dr. Judd, of Rochester, Minn., is most excellent. 
He grasps the prostatic mass with forceps, when possible, and lifts 
it up, at the same time using one or two fingers to free it from the 
bladder wall and sphincter muscle. From here on the method of 
enucleation is practically the same in all cases, the prostate being 
shelled out by forcing the finger between and around the enlarged lobes 
and turning them out into the bladder. After the mass has been 
removed from the bladder, the lacerated area is inspected and if any 
spurting vessels are seen, these are secured and tied with catgut (Fig. 
333). As a routine, Judd places a few sutures of chromic gut through 
the bladder wall, including the depths of lacerated tissue on either 
side of the lacerated posterior urethra, and ties them, thus controlling 
the oozing surfaces and the cut edges of the bladder mucous membrane 
(Fig. 334). Most operators prefer to close the suprapubic wound 
around a drain of large calibre to prevent the accumulation of blood 
clots. The after-care is the same as in the two-stage operation. 
TECHNIC OF PERINEAL PROSTATECTOMY. 
The early work in this country was all through a median perineal 
incision, but since 1903, when Young published his first article on 
conservative prostatectomy, the inverted “V” or curved incision 
has been most usually employed. 
The preoperative treatment consists of water in large amount, 
catheter drainage, and an enema several hours before operation and 
morphia one-half hour before operation. 
The patient should be placed in an exaggerated lithotomy position 
with the pelvis elevated and the legs held by special supports so that 
the plane of the perineum is as nearly horizontal as possible. Imper- 
fect position has led to the greatest difficulty in carrying out the oper- 
ation. The Ilalsted perineal board, which is placed at an incline on 
the table and has vertical posts to draw back the legs, gives an excellent 
position; but recently a special urological operating table with adjust- 
able leg supports and an automatic perineal elevator has been intro- 
duced,34 by which a splendid exposure can be very quickly obtained. 
Without a good position perineal prostatectomy is a much more 
difficult operation. 
When the patient is in proper position, the genitalia as well as the 
perineum and buttocks having been sterilized either with weak tincture 
of iodine or a solution of potassium mercuric iodide (which has the 
advantage of not being irritating) and the urethra having been injected 
with some antiseptic solution, a No. 24 sound is passed by the operator 
until he is certain that the beak is well within the prostatic urethra, 
when the handle of the sound is given to an orderly to hold through 
a sterile towel. The perineal incision is then made, and in order to 
best take advantage of the space between the ischiopubic rami and 
back of the triangular ligament, this incision should be somewhat 
of an inverted “U,” the apex being about l\ inches in front of the TECHNIC OF PERINEAL PROSTATECTOMY 
703 
anus and the two branches running backward within the ischiopubic 
rami for a distance of about 2 inches on each side (Fig. 335). This 
incision is carried through skin, fat and subcutaneous fascia and the 
posterior part of the bulb exposed but not opened. By blunt dissection 
with the finger and handle of the scalpel the space behind the trans- 
versus perinei muscles on each side of the central tendon and in front 
of the levator ani muscles is opened up, as shown in Fig. 336. In 
Fig. 335.—Perineal incision used for prostatectomy, radical excision of carcinoma and 
excision of tuberculosis of seminal vesicles. 
introducing the finger great care is taken that it shall be directed slightly 
upward and forward so as to avoid going toward the rectum, the 
operator being sure that the line of dissection is back of the triang- 
ular ligament on each side. 
The lateral spaces having thus been opened up, a special bifid 
retractor facilitates the next step by making traction upon the central 
tendon and thus drawing the bulb well up into view and at the same 704 
PROSTATIC OBSTRUCTIONS 
time pushing the rectum back out of the way. The operator then 
cuts across the central tendon close to its attachment anteriorly 
(Fig. 337) to the bulb until the region of the recto-urethralis muscle 
is reached. At this point it is best to remove the bifid retractor, 
Fig. 336.—Opening up the space on each side of the central tendon by blunt dissection. 
which is no longer essential, and insert a small simple retractor (with- 
out a posterior lip, which might injure the rectum) and thus make taut 
the recto-urethralis muscle, which running from the rectum to the 
triangular ligament produces the anterior fecal pouch of the rectum. 
This muscle covers the membranous urethra, and great care must be TECHNIC OF PERINEAL PROSTATECTOMY 
705 
taken to get a good exposure and to divide the muscle well forward 
so as to avoid any injury to the rectum, which can thus be pushed 
backward by blunt dissection with the handle of the scalpel, ex- 
posing the membranous urethra and apex of the prostate. By the 
use of a special grooved retractor, which is so constructed as to encircle 
Fig. 337.—Bifid retractor inserted—division of central tendon. 
the membranous urethra, anterior traction draws forward the tri- 
angular ligament and most of the muscular fibres of the external 
sphincter, and with care the operator is able to push forward the 
remaining circular muscle fibres and to push backward the rectum 
sufficiently so as to expose a small area of the apex of the prostate and 
to make an incision upon the urethral sound through the membranous 706 
PROSTATIC OBSTRUCTIONS 
urethra where it joins the prostate, thus carrying out a urethrotomy 
entirely behind the external sphincter and effectively guarding against 
postoperative incontinence (Fig. 338). 
The edges of the urethrotomy wound are then picked up with 
special toothed forceps which do not crush the urethra (Allis clamps) 
the operator being certain that the mucous membrane is engaged, 
Fig. 338.—Prostatic urethra exposed, incised longitudinally upon sound, and 
edges picked up with non-crushing mucosa clamps. Prostatic tractor ready for inser- 
tion. 
after which the sound is removed from the urethra. A straight sound 
is passed through the urethrotomy wound into the bladder (to make 
sure that the passage is clear). The prostatic tractor (Fig. 339) is then 
introduced through the urethrotomy wound into the bladder, opened 
out and traction made. In this way the prostate is brought much 
closer to the perineum and an inspection will generally show that it is 707 
TECHNIC OF PERINEAL PROSTATECTOMY 
still covered by a fibromuscular layer through which it is necessary 
to go before the capsule of the prostate is reached. 
It will be remembered that in fetal life the peritoneum extends 
down almost to the perineum, but subsequently these two layers 
become approximated and the space obliterated up to the region of 
the seminal vesicles. These two layers of prenatal peritoneum, now 
approximated, form what is known as the anterior and posterior 
layers of Denonvilliers’ fascia and between them lies the route for 
the proper exposure of the posterior surface of the prostate and seminal 
vesicles. This part of the operation is the most important as to detail, 
for if the operator does not satisfactorily divide the posterior layer 
of fascia and attempts to push the rectum back before so doing, it 
is not difficult to penetrate the rectum, and practically all injuries of 
the rectum are due to such failure in technic. 
Fig. 339.—A, Prostatic tractor closed, before insertion into membranous urethra; 
B, prostatic tractor opened, after entering bladder. 
In order, therefore, to be sufficiently careful, it is wise at this point 
while drawing the prostate up into the wound to make an incision 
on each side upon the apex of the prostate and push back the tissues 
carefully until the pearly-white anterior layer of Denonvilliers’ fascia, 
which closely covers and in reality forms the prostatic capsule, is 
reached. As soon as it is exposed on either side it is quite easy to 
follow this white covering of the prostate across to the other side and 
to divide fibres running to the rectum, which is then very easily pushed 
backward by blunt dissection. The operator should be careful to 
work with the handle of the scalpel and subsequently with his finger, 
upon the surface of the prostate and not to press forcibly against the 
rectum. However, the latter is protected by the posterior layer of 
Denonvilliers’ fascia if the technic has been properly observed. A 708 
PROSTATIC OBSTRUCTIONS 
posterior retractor, which is slightly curved, not too deep and has no 
posterior lip, is then carefully introduced in front of Denonvilliers’ 
fascia and levator muscles and traction made, thus drawing backward 
Fig. 340.—Tractor has been inserted and opened; posterior surface of prostate exposed 
showing anterior layer of fascia of Denonvilliers. 
the rectum with the central tendon and the recto-urethralis, and 
levator ani muscles on each side. By the use of narrow lateral 
retractors an excellent view of the entire posterior surface of the 
prostate can now be obtained (Fig. 340) and if it is necessary to see TECHNIC OF PERINEAL PROSTATECTOMY 
709 
the region of the seminal vesicles, by further blunt dissection on each 
side this can be accomplished. 
The prostate is now drawn well down into view so that the operator 
is free to carry out any method of excision and enucleation that he 
may fancy. Up to this point the operation has avoided the following 
important anatomical and physiological structures: The hemorrhagic 
bulb, Cowpers’ glands, triangular ligament and external sphincter, and 
Fig. 341.—Prostate exposed through an inverted V skin-incision. Tractor intro- 
duced, capsule. incised on each side of median line. Enucleation of left lateral lobe 
partially completed. 
the rectum posteriorly. The next important structures to preserve 
are the verumontanum and ejaculatory ducts, not only on account of 
their sexual importance but also in order to avoid epididymitis to which 
their injury may lead. It is important also to preserve in as normal 
a condition as possible the internal or vesical sphincter. In his 
earlier publications Young insisted on the importance of preserving, 
if possible, the entire prostatic urethra intact, and for this purpose 
devised bilateral capsular incisions which passed through the posterior 710 
PRO STATIC OBSTRUCTIONS 
capsule and posterior lobe parallel to the urethra, as shown in Fig. 
341, exposing on each side the whitish capsule of the hypertrophied 
lobe, the enucleation of which is then commenced with a blunt 
dissector and followed with the finger, removing entirely each lateral 
lobe. The median portion of the prostate then remains and it is 
usually possible by turning the blade of the tractor in the bladder 
90 degrees to catch and draw down into the wound of the lateral 
Fig. 342.—After removal of both lateral lobes the median is drawn down with tractor 
and pushed into left lateral cavity with index finger in the opposite cavity previous 
to enucleation of middle lobe. 
cavities the median lobe, where under inspection it is usually enucleated 
without difficulty (Fig. 342). In many instances it is found possible 
to remove a middle lobe along with one of the lateral lobes, thus enu- 
cleating the entire hypertrophied prostate in two pieces. In some 
cases, where the median portion is very fibrous or intravesicallv pedun- 
culated, this is difficult to remove and it is found necessary to intro- 
duce the finger into the bladder, generally after division of one lateral 
wall of the urethra, in order to successfully invert the middle lobe TECHNIC OF PERINEAL PROSTATECTOMY 
711 
into the wound of the lateral cavities, where it can be enucleated by 
blunt dissection or with a sharp curette (Fig. 343). 
A careful examination is then made with the finger inside the vesical 
sphincter to determine the presence of any contracture or bar or 
remaining lobes at the prostatic orifice. Occasionally an anterior 
lobe or enlargement is found and can be easily removed through the 
urethra. Previous cystoscopy will have told of the presence of cal- 
Fig. 343.—Removal of fibrous median bar or lobe with a sharp curette. 
culi, but they may have been obscured behind hypertrophied lobes, 
and on this account a careful search should be made at this stage of 
the operation with a lithotomy scoop to see if any calculus is present. 
If the calculus is large, it may be necessary to dilate or even divide 
the vesical sphincter to facilitate its removal, but in numerous cases 
calculi 4, 5 and even 6 cm. in diameter have been removed through 
the perineum without difficulty. 
By the technic described above, the operator may remove the 
lateral and intravesical hypertrophied lobes or bars with little or no 712 
PROSTATIC OBSTRUCTIONS 
injury to the mucous membrane of the urethra and with preservation 
of the verumontanum, ejaculatory ducts and vesical sphincter. 
Young33 has called attention to the fact that after an extensive 
experience with some 900 cases in which the technic above described 
was used, a study of the cases and ultimate results had shown 
that in many instances the mucous membrane of the urethra had 
been torn on one or more sides and not infrequently partially removed 
Fig. 344.—Division of the left wall of the urethra with scalpel. This is carried 
out also on the right side thus making it possible to draw down the triangular flap with 
forceps and expose the floor of the urethra and ejaculatory ducts, as shown in insert a, 
in which the urethra is divided on each side, the fold carried downward and the lateral 
adenomas exposed. 
with the hypertrophied lobes, and in some cases the bridge containing 
ejaculatory ducts had been torn from its anterior attachments in the 
vigorous traction necessary to remove the hypertrophied masses 
through the bilateral capsular incisions. This loss of prostatic urethra 
seemed to have very little influence upon the wound healing or ulti- 
mate results. It was also shown that in some instances considerable 
difficulty was experienced in enucleating completely all the hypertro- 
phied lobes or lobules at the vesical neck, and occasionally hyper- 
trophied tissue had been left behind which should have been removed. TECHNIC OF PERINEAL PROSTATECTOMY 
713 
Fig. 345.—’ 
■Enucleation of lateral lobes begun with blunt dissector. 
Fig. 346.—The urethra covering the median portion of the prostate is here divided 
transversely with scalpel previous to enucleation. 714 
PROSTATIC OBSTRUCTIONS 
Fig. 347.—Completion of lateral enucleation with the finger. 
Fig. 348 —Latest technic with single lateral capsular incision almost parallel to the 
urethra and just external to the verumontanum and ducts. This incision opens upon 
the urethra along the left lateral wall. TECHNIC OF PERINEAL PROSTATECTOMY 
715 
It was, therefore, decided to revert to the technic used in the very 
earliest cases and enucleate the entire hypertrophied prostate in one 
piece, being careful to preserve the verumontanum, ejaculatory ducts, 
but intentionally dividing the urethra on each side and in front of 
the median lobe in order to facilitate the enucleation of the prostate 
in one piece. This technic is shown in Figs. 344 to 347 as seen here 
an inverted V or U capsular incision is made and the urethra opened. 
By this technic it is possible to obtain a better view of the deep portions 
of the hypertrophied mass and to remove it completely in one piece, 
and a study of the results seems to show that cutting through lateral 
walls of the prostatic urethra on each side does no harm and the 
Fig. 349.—The prostatic capsule has been opened by oblique lateral incision which 
extends into the urethra and divides the left lateral wall of the urethra to the middle 
lobe. Enucleation of the left lateral lobe begun. Mucous membrane covering the 
right lateral and median lobes divided as shown in subsequent drawings. 
operation is undoubtedly made much more certain. The hyper- 
trophied prostate can also be successfully enucleated through a single 
slightly lateral, capsular and urethral incision, as shown in Figs. 
348 to 353. Here again the urethra is divided on each side and 
in front of the median lobe, the ejaculatory ducts being carefully 
pushed backward and the entire prostate being enucleated in one 
piece, as shown in Fig. 352. 
Not infrequently one finds hypertrophy of the subcervical group 
of glands which forms an entirely separate lobe internal to the vesical 
sphincter. It is, therefore, often advisable before completing the 
deep enucleation to remove the tractor and insert the finger through 
the sphincter into the bladder and draw up so as to enucleate any 
superficial lobule which may be present, with the aid of a curette 716 
P ROST AT 1C OBSTRUCTIONS 
(Fig. 353). The operator can usually see and push back the sphincteric 
fibres and enucleate the subcervical and middle lobes along with the 
rest of the prostate in one piece, as in Fig. 354. As the hypertrophied 
lobes are drawn upward, the mucosa, which extends down from the 
bladder into the urethra, can be separated with the finger, the inner 
aspect of the lobes, leaving, when the prostate is removed, a fairly 
long cone of mucous membrane, in the lateral walls of which, not infre- 
quently, one or more bloodvessels can be seen, clamped and ligated. 
Fig. 350.—Enucleation of lateral lobes which was started with scalpel is complete with 
finger, the tractor being carried downward. 
Another advantage of preserving this cone of mucous membrane is 
that when the drainage tube is introduced a small pack can be placed 
within the vesical orifice, thus retaining this cone of mucous membrane 
in its extravesical position and efficiently stopping hemorrhage. 
Another method of carrying out this total enucleation of the hyper- 
trophied prostate in one piece through the perineum is to break through 
the mucous membrane of the urethra laterally on each side, as in 
the intra-urethral suprapubic method. By this technic the prostate 
can be enucleated with great facility, but more mucous membrane 
is removed and the cone of mucosa above described is usually not 
preserved, and perhaps the hemorrhage is a little greater. TECHNIC OF PERINEAL PROSTATECTOMY 
717 
In some cases an anterior commissure is present which contains 
hypertrophied tissue and even may have the appearance of an hyper- 
trophied lobe, which may be large enough to project considerably 
into the bladder. If such is made out with the cystoscope before 
operation, the anterior commissure should usually be removed with 
the lateral lobes, as shown in Fig. 355. In this way the specimen 
removed is almost identical with that which is removed by the supra- 
pubic technic of Freyer. Figs. 356 and 357 show’ hypertrophied pros- 
tates of this type removed through the perineum. 
Fig. 351.—With tractor held vertically, beak directed downward, the lateral lobes 
having been freed, the mucous membrane in front of the middle lobe is being divided 
transversely with scalpel. Ejaculatory ducts covered by index finger which pushes 
them backward. 
After the operator has satisfied himself by digital inspection within 
the vesical sphincter that all hypertrophied tissue bars and contracture 
have been removed and the bladder has been searched for stone, the 
large drainage tube is introduced and beside it a small gauze pack 
is inserted within the vesical orifice as described above. The lateral 
cavities are packed carefully, each with one or more strips of gauze 
and sufficiently tight to effectively stop the hemorrhage (Fig. 358). 
In some instances it may also be wise to place an additional gauze 
pack behind the prostate and before closing the skin wound the operator 
should be sure that the hemorrhage had almost completely ceased. 718 
PROSTATIC OBSTRUCTIONS 
It is well then to wash out the bladder by means of a large syringe 
with an orifice sufficiently great so that clots may be removed by 
suction. The drainage tube is then fastened to the lower angle of 
the wound on the left side, the gauze packs are brought out in front 
of it and the apex and one angle of the wound closed up either with 
chromicized catgut sutures or metal clamps, leaving about two-thirds 
of the wound open on one side for drainage and packs. 
If the patient is a feeble individual or the hemorrhage or shock 
of operation has been fairly pronounced, a saline infusion or trans- 
fusion should be carried out either during the operation or before 
Fig. 352.—The middle lobe attached to the two lateral lobes already freed is being 
separated from the sphincter and vesical mucosa, and enucleated from behind for- 
ward. 
leaving the table. This however, is rarely necessary and the routine 
is to give submamillary saline infusion on the return to the ward. 
Gas-oxygen anesthesia" is preferable unless pulmonary contraindi 
cations are present, when spinal anesthesia is used with perfect suc- 
cess. In both instances the patient is conscious on return to the 
ward and can usually begin to drink water fairly soon. 
The subsequent treatment in perineal prostatectomy cases is to 
prop the patient up in bed as soon as convenient in order to facilitate 
drainage, to remove the packs within twenty-four or forty-eight 
hours (a good scheme is to insert oil through a small catheter which TECHNIC OF PERINEAL PROSTATECTOMY 
719 
has been placed among the packs at operation so “as'to facilitate 
their removal). If many packs have been introduced it is usually 
wise to remove them piecemeal in two or three steps several hours 
apart. Somewhat later, often the following day, the large perineal 
drainage tube is removed, after which no further drainage, either 
tube, catheter or gauze, is introduced. The wound is allowed to 
collapse as quickly as possible, some mild antiseptic is injected, 
generally through the open wound by orderly when the dressings are 
changed, but simply for cleanliness, the patient is gotten out of bed 
Fig. 353.—The tractor has been removed and the index finger of the left hand intro- 
duced through the vesical orifice into the bladder to investigate the median portion. 
The subtrigonal lobule has been discovered, and is being separated from the sphincter 
by the blunt tractor. 
on the third or fourth day and is encouraged to walk within a week if 
possible. The advantage of all this is that hypostatic congestion 
of the lungs is avoided, the strength of the patient returns more rapidly 
and convalescence is facilitated. 
In a careful study of 450 cases33 the time of closure of fistuhe was 
within one week in 18 cases, two weeks in 73 cases, three weeks in 
130 cases—56 per cent, in less than twenty-one days, but in 15 per cent, 
the fistula was present after the sixth week. In some of these pro- 
tracted closures it may be advisable to pass a sound not on account 
of stricture, which very rarely occurs, but simply to straighten out 720 
PROSTATIC OBSTRUCTIONS 
Fig. 354.—A, anterior view of lateral and median lobes removed in one piece. B, 
side view of right and median lobes of specimen. Note the constriction of median 
lobe by sphincter and small subtrigonal posteriorly projecting lobule. C, vesical aspect 
of prostate showing the small intravesical median and very large extravesical lateral 
lobes. If this had been removed suprapubically the sphincter would surely have been 
destroyed. 
Fig. 355.—Enucleation of prostate en bloc, with anterior commissure intact. A.C., 
t anterior commissure. TECHNIC OF PERINEAL PROSTATECTOMY 
721 
Fig. 356.—Anterior view of hypertrophied prostatic lobes removed en bloc with anterior 
commissure and a portion of the prostatie capsule. Glass tube shows site of urethra. 
Fig. 357.—Anterior view of very large prostate removed en bloc with anterior 
commissure. 722 
P ROST AT IC OBSTRUCTIONS 
the coapted surfaces of the membranous urethra. It is usually wise 
quite early in the convalescence, to force fluid through the meatus 
and out of the perineal wound to open up the membranous urethra and 
to facilitate the escape of urine through the anterior urethra. This 
should be repeated once every four or five days until urination is estab- 
lished. Stricture practically never occurs, but in rare instances dilata- 
tions have been necessary. Occasionally a retention urethral catheter 
is advisable to hasten the closure of the fistula as is sometimes the ease 
after a suprapubic prostatectomy, and of course curettage may be 
necessary to induce healing. In the 450 cases above mentioned, 
Fig. 358.—Large tube has been inserted into bladder, a small tube into the cavity 
for the insertion of oil to facilitate removal of gauze which has been introduced into the 
lateral cavities to arrest hemorrhage. 
however, there are only 5 in which fistulae persisted and 3 of these 
had received practically no treatment after discharge, being pauper 
patients who did not return. Sixty-four per cent, of the patients left 
the hospital within four weeks and only 3 patients had incontinence, 
which however, was not complete but only during the day and not 
at night. 
The most important therapy after the operation is to force water, 
by mouth if the patient can take it, and if not by infusion, by rectum, 
or by transfusion if necessary. In this way severe uremia and often 
also infections of the bladder and kidneys can be washed away. Some 
patients take 10 quarts a day without much difficulty. TECHNIC OF PERINEAL PROSTATECTOMY 
723 
The preservation of sexual powers after operation is important 
and is more or less definitely connected with the careful protection 
of the verumontanum, ejaculatory ducts and floor of the urethra. 
In the 450 cases above mentioned in all patients under sixty years of 
age erections returned after operation. Sexual impairment was 
apparent only among these over sixty years of age; 74 per cent, state 
that coitus is still indulged in, where it was possible before operation. 
Among the 450 cases33 there was a mortality of 3.7 per cent, but 
since 1910 there has been a gradual improvement and in a recent 
paper36 166 consecutive cases of perineal prostatectomy by the technic 
above described without a death were reported, and in a more recent 
paper38 the list of 198 consecutive successful cases without fatality has 
been reported by Young. These figures are quoted to show the fact that 
prostatectomy has become a really benign operation when proper 
care in diagnosis, preoperative and postoperative treatment is given, 
and careful attention during the operation is taken to the control of 
hemorrhage. Among these 202 cases there were 5 patients over 
eighty, and 59 over seventy years of age. Thirty per cent, of the 
cases required preliminary preparatory treatment for ten days or 
more, and 2 had suprapubic drainage. 
Recently interesting papers upon Young’s perineal prostatectomy 
with some personal modifications have been published by Hinman,11 
Cecil,4 Crowell5 and Geraghty.8 All of these papers lay stress upon 
the simplification of the convalescence and the low mortality of 
perineal prostatectomy. The papers by Cecil and Geraghty lay 
stress on the importance of preserving the external sphincter by the 
use of long urethral tractors, such as Young has used for several years 
in cases of excision of tuberculosis of the prostate and seminal vesicles 
without opening the membranous urethra.35 
Geraghty,8 and Cecil a short time afterward, independently of each 
other brought out a modification of Young’s operation. They felt 
that the exposure of the prostate by their technic simplifies rather 
than complicates the dissection. The method proposed differs 
essentially from the technic described by Young38 for hypertrophy 
in that the membranous urethra is avoided. Its intrinsic and extrinsic 
musculature as well as the nerve supply are neither disturbed or 
injured. 
Prostatic surgery has outgrown the experimental stage. The 
methods of preparation and the operative procedure are on a sound 
basis. The choice of operation is one of personal preference of the 
surgeon. There is little difference in the mortality rate or the final 
outcome in the hands of experts. Age is not a contraindication but 
the length of time of the obstruction and the kidney function, deter- 
mine the operative risk. There is no other class of cases in which 
careful attention by the surgeon before and after the operation, plays 
such an important part. 
I wish to thank Dr. Burton Simpson for his kind assistance and 
cooperation. 724 
PROSTATIC OBSTRUCTIONS 
1. Barringer, B. S.: Trans. Am. Assn. Genito-Urin. Surg., 1919. 
2. Bugbee, Henry G.: High-frequency Current in Treatment of Tumors of Bladder 
etc., Int. Abst. Surg., December, 1915, pp. 581-593. 
3. Cabot, Hugh, and Crabtree, E. Granville: The Mechanism of the Protection 
Afforded by the Drainage of Prostatics as a Preliminary to Operation. 
4. Cecil, A. B.: Perineal Prostatectomy, Jour. Urol., December, 1921, vol. vi. 
5. Crowell, A. J.: Modification of Young’s Perineal Prostatectomy, Southern 
Med. Jour., January, 1922, vol. xv. 
6. Deaver: Enlargement of the Prostate, P. Blakiston’s Son & Co., 1905. 
7. Gardner and Simpson: Surg., Gynec. and Obst., 1914, pp. 85-89. 
8. Geraghty J. T.: New Method of Perineal Prostatectomy which Insures More 
Perfect Functional Results, Jour. Urol., May, 1922, vol. vii. 
9. Hada: Studien zur Entwicklung, zur normalen und zur pathologischen Anatomie 
der Prostate, etc., Folia urolog., 1914, vol. ix. 
10. Hagner, Francis R.: Surg., Gynec. and Obst., xix, 555. 
11. Hinman, Frank: Suprapubic versus Perineal Prostatectomy; a Comparative 
Study of 90 Perineal and 38 Suprapubic Cases, Jour. Urol., December, 1921, vol. vi. 
12. Jores: Ueber d. Hypertrophie d. sogenannten mittlenen Lappens der Prostate, 
Virchows Arch., 1894, p. 224. 
13. Labat: Local, Regional and Spinal Anesthesia, Ann. Surg., 1921, lxxiv, 680. 
14. Lower, William E.: A Technic for Performing Shockless Suprapubic Pros- 
tatectomy, Ann. Surg., February, 1914. 
15. Lower, William E.: Trocar and Cannula for Suprapubic Drainage of Bladder, 
Urol, and Cutan. Rev., 1914, No. 1, vol. xviii. 
16. Lowsley, Oswald S.: Am. Jour. Anat., July, 1912, p. 299. 
17. Lowsley, Oswald S.: Jour. Am. Med. Assn., January, 1913, p. 110. 
18. Lowsley, Oswald S.: The Human Prostate Gland in Youth, Med. Rec., Septem- 
ber 4, 1915. 
19. Lowsley, Oswald S.: Ann. Surg., October, 1918, p. 399. 
20. Mouillin: Enlargement of the Prostate, p. 135. 
21. Pilcher, P. M.: Ann. Surg., April, 1914. 
22. Pilcher, P. M.: Transvesical Prostatectomy in Two Stages, Ann. Surg.. April, 
1914. 
23. Proust: Comptes rendus de l’assoc. Franchise d’Urologie, 1901. 
24. Socin: Krankheiten d. Prostate (Pitha-Billroth), Handb. der Chir., 1871, iii. 
25. Squier, J. Bentley: Vital Statistics of Prostatectomy, Trans. Am. Assn, of 
Genito-Urin. Surg., 1913, p. 218. 
26. Squier, J. Bentley, Clarence Bandler and Victor Meyers: Significance of Ele- 
mentary Blood Findings in Urological Conditions, Jour. Am. Med. Assn., October 21, 
1922, lxxix, 1384. 
27. Tandler: Ueber Zucherlcandl Anat. Untersuch. u. d. Prostatehypertrophie (Folia 
urolog. Internat.) Arch. f. d. Krankheiten d. Harnorgane, 1911. 
28. Van Zwalenburg, C.: Emptying a Chronically Distended Bladder (Description 
of a Simple Device), Jour. Am. Med. Assn., 1920, lxxv, 1711-1712. 
29. Virchow: Die Krankhaften Geschwhlste, 1863, vol. iii. 
30. Wallace: Prostatic Enlargement, p. 134. 
31. Wilson and McGrath: Surg., Gynec. and Obst., December, 1911, p. 647. 
32. Young, H. H.: Jour. Am. Med. Assn., January, 1902. 
33. Young, H. H.: The Ultimate Results of Prostatectomy, Trans. Int. Assn. 
Urol., 1911; Jour. Am. Med. Assn., January, 1913, vol. lx. 
34. Young, H. H.: A New Table for Urological Operations, Trans. Am. Urol. Assn., 
1919. 
35. Young, H. H.: Radical Cure of Tuberculosis of Seminal Tract (Brief Survey of 
Literature), Jour. Urol., March, 1922, vol. vii. 
36. Young, H. H.: Technic of Prostatectomy and its Relation to Mortality, Jour. 
Am. Med. Assn., April, 1922, vol. lxxviii. 
37. Young, Geraghty and Stevens: Johns Hopkins Hosp. Repts., 1906, xiii, 272. 
38. Young, H. H.: Surg. Gynec. and Obst., May, 1923. 
BIBLIOGRAPHY. CHAPTER XIX. 
CAXCEIl OF THE PROSTATE. 
By HUGH HAMPTON YOUNG, M.D. 
Cancer of the prostate has until recent years been considered an 
infrequent disease. The first statistics as to the frequency was appar- 
ently an article by Tanchou, who analyzed 8289 cases of cancer in Paris 
between the years 1830 and 1840 and found only 5 cases diagnosed 
cancer of the prostate. 
Gross, in Philadelphia, was one of the first to furnish definite data in 
regard to cancer of the prostate about 1850, but it was not until Sir 
Henry Thompson, in 1861, in his monumental work on the Diseases 
of the Prostate, recognized the importance and predicted the future 
frequency of the disease. 
Thompson published 12 cases, and remarked that cancer of the pros- 
tate was probably overlooked frequently, especially in the more chronic 
forms or indeed where it developed in an already hypertrophied 
prostate. 
Von Recklinghausen contributed greatly to the subject by demon- 
strating that osseous metastases not infrequently came from cancer of 
the prostate which was often unrecognized. 
The disease was nervetheless considered rare. Socin and Burck- 
hardt, in their splendid book Krankheiten der Prostata, in 1902, even 
held it was seldom met with, until Albarran and Halle published their 
“discovery” of 14 cases of carcinoma in 100 supposedly benign prostates, 
and brought to the attention of the surgical world the considerable 
frequency of cancer of the prostate. This was followed by papers by 
Motz, Kaufmann, Hawley, Young, Pousson, Montfort, Hallopeau, 
Kummell, Freyer, McGrath, Wildbolz, Verhoogen, Schapiro, and 
Willms, thus leading to a much greater concentration of interest in and 
wider diffusion of knowledge of cancer of the prostate. 
Frequency.—Statistics vary as to the general frequency of cancer of 
the prostate. In the studies from the records of the Institute of 
Anatomy in Munich there were 29 cases of cancer of the prostate in 
5777 autopsies, or 2 per cent., whereas in Brussels there were only 0.7 
per cent, among all, or 1.8 per cent, among males. In the last fifteen 
years cancer of the prostate has been accorded an increasingly important 
role and frequency as compared with hypertrophy of the prostate. 
As remarked above in 1900, Albarran, in a study of 100 specimens of 
prostatic hypertrophy in the Musee Guyon, discovered malignant 
changes—“epithelioma adenoide”—in 14 cases. This caused Ger- 
aghty and myself to study our clinical and pathological material thor- 
725 726 
CANCER OF THE PROSTATE 
oughly, and whereas we were unable to confirm Albarran’s findings, I 
was able to show a far greater clinical frequency for carcinoma of the 
prostate than had been recognized previously (21 per cent.). 
I made the statement:15 “In the five years between 1902 and 1907 
I have seen 250 cases of benign hypertrophy and 68 cases of carcinoma 
of the prostate (21 per cent.). I am aware that my figures attribute to 
cancer a more frequent occurrence than any other in the literature, but 
I believe they represent the true condition.” 
Since then there have been numerous confirmatory publications: 
Oliver Smith’s statistics gave a proportion of 16 per cent., Davis 20 
per cent., Moullin 25 per cent., Kiimmell 20 per cent., Pauchet 20 
per cent. At the Institute of Pathology in Munich among 103 deaths 
from “prostatic accidents” there were found 27 cancers. Wilson and 
McGrath studying 468 prostatectomy specimens removed at the Mayo 
Clinic, found that 73 wrere cancer or 15.5 per cent. Freyer has recorded 
clinical diagnoses of cancer in 171 cases among 1276 cases of prostatic 
enlargement or 13.4 per cent. Microscopic examination of his opera- 
tive specimens has not been carried out in all cases, so the percentage 
may be higher. 
These statistics are sufficient to show that cancer of the prostate is a 
fairly common disease, and a very important problem in the surgery of 
the prostate, especially as the importance of early diagnosis and radical 
excision has been so conclusively demonstrated. 
Etiology.—The etiology of cancer of the prostate is as obscure as that 
of cancer in general. It appears at about the same period of life as 
hypertrophy—after forty years—and most frequently between sixty 
and seventy years of age. 
