Diseases of the male urethra, including impotence and sterility

Foreword

In my capacity as teacher of both undergraduate and post-graduate students I have long felt the need for a comprehensive monograph on Diseases of the Male Urethra, including Sexual Impotence and Sterility.

My efforts have been directed toward conciseness, clearness, and simpHcity. The clarity of the subject is greatly assisted by the many illustrations, nearly all of which are original and taken from my clinic at the Post-Graduate Medical School.

Some of my views, I realize full well, are reactionary and may not be shared by some of my colleagues, but the work represents my personal experience, except in so far as I make quotation, particularly in the Biologic Chemistry of the Gonococcus and the Studies on Spermatogenesis.

I wish to make pubhc acknowledgment of the untiring and fruitful efforts of my artist. Dr. Dan Z. Klopper, and the help given me by my assistant. Dr. Leon Seidler.

I. S. K.

May, IQ18.

Chapter I

The urethra begins at the neck of the bladder, passes downward and forward, almost vertically, then gradually ascends to the level of the anterior border of the symphysis pubis. It again turns forward, taking the while for a few centimeters a gradually descending course, penetrating the scrotum. It then

— Set. Vtj

Fig. 1. — Sagittal section of the genital tract.

penetrates the penis, which it traverses along the inferior surface throughout most of its length. The urethra thus occupies successively the anterior part of the pelvic cavity, the anterior part of the inferior walls of the pelvis, called the urogenital diaphragm, the scrotum, and the penis (Fig. 1).

The careful consideration of its course and angles is of practical importance in the selection of sounds for the dilatation of strictures of the urethra.

The urethra may be divided into the pelvic, perineal, scrotal, and penile portions. The pelvic, perineal, and scrotal parts are relatively fixed. The penile part has the same mobility as the pendulous portion of the penis. We thus can distinguish between a fixed urethra (perineal and scrotal portions) and a mobile urethra (penile portion), this division being important from a surgical standpoint. Another classification divides the urethra into the prostatic, membranous, and pendulous parts. The prostatic and membranous parts are the fixed portions of the urethra. The anterior alone, or the pendulous portion, is mobile. The pendulous portion extends from the tip of the penis to the inferior surface of the perineum. The urethra is then composed of an anterior and posterior portion, the posterior consisting of the prostatic and membranous portions.

From a physiologic point of view the urethra from the neck of the bladder to the ejaculatory duct is truly urinary; from the opening of the ejaculatory duct to the meatus it is urogenital.

In its entirety the urethra always remains in an anteroposterior plane. It is concave anterosuperiorly. Arising from a part approaching the anterior surface of the symphysis the concavity increases and it goes to the inferior surface or free portion of the penis; this portion it joins at an angle. The urethra as a whole then has the form of a letter S. But of the two curves of the S, the posterior only is fixed. The anterior curve is easily changed. All that is necessary to obliterate this curve is to raise the penis toward the pubes. The urethra is very loosely attached to its neighboring structures. The prostatic portion is held in place by the puboprostatic ligaments.

The membranous urethra is attached behind by the central perineal tendon to the inferior fibers of the deep transverse fascia. The bulbous urethra is joined firmly to the layers of the ischiopubic fascia. The posterior part of the pendulous portion of the urethra is fixed by the suspensory Hgament of the penis to the inferior surface of symphysis. It is this Hgament which produces one of the angles of the urethra, but this angle is easily obliterated. In resume then, we may say that there is no absolutely fixed point of the urethra, but one portion is more fixed than the rest. This region is more solidly joined to the neighboring portion and consists of the union of the membranous and pendulous portions.

Dimensions. — Sappey, who has taken a number of measurements of the length of the urethra, states that it varies from 15 to 17 cm., divided as follows:

Twelve centimeters for the pendulous urethra, 1.2 to 1.4 for the membranous, and 2.4 to 3 cm. for the prostatic. These measurements correspond closely to those given by other authorities.

Form and Diameter.^In the quiet or detumescent state the walls of the urethra are collapsed; during micturition, on account of the narrowness of the meatus and because of the force exerted by the vesical sphincter, the urethral walls expand. The urethra is then said to be in physiologic or normal distention. It is, of course, possible to stretch the urethra with instruments beyond its normal size. It is in this stretched condition that the surgical caHber of the urethra is measured.

