{"1": {"fulltext": "", "height": "4516", "width": "2660", "jp2-path": "irrigationtreat00vale_0001.jp2"}, "2": {"fulltext": "Glass.\\nBook.\\nCOPYRIGHT DEPOSIT", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0002.jp2"}, "3": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0003.jp2"}, "4": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0004.jp2"}, "5": {"fulltext": "THE\\nIRRIGATION TREATMENT\\nOF\\nGONORRHOEA\\nITS\\nLOCAL COMPLICATIONS AND 8EQUELE\\nBY\\nFEED. C. VALENTINE, M.D.\\nprofessor of genito-drlnary diseases, new york school of clinical medicine:\\nGenito-Urinary Surgeon, West Side German Dispensary; Genito-\\nurinary Consultant to the United Hebrew Charities\\nto the Metropolitan Hospital and\\ndispensary, etc., etc.\\nILLUSTRATED BY FIFTY-SEVEN ENGRAVINGS\\nNEW YORK\\nWILLIAM WOOD AND COMPANY\\nMDCCCC", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0005.jp2"}, "6": {"fulltext": "TWO COPIES RECEIVED,\\nLibrary of Cangra\u00c2\u00bb%\\nOffice of the\\nMAP 1 S 1900\\niUglator of Copyright*\\n56211\\nCopyright, 1900\\nBy WILLIAM WOOD AND COMPANY\\n6* CON\u00c2\u00a9 COr*Y f\\nTHE PUBLISHERS PRINTING COMPANY\\n32-34 LAFAYETTE PLACE, NEW YORK", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0006.jp2"}, "7": {"fulltext": "rpiIE GENERAL PRACTITIONER, more particularly he who labors in\\nthe smaller communities, must be a specialist in all branches of medicine.\\nThe demands upon his waking and sleeping hours are usually so great that\\ntime is not his for extensive literary research or for the study of exhaustive\\ntheoretical volumes.\\nHerein lies the motive for the present effort of the writer to offer as con-\\ncisely as possible the essential facts in connection with the treatment of gonor-\\nrhoea, and to place before the busy practitioner the results of his experience.\\nThe General Practitioner, who conscientiously exercises his power to\\nbenefit mankind, must treat gonorrhoea when called upon to do so and he\\nmust treat it in a manner that will protect his patients and the public from\\nthe consequences of this disease. Furthermore, it is the work of the General\\nPractitioner which forms the firm foundation upon which the superstructure\\nof medical specialism is built therefore,\\nTO\\nTHE GENERAL PRACTITIONER\\nTHIS LITTLE BOOK\\nIS FRATERNALLY DEDICATED", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0007.jp2"}, "8": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0008.jp2"}, "9": {"fulltext": "INTRODUCTION.\\nThe larger and better works on genito-urinary diseases fully\\ndiscuss gonorrhoea. Unfortunately none of them, except the\\nmaster-work of Guy on, makes much more than casual mention\\nof the irrigation treatment of this ever-prevalent, painful dis-\\nease, which when empirically treated is likely to be fraught\\nwith most disastrous consequences.\\nIt is the purpose of this little book to fill the hiatus, until\\nabler pens supply the missing chapter in new editions of their\\nworks.\\n1 Guyon Lecons cliniques sur les Maladies des Voies urinaires, troisieme\\nEdition. Paris, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0009.jp2"}, "10": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0010.jp2"}, "11": {"fulltext": "THE IRRIGATION TREATMENT OF\\nGONORRHCEA.\\nGENERAL CONSIDERATIONS.\\nGoldberg 1 was the first to subject the results of the irriga-\\ntion treatment of gonorrhoea to mathematical tests. He summed\\nup the publications of all who had written favorably or other-\\nwise on the method, and showed that these reported\\n60 per cent, of acute gonorrhoeas cured within 10 days,\\n30 14 days,\\n10 were not cured.\\nOf the last mentioned one-tenth of the cases the failure was\\nclearly attributable in one-half of them to indulgence in alcohol\\nand coitus, and the remaining 1iyq per cent, were not explained.\\nThese failures in the hands of such authors will probably find\\ntheir explanation in those rapid invasions of the urethral adnexa\\nwhich will be considered later on in discussing the complications\\nof gonorrhoea.\\nAt all events, no method of treating gonorrhoea offers as many\\nscientific grounds for its employment, and not another can show\\nninety per cent, of cases cured within fourteen days.\\nThat a large number in the profession appreciate this is\\nshown by the following facts\\nIn 1894 not a dozen men in the world were using the irriga-\\ntion treatment in gonorrhoea. Many had attempted and dis-\\ncarded it, owing to defective apparatus; others had obtained\\nnegative or unfortunate results, owing to faulty technique. In\\nface of the adverse criticisms these conditions provoked, it\\n1 Goldberg: Die Behandlung der Gonorrhoe mit Ausspiilungen von uber-\\nmangansaurem Kali. Centralblatt fur die Krankheiten der Harn- und Sexual-\\nOrgane, Band vii., Hefte 3 und 4.\\n1", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0011.jp2"}, "12": {"fulltext": "2 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nrequired commendable courage on the part of Felicke of Buda-\\npest, Janet of Paris, E. R. W. Frank of Berlin, and Swin-\\nburne of New York to persist in a method in which then, they\\nalone succeeded.\\nSome time before, I was convinced of the results obtainable\\nand of the opportunities offered for advancing gonorrhoea from\\nits empiric therapeutic chaos. It seemed to me that if the pro-\\nfession at large were offered an apparatus by which irrigations\\nmight be easily and correctly performed, the advantage to\\nscience and to patients would be more readily appreciable.\\nThere is no purpose in reciting the evolution of the apparatus.\\nIt will suffice to describe herein the last result of six modifica-\\ntions, the one now used.\\nThe middle of 1899 shows about six thousand physicians in\\nthe United States alone, using the irrigation method, errone-\\nously called the Valentine method, of treating gonorrhoea.\\nI did nothing except devise a simple apparatus, develop the\\ntechnique, modify the medications, render the rules precise,\\nand write many articles, carefully weighing the advantages and\\navoidable disadvantages of the irrigation treatment.\\nI. THE IRRIGATOR.\\nThis apparatus consists of a board (Pig. 1, a a) with a brass\\nrod attached (g). Readily sliding upon the brass rod is a metal\\nblock, connected by a strong bar to a collar (c). This firmly\\nholds a percolator (h) of a capacity of 1,000 c.c. (about one\\nquart). The opening that interrupts the completeness of the\\ncollar permits easy removal of the percolator when required.\\nThe nipple of the percolator is inserted into a soft-rubber tube\\n(i) seven feet long. The distal end of this rubber tube is\\npassed through a stopcock, whose essential parts are a ring (J)\\nfor admission of the fourth finger a sliding flange (k) to increase\\nor decrease the pressure of the fluid; a shield to catch the\\nfluid that spurts from the urethra and divert it into a basin held\\nby the patient a small ring (ra) to suspend the stopcock when\\nnot in use. Pig. 1 shows a urethral nozzle (n) inserted into the\\nrubber tube, projecting through the stopcock.\\nThe board has brass plates above and below perforated for", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0012.jp2"}, "13": {"fulltext": "THE IRRIGATOR.\\nscrews, by means of which the apparatus is attached to the wall.\\nAt/, in Fig. 1, a hook attached to the lower end of the board is\\nshown. This hook holds a ring at the end of a stout cord.\\nThe cord passes over a pulley\\n(d) and is fastened to the\\ntravelling block mentioned\\nbefore.\\nThe variations of pressure\\nrequired for anterior and in-\\ntravesical irrigations are ac-\\ncomplished by the action of\\nthe right thumb and index\\nfinger on the stopcock, and\\nnot by variations in the height\\nof the percolator. Its eleva-\\ntion is always the same; it\\nis lowered only for the pur-\\npose of filling or cleaning.\\nReference to Fig. 1 shows\\ntoo clearly to merit further\\nstudy, the manner in which\\nthe parts of the apparatus\\nare put together.\\nExperience has demon-\\nstrated that when the top of\\nthe irrigator board is attached\\nto the wall at an elevation of\\nnine feet from the floor, suffi-\\ncient pressure is obtained\\nfor all purposes. With in-\\ncreasing experience the phy-\\nsician finds that seven and\\none-half feet elevation suffices.\\nIt will be found conven-\\nient to devote a little study to the stopcock and nozzles, de-\\nspite their simplicity.\\nIf the stopcock is taken in the right hand, and the fourth\\n(ring) finger passed through the large ring on the metal tube,\\nthe thumb and index finger will easily reach and control the\\nflange. On pushing it forward it compresses the clips, narrow-\\nFig. 1.\u00e2\u0080\u0094 Author s Urethral\\nIrrigator.\\nIntravesical", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0013.jp2"}, "14": {"fulltext": "THE IRRIGATION TREATMENT OF GONORRHCEA.\\nFig. 2.\u00e2\u0080\u0094 Author s Stopcock.\\ning or even closing the lumen of the rubber tube on drawing it\\nback, the rubber tube resumes its entire calibre. One or two\\nefforts will teach the physician to allow single drops to escape\\nfrom the nozzle. By\\ngradually drawing back\\nthe flange the stream is\\nincreased until a strong\\njet carries over six feet.\\nAll variations in the\\nflow, from mere drops\\nto strong jet, are accom-\\nplished with the percolator raised to its greatest height, nine\\nfeet from the floor. The value of so controlling the flow by\\nslight contraction of the thumb and index linger will become\\nmore evident on considering the technique of irrigations.\\nThe nozzles are of glass that can be easily sterilized. Their\\nshapes are shown in Fig. 3. A is a pointed nozzle, for irrigat-\\ning a normal meatus. It is important that the irrigating fluid\\nhave as easy exit as it has entrance into the urethra. The\\npoint of this nozzle allows\\nNozzle A for normal meatus.\\nNozzle B for large meatus.\\nD\\nNozzle C for small meatus.\\nwashing the entire ure-\\nthra and the meatus as\\nwell.\\nB is a dome-shaped\\nnozzle devised to accom-\\nplish anterior and pos-\\nterior irrigations without\\nchanging the nozzle,\\nwhen a meatus is congen-\\nially very large or has\\nbeen made so by\\nmeatotomy.\\nG is a blunt\\nnozzle for use\\nwhen a congen-\\nitally very small\\n(pin-point) meatus would otherwise prevent irrigation, or when\\nthe normal meatus is so swollen as to prevent the introduction\\nof nozzle A. Its orifice then is merely pressed against the\\nmeatus and the stream so directed through it into the urethra.\\nNozzle D for female urethra.\\nFig. 3.\u00e2\u0080\u0094 Glass Nozzles.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0014.jp2"}, "15": {"fulltext": "THE IRRIGATOR. 5\\nD is devised for irrigations of the female urethra and bladder.\\nIts shape is the same as nozzle A its length, however, is three\\ntimes greater. The reason for its increased length lies in the\\nfact that all females must be irrigated in the recumbent posture,\\nand for the protection of the thighs from soiling with the irri-\\ngating fluid as well as for self-evident anatomical reason, the\\nshield must be brought down between the thighs. If the nozzle\\nwere as short as the others, the shield would prevent it coming\\ninto contact with the meatus.\\nAttachment of Nozzles. The nozzle appropriate for the size\\nof meatus being selected with sterilized fingers, its tubular end\\nis easily inserted into the rubber tube projecting through the\\nFig. 4.\u00e2\u0080\u0094 Manner of Attaching a Nozzle.\\nstopcock. After the tubular end of the nozzle is firmly inserted,\\nthe rubber tube should be drawn backward until the shoulder of\\nthe nozzle is arrested by the metal projection of the stopcock.\\nThis then holds the nozzle firmly, making it practically one\\npiece with the stopcock.\\nAs this book may fall into the hands of one or another prac-\\ntitioner not especially so endowed that he readily grasps me-\\nchanical ideas, I have thought well to be explicit, even to verbos-\\nity, in the above directions for use of the stopcock and nozzles.\\nAnother form of this irrigator was modified from suggestions\\nsubmitted to me by M. Wocher Son, of Cincinnati. The illus-\\ntration shows that in this apparatus a metal bracket takes the\\nplace of the board previously described. The rubber tube ex-\\npanded and reinforced will not slip out of the stopcock, and\\ntherefore requires no nozzle or closing of the clips to retain it.\\nA supplementary bracket (s) receives and holds the percolator\\nwhen it is let down to be filled. The graceful form of this irri-\\ngating apparatus appeals to many practitioners, especially those\\nto whom economy in oflfice space is an object.\\nCare of the Irrigator. Despite the simplicity of the apparatus", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0015.jp2"}, "16": {"fulltext": "THE IRRIGATION TREATMENT OF GONORRHOEA.\\nit, like any other, would not only become unsightly, but its util-\\nity destroyed by uncleanli-\\nness.\\nTo preserve the apparatus\\nand to have it always ready\\nfor work, it will be well to ob-\\nserve the following rules\\n1. When not in use, keep\\nthe flange of the stopcock\\nm well drawn back, so as to\\nhave no compression whatever\\nof the rubber tube.\\n2. When the first described\\nform of irrigator is used, keep\\na clean nozzle inserted in the\\nrubber tube to prevent the\\ntube slipping out of the stop-\\ncock. Its shoulder will hold\\nthe rubber tube in place. With\\nthe bracket irrigator, as men-\\ntioned above, this precaution\\nis not necessary.\\n3. To prevent the formation\\nof angles in the rubber tube,\\nwhich would eventually cause\\nit to break, and to reduce the\\nstrain upon the part of the tube\\ninto which the percolator s\\nnipple is inserted, hang the\\nstopcock mounted as above\\ndescribed, by its small ring\\nupon a cup-hook conveniently\\nplaced for the purpose.\\n4. Thoroughly wash the ir-\\nrigator each time after it has\\nbeen used. Ordinarily it will suffice to let hot water run through\\nit several times. Although the percolator may not be visibly\\nstained, it should be remembered that permanganate of potassium\\ntends quickly to destroy the rubber tube. It will be preserved\\nalmost indefinitely if this rule is observed.\\nFig. 5.\u00e2\u0080\u0094 Modified Bracket Irrigator.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0016.jp2"}, "17": {"fulltext": "THE IRRIGATOR. 7\\n5. Should the percolator become soiled, let a strong solution\\nof oxalic acid run through it. If this does not suffice, use the\\noxalic solution on cotton mops to rub out the stains. Fill the\\npercolator at least three times with clean hot water after using\\noxalic acid, lest some remain and be accidentally injected into\\nthe urethra or bladder.\\n6. After each use wash all parts of the shield with soap and\\nhot water, rub it with cotton soaked in bichloride 1 1,000, dry\\nit and hang upon its hook. This precaution will prevent the\\npossible carrying of infection to another patient. While it is\\ntrue that the majority of cases irrigated have gonorrhoea, there\\nFig. 6.\u00e2\u0080\u0094 Manner of Suspending Stopcock.\\nis no reason for the physician to expose them to new infection.\\nOn the other hand, many patients needing irrigations are not\\ngonorrhceal, as, for example, cases requiring urethral or vesical\\ninstrumentation or cases of contracted bladder. They certainly\\nshould not be exposed to gonorrhceal infection which can be\\navoided by the simple precautions of cleanliness.\\n7. It would be criminal negligence to subject any patient to\\nthe danger of infection by using a nozzle that has been employed\\nin the previous case. This danger is easily avoided by the fol-\\nlowing steps\\n(a) Immediately after irrigation hold the shield with the\\nused nozzle still in place, under boiling, running water.\\n(b) Eemove the nozzle and place it into a strong bichloride\\nsolution, kept ready in a glass dish for that purpose.\\n(c) When the day s office work is done, boil all the used\\nnozzles for ten minutes in strong caustic soda solution.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0017.jp2"}, "18": {"fulltext": "8 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n(d) After boiling, place the nozzles in a strong (1:1,000)\\nbichloride solution, kept in a covered glass or china dish re-\\nserved for sterilized nozzles.\\n(e) Rinse each nozzle again in clean hot water before using.\\nWhile the steps described in a to e suffice for the steril-\\nization of nozzles, it is not amiss to take extra precautions when\\na syphilitic has been irrigated. In a large practice where many\\nnozzles are used, it is well to break the nozzle after employing\\nit on a case with lues. If economy prompts keeping such noz-\\nzles, each one should be boiled separately and kept in a test\\ntube filled with mercuric bichloride, 1 to 1,000. The test tube\\nmay be closed with a rubber cork, marked with a number or\\nletters to designate the patient for whom the nozzle is used.\\nThe indications for irrigations, their technique, and the\\nsolutions employed will be considered under the special heads\\nwhere they properly belong.\\nII. ACUTE ANTERIOR GONORRHOEA.\\nIn intromission during sexual intercourse the lips of the\\nmeatus are more or less pressed apart, causing the meatus to\\ngape. On each withdrawal the lips are pressed together by the\\nsame vaginal pressure that pressed them apart on insertion.\\nThis gives the meatus a motion which may be compared to the\\nopening and closing of a fish s mouth when feeding. If the\\nvagina harbors gonococci, and if the penis is part of a body\\nwith lowered resistance, the infection, however reduced in the\\nfemale, will find a new culture ground in the male urethra.\\nIn contravention to this it may be offered that gonorrhoea\\nmost frequently affects men in the best possible physical condi-\\ntion. It is equally true, though, that men in full vigor are the\\nmost likely to expose themselves to venereal infection.\\nAgain, a number of persons appear who contracted gonorrhoea\\nwithout intromission, such as, for instance, when emission of\\nsemen took place before the penis could be inserted into the\\nvagina. These are easily explained by the fact that the female\\nurethra and Bartholini s glands are a very frequent site of re-\\nsidual gonorrhoea.\\nExtra-genital gonorrhoea, i.e., its acquisition otherwise than", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0018.jp2"}, "19": {"fulltext": "ACUTE ANTERIOR GONORRHCEA. 9\\nfrom an infected female, as for instance from a water-closet, is\\nimprobable, unless a man with an immense meatus were to reck-\\nlessly smear it over the seat upon which gonorrhceal discharge\\nhad been left by another. Taylor 1 says that the acquisition of\\ngonorrhoea on a foul privy or urinal may be looked upon as a\\neuphemism to be used in the case of some clerical, venerable,\\nor married transgressor.\\nOne distinct case of extra-genital gonorrhceal infection, how-\\never, came under my observation in 1897. A gentleman had\\ncontracted gonorrhoea fifteen years before. The case was per-\\nsistent and followed by stricture, for which his physician used\\nsounds. These had been discontinued for several years. The\\npatient had for five years been engaged in severe mental labor,\\nduring which, as happens under such circumstances, he experi-\\nenced no sexual desire. A few months before being sent to me\\nhe became engaged to be married. He had forgotten everything\\nconnected with his former gonorrhoea and stricture. Two\\nmonths before the day set for his wedding, this gentleman,\\nwhile in the rooms of a friend, saw a sound lying on the wash-\\nstand. It was a 30 F, the same number he had last used. To\\nascertain whether his urethra had preserved its calibre, he es-\\nsayed introduction of the sound into his own urethra, and found\\nno difficulty in doing so. Three days later he had all the evi-\\ndences of acute gonorrhoea. If this patient s veracity were not\\nbeyond dispute, the etiology of his attack might have been\\nquestioned. An examination of his discharge showed distinct\\ngonococci grouped within pus corpuscles, attached to epithelia\\nand disseminated between them. The friend whose sound was\\nborrowed had no discharge, but ramonage of his urethra proved\\nthat it contained gonococci.\\nSome time later the Centralblatt fur Krankheiten der Ham-\\nund Sexual- Organ e contained a report made by the patient (a\\nphysician) to show an extraordinarily long period of incubation\\nof gonorrhoea three weeks. The manner of infection is equally\\ninteresting. The doctor had taken a specimen of a fresh gon-\\norrhceal discharge for microscopic examination. Through care-\\nlessness he had soiled his fingers with the discharge. Being\\nsuddenly seized with a desire to urinate, he quickly took his\\n1 Taylor The Pathology and Treatment of Venereal Diseases, 1895.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0019.jp2"}, "20": {"fulltext": "10 THE IRRIGATION TREATMENT OF GONORRHOEA.\\npenis from his garments, and in doing so communicated some\\nof his patient s discharge to his own meatus. The result was a\\nfully developed gonorrhoea.\\nThere doubtless may be similar cases of extra-genital infec-\\ntion, still they are exceedingly rare. At all events, when as-\\nserted, it can do no harm to give the patient the benefit of the\\ndoubt.