There is nothing to show that a preceding prostatitis or hypertrophy 
of the prostate has any causative relation, although both frequently 
occur with cancer of the prostate. Our studies seem to show conclu- 
sively that “malignant degeneration” of hypertrophied lobes does not 
occur frequently, if at all, and the lesions which Albarran and Halle 
described as malignant changes, “epithelioma adenoide,” in otherwise 
benign prostatic enlargements have been seen so often in other con- 
ditions—manifestly not malignant—that we cannot consider them to 
be even forerunners of cancer of the prostate. “Our view has since been 
confirmed by Tietze, who has met with analogous cellular masses in 
young prostates, and attributes to them an important role in the de- 
velopment of the gland. Casper, Renge and others have described 
them in hypertrophy of the prostate. Finally, Brault, Menetrier, and 
Darier, who have studied them in a case of Pasteau, do not consider 
them as epitheliomatous but as tangential cuts of normal glandular 
masses.” (Verhoogen.) Our pathological studies (1915) show hyper- 
trophy present with cancer in 61 per cent, of the cases of cancer of the 
prostate. 
Studies made in 190613 seemed to show that prostatic hypertrophy 
was largely a disease of married men. At that time I remarked that in 
corroboration of this I had never seen a case of enlarged prostate in a PATHOLOGY 
727 
Catholic priest, although there had been many cases among married 
Protestant ministers. Since then two priests with enlarged prostates 
have been encountered, but both were cancer. 
Pathology.—As remarked above we feel convinced that carcinoma of 
the prostate does not result as a degeneration of the previously benign 
adenomatous process; that in about half of the cases it develops where 
no hypertrophy is present; that in such cases the prostate is often little 
if at all enlarged; that the carcinomatous growth follows planes of least 
resistance; that it is very slow in invading fibrous capsules (Fig. 359), 
both of the prostate itself and also of hypertrophied spheroids, lobules 
or lobes; that the mucosa and submucosa of both urethra and bladder 
are also very resistant to it; that the most common site for the begin- 
Fig. 359. —Showing the capsule surrounding adenomatous hypertrophy (above) which 
has resisted extensive adenocarcinoma (below). 
ning of cancer is in the posterior subcapsular stratum or lobe, and that 
from there it may invade the rest of the prostatic glandular tissue or it 
may travel upward, escaping from the upper end of the prostate in the 
region about the ejaculatory ducts, and between the fascia of Penon- 
villiers posteriorly, and the trigone anteriorly; that in its further 
growth the seminal vesicles and vasa deferentia may not become 
infiltrated, but in some cases their lumina may become filled with 
cancer cells and, in the case of the vasa deferentia, these may extend 
upward for a long distance, the outer walls of the vas remaining 
apparently intact; that the muscle of the trigone and bladder and also 
the peritoneum may be invaded from this subtrigonal involvement; 
and, finally, that the fascia of Denonvilliers, which gives the prostate 728 
CANCER OF THE PROSTATE 
its most dense capsule posteriorly, is a most effective agent in pre- 
venting involvement of the rectum and periprostatic structures. 
Histology.—Perhaps we can make our description of cancer clearer if 
we first give our impression of the appearance of the normal prostate 
and in benign hypertrophy. 
The tissue of the normal prostate is rather grayish in color and some- 
what moist. It is soft in consistency, but tough. On pressure a small 
amount of prostatic secretion can frequently be squeezed out. The 
cut surface is apparently smooth and homogeneous, but on close 
inspection the tiny glandular orifices can be discovered. Some- 
times the orifices of dilated acini are very evident. 
The tissue of benign prostatic adenoma is usually quite characteristic. 
It has a lobular appearance due to the formation of varying sized 
spheroidal tumors often definitely encapsulated, the lobular mass as 
a whole being compressed by a more or less well-developed capsule 
formed from the condensed peripheral prostatic tissue. The tissue is 
usually elastic or soft in consistence, and on section is moist. Fre- 
quently large quantities of a milky fluid ooze from the prostatic acini. 
Many of the lobules have a moth-eaten appearance due to the presence 
of dilated acini. In other lobules where the glandular elements are 
not so numerous, and the stroma predominates, the surface is rather 
smooth and slimy. 
Practically no difficulty is encountered in differentiating carcinoma- 
tous prostatic tissue from the tissue of hypertrophy or of the normal 
prostate, presupposing of course that the carcinomatous area is of 
sufficient size to be discernible. The greatest difficulty arises from the 
tissue of a long-standing fibroid prostatitis. Carcinoma is usually 
quite characteristic. It is hard, dense, and on pressure gives very 
little sense of elasticity (which is generally still present even in well- 
advanced fibroid prostatitis). On cutting into the carcinoma it 
imparts a gritty sensation to the knife blade. No secretion oozes 
from the cut surface, which is rather homogeneous, lacking the lobu- 
lation so characteristic of hypertrophy. Occasionally where the can- 
cer has invaded a previously benign adenoma an indefinite lobulation 
may persist in this tissue, but it is seldom confusing. 
The finer details of the cut surface vary. Sometimes irregularly 
interlacing translucent bands of varying size are seen with small gray- 
ish-yellow islands scattered here and there, the translucent bands 
being fibrous in character, and the yellowish areas accumulations of 
cancer cells. This appearance is not present in fibroid prostatitis, 
in which the epithelial elements practically disappear, and the sur- 
face is much more smooth and homogeneous than in cancer. Where 
the cancer is infiltrating in character, fine alternating translucent and 
yellowish lines can frequently be seen by the aid of a small magnifying 
lens. Usually one can be moderately certain of the cancerous nature 
of the tissue from gross inspection alone. When the operator’s 
knife, in making the capsular incisions, cuts through dense tissue 
which does not bulge, the edges of which are firm and rigid, suspicion 
should be at once aroused. CANCER ASSOCIATED WITH HYPERTROPHY 
729 
If after passing through such a layer of hard tissue a bulging hyper- 
trophied lobe is encountered, the diagnosis of coexistent cancer and 
hypertrophy is generally justified. The capsule of the average hyper- 
trophy is rarely thick, nor is it so dense and gritty as that of cancer. 
Microscopical,—The histological character of cancer of the prostate 
is very variable, being greatly modified by the character of tissue in- 
vaded and age of cancer and the method of extension. 
A classification according to type of cell is, as a rule, impossible, as 
no one type is preserved throughout, the same section often showing 
great varieties of shapes and sizes. In our 2 cases in which cancer 
areas a few millimeters in diameter were discovered in the specimens 
removed at operation the microscope showed a definite adenocar- 
cinoma, but in one of these, even at this early stage, marked infiltration 
into the stroma had begun. 
In 10 apparently primary cases the cancer more often tended toward 
the scirrhus type, 7 being of this type. In 3 cases no glandular 
formation was present; in the other 4 cases occasional small groups 
of atypical acini were seen, but the great bulk of the tissue was scir- 
rhus. At times the fibrous overgrowth is so marked that epithelial 
elements may be almost wanting, or the fibrous stroma is so dense that 
the cancer cells are often not recognizable, small nuclear specks being 
alone visible. This may lead to error of diagnosis if only a small 
section is examined. At other times definite masses or infiltrating lines 
of irregular-shaped cancer cells are seen, the size and shape seeming to 
depend largely upon the compressing force of the fibrous stroma. 
Those of the adenocarcinomatous type present most varying pictures. 
At times acini, formed of irregular cells, often with big, deep-staining 
nuclei, are scattered at wide intervals, the intervening tissue being more 
or less densely infiltrated with cancer cells. At other times the cancer 
acini are so numerous and close together that the fibrous stroma may be 
difficult to see. The acini in these areas are usually very small and 
lined by small cylindrical cells, often quite irregular in shape and with 
small rounded nuclei. Often over large areas no attempt at a glandular 
reproduction occurs, cancer cells simply growing aimlessly through a 
fibrous strom*. Occasionally normal acini are found persisting in 
large areas of cancer. 
Cancer of the prostate spreads in two ways, by direct extension 
through the stroma and by extension along the ducts. As a result of 
this duct extension one sometimes sees masses of cancer cells filling the 
acini, the intervening tissue being entirely normal. 
Cancer Associated with Hypertrophy.—In our cases in which cancer and 
hypertrophy were present together (48 in 71 cancer cases, or 01 per 
cent.) the cancer, as remarked before, generally forms a layer beneath 
the posterior capsule, and the hypertrophied lateral lobes lie in front of 
and distinctly separated from cancer by their own capsules which are 
generally intact (Fig. 360). When the cancer breaks into a hyper- 
trophied adenomatous lobule it spreads rapidly along the ducts, thus 730 
CANCER OF THE PROSTATE 
giving an extremely puzzling picture of glandular acini lined or 
filled with cells different in type from the cells of the ducts or acini 
of an adenomatous hypertrophy, but with a basement membrane often 
intact and a normal intervening stroma. Frequently a single layer of 
cells will reline a duct or acinus so that except for the character of the 
cell the acinus looks entirely benign. However, we have never seen 
these broad cylindrical cells with clear, pale-staining protoplasm and 
nuclei centrally placed either in the normal or the hypertrophied pros- 
tate. In other acini the cells are heaped up at different points along 
the gland wall, and grow across the lumina sometimes in solid masses, 
but more frequently as interlacing strands. Sometimes the cancer 
cells arrange themselves circularly, leaving a central lumen as if in an 
attempt to reproduce a gland structure. When the lumen is com- 
pletely filled the cells crowd each other into most odd and peculiar 
shapes. 
Fig. 360.—Transverse section in front of verumontanum, showing two large hyper- 
trophied lobes on each side of the urethra and thick posterior subcapsular area of car- 
cinoma. Capsule of right lateral lobe invaded in one place (cl). 
These areas of duct carcinoma are not apt to be mistaken for benign 
tissue if the character of the cells is noted. Particularly characteristic 
is the tendency of cancer cells to grow in strands across the lumen of the 
acinus without any supporting connective-tissue framework. This does 
not occur in hypertrophy. In the latter when an epithelial budding 
from the wall of the acinus occurs, it is quickly followed by a supporting 
stem of connective tissue. It has been said that the acini of the normal 
or hypertrophied prostate when filled with desquamated epithelial cells 
may be difficult to differentiate from cancer of the duct type. With 
exercise of ordinary care no confusion from this source should occur. 
Later, with the advance of the main growth through the stroma or the 
breaking through from the acini, the picture is changed. The tubules 
of cancer cells with a more or less densely infiltrated stroma are seen, 
sometimes the intervening tissue is scirrhus, sometimes of an adeno- SYMPTOMS 
731 
matous type, and sometimes the cancer cells are so closely packed that 
a fibrous stroma seems almost entirely absent and a medullary form of 
cancer is produced. Sometimes portions of the cancer seem more or 
less definitely alveolar. When the cancer invades hypertrophied lobes 
of the adenocystic type, in which the interacinar stroma is frequently 
small in amount, the picture presented is that of cancer cells packed in 
the dilated spaces, resulting in an alveolar form of carcinoma medullary 
in character. In none of our specimens, either primary or those 
associated with hypertrophy, was a pure adenocarcinomatous type 
preserved throughout. Areas of adenocarcinoma were present, how- 
ever, in great or less degree, in practically every case except in the 
three cases of pure scirrhus previously mentioned, in which the cancer 
occurred in a prostate not previously hypertrophied. 
Very rarely have we found evidence of gross or microscopical necrosis, 
no matter how extensive the disease. The extensions of the disease to 
the seminal vesicles and bladder are usually infiltrating in character, 
although frequently the adenomatous form is here and there discov- 
ered. For one familiar with the histological character of the normal 
and hypertrophied prostate, the microscopical diagnosis of cancer seldom 
entails any difficulty, except in the scirrhus, where, occasionally, over 
small areas, the fibrous overgrowth may be so intense that no definite 
epithelial elements are recognizable, small scattered nuclear specks 
alone being visible. However, this fibrous density is of itself suspicious, 
and a section from a different area will usually at once settle this 
doubt. 
Symptoms.—From a surgical stand-point the early symptoms in car- 
cinoma of the prostate are the important ones, and unfortunately a 
survey of the literature is of little help in this respect. At the onset it 
is necessary to distinguish between early and late cases. 
In a study of 12 early cases17 I found it necessary to make three 
subdivisions. 
1. Those in which the only pathological process present is cancer, 
G cases. 
2. Those in which cancer is associated with hypertrophy, 5 cases. 
3. A case of chronic prostatitis with a small area of cancer in it. 
Class 1 furnishes the most satisfactory group for study, and we find 
the following: 
Cases. 
Age between 60 and 64 years 2 
“ “ 65 69 “ 2 
“ “ 70 74 “ 1 
“ “ 75 79 “ 1 
Duration of symptoms before admission: 
6 months 1 
1 year 2 
2 years 1 
3 years 2 732 
CANCER OF THE PROSTATE 
The initial symptoms were as follows: 
Frequency of urination 1 case, duration 2 years 
Difficulty of urination ...... 1 “ “ 1 year 
Urgency of urination ...... 1 “ “ 1 “ 
Pain in penis during urination 1 “ “ 1 “ 
Frequency and difficulty of urination . . 2 cases, “ each 3 years 
Subsequent symptoms were present as follows: Pain in the penis and 
perineum came on two years later in 1 case. None of the other 5 
patients suffered at all from pain. Hematuria was never present in any 
of the 6 cases. 
In 1 case the catheter life was begun eighteen months after the initial 
difficulty of urination and was followed for eighteen months before 
admission. The other 5 patients had never used the catheter. 
There were apparently no other symptoms present in these G cases, 
and a consideration of those present shows there was nothing diagnostic 
or even suggestive of cancer present. The surprising thing is that in 4 
of the 6 cases symptoms had been present for periods of two years or 
more. The fact that careful pathological examinations of the lateral 
and median portions of these prostates failed to reveal any benign 
adenomatous hypertrophy, seems to point to carcinoma as being the 
sole cause of the obstructive symptoms in these cases. 
The complete absence of hematuria at any time shows, as I have 
pointed out before, the error of expecting this as an early symptom. It 
is distinctly more common in benign hypertrophies (except possibly 
late in the disease). 
Class 2. The 5 cases in which cancer and benign hypertrophy existed 
together in the same prostate were as follows: 
Case I. Aged 60 years, beginning with frequency three years before. 
“ II. “ 69 “ “ “ frequency six months before. 
“ III. “ 75 “ “ “ sudden complete retention ten months before. 
“ IV. “78 “ “ “ frequency four years before. 
“ V. “ 67 “ “ “ frequency and difficulty two and a half years 
before. 
Ill Case I there was pain in the end of the penis before and during 
urination and in Case V a sciatica. In none of the others was there 
ever any pain present. Hematuria did not appear in any case. 
Regular catheterization was necessary in Case V for one year, in Case 
II for ten months, and in Case IY for four months. In Case I supra- 
pubic drainage became necessary three years after onset. 
Class 3. The case in which chronic prostatitis was present along with 
a nodule of cancer was a man, aged sixty-one years, who had for fifteen 
years had symptoms of irritation in the deep urethra and attacks of 
frequency of urination. Catheterization was never necessary and 
hematuria and pain were never present. 
In conclusion it seems from a study of the above early cases (and 
other later cases) that the symptomatology of cancer of the prostate in 
the early stages is almost identical with that of benign hypertrophy, so SYMPTOMS 
733 
that we must look entirely to a careful physical examination to furnish 
suspicion of cancer. 
The Examination.—There was nothing in the appearance of any of 
these twelve patients to suggest malignant disease; they were not 
emaciated nor were they suffering pain, with the exception of 4 cases, 
and in these it was not severe. The urine was free from blood in all 
cases. 
In the 6 cases not associated with hypertrophy the size of the prostate 
was described as considerably enlarged in 3 cases, moderately enlarged 
in 2 cases, and slightly enlarged in 1 case. The surface was smooth in 
2 cases, rough in 3 cases, nodular in 3 cases. Here we have in 6 cases 
conditions which should always make one suspicious of cancer; for the 
benign adenomatous prostates, unless associated with considerable in- 
flammation or with calculi of the prostate, are nearly always smooth, 
though they may be lobulated. The consistence was described as very 
hard in all of the 6 cases not associated with hypertrophy, and in some 
was said to be “ stony hard.” In 5 cases both lobes were involved, but 
in 1 case the left half of the prostate was normal. In this interesting 
case (in which an urgency of urination had been present one year) the 
right lobe was enlarged, very hard and rough, the induration extending 
to the median line, where it ended abruptly, forming a straight edge 
well elevated above the normal left half of the prostate. The lower 
portion of the right seminal vesicle was involved, as was the posterior 
part of the membranous urethra. The contrast between the two halves 
of the prostate here was most sharply defined. In 1 case there was a 
hard nodule in each lobe, which was otherwise soft on each side. Two 
years later the whole prostate was rough, irregular, very hard, and 
greatly enlarged. In the other 4 cases, although in 2 symptoms had 
been present only one year, the prostate was completely invaded by 
cancer on both sides, although the vesicles were mostly free. 
In a recent case, not tabulated above, the first examination three 
years ago showTed a nodule 1 cm. in diameter in the left lobe. At the 
next examination two years later it was 2 cm. in diameter, and one 
year later all of the left lobe was involved, but it was still within the 
prostatic capsule. This case shows the remarkably slow growth in 
some cases. 
The 5 cases associated with hypertrophy are interesting: In Case I 
(J. T. Y., No. 463) the prostate was considerably enlarged, smooth, 
rather hard in consistence. Microscopic study showed benign hyper- 
trophy associated with prostatitis on both sides, with only one small 
area of cancer in prostatic tissue which was the seat of prostatitis. 
In Case II (T. C. S., No. 2750), in which symptoms had been present 
only six months, the left lobe was only slightly enlarged, smooth, and 
elastic. On the surface of the right lobe there was a prominent lobe 
1 cm. in size, which was quite hard, but seemed elastic on pressure. 
(This proved, however, to be entirely cancerous.) The right lobe was 
otherwise very little enlarged, and the seminal vesicles were not in- 734 
CANCER OF THE PROSTATE 
dura ted, but nevertheless cancer was present in the lower portion of the 
left seminal vesicle. The left lobe when removed was found to be a 
benign hypertrophy, the right being cancerous. 
In Case III (W. J. R., No. 1779) the prostate was moderately en- 
larged and generally indurated (but not stony), with three very hard 
nodules present, one in the median line near the apex, one at the upper 
end of the left lateral lobe, and one near the apex of the right lateral 
lobe. Seminal vesicles negative. At operation a layer of cancer be- 
neath the posterior capsule was found on the left side, beneath which 
was a benign hypertrophied lobe, on the right side and also in the 
median portion, benign hypertrophied lobes were removed. 
In Case IV (J. R., admitted June 26, 1905) the prostate was moder- 
ately enlarged, smooth, the right lobe was elastic and only slightly 
indurated. Operation showed a posterior layer of cancer with a hyper- 
trophied lobe beneath. The left lobe was smaller and softer, and 
proved to be benign hypertrophy. 
In Case V (E. G. W., No. 206) the prostate was considerably en- 
larged, smooth, but very hard. Examination showed a posterior 
subcapsular layer of cancer, with benign hypertrophy in front of it on 
both sides. 
A review of these 5 cases shows that the presence of hypertrophy of 
the lateral lobes generally gives an elasticity to the prostate on deep 
pressure which is very deceptive. In these cases a small layer or nodule 
of cancer lying between the capsule and an hypertrophied lobe may be 
compressible on deep pressure. More delicate palpation, and particu- 
larly palpation upon a cystoscope in the urethra, will often show the 
real induration of the local carcinomatous area. 
These localized areas of induration or nodulation should always be 
suspected and subjected to early perineal operation. 
The case characterized by a small nodule of cancer in a prostate 
which was the seat of a chronic prostatitis of fifteen years’ standing 
showed on rectal examination a prostate smooth, slightly indurated and 
not tender. The small nodule was not detected, and was only found 
accidentally when the stained sections of the tissue removed were 
examined. 
The clinical examination of the seminal vesicles in these 12 early 
cases shows no definite invasion of these structures. In 1 case only 
was there an induration for a short distance in the region of one vesicle, 
but subsequent pathological examination (after radical operation) 
showed that the carcinoma had not penetrated the seminal vesicles as 
supposed but lay between it and the excised trigone, an area of cancer 
1 cm. long being present. In the 2 other cases in which the radical 
operation was carried out only the juxtaprostatic ends of the seminal 
vesicles and vasa deferentia were invaded. 
The vesical mucosa was normal in all of these cases, and no invasion 
of the trigone was present, as shown by the cystoscope and at operation. 
The 6 cases in which no coexistent hypertrophy of the prostate was DIAGNOSIS 
735 
present showed, on cystoscopic examination, only a small median bar 
with no intravesical enlargement of the lateral lobes. In 1 case the 
median portion formed a small sessile lobe, and 1 case showed both a 
median bar and a slight right lateral enlargement. 
The characteristic picture, then, in early cancer of the prostate is a 
small bar, unaccompanied by marked lateral intravesical enlargement. 
In 1 case a carcinomatous constriction of the prostatic urethra was 
present, requiring dilatation before cystoscopy was possible, but there 
was no evidence of ulceration of the urethra in any case. 
In later cases stricture of the prostatic urethra is not an uncommon 
finding, and is to be considered very suggestive of cancer. 
Diagnosis.—The diagnosis of early carcinoma of the prostate is prin- 
cipally based on the finding of great induration in a portion of the 
prostate, as shown by our cases. It may occur as one or more small 
nodules or lobules which may be prominent or imbedded in the prostatic 
tissue, but apparently always palpable per rectum. In later cases one 
whole lobe, or both lobes, may be involved, but the disease apparently 
remains well encapsulated for a fairly long period, and the line of prog- 
ress is upward, beneath the fascia of Denonvilliers (which forms the 
posterior capsule of the prostate and seminal vesicles, the ejaculatory 
ducts and the structures between the lower ends of the vasa deferentia 
and the bladder being invaded after the cancer cells pass beyond the 
limits of the prostate Induration immediately above the prostate 
and easily palpable, with a finger in the rectum and a cystoscope in 
the urethra, as a hard subtrigonal thickening, is of great diagnostic 
value. In later cases this “intervesicular plateau” of induration 
becomes more and more pronounced, but it is remarkable how long 
the upper portions of the seminal vesicles and vesical mucosa are 
free from invasion. 
In a series of 111 cases,15 many of them late and over 50 per cent, 
associated with prostatic hypertrophy which necessarily modifies the 
symptoms and the progress of the disease, there were 76 in which the 
first symptom was frequency of urination, and in 48 cases difficulty of 
urination was also present. In 4 cases the onset was ushered in with 
hematuria, and in 4 with complete retention of urine. 
Pain was not infrequently an initial symptom, and its location in 
these cases has been tabulated as follows: 
Cases. 
Urinary tract (bladder or urethra) 16 
Rectoperineal region 7 
Inguinal and scrotal regions 2 
Dorsal, sacral or gluteal regions 6 
Lower extremities 3 
Hypogastrium 1 
In most of the cases in the above tabulation the pain was generally 
quite marked and sometimes very severe. Those cases in which only 
very slight burning was complained of were not included, though several 736 
CANCER OF THE PROSTATE 
cases in which the burning was severe and amounted to a pain have 
been included. There was one patient in which irritability in the 
bladder was quite marked. One patient, aged sixty-four years, was 
suddenly seized, during urination, with an excruciating pain which 
radiated from the bladder to the end of the penis, and after that re- 
curred frequently. In another case the onset symptom was pain in one 
groin and down the back of the thigh, which his physician told him was 
rheumatic in character, and gave him “appropriate” treatment for 
seven months, when, for the first time, a very slight difficulty of urina- 
tion was noticed. Only four weeks before admission were his urinary 
symptoms sufficient to call attention to his prostate, by which time the 
entire prostate and seminal vesicles were involved in an extensive car- 
cinomatous growth. In another case the first symptom, which came 
on suddenly two and a half years before admission, was a severe pain 
in the rectum which became continuous and grew steadily worse. 
Another patient had had only one symptom since the beginning, three 
months before, sharp, shooting pains in the left hip radiating down the 
left thigh to the knee and associated with numbness which extended to 
the foot. There was practically no urinary disturbance, although the 
membranous urethra, prostate, seminal vesicles, pelvic glands, and 
rectum were involved in an extensive carcinomatous mass. 
In 145 cases of benign hypertrophy the onset symptoms were as 
follows: 
Cases. 
Frequency of urination 
88 
Difficulty of urination 
78 
Pain 
25 
Hematuria 
7 
Complete retention of urine 
8 
Incontinence of urine 
8 
In 12 of the 25 cases of benign hypertrophy in which pain was present 
there was only a slight burning in the urethra, and in 3 the pain was 
merely the discomfort produced by straining to void. In 1 case there 
was sharp pain which followed sudden stoppage of urine during micturi- 
tion. In 9 cases calculi were present. In no case were there the 
symptoms of sciatica or severe pain in the hips, buttocks, thighs, or 
groins which have been seen in many of our cases of carcinoma. 
Hematuria is shown to have been a more common initial symptom in 
benign hypertrophy than in carcinoma. 
In conclusion it may be remarked that in the majority of cases the 
onset is much the same as that of benign hypertrophy; an increase in 
the frequency and difficulty of urination, which is often slowly pro- 
gressive in character. Pain alone is a much more common symptom, 
and frequently remains for a long time the only symptom. In one 
remarkable case the first and only symptom complained of was pain in 
the legs. 
In GO cases which were studied by Motz the initial symptom was; DURATION AND COURSE OF DISEASE 
737 
difficulty of urination in 38 cases; complete retention of urine in 8 
cases; hematuria in 8 cases; neuralgia in 5 cases. 
Duration and Course of Disease.—Guyon recognized three forms: (1) 
those with a rapid course, in which the symptoms may have been 
present a very short time; (2) those following a subacute course, the 
disease having been present after the tenth or twelfth month; and (3) 
those following a very slow course with a duration of two or three 
and even as long as nine years. In 26 carefully studied cases Mote 
found that 40 per cent, of the patients died within seven months 
after the initial symptoms, 7 lived over a year, and 6 for periods 
varying from two to ten years. In making this study we have pre- 
pared a table which shows the duration of various symptoms in our 
cases. 
Dubation of Various Symptoms at Time of Admission cf Patient, 
O 05 
CO 
r-b 
o 
to 
oc 
to 
05 
►—* 
6 o 
o 
<T> 
o 
o 
o 
o 
o 
t—‘ H-1 
CO 
to 
l_l 
o o 
Cl 
CO 
O 
CO 
>-* 
05 
3 
£ £ 
£ 
o 
J-J 
- 
0 
DJ 
tr 
(/J 
Difficulty of uri- 
to 05 
00 CO 
4- 
o 
nation. 
to 
Frequency of uri- 
•-1 M CO 
to 
CO 
to 
o» 
CO 
nation. 
Pain in urinary 
tO to 
to 
co 
tract. 
Pain in rectum 
• H* 
to 
to 
and perineum. 
Pain in groin and 
*"* 
co 
testicle. 
Pain in lower ex- 
to 
CO 
CO 
tremities. 
>—1 h-i 
- 
- 
to 
co 
to 
o 
Pain in back. 
Pain in supra- 
to 
to 
pubic region. 
As shown in the above tabulation symptoms were present in many 
cases for prolonged periods, the longest being twenty years, during which 
the patient had difficulty of urination and more or less frequent cathe- 
terization. There were 5 cases in which symptoms had been present 
more than ten years. None of these cases, however, were subjected to 
prostatectomy, and we cannot therefore say with positiveness that the 
early symptoms were not due to benign obstruction to urination. In 
23 operated cases in which there was no hypertrophy, the entire pros- 
tate being carcinomatous, there was one in which difficulty and fre- 
quency of urination had been present for six years and severe pain for 
five years, and other cases in which frequency and difficulty had been 
present for three years in 1 case, two years in 2 cases, one year in 3 
cases, and six months in 1 case. These statistics are sufficient to 
show that the course of the disease is very variable in its duration, 
some cases being extremely rapid and ending in death in less than a 
year; but in the majority is of two or three years’ duration, many 
cases extending over three or four years, and a few cases over five 
years. 
In the above tabulation it is noteworthy that pain came on much 738 
CANCER OF THE PROSTATE 
later than urinary obstruction. In only 13 cases of the 111 had pain 
been present over three years and in the majority of cases under eighteen 
months. 
Catheter Life.—In 21 cases the patient had complete retention of urine 
and had used a catheter regularly for varying periods up to three years. 
In 13 cases the catheter had been used less than six months, in 5 cases 
over a year, and in 2 cases over two years. In 23 cases, although the 
patient was able to void, urination was so slow, difficult, and frequent 
that the catheter was used one or more times daily. In 14 of these 
cases this has been present for less than six months, in 3 cases between 
six months and a year, in 2 cases over one year, in 3 cases over two years, 
and in 1 case five years. In 8 cases complete retention of urine occurred 
occasionally, requiring catheterization, but these patients did not use 
the catheter every day. 
When the 'patient was admitted to the hospital the symptoms presented 
were as folloies: Complete retention of urine and catheter life 19 cases. 
The number of times daily in which catheterization was necessary was 
as follows: Two times, 2 cases; three times, 4 cases; four times, 2 
cases; five times, 1 case; six times, 4 cases; eight times, 3 cases; ten 
times, 2 cases; twenty times, 1 case. 
Incomplete retention of urine but catheter used, 22 cases; once daily, 
2 cases; twice daily, 5 cases; three times, 4 cases; four times, 5 cases; 
five times, 3 cases; six times, 1 case; seven times, 1 case; every few 
minutes, 1 case. 
In those cases in which urination was possible the difficulty of urina- 
tion was great in 28 cases; moderately difficult in 6 cases, slightly 
difficult in 5 cases. 
The frequency of urination was very frequent (every few minutes to 
one hour) in 38 cases; moderately frequent (about every two hours) in 
7 cases; slightly more frequent than normal in 13 cases. In 2 cases 
there was constant dribbling of urine associated with a large amount of 
residual urine. 
Pain.—The location and the severity of the pain present on admission 
is graphically shown in the accompanying table: 
Urethra 
Slight. 
4 
Moderate. 
4 
Severe. 
10 
Penis . 
3 
4 
11 
Perineum . 
3 
5 
7 
Bladder 
4 
2 
9 
Rectum 
2 
0 
10 
Groin . 
1 
1 
0 
Testicle 
3 
0 
3 
Hip 
. 2 
3 
4 
Thigh . . .. 
2 
4 
8 
Leg . . . 
2 
8 
8 
Foot . 
1 
1 
3 
Lumbar . 
5 
3 
7 
Sacral . 
2 
2 
5 
Buttocks . 
0 
4 
1 
Pubic . 
2 
3 
5 
Renal colic 
. . , 0 
0 
0 LOSS OF WEIGHT 
739 
The regional pains above tabulated most frequently occurred in 
groups. Of these the genito-urinary was the most common, and was 
characterized by pain in the bladder, urethra and penis, especially 
during urination. The rectum and perineum were also grouped 
together, the pain there being generally due to pressure from the enlarge- 
ment of the gland, which was often sufficient to greatly reduce the lumen 
of the rectum and render defecation difficult. The other groups of 
symptoms may be classed as referred rather than local. Among them 
were noticed three distinct groups: Those radiating to the groin and 
testicle, those radiating to the lower extremities, and those radiating to 
the back, sides, and buttocks. The explanation of these pains is 
probably the same as in cases of chronic prostatitis, a reference of pain- 
ful stimuli to other nerves running into the same segment of the cord as 
the periprostatic nerves. 
Hematuria.—Hematuria was present at one time or another during 
the course of the disease in 16 cases. In 10 of these it had been inter- 
mittent and only once considerable in amount. In 3 cases the amount 
of blood present was moderate and in 6 slight. In 6 cases blood was 
continuously present, in 1 slight, in 2 moderate, and in 3 considerable in 
amount. Examination of the urine on admission showed blood in 8 
cases, and in 6 of these it was very slight in amount, but in 3 cases it was 
quite considerable. 
Hematuria seems to be more suggestive of vesical tumor, calculus, 
or a benign middle lobe. It is certainly not so commonly present as in 
cases of benign hypertrophy of the prostate, as in my series of 145 cases 
I found it present in 15 per cent. The absence of hematuria is due to 
the fact that carcinoma of the prostate does not invade the bladder 
except in a small proportion of cases, but is retrovesical and pelvic 
rather than intravesical. It is also interesting to note that there are no 
cases in this series in which hemorrhage from the penis occurred, 
although in 3 cases the anterior urethra was surrounded with more or 
less extensive carcinomatous infiltration, in 1 case producing a con- 
tinuous carcinomatous priapism. 
Loss of Weight.—In 30 cases consideraole, in 11 cases moderate, in 7 
cases slight, and in 13 cases no loss of weight was recorded. In 28 cases 
no mention was made on this point. Although in the later stages of the 
disease the emaciation was profound and rapid, I have seen a great 
many cases with very extensive and long-standing carcinoma which 
were not associated with any loss of weight, and the patient remained 
markedly active and strong. 
The following table shows the condition of the sexual powers in 47 
cases present on admission as given by patients in cases in which a 
record had been made: 
Sexual Powers. 
Coitus 
CoitU3 
Coitus not Coitus 
Erections. 
normal. 
impaired. 
attempted, impossible. 
Normal 
. . . . 8 
2 
Diminished . 
, . . . 1 
4 
3 1 
Absent 
4 24 740 
CANCER OF THE PROSTATE 
While it is true that carcinoma has a much more decided effect upon 
the sexual powers than hypertrophy of the prostate, as shown by the 
above table, it is also true that in cases of extensive involvement of the 
prostate and seminal vesicles there may be no impairment of the sexual 
powers. One patient, upon whom a radical operation was performed, 
stated on admission that erections were normal, coitus normal and 
indulged in about three times a week, and that ejaculation, though not 
quite so free as formerly, was not accompanied by pain. In this case 
the entire prostate was carcinomatous and both seminal vesicles and 
vasa deferentia were filled with carcinomatous cells. In another case in 
which symptoms of urinary obstruction had been present for four years, 
in which the seminal vesicles and prostate were extensively involved 
and the radical operation was performed, microscopic examination 
showed both vasa deferentia and seminal vesicles completely filled with 
carcinoma cells, the patient reported that intercourse was entirely 
satisfactory. In some cases the only complaint is that the amount of 
semen ejaculated was less than normal. 
Duration.—As shown in the statistics given above, cancer of the 
prostate (even when unaccompanied by hypertrophy) may be of slow 
growth and remain for a long period well confined within the capsule of 
the prostate. Several years may undoubtedly elapse before peri- 
prostatic structures, seminal vesicles, and trigone are much invaded, so 
that the chances for radical excision are often excellent. 
