CHAPTER XII

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GONORRHEA.

Gonorrhea is an acute infectious process, involving especially the mucous membranes of the genito-urinary organs, but met with elsewhere about the body, in both superficial and deep tissues. The name itself is a misnomer, since it implies a flow of semen, whereas the discharge which issues from the male urethra is simply mucopus, and is the product of a severe inflammation of the mucous membrane. A less inaccurate name for it is _blennorrhea_, although this is usually limited rather to a discharge from the vagina, and indicates a whitish and copious fluid exudate, mingled with pus corpuscles and bacteria. It is stated that probably 80 per cent. of men have at some time contracted this disease. Neisser claims that it is a more common affection than measles.

True gonorrhea is the result of an infection by a specific organism universally recognized as the _gonococcus_ of Neisser, though the discharge, when studied in the clinical laboratory, may give evidence of being the product of a mixed infection and contain the ordinary pyogenic or other organisms. The common name for the disease is _clap_.

The gonococcus is a diplococcus which seems to be injurious only to the tissues of the human being, as inoculations in animals have produced no definite or reliable result. Like syphilis, it is spread by direct or indirect contagion, and usually in the same way. It is generally found in the genito-urinary mucosa of both sexes, but it has been accidentally and even innocently conveyed by immediate and mediate transfer to the mucous membranes of the _eye_, the _rectum_, and even to the _mouth_, although here, as in the nose, the mucous membrane is but little susceptible to its activity. It is generally stated that 20 per cent. of the blindness occurring in the young is due to gonorrheal conjunctivitis. Those membranes covered with cylindrical epithelium are more liable to succumb to infection by this parasite than are those covered with squamous epithelium. The more the epithelial cells conform to the former type, the more difficult it is to get rid of the infection; hence the disease lingers in the cervical canal longer than in the vagina.

The disease always commences as a contagious catarrhal discharge from the mucous membrane. It may spread much farther than this, invading deeper tissues by continuity, or tissues at a distance by the lymph stream, or producing even metastatic expressions of infection in distant tissues and organs. Under these circumstances the serous membranes are likely to suffer, and the peritoneum, the endocardium, the pericardium, the pleuræ, the meninges, and particularly the serous linings of some of the joints, as the elbow and knee, show unmistakable evidences of infection; while through the medium of the venous and then the arterial systems typical representations of pyemia following gonorrhea may occur.

The disease as it usually appears is seriously and often obstinately complicated by the structure of the membranes which it involves. The mucous membranes throughout the body are more than mere mucous surfaces; they are dotted with openings for the escape of glandular secretions, and nowhere is this more conspicuous than in the urethra, where many minute follicles, so called, empty tiny drops of secretion into the mucous canal. Infection may easily travel along these routes and lurk within such minute recesses long after it has apparently disappeared from the surface; and so it often happens that in the male not only the urethral follicles but the ducts leading to Cowper’s glands and prostate become involved, while in the female the follicles around the meatus, the urethra, and the vulva rarely escape. The clinical importance of this statement is of interest, as by it may be explained many of those cases where an old infection seems to have been lighted up, or where the contagion has been conveyed to another after an attack which was supposed to have been entirely cured. Nothing seems to favor outbreaks of this kind as do alcoholic and sexual excesses.

The gonococcus may be scarcely regarded as an obligate pyogenic organism by itself, but the parts most often involved in this disease may be regarded as never free from the presence of other germs of greater or less activity, and by association, if not by actual symbiosis, such an intense reaction is provoked that the resulting products do not differ from true pus, save by the added presence of the specific organism most at fault. Under these circumstances abscesses may form in any tissue infected. Another expression of this fact would be the establishment of a pyarthrosis after involvement of one or more joints. Gonococci may be found in almost every abscess of truly gonorrheal origin; on the other hand, in some of the serous cavities it is possible, at least for a time, that gonococci may be present in the serous fluid without producing in it more than a disturbing effect, the fluid now appearing turbid rather than puruloid.

The amount of toxemia which may be produced by gonococci without reference to formation of pus has not yet been established. It is, moreover, a difficult thing to estimate in cases of mixed infection. Occasionally there are cases of metastasis and gonorrheal invasion which are free from evidences of suppuration, and yet there may be anemia and cachexia of profound type; these can only be explained on the theory of an intoxication.

Besides the serous tissues of the body the _fibrous_ structures may suffer seriously, not only in an acute manner, but also in a chronic and obstinate form.

It has been the custom to speak of _urethritis_ as a synonym for gonorrhea, and to divide it into the specific and non-specific forms, including under the former expression cases where the gonococcus can be demonstrated, and under the latter term those which do not seem to show it. There is no doubt but that urethritis may be set up by the introduction of a foreign body, such as a sound or catheter, as well as by some irritating discharge from the vagina, and also as the result of excess of uric acid in the system, perhaps even of alcohol. These, if occurring in a previously uninfected urethra, may be regarded as distinctly non-specific lesions. It is also supposed that under certain circumstances inflammation may be set up by other organisms than the gonococcus; nevertheless almost all cases of so-called clap are positively gonococcus infections, simple or mixed, and have but one origin.

=Diagnosis.=--_Diagnosis can be made positive only with the microscope._ A recognition of the gonococci by staining them and then watching the effect of iodine in their decolorization will be of great importance and reliable. The affinity of these germs for basic aniline dyes, and the fact that they do not take the iodine stain of Gram, will serve to differentiate them from the numerous other organisms with which they may be found mixed. By staining a cover-glass preparation first with methyl blue or other basic color, then placing it in Gram’s solution, and finally in a solution of Bismarck brown, the true gonococci which have been made visible by the methyl blue will have disappeared under the influence of the iodine, while other bacteria will be stained by it. It has been mentioned that the germ is a diplococcus of rather ovoid form, met in clusters but not in chains, and in groups of four or multiples of four; it may be attached to epithelium and pus corpuscles, or found within them, and is rarely found free in fluid except when present in large numbers. These organisms are capable of cultivation, growing best upon a mixture of human serum and neutral agar, at a temperature of 36° C.

_The urethra may be infected from without and from within_, and this infection may be either of a truly specific type (gonococcus) or of the pyogenic type; as between these forms information may be gained by the history and the clinical course, but the minute diagnosis is only to be made with the microscope. This is of more than theoretical value, inasmuch as it substitutes a certainty for a working hypothesis. It is, moreover, sometimes of great value, as when the question of infection of one of the opposite sex comes up, or it may have at times even an important medicolegal value, as in cases of rape.