\\nWhen gonococci have entered the meatus, they at once pro-\\nceed to proliferate by segmentation. At any time between\\ntwenty -four hours and nine or ten days post coitum, the lips of\\nthe meatus are reddened, swollen, and a watery oozing presents.\\nThis soon becomes successively whitish, white, whitish-yellow,\\nyellowish, yellow, yellowish-green, and later on possibly stained\\nwith blood. With deepening of the color the discharge becomes\\nmore copious and thick.\\nThe other symptoms of acute anterior gonorrhoea merit at-\\ntention. White and Martin 1 hold that even preceding the first\\nslight puffing of the meatus, the patient experiences a constant\\ndesire to handle and examine the penis. I believe that this is\\nnot likely to occur except in those patients who have had gonor-\\nrhoea before, or in married men who have had illicit intercourse.\\nThis direction of the patient s mind to his penis may be due to\\nthat conscience does make cowards of us all.\\nCoincident with or shortly before the first slight tumefaction\\nof the meatus, there may, however, be a tickling in the affected\\nregion. This is soon followed by a sense as if the urine were\\nvery hot. Replying to the irritation caused by the increased\\nnumber of the gonococci seeking more food in the urethral\\nmucosa, nature tries to wash away the disturbance by increased\\nurination and increased secretion of urethral mucus. The pa-\\ntient, yielding to the more frequent calls to urination, experi-\\nences intense scalding and cutting pain with each act. When\\nthe gonococci have caused the destruction of the mucosa in\\nspots, the pain on urination becomes intolerable, to subside\\nonly after the gonococci have exhausted their food supply of\\nmucosa, or when the nerve terminals are protected by tissue\\nhyperplasia.\\n1 White and Martin Genito-Urinary Surgery and Venereal Diseases,\\nLippincott, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0020.jp2"}, "21": {"fulltext": "ACUTE ANTERIOR GONORRHOEA. 11\\nCoincident with the irritation, the urethra and its adjacent\\ntissues are the site of blood afflux. Its results will be con-\\nsidered under the complications of acute gonorrhoea.\\nAs the pains on urination grow more severe, the first 50 to\\n100 c.c. (fl 3 ii. to fl 1 iii.) become turbid. Caustic potash\\nadded to this urine shows it to be laden with pus. The pain\\nmay, however, be entirely absent or may, in severe cases, con-\\ntinue even between the intervals of urination.\\nThis mere outline of a sketch of the development of a clap\\npremises its arrest at or before the compressor, i.e., when it re-\\nmains an uncomplicated anterior gonorrheal urethritis. That\\nit rarely does so is only too evident to physicians who give the\\nsubject careful attention.\\nMany text-books advocate waiting for the acute stage to\\npass off. This waiting unfortunately allows the gonococci to\\nincrease, the infection to invade the tissues more deeply, to pro-\\nceed beyond the compressor, to develop local complications, to\\ninvolve other organs, and to make a life-endangering disease of\\nwhat should have been arrested in its incipiency.\\nSo far as our present knowledge goes, the end in view is best\\nattained by irrigations, employed as early as possible. How\\nthe irrigations exercise a beneficial effect may be subject to hon-\\nest differences of opinion.\\nPotassic permanganate, the drug most frequently employed\\nfor the purpose, is held to liberate oxygen in the tissues if the\\ngonococcus is an anaerobic microbe, it would die in the presence\\nof oxygen. Then irrigations of hydrogen peroxide should have\\na more prompt effect, which, however, is disproven in practice.\\nThe theory that seems most acceptable is that the large\\nvolumes of hot water (110\u00c2\u00b0 to 120\u00c2\u00b0 F.) employed induce a species\\nof artificial oedema of the urethra, making it an unfavorable cul-\\nture medium for gonococci. At all events, it is nothing rare to\\nfind the heavy greenish or bloody discharge, the frightful pains\\non urination, converted into a mere watery excess and painless,\\nnormal urination after one or two irrigations. Even if the\\ncourse of the disease were not abbreviated and complications\\navoided by irrigation, these two results alone would justify\\nardent advocacy of this method of treatment.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0021.jp2"}, "22": {"fulltext": "12 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nIII. ANTERIOR IRRIGATIONS.\\nIrrigations of the anterior urethra are employed\\n1. In infection of the anterior urethra;\\n2. After any instrumentation of the anterior urethra, whether\\nfor diagnostic or therapeutic purposes. Since making it an in-\\nvariable rule to irrigate the uretha even after urethroscopy, I\\nhave had not a single case of urethral fever to record.\\nThe technique of anterior irrigations may be divided into\\npreparation of the patient and the performance of the irrigation\\nitself. Their necessarily detailed description may male them\\nappear complicated and difficult their proper execution, how-\\never, is simple and easy. The time they consume never ex-\\ntends over five minutes, even with a very sensitive or apprehen-\\nsive patient receiving his first irrigation. As soon as the patient\\nhas learned the painlessness of a gentle, properly executed irri-\\ngation and has experienced the relief it affords him, he becomes\\nthe physician s active coadjutor in further treatment.\\nPreparation of the Patient. After the record of the case is\\nwritten, a specimen of the discharge taken for microscopic ex-\\namination, and the urine examined, the patient is instructed\\n1. To drop his trousers to his knees.\\n2. To fold his shirt and undershirt upward, exposing the\\nabdomen.\\n3. To sit on a chair with a firm, strong back, in such a posi-\\ntion that his weight does not rest upon the tuberosities of the\\nischium but upon the sacrum in other words, he is placed as\\nfar forward as possible upon the front margin of the chair.\\n4. To rest his shoulders against the back of the chair.\\n5. To plant the soles of his feet firmly upon the floor.\\n6. To direct his face upward, toward the ceiling. It is well\\nalways to give this last instruction, lest a patient with a malo-\\ndorous breath discover that an invidious distinction is made in\\nhis case. This position serves the good purpose of saving the\\nphysician the unnecessary disagreeable knowledge that would\\notherwise interfere with his work.\\nWhen the bad odor of the breath is due to digestive disturb-\\nance it should be remedied by appropriate treatment as quickly", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0022.jp2"}, "23": {"fulltext": "ANTERIOR IRRIGATIONS.\\n13\\nas possible, so that no other condition may reduce the patient s\\nresistance to further invasion of the gonococci.\\n7. If the physician is not experienced in irrigations, it is\\nwell to protect the patient s garments with a large rubber apron,\\nmade for the purpose with a hole for the penis.\\n8. A pan or bowl of tin or agate ware is then washed, inside\\nand out, in hot running water and then wiped dry. It is well to\\n|p ]l l\\\\ 1 J~l\\n1 T 1 i\\n^/vr-\\nFig. 7.\u00e2\u0080\u0094 Posture of Patient for Irrigation in Recumbent Position.\\ndo this before and after each irrigation, and in such a manner\\nthat the patient must observe the precaution it aids in keeping\\nhis attention fixed upon the need of taking every care against\\ninfection of others and of auto-reinfecfcion.\\n9. A clean towel is placed upon the patient s lap and drawn\\nup to cover his testicles, but not his penis.\\n10. The basin, still warm from its cleansing in hot water, is\\nplaced upon the towel, and the patient is told to hold it with\\nboth hands. The penis is laid upon the margin of the basin", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0023.jp2"}, "24": {"fulltext": "14 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nand the latter slightly tilted, so that the rim upon which the\\npenis lies encroaches upon the peno-scrotal juncture.\\nExcessively nervous patients may be inclined to faint on\\nmerely receiving the above instructions. It is well to irrigate\\nsuch patients in the recumbent posture. For this purpose place\\na bidet or irrigating pan upon the operating-table. Draw the\\npatient s linen well up to beyond his lower ribs, and his trou-\\nsers and drawers down to below his knees. Let his buttocks rest\\nfar back on the pan, to leave as much of it exposed as possible.\\nPlace a tin bowl between his knees, tilted with its concavity up-\\nward, so that any untoward motion on his part sending the irri-\\ngating fluid beyond the shield may be caught by the bowl and\\ndirected into the pan upon which he lies. The irrigation may\\nthen be made as easily as when the patient is seated, and with-\\nout danger of his fainting.\\nIn very exceptional cases, perhaps once in a thousand, a pa-\\ntient is found who unconsciously responds to irrigations by a\\nrelaxation of the compressor. The consequence is that the fluid\\nintended for anterior irrigation enters the bladder. When a\\nvery strong solution (such as potassic permanganate, 1 500)\\nis used, a very severe vesical tenesmus at least is induced there-\\nby. In such cases it is best to irrigate the patient in the stand-\\ning posture, and to teach him to press his fingers upon the\\nperineal portion of the urethra to occlude it.\\nTechnique of an Anterior Irrigation. 1. Stand at the pa-\\ntient s right side.\\n2. Cleanse the penis, foreskin, glans, and meatus with cotton\\ntampons soaked in mercuric bichloride, 1:3,000. If it is pre-\\nferred to accomplish the cleansing with the irrigating solution\\nthen\\n3. Take the stopcock in the right hand as shown in Fig. 4,\\npage 5, and for additional safety pass it under running boiling\\nwater, into which a small quantity of the irrigating fluid should\\nbe allowed to escape then close the flange.\\n4. Take the penis in the left hand, holding the left corpus\\ncavernosum by the third, fourth, and fifth fingers in such a\\nmanner that their tips rest lightly upon the urethra. The left\\nthenar eminence, by being pressed inward, compresses and al-\\nmost grasps the right corpus cavernosum. The bent thumb and\\nindex finger are thus left free for manipulation of the foreskin,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0024.jp2"}, "25": {"fulltext": "ANTERIOR IRRIGATIONS.\\n15\\nglans, and meatus. Tins manner of holding the penis will at a\\nfirst effort appear to cramp the hand, but after two or three irri-\\ngations it will be found the most effective and easiest.\\n5. Gently draw the flange of the stopcock back by contract-\\ning the right thumb and index finger. This will allow a fine\\nstream to escape from the nozzle. Direct this stream to the\\nouter surface of the foreskin until all its parts are thoroughly\\ncleansed.\\n6. Increase the stream slightly while directing it to the\\nopening of the foreskin. With the left thumb and index finger\\nslowly evert the foreskin\\nand, as its mucous lin-\\ning is thus being ex-\\nposed, wash each part\\nas it comes into view.\\n7. When the entire\\nforeskin is retracted,\\nwash the sulcus behind\\nthe corona, the glans,\\nthe sulci at either side\\nof the frenum, and the\\nlips of the meatus in the same manner. When the foreskin is so\\ntight that it cannot be everted, drop the penis and take up the\\ntop of the foreskin with the left thumb and index fingers. This\\nwill leave the opening of the foreskin slightly gaping. Insert\\nthe nozzle into the opening of the foreskin and increase the force\\nof the stream until the preputial pouch is thoroughly ballooned.\\nGive the tip of the nozzle every possible direction, so that the\\npouch may thus be as effectively cleansed as possible.\\n8. After cleansing the foreskin, glans, etc., and holding the\\npenis as shown in Fig. 8, above, contract the thumb and index\\nfinger upon the glans, so as to open the meatus.\\n9. Direct the stream at first gently and then with increasing\\nforce into the opened meatus, until all visible excess of secretion\\nis washed from it.\\n10. Bring the nozzle closer and closer to the meatus until its\\npoint is within the lips.\\n11. Compress the urethra with the tips of the left third,\\nfourth, and fifth fingers, to entirely occlude it.\\n12. Augment the force of the flow until the fluid spurts from\\nQ.-r\\\\s\\nFIG. 8.\u00e2\u0080\u0094 Manner of Holding Penis for Irrigation.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0025.jp2"}, "26": {"fulltext": "16 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nthe meatus in such a manner that it is received by the shield\\nand flows from it into the basin held by the patient. The im-\\npact of the fluid is felt against the tip of the middle finger, where\\nit compresses the urethra.\\n13. When one-fifth of the contents of the percolator are con-\\nsumed in the irrigation of the anterior third of the anterior\\nurethra, the middle finger is relaxed and the fluid s impact is\\nimmediately felt upon the tip of the fourth left finger that com-\\npresses the urethra.\\n14. The same procedure is successively observed regarding\\nthe urethra compressed by the fifth left finger, and the impact\\nof the fluid, with increased force, is sent to the bottom of the\\nanterior urethra, i.e., to the anterior surface of the mucosa in\\nfront of the compressor.\\nDuring every step of an anterior irrigation enough force\\nmust be used to fully dilate (balloon) the urethra. The nozzle\\nshould never occlude the meatus entirely, especially when strong\\nsolutions are used, lest they be forced beyond the compressor\\ninto the bladder.\\nThe division of the amounts of fluid used for each part of the\\nurethra will soon become so much a matter of routine that the\\noperator need not observe the percolator to guide him.\\nAfter each irrigation a layer of absorbent cotton soaked in\\nmercuric bichloride, 1:6,000, should be placed upon the glans\\nto receive any subsequent discharge, preventing as far as pos-\\nsible auto-reinfection, and to keep the clothing clean. If the\\nforeskin is absent or too small to hold the cotton, it should be\\nfixed in place by means of a light gauze bandage. The patient\\nshould be instructed to apply a clean piece of cotton soaked in\\nbichloride after each urination.\\nSome cases are exceedingly susceptible to the irritant effect\\nof mercuric bichloride, even a solution of 1:10,000 or of 1\\n30,000 sets up an inflammation of the glans. Boric acid, four\\nper cent., may be used in such cases to wet the cotton.\\nThe cotton used as above must not be substituted by any-\\nthing else. Gonorrhoea-bags and condoms, so often advised for\\nthe purpose, keep the glans macerated in pus, not only inviting\\npersistent auto-reinfection, but also exposing the glans to gon-\\norrhceal balanitis, for whose existence there is no excuse.\\nSome authors recommend a little apron made of linen or", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0026.jp2"}, "27": {"fulltext": "ANTERIOR IRRIGATIONS. 17\\ngauze, cut about two inches square, with a slit in the centre to\\nlet the glans pass through. The ends of the apron are then\\nfolded forward to cover the glans and meatus. If the patient be\\nsure to take off this apron each time he urinates and replace it\\nwith a fresh one, its convenience might make it advisable to a\\ndegree. But it is entirely too convenient merely to open the\\nends, urinate and replace the soiled ends over the glans. More-\\nover, the ends are easily brushed open and thus the garments\\nFig. 9.\u00e2\u0080\u0094 Anterior Irrigation, Patient Seated. Towel over thighs omitted for clearness of illus-\\ntration.\\nare exposed to being soiled by the pus. For these reasons it is\\nbest to use absorbent cotton, as above suggested.\\nAll parts of an irrigation can, without any special dexterity,\\nbe so conducted that neither the patient s garments, his person,\\nnor the office floor be soiled. Nothing need be stained, except\\nthe operator s left fingers, when using strong solutions of potas-\\nsic permanganate. They can be quickly cleaned with oxalic acid\\nor sodic bisulphide.\\nAs cleanly as an irrigation should be, so painless it is when\\nproperly carried out. Even an intensely inflamed urethra ex-\\nperiences no pain if the operator is sufficiently gentle. In\\nthis, as in all other genito-urinary work, suaviter in modo occu-\\npies first place fortiter in re need not at all suffer thereby.\\n2", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0027.jp2"}, "28": {"fulltext": "18 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nFor this reason analgesia of the urethra with cocaine or eucaine\\nneed not be induced. Moreover, when their obtunding effect\\nwears off, the patients experience more pain than if they had\\nnot been used at all.\\nThe time consumed by irrigations has been alleged as an ob-\\njection to their employment. A deliberate, properly conducted\\nanterior irrigation requires about two minutes, certainly not too\\nmuch time to devote in each visit to so important a disease as\\nanterior gonorrhoea. If only relief from suffering were obtained\\nthereby, even ten times two minutes would be well employed.\\nBut the physician, knowing how dangerous to life gonorrhoea is,\\nshould not begrudge any amount of time and labor directed to\\nthis end. Even if the disease was acquired in the grossest im-\\nmorality, even if the patient is of the lowest, most degraded type,\\nit is unqualifiedly the physician s duty to give the best efforts\\nin order to prevent the dissemination of the disease to others\\nwho may possibly be innocent of any wrong.\\nThe frequency with which irrigations should be employed\\nin acute anterior gonorrhea is set forth in the following table.\\nThe solutions referred to therein are of potassium permanganate,\\nthe drug most frequently used by all who employ irrigations.\\nTrie dilutions are modified from those advised in Janet s tables,\\nwhich, for some reason, seem too strong for use in this country.\\nIt will be observed that intravesical irrigations appear in this\\ntable. The technique of these will be described in Chapter V.\\n(Intravesical Irrigations)\\nFirst day, first visit. Anterior irrigation 1 3,000\\nFirst day, 7 p.m. Anterior irrigation 1 4,000\\nSecond day. 9 a.m. Anterior irrigation 1 3,000\\nSecond day, 7 p.m. Anterior irrigation 1 4,000\\nThird day, 9 a.m. Intravesical irrigation 1 6,000\\nThird day, 7 p.m. Anterior irrigation 1 5,000\\nFourth day, 9 a.m. Intravesical irrigation 1 5.000\\nIntravesical irrigation 1 5,000\\nFourth day, 7 p.m.\\nAnterior irrigation 1 2,000\\nFifth day, noon. Intravesical irrigation 1 5,000\\nSixth day, noon. Intravesical irrigation 1 5.000\\nSeventh day, noon. Intravesical irrigation 1 5,000\\nn Intravesical irrigation 1:5,000\\nEighth day, 9 a.m.\\nAnterior irrigation 1 o.OOO\\nEighth day, 7 p.m. Intravesical irrigation 1 5,000\\n5 J Anterior irrigation 1 2.000", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0028.jp2"}, "29": {"fulltext": "ACUTE POSTERIOR GONORRHOEA. 19\\nNinth day, 9 a.m. Intravesical irrigation 1 4,000\\nAnterior irrigation 1 1 000\\nNinth day, 7 p.m. i Intravesical irrigation 1 4.000\\nAnterior irrigation 1 1.000\\nTenth day, 9 a. m. i Intravesical irrigation 1 4,000\\nAnterior irrigation 1:1 ,000\\nTenth day, 7 p.m. J| Intravesical irrigation 1 5,000\\nI Anterior irrigation 1 500\\nThe hours at which irrigations are to be administered have\\nbeen fitted to the exigencies of most physicians office hours.\\nIt would be always preferable, however, when irrigations are to\\nbe given twice in one day, that they be made twelve hours apart.\\nIV. ACUTE POSTERIOR GONORRHOEA.\\nDe Keersmaecker and Yerhoogen 1 in brief remarks on acute\\nposterior gonorrhoea, say The inflammation proceeds along\\nthe whole urethral mucosa, but its intensity decreases generally\\nin accord with its distance from the point where the inoculation\\nwas produced, as is observed in every local infection. It seems,\\nhowever, that posterior gonorrhceal invasion is an exception\\nhereto. The gonococci having traversed the compressor find a\\nnew field of culture in the posterior urethra. They often set up\\nan inflammation far exceeding in virulence that which affects\\nthe anterior urethra. In mam* cases the patient s sufferings\\nare not only materially increased, but, as Posner says, the\\nportals for infection of other organs are thereby thrown open.\\nJadassohn holds that sixty to seventy per cent, of anterior\\ngonorrhoeas invade the posterior urethra Finger places the ex-\\ntreme figure at eighty per cent. while Taylor 3 claims that an-\\nterior urethritis in between eighty and ninety per cent, of cases\\nwithin the early days of infection passes backward and involves\\nthe posterior urethra. Close clinical study of the question\\nmakes it appear likely that even Taylor underestimates the fre-\\nquency with which the posterior urethra is involved in the dis-\\n5 De Keersmaecker et Verhoogen L Ur \u00c2\u00a7thrite chroniqne, Brussels, 1898.\\n-Posner: Diagnostic der Harnkrankhei ten. Berlin, 18i 4.\\n3 Taylor The Pathology and Treatment of Venereal Diseases, Lea Bros.\\nCo., 1895.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0029.jp2"}, "30": {"fulltext": "20 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nease. Indeed White and Martin 1 say that the gonococcus with\\nbut few exceptions invades the posterior urethra.