Behind the meatus the urethra dilates into an ovoid, measuring between 20 and 25 mm. in length. This forms the navicular portion. Posterior to this the canal takes the form of a cylinder 6 to 7 cm. in length, extending to the penoscrotal junction. Here again there is a widening, ovoid in shape, extending into the culdesac of the bulb. The membranous and penile portions are cylindric.

The diameters given by Raybard and Guy on are as follows: Fossa navicularis, 7 mm.

Meatus, 8 mm .

Bulbous, 10.3 mm.

Membranous, 8.6 mm.

Prostatic, 8 to 11 mm.

A median section through the entire urethra shows that the meatus, fossa navicularis, and penile portions are in the same axis; this is not true of the bulb, which joins below and behind the true culdesac (Fig. 1). This becomes continuous with the membranous portion. This culdesac develops at puberty and is present only during micturition; it becomes permanent in old age, probably because of the relaxed condition of the walls at this point. An instrument introduced into the urethra and passed straight back encroaches upon the wall of the culdesac and may not pass into the lumen of the urethra. Force exerted will cause the instrument to pass into the wall of the urethra, thus producing a false passage. This, too, may occur in the prostatic portion. Here, near the internal urethral arch, there is an overhanging lip made by the sphincter. The sound introduced incorrectly or brutally may easily produce a false passage.

These depressions or irregularities lie upon the posteroinferior wall. The anterosuperior walls run in a straight line. The tip of a sound should be made to follow along this line in order that it may enter the bladder unobstructed.

Form and Surgical Caliber. — The urethra is supple and can easily take on the form of the instrument introduced into its cavity. According to Otis, the diameter of the urethra can be raised artificially from 8.9 to 12.7 mm. In this proportion it would compare with the diameter of the penis as 1 : 2.25.

The narrowest point of the urethra is at the meatus; it permits of the least amount of dilatation. However, a No. 54 Benique, of which the diameter is 9 mm., may easily be introduced. The membranous urethra may be dilated up to 10 mm. The prostatic region may be enlarged to 2 cm. in diameter. Oberlander and Kollman give the following dimensions to which the urethra can be dilated :

Prostatic and membranous portions, 13 to 15 mm.; bulb, 16 to 17 mm.; the neck of the fossa navicularis, 8 to 10 mm. The capacity of the urethra varies in different individuals and also according to the method by which one distends it. This fact is of practical importance in connection with instillations. According to different investigators the capacity may be said to vary from 4 to 22 c.c.

The prostatic urethra (Figs. 2 and 3) is surrounded throughout its entire length by the prostate gland. In front the prostate separates the urethra from its sphincter, the anterior ligament of the bladder, the plexus of Santorini, and the symphysis pubis; laterally from the fascial layers of the prostate and the venous plexuses which they enclose, and further from the levator ani l/a*- elejt

UC>ni«t<v\

Ve.sicle

-- urelW«v

Fig. 2. — -A dissection of the prostate and adnexae.

muscle; behind from the prostatoperitoneal fascia of Denonvilliers. The openings of the ejaculatory ducts penetrate the lumen of the urethra through the posterior wall. Above, the prostatic urethra becomes continuous with the bladder; below, with the membranous urethra.

The membranous urethra then is a continuation of the prostatic urethra. Below it joins the culdesac of the bulb. Behind, it is in close relation in its superior segment with the rectum, from which it is separated a trifle as it expands, the rectum going i6 behind, the urethra forward. The space between these two structures forms the two sides of the recto-urethral triangle. This triangle contains a quantity of fatty connective tissue, fibers of the superficial perineal fascia, and a fibromuscular raphe joining the central perineal body.

Cowper's glands (Fig. 4) occupy the triangular space which surrounds the membranous urethra and the superior surface of the bulb.

, /HmpuUcL iSemmaL

Sjacu/atoryDuc^- ■ -j I/era Afontanu/n- - J'.

EjaculaTory Duct ..Utricle

Ure/'hra.^ Fig. 3. — Showing the gross structure of the seminal vesicles.

This recto-urethral triangle is of surgical importance in reaching the membranous urethra, the prostate, and the neck of the bladder.

The pendulous urethra (Fig. 2) extends from the membranous portion to the meatus. It is divided into three parts: perineoscrotal, penile, and navicular.

The perineoscrotal part is in relation above with the transverse pelvic ligament and some fascia lamellae which end at the point of union with the corpora cavernosa. This lamella separates the urethra from the dorsal nerve and vessels of the urethra and from the plexus of Santorini. On its posterior surface, running along the bulb a distance of about 2 cm., lie the ducts of Cowper's glands, which empty into the cavity of the urethra.