_Infection from without_, so far as the male urethra is concerned, is a question of the venereal origin of the disease. _Infection from within_, in the specific form, is a matter of recrudescence of a formerly active lesion supposed to have disappeared. Infection of _non-specific type from without_ affects the introduction of germs either by venereal contact or by the medium of an unclean catheter, sound, or some other instrument, or _from within_ by the extension forward of an inflammation higher up in the genito-urinary tract, such as may be due to stone in the bladder, cystitis, enlarged prostate, or uric acid or oxalic acid crystals. Urethritis, usually of mild type, is not infrequent in old men from either of these causes. It may also be produced by the infection of a too strong or irritant injection, whether used either for prophylaxis or for ordinary treatment.

Classifying them we may then have urethritis of the following four types:

_A._ Gonorrheal of extrinsic origin.

_B._ Gonorrheal of intrinsic origin (originally extrinsic).

_C._ Non-specific urethritis of extrinsic origin.

_D._ Non-specific urethritis of intrinsic origin.

_A._ The period of incubation is short, usually two to six days, and the resulting inflammation is severe; the consequences are often remote and sometimes disastrous. Gonococci will be found in the pus and epithelial debris.

_B._ This has been described as “_bastard clap_.” It is really an auto-infection, with an incubation period of a few hours, and is practically the reawakening of a quiescent stage of _A_. It is characterized by abundant purulent discharge; this latter is thin and mucilaginous, more like that of so-called gleet, with an abundance of pus threads, or “clap threads,” in the urine. In this form gonococci are also found, but less frequently.

_C._ Much like _A_ in its clinical course, but less violent, and with less widespread reaction. Its period of incubation is rarely over thirty-six hours. This type is most common after alcoholic and sexual excesses; the latter especially with one already suffering from vaginal discharge, particularly so when near the time of menstruation. Here the microscope will show few if any true gonococci, but a profusion of pyogenic organisms.

_D._ This form of disease is of non-venereal origin, and is susceptible of easy explanation and of satisfactory treatment if the cause be properly treated. No case of urethral discharge which does not seem to fall easily into one of the above categories should be treated without a search of the anterior urethra, especially the fossa navicularis, for possible _chancre_ or _chancroid_, as well as for stricture.

Among the laity the idea is prevalent that gonorrhea is a disease of more or less trifling import, while many of the profession regard it as rarely worthy of serious consideration. This is an unfortunate notion regarding this disease, and those who have had largest experience unite in expressing the opinion that gonorrhea reckons more victims in the death list than does syphilis--not because it is more common, but because of its complications and the ravages, especially in the kidneys, resulting therefrom. It has been shown that the specific organism producing it may linger for years in the follicles of the urethra, whence it may issue forth, unexpectedly, to produce vaginitis, perhaps in the most innocent of women, and thus bring on a train of pelvic disorders which may involve the ovaries, the tubes, and the peritoneum. Doubtless _gonorrhea has made_ in this indirect way _many more victims than syphilis_.

Regarding gonorrhea thus seriously, it is well to treat it cautiously and to inculcate vigilance in the daily life and habits of the patient. There are no arbitrary limits during which danger exists and then passes; peril lurks about such a case for an almost indefinite time. There is danger not alone to the individual, but to all with whom he may have sexual or even other relations. This advice pertains not alone to the urethral discharge and the care of the urethra, but especially to the avoidance of all possible contamination of the conjunctiva. One of the saddest spectacles in the domain of medicine is to see one or both eyes of an innocent victim injured or ruined by gonorrheal infection.

There is no denying the clinical fact that individuals vary considerably in their susceptibility to this disease; moreover, individual susceptibility varies at different times. Alcoholic and sexual indulgence seem to materially lower this susceptibility. Thus from the same individual, and within twenty-four hours, one may acquire the disease while others escape. In some instances immunity seems to be afforded by repeated attacks; in other individuals repeated attacks seem only to enhance the liability to the disease. The gonococcus grows best in alkaline media. Prolonged sexual excitement diminishes the acidity of the urethral fluids, and this favors the growth and development of the germ. No credence should be given to popular notions concerning the possible avoidance of infection after exposure. Even a careful _toilet_ is usually inefficient for this purpose, while the use of prophylactic injections is to be reprehended. They do more harm than good. If strong enough to be bactericidal, they should be extremely irritant; if weak enough to be tolerated, they will prove useless. The patient should also be warned concerning possible transfer of the disease without sexual contact, and all toilet utensils, towels, etc., should be kept by themselves, and all syringes and instruments used in the treatment of the case should be carefully sterilized.

=Course.=--The period of incubation generally varies within wide limits, as mentioned above under classification of the various types; it may be as short as a few hours or may extend to ten days, or possibly even longer. Usually it is from two to five days. The early symptoms consist of discomfort along the course of the urethra, chemosis or edema, and swelling of the meatus. Within a short time after these symptoms the characteristic discharge appears. It may at first be viscid, but soon becomes purulent, and then more or less profuse, while urination gives rise to great discomfort. By the end of the first week the discharge is usually grayish in color, thick, continuous, and so profuse as to equal in volume 20 to 50 Cc. in twenty-four hours. The lesion is not confined to the urethra, and soon spreads to the peri-urethral tissues and thence to the lymphatics. A peri-urethritis with venous engorgement is added to the urethritis, and there is such an obstruction of the return circulation as to produce swelling and edema of the prepuce; this not only makes access to the urethra difficult, but conceals any excoriation and ulceration which may be going on beneath it. Sometimes this tumefaction proceeds to a degree where gangrene results.

All these local disturbances will be accompanied by more or less lymphatic involvement in the groins and in the perineum, with great soreness and tenderness throughout the entire genital tract. _Chordee_ (painful erection) is a common and painful complication of this stage of the disease. Finally a well-marked degree of _auto-intoxication_, with its ordinary febrile and septic manifestations, may ensue. As the disease spreads farther back into the deep urethra there is irritability of the bladder, while in severe cases the frequent attempts at urination thus excited, with the accompanying pain during the act of expelling a few drops of urine, are distressing features of the disease. The pains are not limited to the organs involved, but are often referred to the back, to the perineum, and down the thighs. The symptoms above referred to belong to a well-marked case of acute specific type. There may be milder manifestations of each kind, and occasionally a case will run its course with but a minimum of the difficulties and discomforts above mentioned. Sometimes by the end of the third week, usually before, the disease will show a tendency to subside, even if inadequately treated. The inflammatory symptoms become less marked, the discharge thinner and less voluminous, until perhaps by the end of the seventh week there is noticed only a small amount when the patient rises in the morning. With all this apparent and spontaneous improvement there may be present, nevertheless, a serious and distressing amount of peri-urethral infiltration, which will soon be followed by cicatricial contraction and the formation of a _stricture_, the most frequent sequel of gonorrhea.

