Chronic urethritis of gonococcic origin

Front matter

Class

Book A

CofiyrightN

Preface

The procedures of exploration employed for the nana] of the urethra have undergone remarkable improvements during the past twelve years. Thanks to these advances, it has become possible at present to carry out a complete study of urethral pathology. Numerous researches have been directed toward this end. Gonorrhea has especially been made the object of important researches, and we have been enabled to witness, under their influence, the therapy of this affection undergo incessant modifications, which one will search in vain to find duplicated in other special branches of the healing art.

When Desormeaux employed his endoscope for the first time, some forty years ago, he endeavored to establish a rational classification for the various forms of urethritis; but his attempt failed because the method was still too imperfect. The discovery of the gonococcus came in then to modify the conception which had been formed of the pathology of this affection, and endoscopic studies were abandoned, while all efforts were directed toward the newer route which had been opened up. Unfortunately, Xeisser's discovery had but slight practical results, so far as the treatment of chronic urethritis is concerned. During this period the original instrument of Desormeaux underwent successive modificatious. Xitze finally proposed the introduction of a luminous source

(Hi;

IV PREFACE

within the urethra itself, almost in contact with the mucous membrane to be observed and studied. The instrument which he devised, and which Heynemann, a mechanic of Leipsic, afterwards improved under my directions, possesses the practical qualifications which are indispensable to the macroscopic study of the lesions met with in the urethral mucous membrane.

It is thus that a suitable classification of these lesions can be established. The results which the urethroscopic study of the canal had already given me were confirmed by the anatomical researches of Neelsen and Finger. We may assert that the pathological anatomy of chronic urethritis is at the present completely studied. The utility of this study is evident. It is impossible to institute the treatment of a disease without knowing exactly its lesions. It is necessary, in chronic urethritis, as in all other diseases, to make a precise diagnosis. If this precision is insisted upon for affections of the larynx, lungs, eyes, bladder, etc., why should it be otherwise for the diseased urethra ? The term chronic urethritis is quite as vague as that of ophthalmia or of gastritis; it masks an incomplete diagnosis.

Finding the gonococcus scarcely completes the insufficiency; if it is positive it proves the contagious nature of the discharge. Still, a negative result does not authorize a contrary conclusion, since it is demonstrated that in most chronic cases the microbe is found only exceptionally.

To arrive at a precise diagnosis and apply a rational therapy, we must resort to urethroscopy; all other instruments employed in the exploration of the canal give insufficient results. While urethroscopic study of the canal

PREFACE V

permits us to arrive at the required exactitude from a diagnostic point of view, it gives also equally important results regarding treatment. It was thus, in a large measure, that I was led, in the treatment of chronic urethral gonorrhea, to employ a particular mode of dilatation.

Furthermore, once treatment is begun it becomes possible, by means of the urethroscope, to follow, step by step, the progress of the cure, to predict the exacerbations which may arise, and to recognize finally the moment, when all lesions having disappeared, the patient may be considered as cured.

More than fifteen years ago I described the method of dilatation which I have always since employed, and which has been gradually adopted in Germany and in foreign parts. I have added few modifications since this time, but the method has proven its own worth in the hands of my pupils, and its results are incontestable. I should, however, add that it cannot be employed with any certainty of success without the aid of urethroscopy.

The study of urethroscopy is long and laborious indeed, but the difficulties which a science presents should never discourage a serious worker; only superficial natures take fright at them. The appearances that the urethroscope reveal present an enormous variety, and are modified in the different portions of the canal. The lesions are often but faintly marked and difficult of recognition; but with a good method one learns, little by little, to know what he is about. In the work which Doctors De Keersmaecker and Verhoogen now present to the medical public, they have exposed with distinctness the principles of urethroscopy. Its study will thus become an almost easy matter

VI PREFACE

for him who is willing to devote to it the necessary time, for he can only attain it by perseverance and after having attentively examined a large number of patients.

As to the method of treatment which I have advised, it gives indisputable results. To succeed, the novice should conform himself exactly to the rules which experience has dictated. Later on, when he knows how to appreciate to their full extent, the results of each one of his interferences, he may permit himself, on his own responsibility, to take such liberties as he may deem useful; but before reaching this point he should have had an experience of several years. Furthermore, it is indispensable to be able to follow, step by step, during the whole course of treatment, the results obtained; and to accomplish this he must frequently examine the canal by means of the endoscope. No maneuver should be undertaken without a previous examination to determine whether it is surely indicated.