Physical Signs.—We have already recorded our findings in the early 
cases. Briefly stated, induration is the most important diagnostic sign 
and should lead to suspicion if only a small area of the prostate is 
involved. This induration is generally very marked and often almost 
stony. In our earliest cases the area was so minute that it was not 
recognized clinically, but in all these cases the region involved was near 
the posterior capsule. In a few instances a smooth, rounded, very hard 
area in an otherwise soft prostate was present and proved to be car- 
cinoma, and in other cases one-half was indurated and sharply demar- 
cated from the rest of the prostate. As a rule, however, the whole 
posterior surface presented a very hard surface which was often smooth 
and well defined laterally. In many cases there was a slight roughness, 
and in a few early and most late ones a markedly nodular condition. 
This diagnostic, induration is generally harder than in prostatitis or 
tuberculosis of the prostate, and the suburethral portion is more uni- 
formly involved. In some cases, especially where prostatitis has also 
been present, diagnosis is very difficult, and an exploratory perineal 
operation, at which sections of the subcapsular indurated areas may be 
necessary before diagnosis can be made, should be done. 
The progress of the cancerous invasion is usually into the tissues 
between the seminal vesicles and the bladder and characterized by 
an induration which is usually more marked than in seminal vesiculitis. 
Sometimes the seminal vesicles are not in themselves invaded and can 
be palpated as soft distended sacs behind the indurated area beneath 
the trigone. RECTAL EXAMINATION 
741 
A transverse plateau of induration above and continuous with the 
prostate, and involving the region of both seminal vesicles, the inter- 
vesicular, and subtrigonal tissues, is often encountered. If this has not 
progressed too far above the prostate the case may still be radically 
operable. But usually it is much too far advanced. 
Enlarged glands which are rarely found except late are of little 
diagnostic value—when present the malignant nature is evidenced by 
the character of the prostate itself and the glands are usually so far out 
along the pelvic wall that hope of radical cure is gone. 
In a series of 111 cases enlarged glands were found by rectal examina- 
tion adjacent to the prostate in 3, near the seminal vesicles in 4, along 
the lateral wall of the pelvis in 13, and in the sacral fossa in 6 cases. In 
22 cases enlarged glands of the groin were found and in 2 cases in the 
iliac fossa. 
When we consider the very extensive enlargement of the prostate and 
seminal vesicles which was present in these cases it seems remarkable 
that the lymph glands were so seldom involved, but our findings 
correspond to those of Kaufmann, who discovered in 100 autopsies upon 
patients dying of carcinoma of the prostate only 27 cases in which there 
was involvement of the pelvic lymph glands. It shows the fact that 
one should not expect enlarged glands before making a diagnosis of 
carcinoma of the prostate. 
Rectal Examination.—The condition of the prostate, etc., at examina- 
tion, is shown thus: 
Prostate. 
Seminal vesicles. 
Both. Right. Left. 
Intervesic- 
ular space. 
Membran- 
ous 
urethra. 
Size: 
Slight enlargement . 
. 16 
8 
3 
2 
10 
2 
Moderate .... 
. 27 
19 
3 
3 
16 
8 
Considerable .... 
. 64 
39 
2 
3 
37 
24 
Indefinitely described 
4 
Surface: 
Smooth 
. 32 
7 
1 
1 
5 
Rough ..... 
. 69 
30 
3 
3 
25 
6 
Not noted .... 
. 10 
Consistency: 
Soft 
2 
Elastic 
1 
14 
3 
5 
7 
11 
Slightly indurated 
2 
2 
1 
3 
Moderately indurated . 
6 
3 
7 
4 
2 
24 
Very hard .... 
. 78 
56 
2 
2 
49 
26 
Stony 
9 
9 
10 
5 
Mixed, soft and hard 
. 10 
Consistence.—In the above tabulation of the prostatic findings the 
one thing that stands out prominently is the induration. Whereas the 
large majority of benign prostatic hypertrophies are elastic or even soft, 
there is only 1 case of cancer which was described as elastic, and none 
were entirely soft (barring 2 cases spoken of below). 
In our series of 145 cases of benign hypertrophy the prostate was 
described as soft in 56, firm in 45, moderately hard in 14, very hard in 
none, stony in none. The marked contrast is at once apparent, and it is 
only necessary, therefore, to say that whenever the prostate or only a 
portion of it is quite hard it should be viewed with suspicion. 742 
CANCER OF THE PROSTATE 
The case in which the prostate was everywhere elastic was one in 
which the lateral and median lobes were considerably enlarged by 
benign hypertrophy and the carcinoma was confined to a small area 
(about 1 cm. in diameter) in the anterior commissure, which could not 
be palpated by rectum. In 2 cases the seminal vesicles were very 
hard and evidently markedly involved by cancer, but in the region of 
the prostate there was a very prominent, smooth, soft, almost fluctuat- 
ing mass, oval in shape, and evidently hematoma or blood cyst beneath 
the posterior capsule. In neither of these cases was operation per- 
formed; but in another case in which a perineal prostatectomy was 
done a cyst 1 x 1.5 cm. in size, filled with brownish fluid, was found just 
beneath the capsule next to the cancer, and was, I believe, the same 
process (old hematoma) but of a smaller size. 
It is the group of 10 cases described above as mixed, soft, and hard 
that are the most interesting, as it contains many in which the diagnosis 
was extremely difficult, and often not made except on the operating 
table and with the aid of stained frozen sections. In all but 2 of these 
10 cases perineal operations were performed (radical 2, conservative 6), 
and the tissues have been carefully examined. In 6 of these benign 
hypertrophy was present along with cancer. In 2 of these one lobe of 
the prostate was soft and showed only a benign hypertrophy, but on the 
other side, which was hard, there was a layer of carcinoma between 
the capsule and the hypertrophied lateral lobe. In 3 cases the sub- 
capsular “ shell” of carcinoma was present also on the soft side, but was 
thin enough to transmit the elasticity of the hypertrophied lobe beneath. 
In 1 case only one nodule of cancer (about 1 cm. in diameter) was 
found beneath the capsule on the left side. The rest of the prostate 
was composed of benign adenomatous spheroids. 
In 2 cases in which the radical operation was done no benign ade- 
nomatous hypertrophy was present, the entire prostate being replaced 
by cancer. In both of these cases it is difficult to explain the compara- 
tive softness of one of the lobes which was noted on several careful 
examinations. 
A review of these 10 cases seems to show that the coexistence of 
benign adenomatous hypertrophy may lead to a modification of the 
induration usually found in cancer of the prostate when the layer of the 
cancer between the posterior capsule and hypertrophied area is not too 
thick to transmit the elasticity of the hypertrophied lobe beneath. 
When no hypertrophy is present the prostate is almost always very 
hard in those portions of the prostate involved by cancer. 
The induration usually found in carcinoma of the prostate is of a 
peculiar incompressible character, entirely different from that seen in 
tuberculosis and chronic prostatitis, and, as shown above, usually not 
associated with any areas of softness unless a portion of the prostate be 
still uninvaded or unless there be an elastic hypertrophied lobe beyond 
a thin shell of carcinoma. When the entire prostate has become 
involved the diagnosis is at once apparent. The prostate is usually 
more firmly fixed in its location by pericapsular adhesions (due to 
inflammatory infiltration as is often seen adjacent to carcinoma and not RECTAL EXAMINATION 
743 
necessarily cancerous invasion). Where only a portion of the prostate 
is involved, and especially when coexistent with hypertrophied lobules, 
the diagnosis is often very difficult, and in fact impossible; but the 
presence of such an area of induration should lead to a suspicion of 
carcinoma, and careful investigation at operation with incision of the 
suspected area (if necessary) and perhaps stained frozen sections. In 
such cases the consent of the patient to a radical operation, in case the 
disease should prove carcinomatous, should be obtained beforehand. 
As noted above the enlargement was slight in 16, moderate in 27, and 
considerable in 64 cases. As a rule, when the carcinoma has not spread 
beyond the prostate there is only a moderate amount of enlargement 
present, and often the prostate is only very slightly enlarged. In most 
of our early cases this was the condition present, and not infrequently, 
owing to the small size, their physicians.were apt to consider the pros- 
tate negative on rectal examination even when the disease had spread 
to the space between the seminal vesicles and bladder. The line of 
demarcation between the prostate and the extensive transverse plateau 
of induration above it is often impossible to outline, and not infre- 
quently the prostate is described as considerably larger than normal, 
and at operation the enucleated lateral lobes are found to be very little 
enlarged. 
The surface of the prostate, as indicated above, was smooth in 32 
and rough in 69 cases. Under the head of rough we have included cases 
described as irregular, with a nodule here and there, as well as those in 
which marked roughness was everywhere present. One of the most 
surprising findings has been that the surface is remarkably smooth in 
many cases. This is due to the fact that the fascia of Denonvilliers, 
wThich extends from the triangular ligament upward beyond the seminal 
vesicles as a tense fascia closely applied to the posterior surface of the 
prostate in the anterior of its two layers, makes a firm barrier against 
invasion toward the rectum. In fact, this fascia remains itself free 
from invasion generally until late in the disease, but although many of 
the cases are perfectly smooth, wrhen roughness is present, it is usually 
so entirely different from anything seen in hypertrophy of the prostate 
that carcinoma should at once be suspected. 
In our series of 145 cases of benign hypertrophy there was only 1 
case which was rough and nodular, and in 14 cases in which the smooth- 
ness of the posterior surface was distorted by the presence of one or more 
lobules which projected beyond the confines of the rest of the hyper- 
trophied prostate, in some cases having broken through the posterior 
capsule, generally at the upper end on one or both sides, and thus pro- 
jecting into the region of the seminal vesicles, and occasionally toward 
the apex of the prostate, where the lobule sometimes encroached upon 
the rectum. In these cases, howrever, the lobule wras smooth and gen- 
erally somewdiat elastic, and entirely different in its appearance from 
the indurated areas seen in our cases of early carcinoma. In some cases 
of benign hypertrophy writh a history of suppurative conditions, ad- 
hesions, and irregular areas of infiltration suggested carcinoma strongly, 
and in one such case the diagnosis of carcinoma was held until after a 744 
CANCER OF THE PROSTATE 
suprapubic drainage the prostatitis disappeared, and along with it the 
posterior surface of the prostate became smooth and elastic, so that the 
benign character of the enlargement was at once evident and demon- 
strated by perineal prostatectomy. 
Seminal Vesicles.—As shown in the above tabulation the seminal 
vesicles were frequently involved. The seminal vesicles, one or both, 
were indurated in 88 cases and more or less enlarged in 82 cases. It is 
probable that both of these figures should be a little larger, as the semi- 
nal vesicles were in some cases difficult to reach, owing to the thickness 
of the perineum, the fatness of the patient or the large size of the pros- 
tate. Only 14 cases are recorded in which both seminal vesicles were 
normal in consistence and size, and therefore probably not involved by 
the carcinoma. These 14 cases are of considerable interest. In all but 
2 cases the diagnosis of carcinoma was confirmed by study of tissues 
removed at operation (radical excision 3, perineal prostatectomy 9). 
In 2 of the cases, in which the radical operation was performed, although 
the seminal vesicles were free from invasion, there was a small area of 
carcinoma just above the prostate, beneath the anterior part of the 
trigone and adjacent to the lower end of the seminal vesicles. In the 
other case the disease had not spread beyond the upper limit of the 
prostate. In all 3 of these cases the diagnosis was made before opera- 
tion. In 2 cases (seen in 1901 and 1903) the malignant nature of the 
disease was not recognized either before or during the operation (1 
suprapubic and 1 perineal prostatectomy), but the microscope sub- 
sequently showed carcinoma. In both of these cases the disease had 
not spread above the prostate, and a radical operation should have 
given good results. 
As noted in the above table there were 18 cases in which only one of 
the seminal vesicles was found to be involved, and in view of the cases of 
apparent cure, detailed above, it would seem probable that in several 
of these cases the upper portion of the vesicle was free from disease and 
that a radical operation might have been performed with success. 
Inter vesicular Space.—As noted in the above table the space between 
the seminal vesicles above the prostate was involved in a great many 
cases, and had careful notes in regard to this region been made in some 
of the cases seen several years ago, it is probable that the percentage of 
involvements of this region would be even greater than that of the sem- 
inal vesicles. As a rule, when the disease spreads above the prostate it 
invades the soft tissues beneath the trigone adjacent to the ejaculatory 
ducts, the lower ends of the vasa deferentia and seminal vesicles usually 
forming a small plateau of induration which, in some cases, occupies a 
breadth of 1 cm. on each side of the median line. In other cases it 
extends to the outer side of each vesicle, thus forming a plateau con- 
tinuous with the prostate, and often difficult to distinguish from it. 
Further progress generally consists of involvement of the interior of 
one or both seminal vesicles and tissues between them and the bladder, 
thus forming usually a bicornate mass of induration with a sharp con- 
cave upper border (determined by the lower limit of Douglas’s pouch of 
peritoneum). The posterior surface of these supraprostatic invasions is RECTAL EXAMINATION 
745 
usually smooth (on account of the strong fascia covering them), but not 
infrequently they are irregular and nodular. The induration like that 
of the prostate is usually very great, often of stony hardness, and the 
whole mass is fixed by adhesions to the pelvic wall. When a portion or 
all of the seminal vesicles escapes invasion it may form a soft, somewhat 
elastic layer between the rectum and the subtrigonal infiltration and 
lead to mistake, as in one of my cases in which the radical operation was 
performed on the assumption that the disease had not progressed far 
above the prostate. In this case, although the upper portions of the 
seminal vesicles were healthy, the disease had reached the peritoneum 
by traveling in the space between them and the bladder. A more 
careful examination, especially making use of the cystoscope in the 
bladder and the finger in the rectum, should have demonstrated this. 
Membranous Urethra.—The above tabulation also shows a consider- 
able involvement of the membranous urethra, and here again the figures 
are probably less than the truth, because in many of the early cases the 
records are not complete in this respect. As shown here, however, there 
was more or less thickening of the membranous urethra in 32 cases, and 
in 61 cases distinct induration, often of stony hardness. In most of 
these cases the invasion was continuous with that of the prostate and 
simply surrounded the membranous urethra. In no cases was there 
any evidence of ulceration into the membranous urethra, which like the 
prostatic urethra very seldom becomes ulcerated in cases of carcinoma. 
In a few cases the disease spread to the perineum from the mem- 
branous urethra, involving the fascia back of the triangular ligament 
on one or both sides; this was recorded in 5 cases. In only 3 cases did 
the disease extend in front of the triangular ligament, and in these the 
corpus spongiosum had become infiltrated. In one interesting case the 
corpora cavernosa were apparently completely replaced by carcinoma- 
tous infiltration which extended up to the glans penis, thus producing a 
constant erection of almost complete character which was due entirely 
to the carcinoma. In this case, as well as the two mentioned above, 
there was no ulceration of the urethra and no hematuria. 
Rectum.—As remarked above, the two layers of the aponeurosis of 
Denonvilliers act as a powerful barrier against backward invasion of 
carcinoma of the prostate, and this is abundantly proved by the fact 
that among these 111 cases there is only 1 in which the mucous 
membrane of the rectum was invaded, and 13 cases in which the prostate 
was adherent to the rectum. In many of the later cases, however, the 
adhesions were probably only of such inflammatory character as is often 
seen adjacent to malignant growths and do not necessarily mean in- 
vasion. While the aponeurosis of Denonvilliers protects the rectum 
from invasion it does not prevent constriction of its lumen either by 
the bulk of the carcinomatous mass or by constriction in the region of 
the seminal vesicles through the development of a ring of carcinoma 
around the rectum. This was present in only a few cases when first 
examined; but from letters I have received concerning the progress of 
the disease I am satisfied that it has occurred not infrequently later in 
the disease. In fact, it forms one of the most troublesome later com- 746 
CANCER OF THE PROSTATE 
plications, leading to a partial or almost complete stricture of the 
rectum, severe constipation, and occasionally requiring colostomy. 
The Bladder.—The conditions present in the bladder have been 
studied in various ways: in 49 cases by cystoscopy; in 6 cases by supra- 
pubic cystotomy; in 21 cases by perineal prostatectomy, and in 12 
cases by autopsy. In not all cases were the notes full in every respect, 
so that the figures in the tabulation given below are not always complete. 
They show, however, very forcibly the fact that intravesical tumor 
growth is extremely rare and only occurs very late in the disease, and 
then in only a small percentage of cases, that the trigone is often thick- 
ened, and that the changes at the prostatic orifice consist usually in 
thickening or possibly slight rounding of the median portion. In those 
cases in which considerable enlargement of the lateral lobes was found 
it was probably due, in all cases, to a coexistent adenomatous hyper- 
trophy. 
Conditions within the Bladdeb. 
By cystoscopy. 
Suprapubic opera- Perineal operative 
tive examination, examination. 
Median portion: 
Normal 
. . . 1 
3 
Slight bar . 
. . . 23 
8 
Considerable bar 
. . . 15 
1 
6 
Rounded lobe 
. . . 5 
2 
3 
Right lateral: 
Normal 
. . . 16 
3 
Slight 
... 25 
2 
17 
Considerable . 
. . . 5 
2 
Left lateral: 
Normal 
, . . . 17 
3 
Slight 
. . . . 22 
2 
17 
Considerable . 
. . . 7 
2 
Trigone: 
Negative 
, . . . 13 
2 
Thickened . 
. . . 17 
3 
8 
Ulcerated . 
Tumor 
Ureteral ridges: 
Negative 
. . . 20 
3 
Elevated 
. . . 15 
1 
Ulcerated . 
Tumor 
, . . . 2 
Rest of bladder: 
Negative 
, . . . 21 
4 
16 
Ulcerated . 
. . . 1 
Tumor 
. . . . 1 
1 
In the 12 autopsies of which we have careful examinations there were 
only 2 in which the disease had spread into the bladder in the shape of 
a tumor or ulcer. In both of these cases suprapubic cystotomies had 
been performed several months before, and although the base of the 
bladder was found invaded there was no ulceration or any form of 
intravesical tumor. 
As a result of our clinical studies we feel justified in saying that when 
no hypertrophy is present the enlargement of the prostate in cancer is 
generally not great; that the growth is almost invariably upward into T RE AT ME NT 
747 
the space between the seminal vesicles and around the vasa deferentia 
beneath the trigone; that the changes at the vesical orifice consist 
usually in a thickening of the median portion of the prostate, with 
sclerotic condition of the internal sphincter (making a urethral orifice 
which is difficult to dilate), and that in some cases the median portion 
is in the shape of a moderately thickened bar, but rarely a rounded 
intravesical lobe; that the trigone very frequently becomes thickened 
and sometimes considerably elevated from infiltration, but that the 
mucous membrane everywhere (bladder and urethra) preserves its in- 
tegrity wonderfully; that it rarely becomes ulcerated, and then only 
very late in the disease. 
Str icture of the prostatic urethra was discovered in 8 cases and probably 
existed in others. In only 1 case was it impermeable to filiforms and 
all other instruments. Most often it was merely a contracture through 
which small straight instruments (Nelaton catheters) could be passed, 
but impermeable to Coude catheters and cystoscopes. 
Suburethral Thickening.—The condition found between the cysto- 
scope in the bladder and the index finger in the rectum is a very im- 
portant diagnostic sign. An invasion of the posterior commissure of 
the prostate leads to considerable thickening and induration, and when 
examination is made with the finger in the rectum and cystoscope in the 
urethra an increase in the thickness is made out it is often impossible to 
feel the instrument anywhere along the urethra, and particularly in the 
region of the median portion. If the disease has progressed above the 
upper end of the prostate, thus forming an intervesicular plateau, it is 
usually impossible to feel the beak of the instrument in the bladder. 
This condition is entirely different from that found in benign hyper- 
trophy, in which it is usually possible to palpate the shaft of the instru- 
ment through the posterior commissure (which is usually not much 
increased in size until the median portion of the prostate just beneath 
the vesical orifice is reached), and it is very rare to find even in the 
median portion a marked induration in benign hypertrophy, and the 
beak of the instrument can generally be felt through the bladder unless 
the enlargement of the median portion is considerable. 
Treatment.—There is such a wide variety of opinion as to the proper 
treatment of cancer of the prostate that it seems necessary to furnish 
here as complete a statistical study as possible. I will first give my own 
experience and then records from the literature. My cases (see 13) 
comprise the following: 
Cases. 
I. Radical operation 10 
II. Subtotal, excision 4 
III. Conservative (partial) perineal prostatectomy 71 
IV. Suprapubic prostatectomy 2 
V. Bottini electrocautery operation 8 
VI. Castration 2 
VII. Suprapubic drainage 12 
VIII. Perineal drainage 2 
IX. Treated by catheterization 39 
X. No catheter or operative treatment 29 
Total cases studied 179 748 
CANCER OF THE PROSTATE 
I. Technic of the Radical Operation.—Described first in the Johns 
Hopkins Hospital Bulletin, October, 1905. 
The patient is placed in the exaggerated lithotomy position and an 
inverted U perineal incision made, as in the operation for simple hyper- 
trophy of the prostate, the successive steps of which are followed until 
the tractor has been inserted through a urethrotomy wound of the 
membranous urethra, and the posterior surface of the prostate has been 
exposed, largely by blunt dissection. If there is then any doubt in the 
mind of the operator as to the malignant nature of the disease an in- 
cision is made through the capsule and a section removed for examina- 
Fig. 361.—Longitudinal section of body, showing the line of excision to be carried out 
in radical operation for carcinoma of the prostate. The posterior surface of the prostate 
has been exposed through a perineal incision. 
tion, frozen sections being made if necessary to establish the diagnosis, 
when either the simple prostatectomy for hypertrophy or the radical 
operation for cancer can be performed as the case requires. In the 
case of cancer the next step after exposing the posterior surface of the 
prostate is to follow the fascia of Denonvilliers upward and expose the 
posterior surface of the seminal vesicles as much as possible by blunt 
dissection. It is important here to carry the dissection along the 
lateral surface of the gland, hugging the capsule, and passing between 
it and the antero-lateral pelvic fascia shown in Fig. 361. By elevating 
this fascia carefully from the antero-lateral surfaces of the prostate 
the nerves and rich blood supply of this region are avoided21 (Figs. TREATMENT 
749 
Fig. 362,—Division of membranous urethra. 
Fig. 363.—Transverse section of prostate and rectum. Arrows indicate points of 
beginning dissection beneath anterior prostatic fascia. 750 
CANCER OF THE PROSTATE 
364 and 365). Then the membranous urethra is divided in front of 
the tractor, as shown in Fig. 362. The handle of the tractor is then 
depressed markedly and the fascia elevated, the operator hugging the 
anterior surface of the prostate, efforts having previously been made to 
Fig. 364.—Prostatic plexus of veins, side view. A, prostate; B, bladder. 
push away the anterior plexus of veins by blunt dissection. By thus 
going between the lateral periprostatic fascia and the prostate it is 
possible to avoid much hemorrhage. Hemorrhage should be controlled 
Fig. 365.—Prostatic plexus of veins, anterior view. 
as much as possible by ligatures and then by gauze packs, which 
should be held tightly against the posterior surface of the pubes and 
the triangular ligament by means of a retractor. The seminal vesicles 
should be freed further. TREATMENT 
751 
The prostate is drawn outward as far as possible, thus exposing the 
anterior surface of the bladder, which should be punctured, as shown in 
Fig. 366, just above the prostatovesical juncture. This wound is now 
enlarged on each side by scissors, the line of division being close to the 
prostatovesical juncture, until the trigone is exposed, as shown in 
Fig. 366.—Incision into bladder, just above prostatovesical juncture. 
Fig. 367. With the scalpel a curved incision is made across the 
trigone, thus leaving the upper angles of the trigone intact, and 
being careful to do no injury to the ureters. By blunt dissection the 
bladder is pushed upward, the seminal vesicles are then exposed, as 
shown in Fig. 368, and the vasa deferentia picked up with a blunt 
hook and divided with scissors as high up as possible. (In doing this 752 
er NCER OF THE PROSTATE 
it should be remembered that the vasa deferentia pass around the 
lower end of the ureters.) The deeper attachments of the seminal 
vesicles are then freed and the mass, consisting of the prostate, urethra, 
cuff of the bladder, seminal vesicles, and about 5 cm. of the vasa 
deferentia, is removed in one piece (Figs. 369 and 370). Hemorrhage 
is again encountered in the last step above described, owing to the fact 
that the prostatic plexus of veins, which pass up along each side of the 
prostate, is closely attached to the lateral border of the seminal vesicle, 
but this can easily be controlled by ligatures or long clamps. The bleed- 
Fig. 367.—Bladder opened. Dotted line shows site of incision across trigone, below 
ureters. 
ing which comes from the vesical wound is easily controlled by the 
subsequent sutures, which are placed so as to anastomose the bladder 
(Fig. 371) with the membranous urethra, and completely close the 
vesical wound. This is easily accomplished, as shown in Fig. 372. As 
seen here the anterior wall of the bladder is drawn down and fastened 
to the stump of the membranous urethra by means of interrupted 
chromicized catgut sutures. After forming the anastomosis with 
the urethra a considerable vesical wound is left posteriorly, but it is 
easily closed by a continuous chromicized catgut suture (Fig. 373). 
A retained rubber catheter, which should be inserted before the TREATMENT 
753 
vesico-urethral anastomosis is made, is fastened to the glans penis 
with adhesive plaster. After placing light gauze packing in the depths 
of the wound the levator ani muscles are approximated with two or 
three interrupted sutures of catgut, so as to protect the rectum against 
pressure from gauze, and the external wound is almost completely 
closed with interrupted sutures of catgut. In some instances I found 
it difficult to place ligatures around hemostatic clamps which were 
deeply placed, and have therefore not removed the clamps but allowed 
Fig. 368.—Seminal vesicles and vasa exposed, previous to division of vasa and removal 
of seminal vesicles and prostate. 
them to emerge with the gauze packing from the anterior angle of 
the wound (they were removed twenty-four hours later). If careful 
attention has been given to the prevention of hemorrhage and 
an infusion has been begun early in the operation there should be little 
or no shock. 
The treatment during convalescence is very similar to that employed 
after perineal prostatectomy, viz., water in abundance, urotropin, the 
patient allowed to sit up as soon as possible, daily irrigations of the 
bladder with small amounts of boric acid solution, not more than 754 
CANCER OF THE PROSTATE 
30 c.c. being injected at a time. The gauze packs are removed in two 
or three days and the urethral catheter in a week. No difficulty is 
experienced in getting a good approximation and wound healing, and 
little or no stricture formation has been encountered at the point of 
vesico-urethral anastomosis. Sounding is not necessary. None of 
my patients have had persistent fistulse (see literature: 12, 13, 14, 15, 
16, 17, 18, 19). 
Analysis of the First 10 Cases in which the Radical Operation teas Per- 
formed.—The ages of the patients were seventy, sixty-four, sixty-five, 
sixty-four, seventy-five, sixty-eight, sixty-nine, seventy-seven, seventy, 
and fifty-eight years respectively, and symptoms had been present 
eleven months, three years, four years, one year, eight months, one year, 
eight months, two years, three years, and two and a half years respec- 
tively. Physicians had been consulted and treatment given eight 
R.Va s. 
■ L.Vas. 
L.S.V, 
L.V. 
, R V. 
. L.S.V. 
R.5.V. 
.R 5.V. 
Mucosa. 
Prostate’ 
Mem. Urel h ra 
■Pro state 
Fig. 369.—Anterior view, showing area 
of bladder mucosa removed. 
Fig. 370.—Posterior view of prostate, 
seminal vesicles and vasa deferentia 
removed in radical operation. 
months before in one case, and seven months before in another. In 
both of these cases an osteopath was employed who gave prostatic 
massage, thus losing valuable time. One patient consulted a physician 
for prostatic trouble two and a half years before. One case was sub- 
jected to a Bottini operation six months before admission. In all eases 
sufficient symptoms were present to warrant rectal examination by 
which diagnosis could have been made long before the patient applied 
for treatment with us. 
The initial symptoms were difficulty and frequency of urination in all 
cases except Case I and Case VII, in which the first symptom was pain 
in the urethra. Four patients (Cases II, IV, VI and VIII) had never 
suffered any pain. In 4 cases pain either local or referred was a promi- 
nent symptoms. One patient had pain only on ejaculation, and another 
only slight pain in the buttock. On admission, urination was extremely TREATMENT 
755 
frequent and difficult in 5 cases. In 1 case a catheter was used twice 
daily. In 3 cases there was little difficulty, and in 2 cases the patient 
only got up once at night to urinate, and only 2 patients had had 
hematuria. 
Fig. 371.—Use of “boomerang” needle holder in making anastomosis between bladder 
and membranous urethra. 
The prostate was described as considerably enlarged in 4 cases, 
moderately in 3 cases, and slightly enlarged in 3 cases. There was 
marked induration in all cases, involving the whole prostate in 4 
cases. In Case IV the marked induration was confined to half of the 
prostate, the other half being very slightly indurated. 
In 3 cases (Cases VII, VIII and X) the carcinoma consisted of one 
very hard circumscribed mass or lobule, which in each case projected 756 
CANCER OF THE PROSTATE 
from the general level of the left lateral lobe, but was still well encap- 
sulated. The rest of the prostate showed adenomatous hypertrophy. 
The seminal vesicles were found on rectal examination to be free from 
infiltration or induration in 8 cases. An area of induration between the 
seminal vesicles was present in 4 cases. The catheter showed 400, 300, 
500, 400, 80, 600, 60, 160, 20 and 10 c.c. residual urine respectively. 
The cystoscope showed a slight elevation of the median portion in 5 
cases, in 3 cases a small, definitely rounded median lobe with a shallow 
cleft on each side, and in 1 case a large median lobe. 
The lateral lobe were scarcely at all enlarged intravesically in all 
cases but 1 in which they were moderately enlarged. There was 
generally not even a sulcus between them in front, but in 2 cases it was 
Fig. 372.—Anastomosis completed; remainder of bladder opening being closed with 
continuous chromicized catgut. 
shallow. In 2 cases enlargement of the anterior portion of the prostate 
was present. The vesical mucosa was everywhere intact, but the 
cystoscope showed in 2 cases an elevation of the trigone, which involved 
only the anterior portion in Case II. In Case III the trigone was con- 
siderably elevated and irregular, extending out on the left side as far as 
the ureter. In 8 cases the trigone was negative. 
At operation the lower ends of both ureters were intentionally excised 
for a short distance in Case II, the operator thinking that the disease 
had reached this point. This was a mistake, as it was afterward found 
that the induration was inflammatory in character. In Case V the 
lower end of the left ureter was involved and had to be excised. This 
patient died of shock, and autopsy showed that while the seminal TREA TMENT 
757 
vesicles were free the disease had travelled into the peritoneal cavity. 
The cystoscopic evidence of elevation of the whole trigone should 
evidently militate against the radical operation, as shown by this case. 
In Case III the lower end of the left ureter was unintentionally divided 
with scissors in making the division along the left lateral wall of the 
bladder. Anastomosis was made high up and no inconvenience resulted 
Fig. 373.—Longitudinal section, showing result of suture of bladder to urethra. 
(the patient living three years). In 9 cases the operation was carried 
out with apparent success and without shock, but a study of the 
specimen removed showed carcinoma near the upper limit in 2 cases 
(Cases I and III). In Case V (patient dying of shock) autopsy showed 
extensive carcinoma of the peritoneum and retroperitoneal glands, 
although the bladder and seminal vesicles wrere free from invasion. In 
Case I the patient died nine months after the operation as a result of 758 
CANCER OF THE PROSTATE 
traumatism and infection, caused by an attempt to remove a stone 
adherent to a silk suture. Autopsy showed a very small area of recur- 
rence 1 cm. in diameter back of the bladder. In Case III the patient 
lived over three years in comfort, but autopsy showed metastases in 
various parts of the body, the bladder and urethra, however, being free 
from ulceration. In Case II, in which the patient died six weeks after 
the operation from ascending renal infection, as a result of the inten- 
tional but injudicious division of the two ureters, extremely careful 
examination of all the pelvic tissues at autopsy with numerous sections 
taken for microscopical study failed to reveal any evidence of carcinoma, 
and it seems probable that the disease had been completely eradicated. 
Two patients have apparently been cured. One died six and a half years 
after the operation and the other is well five and a half years after the 
operation. In both of these cases the operative specimens showed 
that the disease had not reached the upper line of excision. Three 
patients operated upon two years ago are alive and apparently well. 
A further study of the ultimate results in these radical cases was 
carried out on July 1, 1922 and is as follows: 
Up to date there has been 19 cases. The ages at time of operation 
were: 
2 cases between fifty and sixty years of age. 
13 cases between sixty and seventy years of age. 
4 cases between seventy and eighty years of age. 
The ultimate results are known in 18 cases and are as follows: 
Case I.—Lived nine months after operation and died of sepsis 
following urethral instrumentation. Autopsy showed recurrence. 
Case II.—Died six weeks after operation of pyelonephritis. At 
autopsy, no carcinoma was present. 
Case III.—Lived three years and two months after operation and 
died of recurrence. 
Case IV.—Lived six and a half years after operation and died with- 
out recurrence. Careful autopsy was performed. 
Case V.—Died from shock. Autopsy showed peritoneal and deep 
glandular metastasis. 
Case VI.-—Alive and well thirteen years after operation. 
Case VII.—Lived eight and a half years after operation. Patient’s 
doctor reported operative result excellent. No metastases. 
Case VIII.—Patient died in hospital three weeks after operation 
from sepsis. 
Case IX.—Aj>parently well on examination six years after operation. 
Died eight and three-quarter years after operation of cancer of liver. 
Case X.—Alive and well eight years after operation. 
Case XI.—Died two years after operation of “ acute heart failure.” 
Excellent operative result. No recurrence. 
Case XII.—No reply to letters. 
Case XIII.—Alive and well five years after operation. 
Case XIV.—Alive and well three years after operation. 
Case XV.—Alive and well. No incontinence two and one-third 
years after operation. Examination negative for recurrence. TREATMENT 
759 
Case XVI.—Died nine months after operation; local recurrence 
and metastases. 
Case XVII.—Lived one year and nine months after operation. 
Examination at the end of eight months showed no evidence of recur- 
rence. Cause of death unknown. 