=Complications.=--Complications may occur along any portion of the genito-urinary tract. These will be considered in their anatomical order.

=Balanitis.=--Balanitis signifies an inflammation of the mucosa covering the glans. When the mucous surface of the prepuce is also involved, as it usually is when the orifice is contracted, then the condition is known as _balanoposthitis_. In the absence of ordinary cleanliness of the parts this may go on to erosion or extensive ulceration. It is sometimes complicated with chancroid or chancre. When such a condition exists, and the glans cannot be sufficiently exposed for purposes of cleanliness, the dorsum of the prepuce should be slit up sufficiently to permit of complete exposure, while in some cases the edema and the infiltration will be such as to justify circumcision. When needed these operations should be practised even if raw surfaces are thereby left exposed to infection. Such possibility may be usually obviated by cauterizing a fresh surface, as soon as exposed, with pure carbolic acid or one of the stronger caustics, or operation may be made with the thermocautery.

=Folliculitis.=--Folliculitis implies the extension of the infection to the follicles and lacunæ which abound within the urethral canal. As long as their orifices do not become occluded they easily discharge their contents into the urethra, but when so swollen as to become occluded they lead to the formation of abscesses, which, beginning in a minute way, may sometimes give relatively extensive disturbance. These discharge internally; sometimes they so present that they may be opened externally, as they should be under these circumstances. They form a communication between the urethra and the exterior, and in this manner the majority of the ordinary urinary fistulæ are produced. These often occur in the perineum, but sometimes even in the pendulous portion.

=Peri-urethritis.=--Inflammation frequently extends beyond the anatomical confines of the urethra, and produces a degree of infiltration which is often well marked and disastrous. The site of such a lesion is marked by a nodule, more or less tender, which may subsequently break down into an abscess. The pus from these abscesses will usually escape into the urethra. Sometimes it burrows into the tissues of the corpus spongiosum, or travels even farther, and produces locally extensive destruction of tissue, with its possibility of urinary infiltration as a sequel, and all the septic disturbances which can be imagined as resulting therefrom. Thus fistulas often follow abscess formation, and these may be succeeded by phlebitis of the peri-urethral and prostatic plexuses, extensive destruction or multiple abscesses, or even gangrene and pyemia. Peri-urethritis is the essential factor in the production of strictures of the urethra, which constitute an exceedingly common condition.

While urethral stricture is a common result of gonorrhea it constitutes by itself a special lesion. (See chapter on the Genito-urinary Tract.) These peri-urethral infiltrations may occur in irregular patches, so variously placed as to encroach upon the urethra at different points without completely surrounding it, or they may form tubular lesions by which very serious annular constriction is produced. The degree of infiltration is, to some extent, a measure of the violence of the inflammation and of the virulence of the infection. This is true, however, only up to a certain point. One object of properly directed treatment should be to guard against the deep extension of a gonorrheal infection, in order to limit the tendency to the formation of stricture.

Between the folds of the triangular ligament are situated two racemose follicles known as Cowper’s glands. These occasionally become infected in the same way as the anterior follicles of the urethra and give rise to a painful swelling in the perineum, which gives most discomfort to the patient in the sitting posture. This condition is known as _Cowperitis_. It may proceed to abscess formation, in which case incision in the perineum should be made for its relief.

=Prostatitis.=--The prostate consists of a collection of follicles embedded in a mass of involuntary muscle fiber. The largest of these follicles is known as the _utricle_, or, under the old anatomical name, _uterus masculinus_. These are liable to invasion when the infection has reached the deep urethra. The reaction which follows in this tissue after such invasion gives rise to _prostatitis_ and causes much pain and general reaction. The prostate, being embedded within a fibrous capsule, cannot expand easily when it becomes inflamed, and the pressure thus made not only causes intense pain, but will also obstruct the urethra and occasion great difficulty in urination, sometimes retention of urine. In proportion to the other disturbance will be the general reaction, and fever may run high, with early expressions of septic intoxication or of septicemia. The prostate becomes tender, and pain is felt not only in the pelvic region, but in the back and in the thighs, as well as along the urethra. Prostatic abscess is a frequent sequel to this condition; it sometimes evacuates spontaneously into the urethra, or bursts through the capsule and burrows along the structures in the perineum and lower pelvis; occasionally it empties into the rectum. Intensity of symptoms should give rise to a suspicion of prostatic abscess, and a perineal incision should be made early and the abscess evacuated. Occasionally these abscesses present toward the rectum, when they should be tapped or incised through the bowel.

From the prostatic urethra inflammation may extend on one side or both along the vas deferens to the seminal vesicles. The production in this way of a _vesiculitis_ is made known by the reference of pain to the rectum and by the appearance of blood, sometimes with pus, in the seminal discharge. By a digital examination of the rectum the enlarged and tender vesicles can be recognized above the prostate.

When the deep urethra has become seriously involved the condition of the patient is unpromising. Belfield calls attention to the triple function of the deep urethra, in that the impulse to urinate originates therein, that it is a sphincter for the bladder, and that it is intimately concerned with the sexual act. When it is disturbed by gonorrheal infection all of these functions are disturbed, the most serious symptoms being increased desire to urinate, amounting to almost constant vesical tenesmus; marked difficulty in expulsion of urine, which may increase to complete retention, and frequent bloody emissions, with chordee. The pain, the heat, and the sense of tension in the perineum and in the parts around it are distressing, as well as pain during and after urination, which is usually referred to the end of the urethra. The last few drops of urine will often be bloody.

=Cystitis.=--Cystitis is the not infrequent result of the further migration of the infectious process from the deep urethra to the bladder. The process is usually acute and serves to further complicate the case and to harass the patient. Except in the nature of the exciting causes cystitis differs but little from the other varieties to be considered in their appropriate place (_q. v._). Cystitis of gonorrheal origin is likely to travel along the ureters and lead to involvement of the kidneys. Ascending infection is most commonly of gonorrheal origin. In proportion to the extent and rapidity with which the disease travels upward the case is marked by expressions of septic intoxication and infection, such as chills, fever, pain in the loins, along the ureters, and in the testicles. The kidneys may become enlarged. A more minute appreciation of the condition of affairs can be obtained by microscopic examination of the urine. In proportion as the kidney is involved, there is a preponderance of albumin, _i. e._, more than pus alone would produce. One of the numerous ways in which gonorrhea kills its victims is by the production of a _pyelonephritis_ of the type known as “_surgical kidney_.”