The results, however, which will thus be obtained are remarkable, and we can say that every chronic gonorrheal urethritis may surely be cured, provided that the lesions of the mucous lining of the canal are solely of gonococcic origin.

F. M. OBERLANDER,

Dresden, July 1, 1897.

EDITOR'S PREFACE

After the exhaustive preface of the great authority on urethroscopy, there would scarcely be any need of another preface by the editor of this volume, were it not for a few words of explanation to the American medical reader.

The treatise in its original form deals with chronic gonorrhea of the urethra only. In view of the extremely frequent complications of the contiguous seminal glands, it seemed eminently appropriate to the editor to append a chapter dealing with some aspects of their involvement, dependent upon the gonorrhoic process.

Some gaps in the original work, as pointed out by many reviewers, prompted me to the attempt to incorporate in this work Chapter XIV, on Palpation and Expression of Cowper's, the Prostate, and the Seminal Glands; while Chapters XI, XII, and XV represent another effort, to acquaint the reader with details on the treatment of Chronic Gonorrhea, Urethral Asepsis, and the question of Gonorrhea and Marriage, respectively. Also revision and enlargement on the subjects of urethroscopy, instillation, flushing, gonococcus life, and treatment.

The urethroscope, or endoscope as it is still inappropriately called, has proved to be indispensable to the specialist, and ought soon to become as favored an instrument in the hands of the versatile general practitioner as the otoscope or laryngoscope.

The information it gives us in the diagnosis and treat-

(vii)

viii editor's preface

merit of gonorrheal urethritis can only be appreciated by those who have been enlightened by its revelations. The exactness with which it enables us to perform rational dilatation under its control, the distinctiveness to discover granulations, diverticuli, or polypi, responsible for many an inexplicable, obstinate discharge, cannot be superseded by any other instrumental contrivance in use. Besides showing the well -characterized changes of chronic urethritis, it enables us to diagnose the earliest onset of a relapse, which the most painstaking exploration with bougies, etc., would fail to reveal. It enables us to localize circumscribed patches, erosions, and ulcers for topical applications; to treat or destroy the main abodes of the gouococci, the diseased urethral glands; to presage relapses, to determine the stage of infiltrations, and to pronounce a cure. In short, it furnishes information unobtainable by any other method or methods.

But in thus extolling the virtues of the urethroscope, I do not claim it to be a cure-all, to the exclusion of other well-tried methods in use. The reliance on bacteriologic and microscopic methods solely for diagnosis, without using clinical means, is a one sided procedure. Without doubt, the employment of both methods will bring us as near to perfection in the diagnosis and treatment of chronic gonorrheal affections as is possible in the present state of scientific research.

The joint authors of this volume have admirably succeeded in giving to the specialist an exhaustive and scientific presentation of urethroscopy in all its details, which, it is hoped, will prove a welcome guide!

The translation of this treatise was conceived bj r the

EDITOR S PREFACE IX

editor while pursuing his studies abroad, and enjoying*

the privilege of meeting the foremost representatives of

urethroscopy.

The editor is conscious of some short-comings; yet

he feels that his attempt to make urethroscopy available

to the general practitioner, and acquaint his American

confreres with so useful a department of our science,

may not be in vain. If he has partly succeeded in this

effort, he will consider himself amply rewarded for his

labors.

LUDWIG WEISS.

77 East Ninety-first street, New York, March, 1901.

Those portions of the text included between brackets ( [ ] ) have been added by the Editor.