^ e mbrAtt o«» « lo-ftTo-n .

\ P«n\\e Tort}*

Gland ol L'tifre --

Fig. 4. — Sagittal section of the entire urethra and penis.

Penile Portion. — This part of the urethra is separated by its spongy sheet of fibro-elastic tissue from the circular muscle of the penis and from the skin.

The Navicular Portion. — This part of the canal extends from the level of the crest of the glans penis, the corona, to the meatus.

lis DISEASES OF THE MALE URETHRA

The Structure of the Urethra. — The mucous membrane extends from the vesical orifice to the meatus. It covers the canal throughout its length and acts as a smooth sphincter to the prostate, to the verumontanum (Fig. 3), to the membranous and pendulous urethra. It shrinks at the vesical neck, at the membranous urethra and meatus, at which level the urethral cahber is less. It widens at the prostatic sinus, the culdesac of the bulb, and the fossa navicularis. The utricle, a depression in the veru, and the openings of the ejaculatory ducts are covered with mucosa continuous with that of the canal. On each side of the veru the mucosa is depressed into sinuses which run laterally to it.

The color of the mucosa is uniformly pink, due to the richness in blood supply. The mucosa permits of considerable traction, but it is easily penetrated by instruments. The surface is, as a rule, smooth and lies in longitudinal folds, which are drawn taut during the tumescent period.

The utricle (Fig. 3) lies in the median line upon the superior surface of the verum. Its average length is 5 mm. and at times it may become greatly enlarged, so as to engage the tip of a sound. The two openings of the ejaculatory ducts (Fig. 3) lie on either side of the verum; they are not always symmetric. The prostatic ducts (Fig. 3), numbering from ten to twenty, open into the floor of the prostatic urethra. They are usually arranged symmetrically in lines.

The folds of the mucous membrane are present only when the penis is quiescent. They lie parallel to the axis and are slightly elevated. They are finest on the verumontanum, but here they are very elastic, to allow for the pronounced turgescence which occurs at tliis point. The folds are quite pronounced in the floor of the prostatic urethra proper. Lower down they are less hard and are traversed by perpendicular folds, which give to the mucous membrane of this region a fine reticular appearance. In the membranous portion of the urethra they are more elevated. In the region of the bulb the folds are not pronounced, but reappear in the penile portion to become obliterated in the fossa navicularis, where the mucous membrane is quite smooth. There is not infrequently a longitudinal fold on the posterior aspect of the fossa navicularis. This is spoken of as the valve of Guerin (Fig. 2). This is of practical importance in dealing with gonorrhea, and should always be taken into consideration in the passing of instruments which may impinge in its fossa.

The Histology of the Mucous Membrane. — The thickness of the mucous membrane varies in different portions of the canal. Its greatest thickness is in the prostatic urethra. Here the epithelium is of the stratified squamous type, at times showing transitional characteristics. Throughout the bulb and penile portions it is of the columnar variety, and at the fossa navicularis the cells change to the true stratified squamous form, which variety continues to the meatus.

The submucous supporting tissue is of the greatest importance in considering infections invading the urethra. It is not intimately connected with the membrane which forms the base of the epithelial layer. This is shown by the ease with which the epithelial folds can be stretched during erection. The submucous layer carries the blood and nerve supply and the glands of Littre (Fig. 5). These glands were first described by Littre in 1706; they are present throughout the entire length of the urethra. They form linear series all around the urethra in the prostatic region and present the same character as the trigonal glands, which seem to be aberrant Littre glands. Their distribution in the membranous urethra has no regularity. They are much more abundant on the anterior wall than upon the posterior, but fewer in number here than in either the prostatic or anterior urethra. These glands are most numerous in the pendulous portion of the canal. The anterior wall is more richly supplied than the posterior. The glands are much more perfectly developed in the anterior than in the posterior urethra. In the anterior region their excretory canal reaches a considerable length, often as long as 5 mm. In the penile portion they are most numerous in the midst of the erectile tissue, which explains the abundance of secretion at the moment of erection. The secretion from all these glands is a clear mucus. It is the presence of these glands, with their long ducts and complicated structure, that makes the course of gonorrheal urethritis so long and so seriously influences the prognosis. They also are most important factors in contributing to the pathology and complications of the same infection. These points will be considered in detail in their proper places.