Case XVIII.—Recent case. Alive and well six months after 
operation. 
Case XIX.—Recent case. Alive and well seven months after 
operation. 
Summary.—Total number of cases, 19. Died from operation, 1. 
Died from postoperative infections, 3 (renal, 1; perineal, 2). No re- 
currences at autopsies. Died from recurrence or metastases, 3. Died, 
cause and time unknown, 1. Not heard from 1 (Case XII). 
Remote deaths, no evidence of recurrence or metastasis, 2 patients 
Case XVII, lived one year and nine months after operation; Case VII 
lived eight and a half years after operation. 
Alive and well, duration of each, as follows: Thirteen years, eight 
years, five years, three years, two years, eight months, six months. 
Total, 19 cases. 
No recurrence after operation at autopsy or on clinical report, 15; 
doubtful, 1. Percentage of probable cures of carcinoma by operation, 
to date, 80 per cent. Well three years or more, 70 per cent, (not 
including the 3 cases which died of infections, in which autopsy was 
negative for carcinoma. 
These results show conclusively the value of the radical operation. 
In the first cases there was incontinence when the patient was on his 
feet, but when in bed and in a sitting posture there was fair control. In 
more recent operations control has been much better, in Case IX 
hardly any incontinence, and in Cases X to XVII no incontinence 
at all, the patient voiding naturally with normal force only three or 
four times by day and none at night. This has been accomplished 
by using great care21 to elevate the anterior layer of pelvic fascia, 
which encloses the lateral and anterior aspects of the prostate, with 
the nerves and bloodvessels of that region. This not only obviates 
hemorrhage but preserves the vascular and nervous supply of the 
triangular ligament and sphincter, and thus prevents incontinence and 
removes the one object to the operation. 
As a result of the experience gained in these 19 cases it may be said 
that the operation should not be attempted when the infiltration 
extends more than a short distance beneath the trigone, as determined 
by the cystoscopic examination with the finger in the rectum and 
the cystoscope in the urethra; nor where the upper portions of both 
seminal vesicles are involved, nor where an extensive intervesicular 
mass or indurated lymphatics or glands or involvement of the mem- 
branous urethra or muscle of the rectum shows that the disease is 
manifestly too far progressed; that the corners of the trigone con- 
taining the ureteral papillae should be left intact with sufficient tissue 
below them to ensure proper suture and to leave their opening free 760 
CANCER OF THE PROSTATE 
from constriction, 1 or 2 cm. above the wound; that the hemorrhage 
should be carefully checked (by hugging the capsule, injury of the 
periprostatic plexus being largely avoided); that silk should never 
be used but chromacized catgut should be employed in making the 
urethro-vesical anastomosis; that when the operation is attempted early 
it can be performed without much danger or great difficulty, and with 
excellent chance of cure; that 4 cases above recorded were suitable 
for the radical operation, and that in all of the others the disease was 
apparently completely removed. Only 3 with definite recurrence 
have been found. It seems probable that radical cures have been 
obtained in at least 70 per cent, of patients leaving hospital. 
Radical Cures by Partial Prostatectomies .—Two cases, in which small 
nodules of cancer were completely removed in the course of perineal 
prostatectomy for supposed benign hypertrophy, have been radically 
cured, and therefore deserve mentioning. They are reported elsewhere. 
The literature on the radical cure of cancer of the prostate has become 
fairly voluminous since my first paper in 1906. Interest has been 
greatly increased by the fact that this subject was assigned for report 
and discussion at the International Medical Congress in London, 1913, 
and at the International Association of Urology in Berlin in 1914. At 
London reports of successful results with the operation were made by 
Joly, Wildbolz, Legueu, and others, and at Berlin excellent clinical 
compilations from the literature were made by Verhoogen, Schapiro, 
and Wildbolz. The consensus of opinion was that for radical cure 
radical excision was necessary, and that good results could be expected 
if the operations were performed early. 
II. Subtotal radical excision of carcinoma, with conservation of sphinc- 
ters, and most of the urethra and capsule. This operation has been 
carried out in 4 cases. The first case showed a well-circumscribed area 
of carcinoma in the right half of the prostate. The right lateral lobe 
lay in front of this and was an adenomatous hypertrophy, the left and 
median lobes of the prostate were also benign hypertrophies. The area 
was so well circumscribed that I did not perform the typical radical 
operation but contented myself with removing the right half of the 
prostate with its capsule, the right lateral wall and floor of the urethra, 
the suburethral tissues with ejaculatory ducts and lower portion of the 
right seminal vesicle and vas deferens, all in one piece. The left lateral 
and median lobes were then excised as usual, preserving the roof, left 
lateral wall of the urethra and vesical sphincter. 
The result was splendid. Perineal fistula closed on the ninth day, 
patient discharged on the fourteenth day. Report by letter five years 
later: “Entirely wTell; urination normal.” 
Two other patients have been operated upon by a similar technic, 
also with excellent results, now four years in 1 case, and the method 
can be recommended in cases in which a small nodule of carcinoma well 
circumscribed and surrounded by healthy tissue is present. Great care 
must be exercised, however, in choosing cases, and the radical operation 
is generally the safer to employ. TREATMENT 
761 
In a recent paper, Geraghty7 collected our combined cases up to 
1922 and found 7 in which a subtotal prostatectomy was carried out, 
and states that in all these cases there have been no recurrences of 
the disease up to date. In this paper he presented illustrations show- 
ing the ease with which the entire prostate with its capsule could, 
after division of the membranous urethra, be separated from the blad- 
der without removing the internal sphincter, and that the blunt dis- 
section could be carried upward beneath the bladder and thus remove 
the seminal vesicles with the prostate in one piece. This procedure 
which we have carried out in rare cases is, of course, only applicable 
where the operator is quite sure that the mucous membrane and 
muscle of the trigone and at the prostatic orifice have not been invaded, 
and even in such cases the radical operation is so simple that it is 
usually to be preferred, as no difficulty is experienced in anastomosing 
the remainder of the bladder with the prostatic orifice, and the radical 
procedure is manifestly more complete. 
ill. Typical Conservative (Partial)Prostatectomy.—Seventy-one cases. 
This operation was done with no idea of radical cure but merely to 
remove the obstruction to urination. In 2 cases, however, a small 
nodule of carcinoma was completely excised in the removal of the lateral 
lobes. 
In 1 case the carcinoma lay adjacent but not within an adenoma- 
tous lobe, but was radically removed, as shown by the fact that the 
patient is alive now, eleven years after operation. 
The other case was one of obstructive prostatitis, the microscope 
showing a small but definite nodule of cancer in the tissues removed 
from one lobe. The patient is alive and well now, seven years after 
operation. 
In 71 cases conservative perineal prostatectomy was carried out to 
remove the obstruction and thus furnish relief from very difficult and 
painful urination or a painful catheter life. 
Discovery of the fact that a manifestly incomplete operation of this 
character could give lasting functional results came accidentally, but 
has now been tried sufficiently to make it an operation of election in 
many cases. 
It has indeed been surprising to find patients with extensive carci- 
noma of the prostate and seminal vesicles permanently relieved of 
obstruction to urination by a simple shelling out of the carcinomatous 
tissue from the lateral and median portions of the prostate, but such 
is most often the case. 
The operation is as follows: A description of the principal steps in the 
operation of conservative perineal prostatectomy seems desirable here, 
as many of the steps are the same as for the radical operation for cancer 
of the prostate. 
Position of the Patient.—The exaggerated dorsal position of the pa- 
tient is the most satisfactory and the perineal board devised by Halsted 
is admirably suited for this purpose. The perineum should be so ele- 
vated that it is almost parallel with the floor, thus allowing excellent 762 
CANCER OF THE PROSTATE 
retraction of the rectum and splendid exposure of the posterior surface 
of the prostate. After placing the patient upon the table, before ele- 
vating the thighs, a No. 24 F. sound should be inserted into the posterior 
urethra, to be used subsequently as a guide for urethrotomy. If the 
operator waits until the patient is placed in the urethrotomy position he 
will frequently find it difficult to introduce the sound through the tri- 
angular ligament. 
Cutaneous Incision.—The inverted U cutaneous incision unquestion- 
ably gives a far better exposure than a median incision. The apex 
should be just over the posterior part of the bulb, about two inches 
in front of the anus, and the lateral branches directed outward and 
backward parallel to the ischiopubic ramus, each about two inches 
in length. The incisions are carried through the skin, fat, and super- 
ficial fascia, and then by blunt dissection with the handle of the 
scalpel and the index finger of the left hand the space to each side of 
the central tendon is opened up. In this way it is very simple to open 
up by blunt dissection very quickly a space on each side reaching as far 
as the triangular ligament. In so doing the levator ani is pushed back- 
ward and outward on each side and the transversus perinei muscles are 
pushed forward (Fig. 374). 
Exposure of the Membranous Urethra.—The bifid retractor is inserted. 
Traction upon this instrument gives an excellent exposure of the 
narrow band of central muscle and tendon and greatly facilitates the 
division close to the bulb without injuring this hemorrhagic structure 
as shown in Fig. 375. After the central tendon has been completely 
divided and the posterior surface of the bulb freed it is well to insert a 
grooved retractor by which the bulb and triangular ligament and 
external sphincter are drawn upward and a better view obtained of the 
recto-urethralis muscle, which lies between the two branches of the 
levator ani and covers the membranous urethra, toward which it draws 
the anterior wall of the rectum. In dividing the recto-urethralis muscle, 
care should be taken not to injure the rectum, which is often drawn 
forward so that it lies almost in front of the membranous urethra. It 
nearly always covers the apex of the prostate. As soon as the recto- 
urethralis has been thoroughly divided it is easy, by blunt dissection, to 
push the rectum backward and thus obtain a good view of the mem- 
branous urethra, the bulb being drawn forward along with the muscular 
structures of the triangular ligament. The membranous urethra is then 
opened upon the sound and the edges picked up with artery clamps, 
being sure to secure the mucous membrane. A straight sound is then 
inserted into the bladder through the urethral wound (an assistant hav- 
ing withdrawn the sound from the anterior urethra), to open up the way 
for the prostatic tractor (Figs. 376 and 377). In these cancerous cases 
it may be necessary to stretch the contracted posterior urethra consider- 
ably with a glove-stetcher before it is possible to insert the tractor 
into the bladder through the perineal urethrotomy wound. Owing to the 
pronounced curve of this instrument (Fig. 376) it is sometimes difficult 
to insert. Sometimes it is well to begin its introduction with the beak TREATMENT 
763 
turned backward and then to rotate the instrument 180 degrees before 
carrying it into the bladder. After the instrument has penetrated into 
the prostatic urethra it is generally advisable to remove the anterior 
bulb retractor and thus allow the shaft of the tractor to be carried 
Fig. 374.—Opening up space on each side of central tendon for conservative or radical 
operation. 
farther forward. As a rule, little difficulty is experienced in inserting 
the tractor if one has been careful to secure the edges of the mucosa of 
the membranous urethra. After reaching the bladder the blades of the 
tractor are opened out by means of the external handles (Fig. 378), and 
after being fixed in this position by means of a set-screw, traction is 764 
CANCER OF THE PROSTATE 
made upon the prostate and the farther separation of the rectum from 
the posterior surface of the prostate made. After dividing the recto- 
urethralis muscle and exposing the apex of the prostate one generally 
finds it necessary to use the knife to divide a layer of fibrous tissue which 
Fig. 375.—Bifid retractor inserted. Division of central tendon and recto-urethralis 
muscle beneath it. 
lies behind the posterior surface of the prostate. After this (the pos- 
terior layer of Denonvillier’s fascia) has been divided the rectum can 
be more easily pushed backward, and one enters, generally with ease, 
into the space between the two layers of Denonvillier’s fascia and the 
smooth, glistening surface of the prostate is exposed (Fig. 379). When TREATMENT 
765 
this layer is properly exposed no difficulty is generally experienced in 
rapidly freeing the entire posterior surface of the prostate and seminal 
vesicles, a good view of which is obtained at once by the insertion of 
a broad angular retractor posteriorly. 
Incision of Capsule.—Lateral retractors are so placed that with the 
posterior retractor drawing the rectum backward, and the prostatic 
tractor drawing the gland outward a splendid exposure of the posterior 
surface of the prostate is obtained. An incision is then made through 
the capsule on each side of the median line for almost the entire length 
of the posterior surface and about 1.5 cm. deep. These incisions are 
about 1.8 cm. apart behind and 1.5 cm. apart in front, as shown in 
Fig. 380. The bridge of tissue which lies between them contains the 
ejaculatory ducts and the floor of the urethra. 
Fig. 376.—Young’s prostatic tractor (closed). 
The lateral lobes are then each completely removed, much of this 
being done by the blunt dissector. When the deep portion is reached— 
that is, at the base of the seminal vesicle and the bladder—it is often 
necessary to use a sharp periosteal elevator or a curette in order to com- 
pletely remove all of the carcinomatous prostatic tissue in that region. 
The entire lateral mass of prostatic tissue usually comes away in one 
piece, but in those cases in which the cancer is confined to the posterior 
subcapsular layer in front of which is a hypertrophied adenomatous lobe 
the latter is usually separately enucleated. After the two lateral cavi- 
ties are emptied the median portion of the prostate is next attacked. 
This is indicated in Fig. 381, in which the median portion is shown 
diagrammatically, caught with a sharp hook. It should be out object 766 
CANCER OF THE PROSTATE 
here to excise this median suburethral portion without injury to the 
ejaculatory ducts which lie behind it (in order thus to avoid epididy- 
mitis), and with as little injury to the urethra in front of it as possible. 
Remaining tissue can be removed with scissors, curette, or ronguer. If 
a rounded middle lobe is present it may be drawn down and removed 
Fig. 377.—Membranous urethra opened on sound, edge caught with clips, tractor about 
to be introduced. 
through a lateral cavity (Fig. 382). It is then advisable to remove the 
tractor and dilate thoroughly the external prostatic orifice with large 
forceps after removal of the tractor. The finger is then carefully 
inserted through the urethra and an examination of the vesical neck 
made. As a rule the sphincter will be found tight, or often sclerotic, 
and through dilatation should be made. If there remains any pros- TREATMENT 
767 
tatic tissue in the median portion or elsewhere around the orifice this 
can easily be enucleated or excised, using the finger as a tractor. In 
some cases the carcinomatous infiltration continuous with the median 
bar and extending beneath the trigone is felt, and it may be advisable to 
remove this more or less completely (which can usually be done with 
ease with a curette working upon the finger in the bladder against the 
trigone as a guide). Care should be taken not to tear a hole in the 
urethra or bladder, but it is a remarkable fact that although the urethra 
may have been torn laterally or posteriorly during some of my opera- 
tions, and in a few cases a small portion excised, the healing in these 
cases has been entirely satisfactory and there has been no evidence of 
intra-urethral ulceration or tumor outgrowth through the rent. If a 
Fig. 378.—Prostatic tractor opened, as in operation. 
globular median lobe is present this is usually easily enucleable, as in 
cases of benign hypertrophy. The rest of the operation is similar 
to that for benign cases: A large drainage tube through the urethra 
into the bladder, irrigation begun at once, the lateral cavities packed 
each with strips of iodoform gauze (Fig. 383), the levator ani muscles 
drawn together in front of the rectum with a single suture of cat- 
gut, and the skin approximated on one side by the interrupted sutures 
of catgut. If the patient is very weak an infusion is often begun at 
the beginning of the operation, but usually we wait until the return 
to the ward. From 500 to 800 c.c. are generally given beneath the 
breasts. Irrigation, begun on the operating table, is given inter- 
mittently in the ward. The patient is given water to drink as soon 768 
CANCER OF THE PROSTATE 
as possible and an effort is made to make him take as much as he can. 
The gauze is generally removed on the morning after the operation, 
and the tubes during the afternoon, when all bleeding following the 
Fig. 379.—Prostate drawn down by tractor, posterior surface freed. 
removal of the gauze has ceased. On the following day the patient 
is usually put in a wheel-chair and taken outdoors, and, as a rule, the 
convalescence is as rapid as we see after perineal prostatectomy for 
benign hypertrophy. In fact, owing to the small size of the cavity, the . TREATMENT 
769 
closure of the fistula and restoration of normal urination are usually 
somewhat quicker, as shown by reference to the detailed report else- 
where of cases treated by perineal prostatectomy. 
Results of conservative perineal prostatectomy in 71 consecutive 
cases of cancer of the prostate. There were 4 deaths, none immedi- 
ately following the operation, the earliest being twenty-three days after 
operation for uremia, and the others twenty-six, thirty-six, and forty- 
Fig. 380.—Incision of capsule and enucleation of lateral lobes. 
nine days after operation. All of these were desperate cases, suffering 
greatly, operation being performed in hope of relief, and having little to 
do with the fatal ending. The mortality of 5.6 per cent, is therefore not 
just to the operation. The results obtained have been analyzed and 
tabulated as follows: 
A. Good Result as Long as Patient Lived, 24 Cases.—In these cases 
the operation was entirely successful in removing the obstruction 
permanently. The duration of life was over four years, 1 ease; over 770 
CANCER OF THE PROSTATE 
three years, 3 cases; over two years, 5 cases; over one year, 4 cases; six 
to twelve months, 5 cases; under six months, 6 cases. 
Many of these cases were remarkable not only in being completely 
free from urinary obstruction, but also in being otherwise comfortable 
almost up to the end. In 4 cases there was some intestinal obstruction 
due to growth of cancer higher up. In only 3 cases did a small fistula 
develop at the site of operation before death, but in no case was there 
hematuria at any time. 
Fig. 381.—Excision of infiltrated median bar. 
Twelve of the 24 cases are reported to have had no pain up to death. 
In 7 severe pain,' generally in back or thighs, was present. It was 
present before operation in most of these cases, but there were others 
not in this group in which severe pain developed later. I think I can 
safely say, however, that it is not hastened by operation and is often 
relieved thereby. Fenwick pointed out years ago that in cancer of the 
prostate, pain would often disappear when the disease broke through 
the capsule—apparently thus relieving tension. 771 
TREATMENT 
B. Patients Still Alive and Entirely Relieved of Obstruction to Urination 
14 Cases.—Twelve of these cases are free from pain. In 3 a pin-point 
fistula exists. No hematuria is reported, and none have required ca- 
theterization, micturition being fairly normal. The duration since 
operation is three years, 1 case; over two years, 2; over one year, 5; 
between six and twelve months, 2; indefinite, 2. If group B be added 
to group A we have 38 in 71 cases with excellent operative result, or 
Fig. 382.—Removal of rounded median lobe through the left lateral cavity. 
53.5 per cent. To this may be added 11 cases in which, although the 
operative result, removal of obstruction and restoration of free urination 
has been accomplished, still accompanying conditions, present before 
operation, have been so severe as to negative the results, e. g., 7 
patients were terrible sufferers from pain (generally in back and legs) 
before operation, and this still continued in such severity as to over- 
shadow everything else. In 2 there was very little residual urine 
before operation, and the size of the bladder was small. Urination has 772 
CANCER OF THE PROSTATE 
since been free but frequent. In only 1 case were there hemorrhages. 
These were all bad cases, 3 lived less than one year, 7 between one and 
three years, 1 is still alive. They represent a class of patients whose 
sufferings are so intense from pain, and dfficulty and frequency of 
urination are so great, that something is demanded. 
The operation, however, relieved the obstruction permanently, and 
these should therefore be added to the previous groups, thus giving as 
Fig. 383.—Lateral cavities in prostate packed with gauze. Tube drain of bladder 
through membranous urethra. 
results in removing obstruction and giving free urination 4-9 in 71 cases, or 
69 per cent, successful. 
C. Partial Recurrence of Obstruction.—There were 4 cases (5.6 per 
cent.) in which the obstruction relieved for a time partially returned 
within six months in 3 cases and after eighteen months in 1 case. The 
latter patient lived over four years, the others twenty-two, ten, and four 
months respectively. None of these 4 patients returned to the catheter 
life, and all were undoubtedly improved by operation. 
D. Complete Recurrence of Obstruction.—This class comprises 11 cases 
in which recurrence of obstruction was sufficient to require catheteriza- TREATMENT 
773 
tion in 5 cases (7 per cent.), a Bottini operation in 1 case, suprapubic 
drainage in 4 cases (5.6 per cent.), suprapubic prostatectomy in 1 
case. 
In 4 of these cases the obstruction returned within six months after 
operation, in 2 within a year, in 2 over two years later, in 1 over three 
years later. These cases may therefore be set down as failures, 16.6 
per cent., although a definite period of freedom from obstruction was 
afforded. Three patients lived one year, 5 over two years. In 8 of 
these 11 recurrent obstruction cases, hypertrophy was present (74 
per cent.), and one patient was subsequently relieved of the obstruction 
by suprapubic enucleation of two large adenomatous lateral lobes, 
normal urination being restored. In this case the cancer lay entirely in 
the posterior part of the prostate and seminal vesicles. Freyer has 
reported similar cases in which the demarcation was so sharp that 
suprapubic enucleation could easily be carried out successfully. 
The patients in this group were happily free from pain in all but 
2 cases. 
Careful review of the operative notes fails to reveal any reason for the 
recurrence of obstruction in these 11 cases—apparently the removal 
was just as completely successful as in the other cases which remained 
free from obstruction. Perhaps it is surprising that in more cases this 
frankly partial operation is not temporary in its results. 
E. Complete Radical Cures, Two Cases.—These 2 cases were accidental 
cures. The cancer in each case was only a small nodule, not recognized 
until after operation, but removed with a sufficiently wide margin of 
healthy tissue, so that a complete cure has been obtained. Both 
patients are alive and well now, seven and a half years in 1 case and 
eleven years in the other. 
These cases may be used as an argument for early perineal 
prostatectomy. 
General Remarks.—The foregoing study of 71 patients with cancer of 
the prostate in which 69 per cent, were permanently relieved of obstruc- 
tion to urination demonstrates fully, I believe, the great value of 
perineal prostatectomy, where care is taken to remove the cancerous 
lateral and median lobes, and any adenomatous hypertrophy which may 
coexist, as it has been shown to do in 61 per cent, of the cases. Special 
care should be taken to see that the vesical orifice, which is often con- 
tracted, is well dilated and that no small spheroids of hypertrophied 
tissue remain, as these have probably caused the recurrence of obstruc- 
tion in several of my cases. To recapitulate: We have in 71 cases 
treated by conservative perineal prostatectomy, complete cures, 3 per 
cent.; permanently successful removal of obstruction, 69 per cent.; 
partial recurrence of obstruction, 5.6 per cent.; recurrence of complete 
obstruction, 16.6 per cent.; deaths in hospital, 5.6 per cent.—the earli- 
est twenty-three days—and no deaths strictly attributable to operation. 
In a recent paper, Geraghty has made a study of the cases from the 
records of the Brady Institute.7 
Of the 250 cases of cancer of the prostate seen in the Urological 774 
CANCER OF THE PROSTATE 
Clinic up to the year 1915, in 100 of these perineal prostatectomy was 
carried out. In 75 per cent, of these there was no return of obstruction 
up to the time of the patient’s death, many of these patients living 
a number of years. Of these 100 cases, there was an operative mor- 
tality of 3 per cent. In 70 cases it has been possible to secure informa- 
tion concerning the duration of life. Sixteen of these lived less 
than six months, 15 between six months and a year; 12 between one 
and two years; 10 from two to three years, and 17 three years or more. 
Of these 17 cases, 9 lived between three and four years. Of the 
remaining 8 cases, 2 lived about four and a half years, 2 six years, 
2 nine years and 2 fourteen years. The average time of closure 
following operation differs not at all from the time of closure in the 
benign hypertrophy cases. In 7 cases, a fistula persisted up to the 
time of death. In none of these 100 cases, in which prostatectomy 
was carried out, was anything more than relief of obstruction con- 
templated, and there was no attempt or thought of eradicating the 
disease. The low mortality and the relief of distressing obstructive 
symptoms secured by this operation, relief in the majority of cases 
extending up to the time of death, is a sufficient justification for this 
operative procedure. 
' IV. Suprapubic Prostatectomy, Two Cases.—The prostate was enucle- 
ated in 2 cases, in both of which the malignant nature of the disease was 
not recognized. One of these was operated upon in 1898 by another sur- 
geon and resulted in death thirty hours after the operation. Autopsy 
showed numerous pelvic metastases. In the second case I failed to 
recognize the malignant nature of the disease and performed a supra- 
pubic prostatectomy after removing a very large vesical calculus. It 
was impossible to separate the prostatic lobes from the urethra, and the 
entire prostate was shelled out in one mass along with the urethra. The 
patient returned five years later complaining of a tumor of the kidney. 
He reported that there was no difficulty or frequency of urination and 
that the operation had cured him completely. Rectal examination, 
however, showed a large indurated mass in the region of the prostate, 
and seminal vesicles, and study of the microscopic sections of the 
prostate removed at operation showed carcinoma, thus explaining the 
nature of the supposed kidney tumor. The patient died a few months 
later. The prostatic enlargement in this case was largely due to ade- 
nomatous hypertrophy. This probably accounts for the ease with 
which it was shelled out suprapubically. In cases in which there is no 
hypertrophy present, but the prostate is of the small, hard variety, as 
seen in many of our cases, it would seem almost impossible even to start 
the enucleation through the bladder and that for such cases a supra- 
pubic prostatectomy is out of the question. Freyer agrees to this. 
The fact that the urethra comes away with the prostate in these cases is, 
I believe, a distinct objection to the suprapubic route even when the 
presence of intravesical adenomatous lobes makes it possible, as the 
cavity may fill up with a fungating carcinomatous growth. 
It seems advisable here to refer to recent papers by Freyer and 
by Judd. TREATMENT 
775 
In the Lancet for December 13, 1913, Freyer gives his statistics in 
regard to cancer. He says he has seen 171 cases of cancer to 1105 of 
hypertrophy, or 13.4 per cent, of all cases were cancer. He does not 
give the number of these cancer cases which were operated upon, nor 
has he had complete pathological studies made of all the prostatectomy 
specimens to see how many contain cancer. He details, however, 10 
cases in which suprapubic prostatectomy was successfully carried out, 
the entire prostate, with the urethra, anterior commissure, and “true 
capsule,” being removed in one piece. That this procedure may be 
radically successful in certain early cases in which the cancer is not too 
close to the capsule, and still confined within the substance of the 
prostate, is quite admissible, and this is borne out by the fact that in 
5 of Freyer’s 10 cases the patients have been well now from six to ten 
years since operation. 
Freyer does not recommend the procedure as a radical operation, and 
remarks: “ I could give details of other cases in which the results were 
not so satisfactory, the disease recurring and leading eventually to 
contraction of the urethra,” etc. 
One of my cases (mentioned above) operated as early as 1901 and 
published in 1909 demonstrated that it is possible occasionally to get a 
good functional result for over five years—death finally supervening 
from cancer—but such are rare, and the general consensus of opinion is 
that cancers of the prostate should not be attacked suprapubically. 
In Judd’s paper before the Southern Surgical and Gynecological 
Association, 1914, he reports among 878 specimens removed by pros- 
tatectomy 93 containing cancer were studied microscopically. Seventy- 
five per cent, showed a coexistent hypertrophy, and he confirms our 
discovery that in such cases “ the malignant process always started in 
the posterior lobe, and was often distinctly separated from the rest of 
the gland which was not involved.” 
He has heard from 82 of the 93 patients, but gives no figures as to 
the number of successful cases, simply remarking that “many of the 
patients living at the present time are entirely free from symptoms.” 
“ In the cases of recurrence, hematuria was one of the first evidences of 
the recurrence. Difficulty of urination was an early symptom and 
became rapidly marked, necessitating suprapubic cystotomy in a num- 
ber of cases. Several lived three years without trouble, when there was 
a return of all symptoms.” “ One patient living nine years had a small 
carcinomatous nodule removed.” “Twenty-four died within the first 
six months.” 
In a recent paper by Judd, Bumpus and Scholl10 a clinical and 
pathological study of 146 operative cases has been made. Of 75 
patients traced, who were operated on by the suprapubic route, 14 
per cent, lived more than three years after operation. Of 42 patients 
traced, operated on by the perineal route, 12 per cent, lived three 
years. In a study of 231 untreated patients, the subsequent duration 
of life was found to be almost three years. From this the conclusion 
is drawn that operation has little to offer. (It must be remembered, 776 
CANCER OF THE PROSTATE 
however, that the comfort obtained by operation is generally very 
great.) 
V. Bottini Electrocautery Operation, Eight Cases.—The Bottini opera- 
tion was employed to relieve prostatic obstruction in 7 cases. In 4 of 
these cases the diagnosis of carcinoma was made, and the operation 
employed simply as a palliative procedure with distinct improvement 
in all 4 of them. 
In 3 cases the malignant nature of the enlargement was not recog- 
nized, and the Bottini operation was employed, as I was using it to the 
exclusion of other methods at that time. The results obtained were 
very good in all 3 cases. In 1 case the obstruction recurred, and the 
patient died within a year. In the second case the result was excellent 
for sixteen months when symptoms of obstruction again appeared, and 
suprapubic cystotomy for drainage had to be employed three years 
after the Bottini operation. The last case has been remarkable for the 
immense benefit conferred by the Bottini operation. For almost six 
years after the Bottini operation the patient lived free from pain and 
discomfort, although the prostate and seminal vesicles were markedly 
involved, and general glandular metastases were present. A review of 
these seven cases shows several remarkably good results with the 
Bottini operation, but, as a whole, perineal prostatectomy is the pref- 
erable operation where it is desired to relieve the patient from the 
necessity of painful and difficult catheterization, and the discomforts of 
life with a suprapubic drainage apparatus. 
VI. Castration, Two Cases.—Castration was performed for the relief 
of prostatic obstruction in 2 cases fifteen years ago. In 1 case the 
operator did not recognize that the disease was carcinomatous, and per- 
formed castration, which was then in vogue, in order to produce an 
atrophy of the enlarged prostate. Suprapubic cystotomy for drainage 
was provided at the same time. The result was negative, and the 
patient wore a suprapubic drainage apparatus until his death a year or 
so later. 
In the second case, which was operated by the writer, the diagnosis 
of carcinoma was evident. There was no frequency or difficulty of 
urination, but the patient complained of severe pain in the rectum, 
buttocks and limbs. No operation to relieve obstruction was indicated, 
and castration was performed with the hope that some change in the 
prostate, which might bring about relief of the rectal pain, might follow. 
The result, however, was negative. 
VII. Suprapubic Drainage, Twelve Cases. — In all these cases tne 
catheter was tried first, and the operation performed either because it 
was impossible to introduce the catheter or its use was so painful or 
difficult that catheter life could not be endured. In several cases the 
patient employed the catheter for a long period before finally demand- 
ing operative relief. In nearly all of these cases the disease was far 
advanced and the condition often desperate. One patient died 
a week after the operation, one lived only a month, another only 
five months, and a third six months. In these 3 cases the patients TREATMENT 
777 
suffered very greatly and the operation afforded very little relief. In 
2 cases it has been impossible to find the patients since their departure 
from the hospital. In 6 cases the drainage apparatus was employed, 
and in 5 cases all reports state that it worked well; there was no leakage 
around the tube, the patients were able to empty the bladder at 
fairly long intervals by opening the stop-cock, and there was very little 
pain or vesical discomfort. 
As noted above, the results obtained by suprapubic drainage were 
distinctly better when an apparatus was provided by which the bladder 
would be emptied only at stated intervals rather than being allowed to 
drain continuously. 
VIII. Perineal Drainage, Two Cases.—In 2 cases perineal urethrot- 
omy had been performed, in 1 case on account of abscess of the 
prostate involving the perineum, and in the second case on account 
of the inability of the patient’s physician to pass a catheter, complete 
retention of urine being present. Except in suppurative conditions 
perineal urethrotomy has little to commend it. 
IX. Cases Treated by Catheterization.—There were 39 cases in which 
the patient was advised to lead a catheter life and no operation was 
attempted. In nearly all these cases the disease was too far advanced 
for a radical operation, but in many of the cases conservative perineal 
prostatectomy might have been performed with considerable relief. In 
order to compare the results obtained by the use of the catheter with 
those of prostatectomy we have attempted to get an accurate idea of 
the subsequent course of the cases. 
It has been impossible to get an accurate reply in all cases as to the 
progress of catheter life. In 2 cases subsequent operations were re- 
quired. Suprapubic cystotomy 1, perineal prostatectomy 1. In 10 
cases the catheter life was said to be painful, difficult, or very obnoxious, 
and often the catheter had to be used very frequently. In only 8 cases 
was the catheter life said to have been satisfactory and in 2 of these the 
patient said it was quite disagreeable. In other cases no reply could be 
obtained. Final notes have been received in regard to 28 patients. 
Five are still alive two years, ten months, six months, five months, and 
five months since admission, and in these cases the disease has been 
present five years, two years, two years, six years, and four years. 
Twenty-three patients are dead, the length of time they lived after 
being seen by us being a month or less 6 cases, under six months 3 cases, 
under a year 6 cases, over a year G cases, two years 1 case, five years 
1 case. 
As seen in this tabulation of 23 cases only 3 patients have lived two 
years or more since their first visit, so that it would seem that the dura- 
tion of life after perineal prostatectomy was, as.a rule, longer than with 
a catheter life. 
X. Cases in which Neither Operation nor Catheter Life was Advised.— 
There were 29 which came in this category. These cases present an 
unusual and interesting group because of the lack of the usual severe 
obstruction to urination. In 19 cases a catheter had never been used, 778 
CANCER OF THE PROSTATE 
in 4 cases it had been only occasionally employed. In 1 case acute 
retention of urine was present on admission and in 4 cases the catheter 
was employed daily. In 8 cases the difficulty of urination was con- 
siderable, in 2 cases slight; the increased frequency was considerable in 
11 cases, moderate in 4, and slight in 7 cases. Pain was the most promi- 
nent symptom in most cases and involved various regions from the 
chest to the feet. The duration of symptoms of the disease was less 
than one year in 7 cases, two to three years in 14 cases, and over three 
years in 7 cases. 