\\nWossidlo 2 urges that no apparently cured case of acute gon-\\norrhoea be dismissed without examination of the prostate, al-\\nthough the posterior urethra does not seem to have been affected.\\nThe absence of symptoms of posterior urethritis is no proof that\\nthe posterior urethra was not infected by the gonococci on their\\nway to the adnexa.\\nCauses. Anything that decreases the vital resistance of the\\nposterior urethra, menaced by the presence of anterior gonor-\\nrhoea, and increases the intensity of the latter, is likely to pro-\\nduce posterior gonorrhoea. Among the most frequent causes are\\nneglect of treatment, coitus, irritants applied to the urethra, alco-\\nhol, fermented or carbonated beverages, and excessive activity.\\nTime of Invasion. A neglected or badly treated anterior\\ngonorrhoea usually invades the posterior urethra by the end of\\nthe first week. The patient, however, may perceive no symp-\\ntoms thereof until the end of the second week. A few days later\\nthe evidences are often too marked to escape attention.\\nPosterior gonorrhoea may, on the other hand, become pain-\\nfully manifest at the very beginning of the disease, especially\\nif strong injections, violently applied, increase the irritation.\\nThis may convey to those not familiar with the irrigation treat-\\nment, a condemnation of its employment. But it must be re-\\nmembered that the irrigations applied to the entire urethra are\\nnot strong moreover, they so modify the urethral mucosa as to\\nmake it an unfavorable culture medium for gonococci. This in\\na measure explains the absence of posterior gonorrhoea when\\nirrigations are properly employed.\\nSome authors mention the use of bougies as a means of im-\\nmediately establishing a posterior gonorrhoea. Naturally they\\ndo this only to condemn the insertion of any instrument into an\\nacutely inflamed urethra. Ipse facto, this is a condemnation of\\nattempting to wash the urethra with a catheter or treat it with\\nanthrophores.\\nSymptoms. As noted above, very many cases of acute pos-\\n1 White and Martin Genito-Urinary Surgery and Syphilis, Lippincott,\\n1898.\\n2 Wossidlo: Chronic Prostatitis and Its Treatment. Journal of the\\nAmerican Medical Association, August 27th, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0030.jp2"}, "31": {"fulltext": "ACUTE POSTERIOR GOXORRHCEA. 21\\nterior gonorrhoea are insiduous in their onset, course, and decline.\\nMost of these disappear without any special treatment being\\ndirected to the region infected. Indeed in former times the\\nposterior urethra was deemed one of the sacred regions not\\nto be entered by instruments or drugs, and yet many cases ap-\\npeared to have recovered. How many of these subsided after\\ncarrying gonococci to the urethral adnexa and general organism\\nis beyond calculation. The hope of those who strive to heal\\nacute posterior urethritis by treatment of the anterior urethra\\nalone, may be compared with that of the gynecologist who en-\\ndeavors to drain pus-tubes by curetting, washing, and draining\\nthe womb. Both appear to succeed often; but as concerns pos-\\nterior urethritis, the physician would fall short of his duty if he\\nrisked further complications by trusting to the chance that oc-\\ncasionally seems to have favored the past.\\nMechanism of the Symptomatology. In the insidious form,\\nthe very slight sufferings or their absence may not direct atten-\\ntion to the posterior urethra. In the severe form, nature endeav-\\nors to assuage the inflammation by free secretion of urine. Its\\ncontact with a surface rendered exquisitely sensitive produces\\nintense burning. After the flow of urine has ceased, the in-\\nflamed surfaces fall against each other, and in so doing give the\\nsensation of an incompletely accomplished urination. At the\\nsame time the folds of the thickened mucosa squeeze between\\nthem the delicate nerve terminals, producing the characteristic\\nafter-pains. When somewhat deep denudations have taken place,\\nthe capillaries may break, allowing blood to escape, which may\\nbe mixed with the last portion of the urine, may follow it as\\nclear drops or a distinct stream of blood may flow, or the urine\\nmay carry small worm-like clots, if blood coagulates in the pos-\\nterior urethra.\\nThe swelling of the mucosa and pain evoke frequent, almost\\ncontinual spasmodic and semi-voluntary contractions as if in\\neffort to eject the obstructions. This activity of the region in-\\ncreases the symptoms as it augments the inflammation. The\\nvicious circle obtains another segment by each effort of nature\\nto pour out urine. The latter becomes so frequent that the\\npatient continually strives to empty his bladder, and while he\\nfails to obtain a sense of relief, by acting upon the desire to uri-\\nnate, he increases his pain.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0031.jp2"}, "32": {"fulltext": "22 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nAs above suggested, there is no exact chronological order in\\nwhich the manifestations of acute posterior urethritis follow each\\nother. Indeed, they may all appear to come on together with\\nextreme severity. For convenience in studying them a little\\nmore closely, they are here placed in alphabetical order.\\nAlbuminuria. When the urine carries pus, it accounts for\\nthe presence of a proportionate amount of albumin. In acute\\nposterior gonorrhoea, when vesical tenesmus is at its highest,\\nthe amount of albumin carried by the urine exceeds that which\\nwould be expected from the amount of pus present. White and\\nMartin 1 deem this excess probably due to damming back of\\nthe urine in the ureters, dependent upon closure of the orifices\\nof these canals by contraction of the detrusor muscles of the\\nbladder this having been shown to take place when tenesmus\\nis severe.\\nComplications. Proximity and continuity of mucous surface\\nrender the prostate, seminal vesicles, and epididymides exceed-\\ningly susceptible to infection from posterior gonorrhoea. The\\nepithelium covering the trigone, from its similarity in character\\nto that of the posterior urethra, is also liable to the infection,\\nbut to a limited degree. The epithelium lining the body of the\\nbladder, however, seems immune to gonorrhceal infection, ex-\\ncept when a pre-existent disease has weakened its resistance,\\nor when traumatism has been exerted upon it, as by the abuse\\nof instruments.\\nConstitutional Symptoms. When a patient with gonorrhoea\\nsuffers from loss of appetite, headache, constipation, marked\\nmental depression, even to profound neurasthenia, and appre-\\nciable fever, the physician s attention is naturally directed to\\nthe probable invasion of the posterior urethra. These general\\nsymptoms may come on gradually or suddenly, and are as likely\\nto occur in chronic as in acute anterior gonorrhoea. If given\\nimmediate attention, severe general suffering and more danger-\\nous involvement of the urethral adnexa may be averted.\\nDischarge. The tonic contraction of the compressor prevents\\nthe discharge of acute posterior gonorrhoea from entering the\\nanterior urethra. When it is so copious as to fill the posterior\\nurethra, the slight, weak bundle of fibres constituting the\\n1 Op. cit.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0032.jp2"}, "33": {"fulltext": "ACUTE POSTERIOR GONORRHOEA. 23\\nsphincter vesicae is more likely to yield to the pressure and so\\nadmit the discharge into the bladder. Even stripping the\\nposterior urethra per rectum will not aid satisfactorily in the\\nproduction of discharge from the posterior urethra, for the same\\nreasons as given above. The only means of positively reaching\\nconclusions regarding involvement of the posterior urethra, in\\naddition to giving due heed to the other symptoms, is by ex-\\namination of the urine (vide Urine infra). Naturally when the\\nsymptoms appear in the fulminant type, this aid to diagnosis\\nis impossible and would be superfluous.\\nEmissions. JVs abstinence from sexual intercourse is impera-\\ntive during gonorrhoea, for the patient s sake as well as for the\\nsake of those to whom the disease may be communicated by\\nhim, and as the local irritation of even an anterior gonorrhoea is\\nprone to stimulate increased secretion of semen, seminal emis-\\nsions are not infrequent. They occur especially in men who are\\ngiven to daily sexual intercourse. When, however, posterior\\nurethritis has produced hyperesthesia of the caput gallinaginis,\\nthe emissions of semen may be exceedingly painful, the suffer-\\nings being either disseminated through the perineum, extend-\\ning up to the rectum, or tearing and shooting along the posterior\\nurethra. These pains are often so intense that the patient is\\nafraid to fall asleep, lest he be awakened by an emission that\\nwould evoke their recurrence.\\nErections. Posterior urethritis is liable to provoke erections\\nat all times, with or without erotic incitation. They are most\\nfrequent when warm in bed, but are painless unless there be\\nacute anterior urethritis as well.\\nHematuria. Drops of blood, unmixed with urine, may\\nescape from the urethra at the end of micturition. This is usu-\\nally considered a positive evidence of posterior urethritis.\\nWhile it most frequently occurs in this disease, it may also be\\npresent in some forms of bladder growths (polypus, papilloma)\\nand stone. When due to posterior urethritis, the bleeding comes\\nfrom the swollen, congested, and even eroded mucosa. If the\\nbleeding is copious it may flow into the bladder and be mixed\\nwith its contents then, too, some drops or a jet of clear blood\\nwill follow urination. In such a case the urine may also carry\\nsmall, worm-like clots of blood.\\nPain. The pain of fulminant acute posterior urethritis is", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0033.jp2"}, "34": {"fulltext": "24 THE IRRIGATION TREATMENT OP GONORRHOEA.\\nusually most marked in the perineum. It is due to muscular\\nspasm, provoked by the tenesmus. Its severity may be so great\\nas to cause the patient to act as if afflicted with acute mania.\\nBetween the attacks of intense pain the patient may have tick-\\nling, burning, and sharp lancinations through the deep urethra,\\nextending up the rectum. All these disturbances are aggravated\\nby urination or defecation they most frequently follow the act\\nof urination.\\nRetention of Urine. If the posterior urethra is very much\\nswollen, the frequency of urination may suddenly be arrested\\nand acute retention take its place. The sufferings that before\\nwere somewhat remittent then become continuous. The reten-\\ntion may become quite obstinate from the increase of swelling\\nand reflex tonic contraction of the sphincters. (See also Com-\\nplications of Gonorrhoea Retention.\\nUrination. The slightest quantity of urine coming into con-\\ntact with the inflamed posterior urethra provokes the desire to\\nurinate. The patient must then micturate every few minutes.\\nHis straining to pass the few drops is accompanied by intense\\npain. Although passage of these drops gives no relief, the\\npatient continues his efforts to urinate incessantly, being im-\\npelled thereto by the sense of vesical repletion. His only relief,\\nwhen not treated, is in the few moments of sleep or fainting that\\nexhaustion brings.\\nIn a case that is not so acute as the one described, there\\nmay be no painful straining. But the urination is frequent and\\nimperious. The desire when felt must be immediately gratified,\\notherwise the patient will urinate into his trousers.\\nUrine. When acute disturbances of urination do not pre-\\nvent examination of the urine, and when the other symptoms or\\nconditions direct attention to the posterior urethra, the only\\nmethod of reaching a diagnosis is by examination of the urine.\\nEven when no suspicion guides to thoughts of posterior urethral\\ninvasion, the urine of a gonorrhoeic should be examined daily,\\nso that the extension of the disease may be met at its inception.\\nThe examination should be made, if possible, of the first\\nurine the patient passes in the morning. When this is not pos-\\nsible, because of the distance at which the patient lives from the\\nphysician s office, the examination may be made during the day,\\nbut after the patient has held his urine for at least four hours.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0034.jp2"}, "35": {"fulltext": "ACUTE POSTERIOR GONORRHOEA. 25\\nThe patient should be caused to pass the first portion, about\\n150 c.c. (fl 3 v.) into a twelve-inch ignition tube. 1 This washes\\nthe anterior urethra as clean as possible, but naturally carries\\nwith it as much discharge from the posterior urethra as can be\\neasily detached from its walls. The urine so emitted will there-\\nfore often be much more turbid than would be expected from a\\nslight discharge.\\nThe second 150 c.c. emitted into another tube, if the patient\\nhave posterior urethritis, will be found more turbid than the\\nfirst portion. Naturally this symptom is not characteristic if\\nthe patient have cystitis or pyelitis, or when a disease of the\\nprostate or seminal vesicles causes their contents to be expressed\\nwith the final efforts of micturition. In the absence of these\\ndiseases, and when the posterior urethra produces much dis-\\ncharge, it may flow back into the bladder and render its con-\\ntents turbid. If the discharge is not copious, it will be carried\\noff by the first urine, and leave the subsequent urine clear.\\nBoth urines, however, may be clear when the patient urinates\\nfrequently.\\nTo cover the possibility of error in these cases, practitioners\\nare ordinarily advised to wash out the anterior urethra by means\\nof a soft catheter before allowing the patient to urinate. The\\ngreater ease and safety by which the urethra can be cleansed by\\nmeans of anterior irrigations make the latter method preferable.\\nBy carefully exercising the technique of anterior irrigations (see\\npage 12), and using warm boric-acid solution for the purpose,\\nthe anterior urethra can be quickly freed from any discharge it\\nmay at the time harbor. When the solution that spurts from\\nthe meatus is entirely clear of even fine granules, the patient\\nshould immediately urinate into two tubes. If the first tube\\ncontains pus and the second does not, the diagnosis of posterior\\nurethritis is established with a fair degree of accuracy.\\nA better and not much more circumstantial test, especially\\napplicable when the urine is not turbid, can be made by add-\\ning to the boric acid used for irrigation a quantity of methylene\\nblue representing one per cent, of its quantity (twenty-four grains\\n1 These twelve-inch ignition tubes are erroneously called Valentine s urine\\ntubes by dealers. I did nothing but suggest the convenience of these tubes\\nfor macroscopic examination, comparison, and chemical and microscopical\\ninvestigations of urine.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0035.jp2"}, "36": {"fulltext": "26 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nto the quart) If the urine passed into the first tube contains\\nshreds, filaments, flakes, or granules which the microscope shows\\nto be stained blue, it would tend to prove that they come from\\nthe anterior urethra. If they are not stained by the irrigation,\\ntheir source is the posterior urethra.\\nThe need of careful study and early treatment of posterior\\nurethritis is evident, despite the fact that many of the cases\\nappear to recover without treatment. Their tendency is to go\\nover into a subacute or chronic state, to produce recurrent gon-\\norrhoea, and to evoke a long list of neuroses which are often in-\\neffectually treated until the source of the evil is ascertained.\\nTreatment. As is quite natural, the treatment of acute pos-\\nterior urethritis must vary in accord with the form in which it\\nappears. If its onset is in the most insidious manner, so that\\nits presence is determined only by examination of the urine, the\\nsafest, quickest, and easiest method of cutting it short is by\\nintravesical irrigations, whose technique is fully detailed on\\npage 29.\\nThese intravesical irrigations may be performed once daily,\\nbeginning with potassium permanganate solution of 1 6,000; on\\nthe second day the strength of the solution may be increased\\nto 1:5,000; on the third day 1:4,000 may be used and if no\\nreaction result, a further increase to 1:3,000 may be employed\\non the fourth and subsequent days. Some patients bladders\\nwill very comfortably bear much stronger solutions.\\nIf in ii\\\\e or six days the urine does not indicate complete\\nsubsidence of the posterior urethritis, mercuric bichloride may\\nbe added to the potassic permanganate solution last employed.\\nThe addition of the bichloride should at first not be stronger\\nthan 1 50,000. On the second day this may be made 1 40,000\\non the third day 1 30,000 on the fourth day 1 25,000. Only\\nin very persistent cases can 1 20,000 be employed.\\nSome cases do better with the bichloride alone and in the\\nsolutions above indicated.\\nOccasionally a case will be found in which neither the per-\\nmanganate nor the bichloride nor both in combination yield\\nprompt effects. Then silver nitrate may be employed in solu-\\ntions of 1 5,000, 1 4,000, 1 3,000, or 1 2,500, using the mildest\\non the first day and daily increasing the strength, but not beyond\\n1:2,500.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0036.jp2"}, "37": {"fulltext": "ACUTE POSTERIOR GONORRHOEA. 27\\nThese irrigations, when properly conducted, are borne ex-\\nceedingly well by patients they experience an almost immediate\\nrelief from the slight subjective or reflex symptoms due to the\\niDsidious form of the disease under discussion.\\nWhen acute posterior gonorrhoea asserts itself in the fulmi-\\nnant form, the prime indication is to break the before-described\\nvicious circle at some point. As in all acute inflammations,\\nrest of the affected region must be sought.\\nPatients so affected should be kept in bed and on a diet of\\nlittle else than skimmed milk. Mild laxatives, that keep the\\nrectum clear and deplete the pelvic viscera, must be persistently\\ngiven.\\nThe one drug that gives signal relief in hyperacute cases is\\nsantal oil. As was shown by investigations made in Berlin in\\n1894 and 1895, santal oil cannot be expected to act as a gono-\\ncoccicide. 1 It does, however, prove a decided analgesic of the\\nurinary apparatus, and especially its lower part. To procure\\nits effect as quickly as possible, it may be given in ten minim\\ndoses every two hours for six or eight hours. As soon as the\\ntenesmus begins to subside and the bleeding after urination\\nmaterially decreases, the intervals should be increased to four,\\nfive, or six hours, until pain has entirely disappeared. As this\\ndrug is prone to evoke renal irritation, it should be withdrawn\\nas soon as the indications for its use have subsided.\\nThe teas (infusions) of uva ursi leaves, herniaria, chenopo-\\ndium, triticum repens, etc., which were formerly highly lauded\\nfor their presumed effects in such cases, have proven ineffective\\nin my hands. They only augment diuresis, and in doing so in-\\ncrease the activity of the inflamed parts, that should be kept at\\nrest. Salicylate of sodium and salol, which often show such fa-\\nvorable results in cystitis, prove utterly inactive in acute poste-\\nrior urethritis.\\nWhen the attack is so severe that the effect of santal oil can-\\nnot be awaited, then morphine gr. especially in supposi-\\ntories, will afford quick relief. When this does not act promptly\\niodoform, gr. may be added to the suppository. Belladonna\\nhas yielded no results to me in doses that are safely adminis-\\ntered. At the same time that the suppositories and santal oil\\nValentine Der Einfluss der Balsamicis, insbesondere des Santalols auf\\nGonococcen. Pick s Archiv, April, 1895.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0037.jp2"}, "38": {"fulltext": "28\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nare used, local depletion may be hastened by the\\napplication of four to six leeches to the peri-\\nneum.\\nIt is generally held that when acute gonor-\\nrhoea suddenly invades the posterior urethra,\\ndirect treatment of the anterior urethra is contra-\\nindicated. Comparison of the results of this\\nneglect of treatment with those obtained by con-\\ntinuing local treatment show to the decided ad-\\nvantage of the latter. Therefore irrigations must\\nbe continued. If the patient is too weak to have\\nthem administered in the sitting posture, he may\\nreceive them while lying in bed. To facilitate\\nsuch irrigations a sewing-board or leaf of an ex-\\ntension table may be pushed under that part of\\nthe mattress beneath the patient s buttocks. With\\nordinary care, irrigations can then be performed\\nwithout even moistening the bed-clothes.\\nIt is more particularly in the exceedingly severe\\ncases which persist despite all the treatment above\\ndescribed that intravesical irrigations of potassium\\npermanganate give prompt relief. The hot (110\u00c2\u00b0\\nto 120\u00c2\u00b0 F.) antiseptic solutions, very gently ad-\\nministered, seem to act as a soothing poultice to\\nthe inflamed, eroded posterior urethra. It is not\\nrare to see a patient after such an irrigation fall\\nasleep and rest comfortably for several hours, to\\nawake much relieved.