CHAPTER II The Gonoccus

I. Preparation and Staining . 17

II. Morphological Features 23

III. Cultures 25

IV. Biology of Cultures 26

V. Inoculations 27

VI. Clinical Study of the Gonococcus 28

VII. Extension and Generalization 30

VIII. Persistence and Increase 31

IX. Secondary Infections 34

CHAPTER VIII Urethral Endoscopy (Urethroscopy)

I. Instruments and Operative Technique 68

II. Endoscopy of the Normal Urethra 85

III. Endoscopy of the Pathologic Urethra — General Survey . 91

Description of the Lesions Met with in the Tissues of the Canal —

I. The Mucous Membrane 96

II. The Epithelium 100

III. The Folds 104

IV. The Glands, and Lacunae of Morgagni 106

Special Description of the Various Forms of Chronic

Urethritis 118

V. Endoscopy of the Posterior Urethra 140

VI. Appendix — Papillomatous Urethritis 151

CONTENTS Xlll

Introduction

The actual progress in the study of chronic urethritis during the last few years has completely modified the conception which had been formed of this very frequent disease. Therefore we have thought that it would be useful to take up the study of the question in its entirety again, pajdng especial regard to the facts as they actually exist. There is no chronic disease so wide -spread as gonorrheal-urethritis — its tenacity and its resistance to all forms of treatment are features universally known. We may add that the special gravity which it presents from a sociological point of view, and which is often hidden under insidious forms, did not clearly stand forth until recent discoveries of gynecology made it clear.

[The French use the word "blennorrhagie urethrale" to denominate what we call in the vernacular "clap," and the Germans, "Tripper." As a technical expression the words blennorrhea or blennorrhagia possess the advantage of being logically correct, but devoid of a more specific meaning. Blennorrhea comprises every discharge containing pus, while the term gonorrhea denotes only a flow emanating from the genital organs. The ancients identified the disease with the seminal flow. (Hence the name gonorrhea — from yoVos, seed and pw, to flow.) Neisser, in giving the causative coccus the name gonococcus, conveyed to us

Z CHRONIC URETHRITIS

the meaning of a parasite contained in the flow. Although the generic term, gonorrhea, is etymologically incorrect, it is almost universally used in its application to a specific type of inflammation affecting the genito-urinary organs, and answers all practical purposes well.]

Besides, physicians themselves do not appreciate in general the importance of chronic urethritis. ■ The whole tableau of the symptoms which it presents passes only too often unrecognized; only the purulent discharge, the goutte militaire, seems to deserve their attention. The importance that is accorded this symptom becomes even so predominant that it appears to constitute, in itself, the entire disease. All the efforts of therapy are directed against it, and if it disappears the disease is declared cured.

Nevertheless, whether there be a discharge or not, the disease continues its evolution, frequently carrying with it consequences of the most disastrous nature; for chronic gonorrhea of the urethra is not, as is often thought, a benign affection without gravity. It is, on the contrary, a redoubtable enemy, which seems at times, it is true, to remain inactive, but never becomes wholly disarmed.

At each instant the disease may take on again an acute form; it extends without cessation, and its immediate or remote complications form one of the most outbranchiiig chapters of pathology. Finally the patient who is affected furnishes a focus of infection for others, the more dangerous because it is almost always unrecognized.

The affection may be transmitted unwittingly or innocently from the man to the woman, and provoke in the latter the occurrence of serious accidents of genital blennorrhagia with all its consequences.

[As early as 1872 Noeggerrath of New York maintained and emphasized the fact, alluded to by Bernultz in 1859, that gonorrhea, and especially the latent form, is the cause of many serious ailments in women. The acute and chronic metritis, endometritis, perimetritis, ovaritis are, in nine-

INTRODUCTION 3

tenths of the cases, due to latent gonorrhea in man. We know that gonococci may lie dormant in Littre's glands, or in the secure depths of Morgagni's crypts, in Cowper's, or in the ducts of the prostatic glands, or in the remote abodes of the seminal vesicles. The "morning drop " of the patient may not show the presence of any gonococci, the scrapings of the urethral mucosa, the careful and trying examination of the threads in the urine may all prove negative, and yet there might be gonococci hidden in the contiguous tissues and glands. There they lie, seemingly innocuous in their latency, until a sudden mechanical impulse sets them free. Excesses in Baccho and Venere and irritations of the genitalia of a kind to cause often-repeated hyperemia; over-indulgence, better known as the muchcomplained of "strain"; chronic prostatitis, perchance even constipation, all these may cause, in a mechanical way, an expression of gonococci and a new invasion of the urethral mucosa by them.