The prostate and seminal vesicles were considerably enlarged in 50 per 
cent, of the cases, so the lack of urinary obstruction was not due to the 
absence of prostatic enlargement. Among the 21 patients from whom 
replies have been obtained in only 5 did catheterization become neces- 
sary, and in 3 of these subsequent operations were necessary (two supra- 
pubic drainage and one perineal prostatectomy with relief from catheter 
life). Among the 21 patients that have been heard from, 7 are still 
alive, 3 of them six months, 3 between six and eleven months, and 1 one 
year after being seen by us. In these 7 cases the patients have lived 
five, four, three, and two years, nine, nine, and seven months since the 
beginning of symptoms. Fourteen patients have died since our exami- 
nation, having lived less than six months, 4 cases; between six and 
eleven months, 2 cases; one year, 1 case; two years, 5 cases; and three 
years, 2 cases. The total length of time these patients lived after be- 
ginning of symptoms was under six months 1, under one year 1, over 
one year 1, two years 4, three years 3, four years 1, five years 1, eight 
years 1, ten years 1. 
This class of cases therefore is remarkable for the extent of the 
involvement and the freedom from marked urinary obstruction for long 
periods. They represent a class in which early diagnosis is difficult 
unless rectal examination be made before the beginning of obstruc- 
tive symptoms and for merely slight pain and discomfort in various 
regions from the chest down (which are shown to be reflexly involved 
by carcinoma of the prostate). The presence of an indurated prostate 
in any such case should lead to careful investigation and probably 
exploratory operation. These cases show the great importance of 
rectal examinations as a routine in physical examinations. 
THE USE OF RADIUM IN CANCER OF THE PROSTATE. 
Pasteau and Degrais have contributed several important articles on 
the use of radium in cancer of the prostate. They made use of from 
20 to 50 mgs. of radium, screened by a thin capsule of silver and by the 
gum coude catheter, in which it was placed by means of a stylet. A 
No. 17 catheter was used, being large enough to let the escape of urine 
around the capsule containing radium, thus allowing the use of radium 
in the prostatic urethra for several hours. 
Their first patient with inoperable cancer of the prostate and adjacent 
portion of the bladder (hard, nodular, fixed prostate, irregular cancer of THE USE OF RADIUM IN CANCER OF THE PROSTATE 
779 
middle lobe) had 29 seances of radium treatment (20 to 50 mgs. at a 
time and usually for two hours at a time). He had three treatments in 
October, 1909, 13 in the next eight months, 7 in the year 1911, and 4 in 
1912. As early as February, 1910, the tumor had apparently disap- 
peared, and numerous examinations since (the last being July, 1913) 
failed to show a return—the prostate being soft, small, mobile, and the 
bladder negative. On last report the cure had been maintained almost 
four years. Another case was that of a man seen in 1909 with a hard, 
nodular, fixed prostate, the cancer extending into the region of one 
seminal vesicle. Series of radium applications were made in July and 
August, 1909, with a tube of 50 mgs. remaining in place for two hours, 
the applications being repeated in September and October. In Febru- 
ary, 1910, marked improvement was found, and under the influence of 
renewed application of the rays by the end of 1910 one-half of the pros- 
tate was much softer. Series of treatments—three or four two-hour 
exposures during the course of a month constituted a series—were con- 
tinued for two years, and at the time of reporting “ three years after the 
commencement of the treatment the extension has been arrested and 
the patient has improved greatly in health.” 
In another case eight seances of three hours each with 40 mgs. of 
radium caused marked shrinkage and softening of the prostate. Pas- 
teau remarks that they have observed 3 patients in all of whom, when 
they came under observation, the prostate was enlarged, nodular, and 
very hard, in whom now the prostate is soft, not adherent, and does not 
at all resemble cancer. Each of these had only one series of radium 
applications, yet they are reported as remarkably benefited if not cured. 
I have tried the urethral catheter method of Pasteau with some 
success, but have found it inaccurate and unsatisfactory. I accordingly 
devised (in 1914) radium-carrying instruments of metal, which are 
capable of being used with a cystoscope, which permits of accurate 
application of the radium in the bladder and at the vesical orifice. I 
have also introduced the use of the rectal route for applications upon 
the prostate and seminal vesicles. After a long series of experiments 
and treatments I have shown that a great many treatments can be 
made through the rectum, urethra, or bladder if a new place is selected 
each time—the sites of the treatments do not overlap. The results 
have been a remarkable series of cases in many of which the cancerous 
infiltration of prostate and vesicles have apparently disappeared— 
a marvelous change—I do not dare to call them cures.22 
The previous paragraphs are those which have appeared in the 
first edition of this book. Recently our cases have been studied more 
carefully as to methods and ultimate results. 
The first instruments employed were provided with a straight 
cystoscope, the same cystoscope which I have used for several years 
in the construction of my cystoscopic rongeur. With this cystoscope 
as a basis, the instrument shown in Fig. 384 was made, and it at once 
became possible to introduce radium not only into the urethra and 
rectum, but into the bladder where, under cystoscopic direction, it 780 
CANCER OF THE PROSTATE 
could be applied to the region desired. It became evident at once 
that some means of firmly fixing and holding the instrument con- 
taining the radium was necessary in order to keep the application 
against the desired area for the entire period of treatment. Casting 
about for an instrument, I made use of the cystoscopic clamp or 
artificial hand, which I had employed for several years, to hold a photo- 
graphic cystoscope in place during exposure of the plates (Fig. 385). 
A ball of appropriate size was then placed around the shaft of the 
radium applicator which, when firmly grasped by the cystoscopic 
clamp, held the radium instrument in its grasp upon the desired spot. 
The completed instrument is shown in Fig. 384. This then was the 
basis for a series of instruments which have since been constructed, 
Fig. 384.—Young’s cystoscopic radium instrument, No. 1. 
the object of which has been to place radium upon a certain spot under 
the direction of either the cystoscope in the bladder or a finger in the 
rectum and to hold it there during the entire treatment seance. 
It soon became evident that it was not necessary to use the cysto- 
scope for applications of radium in the urethra or at the vesical orifice 
or even against the trigone, as it is possible by simple manipulation 
to determine where the instrument is in its relation to the vesical 
neck or to place the radium exactly where it is desired and then hold 
it there with the clamp. For the rectum the cystoscopic instrument 
was manifestly not necessary as the radium containing beak could 
easily be placed at the desired spot along the posterior surface of the 
prostate or vesicles or along the pelvic wall and held there by the THE USE OF RADIUM IN CANCER OF THE PROSTATE 
781 
clamp. We, therefore, constructed instruments of appropriate form 
not containing cystoscopes for treatment through the rectum, urethra, 
at the vesical neck or through the trigone and base of the bladder 
to the region of the seminal vesicles. 
Fig. 386 shows the present form of instrument which is employed 
for these treatments. The radium is contained in a small platinum 
tube which is surrounded by a silver cap covered with hard rubber, 
thus affording screening for both the a- and /3-rays, and also the 
secondary rays. The ball is placed at the end of the rod, thus facili- 
tating usage in both rectum, urethra, and bladder; the small handle 
at right angles to the shaft facilitates operation, and indicates the 
direction of the beak. 
Recently, since the introduction of the needling method for the 
treatment of carcinoma of the prostate through the perineum, I have 
Fig. 385.—Mechanical arm and clamp attached to table to hold radium in position. 
constructed in the workshop of the Brady Urological Institute an 
instrument which contains within the beak four needle points, each 
containing 12J mg. of radium, surrounded by a cap of silver which 
is surrounded by gutta percha. This instrument was supplied to and 
is in use by Dr. John H. Cunningham of Boston. Fig. 387, b shows 
the needle with shaft attached for insertion through the perineum. 
Technic Employed.—In the preliminary study of the cases a careful 
diagram showing the size and consistence of the prostate is made, 
utilizing a rubber stamp outline of normal prostate and vesicles as 
a basis. In making the examination with the finger of the left hand, 
the outline chart is drawn simultaneously, careful attention being 
made to get an accurate reproduction of the size and induration of 
the mass. The degree of induration is indicated on a scale of four, 
blank being normal; parallel lines slight induration; cross lines moder- 
ate induration, and additional cross lines (at 45° to the other lines) 782 
CANCER OF THE PROSTATE 
great induration, such as is characteristic of carcinoma. A typical 
chart of carcinoma of the prostate and seminal vesicles is shown in 
Fig. 388. 
If the diagnosis is clear from the extreme induration of a portion 
of the prostate and the absence of calculus from the roentgen-ray 
examination, a cystoscopic examination may not be carried out. As 
a rule cystoscopy is much more painful in cases of carcinoma than in 
cases of hypertrophy, and if it is not necessary for diagnosis we usually 
do not insist on cystoscopy. If there is a question as to the diagnosis, 
Fig. 386.—Radium applicator carrying one or two tubes of radium 100 mg. each in 
platinum tubes, the beak being composed of silver surrounded by gutta percha. Note 
the fixation ball externally. 
cystoscopy is performed and is of diagnostic importance, (1) because 
in cases where no hypertrophy is present, the prostatic orifice usually 
shows no intravesical lobes or enlargement more than a small median 
bar or minute rounded lobe; and (2) because there is shown by examin- 
ing with the finger in the rectum and cystoscope in the urethra a 
marked increase in the suburethral portion of the prostate, not merely 
in the prespermatic or subcervical group of glands, but also beneath 
the entire prostatic urethra from the vesical orifice to the apex, and 
this increase in the suburethral portion of the prostate is usually 
associated with marked induration. This is based on the pathological 
fact that prostatic hypertrophy almost never involved the so-called 
posterior lobe which lies between the posterior capsule and the ejacula- 
Fig. 387.—New radium applicator with enlarged cap, a, made to contain four needles 
containing 12.5 mg. of radium each, which may be used also for needling through the 
perineum by means of attachable shaft, b. 
tory ducts above and the lower portion of the prostatic urethra below, 
and that the same region is strangely the point of predilection for 
carcinoma. This diagnostic sign was first pointed out sixteen years 
ago, and has been of great value in the diagnosis of early and doubtful 
cases. 
The diagnosis of carcinoma having been made, the question arises 
as to whether a radical operation can be carried out with the prob- 
ability of success. 
Experience has shown that in cases in which the carcinoma is con- THE USE OF RADIUM IN CANCER OF THE PROSTATE 
783 
fined well within the capsule of the prostate, in which it has involved 
only the lower portion of one or both seminal vesicles, and in which 
it has not penetrated the prostatic capsule or fascia of Denonvilliers, 
which covers not only the prostate but the seminal vesicles, the 
radical technic can be carried out with strong probability of a com- 
plete cure and a functioning bladder with perfect control and with- 
out urethral stricture at the site of anastomosis. 
Unfortunately, the great majority of cases present themselves 
much too late, the disease has already progressed well up along the 
sides of the seminal vesicles, and frequently involves*the lower pelvic 
glands, often forming a plateau of marked induration above the pros- 
tate in the intervesicular region. In many of these cases there is no 
marked urinary disturbance beyond a slight residual and some increased 
frequency, owing to the fact that carcinoma of the prostate tends to 
Fig. 388.—Rectal chart showing application of radium to prostate and seminal vesicles. 
invade the structures above, behind the bladder, and does not pene- 
trate or ulcerate until later into the urethra or bladder. On this 
account operative relief for the obstruction is usually not necessary, 
and one is free to choose methods of attack upon the carcinoma, which 
is usually producing symptoms due to its size and pressure upon 
nerves and adjacent structures. The plan of procedure for thorough 
treatment of cancer of the prostate with radium, which was first pro- 
posed by me before the American Urological Association at its meeting 
in Baltimore, 1915, and subsequently presented in a paper22 has been 
carried out in over 100 cases,25 the results of which were presented 
in an accompanying paper by I)r. Clyde L. Deming,6 resident urologist 
of the Brady Urological Institute. 
In my first paper, the charts of cases were presented in which 100 mg. 
of radium was applied for one hour each by rectum, urethra and 784 
CANCER OF THE PROSTATE 
bladder to various positions (Figs. 388 and 389). In this case it 
was given twenty-one times through the rectum and fourteen times 
through the urethra and bladder, as shown. The only modification 
which has been made in the past four years has been to employ an 
instrument, the beak of which is protected by a gutta-percha cap, 
scrupulous care being taken to avoid applying radium twice in the 
same place, generally the successive treatments being given to places 
quite remote from each other, and alternating between the rectum, 
urethra, and bladder. Before the introduction of these methods it 
had been freely stated that it was impossible to employ radium in 
sufficient dosage through the rectum without producing radium burns. 
By means of this technic, in which the radium is placed in position 
Fig. 389.-—Urethral and bladder chart. 
with the finger in the rectum and held there by the fixation-clamp, 
care being taken to avoid regions that have already been treated 
before, radium burns and even pronounced irritation have been practi- 
cally eliminated, so that we now find it possible to give with impunity 
twenty treatments, one hour each, through the rectum with 100 mg., 
properly screened, in the small applicator above described. The 
treatments through the urethra and through the trigone and lateral 
portions of the base of the bladder are of very great importance, as 
only the mucous membrane and submucous tissues separate the 
radium from the carcinomatous prostate or vesicles. Since the 
introduction of Barringer’s needles we have often added this method 
of treatment to our routine technic, and now employ two needles at 
a seance, each of which, containing 12| mg., is inserted through the THE USE OF RADIUM IN CANCER OF THE PROSTATE 
785 
skin of the perineum (which has been cocainized) into one or both 
prostatic lobes or even into the carcinomatous mass above the pros- 
tate or along the lateral wall of the pelvis in the region of the seminal 
vesicles. These needles are usually allowed to remain in place for a 
period varying from eighteen to twenty-four hours. They are intro- 
duced under the direction of a finger in the rectum (which should 
not be covered with glove or finger cot in order to be acutely sensitive 
to the exact position of the needle). This procedure may be repeated 
several times during the first series of treatments and adds a valuable 
amount of radiation to the central portions of the prostate and seminal 
vesicles where it is most remote from the radium applied through 
urethra, bladder, or rectum. As at present given, one complete 
series consists of an hourly treatment of 100 mg. of radium properly 
Fig. 390.—Technic for radium application to posterior surface of prostate and 
vesicles with applicator introduced through anus and held in place by clamp attached 
to table. 
screened and applied with the special applicator alternately twenty 
times (one hour each) through the rectum, ten times through the 
urethra, and ten times through the trigone and also 12| mg. several 
times through the perineum. As noted before in these regions there 
is sufficient area to provide for treatments which do not overlap or 
repeat at the same spot and therefore do not produce ulcerations. 
With such a series of treatments most amazing resorption of extensive 
carcinomatous involvement of prostate and semifial vesicles and tissue 
adjacent to them is obtained in the majority of cases, and along with 
it there comes a disappearance of pain and obstruction, a return 
usually to more normal urination and freedom from straining, which 
is indeed remarkable. Fig. 390 shows radium applied through the 
rectum with patient upon his side and the clamp in operation. Fig. 786 
CANCER OF THE PROSTATE 
385 shows the instrument in place for treatment of the urethra or 
bladder. 
Recently I have constructed an applicator (Fig. 384) which carries 
in the beak two tubes of radium, 100 mg. each, placed end-to-end and 
thoroughly screened with 2 cm. of platinum and a thin layer of gutta 
percha. This materially shortens the treatment, as 200 mg. hours is 
given each hour with this applicator instead of 100 mg. hours. 
Details of Treatment.—Before mounting the table, the patient should 
empty the bladder, and if necessary evacuate the bowels. For treatments 
through the rectum no anesthesia is necessary. For the urethra 
and bladder the instrument is sterilized with alcohol, the urethra is 
•sterilized with 1 to 500 Meroxyl and it is well to inject 4 per cent, 
procaine before the introduction of the radium applicator. In very pain- 
ful cases it may be desirable to give \ of a grain of morphine or opium 
suppository one-half hour before treatment. In some cases treat- 
ments can be given twice a day, but usually the patient objects and 
one treatment of one hour each day is all he will take. We usually 
alternate between urethra, rectum and bladder, picking each time a 
region which has not been previously treated. The record of treat- 
ment is made upon either the prostatic or urethral and bladder chart, 
as shown in the accompanying Figs. 388 and 389. A line is drawn 
showing exactly where the radium was applied and the date and 
amount is indicated on the line which points to the site of appli- 
cation. The treatments through the perineum with needles is indi- 
cated in a similar way upon a third chart, thus the entire treatment 
is recorded simply upon one page, and the operator can determine 
at once the location to be treated next in order to avoid overlapping 
and consequent burning. Another series of rectal charts, four in 
number, are made two weeks apart. These show the progress of the 
case and often demonstrate the remarkable disappearance of extensive 
infiltration and induration, as shown in some of the cases charted 
below. In a certain proportion of our cases, probably 10 per cent., 
obstruction persists, and the presence of residual urine and frequent 
urination necessitated operative removal of the obstruction. In 
these cases I have pursued a plan which I have employed in carcinoma 
of the prostate (associated with hypertrophy or with great obstruction) 
since 1905,12 13 14 15 viz., conservative perineal prostatectomy with 
enucleation of the obstructing median and lateral lobes and careful 
preservation of the urethra and ejaculatory ducts. Almost invariably 
the patient is given as thorough a treatment as possible with radium 
through the rectum, urethra, and bladder before the prostatectomy 
is carried out. During this course of radium treatment, in many 
cases, the obstruction disappears, but in others operation is necessary, 
and the results obtained are generally functionally as good as in benign 
hypertrophies. In some cases radium is introduced into the prostatic 
cavities only at operation, but care must be taken to protect the rectum 
by sponges and rubber protective which holds the radium sufficiently 
far away from the rectum. Sufficient radium should be on hand to THE USE OF RADIUM IN CANCER OF THE PROSTATE 
787 
thoroughly treat the remaining urethra, neck of bladder, lateral cap- 
sules and region of seminal vesicles. I usually use two tubes of 100 
mg. each, two needles of 25 mg. each and two needles of 12| mg. 
each after enucleating the prostatic lobes. The tubes of 100 mg. 
remain six hours (1200 mh), the needles of 25 mg. twelve hours 
(1200 mh) and the needles of 12| mg. twenty-four hours (1200 mh). 
Ultimate Results of Radium Treatment in 100 Cases of Cancer of the 
Prostate and Seminal Vesicles Without Operation by Rectal and Urethral 
Applications.—(From a very careful and extensive study made by Dr. 
C. L. Deming6 of our cases at the Brady Institute.) Symptomatically, 
the results from radium have been most remarkable, as will be shown 
by the tables which I have taken from Deming’s report. 
Table I.—Sixty-five Cases Receiving only One Series of Treatments. 
Results Obtained. 
Average 
milligram hours. 
No. 
cases. 
Symptoms. 
Size of 
prostate. 
Percentage 
improved. 
Percentage 
not improved. 
625 
26 
No response 
No change 
0 
100 
999 
39 
Improved 
No change 
60 
40 
1415 
16 
Improved 
Decreased 
77 
23 
It will be seen that those cases which showed no response to radium 
received the smallest amount of treatment. Among 65 cases there 
were 12 in which the patient received between 1600 and 2975 mg. 
hours of treatment, and in all these cases the improvement of symp- 
toms and the regression of the enlargement and induration of the 
prostate was very marked, whereas in 30 cases who received less than 
1000 mg. hours of treatment, only 1 showed any improvement in the 
condition of the prostate, although in 13 there was a slight improve- 
ment in the symptoms. Among 18 cases who were subjected in two 
series of radium treatments, there were only 10 that received 1600 
mg. hours or more, and 6 of these cases showed wonderful improve- 
ment both in symptoms and in the induration and size of the prostate; 
all but 1 who received over 2000 mg. hours were greatly benefited. 
There were 8 patients who received 1500 mg. hours or less and only 
2 of these showed even a slight change in the prostate and vesicles, 
although the symptoms were improved in all but 3 cases. One patient 
received 4600 mg. hours and another 5270 mg. hours without any 
rectal or urethral irritation and with apparent cure of symptoms and 
complete reduction in the size and induration of the prostate. 
In another group of 10 cases which were subjected to three series 
of radium treatments, a study of results showed that where each 
series was small in total mg. hours, although the total might be over 
2000 mg. hours, the results obtained were ineffective. Three of these 
cases, receiving 2100, 2760 and 3290 mg. hours respectively, were 
apparently cured as to symptoms and the size and induration of the 788 
CANCER OF THE PROSTATE 
Table II.—Summary of Tables III, V, VI, VII and VIII, Showing Relation of Amount of Radium to Degree of 
Improvement. 
No. of 
series. 
No. of 
cases. 
Average 
milligram 
hours. 
Duration. 
Symptomatic improvement. 
Total 
percentage. 
Local improvement. 
Total 
percentage. 
Percentage degree. 
Percentage degree. 
+ + + 
+ + 
+ 
O 
+ + + 
+ + 
+ 
O 
i . . . 
65 
1045 
4 wks. 
60.0 
10.7 
18.0 
13.3 
40.0 
23.0 
3.0 
7.7 
12.3 
77.0 
2 . 
18 
2065 
4.3 mos. 
66.6 
33.3 
16.6 
16.6 
33.3 
47.6 
11.1 
111 
27.4 
52.4 
3 . 
10 
2503 
5.6 mos. 
70.0 
30.0 
20.0 
20.0 
30.0 
70.0 
20.0 
30.0 
20.0 
30.0 
4 . 
5 
3037 
20 mos. 
100.0 
80.0 
20.0 
0 
0 
100.0 
60.0 
40.0 
0 
0 
5 . 
2 
5628 
16 mos. 
100.0 
100.0 
0 
0 
0 
100.0 
50.0 
50.0 
0 
0 
Note. b + + = compete subsidence of all symptoms 
or complete resorption of the tumor. 
+ + = moderage change. + = slight change. THE USE OF RADIUM IN CANCER OF THE PROSTATE 
789 
No. 
Age. 
Frequency 
of 
treatment. 
Radium. 
Results. 
Urethral. 
Vesical. 
Rectal. 
Interglandu- 
lar (needle). 
Total. 
Duration. 
Irritation. 
Symptoms. 
Prostatic 
tumor. 
1 . . . 
69 
2 days 
600 
700 
1300 
2600 
6 wks. 
Slight 
+ + 
+ + 
2 . . . 
65 
1 “ 
1000 
400 
1500 
2900 
6 “ 
None 
+ + + 
+ + 
3 . . . 
67 
1 “ 
400 
400 
1000 
1800 
4 “ 
Slight 
+ + 
+ 
4 . . . 
73 
1 “ 
500 
400 
1800 
500 
3200 
6 “ 
None 
+ + + 
+ + + 
5 . . . 
78 
1 “ 
800 
900 
2300 
4000 
6 “ 
Slight 
+ + + 
+ + + 
6 . 
62 
1 “ 
500 
400 
1000 
1900 
7 “ 
None 
+ + 
7 . . . 
63 
1 “ 
800 
300 
1300 
2400 
5 “ 
None 
+ + 
+ 
8 . . . 
72 
1 “ 
900 
2100 
500 
3500 
7 “ 
None 
+ + 
+ + + 
9 . . . 
80 
1 “ 
500 
400 
1800 
2700 
7 “ 
None 
+ + 
+ + 
10 . . . 
68 
1 “ 
500 
400 
1900 
2800 
5 “ 
None 
+++ 
"t" 4" 
11 . . . 
71 
1 “ 
1100 
800 
2100 
500 
4500 
6 “ 
Slight 
+++ 
+ + + 
12 . . . 
65 
1 “ 
700 
500 
2700 
500 
4400 
6 “ 
Slight 
+++ 
+ + + 
13 . . . 
64 
1 “ 
900 
500 
2300 
1000 
4700 
6 “ 
Slight 
+++ 
+ + + 
14 . . . 
68 
1 “ 
900 
400 
2700 
500 
4500 
6 “ 
Slight 
+++ 
+ + + 
15 . . . 
71 
1 “ 
400 
500 
2300 
1000 
4200 
6 “ 
Slight 
+++ 
+ + + 
16 . . . 
66 
1 “ 
1100 
900 
2000 
1000 
5000 
8 “ 
Slight 
+++ 
+ + + 
17 . . . 
62 
1 “ 
800 
800 
2400 
1000 
5000 
7 “ 
Slight 
+++ 
+ + + 
18 . . . 
69 
1 “ 
500 
600 
3100 
500 
4700 
7 “ 
Slight 
+++ 
+ + + 
Table III.—E ighteen Cases Treated Recently (not Included in the 100 Cases). 790 
CANCER OF THE PROSTATE 
prostate greatly improved. The same was true of 5 cases who received 
four series and 2 cases which received five series of radium treatments, 
all but 3 totaling 3000 mg. hours or more. In all of these the results 
obtained as to symptoms and reduction in the size of the prostate 
was said to be 100 per cent. One of these patients received 6225 mg. 
hours with only slight rectal and urethral irritation. 
Table II from Deming graphically shows a comparison of the results 
obtained by varying amounts of radium treatment. 
Fig. 391.—Showing use of radium in bladder with Young’s cystoscopic radium appli- 
cator to cancerous infiltration of trigone. 
Fig. 392.—Chart showing involvement on admission, April 21, 1921; after 2700 milli- 
gram hours, June 6, 1921; and after 4200 milligram hours, June 15, 1921. 
During the past two years T have given the treatments more fre- 
quently, if possible every day and occasionally twice a day, and the 
results obtained in such cases is graphically shown in Table III from 
Deming, page 789. 
As seen here, 8 of these patients received 4000 mg. hours or more 
with nothing more than slight irritation resulting. This effectually 
answers the criticism of those who advise against the use of radium 
in the rectum and urethra on account of burns. The technic must THE USE OF RADIUM IN CANCER OF THE PROSTATE 
791 
be intelligently carried out so as not to apply the radium twice in 
the same place. Fig. 392 shows most graphically the improvement 
obtained in one case. 
Although many of the 100 cases analyzed by Deming, as stated 
above, received very inadequate amounts of radium (05 receiving 
less than 1500 mg. hours, which has been shown to be too little to 
be of much value) the following Table IV shows the really remarkable 
effect upon the various symptoms presented by these patients. 
Table IV.—Improvement in Symptoms. 
Before treatment. 
Result of treatment. 
Symptoms. 
Percentage 
present. 
Percentage 
entirely 
relieved. 
Percentage 
improved. 
Percentage 
unimproved. 
Frequency . 
. . 96 
57.0 
25 
18.0 
Nycturia 
. . 95 
57.0 
25 
18.0 
Dysuria .... 
. . 80 
90.0 
— 
10.0 
Hematuria . 
. . 17 
100.0 
— 
— 
Hesitancy 
. . 65 
80.0 
7 
13.0 
Dribbling 
. . 76 
75.0 
5 
20.0 
Small stream 
. . 87 
74.0 
6 
20.0 
Complete retention 
. . 21 
95.0 
— 
5.0 
Residual urine . 
. . 61 
85.0 
12 
3.0 
Pain in back 
. . 28 
60.7 
— 
39.3 
Pain in extremities 
. . 22 
59.0 
— 
41.0 
Loss of weight . 
. . 14 
57.1 
- 
42.9 
Of these 100 cases, only 2 developed ulceration of the rectum, 1 
a recto-urethral fistula, but both were apparently cured by the radium 
treatment. “With the intensive treatment now used, no ulcerations 
have developed and the patient is able to tolerate 4000 mg. hours 
or more. Frequently the patient passes mucus and has from two 
to four stools a day with discomfort or tenesmus, but these symp- 
toms finally disappear. There have been no severe systemic reactions 
with nausea, vomiting or temperature.” Deming’s conclusions are as 
follows: 
1. Radium gave symptomatic relief and return of normal urination in 
75 per cent, of the cases. 
2. Radium relieved the pain in the back in 50 per cent, of cases suffering 
from metastases. 
3. Irritation from radium can be avoided by treating widely remote areas 
in successive treatments and by alternating between rectal, urethral, and 
vesical applications. 
4. At least 1000 mg. hours must be given to produce any symptomatic 
improvement. 
5. Fourteen hundred mg. hours must be given to produce any perceptible 
change in the tumor mass. 
6. Three thousand mg. hours must be given to produce symptomatic and 
local results in the same patient. 
7. Four thousand and 5000 mg. hours in a period of six to eight weeks 
should be given if possible, in addition to needle treatments of 500 to 2000 
mg. hours through the perineum. 
8. Cases which did not respond to radium did not receive sufficient radi- 
ation. 792 
CANCER OF THE PROSTATE 
9. Large doses must be given in as short a period as possible to produce 
maximum results. 
10. No general systemic reactions have been encountered. 
11. Combined extraglandular and intraglandular radiations apparently 
give the most satisfactory results. 
12. Thus far we have no actual proof that radium has produced an actual 
cure for cancer of the prostate and seminal vesicles, although 3 cases have 
remained free from symptoms and tumor growth for more than four years 
and many others show on rectal examination a condition of the prostate which 
does not now resemble cancer. 
Deming also made a very careful study of 33 eases in which the use 
of radium was combined with perineal prostatectomy, and I quote as 
follows: 
Histological Picture.—Study of the specimens removed at operation is 
the only method of deducing accurate conclusions regarding the effect of 
radium. 
The action of radium has been found to be of two kinds: (1) A gradual 
disappearance of the cancer tissue and the development of fibrous tissue and 
(2) necrosis. 
The gradual changes produced by radium have been well described by 
Young and Frontz24, and Alter. The effect of radium does not correspond 
in all cases to the amount of radium given. Some tissues show marked 
changes while others show little change that can be ascribed to radium. The 
periphery of the specimens naturally shows the first evidence of radiation. 
Different conditions of degeneration can be easily seen in many of the speci- 
mens, such as pyknosis of the nuclei, vacuolization, shrinking of the cyto- 
plasm, and in some cells a few poorly stained granules. Other cells show gran- 
ules taking very deep stain. Increase in fibrous tissue is a prominent factor 
in most of the sections. It is firm, the strands are packed tightly together 
and form a dense, hard tissue. Between some of the layers of fibrous tissue 
small darkly stained granules or outlines of a few cancer cells may be seen, 
indicating complete destruction of the cancer 'with development of fibrous 
tissue. 
In all the cases treated with extraglandular methods no necrosis of tissue 
was found. Whenever a change occurred it was a picture of gradual melting 
away of the cancer tissue and a development of fibrous tissue. One speci- 
men had been treated intraglandularly with two needles. Each needle con- 
tained 12| mg. of radium and was allowed to remain in position for twenty- 
four hours. The operation occurred two weeks later. Sections from this 
specimen showed necrosis of all the tissue within a radius of 4 mm. The 
connective tissue stroma as well as the cancer forms a necrotic area. No 
such areas have been seen in the other specimens although some received 
4000 mg. hours. 
The results obtained by operation plus radium are stated by 
Deming to be as follows: 
Four patients are alive and apparently well three years after operation. 
Twelve per cent, have an excellent result. Sixty-six per cent, are improved 
and 21 per cent, unimproved and still have difficulty in urination and pal- 
pable cancer of the prostatic tissue. Of the 33 cases, 51 per cent, have died 
within twenty-two months, the average being eleven months after operation. 
All had metastasis. Those cases in which good results were obtained received 
a combination of radium before operation, 2000 to 3000 mg. hours, and after 
operation, 1000 to 2000 mg. hours. Rectal examination two years after 
operation showed no return of carcinoma. THE USE OF RADIUM IN CANCER OF THE PROSTATE 
793 
A Method of Implantation into Prostate and Vesicles.—A recent 
patient who presented himself in November, 1921 (No. 10,109 B. U. I.) 
complained of no obstruction to urination, but although the carcinoma 
involved both seminal vesicles and the membranous urethra to an 
Fig. 393.—Implanting radium into prostate and seminal vesicles after exposure 
through perineum without opening urinary tract. Young’s long prostatic tractor used 
to draw down the prostate and vesicles. 
extent which made radical operation impossible, it seemed wise to 
do something more radical with radium than I had ever employed 
before. I therefore carried out the following procedure: The prostate 
was exposed as for perineal prostatectomy but with my long urethral 
prostatic tractor in the bladder to draw down the prostate, thus avoid- 794 
CANCER OF THE PROSTATE 
ing the necessity of opening the membranous urethra for this purpose. 
By blunt dissection the whole posterior surfaces of the seminal vesicles 
and the space between them were exposed, a good view being obtained 
by deeper retractors placed obliquely in the two lower angles of the 
wound which was a little longer than in the prostatectomy operation. 
Palpation showed it was possible to get well about the upward limits 
of the carcinoma on each side, and I then proceeded to insert with 
Fig. 394.—Diagram showing location of radium implantations, some superficial 
some deep in the prostate and left seminal vesicle. 
Fig. 395.—Prostate on rectal examina- 
tion before operation. Note triple degree 
of induration of left lobe of prostate and 
left vesicle. 
Fig. 396.—Condition found on rectal 
examination six months after treatment. 
Note complete disappearance of infiltra- 
tion in region of left vesicle and left lobe of 
prostate. 
needles small glass tubes, each containing 1 me. of radium emanation 
Fig. 393). These were placed so that all the needles would be 1 cm. 
apart, and an effort was made to cover the entire substance of the pros- 
tate, seminal vesicles, tissues between, as well as adjacent apparently 
uninfected tissues above and around the regions involved. About 
lb emanation points were thus used, the result being as shown in 
Fig. 394, in which it is difficult to show the depth to which some THE USE OF RADIUM IN CANCER OF THE PROSTATE 
795 
of the needles were placed. No portion of the prostate or seminal 
vesicles was excised as the patient at that time had no difficulty of 
urination. The wound was lightly packed with gauze and rubber 
protective so as to keep the radium-bearing area well away from the 
rectum, and the skin was closed with a small area for drainage. 
The results obtained are graphically shown in the two charts before 
operation and six months later (Figs. 395 and 39G). As seen here, the 
mass in the region of the seminal vesicles had completely disappeared 
and that in the prostate reduced to one-half its previous size, and the 
induration, except near the apex of the prostate, very greatly reduced. 
It is too early to predict the ultimate result. It should be mentioned, 
however, that urination became very difficult and catheterization was 
subsequently necessary for a time. More recently, the same plan has 
been carried out in 4 additional cases in all of which, on account of 
the presence of marked obstruction to urination, it was necessary 
to perform a prostatectomy. In these cases I exposed the regions 
well above the prostate and seminal vesicles on each side and inserted 
the radium into these regions before opening the prostate. Pros- 
tatectomy was then carried out and radium emanations were inserted 
into the remaining portions of the capsular and glandular tissue, 
the membranous urethra and the neck of the bladder, thus covering 
as completely as possible the regions invaded and tissues immediately 
adjacent. In 2 of these cases I also inserted 200 mg. hours of radium 
element into the urethra so as to radiate the remaining carcinoma 
from within, and removed these tubes of radium eight hours later. 