\\nGuyon uses several drops of a one to two per\\ncent, silver nitrate solution instilled into the pos-\\nterior urethra. While the relief so obtained can-\\nnot be denied, the local reaction that follows is\\nfrequently very severe. This may be limited by\\nprecedent appreciable doses of morphine, by pre-\\nliminary instillation of a few drops of cocaine if\\none is sure that the patient is not too susceptible\\nto its toxic effects, or by giving the patient a quarter of a tea-\\nspoonful of sodic bicarbonate (Kobner) thirty minutes before\\nmaking the instillation.\\nIf, for anj r reason, irrigations cannot be employed, Guyon s", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0038.jp2"}, "39": {"fulltext": "POSTERIOR OR INTRAVESICAL IRRIGATIONS. 29\\ninstillations may be used every two or three days. The severe\\npains they produce can be very materially reduced, and often\\nentirely avoided, if Guy on s technique be closely followed.\\nThe instrument found best for the purpose is Albarran s\\nmodification of Guy on s instillator. It consists of a syringe, a\\nlittle larger than the ordinary hypodermic syringe, with a rod\\npassing through the piston, by means of which the packing can\\nbe rendered tight or loose at will. A tightly fitting metal funnel\\nserves to connect the syringe with a rubber capillary catheter\\nshaped like a bougie a boule, and soft enough to be easily in-\\nserted. Each complete turn of -the handle deposits a drop of\\nthe solution in the posterior urethra. If the deposits are made\\nby quarter turns, and consequently by quarter drops, with an\\ninterval of ten to twenty seconds between each application, the\\npain will be minimized, larger quantities can be introduced, and\\na quicker effect obtained (Guy on).\\nV. TECHNIQUE OF POSTERIOR OR INTRA-\\nVESICAL IRRIGATIONS.\\nKeeping in mind how feeble a bundle of muscular fibres\\nconstitute the sphincter vesicae, it is evident that any appreciable\\nquantity of fluid carried into the posterior urethra through the\\nstrong compressor must enter the bladder. Hence irrigation\\nof the posterior urethra distinctly implies irrigation of the\\nbladder at the same time. For convenience, therefore, irriga-\\ntions of the posterior urethra are called intravesical irriga-\\ntions.\\nPreparation of the Patient. The patient is prepared and sits,\\nstands, or lies down, as may be necessary, under the rules de-\\ntailed on page 12.\\nTlie Irrigation. 1. Perform thoroughly all the steps de-\\nscribed under Anterior Irrigation (page 16), using only half the\\nquantities of fluid there mentioned.\\n2. Hold the penis firmly, while gently sinking the nozzle\\ninto the meatus, until it is entirely occluded thereby. At the\\nsame time slowly increase the force of the flow, by drawing back\\nthe flange of the stopcock.\\n3. As the urethra is felt distending under the left finger tips.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0039.jp2"}, "40": {"fulltext": "30\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\norder the patient to breathe deeply and slowly, and to make\\nefforts at urination.\\n4. Ordinarily when the third step of this operation is being\\nperformed, a sensation of purling of the liquid, as it enters the\\nbladder, will be communicated to the left fingers.\\n5. After one-half or three-quarters of a minute the inflow will\\nbecome less accentuated and slower, as the bladder is being filled.\\nFig. 11.\u00e2\u0080\u0094 Holding Basin and Stopcock and Handing Urinal to Patient.\\nThen slowly push forward the flange of the stopcock, to dimin-\\nish the force of the flow, until it is stopped. By close observ-\\nance of this technique, the bladder can be entirely filled without\\nproducing pain or even an urgent desire to urinate.\\n6. Best the penis on the margin of the basin, leaving the left\\nhand free.\\n7. Place the stopcock in the basin; pass the right thumb\\nthrough its large ring pass the right fingers to the outside of\\nthe basin to hold it firmly with the stopcock.\\n8. Extend the left hand to the shelf on which the glass\\nurimils are kept (one may also conveniently stand under the\\npatient s chair), take one and hand it to the patient.\\n9. Order the patient to take his penis with his left hand and\\nto direct it toward the urinal, which he holds in his right.\\n10. Take the basin and stopcock from the patient s lap.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0040.jp2"}, "41": {"fulltext": "POSTERIOR OR INTRAVESICAL IRRIGATIONS. 31\\n11. Order tlie patient to void his bladder into the urinal;\\nsome can do this sitting, others must rise for the purpose.\\n12. While the patient is emptying his bladder, pour the\\ncontents of the basin into the sink and wash out the basin with\\nwarm water, if the patient is to be immediately irrigated again.\\nIf not, wash the basin with boiling water, and place it with the\\nused basins, to be thoroughly cleansed after office hours.\\n13. Without removing the used nozzle from the stopcock,\\nhold both under running, boiling water for a few moments.\\nThen remove the nozzle and place it in a dish kept for used\\nnozzles and containing mercuric bichloride 1:1,000. After\\noffice hours boil the used nozzles in water and caustic soda;\\nrinse them in clean water and place them in a dish containing\\nmercuric bichloride 1 1,000.\\nAll the steps of intravesical irrigation, like those of anterior\\nirrigation, can be effectively, thoroughly, and painlessly per-\\nformed without soiling any part of the patient s person or body,\\nor of the office.\\nAmount Required for Filling the Bladder. The average male\\nbladder can comfortably hold about 350 c.c. (nearly fl 3 xiss.);\\nvariations between 250 and 500 c.c. are, however, within the\\nlimits of health.\\nRepetition of an Intravesical Irrigation. Ordinarily after one\\nirrigation the glass urinal shows its contents to be as clear as\\nwhen the fluid was sent into the bladder. When this is not the\\ncase, the irrigation may at once be repeated.\\nImpediments to Irrigation. In some cases, when for any\\nreason the preparations for irrigation are somewhat prolonged,\\nor when the patient is nervous, there may be a somewhat free\\noutpouring of urine from the kidneys, after the patient has\\nemptied his bladder. A small quantity of urine in this viscus\\nmay set up such a spasm of the compressor that when an intra-\\nvesical irrigation is attempted it cannot be overcome by the\\npressure of the irrigating fluid. Such a patient should be\\nordered to again empty his bladder the irrigation will then be\\nquite easily performed.\\nWhen potassic permanganate is used in a case in which some\\nurine is withheld, it will be returned from the bladder either\\nturbid or of a light straw or brownish hue. A second irrigation\\nwill then produce as clear a fluid as was used.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0041.jp2"}, "42": {"fulltext": "THE IRRIGATION TREATMENT OF GONORRHOEA.\\nFig. 12.\u00e2\u0080\u0094 Office Arrangement. A, Author s urethral and intravesical irrigator; upper margin\\nof board attached to wall nine feet from floor B, stand eighteen inches high C, marble\\nwash-stand (constructed by Mr. John H. Graham of New York); D, hot-water pedal E, cold-\\nwater pedal F, outflow trap G, mortar for rapidly making potassic permanganate solu-\\ntions from tablets H, glass urinal i, bottle containing potassic permanganate tablets, 2\\ngrains each; J. glass graduate 1,500 c.c. to measure urine; V, tray holding clean urine", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0042.jp2"}, "43": {"fulltext": "POSTERIOR OR INTRAVESICAL IRRIGATIONS. 33\\nSome patients, in making violent respiratory efforts, coupled\\nwith endeavors to urinate during irrigation, will force the com\\npressor into a firm tonic spasm. It is well, in such cases, to\\nask the patient to desist from his efforts, and, while reducing the\\nhydrostatic pressure, to divert his attention from the matter in\\nhand. This is best accomplished by some witticism not, how-\\never, one of which the patient is the object. The slightest ten-\\ndency of the patient to laugh is instantly accompanied by a\\nrelaxation of the compressor and a consequent inflow of the\\nirrigation fluid into the bladder.\\nOffice Arrangement. In a large genito-urinary practice much\\ntime can be gained and convenience secured by an office arrange-\\nment as shown in Fig. 12, page 32. It will be observed that the\\npatient s chair stands on a platform. This is eighteen inches\\nhigh, which is equivalent to irrigating the patient when the\\nchair is on the floor and the irrigator raised only seven and\\none-half instead of nine feet from the floor. This reduction of\\npressure will make no difference to the physician experienced\\nin irrigations. Moreover, the platform will prove very con-\\nvenient, when many irrigations must be done during the day,\\nas it saves the physician much stooping.\\nPhysicians who are obliged to irrigate only a few patients\\ndaily do not need the somewhat expensive office arrangements\\nhere shown. They can do fully as effective and satisfactory\\nwork without.\\nFurther points concerning irrigations will be discussed\\nunder the conditions to which they especially apply.\\ntubes K, small glass graduate to make solutions of silver nitrate, cupric sulphate, etc. K 1\\nglass dishes holding sterilized nozzles in bichloride 1 1,000 i, glass tray containing used\\nnozzles M, tray to hold used instruments N,N,N,N, solutions of silver nitrate 0. minim\\ngraduate P, bottle containing powdered boric acid other bottles on this shelf contain car-\\nbolic acid, nitric acid, etc. q, bottle holding three gallons boric acid, four-per-cent. solu-\\ntion P, five-gallon bottle containing mercuric bichloride 1 1,000 (q and P have rubber\\ntubes pending from them); S, Bernstein Company s office table; T, irrigating basins Z7,\\nglass urinal FT, pan for irrigation in recumbent posture.\\n3", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0043.jp2"}, "44": {"fulltext": "3i THE IRRIGATION TREATMENT OF GONORRHCEA.\\nVI. CONSTITUTIONAL AND ACCESSORY\\nTREATMENT.\\nAny conduct, food, or drink that increases the irritation of\\nthe inflamed region or regions in gonorrhoea must, as in inflam-\\nmations of other parts, necessarily increase the disease, prolong\\nits duration, and thwart the ultimate object of treatment.\\nThere is little difficulty in causing patients to submit to the\\nnecessary restrictions when they are made aware of the risks\\nincurred by their infraction (see Chapter VII. Complications\\nThe constitutional and accessory treatment entails some restric-\\ntions, which will be indicated here.\\nAmusements. The depressing influence which clap exercises\\nupon most minds may be due to the consciousness of being\\naffected with an unclean disease, to the deprivation of sexual\\nintercourse, and to enforced abstinence from alcohol. This, how-\\never, would not account for the depression so frequent in those\\nwho do not allow the presence of a clap, unless accompanied\\nby painful symptoms, to interfere with their self -gratifications.\\nThe possible effect of gonococci toxins directly upon the nervous\\nsystem may, when better understood, give the explanation.\\nIf a patient with gonorrhoea were to withdraw from all enter-\\ntainments during the disease, he would necessarily brood over\\nthe cause of his ostracism and its consequences. This would\\naccentuate the mental depression. He should therefore seek\\ndiversion, such as society, theatres, etc., offer, but most posi-\\ntively avoid people, scenes, exhibitions, and literature that could\\nevoke lubricious thoughts.\\nBathing. There is no reason, during gonorrhoea, for absti-\\nnence from the daily bath on the contrary, it is necessary for\\nthe purpose of maintaining the patient s resistance. But sev-\\neral precautions in bathing are absolutely imperative. Before\\nbathing, the patient should urinate, dress the glans with cotton\\nsoaked in mercuric bichloride 1 6,000, or boric acid four per\\ncent., and cover the entire penis with a well-fitting condom, to\\nbe worn throughout the bath. This is the only safe manner in\\nwhich gonorrhceal pus can be prevented from mixing with the\\nbathing water and possibly adhering to the sides of the tub,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0044.jp2"}, "45": {"fulltext": "CONSTITUTIONAL AND ACCESSORY TREATMENT. 35\\nwith all the danger to the eyes of the patient, and to the eyes,\\nvagina, or rectum of another who may use the bath-tub after him.\\nWhile do one, even in health, will rely upon the care of servants\\nto cleanse a bath after he used it, the gonorrhceic must be spe-\\ncially cautious in this regard. It would never be an excess of\\nconscientiousness if the patient scrubbed the entire bath-tub\\npersonally with brush and strong soap, using boiling water into\\nwhich he has dissolved two ounces of corrosive sublimate, for a\\ntub capacity of twenty-five gallons. Following this, the hot\\nwater should be allowed to run again until the tub is entirely\\nfilled, to rinse it after the scrubbing. Even those who live in\\nbachelor apartments and have their individual baths should be\\ninstructed to do this for self-protection.\\nAfter the bath the condom should be removed at once, and\\nthrown into the water-closet or preferably burned.\\nBed. The gonorrhceic patient should sleep on a hard mat-\\ntress with light coverings, lest the heat of either provoke erec-\\ntions, with their determination of blood to the inflamed region,\\nand possibility of chordee. As erections are not likely to occur\\nwhile the patient sleeps on his side, it will be well if he ties a\\ntowel around his abdomen with a hard knot immediately over\\nthe spine. Should he turn on to his back during sleep, the pres-\\nsure of the knot will either awake him or cause him to return to\\nhis side without disturbing his sleep.\\nBeverages. With a view to diluting the urine so that it may\\nprove less irritating to the urethra, diuretics and diluents of\\nall kinds are advised. The only diluent of any value is pure\\nwater in very large quantities, as a gobletful (fl 3 vi.) every two\\nhours or every hour.\\nAll alcoholic beverages must be strictly interdicted, unless\\nthe patient is in the habit of using them to such an extent that\\nhis appetite would suffer from the deprivation. Then a glass,\\nor even two, of light claret may be allowed at meals. But beer,\\nwhite wine, champagne, whiskey, and brandy must be positively\\nforbidden.\\nCarbonated drinks, such as vichy, seltzer, ginger ale, sarsa-\\nparilla, soda water, and other beverages charged with carbonic\\nacid gas, are much used by patients with gonorrhoea, under the\\nprevailing impression that they are beneficent in the disease.\\nThis is a signal error, as all these drinks are genito-urinary", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0045.jp2"}, "46": {"fulltext": "36 THE IRRIGATION TREATMENT OP GONORRHOEA.\\nirritants. The extent to which the damage caused by carbonated\\ndrinks can go is well shown in a case reported to the Deutsche\\nniedicinische Gesellschaft by its president, Dr. H. G. Klotz, on\\nMarch 6th, 1899. The patient, aged twenty-two, had been\\ntreated for gonorrhoea and stricture. Suddenly a white lump,\\nresembling macerated chalk geschlemmte Kreide and some\\nblood were ejected from the urethra, amidst violent pains radi-\\nating from the renal region. For some days the urine was\\nheavily turbid and contained albumin. Chemically and micro-\\nscopically phosphates were found, and the sediment contained\\nvarious cocci and epithelial cells. The author assumes that\\nphosphates had accumulated in and irritated the renal pelvis\\nand calices in consequence of the patient s drinking large quantities\\nof carbonated soda. The author shows that an accumulation per\\nse so innocent as that of phosphates can produce inflammation\\nof the kidney, if improperly treated or neglected. Such an\\nacute nephritis can as readily proceed to chronic nephritis as\\ncan the renal inflammations due to other causes.\\nKlotz relied mainly upon urotropin in this case, which was\\ncured in the course of three weeks.\\nThis and many cases with a similar history may account for\\nthe large number of kidneys invaded and destroyed by gono-\\ncocci, if they were perfectly healthy before the patient was the\\nvictim of clap.\\nDrinking away a Clap. Many patients assure their phy-\\nsician that they have known men with very acute gonorrhoea to\\ndrink heavily for a long time and thus cause the clap to disap-\\npear. Some will relate this as a personal experience in a pre-\\nvious attack. This statement deserves all the allowance phy-\\nsicians must make for the curious ideas that in some manner\\nhave forced themselves upon the laity. The fact remains that\\nthe patient who alleges that he drank away a previous clap,\\nor honestly thinks he knows of others who performed this im-\\npossible feat, is then under treatment and continues under it\\nuntil he is well. Meanwhile he abstains from fantastic efforts\\nto cure the disease with alcohol in any form.\\nExercise. Unless the patient has fever, he should take\\nsufficient exercise to keep himself in good condition. Walking,\\nKlotz-. Phosphaturie und Pyelo- Nephritis. New Yorker niedicinische\\nMonatschrift, October, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0046.jp2"}, "47": {"fulltext": "CONSTITUTIONAL AND ACCESSORY TREATMENT. 37\\ndriving over smooth roads, rowing, and such outdoor sports as\\nwill give him gentle exercise are certainly recommendable, not\\nonly for their physical but also for their mental effect.\\nBicycling and horseback riding must be positively forbid-\\nden during gonorrhoea, as they expose the testicles and pros-\\ntate to vibration at least, or small concussions, if not severe\\ninjury, inviting extension of the disease to these organs.\\nIn this connection Prof. G Frank Lydston says:\\nCycling frequently produces hyperactivity of the sexual\\norgans with resulting disposition to sexual excess and aggrava-\\ntion of any pathological condition which may be present\\nurethral and prostatic inflammation are often aggravated by\\nbicycle riding. Kelapses of inflammatory troubles of the ure-\\nthra, prostate, and bladder very often follow bicycling- I doubt\\nwhether inflammation may be produced de novo in individuals\\npossessing a previously healthy genito-urinary apparatus. An\\nexception might possibly be made in the case of individuals who\\nride that peculiar form of bicycle invented by the devil and\\ndedicated to Eros\u00e2\u0080\u0094 the bicycle built for two.\\nFood. If a patient with gonorrhoea has not a disturbing\\nelevation of temperature, he certainly requires sufficient food to\\nkeep him as well nourished as possible, to aid him in resisting\\nthe microbic invasion. In this quest all articles difficult of\\ndigestion must be avoided, as must all food that for any reason\\ndisagrees with the patient.\\nSome authors hold that if a patient with gonorrhoea were\\nkept in bed on a very low diet, he would recover from the infec-\\ntion without local treatment. I regret that I must confess hav-\\ning made the experiment, which each time resulted in abject\\nfailure.\\nWhile complete rest in bed and low diet are absolutely neces-\\nsary in the severe form of posterior gonorrhoea, they are useless\\nwithout proper medication (see Chapter IV., Acute Posterior\\nGonorrhoea\\nWhen acute gonorrhoea is not accompanied by much eleva-\\ntion of temperature, and when no complication obliges the pa-\\ntient to remain in bed, this, together with reducing his food,\\nLydston: Athletics in their Relation to the Male Geni to-Urinary Or-\\ngans. Medical Mirror, St. Louis, September, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0047.jp2"}, "48": {"fulltext": "38 THE IRRIGATION TREATMENT OF GONORRHCEA.\\nwould supply means for reducing his resistance to the microbic\\ninvasion.\\nGin i3 mentioned separately because of the wide reputation\\nit unjustly enjoys for beneficial effects in gonorrhoea. While it\\nacts as a diuretic, it irritates the kidney directly and the rest of\\nthe genito-urinary apparatus as much or even more than any\\nother alcoholic beverage.\\nSuspensoky Bandages.\u00e2\u0080\u0094 Their necessity in gonorrhoea is\\ndiscussed under Epididymitis, page 55.\\nTobacco. It is not shown at all that smoking or chewing\\ntobacco exerts any unfavorable or favorable influence upon gon-\\norrhoea, unless the patient uses tobacco to a depressing extent.\\nThen, naturally, its use must be curtailed.\\nVII. COMPLICATIONS AND SEQUELiE OF\\nGONORRHCEA.\\nAn acute gonorrhoea, if treated by properly conducted irriga-\\ntions from the inception of the disease, does not become com-\\nplicated. But patients with a first gonorrhoea, or those who\\nhave never been treated by irrigations, are not likely to come\\nfor treatment early, i.e., when the first swelling of the lips of\\nthe meatus presents, or shortly thereafter. Others, in whom\\nirrigations have not been judiciously employed, may present\\ncomplications. A final and very large class embraces those\\nmen who had gonorrhoeas before and, having been improperly\\ntreated, acquired conditions (strictures inter alia) which com-\\nplicate the newly acquired disease.