=Lymphangitis.=--No such invasion of mucous membrane by septic organisms can take place without active participation of the lymphatics in the region involved. In cases of gonorrheal or even non-gonorrheal urethritis, not merely enlargement of the lymph nodes in the groin may occur, but an active lymphangitis, manifested as a tender, sensitive cord beneath the skin, especially along the dorsum of the penis. The lymph nodes thus become involved and sometimes suppurate, and these abscesses are referred to as _suppurating gonorrheal buboes_. The suppurative feature is probably caused by contamination with the ordinary pyogenic organisms.

=The Testicles.=--Gonorrheal infection seems often to extend along the vas and thus invades the epididymis, where evidences of activity are more frequent than in the vas itself. _Epididymitis_ complicates cases of clap usually after the second week. It is characterized by pain, tenderness, and swelling of the epididymis, which occupies the same position relative to the testis proper that the heel does to the rest of the foot when a person stands in the ordinary military position, _i. e._, to the rear and inner side. The swelling becomes pronounced, and it is not unusual for a certain degree of swelling to be manifested in the testis proper, with the accumulation of a small amount of fluid in the sac of the tunica vaginalis, thus constituting a mild degree of acute hydrocele. While the inflammation is confined to the epididymis the pain is not intense, but of a dull, heavy character; but when the testis proper is involved there is a true _orchitis_, the inflammation being confined within the inelastic sclerotic tunic, and the pain then may be severe. Considerable fever accompanies many of these cases, with occasionally some edema of the scrotum and congestion of the testicular coverings. The weight of such a “swelled testicle,” as this condition is called by the laity, is irksome, and occasionally causes extreme discomfort. Under these circumstances physiological rest, _i. e._, in bed, and the use of a suitable suspensory apparatus are essential.

While resolution of this swelling ordinarily begins early and proceeds satisfactorily, the latter portion of the process is often slow and tedious, and the epididymis thus once involved will for months contain nodules and irregularities of contour. Usually the affection is limited to one side; but both testicles may be involved. If the infection be violent and the treatment inefficient abscesses may result.

This condition calls for early and effective treatment. If seen at the very outset, progress of the lesion may be checked by embedding the affected part in cold, wet compresses, and keeping them cold with ice. Relief later is more likely to be afforded by hot applications, and a hot poultice containing a small amount of fine-cut tobacco has been popular as a local application--the tobacco apparently being anodyne in its effect, although perhaps no more so than belladonna leaves. This may be regarded as a good emergency dressing when it affords the only means of treatment. The greatest relief will be obtained by the application of guaiacol, diluted with three volumes of olive oil or castor oil, well applied over the scrotum, and covered with oiled silk or rubber tissue. This application should be made twice a day. Later, in the more chronic and less painful stages, a reduced mercurial ointment containing a little guaiacol or ichthyol may be used to advantage, resolution being thereby assisted. In quite tedious cases the flying application of the actual cautery is serviceable. Internally tincture of pulsatilla has proved beneficial. It should be given in 1 Cc. doses every two hours. While the benefits accruing from its use are questionable, it has helped to allay fever and subdue pain.

Much has been said about the _sterility_ which results from epididymitis, especially when both sides have been involved. It is easy to understand how the vas may become occluded in many cases, either temporarily or permanently, and yet within my own observation men have suffered from the double lesion and yet begotten children.

=Gonococcus Septicemia and Pyemia. Postgonorrheal Arthritis= (=Gonorrheal Rheumatism=).--Considering the extent of the mucous tract involved, the open port of entry for germs, and the virulence of these organisms in many cases, it is remarkable that there are not more conspicuous illustrations of septic absorption in cases of gonorrheal urethritis. That these do occur and have a widespread, sometimes disastrous, effect has long been recognized. The severe forms are usually the more acute, and if they assume the septicemic type, go on to abscess formation, and in parts which are not always accessible. In rare instances septic disturbance assumes the pyemic type. The writer believes that he was the first to report a case of typical pyemia following gonorrhea, and to recognize it as such.

Aside from these acute manifestations, more chronic and mild affections, especially of the serous membranes, are well known. The most common of these exhibitions occur in the joints, mostly in the knee. A gonococcus peritonitis, pericarditis, or endocarditis are, however, well known. Because of the similarity of the discomfort and the disability resulting from the joint complications of clap to the ordinary joint manifestations of rheumatism, these lesions have long been popularly called _gonorrheal rheumatism_. The name, however, should be discarded as being incorrect, and for it the best substitute would be _postgonorrheal arthritis_.

These lesions may be sudden in their onset or may come slowly. They may occur at any time during the acute stage or after its apparent subsidence. The first manifestations involve the serous membranes proper; the fibrous tissues participate sooner or later, and the infiltration resulting from the inflammation thus set up will often permanently compromise their integrity and cause an impairment of their function for the rest of the patient’s life. They are usually confined to one of the larger joints, but may involve several, either simultaneously or consecutively. In acute cases the swelling is somewhat pronounced and the pain and soreness intense. The local symptoms simulate those of acute articular rheumatism. In the fluid drawn from these joints the gonococcus can be occasionally demonstrated. The course of the disease is usually slow, and convalescence may be protracted. Nor is the disability acute only and temporary, but it is often made permanent by the formation of adhesions resulting from the condensation of exudates. Partial or complete ankylosis may result, with considerable deformity. The muscle spasm provoked by the acute joint inflammation will occasion the same distortions and subluxations as are produced by tuberculous and other forms of arthritis, and operations varying in severity from forced motion to joint exsection may later be necessary. (See pp. 392 and 393.)

The writer has seen cases of postgonorrheal toxemia of extremely chronic and even fatal type, where the joints were conspicuously involved and where they did not constitute the most serious features of the disease. These cases proved most intractable to treatment and illustrate the possible complications of gonorrhea.

In addition to the joints various _bursæ_ and _tendon sheaths_ may suffer in the same way as do the joint membranes. Such lesions are seen about the hands and feet, especially about the tendo Achillis, and are also seen in the muscles of the neck and of the orbit.

The treatment of these gonorrheal complications should be effected largely by improving elimination and getting rid of the general toxemia; thus hot-air baths, diuretics, and cathartics are advisable. These eliminants, with free massage, are useful in dislodging the toxic products.