We have but lately seen such a case of auto -reinfection in a young man who had gonorrhea two years ago. He went through a well-conducted treatment of permanganate of potash irrigations in vogue at that time, and afterwards with astringents. No discharge being present, he considered himself cured. Lately he appeared with a discharge for the origin of which he could not account. The patient we knew to be trustworthy, and there was not the slightest necessity to withhold the truth. He had had no sexual intercourse for six weeks. He complained of excessive constipation and of very frequent nocturnal seminal emissions. On examination, the meatus did not show any sign of inflammation, there were no pains on pressure on the fossa navicularis, — in short, not the slightest sign of an acute process. The discharge showed a few gonococci. We carefully washed out the anterior urethra with a warm boric acid solution until the fluid returned absolutely clear. On massaging his prostate, a viscid white fluid soon trickled out of his meatus. Microscopic examination showed the presence of very numerous gonococci. Whence did these come ? There can be no doubt that they came from the prostate. The patient, when he ceased treatment, must have had an uncured posterior urethritis which infected the prostate. Attenuated virulency of the gonococci did not at that time set up an acute prostatitis, but caused a chronic involvement of that organ with gonococci which remained latent until, by accident, they became again active. A thorough examination of a candidate for marriage is therefore a necessity.]

We will not dwell upon all the accidents to which this transmission niay give rise. We will, however, recall the fact that from a social point of view, sterility in the woman is only too often the consequence of this gonorrheal infection of the genital tract and of the surgical mutilations to which it leads.

When gonorrhea is thus introduced into a family, are we to limit ourselves to looking after the purulent ophthalmia of the infants, the vulvo- vaginitis of the little girls, or the gynecological affections of the mother ?

Should we not, on the contrary, go back to the origin of all these ills, and cure, first of all and in a definite manner, and completely, the gonorrhea of the head of the family ?

Now it is quite rare that this result is obtained, owing to the fact that the diagnosis of gonorrhea in man is not made with all the exactitude and precision necessary. Besides, until recent times, it was a m3 T sterious disease whose pathology was vague and whose lesions were scarcely known.

The discovery of the gonococcus (1879) cleared up this question. Since then works on this topic have multiplied and taught us, little by little, that gonorrhea is a specific disease, due to the action of a particular microorganism — the gonococcus. In its development upon the mucous lining this microbe produces in it an acute inflammation, a

INTRODUCTION 5

urethritis of typical course whose violence and spread may be more or less extensive according* to the resistance of the subject and, without doubt, also, the virulence of the infection.

At the end of a certain time the period of acute evolution is terminated, and the disease begins to retrogress.

At times the cure is effective in this manner, but most often gonorrhea, even subjected to a well-directed treatment, passes gradually into a chronic state. Lesions persist which, instead of disappearing have, on the contrary, a strong tendency to spread without ceasing.

Chronic urethritis is, accurately speaking, made up of the subsequent evolution of these lesions.

At the same time that this pathogenic conception of the disease was taking definite shape, the processes of investigation indispensable to diagnosis were being continually perfected. The canal of the urethra became directly accessible to visual observation, and its slightest details could be studied.

From this time on it became possible to follow here the evolution of gonorrheal lesions in situ, to determine, with exactness, its seat and extent, to observe its progressive advance or its cure. In a word, we were enabled at last to make a precise diagnosis.

The practical results of these advances were not slow in showing themselves. Up to this time the treatment of chronic urethritis had been purely empirical, and the physician found himself guided only by some vague precepts derived most often from incomplete observations.

All the general or local treatments, which promised to be appropriate for the urethra because they had given good results in the treatment of suppurative processes elsewhere, were successively advocated with enthusiasm and then abandoned after a more or less ephemeral existence.

A few local applications alone were retained because a prolonged usage had shown their beneficial effects. Such b CHRONIC URETHRITIS

was the case with the balsamics, the astringents, and the nitrate of silver. These were employed, however, more or less in a haphazard way, without their utility being accurately predicted or their action controlled. Such should no longer be the case. Henceforth the treatment of chronic urethritis cannot be left to chance.

An accurate diagnosis will be followed by a rational treatment; but, to arrive at this result, we must be able to make a complete study of the question.

The domain of gonorrhea in man is indeed vast. The disease can, in certain cases, become generalized and invade the entire economy. In its chronic state it is almost always limited to the genital and urinary organs.