\\nWhen urethral complications existed before the new gonor-\\nrhoea, they cannot be diagnosed until the acute symptoms have\\nbeen subjugated by irrigations, as the insertion of an instru-\\nment into an acutely inflamed urethra is never warranted. The\\nonly exception hereto may be in acute retention, when all other\\nmeans have failed, and catheterization remains the sole refuge\\nfor emptying the bladder.\\nFor convenient reference, the most frequent complications of\\ngonorrhoea are here placed in alphabetical order.\\nAbscess, Follicular and Peri-urethral. If the gonococci lim-\\nited their search for pabulum to the surface of the urethra, their", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0048.jp2"}, "49": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 39\\nprogress, and that of the inflammation they produce, would ex-\\ntend only backward. But they also invade the mucous follicles\\nand gland ducts. When this occurs, as it very frequently does,\\nthe ringer passed along the lower surface of the urethra when\\nexposed as for anterior irrigation (vide ante, Fig. 8, page 15)\\nfinds distinct nodulations. The glands and follicles are espe-\\ncially well developed at the meatus, whence pus may be easily\\nexpressed.\\nWhen swelling or inflammatory exudation occludes the ducts,\\nthe normal or catarrhal secretion of their glands is retained.\\nThe resultant pus pockets (follicular abscesses) are thus ex-\\nplained. As the follicles are ordinarily most numerous in the\\nanterior third of the pendulous portion, this is the most frequent\\nsite of these abscesses. They soon become distended with pus\\nand then feel like shot of various sizes under the skin, which\\nis normal in color and freely movable over the abscesses.\\nTouching them sometimes causes quite sharp pain. While in\\nthis condition, the probability is that they will open into the\\nurethra. When the abscesses terminate in this manner, the\\nducts that have been occluded become patulous again.\\nWhen the follicular abscess does not terminate as just de-\\nscribed, the skin over it becomes red and attached to the nodule.\\nIf not relieved by early incision it breaks down and the pus\\ncavity is evacuated externally. The duct of the gland so de-\\nstroyed is obliterated, and the abscess cavity heals by granula-\\ntion.\\nSometimes quite an agglomeration of such follicular abscesses\\npresents near the attachment of the frenum to the meatus. The\\nfrenum is then apt to become very \u00c2\u00a9edematous, entirely obliter-\\nating the normal depressions at its sides. The angry appear-\\nance of the region conveys the impression that the abscess must\\ndestroy or at least perforate the frenum or result in fistula.\\nBut after discharge of the pus, the abscesses ordinarily heal,\\nthe oedema subsides, and the ducts of the follicles remain closed\\nconsequently neither fistula nor destruction of the frenum re-\\nsults. As,, however, either outcome is possible, the unaided\\nbreaking of these abscesses should not be awaited.\\nA gummatous nodulation at the base of the frenum, usually\\npainless, may be mistaken for follicular abscess, especially if\\nthe patient has forgotten, as sometimes in reality happens, that", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0049.jp2"}, "50": {"fulltext": "40 THE IRRIGATION TREATMENT OF GONORRHOEA,\\nhe ever had syphilis. If the tumor is gummatous, vigorous\\nantiseptic dressings are decidedly contraindicated. Incision\\ncould produce only breaking down of the gumma, insuring per-\\nhaps large destruction of the penis. Therefore when such a\\ngumma presents, nothing but mild antiseptic dressings should\\nbe employed, while remedial measures are administered con-\\nstitutionally.\\nAs the mucous follicles at the frenum are walled by rather\\ndense fibrous tissue, their abscess formation is circumscribed.\\nYet from any cause this fibrous envelope may give way and pro-\\nduce extensive destruction and deformity of the glans. There-\\nfore surgical intervention, as early as possible, is a wise and\\nnecessary precaution. Failure to employ it has occasionally\\nbeen followed by such cicatricial contractions as to so distort\\nthe relation of the glans to the penis as to make erection ex-\\nceedingly painful and coitus impossible.\\nThe follicles at other parts of the urethra than those near\\nthe frenum have less connective- tissue protection. Therefore\\nwhen they become involved their disease products are prone to\\ninvade the tissue of the corpora cavernosa penis and still more\\nthe corpus cavernosum urethral. Suppuration of the follicles\\nhere takes on the form of peri-urethral abscess.\\nThese abscesses around the urethra originate as folliculitis\\nor adenitis. Their pain, tenderness, and swelling are greater\\nand develop more rapidly. If the swelling urethra ward is more\\nmarked, the urinary stream is smaller than normal. Some-\\ntimes, when the pain is greatest, the duct proves to be the point\\nof least resistance. It will then suddenly give way and permit\\nthe pus to escape into the urethra. The pain then is arrested\\nor very much mitigated, the tension about the swelling is re-\\nduced, and the urine carries with it pus and blood. If the ab-\\nscess cavity points forward, i.e., toward the meatus, it will\\nprobably heal rapidly. If, however, it has not this direction,\\nurine may enter it and urinary infiltration with all its dangers\\nmay result, requiring rapid, free incision. Should the abscess\\nopen both within the urethra and through the skin, urinary\\nfistula is the consequence.\\nWhen a peri-urethral abscess first presents, gentle massage\\nmay cause its contents to overcome the swelling of the duct and\\nrestore its patulousness. When this fails, the enlarged glands", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0050.jp2"}, "51": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA 41\\nor follicles should be slit, curetted, and dressed with nosophen.\\nThe large amount of pus that then escapes seems utterly out of\\nproportion to the size of the tumor. When the swelling is dif-\\nfuse or painful, enveloping the penis in hot or cold antiseptic\\ndressings may give relief.\\nWhile it is true that many peri-urethral abscesses open spon-\\ntaneously, it is not well to rely upon this outcome; it is likely\\nto result in an open sinus or fistula. When such spontaneous\\nopening has occurred, permanent catheterization should be em-\\nployed as a safeguard against urinary infiltration.\\nIf unhealed follicular or peri-urethral abscess precedes an\\nacute gonorrhoea, the dangers and difficulties of cure are very\\nmuch enhanced.\\nAdenitis (gonorrhoea!) see Lymphadenitis.\\nAdhesions (preputial) are often practically congenital. At\\nall events many children sent to the specialist for circumcision\\nare found to have the prepuce more or less firmly adherent to\\nthe glans. Concretions of smegma may harden and cause ulcer-\\nation of the delicate mucosa drops of urine may be retained in\\nthe preputial sac, decompose and irritate the tissues, and uri-\\nnary salts may form calculi there. The constitutional conse-\\nquences of adherent prepuce and the other conditions mentioned\\nare well described by pediatrists.\\nWhen an adult with adherent prepuce acquires gonorrhoea\\nthe case is practically incurable, unless the prepuce is immedi-\\nately detached from the glans. This is easily done with a stout,\\nblunt probe, after injecting a four-per-cent. solution of cocaine\\ninto as much of the sac as can be reached by it. While the\\ndenudations so produced may threaten invasion of the organism,\\nespecially if the gonorrhoea depends upon a mixed infection,\\nthe chance of danger is far less than if the disease is allowed to\\ncontinue because of the adhesions. After separating the pre-\\npuce, readherence of the raw surface will be prevented by dress-\\ning the glans with absorbent cotton soaked in mercuric bichlo-\\nride, as described on page 16. When the orifice of the foreskin\\nis too tight for the admission of cotton, reformed adhesions\\nshould be broken up by passing the sterilized probe entirely\\nabout the glans, beneath the prepuce, before each irrigation.\\nThe lesions produced by this little operation ordinarily heal\\nin about forty -eight hours, leaving a freely movable foreskin.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0051.jp2"}, "52": {"fulltext": "42 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nNotwithstanding the favorable result, such patients should be\\ncircumcised as soon as they have recovered from gonorrhoea.\\nWhen preputial adhesions result from gonorrhceal balano-\\nposthitis, they should be treated as above outlined. As then\\nthe inflammatory process has usually much thickened the fore-\\nskin, greater gentleness in the operation, if possible, is required.\\nIt may be well, in such a case, to keep the penis continually\\nsoaked for a day or two in hot bichloride solution 1 10,000 that\\nthe swelling may subside before separating the prepuce from the\\nglans. In extreme cases it may be wise to remove the foreskin\\nentirely if the above-mentioned measures cannot bo carried out.\\nStripping the prepuce beyond the glans to break up adhe-\\nsions is exceedingly painful, unsurgical, and unnecessarily pro-\\nlongs the treatment. Moreover, it exposes the patient to the\\ndangers of paraphimosis.\\nAlbuminuria. The urine of a gonorrhceic always contains\\nalbumin as part of the pus it carries. When vesical tenesmus\\naccompanies the disease, the urine shows more albumin than\\nis accountable by the amount of pus present. The explanation\\nof this excess of albumin that seems most reasonable has been\\nmentioned on page 22. The treatment for this mechanical al-\\nbuminuria is touched upon under vesical tenesmus (page 27).\\nAnemia. When anaemia complicates a gonorrhoea, the pa-\\ntient s vital resistance is reduced, the case prolonged, and inva-\\nsion of other organs invited. Such a condition must be met by\\nthe appropriate constitutional remedies, in addition to irriga-\\ntions.\\nBalanitis and Balanoposthitis. Though gonococci seem\\nto play no causative role in the production of balanitis, or in-\\nflammation of the surface of the glans penis, this is a frequent\\ncomplication of gonorrhoea (White ^nd Martin). On the other\\nhand balanitis, so frequently produced by uncleanliness, phi-\\nmosis, or adhesions of the prepuce, may extend to the urethra\\nevoking a discharge therefrom which symptomatically resembles\\ngonorrhoea. The absence of gonococci from this discharge may\\nprove the urethritis to be due to an infection from the balanitis.\\nMost frequently, predisposition to inflammation of the\\nmucous lining of the glans and foreskin is brought about by a\\nvery large or very dense or tight prepuce, or one with a small\\nopening. The normal secretions are then retained causing", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0052.jp2"}, "53": {"fulltext": "COMPLICATIONS AND SEQUEL M OF GONORRHOEA. 43\\nepithelial softening, and the apposed surfaces rub upon each\\nother, producing denudations. When contagious material enters\\nthe preputial sac, it finds at least some of the region without its\\nuppermost epithelial protection and therefore a good culture\\nmedium.\\nEheumatism, gout, and diabetes also predispose the patient\\nto balanoposthitis.\\nTraumatisms, even so slight as friction from the clothing,\\nviolent attempts at intercourse, and contact with irritating dis-\\ncharges may also cause balanoposthitis.\\nHeat, some tickling or itching about the glans, provoking\\nfrequent erections, inaugurate inflammation of the mucous cover-\\ning of the glans or lining of the foreskin. This is usually asso-\\nciated with or quickly followed by redness and swelling of the\\npreputial orifice. A little later a foul-smelling discharge, if not\\nso copious as to escape unaided, can be pressed out of the\\norifice. If the prepuce can be stripped back, a thick, paste-\\nlike, irregularly lumpy secretion, mixed with liquid pus of a\\nvery putrid odor, is discovered. When the inflammation has\\nexisted some days, the mucous membrane of the glans may be\\neroded, occasionally in circular or irregular spots, grossly re-\\nsembling chancre or chancroid.\\nIf neglected, the inflammation of the preputial sac is likely\\nto cause immense swelling of the foreskin and glans. The\\noedema of the foreskin may go over into an erysipelatous red-\\ndening, which may extend to thefroot of the penis. The lymph\\nducts may be involved. Inflammatory phimosis or paraphimosis\\nmay result. The pressure then exercised by the prepuce and the\\nglans upon one another may produce gangrene of either or both.\\nEven if such extreme results do not obtain, balanoposthitis\\nmay cause adhesions of the prepuce to the glans, rendering\\nerection painful and coitus impossible.\\nThe first indication for treatment of balanitis and balano-\\nposthitis is naturally in the removal of the cause. When the\\nforeskin can be everted, the sac must be gently but thoroughly\\ncleansed with cotton tampons soaked in hot bichloride solution\\n1 3,000 or 1 4,000. Then nosophen is thinly strewn upon the\\nexposed mucosa. A thin layer of absorbent cotton is placed\\nabout the glans, and the foreskin drawn into place again. Ac-\\ncording to the severity of the case this may be repeated twice", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0053.jp2"}, "54": {"fulltext": "44\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nor three times daily. Light cases, that seemed inveterate under\\nother treatment, yield to the one just described very quickly,\\nsometimes as soon as within forty-eight hours.\\nWhen the disease has proceeded to such swelling of the pre-\\npuce that it cannot be retracted or when it affects the sac of a\\ntight or partially adherent prepuce, irrigations of the sac with\\npotassic permanganate 1 2,000 or 1 3,000, twice or three times\\ndaily, will cause the inflammation to abate.\\nWhen the prepuce is cedematous and very tender to the touch,\\nthe penis may be kept continuously wrapped in a hot bichloride\\nFig. 13.\u00e2\u0080\u0094 Taylor s Phimosis Scissors.\\nsolution 1 10,000 until the swelling subsides sufficiently for\\nmore direct treatment.\\nWhen the inguinal glands are enlarged in the presence of a\\nvery intense swelling of the foreskin, through which an indura-\\ntion is felt, the surgeon may be justified in splitting the prepuce\\nto expose and treat a possible phagedenic ulcer, which, if neg-\\nlected, may destroy the glans or a great part of the penis.\\nUnder such circumstances, or when the patient is a diabetic,\\nit is usual to slit the dorsal aspect of the prepuce, with a view\\nto complete circumcision, after the acute inflammatory condi-\\ntion has passed off. But this slitting, especially when the swell-\\ning and induration are great, does not expose the glans and\\nthe lining of the prepuce nearly as much as would be desirable.\\nTherefore it is much better and more effective to cut both sides\\nof the foreskin midway between the dorsum and the frenum, as\\nproposed by Taylor. The scissors he devised for the purpose\\nwill be found the best instrument that can be used. When these\\nscissors are not at hand they can be substituted by a grooved\\ndirector to protect the glans and guide a stout curved bistoury\\nto the coronary sulcus.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0054.jp2"}, "55": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 45\\nThe danger of infecting the so cut surfaces must be accepted\\nas the risk preferable to the one of allowing the penis to be de-\\nstroyed by an unknown ulcer.\\nImmediate circumcision would be more desirable, but the\\nincision that then encircles the penis would not be likely to\\nunite by primary union. Even if general infection does not\\nresult, circumcision in such cases is prone to be followed by\\nextensive sloughing, from whose destructive results the thermo-\\ncautery even may not save the penis.\\nLater on, when the primary condition has subsided, com-\\nplete circumcision may be advantageously performed for cos-\\nmetic effect.\\nBladder, Inflammation of see Cystitis.\\nBleeding\u00e2\u0080\u0094 see Hemorrhage.\\nBlind fistula, i.e., minute canals having their opening\\nposteriorly from the meatus, may cause a gonorrhoea to be ex-\\nceedingly obstinate. If the inflammatory condition does not\\nproduce their obliteration, or if irrigations do not produce in\\nthem that general cedema which would make them an unfavor-\\nable culture medium for gonococci, they continue to supply in-\\nfection to the urethra. They may, in part, account for the five\\nper cent, of failures in the irrigation treatment as collated by\\nGoldberg (page 1).\\nIn obstinate cases they should be sought by means of the\\nurethroscope and silver nitrate injected into them by Kollmann s\\nsyringe this failing they must be slit into the urethra or extir-\\npated. When such a fistula is very shallow and close to the\\nmeatus, it can usually be destroyed by electrolysis, performed\\nunder cocaine anaesthesia.\\nBubo see Lymphadenitis.\\nCavernitis may complicate a yery mild gonorrhoea, when\\nthe urethral epithelial layer is subject to traumatism, admitting\\ngonococci to the mucosa itself, to the submucous tissues, and\\nthrough these to the corpora cavernosa penis or corpus caver-\\nnosum urethrse. The traumatisms doing this damage may be\\nstrong injections destroying the epithelium, misuse of a sharp-\\npointed syringe, clumsiness in use of sharp irrigation nozzles,\\nantrophores, sounds, or catheters. Violence in irrigations, per-\\nformed by people who mistook their vocation when they en-\\ntered the profession of Medicine, may cause rupture of the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0055.jp2"}, "56": {"fulltext": "46 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nsuperficial layers of tlie urethral mucosa, with a consequent\\ncavernitis.\\nIn the beginning of cavernitis the slight swelling may escape\\nnotice except during erection. Then, as the infiltration does\\nnot expand with the rest of the organ, it is bent or twisted\\ntoward the affected side. If the corpus cavernosum urethrse is\\naffected, the penis is bent in the bow-form, familiarly called\\nchordee (q. v. infra).\\nIf the invasion of the corpora cavernosa does not end in reso-\\nlution, permanent infiltration or abscess forms. In the former\\ncase local circulation may be seriously impeded, with possibly\\nconsequent atrophy of the surrounding tissues. This may so\\ndeflect the penis during erection as to render coitus impossible.\\nIn the beginning of cavernitis rest, persistent hot or cold\\nantiseptic applications, leeches to the perineum, low diet, pur-\\ngatives, camphor or its monobromate, with or without opium,\\nwill give relief and aid resorption. In hyperacute cases, in\\nwhich relief is not obtained by the above-mentioned measures,\\nthe infiltration may be punctured with fine needles to allow some\\nblood to escape. The most exquisitely employed aseptic pre-\\ncautions must be observed in this operation, which, as has been\\nsuggested above, is in place only as a last resort. In G.\\\\e cases\\nso treated immediate relief was obtained. One retained a slight\\ncontraction of the right corpus cavernosum, not enough, how-\\never, to interfere with coitus. The others recovered entirely.\\nIn chronic cases galvanism, several times a week, one pole\\napplied to the infiltration and the other to the opposite portion\\nof the penis, may stimulate resorption.\\nSometimes general infiltration affects the three corpora cav-\\nernosa equally, producing persistent but painless priapism.\\nOne patient treated for subsequent stricture said that for three\\nweeks he had been so affected all remedial efforts proved un-\\navailing. He was sent on a sea voyage, and on the first day the\\nerection subsided. As the physician who had treated this case\\nhad died, the exact facts could not be obtained.\\nOberlaender 1 cites a case of cavernitis reported by Kollmann\\nwhich differs very much from those generally described. Im-\\nOberlaender Die chronischen Erkrankungen der mannlichen Harn-\\nrohre. Kliniscb.es Handbuch der Harn- und Sexual-Organe, Leipzig, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0056.jp2"}, "57": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 47\\nmediately after the excision of a primary chancre on the pre-\\npuce, preceded by an injection of cocaine, a small infiltration\\nbehind the glans appeared. It grew to the size of a bean, and\\nas it became larger, it travelled several centimetres toward the\\nscrotum in the course of a few months. Then it proceeded for-\\nward again, dividing into two parts. When so situated erections\\nwere disturbed once the penis was doubled into a decided right\\nangle. Later on the infiltrate travelled to the peno-scrotal junc-\\nture, where it remained and became smaller, but could be dis-\\ntinctly palpated four and one-half years after its first appearance.\\nGonorrhoea could never be proven in this case nor could this\\ncavernitis be attributable to syphilis, as it was not affected by\\nantisyphilitic treatment. The excision of the chancre did not\\nprevent general infection.\\nChancroid, or chancre, or a mixed sore, may complicate gon-\\norrhoea. But even if either involves the meatus or the urethra,\\ncareful irrigations need not be omitted.