Here again, the results obtained are not yet evident as the cases are 
recent, but the immediate results have been good. 
In many other cases in which radium has been employed before 
or after prostatectomy, the amount of radiation given has been far 
less than that which has been described in the technic above and as 
a consequence, the results obtained are in many cases imperfect. 
In a recent paper Barringer1 presents a statistical study of 145 
cases of carcinoma of the prostate and gives again the technic which 
he employs. The prostatic needles which were introduced by Dr. 
Goeller of the Memorial Hospital staff are still used and he thinks 
are the most efficient and least painful method of destroying car- 
cinoma of the prostate. “A steel needle 10 to 15 cm. long of No. 18 
gauge is used. Fifty to 100 me. of radium are placed in the end 
(terminal centimeters) of the needle. Under local anesthesia, with 
a guiding finger in the rectum, the needle is inserted through the 
perineum into one of the lobes of the prostate. Then at the end of 
treatment for that lobe the needle is drawn from the prostate (not 
entirely out of the perineum) and inserted into the second lobe. A 
carcinomatous mass 2 cm. in diameter will stand an initial radium 
dose of from 300 to 400 me. hours of radium. This may be repeated 
in small doses in two or three months. We have in certain cases used 
smaller doses at shorter intervals (25 to 50 me. every week). But 
I have no evidence that this method does any more than the above.” 796 
CANCER OF THE PROSTATE 
The method of inserting radium into the seminal vesicles have 
been through the perineum but often through the rectum. “With 
a guiding finger in the rectum a small cannula is inserted up to the 
seminal vesicle. A needle is put through the cannula, and so into the 
vesicle.” The lower rectum has previously been cleansed with soap 
and water. 
Barringer has not found “bare tubes of radium unscreened” as 
satisfactory as the needle method. 
Barringer gives no analytical study or tables of all the cases that 
have been treated nor the results obtained but he cites among the 145 
cases treated, 4 remarkable cases, which have gone from three to five 
years after the first radium treatment, and have shown complete 
regression of the carcinoma. These 4 cases are worthy of special 
reference. 
Case I.—Very hard, fixed, irregular prostate, but no involvement 
of the seminal vesicles, was treated with one needle of 50 me. in each 
lobe of the prostate for six hours. Three months later 60 me. of 
radium by needle was placed for four hours in each lobe, and then 
one month later the right lobe was again treated with 30 me. for 
eight and a half hours. Three years later the left lobe with 64 
me. for six hours. On examination “five years and three months 
after first radium and two years and three months after last radium, 
the prostate and vesicles are normal and the patient is in excellent 
condition.” 
Case II.—Prostatectomy. Tissues show carcinoma microscopically. 
One month later 50 me. for eight hours in remains of prostate. At 
two months and three months radium treatments; but amounts not 
stated. Eight months from operation prostate irregular, nodular 
and carcinomatous. Additional radium treatments left vesicle and 
prostate. Examination “four years and three months after first 
radium and three years after last radium; patient in excellent con- 
dition, patient empties bladder, prostate feels normal.” 
Case III.—Prostatectomy. Specimen found microscopically to be 
carcinomatous. “Three months later 50 me. of radium for six hours 
in each lobe. Three months later 60 me. in each lobe for six hours. 
Nine months later 50 me. of radium for seven hours and then 15 me. 
of bare tube implanted in the right side of the prostate. This burned 
him considerably and was probably too large a dose.” Examination 
“four years after first radium and three years after last,” condition 
excellent, residual urine to 2 ounces, small hard area at apex of the 
prostate. Otherwise negative. 
Case IV.—“Very hard irregular carcinoma running into left vesicle 
and involving base of the bladder.” “Steel needle holding 95 me. 
of radium was placed in left prostate for four hours,” three years 
later “bare tube of radium placed in the vesicles” amount not stated. 
Examination “ three years and five months after first radium and one 
year after last radium, condition excellent, prostate feels absolutely 
normal.” THE USE OF RADIUM IN CANCER OF THE PROSTATE 
797 
In regard to the use of the bare tubes Barringer says it is a procedure 
not without danger as 1 patient died in two weeks after bare tubes 
were placed in the bladder neck, 3 cases with improvement in residual 
urine and urination are mentioned. 
Barringer employed the “Young Punch Operation” in 4 cases, in 
2 without success, in 1 the patient went from complete retention to 
1 to 2 ounces of residual urine, but died of renal infection. The 
fourth patient left the hospital emptying his bladder. 
Barringers conclusions are: “The results of radium treatment for 
carcinoma of the prostate are superior to operative removal both in 
causing regression of the disease and in coping with urinary retention.” 
Comment.—Considering the fact that Barringer’s reports cover a 
period of six years and the series of 145 cases, results are not, I believe 
very satisfactory with the exception of the 4 cases apparently cured, 
detailed above, which are really brilliant cases. Based on my experi- 
ence I am convinced that much can be accomplished, certainly by 
additional treatments through the rectum, urethra and trigone as 
detailed elsewhere, if care is used not to apply in the same place and 
thus avoid burns. 
In 1919, Herbst8 advocated implantation of radium-containing 
needles directly into the prostate through a suprapubic or a 
perineal wound. “Suprapubic cystostomv is made with a liberal 
opening in the bladder, bimanual examination is then made to 
determine the limits of the tumor, by means of a metal carrier, 
gold needles containing 12 me. of radium are inserted into the 
tumor mass 1 cm. apart in different directions. The tumor is con- 
verted into a pin cushion. A silk guide is attached to each needle 
and brought out the suprapubic wound, and at the end of twelve to 
fifteen hours the needles are removed by traction on the silk guide. 
One such exposure would usually cause the removal of most of the 
upper part of the tumor, although this can be repeated in a few weeks 
if found necessary. As most of the tumor begins in the lower part 
of the gland a second introduction of needles is made by making a 
dissection through the perineum and obtaining an exposure of the 
lower part of the prostatic mass. It is well to make the upper exposure 
first and the perineal four to six weeks later. The number of cases 
treated has been limited and the duration short.” 
One case was reported which had been subjected to prostatectomy 
and the tissues found malignant. The patient was treated by radium 
per rectum and urethram without results and then later seen by 
Herbst who found an irregular, hard, nodular mass in the region of 
the prostate with almost complete retention of urine. Through a 
suprapubic incision eight needles were inserted into the prostatic 
tumor about 1 cm. apart in different directions and allowed to remain 
twelve hours. There was practically no reaction. After six weeks 
the upper part of the mass had almost entirely disappeared. At 
this time a perineal section was made thoroughly exposing the lower 
part of the tumor and the needles were inserted, and allowed to remain 
in place for twelve hours; exact number of needles is not stated. 798 
CANCER OF THE PROSTATE 
Both suprapubic and perineal wounds healed in a few weeks. “After 
a few months all that could be palpated was a moderate degree of 
induration along the urethra. Recently examination showed only 
slight infiltration at the site of the tumor, he had gained in weight, 
looked well, had no residual urine, and his urinary function is good.” 
(Case probably followed about one year but results remarkably good.) 
Comment.—The method described by Herbst has the advantage 
of accuracy and ability to insert a large amount of radium over a 
large area. With the use of such large tubes (12 me. for twelve hours) 
the possibility of marked necrosis, particularly of the vesical mucosa 
is to be thought of. No subsequent report of cases and ultimate 
results has been made. 
Bugby2 makes a brief report detailing recent cases, in some of which 
the rectal, urethral, and vesical applications described elsewhere were 
employed, and also with radium needles which have been introduced 
through a suprapubic wound, which Bugby has found the most effec- 
tive, especially when combined with radium needles through the peri- 
neum and applicators introduced per rectum. 
Bumpus,34 in a report of 217 cases treated by radium, states that 
about GOO mg. hours represents the maximum safety in rectal appli- 
cations (which is to be explained by his use of the fenestrated bougie 
in making the rectal applications). 
Thirty-seven patients were treated by inserting needles directly into the 
gland through the perineum. The average dosage was approximately 2000 
mg. hours. Completed records of 27 patients show that they lived an average 
of fourteen months after treatment, and that the duration of the disease from 
the onset was forty-five months, slightly longer than the average for patients 
not treated. These poor results are explainable by the fact that by abandon- 
ing the rectal and urethral applications the periphery of the growth, where 
the greatest cell activity occurs, was not thoroughly irradiated. The needles 
were allowed to remain long enough in one location to destroy the malignant 
tissue immediately around them, but the tissue was only slightly affected 
beyond. The radium rays, like light, diffuse as they leave their source, and 
their effect diminishes progressively. Therefore, instead of stimulating 
fibrosis and hyalinization, the natural barriers of malignancy, destruction 
of only limited areas of malignant tissue had resulted. At the Memorial 
Hospital, New York, results of the work with buried emanation tubes have 
shown that 0.5 me. of emanation, when buried in tumor tissue, affects an 
area approximately 1 cm. in diameter, and that to increase this dosage to 
three or four times this amount does not increase the area irradiated appre- 
ciably, but causes marked destruction of cancer tissues with resulting necrosis. 
Each | me. emits 66 me. hours; this is equal to a needle containing 12§ mg. 
radium in place for five hours. Therefore, keeping needles containing 12| 
mg. in one position for from twelve to twenty-four hours causes localized 
necrosis and sloughing. The desired minimal dosage is obtained by leaving 
a needle bearing mg. of radium in one position for five hours, and then 
withdrawing it 12 mm., the length of the radium-bearing portion, in order 
to irradiate a second area 1 cm. in diameter. By using four needles at once 
and changing their position three times, twelve such areas, or twenty-four 
areas in two treatments, will be irradiated, affording approximately 1500 
mg. hours of irradiation. If to this, 600 mg. hours in the rectal exposure and 
400 mg. hours in the urethral exposure are added, the maximum of malignant THE USE OF RADIUM IN CANCER OF THE PROSTATE 
799 
tissue is affected. In this way it is possible to avoid the necessity of giving 
from 4000 to 5000 mg. hours of exposure, with the danger of slough and fistula 
formation, and the so-called radium reactions incident to heavy dosage, which 
are really due to absorption of the toxic necrotic tissue destroyed. It has 
been our experience that approximately 2500 mg. hours is the maximal dose 
that may be safely given, even in the largest glands, without producing sloughs. 
On the supposition that the poor results obtained from the use of rectal 
and urethral exposures alone, or from the use of needles alone, was attribu- 
table to the fact that not all of the cancer cells were reached by the radium 
emanations, the last 127 patients were treated by a combination of the three 
methods. The completed records of 83 patients show that the average dose 
of radium was 1960.45 mg. hours. Sixty patients (72.28 per cent.) are dead; 
they lived an average of eleven and a quarter months after treatment; 66 
per cent, died the first year. The duration of the disease in the patients 
who died (thirty-three and two-thirds months) is approximately the duration 
of the disease in the untreated patients; 23 (27 per cent.) are alive, the 
duration of the disease having increased to forty-seven and a third months, 
and the time since their last treatment to twenty months, an extension 
approximately of one year in each. 
Since only 8 of the 217 patients treated with radium are alive after three 
years, it will be seen that the results are far from satisfactory. However, 
the average extension of life for one year as a result of the combined method 
of administration is significant, and demonstrates that by careful selection 
of cases and care in irradiating all portions of the gland, better results may 
be expected in the future. The fact that 27 per cent, of the living patients 
are now in their third year after treatment, and that a number do not show 
evidence of malignancy either by palpation or any symptoms, while only 8 
per cent, of untreated patients survive to their third year, prevents the 
abandonment of this form of therapy. The results emphasize, however, 
that the treatment is applicable only to a selected few; to apply it to all patients 
with carcinoma of the prostate is to encourage false hopes and cause results 
disheartening to both patient and physician. 
The writer believes that Bumpus’ results show the greater value 
of my plan of applying radium through the rectum, urethra and 
bladder. The fear of radium burns per rectum which caused him to 
limit the rectal treatment to 600 mg. hours could have been obviated 
by the use of the fixation-clamp and special applicators. My cases 
receive generally three times as much radium per rectum (1800 mg. 
hours or more) without burns. 
The Use of Deep Roentgen-ray Therapy of High Voltage.—The treat- 
ment of metastases, particularly to the bones, often requires special 
attention. This is particularly true when it is associated with severe 
pain in the back, hips or extremities. In a few instances, massive 
doses of radium have been applied with some benefit, but recently 
Dr. C. A. Waters has treated some of my cases with deep roentgen- 
ray therapy, using about 200,000 volts, which is directed through 10 
or 12 limited portals of entry, each for a sitting of about one hour 
and on succeeding days, if possible. The reaction obtained is some- 
times considerable and prostration, loss in weight and diminution 
in hemoglobin is not infrequently very perceptible, showing the 
necessity of great caution and particularly the need of limiting the 
portals of treatment, especially where the intestines are exposed. 
Really extraordinary results in the relief of pain have been secured 800 
CANCER OF THE PROSTATE 
in some of my cases, and it seems justifiable to predict that great 
advances will be made with the use of the roentgen ray, and perhaps 
by a combination with radium even better results than those now 
obtained will be secured. There is no literature on ray treatment 
of cancer of the prostate that I know of. 
Resume.—The present situation as regards the treatment of cancer 
of the prostate may be summarized as follows: (1) Where the car- 
cinoma is sufficiently early for the radical operation, the chances of a 
cure are excellent, probably over 70 per cent, with good functional 
results. In later stages, the use of radium alone in the form of emana- 
tion points, 1 me. each, and implanted into the surface of the prostate 
and seminal vesicles and adjacent uninvaded tissues, promises splendid 
results, possibly as radical as the complete resection. (2) The use 
of radium through the rectum, urethra and trigone has given extra- 
ordinary results both in the relief of symptoms and disappearance 
of tumor mass. If possible, over 3000 mg. hours should be given in 
a series of daily treatments, and often no further treatment will be 
indicated. Unless hypertrophy of the prostate is present, more or 
less complete disappearance of obstructive symptoms may be expected, 
and in some cases with moderate prostatic hypertrophy, fairly normal 
urination may be established. (3) Cases with considerable prostatic 
hypertrophy or with more or less complete retention of urine will 
usually require prostatectomy; but these cases should either be pre- 
ceded by a full treatment with radium before operation or by radium 
emanation needles or large amounts of radium element at operation, 
to be followed later by additional radium after operation. In such 
cases, by either partial or subtotal prostatectomy, extraordinary 
results both as to cure of symptoms and disappearance of tumor mass 
are sometimes obtained. The use of needles has been shown by 
Barringer to be of great potency and some extraordinary results have 
been obtained. The effect is most evident around the needles where 
marked necrosis is often obtained; and I believe a combination of 
rectal and urethral applications and perineal needles should usually 
be carried out, but, as yet, the limits as regards methods to have not 
been adequately studied. 
In conclusion, it is safe to say that with radium already extra- 
ordinary results have been obtained in carcinoma of the prostate, 
and with the advent of the roentgen-rav treatment by deep therapy 
with huge voltages, it is possible that still further results of far-reaching 
prominence may be obtained. The whole subject is in its infancy 
and the future is very bright. 
BIBLIOGRAPHY. 
1. Barringer, D. S.: Carcinoma of the Prostate, Surg., Gynec. and Obst., February, 
1922, vol. xxxiv, No. 2. 
2. Bugbee, H. G.: Experiences with Radium in Cancer of the Prostate, Jour. Urol., 
December, 1921, vol. vi, No. 6. 
3. Bumpus, H. C.: Radium in Cancer of the Prostate, Jour. Am. Med. Assn., 
May 6, 1922. BIBLIOGRAPHY 
801 
4. Bumpus, H. C.: Carcinoma of the Prostate (a Clinical Study), Surg., Gynec. 
and Obst., 1921, xxxii, 31-43. 
5. Chute, A. L.: Some Aspects of Cancer of the Prostate, Boston Med. and Surg. 
Jour., October 27, 1921. 
6. Deming, C. L.: Results in One Hundred Cases of Cancer of Prostate and 
Seminal Vesicles, Treated with Radium, Surg., Gynec. and Obst., January, 1922. 
7. Geraghty, J. T.: Treatment of Malignant Disease of the Prostate and Bladder, 
Jour. Urol., January, 1922, vol. vii, No. 1. 
8. Herbert, R. H.: Cancer of the Prostate (a Combined Surgical and Radium 
Method of Treatment), Jour. Am. Med. Assn., May 31, 1919. 
9. Hinman, Frank: Newer Methods for Radium Treatment of Prostatic and 
Vesical Cancer, Jour. Am. Med. Assn., June 21, 1919. 
10. Judd, E. S., Bumpus, H. C., Jr., Scholl, A. J., Jr.: Prognosis in Cases of Car- 
cinoma of the Prostate Discovered at Operation, Surg. Clin. North America, Phila- 
delphia, 1921, i, 1279-1290. 
11. Kolischer, Gustav: Diathermy in the Treatment of Carcinoma of the Prostate 
and Bladder, Jour. Urol., September, 1922, vol. viii, No. 3. 
12. Young, Hugh H.: The Early Diagnosis and Radical Cure of Carcinoma of 
the Prostate, Johns Hopkins Med. Bull., 1905, vol. xiii. 
13. Young, Hugh H.: The Early Diagnosis and Radical Cure of Carcinoma of 
the Prostate, Johns Hopkins Hosp. Rep., 1906, xiv, 485-628. 
14. Young, Hugh H.: The Early Diagnosis and Radical Cure of Carcinoma of 
the Prostate; a Study of 50 Cases and Presentation of a Radical Operation, Jour. 
Am. Med. Assn., 1906, vol. xlvi. 
15. Young, Hugh H.: Cancer of the Prostate; a Clinical, Pathological and Post- 
operative Analysis of 111 Cases, Ann. Surg., 1909, pages 1144-1233. 
16. Young, Hugh H.: The Ultimate Results of Prostatectomy, Trans. Int. Assn. 
Urol., London, 1912. 
17. Young, Hugh H.: The Diagnosis and Treatment of Early Malignant Disease 
of the Prostate, Trans. Int. Cong. Med., 1913, London, 1914; also Am. Jour. Urol., New 
York, 1914, x, 251-292. 
18. Young, Hugh H.: Keen’s Surgery, vols. vi, vii, viii. 
19. Young, Hugh H.: Cabot’s System of Urology, 1st edition, vol. i. 
20. Young, Hugh H.: Preliminary Treatment for Prostatectomy in Unfavorable 
Cases, Jour. Am. Med. Assn., February 17, 1917, vol. Ixviii. 
21. Young, Hugh H.: Carcinoma of Prostate, Jour. Am. Med. Assn., November 
10, 1917, vol. Ixix. 
22. Young, Hugh H.: Use of Radium in Cancer of the Prostate and Bladder, Jour. 
Am. Med. Assn., April 21, 1917, vol. Ixviii. 
23. Young, Hugh H.: The Use of Radium and the Punch Operation in Desperate 
Cases of Enlarged Prostate, Ann. Surg., May, 1917. 
24. Young, Hugh H., and Frontz, Wm. A.: Some New Methods in the Treatment of 
Carcinoma of the Lower Genito-urinary Tract with Radium, Jour. Urol., vol. i, No. 6. 
25. Young, Hugh H.: Technic of Radium Treatment of Cancer of the Prostate and 
Seminal Vesicles, Surg., Gynec. and Obst., January, 1922. CHAPTER XX. 
SARCOMA OF THE PROSTATE. 
By HUGH HAMPTON YOUNG, M.D. 
The first case of sarcoma of the prostate was described by Stafford 
in 1839, a melanotic tumor in a child five years of age. In 1858, 
Thompson found 6 cases in the literature, and in 1902, Burckhardt was 
able to collect 24 cases. Proust and Vian, in 1607, published 34 
“incontestable” cases, and in 1909 Gibson collected reports of 37 cases. 
Parmenter, who has made the latest full report on this subject, was 
able to find 59 cases in 1917. In 1920 Quinby reported an additional 
case, corroborated by operative and pathological findings. 
In the first edition of this system of urology I reported 1 case and 
analyzed 35 cases which I found in the literature as follows: 
Age.—In the 35 cases in which the diagnosis has been confirmed by 
the microscope, 15 were under ten years of age; 12 were between ten 
and forty-nine years of age, and 8 were between fifty and eighty years 
of age. In 4 cases the patient was less than a year old and three 
patients were between seventy and seventy-three years of age. 
Various types of sarcoma have been present, viz., small cell, C; large 
cell, 3; spindle cell, 5; polymorpho cell, 4; lymphosarcoma, 2; angio- 
sarcoma, 2; myxosarcoma, 3; adenosarcoma, 1; chondrosarcoma, 1; 
“rhabdomyoma,” 3; “fibroid,” 1. 
The tumor soon reached considerable size and in some places almost 
completely filled the pelvis. It wras usually oval in form, regular or 
slightly lobulated, but occasionally irregular and nodular. The con- 
sistence was variable, sometimes firm, sometimes elastic, sometimes so 
soft as to give the sensation of fluctuation. In many cases, however, 
the induration was considerable. The bladder was generally pushed 
upward and forward by the tumor, which grew backward beneath the 
base of the bladder. The mucous membrane was generally intact, but 
occasionally small papillomatous intravesical outgrowths were present, 
almost always in the region of the trigone. The rectum was usually 
compressed, flattened, but its walls were rarely infiltrated and the 
mucous membrane was healthy in all cases. The urethra was almost 
always invaded and generally strictured. Occasionally intra-urethral 
polyps were present. The seminal vesicles have generally been found 
involved. The perirectal and retroperitoneal tissues were often 
invaded, as were also the peritoneum, the intestines and the pelvic 
bones. The lymph glands were involved in 7 of the 35 cases, but 
metastases elsewhere occurred more frequently. 
That sarcoma of the prostate is a rare disease is shown by the fact 
802 SARCOMA OF THE PROSTATE 
803 
that only 1 case has been detected among the immense number of cases 
seen at the Hopital Necker in Paris. I have personally had 1 case in 
which the diagnosis of sarcoma of the prostate was positively made by 
microscopical examination, but in our service there have been 3 cases in 
which a clinical diagnosis of sarcoma has been made. My patient, a 
man, aged fifty-one years, had suffered with pain in the lower abdomen 
and rectum for fourteen months. Urinary trouble had been present for 
six months, but had only recently become marked. On rectal examina- 
tion an immense smooth mass, which almost filled the pelvis, was felt. 
It was very soft and homogeneous to the touch and almost completely 
obliterated the rectum. Only 40 c.c. residual urine was present. Per- 
ineal prostatectomy was performed and the tumor found to spring from 
the upper portion of the prostate, the anterior two-thirds of which was 
apparently normal. The urethra and bladder were not invaded, but 
the latter was greatly elevated by the huge retrovesical mass. The 
tumor was composed of soft hemorrhagic material which was easily 
scooped out with the finger. The patient recovered and was able to 
void urine without difficulty and lived for almost a year. The micro- 
scope showed a sarcoma of mixed-cell type. 
Symptoms.—Proust has divided his study into those of early age, 
24 cases, and those of advanced age, 10 cases. Among these of early 
age the first symptom was usually pain, and this did not come on until 
obstruction to urination developed. Constipation was often present. 
In most cases the tumor had reached great size before any symptoms 
were present. Among those patients older than thirty years of age the 
development was slower. In rare cases sudden retention of urine 
occurred, but often there was very little obstruction to either urine or 
feces. At times, owing to its softness, it is difficult to differentiate from 
abscess. In the adult, sarcoma of the prostate is generally more 
irregular than hypertrophy, produces less lengthening of the canal and 
is more infiltrated. Sarcoma is less often accompanied by hematuria 
than carcinoma, which is usually much harder and characterized by 
indurated prolongations into the region of the seminal vesicles. In my 
case the consistence was much softer than is ever seen in simple hyper- 
trophy, and the immense, smooth, globular mass could never have been 
mistaken for carcinoma. 
Treatment.—In young patients operations have been absolutely 
unsuccessful. In the adult the results have not been brilliant, but 
several cases in which the patient was relieved for a considerable period 
are on record. Spanton, in 1882, enucleated through the perineum a 
very large sarcoma of the prostate, but the patient died on the following 
day. In 1894 Socin removed a tumor the size of two fists through the 
anus and rectum, without injury of the urethra or bladder. The 
rectum was then sutured. The patient showed no evidence of recur- 
rence for three years. Verhoogen, in 1898, extirpated the prostate with 
its capsule and urethra after division of the membranous urethra. The 
patient died later of a recurrence of the sarcoma. McGowan reported 804 
SARCOMA OF THE PROSTATE 
Owing to the fact that sarcoma of the prostate generally begins in the 
upper portion of the posterior part of the gland and rapidly involves 
the capsule and retrovesical structures, it seems probable that radical 
measures can never be as successful as in cancer. Sarcoma may remain 
encapsulated, as in Socin’s case, and a complete extirpation through 
the perineum may be possible. The suprapubic route will probably 
not be available, owing to the retrovesical character of the growth. 
Suprapubic drainage may be necessary in some cases. 
In general it would seem probable that operative intervention in 
cases of sarcoma of the prostate which are extensive enough to be 
diagnosed clinically should be limited to the relief of obstruction or 
to the treatment of complications, such as abscess formation. 
Radium Treatment.—Since the introduction of radium in the treat- 
ment of malignant disease it would seem that the prognosis in cases 
of sarcomatous disease of the prostate would be more favorable, 
especially as it has been the general impression of those who have 
had large experience in the radium treatment of malignant disease 
that sarcoma is more susceptible than carcinoma to the effect of 
radium. 
A case in which a clinical but unquestionable diagnosis of sarcoma 
was made, has been treated in our clinic. The tumor disappeared 
rapidly under rectal, intra-urethral and intravesical applications and 
the patientis now, after five and a half years, in excellent health 
and no evidence of tumor or of metastases can be made out. 
B. U. I.-5664, E. G. C., aged forty-one years,was seen in January, 
1917, complaining of pain and frequency of urination. The history 
was unimportant except for an attack of gonorrhea at the age of nine- 
teen years, which cleared up in two months without any complications 
and without evidence of involvement of the prostate. Increasing 
frequency and difficulty had been noticed for about a year and during 
the past few weeks the urine had been blood-stained. The patient 
had lost 20 pounds. 
General physical examination was negative and the external genitalia 
were normal except for a left varicocele. The urine contained red 
cells, white cells and a few bacilli but no tubercle bacilli. 
On rectal examination a large irregular mass was felt in the region 
of the prostate and extending upward in the direction of the vesicles 
and retrovesically as far as the finger could reach. This was firm 
in some portions, soft and semi-fluctuating in others but no areas of 
stony hardness were made out and it did not suggest a prostatic 
abscess. 
On cystoscopic examination the bladder was quite irritable. 
The mucosa just inside the prostatic orifice was reddened, elevated 
in the form of bullous like projections and seemed definitely infil- 
trated with tumor. The mucous membrane was elsewhere normal. 
The patient was given 1100 mg. hours of treatment per rectum and 
400 mh intra-urethrallv and intravesically by I)r. J. A. C. Colston. 
The response in this case was much quicker than in cancer. TREATMENT 
805 
On discharge six weeks later the patient was quite free from symp- 
toms and the outlines of the prostate could now be made out per rectum, 
slightly larger than normal and surrounded everywhere by rather 
dense adhesions Cystoscopic examination showed a normal bladder 
except for moderate congestion about the prostatic orifice. 
Four years later the patient returned for observation—entirely 
free from symptoms. The prostate was quite normal except for 
moderate induration of the lateral lobes and periprostatic and peri- 
vesicular adhesions. The great tumor mass in the region of prostate 
and vesicles had completely disappeared. The age of the patient 
(forty-one), the soft nature of most of the tumor and its great size 
make the diagnosis of sarcoma positive. This is the first case of 
apparent cure of sarcoma of the prostate to be reported, and the 
brilliant result obtained would seem to hold much promise for the 
future in the treatment of sarcoma of the prostate with radium. 
The technic is the same as that for cancer given in the preceding 
chapter—100 mg. screened with platinum and gutta percha is applied 
alternately through the rectum, urethra and bladder so as to cover 
well the area of the tumor and adjacent tissues. As a rule much more 
radium treatment than was given in our case should be applied, the 
same care being taken not to apply twice in the same place and to 
fix the applicator in the proper place with the fixation-clamp. If 
possible at least 3000 mh should be given, and to prevent metastases 
deep radiotherapy of the body may be desirable. O. II., second case 
which has just completed a course of radium applications has now 
after 1200 mh per rectum, 200 mh per urethram and 200 mh per 
vesicam, no evidence of the tumor which was as large as a big apple 
and almost completely obliterated the rectum. lie subsequently had 
two full courses of deep roentgen-ray therapy, about twenty hours in 
all, and on examination nine months later no evidence of malignancy 
could be made out. CHAPTER XXI. 
CALCULUS DISEASE OF THE PROSTATE. 
By HUGH HAMPTON YOUNG, M.D. 
Prostatic calculi may be divided into two groups, on account of their 
origin and location: (1) Calculi which lodge in the prostatic urethra, 
having escaped from the kidney, bladder, or seminal vesicles, and the 
small group of cases in which the stone is primarily formed in the pos- 
terior urethra. (2) Calculi which are formed in the substance of the 
prostate gland, the true prostatic calculi. This second group is entirely 
distinct in origin and nature from the urinary calculi. 
On account of the intimate relation existing between corpora amy- 
lacea and prostatic calculi, it is necessary to consider the former before 
taking up the subject of true prostatic stones. 
Etiology.—This is uncertain, as is the case with calculi elsewhere. 
Various authors have ascribed to corpora amylacea a causative influ- 
ence. According to Thompson, corpora amylacea, having attained the 
size of their inclosing follicle, act as foreign bodies, and in consequence 
of the general law that all mucous membranes when sufficiently irri- 
tated throw out a deposit of calcium phosphate and carbonate, ulti- 
mately form calculi. The amount of earthy matter varies from 45 
per cent, in the concretion to 85 per cent, in the calculus. The number 
of calculi present may vary from one to several hundred. They are 
generally a little less than that of a barley-seed in diameter, but they 
may range in size from 2 mm. to 3 or 4 cm. 
Symptoms.—Stones deeply embedded in the gland cause, as a rule 
but slight disturbance, and the gland may be filled with stones and yet 
no marked symptoms occur. Irritability of the bladder and pain are 
sometimes present. Frequency or hesitancy of urination is seen oftener 
than initial or terminal hematuria, the latter being much more constant 
and characteristic in the case of vesical stone. Retention or incon- 
tinence occurs especially if stones are located in the middle lobe. Occa- 
sionally the genital symptoms are marked; testicular pain, frequent 
ejaculations, feeble erections and a condition of semipriapism having 
been noted in different cases. Rectal palpation in the early stages may 
disclose an enlarged but not indurated gland. When the calculi are not 
near the posterior surface, the gland is smooth and regular; as the 
stones approach the periphery it becomes irregular and the hardness 
may be very marked. When two or more stones are in contact, 
crepitus may be elicited. It may be absent, however, even when a 
great many stones are present. When the stone is in communication 
with the urethra, a sound will give crepitus, and considerable additional 
806 TREATMENT 
807 
advantage is obtained by the simultaneous rectal palpation with the 
finger. If a rectal or perineal fistula exists, the passage of a probe 
through it frequently leads to the stone. With the cystoscope or the 
urethroscope the calculus can sometimes be seen and the roentgen-ray 
has been used with considerable advantage. 
Fig. 397.—Lateral capsular incisions have been made, the calculi which are found 
in the stratum between the lateral hypertrophied lobes and the posterior portion of 
the prostate being removed. 
Fig. 398.—The lateral lobes have been removed and the median lobe has been partially 
separated, exposing calculi beneath it. 808 
CALCULUS DISEASE OF THE PROSTATE 
The complications occasioned by prostatic stone are, briefly: abscess, 
fistula, prostatic hypertrophy, incontinence or retention of urine, sexual 
disorders, including deferentitis and epididymitis. 
Treatment.—When the stone communicates with the prostatic ure- 
thra, it may be removed through the bladder by suprapubic cystotomy. 
In cases where the stone is more or less completely embedded in the 
prostatic substance the suprapubic route is contraindicated. The 
perineal route is preferable in most cases. The prostate should be 
exposed as for a perineal prostatectomy, and opened either upon a 
grooved staff or upon a prostatic tractor which has previously been 
inserted. In young patients the calculi are usually not great in number 
and it is not necessary to remove gland tissue. The multiple seed cal- 
culi which are found scattered throughout the gland are almost always 
associated with prostatic hypertrophy or obstructive prostatitis, and 
prostatectomy is indicated, being the simplest way of removing the 
calculi. Figs. 392 and 393 were made from a recent case of multiple 
calculi of the prostate associated with slight hypertrophy and show 
very graphically and completely the operative removal of the calculi 
through bilateral capsular incisions through which the lateral and 
median lobes are also removed. 
Kretschner has recently added a splendid article to the literature 
of the subject. 
BIBLIOGRAPHY 
Conforti, G., and Favento, P.: II Sarcoma della Prostata, Folia Urologica, 1907- 
OS, i, 180. 
Coupland, S.: Lymphoma (Lymphosarcoma) of the Prostate; Secondary Nodules 
in Pancreas and Suprarenal Capsule, Trans. Path. Soc., London, 1877, xxviii, 179. 
Gibson, Charles L.: Sarcoma of the Prostate, Trans. Am. Assn. Genito-Urinary 
Surgeons, 1909, iv, 107. 
Kaufmann, E. (in Socin and Burckhardt): Die Verletzungen und Krankheiten der 
Prostata, Deutsch. Chir., 1902, p. 395. 
Parmenter, F. J.: Sarcoma of the Prostate, Surg., Gynec. and Obst., 1917, xxiv, 336. 
Quinby, W. C.: Lymphoblastoma (Lymphosarcoma) of the Prostate, Jour. Urol., 
1920, vol. iv, No. 2. 
Young, Hugh H.: Surgery of the Prostate, Keen’s Surgery, vols. vi-viii. 
Young, Hugh H.: Carcinoma of the Prostate, Cabot’s Urology, edited by Hugh 
Cabot, vol. i, 1st edition. 