=Treatment.=--The treatment of gonorrhea is directed not alone toward the mere alleviation of symptoms, but to the destruction of the invading germs. The patient should abstain from much exercise, and in cases of severity should be kept in bed, avoid alcohol and tobacco, and eat sparingly of meats and of richly seasoned foods. He should wear a “gonorrhea bag,” or large condom, and there should be no obstruction to the outflow of pus. His hands should be washed immediately after contact with the parts involved, and all dressings and linen which may have been contaminated should be promptly burned.

The actual treatment of gonorrhea should be both internal and local. _Internal treatment_ should consist (1) of the administration of laxatives; (2) of such amount of alkali as may be necessary to overcome hyperacidity of the urine and mitigate the distress caused during its passage; (3) of remedies which, being eliminated by the kidneys, serve to medicate the urine and give it the effect of a retrojection; (4) of such anodynes and sedatives as may be necessary to give comfort, allay distress, and produce sleep or relieve and prevent chordee.

Of the drugs which are supposed to be eliminated by the kidneys, the balsams have sustained a high reputation. Among these is cubebs, of which 2 or 3 Gm. may be taken every two or three hours, as this remedy favorably influences the amount of discharge, though sometimes disturbing the stomach. Of the oleoresin of copaiba a ¹⁄₂ Gm. capsule, taken several times a day, is more pleasantly borne by the stomach, and with nearly as good effect as cubebs. Copaiba is known to produce a vivid scarlatiniform rash. The oil of sandal-wood, or santal oil, is the most efficient of these remedies, and may be given in the same dose as copaiba. That these drugs are eliminated by the kidneys is shown by the odor which they impart to the urine. It must be said, however, that these remedies are of but trifling benefit until the bladder is involved; when this occurs, they may prove of great value.

The urine should be diluted that it may be less irritating, and also to overcome its acidity. Fluids should be administered in profusion and alkaline diuretics in considerable doses. Hyperacidity is readily controlled by the administration of liquor potassæ, or the common sodium bicarbonate.

Sedatives may be necessary even from the first. The stronger anodynes are rarely needed during the first day or two, but by the end of the first week vesical tenesmus and chordee may be so marked that remedies such as cannabis indica, lactucarium, chloral, and the bromides may prove insufficient, and an opiate should then be administered. When required, morphine or heroine subcutaneously and in doses sufficient to promptly bring about the effect desired are preferable.

The _local treatment_ of urethritis is directed to the alleviation of discomfort and distress and the cure of the local disease. Much has been said about _abortive_ treatment. There is no such thing as aborting the disease. Much may, however, be done in the way of mitigating and shortening its course, and mild cases, especially of the non-specific form, may be considerably relieved within a few days.

The local treatment is carried out by injections into the urethra, which must be made with a syringe, preferably of hard rubber, with a blunt tip and without a nozzle, or by a douche bag connected with a soft catheter, all of which should be kept constantly sterilized. During the first days of an attack, when only the anterior part of the urethra is affected, treatment can be made more readily and effectively with a small “P” syringe, and at this time only 15 to 20 Cc. of fluid will be required, which should be held in the urethra for some time. When irrigation is decided upon a douche should be employed. Accurate directions should be given the patient as to how to make the injections, and he should be cautioned to first empty the bladder before using the syringe. The patient’s comfort may be increased by injections of water up to a temperature of 115° F. Antiseptics, _i. e._, potassium permanganate, boric acid, or one of the new preparations of the silver salts, may be added to the water. The parts may be advantageously immersed in hot water at intervals during the day, and for fifteen or twenty minutes at a time. There are many ways of conducting local treatment in these cases. Those mentioned below have given the best results in the practice of the writer.

A very satisfactory method would be to commence the local treatment with the use of hot water, as above, every two to six hours, and to follow it with a small injection of an emulsion of bismuth subnitrate, with sufficient cocaine and a little morphine to blunt sensibility and diminish tenderness and pain. The following formula, which may be varied, will accomplish this purpose: Morphine sulphate 0.3, cocaine muriate 2, bismuth subnitrate 20, cherry-laurel water 150, mucilage of acacia 50.

The injection should be retained for a few moments and no effort made to expel it. The bismuth salt is not only antiseptic, but is soothing, slightly astringent, and non-irritating.

Belfield has recommended the use of the yellow hydrastia muriate in connection with protargol. His formula is as follows: Yellow hydrastia muriate 2.50, protargol 1.50, glycerin 15, water 500. After using this for a few days the proportion of protargol may be doubled. Of this preparation 15 to 20 Cc. should be injected several times a day. The silver salts are the least irritating of all the stronger and more reliable antiseptics, and drug manufacturers are putting upon the market at frequent intervals new preparations for which much is claimed. Among the latest of these is argyrol, a combination of silver with albumen (vitellin), in such form as to make it antiseptic and non-irritating. In solution it is of a dark mahogany color and stains whatever it comes in contact with; these stains, however, are readily washed out. Argyrol in solutions of 2 to 5 per cent. strength has proved reliable, and if such a solution be retained in the urethra for five minutes at a time a pronounced effect may be made upon the disease. It is my custom to alternate the use of the bismuth formula with a solution of argyrol as above, and in this way give the greatest relief in the shortest time. It has been demonstrated that under the influence of this preparation all gonococci which are reached by it are destroyed; therefore the earlier it is employed the better. Before using either of these formulas the anterior urethra should be washed with hot water or with hot normal salt solution. No harm need be feared should either of the above injections reach the deep urethra, and the effort should be to make them reach at least as deeply as the disease has gone.

When the discharge has reached what Finger has called “the mucous terminal stage,” then the argyrol may be used two or three times a day only, and one of the following solutions substituted for it part of the time: Zinc sulphate 0.75, bismuth subnitrate 8, colorless liquor hydrastis 15, cherry-laurel water 60. Of this solution 10 Cc. may be used three or four times a day.

Belfield strongly recommends the use at this time of a solution of muriate of berberine, in strength of ¹⁄₂ to 1 per cent., or the yellow hydrastia muriate in about the same strength. He also recommends zinc chloride 0.25, zinc iodide 0.50, water 500. Either of the above salts may be added to this.

When nothing remains of the discharge but the so-called “morning” or “military drop,” and the urine is almost clear, argyrol solution at night and one of the above formulas once or twice through the day will be sufficient. This, in brief, is a description of how a case of urethritis may be satisfactorily treated.

The systematic use of potassium permanganate solutions was introduced by Janet, and has been enthusiastically described and prescribed by Valentine. The treatment is more complicated and less satisfactory than that advised above.