\\nChordee, Chorda Venerea. Da Costa, 1 in his admirable\\nchapter on Diseases of the Genito-urinary Organs, defines\\nchordee as a condition of painful erection in which the penis\\nis markedly bent. The patients describe it as the sensation of\\na hot wire drawn through the penis, like the cord of a bow.\\nThis bending is naturally in the direction of that part of the\\npenis which is rendered less elastic and therefore cannot take\\npart in the general turgescence of erection. When the inflam-\\nmatory action penetrates the submucous tissues and from them\\ninto the trabeculse of the corpus spongiosum, its extensibility is\\nnaturally impaired. Keflex irritability provokes frequent erec-\\ntions, and as the inflamed corpus spongiosum cannot swell and\\nstretch with the rest of the organ, the penis is bent. In the\\nbending intense pain is produced. The lymph exudation that\\nfollows this inflammatory condition fills the intratrabecular\\nspaces, preventing their filling with blood during erection.\\nThe pain may become so intense that the patient in his des-\\nperation may recall having heard of breaking the chordee.\\nThis is accomplished by laying the penis on a flat surface, such\\nas that of a table, and striking the curved organ with the fist or\\na book. One patient reported that he placed his penis on a win-\\n1 Da Costa A Manual of Modern Surgery, Saunders, Philadelphia, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0057.jp2"}, "58": {"fulltext": "48 THE IRRIGATION TREATMENT OF GONORRH03A.\\ndow ledge and violently pulled down the sash upon it. White\\nand Martin (op. cit., p. 96) say that at times patients have\\nsought relief by intercourse. The results are nearly as disas-\\ntrous as those consequent on forcible breaking, at least one\\ndeath being attributable thereto.\\nNaturally, no physician would advocate the brutal violence\\nabove mentioned. It may cause laceration of the urethra, with\\npossibly fatal haemorrhage, rupture, with extravasation of urine\\nand death from urinary infection, laceration of the corpora cav-\\nernosa, and gangrene of the penis. Even if none of these super-\\nvene and if no very heavy stricture result, the part of the penis\\nanterior to the site of the infiltration may be cut off from enough\\nblood supply to produce erection therein.\\nIn chordee, the treatment outlined under cavernitis may\\nsuffice. In very severe cases, persistently continued very hot\\nsitz baths may be added. If these fail, it may be necessary to\\nuse opium or any of its derivatives to its full effect.\\nCondylomata. The fact that condylomata usually appear\\nupon the genitals probably accounts for their being called vene-\\nreal warts. No proof, however, exists that they are due to vene-\\nreal infection. As they originate most frequently upon moist\\nsurfaces, such as the mucous membranes of parts of the male\\nand female genitalia, the Germans call them Feuchtwarzen (moist\\nwarts). Through careless mispronunciation this easily becomes\\nFeigwarzen whose translation fig warts has in some man-\\nner invaded the English language. It would require more than\\nordinary imagination to conceive any resemblance to fresh or\\ndried figs in these warts, except perhaps when the latter have\\ngrown very large and their upper surface exposed to the air\\npresents a dry, horny yellowish-brown color, with rough nodu-\\nlar surfaces.\\nWeichselbaum described a condylomatous excrescence as a\\nsimple or branched papilla, built on the type of a skin or\\nmucous papilla, and covered with epithelium of varying thick-\\nness. The connective tissue in these papillae is generally much\\nricher in cells and vessels than -is the connective tissue of the\\nbase from which they spring. The epithelial covering can be\\nmaterially thicker than that of the region from which it origi-\\nnates, but ordinarily it has the usual character of the epithe-\\nlium of the region. The papillomata proceed from the normal", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0058.jp2"}, "59": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA, 49\\npapillae of the skin or mucosa, which enlarge; new formation of\\npapillae also takes place.\\nThese moist or dry papillary overgrowths may be as small\\nas pin points, or may reach almost any size. They may be\\ndiscrete or confluent. They begin in the sulci at either side of\\nthe frenum and in the sulcus behind the corona with equal fre-\\nquency. They less frequently originate on the posterior border\\nof the glans, the orifice of the foreskin, and least frequently\\nupon the lips of the meatus. They rarely appear within the\\nurethra.\\nIrritating discharges either of gonorrhoea or the disturbance\\nset up by uncleanliness, secretion retained and deconrposed by\\na redundant or tight foreskin may cause these warts. Accord-\\ning to their growth, which often is very rapid, and according to\\nwhether or not they are compressed between foreskin and glans,\\nthey may assume a shape and color varying from those of a moist\\nred raspberry to those of a yellowish-white cauliflower. They\\nmay also by pressure of the foreskin form long ridges like a\\ncock s comb (White and Martin).\\nWhen flat and macerated by free secretion or discharge, con-\\ndylomata may be mistaken for mucous patches. When broad-\\nened by growth, they may suggest syphilitic warts. But when\\nlues exists, the excrescences on the penis are not usually its\\nonly evidence, even if a history of syphilis is denied.\\nA wart appearing on the penis after middle life should al-\\nways suggest the possibility of epithelioma, even if its sur-\\nrounding tissues are not infiltrated and the inguinal glands not\\nindurated. The presumed wart should at once be thoroughly\\nextirpated and microscopically examined for purposes of prog-\\nnosis.\\nWhen condylomata proliferate upon the glans they may in-\\nduce pressure gangrene of the foreskin. After the gangrenous\\npart of the prepuce is cast off, the whole or part of the condylo-\\nmata may prolapse through the space so produced. When warts\\ngrow upon the meatus they may interfere with urination and\\nejaculation.\\nAs uncleanliness and maceration of their seat are the cause\\nof condylomata, so scrupulous cleanliness and dryness are the\\nprime indications for treatment while they are still small, i.e.,\\nwhen they are but little more than hyaline spots.\\n4", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0059.jp2"}, "60": {"fulltext": "50 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nWhen they are isolated and take on the accuminate form,\\ncleansing, drying, and dusting with powdered savin acts as a\\ndirect specific. 1 But even when they are quite large, powdered\\nsavin is worth trying for a few days. It occasionally causes the\\nwarts to slough off with surprising rapidity, leaving a base that\\nheals very soon.\\nIf the mass is large and heavy, it may be touched three\\ntimes daily with ferric chloride. The surfaces so treated shrinji.\\nThe shrivelled portions may be curetted and the application\\nrepeated. By successive scrapings and applications of ferric\\nchloride the base is eventually reached. This must be thor-\\noughly curetted and its bleeding arrested with cotton pledgets\\nsoaked in five-per-cent. solution of antipyrin.\\nExceedingly large and confluent warts may require removal\\nby the knife. The base may then be curetted and cauterized, or\\nafter curetting, the wound edges brought together by sutures.\\nUsually the bleeding is very copious. If it cannot be other-\\nwise controlled it must be arrested by the actual cautery.\\nIntra-urethral papillomata, when they do not materially re-\\nduce the urethral calibre, can be removed through the urethro-\\nscope tube. When their number and size prevent introduction\\nof the tube, the first growth may be grasped through a meato-\\nscope by means of a silk thread. This serves to draw the ure-\\nthral mucosa gently forward sufficiently to expose the deeper\\ngrowths, which then can be removed by ligature or the incan-\\ndescent snare.\\nCowperitis is of relatively infrequent occurrence. It may be\\ndue to aggravating an acute or chronic gonorrhoea by sexual\\nintercourse, undue exercise, an untoward motion, or alcohol, by\\nunskilled catheterization (i.e., traumatism from within), a fall,\\nlaceration or cut into the perineum (traumatism from without),\\nor as a consequence of retrostrictural dilatation, when all ducts\\nare stretched and the mucosa is eroded and inflamed by stag-\\nnated and alkaline urine (Horowitz 2\\nCowper s glands being situated between the two layers of the\\ntriangular ligament, and also being contained by the deep peri-\\n1 Posner Therapie der Harnkrankheiten, Berlin, 1895.\\n2 Horowitz Die Krankheiten der Cowperschen Driisen. Zuelzer and\\nOberlaender s Klinisclies Handbuch der Harn- und Sexual-Organe, vol. iii.,\\nLeipzig, 1804.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0060.jp2"}, "61": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 51\\nneal fascia, their inflammatory swelling is necessarily limited.\\nTheir pressure upon these unyielding tissues not only produces\\nintense pain, but also renders the disease externally unrecog-\\nnizable until these envelopes have yielded. Moreover, as the\\nducts of Cowper s glands empty into the bulbous urethra, their\\ninvolvement by gonorrhoea is easily comprehensible. Owing to\\nthe fact that the majority of cases of Cowperitis undergo resti-\\ntution, it may be that they are oftener infected than is supposed\\nand that the complication passes off unobserved.\\nIn the second or third week of neglected or improperlj-\\ntreated gonorrhoea, when the affection has invaded the posterior\\nurethra, Cowperitis is most likely to become manifest. Then\\nslight fever may set in, with a sensation of perineal discomfort.\\nThe mechanical impediment produces difficulty of urination and\\nsome pain on defecation. Shortly thereafter lancinating pains\\npenetrate the region; these are aggravated by pressure upon\\nthe perineum, by sitting and walking. Even when lying down\\nthere is a sensation of perineal tension. The pains on evacu-\\nating the rectum and bladder increase, especially at the conclu-\\nsion of urination, due to contraction about the inflamed gland\\nby the transverse fibres of the compressor, as it forces out the\\nlast part of the urine.\\nWhen but one gland is involved, as is ordinarily the case, it\\nis evidenced by small, hard, exceedingly sensitive swelling at\\nthe corresponding side of the raphe about midway between the\\nscrotum and the anus. This tumor may grow to the size of a\\nchestnut, or become as large as a pigeon s egg, over which the\\nskin is movable, while it retains its normal appearance. Palpa-\\ntion of this tumor will not aid materially in diagnosis, as its\\npainfulness prevents deep pressure. Digital pressure under\\nanaesthesia would be unwise, as it might cause a rupture of the\\ndistended gland into the surrounding tissues with consequent\\ndanger of purulent, and possible subsequent urinary infiltration.\\nThe finger inserted into the rectum, its tip gently pressed forward\\nbetween the external and internal sphincters, will reveal a round,\\nsmooth, hot, painful tumor below the prostate. When the tumor\\nis found on one side of the mesian line, no doubt can obtain re-\\ngarding the diagnosis. When bilateral Cowperitis exists, and\\nif there be much infiltration and distention of the surrounding\\ntissues, the diagnosis is more difficult.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0061.jp2"}, "62": {"fulltext": "52 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThe following will aid in the differentiation\\nWhen Cowperitis set3 in, the urethral discharge is ordinarily\\nmuch decreased or arrested entirely.\\nSimple perineal abscess causes no compression inward or\\nupward, and consequently does not interfere with urination.\\nOnly when it is very large will it produce pain on defecation.\\nPeri-urethral abscess of the bulb is invariably found cen-\\ntrally located about the raphe, and is situated nearer the scro-\\ntum than is Cowperitis.\\nResolution ordinarily takes place within fourteen days under\\nproper treatment. This consists in mild, gently administered\\nwashings of the anterior urethra, rest in bed, long-continued,\\nvery hot baths twice a day, saline laxatives to keep the stools\\nsoft, and a hot-water bag to the perineum. If the pain is very\\nsevere, morphine hypodermically may be required. When em-\\nployed, the needle should be as carefully sterilized as for use\\nelsewhere, and care should be taken not to inject the solution\\ninto the tumor itself, lest suppuration be precipitated thereby.\\nWhen, however, the inflammation is allowed to increase and\\nthe gland and periglandular tissues undergo suppuration, Cow-\\nperitis assumes its grave form. One or more chills, fever,\\nthrobbing in the perineum show that pus has formed, even if\\nfluctuation is not perceptible. If the case is then neglected the\\nabscess may break into the perineum, the urethra, or the rec-\\ntum. If it breaks toward the perineum it may dissect the skin\\nfrom its underlying tissues, leaving it hanging like torn rags\\nafter perforation. Partial gangrene of the scrotum may also\\nresult. Such a spontaneous rupture may produce urethral and\\nrectal fistulae, whose treatment is often very difficult.\\nWhen such dangers are announced free incision should be\\nimmediately made. In making this incision it will be well to\\nsupport the suppurating gland by the index finger in the rectum.\\nAfter incision the cavity should be curetted or irrigated or both,\\nand packed with iodoform gauze. It will be well to guard\\nagainst urinary fistula, by keeping the urethra protected by\\nmeans of permanent catheterization, until the abscess has suffi-\\nciently healed.\\nChronic Cowperitis shows itself as a hard, not very painful\\nnodule at one side of the raphe, which when pressed upon dis-\\ncharges a turbid, milk-like secretion from the urethra. If it", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0062.jp2"}, "63": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 53\\nresults after rupture of the abscess, this discharge issues from\\nthe perineum or into the rectum.\\nIt is always well to keep in mind that Cowper s glands may\\nbe the seat of a tuberculous infection and that therefore the dis-\\ncharge therefrom should be examined for the characteristic\\nbacilli.\\nCystitis. Inflammation of the bladder pre-existing, compli-\\ncating or following gonorrhoea is too vast a subject to be more\\nthan merely outlined in a small sketch. That persons with cys-\\ntitis acquiring gonorrhoea can suffer its extension to the bladder\\nis often proven. That gonococci can find a culture medium in\\na healthy bladder mucosa is denied. This negation seems to\\nbe borne out by the thousands of intravesical irrigations per-\\nformed daily in acute anterior gonorrhoea. Despite all careful\\nwashings of the anterior urethra, the irrigation fluid must cer-\\ntainly carry gonococci into the healthy bladder. Yet no cystitis\\never results. It may be held that the gonococci so carried are\\nbrought into the bladder by an antiseptic solution. While this\\nis true, no solution strong enough to destroy gonococci could be\\ninjected into the bladder without injuring its mucosa. On the\\nother hand, cystitis has often been produced by inserting an in-\\nstrument through a urethra infected with gonorrhoea into the\\nbladder. The bladder wall may have been bruised sufficiently\\nthereby to injure its protecting epithelium.\\nWhether gonorrhoea can invade the bladder by mere conti-\\nnuity of surface is still one of the disputable questions. That\\ngonococci can be carried beyond the strong compressor urethne\\nis proven many times that they can traverse the weak sphinc-\\nter of the bladder is indubitable. But whether the healthy\\nbladder epithelium ever can offer them food is not at all estab-\\nlished, and from all experience is more than doubtful.\\nWhen, however, the urethritis is of a mixed character, i.e.,\\nwhen the gonococcus is associated with other microbes, such as\\nthe bacterium coli commune, the bladder epithelium yielding\\nto the latter may open the way for gonorrhoeal infection.\\nUsually the region of the sphincter and of the trigone is the\\nseat of such extension of inflammation, and has been aptly\\nnamed urethrocystitis by Finger. The great rarity with which\\nthis inflammation extends to the rest of the bladder confirms\\nthe view of immunity of its lining epithelium to invasion by the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0063.jp2"}, "64": {"fulltext": "54 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ngonococcus. Such invasion must be due to lesions produced by\\nother bacteria.\\nThe symptoms of gonorrhoea! cystitis closely resemble those\\nof posterior urethritis. The urgency and frequency of urina-\\ntion are about the same. The patient also strains during and\\nafter ejecting small quantities of urine; he experiences the sen-\\nsation as if the bladder still contained urine. In this urethro-\\ncystitis, however, the patient is somewhat relieved while lying\\ndown, until the urine has filled the most dependent, not in-\\nflamed, part of the bladder. This limit passed, the moment the\\nurine touches the diseased region it re-establishes the urgency\\nand the pain, which burns and scalds along the entire urethra.\\nIn this it differs from acute posterior urethritis, which is not\\nrelieved by any position, because the weak sphincter vesicae\\nyields to slight urinary pressure and lets the fluid escape into\\nthe inflamed posterior urethra, where it sets up urgency, strain-\\ning, and pain after each micturition. The ejection of some\\ndrops of pure blood after each urination, with the other symp-\\ntoms just cited, is pathognomonic of posterior urethritis.\\nThe examination of the urine in portions, for differential\\ndiagnosis, is difficult in localized gonorrhoeal cystitis (urethro-\\ncystitis) when frequent urination prevents sufficient accumu-\\nlation within the bladder. In such case the bladder may be\\nwashed with a warm boric-acid solution until its outflow is\\nclear, when a carefully sterilized soft catheter is inserted and\\nfastened in place for an hour or two, if it can be tolerated so\\nlong. The catheter is clamped, or plugged with a fausset\\n(spigot). If the urine that comes through it at the end of this\\ntime carries pus with it, the pus probably is from the bladder.\\nThe differentiation, however, is open to criticism. Even if\\npain from presence of the catheter be not so great as to prevent\\nits use, there may be sufficient back-flow of pus from the\\nposterior urethra to give the impression of cystitis, by the pus\\nthe accumulated urine carries. The only reliable method of\\ndifferentiation is by means of the microscope. If the urine\\nextruded shows a preponderance of bladder epithelium, and\\nespecially that of its middle or lower layers, the existence of\\ncystitis is established beyond peradventure.\\nPus in the urine is easily recognized by adding to it satu-\\nrated solution of caustic potash, and twirling the tube containing", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0064.jp2"}, "65": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 55\\nthe mixture in as good an imitation of the centrifuge s action\\nas can be done by the hand. The urine becomes clear, and the\\nseparated pus assumes a ropy, mucoid form. Donne, who de-\\nvised this test, forcibly, albeit inelegantly, describes it as rot-\\nzig (snotty) Repugnant as is the adjective, none seems more\\napt for precise description. In cold weather this reaction may\\nnot be very prompt slightly warming the tube will then hasten\\nit. If this does not then result, the turbidity is due to phos-\\nphaturia, albuminuria, bacteruria, or an excess of epithelia.\\nAnother specimen of the same urine may be heated. If it\\ngrows more turbid over the flame, it shows that it contains\\neither earthy phosphates or albumin. The addition of acetic\\nacid will clear the urine if phosphates have rendered it turbid.\\nIf acetic acid does not change or even somewhat intensifies the\\nturbidity, it proves the presence of albumin. The latter, how-\\never, is always present with pus.\\nWhen neither heating nor acidulation affects the urine, bac-\\nteruria will usually be proven by the microscope.\\nThe treatment of gonorrhceal cystitis, which almost invari-\\nably presents itself as urethrocystitis, is practically the same as\\nthat advised for acute posterior urethritis and acute prostatitis.\\nDivekticle, urethral\u00e2\u0080\u0094 see Urethral Diverticulum.\\nEpididymitis, or ORCHi-EProrDYMiTis, or both, like most of the\\nother complications of gonorrhoea, may result from a precedent\\ncondition or from a new gonorrhoea. If preceding a new gonor-\\nrhoea, inflammation of the epididymis or testicle or both may\\nbe due to traumatism, non-gonorrhceal infection, tuberculosis,\\nor syphilis.\\nAs both the epididymis and testicle are frequently affected\\ntogether, it is often impossible to decide whether one or the\\nother is free from inflammation, and as the treatment of both\\nailments does not differ, there is ample warrant for considering\\nthem conjointly.