Young, Hugh H.: Cancer of the Prostate, Johns Hopkins Hosp. Repts., vol. xiv. INDEX TO VOLUME I. 
A 
Abnormalities of scrotum, 479 
Abscess, peri-urethral, anterior gonor- 
rheal urethritis and, 329 
stricture of female urethra and, 
394 
prostatic, acute posterior gonor- 
rheal urethritis and, 331 
gonorrheal stricture of urethra 
and, 422 
of scrotum, 482 
suburethral, acute gonorrheal ure- 
thritis in female and, 409 
Absence of penis, 197 
of urethra in female, 379 
Acriflavine in treatment of gonorrheal 
urethritis, 341 
Actinomycosis of penis, 243 
Acute early syphilitic nephritis, 180 
parenchymatous syphilitic nephritis, 
180 
Adenitis, inguinal, 295 
etiology of, 295 
pain in, 295 
symptoms of, 295 
treatment of, 296 
palliative, 296 
prophylactic, 296 
surgical, 296 
Adenocarcinoma of scrotum, 490 
Andrew’s “bottle” operation for hydro- 
cele, 501 
Anemia in acute parenchymatous syphil- 
itic nephritis, 183 
Anesthesia in cystoscopy, 32 
in gonorrheal stricture of urethra, 
428. 
local, in instrumental examination of 
urethra, 85 
Anorchism, 460 
Anterior urethra, infiltrations of, ure- 
throscopy and, 60 
operative urethroscopy in, 70 
pathological, urethroscopic pic- 
ture of, 60 
Antigonococcus serum in treatment of 
gonorrheal urethritis, 354 
Arsphenamine in acute parenchymatous 
syphilitic nephritis, 185 
in treatment of chancre, 265 
Arteries of penis, anatomy of, 193 
Aspiration in treatment of hydrocele, 500 
Atrophy of testicle, 460 
Autogenous vaccines in treatment of 
gonorrheal urethritis, 354 
Autoserotherapy in treatment of hydro- 
cele, 498 
B 
Bacteriology of balanitis, 276 
Balanitis, erosive and gangrenous, 276 
bacteriology of, 276 
chills in, 281 
definition of, 276 
diagnosis of, 281 
edema in, 281 
etiology of, 276, 278 
fever in, 281 
pathology of, 278 
symptoms of, 280 
treatment of, 282 
Balanoposthitis, acute anterior gonor- 
rheal urethritis and, 330 
Beck’s operation for hypospadias, 200, 
206 
Bevan’s operation for undescended tes- 
ticle, 468-471 
Bladder, calculus of, diagnosis of, from 
obstruction of prostate, 652 
cancer of prostate and, 746 
in genital tuberculosis, 561 
gonococcal infection of, 363 
obstruction of, in diagnosis of 
urinary tract lesions, 112 
suprapubic drainage of, in obstruc- 
tion of prostate, 699 
syphilis of, 146 
pathology of, 167 
secondary, 150 
age in, 167 
cystoscopy in, 167 
tertiary, 152 
age in, 168 
cystoscopy in, 169 
diagnosis of, 169 
hematuria in, 168 
pain in, 168 
pollakiuria in, 168 
spinal cord affections sim- 
ulating, 170 
symptoms of, 168 
treatment of, 170 
tabetic, 170 
809 810 
INDEX 
Bladder, tabetic, diagnosis of, 175 
cystoscopic findings in, 176 
prognosis of, 177 
treatment of, 178 
tumors of, diagnosis of, from ob- 
struction of prostate, 651 
ulcers of, excision of, cystoscopy 
and, 57 
Bloodvessels of penis, diseases of, 241 
Bony formations of penis, 241 
Bottini’s electrocautery operation in 
cancer of prostate, 776 
Bougie catheter, 645 
in gonorrheal stricture of urethra, 
425, 428 
Bubo, inguinale, etiology of, 295 
pain in, 295 
symptoms of, 295 
treatment of, 296 
palliative, 296 
prophylactic, 296 
surgical, 296 
Buerger’s catheterizing cystoscope, 27 
baby, 30 
children, 30 
modified, 29 
cysto-urethroscope, 378 
operating cystoscopes, 48, 49 
combination, 49 
modified, 49 
radium, 49 
Bulbous urethra, urethroscopic picture 
of, 66 
Burns of penis, 236 
C 
Cabot’s operation of resection of urethra 
in gonorrheal stricture, 441 
Calculi, removal of, cystoscopy and, 56 
of scrotum, 484 
urethral, descent of, dilatation of 
ureters and, 55 
diagnosis of, by wax-tipped 
catheters, 53 
Calculus of bladder, diagnosis of, from 
obstruction of prostate, 652 
disease of prostate, 806 
etiology of, 806 
symptoms of, 806 
treatment of, 808 
of urethra in female, 386 
Cancer, chimney-sweeps, 489 
of prostate, 725. See Prostate, 
cancer of. 
Carcinoma of penis, 245 
diagnosis of, 246 
phimosis and, 245 
symptoms of, 246 
treatment of, 246 
of prostate, 725. See Prostate, can- 
cer of. 
of scrotum, 490 
stricture of urethra and, 446 
of urethra in female, 392 
Cartilaginous formations of penis, 241 
Caruncle of urethra in female, 388 
Castration in cancer of prostate, 776 
Catarrhal prostatitis, pathology of, 325 
Catheter-life in cancer of prostate, 738 
Catheter-trauma of urethra in female, 
383 
Catheterization in cancer of prostate, 777 
of ureters, 42, 90 
cystoscopy in, direct, technic 
of, 46 
indirect, technic of, 42 
endoscopes in, 48 
lack of drainage after, 92 
obstructions in, 91 
Catheterizing cystoscopes, 26 
and operating, 30 
Buerger’s, 27 
baby, 30 
children, 30 
modified, 29 
composite, 30 
direct, 27 
indirect, 27 
universal, 30 
Catheters, bougie, 645 
de Pezzer, 683 
Pilcher’s modification of, 683 
Mercier biconde, 645 
conde, 645 
soft rubber, 645 
Cautery in treatment of caruncle of 
urethra in female, 389 
Cavernositis, acute, anterior gonorrheal 
urethritis and, 330 
etiology of, 240 
symptoms of, 240 
chronic, 240 
etiology of, 241 
symptoms of, 241 
treatment of, 241 
diffuse, 240 
of penis, acute, 240 
Cellulitis of scrotum, 482 
Chafing of scrotum, 480 
Chancre, 248 
chancrous erosions, 252 
ulcerations, 252 
classification of, 251 
anatomical, 251 
clinical, 251 
definition of, 248 
diagnosis of, 254 
cell count, in, 261 
dark-ground illumination in, 
254 
Nernst lamp in, 255 
Reichert apparatus for, 255 
differential, 262 
from scabies, 262 
materials for, obtaining of, 256 
preparation of, 256 
Noguchi butyric acid test in, 
262 
Ross-Jones modification of 
Nonne test in, 262 INDEX 
811 
Chancre, diagnosis of, spinal fluid exam- 
ination in, 261 
staining methods in, 257 
Giemsa’s, 257 
Levaditi’s, 258, 259 
Wassermann reaction in, 260 
endo-urethral, 139 
discharge in, 139 
etiology of, 248 
induration in, 139 
pain in, 139 
symptoms of, 139 
hard, 248 
histology of, 250 
Hunterian, 248 
incubation in, 251 
indurated papule in, 252 
Hunterian, 252 
parchment, 252 
of meatus, 138 
symptoms of, 139 
pain in, 252 
pathology of, 250 
prognosis of, 263 
prophylaxis in, 263 
redux, 267 
soft, 289 
Spirochseta pallida in, 248 
synonyms of, 248 
treatment of, 263 
arsphenamine in, 265 
Corbus’s intravenous appara- 
tus in, 266 
excision in, 263 
general, 263 
local, 263 
Chancroid, 289 
complications of, 294 
definition of, 289 
diagnosis of, 292 
Ducrey-Unna bacillus and, 290 
etiology of, 289 
exciting, 290 
predisposing, 289 
location of, 292 
mixed sore in, 292 
pain in, 290 
paraphimosis and, 294 
pathology of, 290 
phagedena and, 294 
treatment of, 294 
phimosis and, 294 
sequel* of, 295 
stricture of urethra and, 446 
symptoms of, 290 
synonyms of, 289 
treatment of, 293 
Chancrous erosions, 252 
ulcerations, 252 
Chills in balanitis, 281 
Chimney-sweeps’ cancer, 489 
Chordee, 328 
Churchman’s operation for hypospadias, 
209 
Chylocele, 507 
diagnosis of, from hydrocele, 497 
Chylocele, treatment of, 507 
Circumcision, tuberculosis of penis and, 
242 
Cleft penis, 198 
Colling’s suspensory treatment of gonor- 
rheal epididymitis, 358 
Complement-fixation test, 319 
and lesions of urinary tract, 107 
cases used in, 321 
in chronic anterior gonorrheal 
urethritis, 334 
gonorrheal prostatitis, 336 
effect of vaccines in, 322 
practical value of, 322 
time of appearance, 322 
of disappearance, 322 
weakly positive, 322 
Composite catheterizing cystoscope, 30 
Concealed penis, 197 
treatment of, 197 
Congenital hydrocele, 505 
malformations of penis, 194 
phimosis, 230 
treatment of, 232 
stricture of urethra in female, 444 
Contusions of penis, 225 
treatment of, 226 
Corbus’s intravenous apparatus in treat- 
ment of chancre, 266 
Corpora cavernosa, anatomy of, 189 
Corpus Highmori, 452 
spongiosum, anatomy of, 191 
Cowperitis, acute posterior gonorrheal 
urethritis and, 331 
pathology of, 325 
Cowper’s glands, anatomy of, 309 
Cryptorchism, diagnosis of, from tumors 
of testicle, 593 
Cutaneous diseases of scrotum, 480 
Cylindroid syphiloma of urethra, 142 
Cystic bodies, operations on, cystoscopy 
and, 57 
Cystitis, acute gonorrheal urethritis in 
female and, 408 
with urinary stasis in prostatic 
obstruction, treatment of, 653 
Cystoscopes, 22 
catheterizing, 26 
and operating, 30 
Buerger’s, 27 
baby, 30 
children, 30 
modified, 29 
composite, 30 
direct, 27 
indirect, 27 
universal, 30 
classification of, 22 
direct, 17, 23 
Elsner-Braasch, 31 
indirect, 25 
Kelly’s, 379 
Nitze, 20 
Nitze-Albarran, 27 
operating, Buerger’s, 48, 49 
combination, 49 812 
INDEX 
Cystoscopes, operating, Buerger’s modi- 
fied, 49 
radium, 49 
Otis-Brown-Nitze, 26 
prismatic, 25 
selection of, 75 
Cystoscopic accessories, 32 
anesthesia, 32 
lighting apparatus, 32 
lubricants, 33 
solutions, 33 
sterilization, 32 
syringes, 33 
table, 32 
ureteral catheter, 33 
findings in tabetic bladder, 176 
Cystoscopy, direct, in catheterization 
of ureters, 46 
in diagnosis of urinary tract lesions, 
88 
contra-indications to, 
89 
indications for, 88 
prostatism and, 89 
urine segregation and, 
90 
indirect, in catheterization of ure- 
ters, 42 
introduction of instrument in, 34 
observation, principles of, 38 
induced movements of 
field, 39 
light, 41 
magnification, 40 
problem of sphincter, 40 
relation of field and cysto- 
scope, 39 
technic of, 35 
routine of inspection, 36 
in obstruction of prostate, 646 
dangers of, 649 
technic of, 646 
value of, 649 
operative, 48 
catheterization and, 54 
diagnosis of ureteral calculi by 
means of wax-tipped cathe- 
ters, 53 
dilating ureters and facilitating 
descent of ureteral calculi, 
55 
excision of ulcers and, 57 
exploratory excision and, 57 
high-frequency treatment of 
tumors and, 55 
intravesical biopsy and, 57 
methods in, 53 y 
operations on cystic bodies and, 
57 
on ureterocele and, 57 
removal of calculi and, 56 
of foreign bodies and, 56 
of phosphatic encrusta- 
tions and, 56 
snaring of papilloma and, 57 
technic of, 52 
Cystoscopy, operative, technic of, with 
recessive type of instru- 
ment, 53 
with scissors type of in- 
strument, 53 
ureteral meatotomy and, 56 
preparation for, 34 
in syphilis of bladder, 167, 169 
Cystostomy, suprapubic, in obstruction 
of prostate, 679 
technic of, 681 
Cysto-urethroscopes, Buerger’s, 62, 378 
Goldschmidts, 62 
McCarthy’s close vision, 378 
operating, 70 
application of, 70 
Buerger’s universal, 71 
in paralytic conditions of 
sphincter, 72 
selection of, 75 
technic of, 70 
Cysto-urethroscopy, 61 
technic of, 62 
Cysts of penis, dermoid, 244 
epithelial, 244 
of scrotum, sebaceous, 482 
of urethra in female, 390 
D 
Dark-ground illumination in diagnosis 
of chancre, 254 
Nerst lamp for, 255 
Reichert apparatus 
for, 255 
Dartos of scrotum, anatomy of, 477 
Dermoid cysts of penis, 244 
Diathetic urethritis, 364 
Dilatation in gonorrheal stricture of 
urethra, 428 
bulbous, 429 
dilators in, 429 
filiforms and followers in, 
428 
instruments required for, 
428 
at meatus, 429 
membranous, 429 
pendulous, 429 
scrotal, 429 
sounds in, 429 
technic of, 429 
woven bougies in, 429 
of ureters, descent of ureteral cal- 
culi and, 55 
Direct cystoscopes, 17, 23 
catheterizing, 27 
cystoscopy in catheterization of 
ureter, 46 
optical system, 17 
Dislocation of penis, 228 
treatment of, 228 
of testicle, 472 
Diverticulum of urethra in female, 396 
Double penis, 195 INDEX 
813 
Double penis, treatment of, 197 
urethra in female, 280 
Dropsy in acute parenchymatous syphi- 
litic nephritis, 183 
Ducrey-Unna bacillus, chancroids and, 
290 
Ductuli efferentes, 447 
Ductus epididymidis, 447 
Duplay’s operation for hypospadias, 200, 
203 
E 
Ectopia of testicle, 462 
Eczema of scrotum, 480, 481 
Eczematous urethritis, 364 
Edema in balanitis, 281 
of scrotum, 482 
Elephantiasis of penis, 243 
of scrotum, filarial, 484 
non-filarial, 489 
Elsner-Braasch cystoscope, 31 
in catheterization of ureter, 
47 
Emphysema of scrotum, 483 
Encysted hydrocele of cord, 506 
Endoscope, Kelly’s, 31 
Luy’s, 31 
Endoscopic tubes, 31 
Endo-urethral chancre, 139 
discharge in, 139 
induration in, 139 
pain in, 139 
symptoms of, 139 
Enlargement of prostate, 635 
Enucleation of prostate in prostatic 
obstruction, 686 
Epididymectomy, technic of, 572 
Epididymis, anatomy of, 452 
blood supply of, 455 
histology of, 455 
lymphatics of, 456 
nerves of, 456 
physiology of, 456 
tuberculosis of, 532, 533 
diagnosis of, 533 
from gonorrhea, 563 
pathology of, 548, 554 
prognosis of, 533 
symptoms of, 558 
treatment of, 533 
Epididymitis, bilateral, 579 
gonorrheal, 356 
diagnosis of, 357 
etiology of, 356 
pathology of, 357 
prognosis of, 358 
sterility in, 362 
stricture of urethra and, 422 
symptoms of, 357 
treatment of, 358 
operative, 362 
suspensory, 358-361 
vaccines in, 361 
prostatectomy and, in obstruction 
of prostate, 667 
Epididymovasectomy, technic of, 533, 
572 
Epispadias, 215 
etiology of, 215 
in female, 381 
treatment of, 381 
treatment of, 216 
Young’s operation for, 216-225 
Epithelial cysts of penis, 244 
Erosions, chancrous, 252 
Erosive balanitis, 276. See Balanitis. ■ 
Erysipelas of scrotum, 483 
Erythema intertrigo of scrotum, 480 
Essential hematuria, 179 
Esthiomene, 268 
etiology of, 268 
lesions of, 268 
race and, 268 
microscopical characteristics of, 269 
pathology of, 269 
treatment of, 270 
Eversion in treatment of hydrocele, 501 
Extra vaginal spermatocele, 507 
F 
Fever in balanitis, 281 
Filarial elephantiasis of scrotum, 484 
orchitis, acute, 519 
Fistula in genital tuberculosis, 560 
syphilis of urethra and, 144 
Fistulse, prostatectomy and, in obstruc- 
tion of prostate, 667 
Follicular prostatitis, pathology of, 325 
Foreign bodies, removal of, cystoscopy 
and, 56 
stricture of urethra and, 446 
Fourth venereal disease, 276 
Freezing of penis, 236 
Frenum of penis, diseases of, 230 
treatment of, 230 
Functional tests in diagnosis of lesions of 
urinary tract, 98 
of kidneys, 98. See Kidneys, 
■functional tests of. 
Funiculitis, orchitis and, 519 
r G 
Galactocele, 507 
Galvanocautery in treatment of caruncle 
of female urethra, 389 
Gangrene of penis, 241 
treatment of, 241 
of scrotum, 483 
Gangrenous balanitis, 276. See Balan- 
itis. 
Genital symptoms in urethral affections, 
116 
tuberculosis, 532 
bladder in, 561 
diagnosis of, 562 
etiology of, 555 
fever in, 560 814 
INDEX 
Genital tuberculosis, fistula in, 560 
incidence of, 534 
operations for, results of, 568 
resume of, 567 
pain in, 559 
pathogenesis of, 538 
prognosis of, 564 
sex function in, 562 
symptoms of, 558 
treatment of, 570 
urine in, 561 
ulcers, 247 
classification of, 248 
historical review of, 247 
non-venereal, 302 
venereal, 248 
chancroid, 289 
erosive and gangrenous 
balanitis, 276 
granuloma inguinale, 296 
inguinal adenitis, 295 
bubo, 295 
syphilis, 248 
chancre, 248 
redux, 267 
esthiomene, 268 
gumma, 267 
syphilitic hypertrophy 
of vulva with ulcer- 
ations, 268 
ulcerated papule, 267 
Genito-urinary diagnosis, radiography in, 
93 
some vital truths regarding, 76 
diseases, symptoms of, 113 
Giemsa’s stain in diagnosis of chancre, 
257 
Giraldes, organ of, 447 
Glands, Cowper’s, anatomy of, 309 
of Littre, anatomy of, 309 
prostate, anatomy of, 309 
urethral, abscess of, anterior gonor- 
rheal urethritis and, 329 
anatomy of, 309 
Gonococcal infection of bladder, 363 
of kidney, 363 
Gonococcus, 312 
appearance of, atypical, 313 
typical, 313 
collection of material for examina- 
tion, 315 
complement-fixation test and, 319 
cases used in, 321 
effect of vaccines on, 322 
practical value of, 322 
time of appearance, 322 
of disappearance, 322 
cultural methods, 315 
agar medium, 315 
Schwartz’s, 315 
fixing of, 313 
isolation of, 314 
microscopical characteristics of, 312 
preparation of slide, 312 
source of specimen of, 312 
spreading of, on slide, 312 
Gonococcus, staining of, 313 
Gram stain in, 314 
methylene blue in, 313 
Gonorrhea, 306 
acute anterior. See Gonorrheal 
urethritis, acute anterior, 
posterior. See Gonorrheal 
urethritis, acute posterior. 
diagnosis of, from tuberculosis of 
epididymis, 563 
prevalence of, 306 
reasons for, 306 
remedy for, 306 
treatment of, 338. See Gonorrheal 
urethritis, treatment of. 
Gonorrheal epididymitis, 356 
diagnosis of, 357 
etiology of, 356 
pathology of, 357 
prognosis of, 358 
sterility in, 362 
stricture of urethra and, 422 
symptoms of, 357 
treatment of, 358 
operative, 362 
suspensory, 358-361 
vaccines in, 361 
prostatitis, acute, pathology of, 325 
chronic, complement-fixation 
test in, 336 
course of, 336 
diagnosis of, 336 
from inflammation of 
verumontanum, 337 
from non-gonorrheal 
prostatitis, 337 
from seminal vesiculi- 
tis, 337 
stricture of urethra, 416 
course of, 423 
cure of, 423 
diagnosis of, 424 
epididymitis and, 422 
etiology of, 416 
location of, 417 
pathology of, 416 
treatment of, 427 
anesthesia in, 428 
antisepsis in, 428 
bougies in, 428 
dilatation in, 428 
meatotomy in, 433 
operative, 432 
palliative, 427 
preventive, 427 
resection of fistula, 442 
of urethra, 441 
sounds in, 429 
urethrotomy in, external, 
435, 439 
internal, 434 
urethritis, acute anterior, abscess of 
uretheral glands 
and, 329 
balanoposthitis and, 
330 INDEX 
815 
Gonorrheal urethritis, acute anterior, 
burning on urina- 
tion in, 328 
cavernositis and, 330 
course of, 329 
diagnosis of, 329 
discharge in, 328 
incubation in, 327 
inguinal adenitis and, 
330 
invasion in, 327 
lymphadenitis and,330 
painful erections in, 
328 
peri-urethral abscess 
and, 329 
peri-urethritis and, 3 29 
red and swollen mea- 
tus in, 328 
spongeitis and, 330 
symptoms of, 327 
urine changes in, 328 
variations in attack of, 
328 
etiology of, 323 
pathology of, 324 
posterior, acute seminal 
vesiculitis and, 332 
complications of, 331 
course of, 331 
cowperitis and, 331 
frequency of urina- 
tion in, 330 
prostatic abscess and, 
331 
symptoms of, 330 
urinary change in, 331 
case treatment of, 345 
chronic anterior, cause of, 332 
complement-fixation 
test in, 334 
complications of, 334 
diagnosis of, 334 
instrumentation in, 
333 
pain in, 333 
palpation in, 333 
symptoms of, 332 
urethral discharge in, 
333 
urethroscopy in, 333 
urine in, 333 
pathology of, 325 
posterior, complications of, 
337 
disturbance of sexual 
function in, 335 
of urination in, 
335 
etiology of, 334 
exacerbations in, 335 
instrumentation in, 
336 
pain in, 335 
palpation in, 335 
pus in urine in, 335 
Gonorrheal urethritis, chronic posterior, 
symptoms of, 334 
urethral discharge in, 
335 
urethroscopy in, 336 
in female, 400 
acute, 403 
complications of, 408 
cystitis and, 408 
etiology of, 403 
examination in, 404 
suburethral abscess 
and, 409 
symptoms of, 403 
treatment of, 406 
urethroscopy in, 407 
chronic, 409 
diagnosis of, 411 
pathology of, 410 
symptoms of, 410 
treatment of, 412 
urethroscopy in, 411 
urine in, 411 
examination for, 401 
pyuria without urethral 
discharge in, 401 
prophylaxis against, 338 
treatment of, 338 
acriflavine in, 341 
anodynes in, 340 
anterior method, injections 
in, 340 
antigonococcus serum in, 
354 
autogenous vaccines in, 354 
balsamics in, 339 
bowels in, 339 
bulbous bougie in, 343 
dilatation in, 344 
discharge in, 339 
food in, 339 
hygienic cleanliness in, 
339 
internal medication in, 339 
posterior urethral irriga- 
tion in, 341 
prostatic massage in, 343 
rest in, 339 
urethral instillations in, 
, 344 
vaccines in, 353 
Granuloma inguinale, 296 
diagnosis of, 300 
etiology of, 297 
pathology of, 300 
prognosis of, 301 
symptoms of, 300 
treatment of, 301 
Gumma, 267 
of kidney, 185 
prognosis of, 186 
symptoms of, 186 
urine in, 186 
Wassermann reaction in, 186 
of penis, 243 
Gunshot wounds of penis, 227 816 
INDEX 
H 
Hagner’s hemostatic bag, 691 
Hard chancre, 248 
Hematocele, 472, 506 
diagnosis of, 507 
from hydrocele, 507 
from tumors of testicle, 593 
etiology of, 506 
spontaneous, 506 
symptoms of, 506 
traumatic, 506 
treatment of, 507 
Hematoma of scrotum, 479 
Hematuria in cancer of prostate, 739 
essential, 179 
in syphilis of bladder, 168 
Hemostatic bag, Hagner’s, 691 
Hernia, diagnosis of, from hydrocele, 497 
Hernial sac, hydrocele of, 506 
Herpes progenitalis, 238, 303 
diagnosis of, 303 
etiology of, 303 
symptoms of, 303 
treatment of, 239, 303 
Herpetic urethritis, 364 
Heterologous tumors of testicle, 584 
High-frequency spark operation in ob- 
struction of prostate, 667 
Homologous tumors of testicle, 583 
Hunterian chancre, 428 
induration in chancre, 252 
Hydatid of Morgagni, 447 
H3'drocele, 491 
acute, 492 
course of, 492 
diagnosis of, 493 
symptoms of, 493 
treatment of, 493 
anatomy of, 491 
chronic, 493 
complications of, 497, 502, 503 
diagnosis of, 496 
from chylocele, 497 
from hematocele, 497 
from hernia, 497 
from solid tumor, 497 
from spermatocele, 497 
from tumors of testicle, 
593 
light test in, 496 
puncture in, 497 
epididymitis and, 495 
etiology of, 493 
fluid in, 494 
amount of, 494 
examination of, 495 
properties of, 494 
pathology of, 494 
prognosis of, 497 
rupture and, 497 
sac in, 495 
suppuration in, 497 
symptoms of, 495 
testis and, 495 
trauma and, 493 
Hydrocele, chronic, treatment of, 498 
Andrew’s “bottle” opera- 
tion in, 501 
aspiration in, 500 
autoserotherapy in, 498 
eversion in, 501 
excision in, 502 
open operations in, 501 
operative, 504 
tapping in, 499 
vaccine therapy in, 498 
Winkelmann’s operation 
in, 502 
congenital, 505 
diagnosis of, 505 
prognosis of, 505 
treatment of, 505 
of cord, 505 
diagnosis of, 505 
diffuse, 505 
encysted, 506 
treatment of, 506 
symptoms of, 505 
treatment of, 506 
definition of, 491 
due to abnormalities of develop- 
ment, 504 
of a hernial sac, 506 
treatment of, 506 
idiopathic, 493 
infantile, 505 
treatment of, 505 
Hypertrophy of prostate, cancer and, 7 29 
of testicle, 460 
of vulva, syphilitic, 268 
Hypospadias, 198 
Beck’s operation for, 200, 206 
Churchman’s operation for, 209 
Duplay’s operation for, 200, 203 
etiology of, 200 
in female, 380 
symptoms of, 380 
treatment of, 381 
Nove-Josserand’s operation for, 207 
plastic operation for, 209 
Rocket’s operation for, 209 
I 
Idiopathic hydrocele, 493 
orchitis, 516, 518 
varicocele, 509 
Impotence, prostatectomy and, in ob- 
struction of prostate, 667 
Incised wounds of penis, 226 
Incontinence of urine, prostatectomy 
and, in obstruction of prostate, 667 
Indigo-carmin in functional tests of 
kidneys, 100 
Indirect cystoscopes, 25 
catheterizing, 27 
cystoscopy in catheterization of 
ureter, 42 
optical system, 19, 21 
Infantile hydrocele, 505 INDEX 
817 
Infiltrations of anterior urethra, urethro- 
scopy and, 60 
Inflammations of penis, 237 
etiology of, 238 
symptoms of, 238 
treatment of, 238 
of scrotum, 482 
of urethra in female, 398 
of verumontanum, diagnosis of, 
from gonorrheal urethritis, 337 
Ingestive urethritis, 364 
Inguinal adenitis, 295 
etiology of, 295 
pain in, 295 
symptoms of, 295 
treatment of, 296 
palliative, 296 
prophylactic, 296 
surgical, 296 
bubo, 295 
Intervesicular space, cancer of prostate 
and, 744 
Intravaginal spermatocele, 507 
K 
Kelly-Pawlik endoscope in catheteriza- 
tion of ureters, 48 
Kelly’s cystoscope, 379 
endoscope, 31 
urethroscope, 379 
Keyes’ deep urethral syringe, 345 
Kidney function, variability of, 98 
gumma of, 185 
prognosis of, 186 
symptoms of, 186 
urine in, 186 
Wassermann reaction in, 186 
pelvis, capacity of, 97 
syphilis of, 179 
Kidneys, functional tests of, 98 
indigo-carmin in, 100 
methylene blue in, 101 
phenolsulphonephthalein in, 101 
technic of, 102 
phloridzin in, 100 
infection of, gonorrheal stricture of 
urethra and, 422 
Kollman’s posterior urethral dilator, 344 
L 
Lacerated wounds of penis, 226 
Lacunse of Morgagni, lesions of, urethro- 
scopic picture of, 60 
Levaditi’s stain in diagnosis of chancre, 
258, 259 
Lewis’ sign for differentiation of ureteral 
stone, 94 
Littre, glands of, anatomy of, 309 
lesions of, urethroscopic picture 
of, 60 
Lupus of scrotum, 481 
Luys’ endoscope, 31 
Luys’ endoscope in catheterization of 
ureters, 48 
Lymphangitis, gonorrheal urethritis and, 
330 
Lymphatics of penis, anatomy of, 194 
diseases of, 241 
M 
McCarthy’s close vision cysto-urethro- 
scope, 378 
Magnification of fields in direct optical 
system, 18 
Malarial fever, orchitis and, 519 
Malformations of penis, 194 
of testicle, 458 
of urethra in female, 379 
Malposition of urethra in female, 380 
Membranous urethra, anatomy of, 308 
Mercier biconde catheter, 645 
conde catheter, 645 
Methylene blue in functional tests of 
kidneys, 101 
Montana region of posterior urethra, 
urethroscopic picture of, 65 
Morgagni, hydatid of, 447 
lacunse of, lesions of, urethroscopic 
picture of, 60 
Mumps, orchitis and, 516, 518 
Muscles of penis, anatomy of, 193 
N 
Neoplasms of scrotum, 489 
of urethra in female, 387, 392 
Nephritis, acute early syphilitic, 180 
parenchymatous, 180 
anemia in, 183 
arsphenamine in, 185 
diagnosis of, 184 
dropsy in, 183 
etiology of, 180 
pathology of, 182 
prognosis of, 184 
symptoms of, 183 
„ synonyms of, 180 
treatment of, 184 
urinary findings in, 183 
Wassermann reaction in, 
183 
syphilitica precox, 180 
Nerst lamp for dark-ground illumination 
in diagnosis of chancre, 255 
Nerves of penis, anatomy of, 194 
Nitze-Albarran cystoscope, 27 
Noguchi butyric acid test in diagnosis of 
chancre, 262 
Non-gonococcic urethritis in female, 398 
treatment of, 399 
Non-gonorrheal prostatitis, diagnosis of, 
from gonorrheal prostatitis, 337 
urethritis, 363 
treatment of, 364 818 
INDEX 
Non-venereal genital ulcers, 302 
Nove-Josserand’s operation for hypospa- 
dias, 207 
O 
Oberlander, infiltration of, 326 
Observation cystoscopy, principles of, 38 
induced movements of 
field, 39 
light, 41 
magnification, 40 
problem of sphincter, 40 
relation of field and cysto- 
scope, 39 
routine of inspection, 36 
technic of, 35 
Olivary bougie, 343 
Open wounds of penis, 235 
treatment of, 235 
Optical system, direct, amplication of 
fields in, 17 
magnification of, 18 
properties of, 17 
indirect, 19, 21 
prismatic, 19 
Orchitis, acute filarial, 519 
bilateral, 519 
funiculitis and, 519 
furunculosis and, 519 
idiopathic, 518 
malarial fever and, 519 
mumps and, 518 
osteomyelitis and, 519 
paratyphoid fever and, 518 
pneumonia and, 519 
prostatectomy and, in obstruction of 
prostate, 667 
smallpox and, 518 
tonsillitis and, 519 
typhoid fever and, 518 
Organ of Giraldes, 447 
Osteomyelitis, orchitis and, 519 
Otis-Brown-Nitze cystoscope, 26 
Otis-Nitze cystoscope, 26 
Oudin spark in treatment of caruncle of 
female urethra, 389 
P 
Pain in cancer of prostate, 738 
in chancre, 252 
in chancroids, 290 
in endo-urethral chancre, 139 
in genital tuberculosis, 559 
in gonorrheal stricture of urethra, 
422 
urethritis, 333 
in inguinal adenitis, 295 
bubo, 295 
in syphilis of bladder, 168 
in torsion of testicle, 474 
Painful erections in gonorrheal urethritis, 
328 
Papilloma, snaring of, cystoscopy and, 57 
of urethra in female, 390 
Papule, ulcerated, 267 
Paradidymis, 447 
Paraphimosis, 232 
chancroids and, 294 
treatment of, 233 
Paratyphoid fever, orchitis and, 318 
Parchment induration in chancre, 252 
Parenchymatous nephritis, acute syphi- 
litic, 180 
anemia in, 183 
arsphenamine in, 185 
diagnosis of, 184 
dropsy in, 183 
etiology of, 180 
pathology of, 182 
prognosis of, 184 
symptoms of, 183 
synonyms of, 180 
treatment of, 184 
urinary findings in, 183 
Wassermann reaction in, 
183 
prostatitis, pathology of, 325 
Pars membranacea of posterior urethra, 
urethroscopic picture of, 66 
Pediculi pubis of scrotum, 481 
Penile urethra, anatomy of, 308 
Penis, absence of , 197 
actinomycosis of, 243 
adherent, 198 
anatomy of, 189 
bloodvessels of, diseases of, 241 
bony formations of, 242 
burns of, 236 
carcinoma of, 245 
diagnosis of, 246 
phimosis and, 245 
symptoms of, 246 
treatment of, 246 
cartilaginous formations of, 242 
cavernositis of, acute, 240 
etiology of, 240 
symptoms of, 240 
chronic, 240 
etiology of, 241 
symptoms of, 241 
treatment of, 241 
diffuse, 240 
cleft, 198 
concealed, 197 
treatment of, 197 
congenital malformations of, 194 
contusions of, 225 
treatment of, 226 
coverings of, anatomy of, 192 
dermoid cysts of, 244 
diseases of, 230 
dislocation of, 228 
treatment of, 228 
double, 195 
treatment of, 197 
elephantiasis of, 243 
epispadias, 215 
etiology of, 215 INDEX 
819 
Penis, epispadias, treatment of, 216 