With deep extension of the disease and its added symptoms of tenesmus, pain local and referred, etc., the limit of the injection should be extended and the entire urethra should now be treated. The bladder being empty, the patient should make a strong effort to empty it again at the moment when fluid is being injected into the urethra; the compressor muscle being thus relaxed, the fluid passes into the deep urethra. It will take a little practice to enable him to do this, but when once learned the procedure is simple, and those who cannot accomplish it in the standing position will succeed if they lie down before making the attempt. In this way the entire urethra may be traversed.

In the treatment of deep urethritis it is not necessary to change the formulas or drugs above advised.

Under this line of treatment it may be possible to cure the majority of cases of gonorrhea in from two to five or six weeks. This by no means indicates that the lesion is actually cured, for trifling evidences, such as adhesion of the lips of the meatus, with the retention of a drop or so of mucopus, and the presence in the urine of the so-called “clap threads,” _i. e._, threads of flocculent material that consist of mucus and epithelial debris loaded with bacteria, will for a long time be noted. These appearances indicate that there are still areas along the urinary tract which are infected, and are sources of possible danger.

The _vesiculitis_ which often follows deep urethritis, as shown by the enlargement of the vesicles, detected by rectal examination, requires physiological rest, hot sitz baths, hot enemas, and opiates, the latter usually by suppository. After a short time the vesicles should be “milked” with a finger in the rectum, gentle pressure being made toward the prostate in the direction of their outlet. This will frequently cause an outflow into the urethra of pus and debris and give great relief. Should the infection persist and the above manipulation prove insufficient, the vesicles may be opened through the rectum, washed out, and packed with gauze.

CHRONIC GONORRHEA, OR GLEET.

Gleet is the name given to gonorrhea which persists, being only partly influenced by treatment, and which has extended over an arbitrary period placed usually at six weeks to two months. Strictly speaking the term _gleet_ should be restricted to cases where there is a mucopurulent discharge from the meatus, often complicated by formation of strictures in the _anterior_ urethra; on the other hand, a _chronic gonorrhea_ may for a long time persist in the _deep_ urethra and the glands and ducts adjoining, whence will issue a discharge which appears anteriorly, but, nevertheless, comes from the depths of the genito-urinary tract.

It is possible to have a chronic gonorrhea with little or no true gleet, the infection being latent, but nevertheless persisting. In gleet the discharge varies from a thin watery flow to one which is profuse and purulent, most noticeable in the morning on rising, when the meatus may be occluded by adhesion of the surfaces and there appears the so-called “morning drop.” Careful investigation of the urethra will generally disclose at least some constriction, with tender areas along the anterior urethra. To successfully treat the disease these areas and constrictions should be determined and suitably medicated. For this purpose two instruments especially are necessary--the _bulbous bougie_, for which a sound of the same size is an unsatisfactory substitute, and the _endoscope_, through which the lesions may be not only viewed but suitably treated.

The peculiar discharge comes from a lesion of one of the following varieties--either from isolated areas of inflamed mucous membrane with underlying exudate, from follicles and vesicles which fail to completely empty themselves, or from preëxisting strictures. The endoscope will easily reveal the first and second of these; the bulbous bougie the first and third, while further examination by the rectum may be necessary to decide in regard to the seminal vesicles.

[Illustration: FIG. 28

Bulbous sound.]

The bulbous _bougie_ is an instrument of great importance in urethral work. It should be carefully sterilized before introduction, and the urethra should be cleansed before its use. The instrument should be gently passed into the urethra; its course will be obstructed by any constriction which will give rise to stricture of smaller caliber than the bougie itself, while the discomfort or pain which it will excite as it passes over a tender or ulcerated area will be significant. The urethra is most distensible at its bulbous portion, while its caliber varies in different individuals, ranging ordinarily from 30 to 35 of the French scale, while the urethral diameter is about four-tenths of the circumference of the penis. We owe more to the studies of Otis in this matter than to any other investigator. He also showed that the size of the meatal opening is not a criterion as to the size of the urethra; that the contracted meatus often produced a certain degree of reflex and spasmodic stricture behind it, and that when the meatus is too small to permit the introduction of such an instrument as the urethra should take it should be enlarged, the operation for its enlargement being known as _meatotomy_, which may be easily effected with a blunt bistoury under the local use of cocaine. The meatus having been enlarged to suitable size, any consistent and organic constriction which then prevents the passage of the bougie should be considered a stricture and treated accordingly. Such a constriction may be of recent origin, when it will be found easily dilatable, or it may be old, resillient, and tough. Otis also devised an instrument known as the _urethrometer_, which is of value in the accurate estimation but not necessary in the treatment of many cases.

[Illustration: FIG. 29

Urethrometer.]

These instruments may be passed down to the bulbous portion of the urethra; beyond this further investigation should be made with the ordinary sounds. By their use much may be determined in regard to prostatic tenderness, and the combined use of the sound in the deep urethra with the finger in the rectum will give more accurate information regarding the size of the prostate than can easily be obtained in any other way. Much reaction, however, may occur from the use of the sounds in this way, and it is a good rule never to introduce an instrument into the deep urethra without having ample reason therefor, and then doing it under antiseptic precautions; while, as a formal measure after it, the patient should be placed at absolute rest. This serious reaction, which occasionally follows instrumentation of the deep urethral passage, is commonly known as _urethral fever_. It is characterized by chills, elevation of temperature, and often by local indications, the constitutional features being sometimes pronounced, and in rare cases terminating fatally. Such serious symptoms are difficult to explain. Doubtless the use of the instrument opens up paths of fresh infection, and absorption rapidly follows, which may be limited to the surrounding tissues or cause widespread trouble. This may ensue after every precaution has been adopted, although doubtless many of these cases have been the result of carelessness and failure in antisepsis. Much may be done in the way of prevention when this condition is feared, for these cases are rarely so urgent but that the urine can be medicated and its quality improved, while a part of the procedure may consist in having the patient empty the bladder and then carefully washing it, or filling it with an antiseptic solution, which may be expelled before any instrument is used except the catheter, through which it may be necessary to introduce the bladder wash. The administration of 2 or 3 Gm. doses of urotropin, with or without quinine, previous to the exploration, may also be of great service. The surgeon perhaps does not always take these precautions, but he should when the history of the case shows that patients have already suffered in this way. In the presence of such a history the urethra should be explored with great caution.