\\nThe frequent difficulty, and often impossibility, of positively\\nestablishing that the testicle is not affected in gonorrhceal epi-\\ndidymitis may have led to the assumption that it limits itself\\nto the epididymis. Further development of radiography of the\\nsoft tissues will probably soon lead to finer differentiation with\\nconsequent improvement in therapeutics. Carl Beck, of New\\nYork, made distinct pictures in which even the walls of the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0065.jp2"}, "66": {"fulltext": "56 THE IRRIGATION TREATMENT OF GONORRHOEA.\\narteries were plainly radiographed in the living there is every\\nreason, therefore, to hope for the outcome above expressed, with\\nall its advantages to diagnosis and treatment.\\nThe pathological changes evidenced by post-mortem exami-\\nnations and the experimental examinations made by Malassez\\nand Terrillon (quoted by Finger 1 primarily show the testicle\\nnot to be involved. As, however, post-mortem changes may not\\nhave left evident serous infiltration or sanguinary engorgement,\\nthese observations cannot be taken as finally decisive.\\nThese authors found the epididymis enlarged, hypersemic,\\noccasionally with circumscribed foci of pus; in old cases the\\nepididymis was tough and calloused. The tunica vaginalis\\ntestis showed acute, serous, or serofibrinous vaginalitis. The\\nvas deferens was often thickened. The microscope showed a\\ncatarrh of the seminal ducts and parvicellular infiltration of\\nits connective-tissue envelope. The epithelium of the seminal\\nducts was turbid and swollen, deprived of its cilia in still older\\ncases it was entirely absent, and the lumen of the canals filled\\nonly with spermatozoa, with parvicellular infiltration, or fibrous,\\ncalloused by connective-tissue change of the infiltrate, in ad-\\nvanced cases. The changes in the vas deferens also begin with\\ncatarrh of the mucosa, to which parietal infiltration and thick-\\nening of the walls are added later on.\\nIt is held that epididymitis sets in most frequently during\\nthe third week after infection. Finger {op. cit.) collected the\\ndata of several authors, showing that in 1,015 gonorrhoeas, epi-\\ndidymitis appeared in the first week after infection in 46 cases\\nsecond week in 157 third week in 132 fourth week in 191 fifth\\nweek in 132 sixth week in 64 seventh week in 44 eighth week\\nin 61 from three to six months after in 117 from six to twelve\\nmonths in 52 two years in 9 three years in 7 four years in 2\\nand seven years after in 1.\\nThe very long intervals between gonorrhoeal infection and\\nepididymitis in some cases being evident from the above, its\\npossibility must not be forgotten when a patient has epididymi-\\ntis with a long passed history of clap. Then often unnecessary\\ncastration for presumed tuberculosis will be avoided. Senn 2 in\\n1 Einger Die Hoden und Nebenhoden. Klinisches Handbuch der Harn-\\nund Sexualorgane, vol. iii., 1894.\\n2 Senn Tuberculosis of the Genito-Urinary Organs, Saunders, 1897.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0066.jp2"}, "67": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 57\\none of his admirable works says Except in cases of acute dif-\\nfuse miliary tuberculosis, the essential organ of generation in\\nman is seldom the seat of primary tuberculosis. On the other\\nhand, gonorrhceal epididymitis and traumatism are often the\\nexciting causes of tuberculous disease of the testicle and epi-\\ndidymis. Senn 1 cites an illustrative case reported by Birch-\\nHirschfeld (Archivfur Heilkunde, 1871, Heft 6)\\nA soldier, 24 years of age and in perfect health, contracted\\ngonorrhoea which led to acute epididymitis. In the course of\\neight days he died of miliary tuberculosis. Miliary tuberculosis\\nwas found in the peritoneum, especially well marked at the in-\\nternal inguinal ring on the side of the affected testicle miliary\\ntuberculosis of the pleurae, lungs, meninges, liver, spleen, and\\nkidneys also existed; the epididymis was transformed into a\\ncheesy mass. In the testicle itself numerous intercanalicular\\nmiliary tubercles were found, with a few cheesy nodules the size\\nof a pea.\\nIn all cases of gonorrhoea the patient should wear a well-\\nfitting suspensory bandage. I am not aware that any statistics\\nexist showing the value of this bandage as a precautionary meas-\\nure. It seems, however, reasonable to assume that the scrotal\\ncontents, so supported, must be less exposed to traumatism\\nthan they would be if left to dangle by the often relaxed gen-\\neral condition of depressed vital tone.\\nThe selection of a suspensory bandage is not an unimportant\\nmatter. The form ordinarily dispensed, having no back\\nstraps to draw the bag perineumward, cuts the posterior\\naspect of the scrotum and pulls it into an abnormal position.\\nThe bag itself is of thick material in which the scrotal sweat\\ncakes and hardens, irritating the skin, unless the bag is fre-\\nquently washed. To avoid these defects, the suspensories should\\nbe of the forms sold as the Syracuse or Army and Navy, or\\nSchnotter suspensories. These have straps passing from the\\ncentre of the posterior boundary of the bag, between the thighs,\\nover the nates, to be fastened to the belt. Eecently the bags\\nhave been made of a strong but very light linen mesh, which\\nnot only firmly holds the scrotum in place, but is also cool and\\ncomfortable.\\nGonorrhceal epididymitis, orchitis, or orcho-epididymitis is\\nOp. cit., p. 54.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0067.jp2"}, "68": {"fulltext": "58 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nusually ushered in by vague aching, sharp stitching, or continued\\nneuralgic pains along the groin. Sometimes the pain is dis-\\ntinctly denned as proceeding the length of the spermatic cord\\nand dipping into the lower abdomen. The pain may be aggra-\\nvated by standing or walking, and not relieved by sitting. Ex-\\namination of the cord shows the vas slightly enlarged and tender.\\nOccasionally none of the pain or tenderness described above\\nwarns the patient or the physician of the approaching complica-\\ntion. This fact emphasizes the need of daily examination.\\nWhen thickening and slight tenderness of the vas on pressure\\nbetween the ringers are found, active steps should be at once\\ntaken to abort the inflammation.\\nIn some cases, when the patient is not observant or when\\nthe physician is compelled to omit daily examinations, the com-\\nplication appears to come on suddenly. A dragging pain is\\nfixed in the testicle; the epididymis swells rapidly; the scrotum\\nover it takes on oedema and soon becomes purplish. The pain\\nnauseates the patient it may even lead to vomiting, as after a\\nkick or blow upon the testicle. The urethral discharge usually\\nis diminished or disappears during the acuity of inflammation\\nof the scrotal contents.\\nThe epididymis is sensitive to touch, but this sensitiveness\\nvaries. In some cases it bears no relation at all to the increased\\nsize of the epididymis. A very slight enlargement of this gland\\nmay be exquisitely tender to the touch, while when it is so en-\\nlarged as almost to entirely envelop the testicle and exceed it\\nmaterially in size, it may be rather roughly handled without\\nproducing pain.\\nNot infrequently the tunica vaginalis becomes involved, with\\nconsequent serous effusion. The acute hydrocele so resulting\\nmay envelop the whole testicle in a large, tense swelling, mis-\\nleading the inexperienced to a diagnosis of orchitis. The trans-\\nlucency of the fluid and the enlarged epididymis behind the\\nswelling will prevent this error.\\nIf the patient can walk, he spreads his bent legs wide apart,\\ncarries his body forward as if in continual desire to rest his\\nhands upon his knees. When about to sit down, he grasps the\\nchair and lets his body down slowly. Kising from the chair is\\naccompanied by the same painful effort, as is any attempt to\\ncross his knees.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0068.jp2"}, "69": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 59\\nIn the erect posture, the pain is increased. The weight\\nof the swelling drags upon the spermatic veins, reducing their\\nlumen the blood from the testicle cannot therefore return up-\\nward. The so augmented tension and pressure may cause the\\npain to be reflected to the perineum, rectum, back, bladder,\\ndown the thighs, abdomen, and the chest. When the reflex\\npains are as extensive as described, chills, fever, anxiety, and\\nmental depression may become so marked as to overshadow the\\ncondition that provokes them. The abdomen may swell and\\nbecome very sensitive nausea, vomiting, and collapse may con-\\nvey the idea that the patient has peritonitis. These reflex\\nsymptoms usually subside rapidly, and the swollen epididymis\\nremains in evidence of their cause.\\nIn undescended testicle, to which inflammation is communi-\\ncated, the patient may have all the symptoms of strangulated\\nhernia. Emptiness of the scrotum, however, will prevent this\\nmistake.\\nWith prompt and proper treatment, inflammation of the\\nscrotal contents generally ends in resolution. The acute symp-\\ntoms usually subside in a week or ten days.\\nWhen through neglect suppuration occurs, there are in-\\ncreased pain, chills, fever, sweating, and abscess is made evident\\nby fluctuation. On opening it, the entire epididymis may pro-\\nlapse out of the wound, especially if the operation has been un-\\nduly delayed. The delay may also lead to destruction of the\\nentire scrotal contents.\\nThe acute hydrocele resulting from acute epididymitis often\\nbecomes chronic.\\nThe most frequent result of epididymitis is the formation of\\na hard, painless nodule at its head or its tail. This nodule in\\nno wise locally disturbs the patient; in some cases it rivets his\\nattention and becomes the object of his continual thoughts, evok-\\ning most persistent neurasthenia.\\nTreatment. In a small number of cases the vas deferens\\nshows the first sign of its carrying infection to the epididymis\\nand possibly, through it, to the testicle. The funiculitis then\\nevidences itself by pain and swelling in the inguinal region.\\nCopious leeching of the region will then relieve the pain and in\\nmany cases prevent active involvement of the scrotal contents.\\nIf the epididymis is found swollen at the same time, and", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0069.jp2"}, "70": {"fulltext": "60 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nthere be enough pain to warrant it, the patient should be kept\\nin bed. A board or a sheet of tin, about the size of a cigar-box\\nlid, should be cut so that it will lie comfortably upon the\\nthighs and support the testicles. A three-inch gauze bandage\\nis then wrapped smoothly entirely about this support to insure\\nits softness. Over this a sheet of impermeable tissue is folded\\nto fit neatly.\\nFig. 14.\u00e2\u0080\u0094 Support for Testicles.\\nFour or six layers of gauze eight by ten inches are then soaked\\nin an antiseptic solution of five per cent, carbolic acid, 1 6,000\\nbichloride or, if preferred lead and, opium lotion, and wrapped\\ngently around the testicles. The solution may be applied hot\\nor cold as may prove most grateful to the patient, and should\\nbe renewed every fifteen or twenty minutes.\\nIf the pain is not relieved in forty-eight hours, the case\\nshould be treated as described further on.\\nWhen the funis is not at all or but slightly swollen, strap-\\nping the testicle will, in the majority of cases, afford instant,\\ncomplete relief from pain and will cut short the disease. This\\ntreatment should, however, not be attempted unless the physician\\nis thoroughly familiar with its technique and has the firmness\\nto give the patient that short increase of pain which strapping\\ninevitably entails.\\nThe technique of strapping a testicle as I employ it is a\\nmodification of Fricke s method:\\nThe patient lies on a table, his legs extended flat upon it and\\nsomewhat abducted; he or an assistant slightly supports the\\nscrotum while the dressings are being prepared. Two strips\\nare cut from a three or four inch gauze bandage, according to", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0070.jp2"}, "71": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA.\\n61\\nthe size of the swelling, and long enough to cover the scrotum\\nfrom the perineum to the pubis. These strips are smeared with\\nan ointment, slightly modified from that proposed by Casper, of\\nBerlin, and composed of ichthyol\\n2.5, guaiacol 5.0, ung. hydrarg.\\n10, vaselin and lanolin, p. ae. ad\\n30.0. The use of these strips\\nrenders shaving the scrotum un-\\nnecessary.\\nThe neck of the scrotum of\\nthe diseased side is then grasped\\nbetween the left thumb and mid-\\ndle or index finger, and with in-\\ncreasing pressure the testicle is\\nforced to the bottom of the scro-\\ntum. The compressing fingers\\nare steadily, forcibly contracted\\nuntil the region about the funis\\nis reduced to its smallest possible\\ncalibre. Without releasing the\\ngrasp of the ringers a half-inch\\nstrip of strong adhesive plaster\\nis firmly wrapped immediately below the fingers so tightly as to\\nconvey the impression that the funis might be strangulated\\nthereby. This is the most painful part of the whole procedure.\\nIf not thoroughly done, the entire purpose of the strapping will\\nbe thwarted the patient will experience no relief, the case will\\nbe aggravated, the scrotum injured and its contents exposed to\\nabscess formation. Cases are not rare in which physicians,\\nguided more by sympathy for their patients than by steadfast-\\nness of purpose, have strapped the swelling so that the testicle\\nwas forced up toward or almost into the inguinal ring and the\\nepididymis away from the testicle.\\nAfter the first strip of adhesive plaster (which I think may\\nbe properly called the choker is firmly applied, the superficial\\nveins of the scrotum will for a moment enlarge and stand as\\nblue, more or less tortuous strings beneath the skin. One of\\nthe gauze strips smeared with the Casper ointment is firmly and\\nsmoothly laid from the posterior neck of the swelling to its an-\\nterior aspect, and the second strip is similarly applied at right\\nFig. 15.\\nThe First Strip of Adhesive\\nPlaster.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0071.jp2"}, "72": {"fulltext": "62\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nangles to the first. A second choker about three to four\\ninches wide is now firmly wrapped around the root of the tumor\\ncovering the first choker and holding the four ends of the\\ngauze strips in place. Then an adhesive strip half an inch wide\\nand of sufficient length, is firmly attached to the centre of the\\nposterior (perineal) aspect of the choker, tightly drawn over\\nthe testicle and attached to the centre of the anterior part of\\nthe choker. A second strip is similarly placed from the choker\\nat the external surface of the scrotum to the mesian surface, at\\nright angles to the first strip.\\nA third strip is attached to the\\nchoker, immediately adjoining\\nand slightly overlapping the\\nsecond strip s entire course.\\nSuccessive strips are placed in the\\nsame manner until the entire tes-\\nticle is firmly encased.\\nIt will be found necessary to\\nheat thoroughly each strip and to\\napply it as hot as it can be borne\\nby the patient, to secure its ad-\\nhesion to the grease that oozes\\nthrough the gauze. It will also\\nbe convenient to apply a new\\nchoker after each three or four\\nlongitudinal strips are applied.\\nAll attention should be di-\\nrected to applying the strips smoothly, and with as firm and\\neven pressure as possible.\\nAfter the last longitudinal strip is applied, the whole dress-\\ning should be reinforced by a final choker about six inches\\nlong. Two or three turns of the choker are made about the\\nneck of the tumor, the remaining strip is made to envelop the\\nother longitudinal strips by interrupted spiral turns, returning\\nto the neck.\\nThe projecting ends of the adhesive plaster about the neck\\nof the scrotum are then cut off closely above the choker; the\\nprojecting ends of the gauze are also trimmed but allowed to\\nextend about one-eighth of an inch above the choker, to protect\\nthe skin from erosions that otherwise would be likely to result.\\nFig. 16.\u00e2\u0080\u0094 Testicle Strapped.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0072.jp2"}, "73": {"fulltext": "COMPLICATIONS AND SEQUELJE OF GONORRHOEA. 63\\nBefore the patient rises, a large suspensory bandage with\\nback-straps is firmly applied, after enveloping the whole testicle\\nin a layer of cotton. Absorbent cotton having lost its resiliency\\nin being prepared, should not be used for this purpose.\\nThe whole procedure, from placing the patient on the table\\nto buckling the suspensory bandage, should not occupy over five\\nminutes; the increased pain caused by applying the first choker\\nshould not, with ordinary skill, extend over ten seconds, the\\nother manipulations should be comparatively painless.\\nAfter the testicle is drawn as closely as possible to the pubis\\nby the suspensory bandage, the patient is told to arise. If all\\nparts of the work have been properly performed, it will be\\nfound that the patient can stand upright; that he can, wheal\\nholding his heels and toes together, take up a small object lying\\nimmediately in front of his toes that he can stand, walk, turn\\nrapidly, sit down, get up, cross his legs absolutely without pain\\nand with no sensation about his genitals further than the feeling\\nof some bulk between his legs, which, however, is but slightly\\nor not at all uncomfortable.\\nThe exhilaration produced by the sudden cessation of local\\nand reflex pains and the stopping of all constitutional effects\\nthereof make the patient exceedingly willing to return in forty-\\neight hours for a second strapping. Usually the longitudinal\\nstraps will then be found loosely encasing the scrotum. A\\ngrooved director passed under the choker into the space between\\nthe scrotum and the plaster strips serves as a guide for strong\\nscissors to cut the choker at the centre of its anterior aspect.\\nThe hair to which it is attached should be cut through, care be-\\ning taken not to snip the skin. When all the hairs are cut, pass\\nthe scissors through the anterior aspect of the entire casing,\\nwhich can then be easily removed. The swelling will then be\\nfound reduced to one-third or one-fifth of its former size. If\\nany excoriations have resulted from defects in the dressing, they\\nshould be dusted with nosophen and cotton packed into a snugly\\nfitting suspensory bandage applied over it. If no excoriations\\nhave resulted, and especially if some tenderness still remains,\\nthe strapping should be reapplied and repeated every forty-eight\\nhours. Some cases may require as many as four such strap-\\npings to reduce the inflammation to a subacute state, which\\nthen may be treated by applications of the Casper ointment on", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0073.jp2"}, "74": {"fulltext": "64 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ngauze strips twice daily. These strips should then be covered\\nby a thick layer of cotton and impermeable tissue over the cot-\\nton, all held firmly in place by a well-fitting suspensory bandage.\\nIn some cases, having reached this stage, resorption of the\\nswelling seems to be hastened by galvanism employed every\\nsecond day. At the first seance the moistened negative elec-\\ntrode may be applied to the scrotum and the positive to the\\nthigh. The seance may last five minutes and two milliamperes\\nbe employed. At the second seance the poles should be change d,\\nthe time lengthened to six minutes and the current increased\\nto three milliamperes. At each subsequent seance the poles\\nshould be changed, the application extended one minute and the\\namperage increased one milliampere. The use of galvanism\\nshould not be carried to a painful degree and the site of applica-\\ntion of the positive pole, while kept firmly applied, should be\\ncontinually moved to prevent excoriations.\\nSometimes the patient s timidity or the physician s lack of\\nfortiter in re (never incompatible with suaviter in modo) prevents\\nstrapping the testicle in the class of cases cited. Then the\\nindications for rest, elevation, warmth, and moisture can be\\napproximately attained by the use of specially constructed sus-\\npensories. These were first suggested by Horand, and sub-\\nsequently modified by Langlebert, von Zeissl, Casper, Falk-\\nson, Letzel, White and Martin, and others. They differ from\\nsuspensory bandages mentioned before, in being much larger,\\nstronger, and adjustable not only in the body and perineal straps,\\nbut also in having adjustable scrotal bags. Their cost is, how-\\never, high. In cases in which the bandages mentioned before\\nwill not suffice, they certainly are serviceable. They are em-\\nployed as was directed for their use after strapping.\\nA substitute for strapping and suspensories is devised by\\nKarl Gerson, 1 of Berlin, who suggested the use of scrotal ele-\\nvating strips. 2 These are strong elastic adhesive strips an inch\\nwide, with one margin softly fringed. The end of the bandage\\nhas two small linen tapes. For use the scrotum is grasped be-\\n1 Gerson Elastische Pflaster-Suspensionsbinden. Dermatologische\\nCentralblatter, Heft iv., 1897 Berliner klinische Wochenschrift, No. 3, 1898.