Fig. 5. — Microscopic section of a gland of Littre opening into the lumen of the urethra: a and b, Lateral branches of the main duct; c, c, trabeculse of the cavernous tissue; d, deeper acinus; e, fibrous layer of the urethral mucous membrane; /, continuation of the main duct. (Watson.)

The lacuna.^ of Morgagni are little culdesacs with large orifices opening into the mucous membrane. They extend from the fossa navicularis to the membranous urethra. They are variable in size, different anatomists also giving varying estimates as to their number. Their practical importance lies in the fact that they contain from thirteen to twenty orifices of the glands of Littre, consequently being the seat of important pathologic changes in urethral infections.

The muscles of the urethra are circular and longitudinal. In the prostatic region the muscular bed is smooth, varying in thickness from 1 to 3 mm. Some of the fibers are continuous with the trigone of the bladder. The circular fibers at this point form a sphincter.

In the membranous region the muscular layer is very thin and contains both circular and longitudinal fibers. These fibers are of considerable strength, however, and are of practical importance, inasmuch as it is due to their contraction that spasmodic stricture of the urethra is produced.

The longitudinal muscular layer disappears in the region of the anterior urethra. The circular fibers become thinner and also disappear.

Blood-vessels.— The prostatic portion of the urethra is supplied by the prostatic branch from the middle hemorrhoidal artery and from the inferior vesical. The middle hemorrhoidal and transverse perineal supply the membranous urethra, and the anterior urethra gets its blood supply from the bulbar artery, a branch of the inferior hemorrhoidal.

The veins from the posterior urethra drain into the lateral prostatic plexus and plexus of Santorini, and from the anterior urethra through the dorsal vein of the penis into the plexus of Santorini.

The lymphatics drain from the venous spaces in the spongy area, along the dorsal vein of the penis, into the superficial and deep inguinal lymph-nodes. This is evidenced by the presence of l>Tnphangitis and adenitis in the more virulent forms of gonorrheal urethritis.

The nerve supply comes from filaments of the hypogastric plexus.

Chapter II

fflSTORY OF GONORRHEA

History. — Our story begins at the fifteenth chapter of the Book of Leviticus, where reference is made to an unclean discharge from the genitals in men and women. Again, the Second Book of Samuel tells us that the curse of God was visited upon the unrighteous Israelites by a ''pusy discharge."

The Papyrus of Ebers, the oldest book of the Egyptians upon medical therapy, contains many prescriptions for injections "for the cure of inflammation and obstruction in the urethra." Hippocrates writes at considerable length about the "genital discharge in both the sexes."

Aretaeus describes the urethral discharge as "an unpleasant and loathsome contagious disease. By day and by night there is a discharge of cold semen; the flow is thin, colorless, and cold. When contracted by young patients they become haggard, weak, discouraged, indigent, pale, effeminate, lose their appetite; their glands become painful, and they become weak and unfit for anything."

Alexander of Tralles (525 to 605 A. D.) describes two types of "seminal flow," one due to "youthful frequent love lust," and the other due to "uninterrupted excess"; in the latter case the discharge is "rancorous and burning."

A slight advance in the conception of gonorrhea was made by the Arabian, Avicenna (980 to 1037 A. D.). He describes it as an "ardor urinae," due either to "too frequent coitus which produces a burning during urination without discharge, or to an internal disease of the smallest structures of the urethra accompanied by burning, purulent and bloody discharge."

Then followed (1530) Paracelsus' account of the disease and the description of Thierry de Hery (1552), who calls it "pisse chaude veneriene," the term which is retained in vulgar parlance

HISTORY OF GONORRHEA 23

among the French. One year later the term "gonorrhea gallica" was coined by Antonio Brassavola.

Lorenzo Terrando (1709) was the first to describe the finer structures of the urethra and their involvement by the gonorrheal infection. Ten years later Morgagni (1719) wrote the first comprehensive anatomic and clinical treatise on the disease.

It was not until the beginning of the eighteenth century that a clear understanding was reached that gonorrhea and s>philis are in no way connected with each other. Up to this time it had been supposed that syphilis was always the result of a primary gonorrheal infection.

Then followed years of experimental attempts to produce gonorrhea in animals. The names of Benjamin Bell (1793), James Tongue (1801), and Jean Frangois Hernandez (1812) are associated with this work. However, it required Philippe Ricord (1838) to settle once and for all that the disease was not communicable to any animal.