In this work we shall limit ourselves to a study of chronic gonorrheal urethritis. For other localizations of the disease (epididj-mitis, cystitis, prostatitis, etc.), we must refer the reader to special treatises.

Part First Anatomo- Pathologic Study

Chronic gonorrheal urethritis results from the evolution of lesions produced by the gonococcus upon the urethral mucosa. It succeeds directly upon the clap, when the acute phenomena have become ameliorated and when the disease takes on a slow course, which may become indefinitely prolonged. This passage into the chronic form is well defined, from an anatomic point of view, by the appearance. of connective-tissue fibers at the seat of parvicellular infiltration, which invades the mucosa during the acute form. These changes appear after a variable lapse of time, generally toward the end of the second month of the disease; but they may also be retarded or show themselves much later. In other respects they do not correspond to a well-defined modification of the symptoms, because they do not appear at the same instant in the whole extent of the canal; they make their debut, on the contrary, in a few spots, only to become generalized little by little. It is thus that gonorrhea passes slowly and gradually from the acute into the chronic form ; and from this fact it results that one can never precisely indicate the moment when chronic urethritis begins.

To make the evolution of the disease clear, we will first briefly recall certain points in the anatomy of the normal urethra and the chief characteristics of the gonococcus, which are indispensable; w T e will then investigate the characteristic lesions of acute gonorrheal urethritis aud, finally, we will observe the alterations which the canal undergoes during the whole course of chronic urethritis.

[The onset of chronic urethritis is not dependent upon the time which has elapsed since the acute attack, but upon the clinical symptoms which have developed after the acute attack has spent its fury. While some gonorrheas will run their course and finally wind up with a perfect cure, others — the majority, by the way — will lose all the characteristics of the acute process and slowly drift into a state of lessened activity.

Besides, some gonorrheas, especially repeated attacks of them, sometimes start ab origine with a slow intensity, representing a lenient form, commonly called subacute gonorrhea. But in the majority of cases acute gonorrhea, after having lost its highly inflammatory character, passes into a sluggish state, with neither pain nor any other functional symptoms, and accompanied only by a moderate secretion (subacute gonorrhea), which invariably drifts either into a latent aseptic urethral catarrh, or in chronic gonorrhea proper.

Therefore it is neither a gonorrhea of long standing, nor a refractory form of it, nor the time which has elapsed since its onset which characterizes chronic gonorrhea, but only the anatomical condition of the mucosa. Through natural or artificial healing influences the diffuse character of the acute state has given place to circumscribed lesions of a lasting character. These consist of erosions, granulations, epithelial changes, and of infiltrations of the glands and of the deeper layers of the mucosa.]

Chapter I Anatomy Of The Urethra

Works on anatomy describe in detail the situation and relations of the canal of the urethra ; ,we will here speak only of its conformation and structure.

I. Conformation. — In the flaccid state the urethra is a canal only in theory, for the walls are in complete apposition throughout its whole extent. In reality the canal exists only when the walls are spread apart to give passage to the urinary stream, or for the passage of some foreign body. This spreading is then the greater the more pronounced the tension to which the walls are subjected. They give way by reason of their elasticity, but once the limits of this elasticity are passed, they tear.

The caliber of the canal is thus not constant; it varies frequently and within wide limits. When the urethra does not functionate, it is reduced to its minimum, and the walls lie in apposition. If we make transversal sections of a flaccid urethra at different levels we observe that the canal has the appearance of a vertical slit in the regions of the glans, that it is transversal in the spongy region, star -shaped in the membranous portion, and takes on the form of an inverted Y in the prostatic region (Fig. 1).

In the state of distension, on the contrary, the form of the canal resembles that of a cylinder of irregular dimensions. The meatus forms almost always its most constricted part; it is almost inextensible and its dimensions are extremely variable. After the meatus comes the fossa navicularis, a small ampulla- like dilatation, which quickly contracts into a neck -like narrowing at times greater than that of the meatus itself. Then comes the spongy portion, which has the form of a truncated cone, decidedly elongated with its summit anteriorly, and which consequently widens out progressively to attain its maximum at the bulb. It is at this point that the canal attains its greatest dimensions. Its walls, especially the inferior, are very extensible. This extensibility of the lower wall, along with the action of the sphincter, which is situated immediately behind, and maintains the urethra completely closed, forms at this point a depression which is the bulbar cul-de-sac. Then the canal again becomes narrowed at the point where it pierces Carcassoune's aponeurosis, and

I 3

^ A

Fig. 1. Transversal Sections of the Male Uretha at Different Levels. (After Quenu.)