Youngs operation for, 216-225 
epithelial cysts of, 244 
freezing of, 236 
frenum of, diseases of, 230 
treatment of, 230 
gangrene of, 241 
treatment of, 241 
gumma of, 243 
herpes of, 238 
treatment of, 239 
hypospadias, 198 
Beck’s operation for, 200, 206 
Churchman’s operation for, 209 
Duplay’s operation for, 200, 203 
etiology of, 200 
Nove-josserands operation for, 
207 
plastic operations for, 209 
Rocket’s operation for, 209 
treatment of, 200 
inflammation of, 237 
etiology of, 238 
symptoms of, 238 
treatment of, 238 
injuries of, 225 
subcutaneous, 233 
diagnosis of, 234 
prognosis of, 234 
symptoms of, 234 
treatment of, 234 
lymphatics of, 194 
diseases of, 241 
muscles of, 193 
nerves of, 194 
paraphimosis of, 232 
treatment of, 233 
phimosis of, 230 
congenital, 230 
treatment of, 232 
phlegmons of, 239 
symptoms of, 239 
treatment of, 239 
rupture of, 227 
treatment of, 228 
sarcoma of, 246 
diagnosis of, 246 
prognosis of, 246 
skin affections of, 239 
strangulation of, 228, 236 
torsion of, 198 
tuberculosis of, 242 
circumcision and, 242 
pathology of, 553 
treatment of, 243 
tumors of, 244 
veins of, 193 
venereal warts of, 244 
vessels of, 193 
wounds of, 226 
gunshot, 227 
incised, 226 
lacerated, 226 
open, 235 
treatment of, 235 
punctured, 226 
Penis, wounds of, treatment of, 227 
Perineal drainage in cancer of prostate, 
777 
prostatectomy in enlargement of 
prostate, 702 
Peri-urethral abscess, gonorrheal urethri- 
tis and, 329 
stricture of female urethra and, 
422 
Peri-urethritis, gonorrheal stricture of 
urethra and, 422 
urethritis and, 329 
de Pezzer catheter, 683 
Pilcher’s modification of, 683 
Phagedena, chancroids and, 294 
treatment of, 294 
Phenolsulphonephthalein in functional 
tests of kidneys, 101 
Phimosis, 230 
carcinoma of penis and, 245 
chancroids and, 294 
congenital, 230 
treatment of, 232 
Phlegmons of penis, 239 
symptoms of, 239 
treatment of, 239 
Phloridzin in functional tests of kidneys, 
100 
Phosphatic encrustations, removal of, 
cystoscopy and, 56 
Pilcher’s modification of de Pezzer cath- 
eter, 683 
Pityriasis versicolor of scrotum, 481 
Plastic operations for hypospadias, 209 
Pneumonia, orchitis and, 519 
Pollakiuria in syphilis of bladder, 168 
Polyorchism, 459 
Polypi of urethra in female, 390 
Posterior urethra, normal, urethroscopic 
picture of, 64 
operative urethroscopy in, 70 
pathological, urethroscopic pic- 
ture of, 67 
urethroscopy of, 61 
Postgonorrheal urethritis, 363 
Prismatic cystoscopes, 25 
optical system, 19 
Prolapse of urethra in female, 384 
treatment of, 385 
Prostate, adenomata of, multiple, 631 
anatomy of, 611, 613, 624 
bloodvessels of, 616 
calculus disease of, 806 
etiology of, 806 
symptoms of, 806 
treatment of, 808 
cancer of, 725 
bladder and, 746 
Bottini’s electrocautery opera- 
tion in, 776 
castration in, 776 
catheter life in, 738 
catheterization in, 777 
course of, 737 
deep roentgen-ray therapy of 
high voltage in, 799 820 
INDEX 
Prostate, cancer of, diagnosis of, 735 
from obstruction, 651 
duration of, 737 
etiology of, 726 
frequency of, 725 
hematuria in, 739 
histology of, 728 
hypertrophy and, 729 
intervesicular space and, 744 
loss of weight in, 739 
membranous urethra and, 745 
pain in, 738 
pathology of, 727 
perineal drainage in, 777 
physical signs in, 738 
prostatectomy in, partial, 760 
suprapubic, 774 
radical operation for, 748 
radium in treatment of, 778 
rectal examination in, 741 
rectum and, 745 
seminal vesicles and, 744 
stricture of prostatic urethra 
and, 747 
subtotal radical incision in, 760 
suburethral thickening and, 747 
suprapubic drainage in, 776 
symptoms of, 731 
treatment of, 747 
embryology of, 611 
gland, anatomy of, 309 
histology of, 616 
hyperplasia of, diffuse, 631 
hypertrophy of, 631, 635 
subcervical gland, 635 
implantation of radium into, 793 
lateral aponeurosis of, 614 
leiomyoma of, 631 
lymphatics of, 616 
muscular apparatus of, 620 
nerve supply of, 621 
nerves of, 616 
obstruction of, 623 
cystitis with urinary stasis in, 
treatment of, 653 
cystoscopy in, 646 
dangers of, 649 
technic of, 646 
value of, 649 
diagnosis of, 644 
from carcinoma, 651 
from chronic prostatitis, 
650 
from retention of urine due 
to spinal disease, 651 
from tuberculosis, 651 
from vesical calculus, 652 
tumors, 651 
history in, 644 
enucleation of prostate in, 686 
examination in, 645 
high-frequency spark operation 
in, 677 
prostatectomy in, 664 
epididymitis and, 667 
fistulse and, 667 
Prostate, obstruction of, prostatectomy 
in, hemorrhage in, 697 
impotence and, 667 
incontinence of urine and, 
667 
orchitis and, 667 
perineal, technic of, 702 
transvesical, 678 
by open method, 700 
urethral stricture and, 668 
rectal examination in, 646 
retention of urine in, treatment 
of, 653 
suprapubic cystostomy in, 679 
technic of, 681 
drainage of bladder in, 699 
symptoms of, 642 
treatment of, 652 
hygienic, 652 
intermittent catheterism 
in, 654 
intra-urethral, 654 
palliative, 655 
preliminary to prostatec- 
tomy, 664 
prostatectomy in, 664 
surgical indications in, 659 
x-ray examination in, 649 
Young’s punch operation in, 
671 
pathology of, 624 
physiology of, 619 
sarcoma of, 802 
symptoms of, 803 
treatment of, 803 
radium in, 804 
secretion of, 619 
syphilis of, 145 
tuberculosis of, diagnosis of, from 
obstruction, 651 
pathology of, 554 
symptoms of, 560 
Prostatectomy in cancer of prostate, 
partial, 760 
suprapubic, 774 
in enlargement of prostate, 664 
epididymitis and, 667 
fistula} and, 667 
hemorrhage in, 699 
impotence and, 667 
incontinence of urine and, 
667 
orchitis and, 667 
perineal, technic of, 702 
transvesical, 678 
by open method, 700 
urethral stricture and, 668 
Prostatic abscess, gonorrheal stricture of 
urethra and, 422 
urethritis and, 331 
symptoms in urethral affections, 114 
urethra, anatomy of, 308 
Prostatitis, catarrhal, pathology of, 325 
chronic, diagnosis of, from obstruc- 
tion, 650 
pathology of, 326 INDEX 
821 
Prostatitis, follicular, pathology of, 325 
gonorrheal, complement-fixation 
test in, 336 
course of, 336 
diagnosis of, 336 
stricture of urethra and, 422 
non-gonorrheal, diagnosis of, from 
gonorrheal, 337 
parenchymatous, pathology of, 325 
Pruritus of scrotum, 481 
Punctured wounds of penis, 226 
Pyelography, dangers of, 93 
R 
Radiogram, interpretation of, 97 
Radiography in genito-urinary diagnosis, 
93 
preparation of patient for, 
98 
technic and mode of, 98 
value of, 93 
stereoscopic, 98 
of upper urinary tract, indications 
for, 97 
Radium, method of implanatation of 
into prostate and vesicles, 793 
in treatment of cancer of prostate, 
778 
ultimate results of, in 
100 cases, 787 
of sarcoma of prostate, 804 
Rectal examination in cancer of prostate, 
741 
in obstruction of prostate, 646 
Rectum, cancer of prostate and, 745 
Reichert apparatus for dark-ground 
illumination in diagnosis of chancre, 
255 
Renal pelvis, obstruction of, in diagnosis 
of urinary tract lesions, 113 
symptoms in urethral affec- 
tions, 115 
Resection of fistula in gonorrheal stric- 
ture of urethra, 442 
of urethra in gonorrheal stricture, 
441 
Cabot’s, 441 
Rochet’s operation for hypospadias, 209 
Roentgen-ray examination of urinary 
tract, 119 
therapy of high voltage in cancer of 
prostate, 799 
Ross-Jones modification of Nonne test 
in diagnosis of chancre, 262 
Rupture of penis, 227 
treatment of, 228 
S 
Sarcoma of penis, 246 
diagnosis of, 246 
treatment of, 246 
of prostate, 802 
Sarcoma of prostate, symptoms of, 803 
treatment of, 803 
radium in, 804 
Scabies, diagnosis of, from chancre, 262 
of scrotum, 481 
Schwartz’s method of culturing gono- 
coccus, 315 
Scrotum, abnormalities of, 479 
abscess of, 482 
adenocarcinoma of, 490 
anatomy of, 477 
areolar tissue of, anatomy of, 478 
bloodvessels of, 478 
calculi of, 484 
carcinoma of, 490 
cellulitis of, 482 
chafing of, 480 
cutaneous diseases of, 480 
dartos of, anatomy of, 477 
eczema of, 480 
marginatum, 481 
edema of, 482 
elephantiasis of, filarial, 484 
associated conditions in, 
,486 
diagnosis of, 486 
edema in, 486 
etiology of, 484 
pathology of, 485 
prophylaxis in, 487 
symptoms of, 486 
treatment of, 487 
non-filarial, 489 
emphysema of, 483 
erysipelas of, 483 
erythema intertrigo of, 480 
gangrene of, 483 
granuloma of pudenda of, 483 
hematoma of, 479 
inflammation of, 482 
injuries of, 479 
loss of substance of, 479 
lupus of, 481 
lymphatics of, 478 
neoplasms of, 489 
nerves of, 479 
pediculi pubis of, 481 
pityriasis versicolor of, 481 
pruritus of, 481 
scabies of, 481 
sebaceous cysts of, 482 
skin of, anatomy of, 477 
steatoma of, 482 
suture of, 480 
varicose veins of, 482 
Sebaceous cysts of scrotum, 482 
Seminal vesicles, anatomy of, 311, 616 
bloodvessels of, 619 
cancer of prostate and, 744 
definition of, 616 
embryology of, 616 
histology of, 619 
implantation of radium into, 
793 
physiology of, 619 
secretions of, 619 822 
INDEX 
Seminal vesicles, tuberculosis of, path- 
ology of, 551 
symptoms of, 560 
vesiculitis, gonorrheal stricture of 
urethra and, 422 
urethritis and, 332 
pathology of, 326 
symptoms of, 338 
treatment of, 354 
operative, 355 
vasectomy in, 356 
vasotomy in, 356 
Sex function in genital tuberculosis, 562 
in gonorrheal urethritis, 335 
Skin affections of penis, 239 
of scrotum, anatomy of, 477 
Smallpox, orchitis and, 518 
Soft chancre, 289 
rubber catheter, 645 
Sounds, use of, in gonorrheal stricture of 
urethra, 425, 429 
Spermatic cord, tuberculosis of, path- 
ology of, 554 
Spermatocele, 507 
diagnosis of, 508 
from hydrocele, 497 
etiology of, 507 
extravaginal, 507 
fluid in, 508 
intravaginal, 508 
pathology of, 508 
symptoms of, 508 
treatment of, 508 
Sphincteric lesions of posterior urethra, 
urethroscopic picture of, 67 
Spinal cord affections simulating syphilis 
of bladder, 170 
fluid, examination of, in diagnosis 
of chancre, 261 
Spirochseta pallida, chancre and, 248 
Spongeitis, gonorrheal urethritis and, 330 
Spontaneous hematocele, 506 
Steatoma of scrotum, 482 
Stereoscopic radiography, 98 
Sterilization of cystoscopes, 32 
Stone, stricture of urethra and, 446 
Strangulation of penis, 228, 236 
Stricture of urethra in female, 394, 446 
diagnosis of, 395 
peri-urethral abscess and, 394 
symptoms of, 394 
treatment of, 395 
urethrotomy in, external, 396 
internal, 395 
in male, 414 
bilharzia and, 446 
carcinoma and, 446 
chancroid and, 446 
classification of, 414 
congenital, 444 
clinical types of, 445 
diagnosis of, 445 
etiology of, 445 
pathology of, 445 
treatment of, 446 
foreign bodies and, 446 
Stricture of urethra in male, gonorrheal, 
416 
chronic urethral discharge 
and, 420 
complications of, 422 
course of, 423 
cure of, 424 
diagnosis of, 424 
epididymitis and, 422 
etiology of, 416 
forms of, 418 
hemorrhage in, 421 
location of, 417 
onset of, 419 
pain in, 422 
pathology of, 416 
peri-urethritis and, 422 
prognosis of, 423 
prostatic abscess and, 422 
prostatitis and, 422 
renal infection and, 422 
symptoms of, 419 
sexual, 422 
treatment of, 427 
anesthesia in, 428 
antisepsis in, 428 
bougies in, 428 
dilatation in, 428 
meatotomy in, 433 
operative, 422 
palliative, 427 
preventive, 427 
resection of fistula, 442 
of urethra, 441 
sounds in, 429 
urethrotomy in, 434 
urination in, 420 
vesiculitis and, 422 
prostatectomy and, in obstruc- 
tion of prostate, 668 
statistics of, 415 
stone and, 446 
syphilis and, 144, 446 
traumatic, 442 
course of, 443 
pathology of, 443 
symptoms of, 443 
treatment of, 444 
tuberculosis and, 446 
Subcutaneous injuries of penis, 233 
diagnosis of, 234 
prognosis of, 234 
symptoms of, 234 
treatment of, 234 
Suburethral abscess, gonorrheal urethri- 
tis in female and, 409 
thickening, cancer of prostate and, 
747 
Sulci lateralis of posterior urethra, 
urethroscopic picture of, 66 
Supramontana region of posterior 
urethra, urethroscopic picture of, 64 
Suprapubic cystostomy in enlargement 
of prostate, 679 
drainage of bladder in obstruction 
of prostate, 699 INDEX 
823 
Suprapubic drainage in cancer of pros- 
tate, 747 
prostatectomy in cancer of prostate, 
774 
Synorchism, 470 
Syphilides, urethral mucous, 141 
Syphilis of bladder, 146 
pathology of, 167 
secondary, 150 
age in, 167 
cystoscopy in, 167 
tertiary, 152 
age in, 168 
cystoscopy in, 169 
diagnosis of, 169 
hematuria in, 168 
pain in, 168 
pollakiuria in, 168 
spinal cord affections sim- 
ulating, 170 
symptoms of, 168 
treatment of, 170 
of kidney, 179 
of prostate, 145 
of scrotum, 481 
stricture of urethra and, 446 
of testicle, diagnosis of, from tumors, 
593 
of ureter, 179 
of urethra, 138 
primary, 138 
chancre of meatus, 138 
complications of, 140 
diagnosis of, 140 
endo-urethral chancre, 139 
frequency of, 138 
location of, 138 
symptoms of, 139 
secondary, 141 
tertiary, 141 
complications of, 144 
fistula and, 144 
modes of invasion, 142 
prognosis of, 145 
stricture and, 144 
symptoms of, 142 
time of appearance of, 
142 
treatment of, 145 
Syphilitic hypertrophy of vulva, 268 
nephritis, acute early, 180 
parenchymatous, 180 
anemia in, 183 
arsphenamine in, 185 
diagnosis of, 184 
dropsy in, 183 
etiology of, 180 
pathology of, 182 
prognosis of, 184 
symptoms of, 183 
synonyms of, 180 
treatment of, 184 
urinary findings in, 183 
Wassermann reaction in, 
183 
urethritis, 364 
Syphiloma of urethra, cylindroid, 142 
of vulvse, 268 
etiology of, 268 
lesions of, 268 
microscopical characteristics of, 
269 
pathology of, 269 
race and, 268 
treatment of, 270 
T 
Tabetic bladder, 170 
cystoscopic findings in, 176 
diagnosis of, 175 
prognosis of, 177 
treatment of, 178 
Tapping in treatment of hydrocele, 499 
Testicle, anatomy of, 450, 452 
blood supply of, 455 
descent of, 447 
imperfect, 460 
diagnosis of, 466 
effect on testicle, 463 
incidence of, 461 
torsion and, 465, 473 
treatment of, 466 
Bevan’s, 468-471 
operative, 467 
dislocation of, 472 
ectopic of, 462 
embryology of, 447 
histology of, 452 
infections of, 517 
diagnosis of, 528 
etiology of, 517 
pathogenesis of, 520 
pathology of, 520 
prognosis of, 529 
symptoms of, 528 
syphilis and, 518 
treatment of, 530 
injuries of, 473 
luxation of, 462, 472 
lymphatics of, 456 
malformations of, 458 
anorchism, 460 
atrophy, 460 
hypertrophy, 460 
polyorchism, 459 
synorchism, 460 
nerves of, 456 
physiology of, 456 
syphilis of, diagnosis of, from tu- 
mors, 593 
torsion of, 473 
age and, 473 
cause of, 473 
diagnosis of, 475 
edema of skin in, 474 
incidence of, 473 
pain in, 474 
pathology of, 473 
symptoms of, 474 
treatment of, 475 824 
INDEX 
Testicle, torsion of, undescended testicle 
and, 465, 473 
tuberculosis of, diagnosis of, from 
tumors, 593 
pathology of, 548 
symptoms of, 561 
tumors of, 580 
diagnosis of, 592 
from cryptorchism, 593 
from hematocele, 593 
from hydrocele, 593 
from syphilis, 593 
from tuberculosis, 593 
etiology of, 580 
heterologous, 584 
homologous, 583 
incidence of, 580 
pathology of, 582 
prognosis of, 594 
symptoms of, 590 
treatment of, 598 
undescended, 460 
diagnosis of, 466 
effect of, on testicle, 463 
incidence of, 461 
torsion and, 465, 473 
treatment of, 466 
operative, 467 
Bevan’s, 468-471 
Tonsillitis, orchitis and, 518 
Torsion of penis, 198 
of testicle, 473 
age and, 473 
cause of, 473 
diagnosis of, 475 
edema of skin in, 474 
incidence of, 473 
pain in, 474 
pathology of, 473 
symptoms of, 474 
treatment of, 475 
undescended testicle and, 465, 
473 
Transvesical prostatectomy in enlarge- 
ment of prostate, 
678 
by open method, 700 
Traumatic hematocele, 506 
stricture of urethra, 442 
urethritis, 364 
Tubercle bacilli, absence of, in urine, 
diagnosis of urinary tract lesions and, 
106 
Tubercular tests in diagnosis of lesions 
of urinary tract, 106 
Tuberculosis of epididymis, 532, 533 
diagnosis of, 533 
from gonorrhea, 563 
pathology of, 548, 554 
prognosis of, 533 
symptoms of, 558 
treatment of, 533 
genital, 532 
bladder in, 561 
diagnosis of, 562 
etiology of, 555 
Tuberculosis, genital, fever in, 560 
fistula in, 560 
incidence of, 534 
operations for, results of, 568 
resume of, 567 
pain in, 559 
pathogenesis of, 538 
prognosis of, 564 
sex function in, 562 
symptoms of, 558 
treatment of, 570 
urine in, 561 
of penis, 242 
circumcision and, 242 
pathology of, 553 
treatment of, 243 
of prostate, diagnosis of, from ob- 
struction, 651 
pathology of, 554 
symptoms of, 560 
of seminal vesicles, pathology of, 551 
symptoms of, 560 
of spermatic cord, pathology of, 554 
stricture of urethra and, 446 
of testicle, diagnosis of, from tumors, 
593 
pathology of, 548 
symptoms of, 561 
of urethra, pathology of, 552 
of vas deferans, pathology of, 552 
symptoms of, 561 
Tumors of bladder, diagnosis of, from 
obstruction of prostate, 651 
high-frequency treatment of, cysto- 
scopy and, 55 
of penis, 244 
of testicle, 580 
diagnosis of, 592 
from cryptorchism, 593 
from hematocele, 593 
from hydrocele, 593 
from syphilis, 593 
from tuberculosis, 593 
etiology of, 580 
heterologous, 584 
homologous, 583 
incidence of, 580 
pathology of, 582 
prognosis of, 594 
symptoms of, 590 
treatment of, 598 
Tunica vaginalis, anatomy of, 451 
Typhoid fever, orchitis and, 518 
U 
Ulcerated papule, 267 
Ulcerations, chancrous, 252 
Ulcers of bladder, excision of, cystoscopy 
and, 57 
genital, 247 
classification of, 248 
historical review of, 247 
non-venereal, 302 
venereal, 248 INDEX 
825 
Ulcers, genital, venereal, chancroid, 289 
erosive and gangrenous 
balanitis, 276 
granuloma inguinale, 296 
inguinal adenitis, 295 
bubo, 295 
syphilis, 248 
chancre, 248 
redux, 267 
esthiomene, 268 
gumma, 267 
syphilitic hypertrophy 
of vulva with ulcer- 
ations, 268 
ulcerated papule, 267 
Ulcus molle, 289 
Undescended testicle, 460 
diagnosis of, 466 
effect of, on testicle, 463 
incidence of, 461 
torsion and, 465, 473 
treatment of, 466 
operative, 467 
Bevan’s, 468-471 
Universal catheterizing cystoscope, 30 
Ureter, obstruction of, in diagnosis of 
urinary tract lesions, 112 
syphilis of, 179 
Ureteral calculi, descent of, dilatation 
of ureters and, 55 
diagnosis of, by wax-tipped 
catheters, 53 
catheter, use of, in drawing urine 
for examination, 107 
catheterization, 42, 90 
cystoscopy in, direct, technic 
of, 46 
Elsner-Braasch’s, 47 
indirect, technic of, 42 
endoscopes in, Kelly-Pawlik, 48 
Luys, 48 
lack of drainage after, 92 
obstructions in, 91 
stones, Lewis’ sign for differentia- 
tion of, 94 
symptoms in urethral affections, 115 
Ureterocele, operations on, cystoscopy 
and, 57 
Ureters, dilatation of, descent of ureteral 
calculi and, 55 
Urethra, anterior, infiltrations of, ure- 
throscopy and, 60 
operative urethroscopy in, 70 
pathological, urethroscopic pic- 
ture of, 60 
female, absence of, 379 
anatomy of, 366 
anesthesia of, 343 
calculus of, 386 
diagnosis of, 386 
symptoms of, 386 
treatment of, 387 
carcinoma of, 392 
caruncle of, 388 
pathology of, 388 
symptoms of, 388 
Urethra, female, caruncle of, treatment 
of, 389 
catheter-trauma of, 383 
catheterization of, 383 
cysts of, 390 
diverticulum of, 396 
symptoms of, 397 
treatment of, 397 
double, 380 
examination of, 371 
instruments for, 374 
inflammations of, 398 
injuries of, 382 
inspection of, 372 
malformations of, 379 
malposition of, 380 
neoplasms of, 387 
benign, 387 
malignant, 387, 392 
palpation of, 372 
papilloma of, 390 
treatment of, 392 
physiology of, 369 
polyp of, 390 
prolapse of, 384 
treatment of, 385 
stricture of, 394 
diagnosis of, 395 
periurethral abscess and, 
394 
symptoms of, 394 
treatment of, 395 
urethrotomy in, 395, 396 
urethroscopy in, 374 
male, anatomy of, 307 
anterior, comparison with pos- 
terior, 312 
glands of, 309 
instrumental examination of, 85 
interior of, 309 
landmarks of, 308 
membranous, 308 
obstruction of, in diagnosis of 
urinary tract lesions, 109 
penile, 308 
posterior, comparison with an- 
terior, 312 
prostatic, 308 
size of, 309 
stricture of, 414 
bilharzia and, 446 
carcinoma and, 446 
chancroid and, 446 
classification of, 414 
congenital, 444 
clinical types of, 445 
diagnosis of, 445 
etiology of, 445 
pathology of, 445 
treatment of, 446 
foreign bodies and, 446 
gonorrheal, 416 
anesthesia in, 428 
antisepsis in, 428 
chronic urethral dis- 
charge and, 420 826 
INDEX 
Urethra, male, stricture of, gonorrheal, 
complications of,422 
course of, 423 
cure of, 424 
diagnosis of, 424 
dilatation in, 428 
epididymitis and, 422 
etiology of, 416 
forms of, 418 
hemorrhage in, 421 
location of, 417 
meatotomy in, 433 
onset of, 419 
pain in, 422 
pathology of, 416 
peri-urethritis and, 
422 
prognosis of, 423 
prostatic abscess and, 
422 
prostatitis and, 422 
renal infection and, 
422 
resection of fistula in, 
442 
of urethra in, 441 
symptoms of, 419 
sexual, 422 
treatment of, 427 
bougies in, 428 
operative, 422 
palliative, 427 
preventive, 427 
sounds in, 429 
urethrotomy in, 434, 
435 
urination in, 420 
vesiculitis in, 422 
prostatectomy and, in ob- 
struction of prostate, 668 
statistics of, 415 
stone and, 446 
syphilis and, 144, 446 
traumatic, 442 
course of, 443 
pathology of, 443 
symptoms of, 443 
treatment of, 444 
tuberculosis and, 446 
posterior, normal, urethroscopic pic- 
ture of, 64 
operative urethroscopy in, 70 
pathological, urethroscopic pic- 
ture of, 67 
urethroscopy of, 61 
syphilis of, 138 
primary, 138 
chancre of meatus, 138 
complications of, 140 
diagnosis of, 140 
endo-urethral chancre, 139 
frequency of, 138 
location of, 138 
symptoms of, 139 
secondary, 141 
tertiary, 141 
Urethra, syphilis of, tertiary, complica- 
tions of, 144 
fistula and, 144 
modes of invasion, 142 
prognosis of, 145 
stricture and, 144 
symptoms of, 142 
time of appearance of, 142 
treatment of, 145 
syphiloma of, cylindroid, 142 
tuberculosis of, pathology of, 552 
Urethral affections in male, symptoms of, 
114 
genital, 116 
prostatic, 114 
renal pelvis, 115 
seminal vesicular, 114 
ureteral, 115 
stone, 115 
vesical, 114 
discharge in gonorrheal stricture of 
urethra, 420 
urethritis, 335 
glands, abscess of, gonorrheal ure- 
thritis and, 329 
mucous syphilides, 141 
syringe, 340 
Urethritis, diathetic, 364 
eczematous, 364 
in female, acute simple, 398 
treatment of, 399 
gonorrheal, 400 
acute, 403 
complications of, 408 
cystitis and, 408 
etiology of, 403 
examination in, 404 
suburethral abscess 
and, 409 
symptoms of, 403 
treatment of, 406 
urethroscope in, 405 
chronic, 409 
diagnosis of, 411 
pathology of, 410 
symptoms of, 410 
treatment of, 412 
urethroscope in, 411 
urine in, 411 
examination for, 401 
pyuria without urethral 
charge, 401 
non-gonococcic, 398 
treatment of, 399 
gonorrheal, acute anterior, abscess 
of urethral glands 
and, 329 
balanoposthit.is and, 
330 
burning on urination 
in, 328 
cavernositis and, 330 
course of, 329 
diagnosis of, 329 
discharge in, 328 
incubation in, 327 INDEX 
827 
Urethritis, gonorrheal, acute anterior, 
inguinal adenitis 
and, 330 
invasion in, 327 
lymphadenitis and, 
330 
painful erections in, 
328 
peri-urethral abscess 
and, 329 
peri-urethritis and, 
329 
red and swollen mea- 
tus in, 328 
spongeitis and, 330 
symptoms of, 327 
urine changes in, 328 
variations in attacks 
of, 328 
etiology of, 323 
pathology of, 324 
posterior, acute seminal 
vesiculitis and, 332 
complications of, 331 
course of, 331 
cowperitis and, 331 
frequency of urination 
in, 330 
prostatic abscess and, 
331 
symptoms of, 330 
urinary changes in 331 
case treatment of, 345 
chronic anterior, cause of, 332 
complement-fixation 
test in, 334 
complications of, 334 
diagnosis of, 334 
instrumentation in, 
333 
pain in, 333 
palpation in, 333 
symptoms of, 332 
urethral discharge in, 
333 
urethroscopy in, 333 
urine in, 333 
pathology of, 325 
posterior, complications of, 
337 
disturbance of sexual 
function in, 335 
of urination in, 
335 
etiology of, 334 
exercerbations in, 335 
instrumentation in, 
336 
pain in, 335 
palpation in, 335 
' pus in urine in, 335 
symptoms of, 334 
urethral discharge in, 
335 
urethroscopy in, 336 
prophylaxis against, 338 
Urethritis, gonorrheal, treatment of, 338 
acriflavine in, 341 
anodyne in, 340 
anterior urethral injections 
in, 340 
antigonococcus serum in, 
354 
autogenous vaccines in, 
354 
balsamics in, 339 
bowels in, 339 
bulbous bougie in, 343 
dilatation in, 344 
discharge in, 339 
food in, 339 
hygienic cleanliness in, 339 
internal medication in, 339 
posterior urethral irriga- 
tion in, 341 
prostatic massage in, 343 
rest in, 339 
urethral instillations in, 
344 
vaccines in, 353 
herpetic, 364 
ingestive, 364 
non-gonorrheal, 363 
postgonorrheal, 363 
syphilitic, 364 
traumatic, 364 
Urethrocele, 396 
Urethroscope, Kelly’s, 379 
selection of, 75 
Young’s, 377 
Urethroscopic picture of lesions of 
lacunae of Morgagni, 60 
of Littre’s glands, 60 
of normal urethra, 64 
of pathological urethra, 67 
Urethroscopy, 58 
in diagnosis of gonorrheal stricture 
of urethra, 425 
in female, 75 
in gonorrheal urethritis, 333, 336 
in female, 405, 411 
in infiltrations of anterior urethra, 60 
operative, 70 
of posterior urethra, 61 
in treatment of stricture of urethra 
in female, 395, 396 
Urethrotomy, external with guide, in 
gonorrheal stricture of ure- 
thra, 435 
without guide, in gonorrheal 
stricture of urethra, 439 
internal, in gonorrheal stricture of 
urethra, 434 
Urethrovesical lesions of posterior ure- 
thra, urethroscopic picture of, 67 
Urinary findings in acute parenchyma- 
tous syphilitic nephritis, 183 
stream, changes in, diagnosis of 
urinary tract lesions and, 83 
tract, lesions of, diagnosis of, 76 
absence of tubercle bacilli 
in urine and, 106 828 
INDEX 
Urinary tract, lesion? of, diagnosis of, 
cardiovascular examina- 
tion and, 109 
changes in urinary stream 
in, 83 
in urine in, 83 
chemical examination in, 84 
cloudy urine and, 104 
complement-fixation test 
and, 107 
cystoscopy in, 88 
examination of urine in, 
103 
functional tests in, 98 
guinea-pig inoculations 
and, 106 
history of case in, 81 
instrumentation in, 85 
local examination in, 84 
method in quest for, 79 
microscopical examination 
in, 84 
physical examination in, 
83, 84 
plan of investigation, 81 
previous personal history 
in, 81 
relative value of symptoms 
and physical examina- 
tion for, 79 
tuberculin tests and, 106 
Wassermann tests and, 108 
middle, diseases of, diagnosis of, 
radiography in, 93 
obstruction of, in bladder, 112 
diagnosis of, 109 
in renal pelvis, 113 
in ureter, 112 
in urethra, 109 
at vesical neck, 110 
without enlargement of 
prostate, 641 
roentgen-ray examination of, 
119 
preparation of patient 
for, 119 
technic of, 121 
upper, disease of, diagnosis of, 
radiography in, 93 
radiography of, indications 
for, 97 
Urination in gonorrheal stricture of 
urethra, 420 
urethritis, 335 
Urine, examination of, 103 
in genital tuberculosis, 561 
in gonorrheal urethritis, 328, 331, 411 
in gumma of kidney, 186 
incontinence of, prostatectomy and, 
in obstruction of prostate, 667 
pus in, in gonorrheal urethritis, 335 
retention of, due to spinal disease, 
diagnosis of, from obstruc- 
tion of prostate, 651 
in prostatic obstruction, treat- 
ment of, 653 
! Urogenital mesentery, 452 
Urologic affections in women, symptoms 
of, 116 
V 
Vaccine therapy in treatment of gonor- 
rheal epididymitis, 
361 
urethritis, 353 
hydrocele, 498 
Vaccines, autogenous, in treatment of 
gonorrheal urethritis, 354 
Varicocele, 509 
idiopathic, 509 
complications of, 512 
diagnosis of, 510 
etiology of, 509 
pathology of, 510 
symptoms of, 510 
treatment of, 510 
symptomatic, 509 
diagnosis of, 509 
treatment of, 509 
Varicose veins of scrotum, 482 
Vas deferens, tuberculosis, of pathology 
of, 552 
symptoms of, 561 
Venereal disease, fourth, 276 
warts of penis, 244 
Vesical symptoms in urethral affections, 
114 
Vision systems, correct, 24 
Vulva, hypertrophy of, syphilitic, 268 
W 
Warts of penis, venereal, 244 
Wassermann reaction in acute parenchy- 
matous syphilitic nephritis, 
183 
in diagnosis of chancre, 260 
in gumma of kidney, 186 
tests in diagnosis of lesions of 
urinary tract, 108 
Winkelmann’s operation for hydrocele, 
502 
Wounds of penis, 226 
gunshot, 227 
incised, 226 
lacerated, 226 
open, 235 
punctured, 226 
treatment of, 227 
Y 
Young’s operation for epispadias, 216- 
225 
punch operation in obstruction of 
prostate, 671 
urethroscope and light carrier, 377