A period of forty years now elapsed before any further definite knowledge was obtained regarding the nature of the disease. A number of parasites, fungi, and bacteria were isolated and heralded as the cause of gonorrhea. It remained for Albert Neisser (1879) to discover the specific organism. His discovery uncovered the true pathology and paved the way for the therapy which today, in general principle, is more or less followed.

It is interesting to note among the various historic accounts of the treatment of gonorrhea the many different medicaments and methods advised. Strict diet combined with rest, cold baths, topical appHcations of water, water irrigation; fomentations of wine, vinegar, oils, and salves to the genitals are among the list of therapeutic measures.

Then came the injection era. Among the drugs suggested as curatives the following are to be found: Lead preparations, especially the acetates; lime-water, calomel, and corrosive sublimate; red wine, sulphate and acetate of zinc; copper salts, alum, opium, and last, silver nitrate. In 1802 Heckert suggested the use of medicated urethral bougies or suppositories.

Internal medication dates back to Marco Gatinario (1462), who advised the use of turpentine as a specific for both gonorrhea and syphilis. Cantharides, suggested by Bartholin (1465), next became the fashion. Then came Sylvius' (1674) recommendation of copaiba, and Sydenham's (1680) of balsam of Peru. Unfortunately both of these drugs are still rather extensively and often disastrously used.

John Hunter in 1786 suggested the abortive treatment by rest alone, without any medication, either local or internal.

We thus enter upon the consideration of this infection with a history quite varied and complicated, and in spite of our advanced medical, pathologic, and bacteriologic knowledge we are forced to admit at the outset that we are far from a uniform agreement on a rational and efficient therapy.

Chapter III Bacteriology Of Gonorrhea

The Gram-negative intracellular diplococcus, as described by Neisser (1879), found in the purulent discharge from the urethra has been accepted without question as the causative agent in each case where its presence has been demonstrated.

We are today confronted by the revolutionary work of Carl C. Warden which, though contrary to our long-cherished acceptance of the biology of the gonococcus, rings so true to the scientific mind that we are forced to change our views in regard to the biochemistry and morphology of the organism which produces what we have, since Neisser's discovery, accepted as gonorrheal urethritis.

Warden has worked upon the gonococcus and allied bacteria for several years, and his thousands of experiments are so convincing that we must perforce accept his results, which in turn will necessarily have an important bearing upon the future therapy of this specific infection.

The following are excerpts, many taken verbatim, from the masterly communications of this tireless investigator.

Working with twenty-two different strains of gonococci he concludes as follows concerning the morphology, which he shows to be of great variability:

"My experience has been that by using many strains and by varying the medium on which they are grown one can observe all the types of the entire coccus family. By undoubted processes of reversion and variation it is possible and common to observe staphylococcus-like clumping of single forms, short-chain formation, as with the streptococci, lanceolate forms, indistinguishable from pneumococci in shape, diplococci forms resembling the catarrhalis group, all in unquestionably pure cultures of gonococci. All return promptly to strain type on appropriate media."

He recommends as the stain giving the sharpest contour, 1 part of carbol-fuchsin and 3 parts of distilled water.

In comparing the role of the staphylococcus in gonorrhea we are astounded by the following dogmatic statements:

"1. Many, if not all, of the Gram-negative intracellular biscuit- or coffee-bean-shaped cocci, observed in the purulent discharge in acute gonorrhea, which are regarded as gonococci and which serve as criteria of diagnosis, are not gonococci, but belong to the staphylococcus group. The provisional designation Staphylococcus urethrce is suggested for this coccus.

"2. True gonococci are demonstrable with difficulty or not at all in smears of gonorrheal exudate, or in preparation of tissues.

''3. Gonorrhea may be due to a double infection and dependent on a microbial sjonbiosis.

"4. The diagnosis of gonorrhea rests on cultural methods only. The old criterion, the microscopic appearance of smears, is unreliable.

"The diplococci in smears of pus from acute gonorrhea are intracellular. Gram-negative, biscuit- or coffee-bean-shaped, clear cut, sharj^Iy outlined, and have a marked avidity for methylene-blue. Comparing these characteristics with those of gonococci from recent cultures we note that single cocci predominate and that they are discrete. j\Iany are irregularly shaped diplococci, many are shadowy and of indistinct contour, some are irregular in size, and nearly all take the methylene-blue stain poorly. They are always Gram-negative. WTien gonococci are taken up by leukocytes in the guinea-pig or in the test-tube they do not at all resemble the cocci within the leukocyte in gonorrheal pus, but there are cocci, namely. Staphylococci urethra?, which under the same conditions appear identical with them. All my efforts to induce free phagocytosis of live virulent gonococci have failed, whereas the staphylococcus is readily phagocy table.