1. At the external orifice. 2. In the middle of the glans. 3. At the base of the glans. 4. At the pars spongiosa. 5. At the height of the angle of the urethra. 6. At the beginning of the prostata. 7. At the height of the verumontanum

preserves a uniform diameter throughout the whole membranous portion, to take on a fusiform aspect in the prostatic region and, for the last time, becomes narrowed at the vesical neck.

The canal then forms a cylindrical, very irregular tube whose diameter varies within a wide range, not only from one portion and another, but also in the same part, according to the amount of distention which the walls undergo. When these dimensions are measured it is seen that the deepest parts are the most dilatable. It is thus that we can, without inconvenience, dilate the prostatic region up to 40 or 45 of the Charriere scale (13 to 15 millimeters). The membranous region, which is somewhat narrower, can be dilated up to 40; at times, however, it is difficult to go beyond 30 (10 millimeters). (Fig. 2.)

The dimensions of the anterior portion of the canal

ANATOMY OF THE URETHRA 11

progressively diminish from the bulb to the meatus. The bulbar region is quite as dilatable as the prostatic region, even reaching the size of 50 Charr. (16 to 17 millimeters). The diameter then progressively diminishes until behind the fossa navicularis it is only half that of the diameter of

Fig. 2. Cast of the Male Urethra. (After Sir Everard Howe.)

the bulbar region (24 to 30 Charr.). As to the dimensions of the meatus, of the fossa navicularis and of its neck, they are very variable. The average seems to be about 24 Charr., but we can often go up to 28 or 30. At other times, on the contrary, the meatus is exceptionally narrow and scarcely admits a very thin bougie, without such atresia being due to any lesion whatever.

II. Structure. — The urethra is formed of several layers of tissue which are :

1. An epithelial layer constituted in the prostatic portion by stratified pavement epithelium which passes gradually into the cylindric form toward the membranous region. The epithelium, in the neighborhood of the bladder, is in all respects similar to the bladder epithelium of which it is only the continuation. As we approach the spongy portion, the epithelium takes on more and more the cylindric appearance. The spongy portion possesses a stratified cylindric epithelium. The urethral epithelium is smooth, moist, and shiny. It shows by its transparency the color of the subjacent mucosa.

2. A connective -tissue layer constituting the mucous membrane. This layer is continuous anteriorly with that of the glands. It is fused posteriorly into that of the bladder, and consequently is continuous with the mucous membrane of the ureters and pelves of the kidney. It extends likewise into the ejaculatory ducts, the seminal vesicles, the vas deferens, and the epididymis. The mucous membrane of the urethra is very elastic ; it clings firmly to the subjacent layers, especially in the prostatic region where it is impossible to separate them.

3. A muscular coat formed of smooth fibers which are very thick, especially in the membranous region. The most internal layer, and the one whose fibers are the finest, is longitudinal; the external layer is circular. At the point where the urethra opens into the bladder these circular fibers form a veritable sphincter, like a ring, which is indeed the internal vesical or prostatic sphincter. In the prostatic and membranous regions there exists a third layer of striated fibers. In the whole neighborhood of the bladder they appear above the urethra, forming a sort of arciform muscle (Finger) held between the prostatic lobes. These fibers increase in number as we advance, and when the urethra emerges from the prostate, they form a sphincter-like ring, external sphincter [the so-called cut-off muscle,] which is continuous with the muscles of the ligament of Carcassonne.

4. An erectile laijer which exists only in that portion of the urethra situated anterior to the ligament of Carcassoune, and which is called the corpus spongiosium of the urethra. The spongy body dilates toward the extremity to form the glans penis. It dilates in the opposite direction, and thus forms a thick reflexion, round and prominent, which constitutes the bulb. The bulb is, in a way, appended to the interior wall of the urethra; it is covered over by the bulbo- cavernous muscle which keeps it fixed at this point. Its posterior extremity is, so to speak, shut in by the median perineal aponeurosis which separates it from the membranous region of the urethra.