When the rectal examination is made the intent should be to discover any enlargement, irregularity, or undue sensitiveness of the prostate, and then to pass the finger still farther and ascertain if there is involvement of the seminal vesicles. At the same time a species of manipulation described as “milking” may be conducted, by which the contents of the vesicles as well as of the prostatic utricle may be incited by gentle pressure, directed from above downward, to empty into the deep urethra, whence they may be promptly expelled or may be carried out by the urinary stream, or removed through the endoscope. The discharge of pus or catarrhal debris in any visible amount is suggestive, and indicates that these passages have participated in the infectious process. This act may be repeated at three or four day intervals; it should be so gently done as not to cause much pain, and will be found of great value in cases calling for it.

=Treatment.=--The treatment of gleet is essentially treatment of the causes which produce it, and these should be carefully determined. In the urethra, as in all other tubular channels of the body, an abnormal constriction is accompanied by an area of excitement behind it, from which will issue more than the normal mucous discharge. We see this in stricture of the esophagus, intestine, or any of the ducts. This discharge is not to be subdued by mere applications nor by astringent and antiseptic injections, but the stricture itself, being the most important factor, must be suitably managed. In recent cases its gradual distention by the use of conical sounds will usually suffice.

In long-existing strictures more radical measures should be adopted, and they should be divided with one of the numerous urethrotomes in general use. Mere division, however, is not sufficient, but the patient should be impressed with the fact that cicatricial tissue tends invariably to contract, and that persistent dilatation is to be practised lest the stricture recur. The old saying used to be, “Once a stricture, always a stricture.” If this is to be disproved, it can only be by the frequent and long-continued use of sounds. Ignorance or indifference impel many a patient to return for further treatment, sometimes in a condition worse than at first, while occasionally the penalty paid for carelessness is life itself.

No routine in the treatment of gleet will give satisfactory results beyond this fact, that patients should be instructed to regulate their lives by absolute rules as regards indulgence of every description, and avoidance of intestinal inactivity and constipation. The urine will be found concentrated and irritating in many of these cases, and this should be overcome by the free use of water and diluent drinks. Hyperacidity should be corrected by suitable alkaline medication, and remedies administered, already mentioned, which are supposed to medicate the urine. Capsules may be procured containing salol, oleoresin of cubebs, balsam of copaiba, and pepsin, and except in cases where there is already great irritation of the urinary tract, these serve their purpose admirably.

When the anterior urethra alone seems to be involved, one of the milder injections already mentioned in describing the treatment of acute cases may be employed. When the deep urethra appears to be the site of continued irritation, it should then be treated extensively with deep irrigations and injections of suitable medicaments. The deep irrigations can be practised with or without the use of a catheter. The deep urethra may be flushed through a smaller catheter than the urethra will comfortably take, allowing the fluid to return through the urethral channel outside of the catheter itself. When this practice is adopted, hot water which has been made antiseptic should be used, preferably with one of the silver salts. The nitrate may be used in proportion of 1 to 500, and the citrate or lactate in strength of 1 to 300 or 1 to 400. Protargol is effective in 1 per cent. solution, or argyrol in 1 to 3 per cent. strength.

In the employment of irrigation in these cases a shield should be used, by which the end of the penis may be covered and all danger of spattering avoided. The simplest expedient for this purpose is one-half of an old atomizer bulb, which may be punctured and slipped over the catheter or irrigator tube.

Apart from mere irrigation it is well to deposit within the depths of the urethra, in the membranous portion, by means of a deep urethral syringe, a drop or two of a fresh solution of silver nitrate in distilled water, in strength of ¹⁄₂ to 1 per cent. This should be deposited behind the “cut-off” muscle, where it will cause a burning sensation for a short time. The strength of the solution is to be regulated by this complaint, as no benefit is derived from using it too strong.

Of all the medication that has been suggested, nothing gives better results for this purpose than this silver nitrate.

For ordinary urethral injections, besides those already mentioned, formalin may be used, but in weak solution (1 to 2000, or stronger if the patient can tolerate it); while picric acid has been recommended by Belfield and others in strength of 1 to 1000 or 1 to 2000.

Some surgeons believe that patients can learn to flush the deep urethra, or even the bladder itself, without the use of the catheter or internal tubing of any kind. The procedure may have to be learned in the sitz bath, the pelvis being immersed in warm water; the nozzle of the irrigator tube is inserted into the urethra and the patient is told to make an effort as if to void his urine. This will so relax the “cut-off” muscle as to permit the passage of fluid into the bladder, and this, which is most desirable in many cases of cystitis, where the bladder washing is an essential feature of the case, is to be avoided when the gonorrheal infection has travelled backward beyond the prostate; no attempt should be made to pass the solution into the bladder, but simply to wash out the urethra. The better plan is to teach the patient the proper use of a small soft catheter, which may also be used in the sitz bath, inserted to the proper extent.

Recent strictures should be treated by sounds after the urethra has been thoroughly cleansed. For this purpose a conical cylindrical sound should be selected, whose urethral end will comfortably enter the stricture. Gentle force should then be brought to bear to pass it beyond the stricture. If gradual dilatation be aimed at, it is well not to go beyond the point of drawing a drop or two of blood; even this may be avoided. On the other hand, should it be decided to use sufficient force, the dilatation should be done thoroughly and at one sitting, in order to avoid repetition of the irritation. The instrument generally in use in this country for this purpose is the _Otis dilating urethrotome_, by which the degree of dilatation and the size of the cicatricial ring can be estimated and the extent of the division and the effect gained also regulated. (See Operative Surgery of the Urethral Canal.)

The _divulsion of strictures_, formerly in vogue, is now abandoned for the more accurate division performed by this instrument. The strictures having been thus divided, sounds should be passed at intervals of from three to five days, by which the urethra is distended to its full caliber and the divided surfaces not allowed to contract. This is an important part of the treatment, and gives opportunity for widest discretion in their employment. Ordinarily they should not be carried farther back than the lesion calls for, as the deep urethra is best let alone. On the other hand, there are many cases where the stimulus of the cold metal passing the entire length of the urethra and the effect which it seems to have in expressing from the various follicles any retained contents seem beneficial. It has been stated that instrumentation sometimes leads to epididymitis or “swelled testicle;” should this take place in a case undergoing treatment for gleet it may necessitate a temporary cessation of the mechanical treatment. It is not good surgery to introduce any instrument into the urethra when one or both testicles present this complication.

In the local treatment of these lesions, cocaine or one of its substitutes should be employed. It is questionable whether the full benefit of applications is obtained when the surfaces are so anesthetized; on the other hand, the treatment can be made more endurable by its use.