"These facts lead me to question the identity and role of the intracellular diplococci, invariably seen in smears of gonorrheal pus, which hitherto have been accepted as gonococci.

"The designation of Staphylococcus urethrce will distinguish

BACTERIOLOGY OF GONORRHEA 27

the coccus from other varieties of Staphylococcus alhus, found elsewhere in the body, from which it differs but Httle. This staphylococcus has been isolated by me from 52 cases of gonorrhea and 20 normal urethras. It may prove to be a habitat of the normal urethra just as the coccus of Welch is a resident in the skin. These organisms do not lie simply in the folds and crypts of the urethral canal. If such were the case they would be recovered more often from the urine. They He in the cell interstices and follicles of the glands, and slight abrasion of the mucous surface is necessary to liberate them. At any rate it is common to see colonies of staphylococci starting from a single individual or pair adhering to the border or surface of an epithelial cell.

"From observation of cultures and a large number of phagocytosis experiments with fifteen strains of staphylococci, I have been led to believe that within the urethra during gonorrheal inflammation the staphylococcus may be Gram-negative, whereas without the body in ordinary cultures it is Gram-positive.

"The action of staphylococcic and gonococcic antisera upon the staphylococci favors phagocytosis.

"Suspension in diluted serum for long periods of time acts similarly to suspension in undiluted serum for shorter periods of time.

"If we accept the conclusion of Benians in regard to Grampositiveness of staphylococci, namely, that it is due to the action of iodin on the cell wall of the cocci, which prevents the alcohol from washing out the stain, it is possible to account for the loss of the stain by the physiologic change represented by the biscuit form.

"It is possible that the toxicity of the staphylococcus induced by serum and possibly evident by the Gram-negative state exert an influence locally in the urethra during the course of gonorrhea, and also on the body as a whole, greater than has been supposed."

It has long been recognized that co-artificial cultivation of the gonococcus is a matter of considerable difficulty. It will grow imder the most minute test and then on only specially prepared culture-medium at body temperature; the slightest variation in the surroundings will prevent its growth. In connection with this, Warden notes that as the infection progresses the gonococcus is less and less in evidence in the cultures, until finally about the sixth or eighth week it has disappeared altogether. The time corresponds fairly accurately with that at which the complement-fixation test is strongest. Of greater interest in this connection is the fact that the complement-fLxation test for Staphylococcus urethrcB is directly parallel to the gonococcus test.

Outside the body the gonococcus is very easily killed, the weakest antiseptic solution, raising or lowering of the temperature, or desiccation, will in a short time kill the organism. The question then that will arise is: Why is eradication of the gonococcus from the urethra difiicult? The pathology of the infection, taken up later, furnishes the answer to this question.

Fig. 6.

Fig. 8.

Fig. 9.

Fig. n.

Fig. 6. — Acute gonorrhea. Third day after discharge was first noted. Evidently a less virulent infection than in Fig. 7. The folds of the mucosa are evident.

Fig. 7. — Acute gonorrhea. Fourth day, showing the pronounced hjqjeremia. The swelling of the mucous membrane is so marked that the folds are scarcely to be seen. There is some pus exuding from the crypts of Morgagni.

Fig. 8. — Gonorrhea one week old. Navicular portion. The distortion of the mucous folds is very marked, suggestive of a beginning abscess seen later, and shown in Ing. 9.

Fig. 9. — Three small abscesses seen one week later than the condition as shown in Fig. 8, or two weeks after the beginning of the discharge. These abscesses were punctured. They closed a few days later and did not re-form.

Fig. 10. — Acute infection engrafted upon a chronic urethritis. The acute attack is ten days old. The previous infection was ten months. The acute, pathology is represented by the marked edema and pus exuding from the crypts. The granulations are indicative of the chronic condition.

Fig. 11. — Gonorrhea two weeks old. A virulent invasion. The lumen of (he urethra is markedly dislocated by the swelling.

Fig. 12. — Gonorrhea four weeks old. The pathology is much more intense than in Fig. 11. Evidently a very virulent strain. The degree of hyperemia and pus formation is very pronounced. Note the profuse suppuration and hemorrhage into the lumen. A large abscess formed (Fig. 13) a few days later.