This is true, also, of the use of the _endoscope_, and applications which may be made through it to inflamed or hypersensitive patches. When these are recognized or exposed, they are best treated by a probang moistened with silver nitrate solution, in 5 to 10 per cent. strength, or by the solid stick or crystal of copper sulphate, pure or mitigated, as used by the oculists.

One of the most important features in the consideration of gonorrhea is to determine, if possible, when a given case has ceased to be dangerous to others. In theory the danger passes with the disappearance of the gonococci, but it is so difficult to determine when this has occurred that it is almost impossible to fix a time limit in any given case. An excellent method of determining the matter in a reasonably accurate way is by having the patient void urine in two different glasses; a small quantity in the first, which will contain, then, the washings of the urethra. In this glass will be found those chains of gonococci clustering around masses of epithelial cells or debris which have been especially described as “clap threads” (tripper-faden of the Germans), upon which, by careful examination, gonococci can often be recognized. As long as these threads are in evidence it may be held that the infection still persists, and might be either brought into activity again by excitement or convey the disease in the sexual act.

Gonococci have been found in clap threads years after the last known infection, and this will illustrate why they are such a source of danger, and how an innocent woman has been made to suffer when it was supposed that all danger of infection had passed away.

GONORRHEA IN WOMEN.

This naturally assumes the type of a _specific vaginitis_, usually with active participation of the mucous membrane of the _vulva_ and of the _vulvovaginal glands_, the urethra and bladder being sometimes secondarily involved, while the role of the lymphatics is about as described in the male. In the young, especially in young girls upon whom rape has been attempted, the mucosa is extremely susceptible. In adults, particularly in those who have borne children, the vaginal walls offer more resistance. The nature of the parts permits of more violent chemosis of the mucous membrane, while in serious cases there will be well-marked edema of the labia. The urethral orifice is usually inflamed and chemotic, even though the infection travel no farther in this direction.

It has been stated that 80 per cent. of deaths from pelvic disease in women are due directly or indirectly to gonorrhea, as well as one-half of the cases of involuntary sterility.

As in the male, there may be different types of so-called gonorrheal infection of the vagina, varying from the pure gonococcus type to that in which the preponderating bacteria are of the ordinary pyogenic varieties. The detection of gonococci in the discharges sometimes assumes medicolegal importance, and upon it has depended the guilt or innocence of more than one individual.

The intensity of the vaginitis will vary with that of the infection. In the worst cases the discharge is profuse and acrid. It may amount to 50 Cc. or even 100 Cc. in twenty-four hours. The burning pain will be extreme, while backache and pelvic soreness will be bitterly complained of. In mild cases the disease assumes the clinical form of a low-grade vaginitis with abnormal discharge, such as may be characterized as a severe case of “whites.”

In these cases of either type the question is, whether infection has already travelled upward beyond the vagina into the uterine cavity or through it into the tubes.

Gonorrhea is the most common, and some believe almost the sole, cause of _pyosalpinx_ with its attendant complications and dangers. Even when not severe, vaginitis may permit of such extension, and so not only induce sterility, but compromise the physical welfare of the patient; while in acute cases the activity is so great that it occasionally terminates in peritonitis, primarily of gonorrheal origin. When both tubes have become involved, the patient is almost invariably sterile.

In nearly all of these cases strings of mucopus will be found hanging out, or beads of it presenting at the external os, and when examined this exudation will afford a fair test as to the character and degree of the infection. Here, as in the male, there are so many follicles difficult of access, and so many recesses in which germs may lurk, that a complete disinfection of the parts is almost impossible. For this reason, then, latent gonorrhea is a frequent outcome of the disease when once it has existed, and a possible and more or less constant source of danger to others.

=Treatment.=--A case of acute gonorrheal vaginitis with its accompaniments will present a difficult problem. The discharge is so great that the danger to others, and especially to the eyes, is pronounced, while the exquisite tenderness of the parts makes radical treatment difficult. The treatment should consist of antiseptic douches, which in serious cases should be made as nearly continuous as possible. The water used for the purpose should be as warm as the patient can tolerate, and contain an antiseptic, of which corrosive sublimate, in strength of 1 to 2000, silver nitrate in the same strength, or formalin in double this strength, are the most serviceable. The irrigating tube should be carried to the upper end of the vagina and the stream made to flow outward. In milder cases a douche at intervals through the day may suffice. The vaginal surface should later be exposed through a speculum and the entire mucous surface treated with nitrate of silver solution in from 6 to 10 per cent. strength. Should the surface be tender, this will be painful, and might justify the use of an anesthetic, especially of nitrous oxide.

If the disease extend upward and there is an _endometritis_ or a _salpingitis_, external applications of ice may be used to lull the pain; but probably hot poultices or some application of external heat might afford greater comfort to the patient. Byford has used succinic dioxide in the treatment of specific vaginitis with great satisfaction. It is sold in the open market under the trade name “Alphozone.”

The edema of the vulva will subside with the general improvement of the case. Abscesses in the vulvovaginal glands are not uncommon. These are easily recognized, are often painful, and should be incised early or as soon as recognized, cleaned out thoroughly, the interior of the cavity cauterized to prevent the result of fresh infection, and then packed and left to heal by granulation.

Urethritis and cystitis may be treated as when they occur in the male. There is the same liability in women as in men to lymphatic involvement, with the consequent bubo, which may perhaps suppurate. They are less liable to the widespread manifestations of postgonorrheal infections of the joints, etc., although they are even more liable to infection of the endocardium, and, as will be readily understood, more so to infection of the peritoneum. It will then be seen that the treatment of the disease is essentially the same in either sex, certain differences in method rather than in principle having to be made in accordance with anatomical requirements.

As to the rectal mucous membrane participating in gonorrheal infection, under ordinary circumstances it would escape. In the treatment of any of these cases by the sitz bath, the question might arise whether there would be danger of extending the contagion in this direction. It does not appear that much fear need be felt, for two reasons: the grasp of the sphincter is usually sufficient to prevent entrance of fluid, and, furthermore, the rectal mucosa is itself extremely resistant to the gonococcus. _Gonorrheal proctitis_ is an exceedingly uncommon infection, and one rarely seen, except in extreme cases of sexual perversion. It should be treated in about the same manner as gonorrheal vaginitis, _i. e._, by continuous irrigation with hot water, and stretching the sphincter in order to overcome the spasm into which it would be thrown by reflex activity.

_Gonorrheal urethritis_ in women is best treated with local applications of argyrol or one of the other silver compounds. These can be made with a syringe or with a small swab. _Cystitis_ is to be treated in the same manner as when it occurs in the male.

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