\\n2 The words scrotal elevating strips are an intentional mistranslation\\nof the author s Suspensionsbinden, which in a literal version would cause\\nconfusion with the accepted English designation of suspensory bandages.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0074.jp2"}, "75": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 65\\nlow, and by compressing the sac, its contents are forced upward\\nto as near the inguinal ring as possible. The bandage, which\\nreadily adheres to the scrotum, is tightly w r ound about it, with\\nthe fringed edge upward, to prevent abrasion. When the whole\\nis wrapped about the emptied scrotum, it is firmly tied by the\\nlinen tapes. This leaves a part of the emptied scrotum project-\\ning below the bandage. The ease with which this manner of\\ntreating epididymitis can be employed, and the facility with\\nwhich the patient can reduce its pressure, should it become too\\nstrong, are decided arguments in its favor. And indeed, in\\nmany cases (perhaps fifty per cent.) it acts quite satisfactorily.\\nIn some, however, the pain becomes so severe as to compel its\\nremoval, and in others it produces no appreciable effect.\\nIn exceptionally severe cases of epididymitis or orcho-epi-\\ndidymitis, or when the patient cannot bear even a touch of the\\ninflamed scrotal contents, and when the treatment described on\\npage 59 will not afford relief, tobacco poultices will assuage\\nthe suffering. These are made of equal parts of common smok-\\ning tobacco and ground flaxseed, boiled together and applied as\\nhot as can be comfortably borne. As soon as such a poultice\\nbegins to cool, a fresh one should be applied. At night they\\nma}^ be substituted by the Casper ointment.\\nWhile the inflammation is at its height, some authors still\\nrecommend crushed ice directly applied or used in an ice-bag.\\nNo relief is obtained by this treatment, which seems to increase\\nthe danger of abscess. It may be a mere coincidence that in\\nevery case I saw of loss of the testicle from gonorrhceal invasion\\nof the scrotal contents, ice had been employed during epididy-\\nmitis.\\nIt is ordinarily held that from the very onset of epididymitis\\ntreatment of the urethra should be stopped. This idea is prob-\\nably due to the usual diminution or entire arrest of the discharge\\nwhen epididymitis begins. But in practice it is found that\\nwhen the physician desists from treating the urethra during\\nepididymitis, its subsidence is followed by a return of the dis-\\ncharge, usually far in excess of the original condition while if\\nirrigations are persistently continued despite the epididymitis,\\nrecurrence of the severe symptoms of gonorrhoea does not take\\nplace.\\nEpispadias and Hypospadias, when not so deforming the penis\\n5", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0075.jp2"}, "76": {"fulltext": "66 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nas to make coitus impossible, are prone to interfere materially\\nwith successful irrigations. It is remarkable that men with\\nvery markedly deformed penes seek to gratify the genesic im-\\npulse. Their large exposure of mucous membrane makes them\\nliable to more ready infection, and in these deformities, the in-\\ngenuity of the physician is often taxed for the successful em-\\nployment of remedial measures. Owing to sacculations and\\ndeviations produced by these deformities, gonorrhoea, despite\\nthe best directed treatment, is prone to go over into chronicity.\\nThe case then is not likely to be finally cured before the urethra\\nis restored by plastic operation.\\nEpithelium in the Urine.\u00e2\u0080\u0094 The only epithelium found in\\nnormal male urine comes from the bladder. Louis Heitzmann, l\\nfollowing the principles laid down by the lamented Carl Heitz-\\nmann, asserts that in addition to other microscopic evidences,\\nthe kind of epithelium found in the urine points out the region\\nof the pathological process going on in the genito-urinary tract.\\nFantastic as this is asserted to be, I have almost daily evidence\\nof the parallelism between microscopical and clinical diagnosis\\nand always find it a decided aid. The details of the character-\\nistics of the various epithelia, their application to diagnosis,\\nwould lead beyond the scope of this little book. Moreover,\\nthey are described by Heitzmann so fully as, in the light of our\\npresent knowledge, cannot be improved.\\nI would like to add an important fact to his description of the\\nepithelia found in the urine of stricture cases, even when a path-\\nological coarctation presents no other evidence of its presence.\\nThe urethral epithelia, then, have among them some thinned\\nscales, with smoothed or faint nuclei and some without nuclei.\\nThese variations prove that stricture is forming and persists as\\nlong as they are present. The case must then be treated by di-\\nlatations and irrigations, as detailed under chronic gonorrhoea.\\nEye, Gonorrhceal inflammation of see Ophthalmia, gonor-\\nrhceal.\\nEig- Warts see Condylomata.\\nFistula, urethral. Whether congenital or the result of peri-\\nurethral abscess or of urethral rupture from stricture, a urethral\\n1 Heitzmann Urinary Analysis and Diagnosis, William Wood Co.,\\n1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0076.jp2"}, "77": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 67\\nfistula is not likely to render irrigation especially difficult, un-\\nless the fistula is very large. If situated in the anterior ure-\\nthra, it can ordinarily be covered by the finger during irriga-\\ntion and evacuation of the bladder, when intravesical washings\\nare employed. In that case it will be well to have the patient\\nlet some of the irrigation fluid pass through the fistula, so that\\nits lining may receive antigonorrhceal treatment at the same\\ntime. Perineal fistulse do not usually offer much hindrance to ir-\\nrigations. If, however, they do, on account of large dimensions,\\nthe patient can be instructed to hold them closed during irri-\\ngation.\\nFloateks, in the urine. Macroscopically visible sub-\\nstances carried from the urethra by the urine are among the\\nnumerous genito-urinary subjects that still merit much detailed\\nstudy. Many eminent authors have made painstaking researches\\nregarding them yet, until more precise devices and methods are\\nemployed, floaters in the urine will remain but partially un-\\nderstood as regards their origin and special pathological signi-\\nficance.\\nTheir importance is well brought into relief by Guiard 1\\nIt is safe to say with Fiirbringer that the abnormal products\\ncontained in the first portion of the urine represent a more\\nconstant symptom of goutte militaire (morning drop) than the\\ndrop itself.\\nThese objects carried in the urine are usually spoken of as\\nfilaments or clap threads (Tripperfaden) without description of\\nany distinctions between their forms.\\nWith a view to a clinical outline of their study I submit the\\ngeneric term floaters for all these objects, fully conscious of\\nits incompleteness, as it does not describe those, composed\\nessentially of pus, which sink: to the bottom of the glass con-\\ntaining fresh urine.\\nKoughly it may be said that these floaters differ in size,\\ntransparency, consistence, and conduct, according to the sever-\\nity of the disease, its chronicity, and the progress of treatment.\\nThese relations, however, are by no means firmly established.\\nIn studying these floaters, it must be remembered that there\\nare floaters which have no relation whatever to disease. These\\n1 Guiard Les Urethrites chroniques, Rueff, Paris, 1398.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0077.jp2"}, "78": {"fulltext": "68\\nTHE IRRIGATION TREATMENT OF GONORRHCEA.\\nMPi*\\nm\\ni j\\nm\u00c2\u00a7KhM\\nmrnnM\\nM\u00c2\u00bb #^!i\\nMM\\nwfi i-M\\n\\\\-sn\\nI have been called normal mucous filaments by Guy on. 1 The\\nfirst urine passed after a night s rest, during which the secre-\\ntions of the mucosa and its glands have not been washed away,\\ncarries with it a long, wavy filament. At spots it is rolled upon\\nitself. It is transparent, occasionally encloses minute air bub-\\nbles, whitish spots and streaks. It remains coherent on shak-\\ning the tube and sinks very\\nj slowly below the surface of the\\nurine. Its coherence is still\\nmore manifest when grasped\\nby forceps or fished by means\\nof a needle; when withdrawn\\nfrom the urine it stretches into\\ngreat length as it is held sus-\\npended.\\nIn consistence this normal\\nfilament suggests the discharge\\nthat comes from the prostate,\\nin that it can be dragged about\\nupon a cover glass, maintain-\\ning its tenuousness for a long\\ntime. When allowed to rest,\\nit shows a tendency to form a\\ncolorless, amorphous heap.\\nAs it dries very slowly, its\\npreparation for the microscope\\nis quite tedious. Endeavors\\nto spread it with the platinum\\nloop result in uneven masses\\ninterspersed with hard lumps.\\nIt is therefore best to press it between cover glasses while\\nmoving them about upon each other until an even smear is ob-\\ntained. Even then, on separating the cover glasses, to let the\\nspecimen dry before flaming, its coherence is so great that it is\\nlikely again to run together into lumps.\\nThe specimen properly spread, stains best with alkaline\\nmethylene blue. For fine distinction this solution should not\\nFig. 17.\u00e2\u0080\u0094 Normal Mucous Filament, from a\\nhealthy man, who never had urethritis.\\nFirst morning urination. The mucous fila-\\nment holds leucocytes and epithelia in se-\\nries. X 300 diameters. (From Guyon:\\nVoies Urinaires, vol. ii., page 363.)\\nGuyon: Lecons cliniques sur les Maladies des Voies urinaires, tome\\npremier, Bailliere, Paris, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0078.jp2"}, "79": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 69\\nbe over two per cent, and left in contact with the specimen for\\nfive minutes before washing it off.\\nOn examination this specimen is found to contain\\nMucous threads and bands with a tendency to curl; their\\nmeshes hold, isolated, in small groups or in rows\\nUrethral flat epithlia with small nuclei\\nPolyhedric or rounded epithelia with large nuclei\\nLeucocytes, often in abundance.\\nThe normal filament never has micro-organisms of any kind,\\nnot even the bacteria of the normal urethra. These bacteria are\\nfound in secretion taken from the meatus, lying amidst the large\\nepithelial cells.\\nNot infrequently a healthy man learns that urethral filaments\\nare evidence of disease. Unless the physician informs himself\\nthoroughly of the appearance and other characteristics of the\\nnormal filament, and uses his knowledge to reassure his patient,\\nthe latter can develop most obstinate neurasthenia. If not con-\\nvinced of the innocuousness of these normal filaments, he may\\nget into the hands of quacks, who by maltreating the healthy\\nurethra with injections or sounds, will set up an irritative ure-\\nthritis with stricture or other complications in consequence.\\nThe dimensions and shapes of pathological floaters in the urine\\ndiffer according to the severity of the disease, its duration, and\\nthe results of treatment. These differences are subject to most\\nmarked variations. With a view to establishing a basis of re-\\ncording cases, and consequently their more detailed study, I\\nsubmit the following classification\\nShreds, coarse, large, medium, small,\\nfine,\\nFilaments, coarse, long, medium, short,\\nfine,\\nFlakes, coarse and fine.\\nGranules, coarse and fine.\\nIn offering the above, concise descriptive terminology is\\nthe sole object. It would be remiss to omit from this list the\\ncomma filaments, which, ^according to Furbringer and Finger,\\nare moulded to the comma shape within the prostatic duct in\\na diseased condition. When found, they usually are emitted\\nwith the last drops of urine.\\nThe conduct and coherence of pathological floaters bear no re-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0079.jp2"}, "80": {"fulltext": "70 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nlation to their dimensions, nor have they as yet an established\\nposition in diagnosis. Guy on (op. cit.), however, advises re-\\ntaining the designations of purulent, muco-purulent, and mucous\\nfloaters as clinical definitions.\\nPurulent floaters are short, multiple, opaque, friable, are\\neasily broken up by shaking the urine, which they render\\nturbid. They sink quickly (drop) to the bottom of the glass\\ncontaining the urine.\\nMuco-purulent floaters are often single, long, knotted; some-\\ntimes one of their ends is rolled upon itself forming a sort of\\nhead. They look grayish-white and have opaque dots or stripes,\\nheld together by a transparent substance. They float toward\\nthe top or middle of the urine, and cohere almost as much as\\nthe normal filament when withdrawn for examination.\\nMucous floaters appear as do those of a muco-purulent char-\\nacter. They differ, however, by remaining at or near the top\\nof the urine column and in being almost entirely transparent.\\nThe conduct of these floaters conveys the thought that there\\nexists a variance in their specific gravity mucus being lighter\\nthan urine and the floaters proportionately heavier in accord\\nwith the amount of pus they contain. Their histological and\\nbacteriological elements also contribute to the floating or sink-\\ning of the floaters. For their study the reader is referred to\\nworks on these subjects. One that embodies the most recent\\nviews is by Louis Heitzmann, 1 whose practical value for pur-\\nposes of diagnosis is beyond calculation.\\nThe examination of floaters, both macroscopic and micro-\\nscopic, must be made from urine passed in the physician s office.\\nFor this purpose the urine brought in a bottle is worthless, as\\nall floaters dissolve in a few hours.\\nUnder appropriate treatment, the shreds soon become broken\\nup into flakes, the long filaments into shorter ones, and as the\\ndisease nears its end, all floaters become converted into granules.\\nThese changes will be more fully discussed under the treatment\\nof chronic gonorrhoea.\\nFolliculitis\u00e2\u0080\u0094 see Abscess, follicular and peri-urethral.\\nForeign bodies in the urethra may complicate and aggravate\\ngonorrhoea. They may be due to bodies inserted into the ure-\\n1 Heitzmann Urinary Analysis and Diagnosis by Microscopic and\\nChemical Examination, William Wood Co., 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0080.jp2"}, "81": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. Yl\\nthra, as has been done in attempts to alleviate itching or tick-\\nling, for masturbatory purpose, or by instruments breaking off\\nwhen introduced for therapeutic objects. Of the articles in-\\nserted to allay itching or cause ejaculation, or broken off dur-\\ning surgical procedures, Englisch mentions pins, bits of wood,\\ntwigs, grasses, roots, sponges, pipe stems, forks, catheters, cau-\\ntery-carriers, pieces of forceps, etc.\\nConcretions formed above, or fragments left in the bladder\\nafter lithotripsy may be carried to the urethra and be pinned\\nfast there by their sharp points penetrating the mucosa.\\nForeign bodies (stones) may also form within the normal\\nurethra they then are usually located in the fossa, rarely within\\nthe bulb. They may also be deposited in congenital or acquired\\ndiverticula or fistulae. They then usually are uric-acid stones.\\nForeign bodies inserted or formed in the urethra may be\\ncarried upward by its motions and those of the bladder. The\\nlengthenings and shortenings of the penis under varying emo-\\ntions may mechanically explain this inward progress. This,\\nof course, is interfered with when the foreign body is sharp or\\nrough, causing its ingression into a consequent adhesion to the\\nurethral wall.\\nA foreign body causes pain and the other inflammatory\\nsymptoms or an increase thereof, when these existed before its\\nintroduction. Efforts at urination, if the body is large, result\\nin forcible distention of the urethra behind it, while the urine\\ndribbles or drops from the meatus. If the body is very large\\nor not promptly removed, retention may result, as may also\\nabscess or extensive pockets of the urethra.\\nPalpation reveals the location of the foreign body. Swelling\\nabout it may deceive the fingers regarding its size and character.\\nIf unduly left in the urethra, the urinary salts may form con-\\ncretions about the foreign body.\\nThe sudden establishment of localized pain within the urethra,\\nbesides the other disturbances, direct attention to the possi-\\nbility of a foreign body having been introduced, although the\\nfact may be strenuously denied by the patient. This is the\\nonly circumstance in which urethroscopy is justifiable in acute\\n1 Englisch Die chirurgischhen Krankheiten der mannlichen Harnrohre.\\nZuelzer and Oberlaender s Klinisches Handbuch der Harn- und Sexualor-\\ngane, vol. iii., Vogel, Leipzig, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0081.jp2"}, "82": {"fulltext": "72 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ngonorrhoea. The pain may be so severe as to require cocaine or\\nencaine before a tube can be introduced to the site of the foreign\\nbody. Great care must be exercised to prevent the substance\\nfrom being thrust farther into the urethra by the obturator. If\\nit can be grasped through the tube by the Guy on urethral for-\\nceps, a dull curette, Guyon s hood or an instrument improvised\\nfor the purpose to cover the special needs of the case, it may be\\nwithdrawn with or through the tube, if their relative sizes per-\\nmit. Whenever a rough or sharp body can be drawn through\\nthe tube, this method is certainly preferable, as thus the ure-\\nthra is protected from additional injuries. When the body is\\ntoo large to pass through the urethroscopic tube, it must bo\\nremoved by the most suitable of the many instruments devised\\nfor the purpose. When it is smooth and located in the pendu-\\nlous portion, it may be pressed out of the urethra by careful\\nmanipulation. If, as occasionally happens, a man inserts a hair-\\npin or a hat-pin into the urethra, their points will bo found\\npresenting forward. Efforts at removal are likely to cause ex-\\ntensive gathering and penetration of the mucous folds. It will\\nbe well, to prevent such additional injury of whose extent the\\nsurgeon cannot judge at the time, to cause the points of such an\\ninstrument to penetrate the urethra at the centre of its floor\\nand to turn the object by the projecting part so that its head\\npresents forward. Then holding the projection firmly with\\nstrong forceps, the penis is stripped backward to cause the head\\nto project from the meatus, so that it can be grasped by another\\nforceps and withdrawn. It is better to thus risk a urethral\\nfistula than to produce internal injuries of the urinary channel.\\nThe surgeon s ingeniousness is often severely taxed for the\\nremoval of stones formed in the urethra. They may be con-\\ntained there for a long time without producing any special dis-\\nturbance. Slow or sudden accretions may, however, establish\\nincreasing inflammatory symptoms, with local swelling, urinary\\ninfiltration, formation of abscesses or diverticulse, incontinence,\\nchills, fever, pain at the site of the concretion or radiating pains\\nthrough the penis. If not removed, nature may throw out the\\nstone through extensive ulceration, producing large urinary\\nfistulse which are difficult and sometimes impossible to repair.\\nIf the stone or stones so formed are left in the urethra, the pa-\\ntient s life is in danger from sepsis.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0082.jp2"}, "83": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 73\\nIf the stone cannot be removed through the urethra, external\\nurethrotomy over it must be performed as soon as possible.\\nFrenum, short or rigid. While extreme degrees of this de-\\nformity may render erection painful and intromission impossi-\\nble, it does not safeguard the patient from acquiring gonorrhoea.\\nIt offers no material interference with irrigations still, while the\\npatient is under treatment, it may be well to slit the frenum to\\ncorrect the deformity. In case of a timorous person, the little\\noperation may be preceded by freezing the frenum with ethyl\\nchloride. The glans is turned back, a narrow straight bistoury\\nor tenotome passed through its base and the frenum cut from\\nwithin outward. The cut may be dressed with iodoform or\\nnosophen gauze and a light bandage applied to keep the fore-\\nskin retracted and prevent coaptation of the cut extremities.\\nFuniculitis. Inflammation of the spermatic cord may\\nmanifest itself while the vas carries infection from posterior\\nurethritis to the epididymis (see Epididymitis) or may in-\\ndependently complicate gonorrhoea especially by rheumatic\\nphlebitis. It may appear in the form of serous funiculitis\\n(acute diffuse hydrocele of the cord) or of phlegmonous funicu-\\nlitis. The former shows itself as a roundish, sausage-like swell-\\ning along the cord, which is translucent and pits on pressure.\\nPhlegmonous funiculitis manifests itself in the same shape, but\\nit is not translucent and is very tender to pressure. From the\\nacuity of the symptoms it may simulate strangulated hernia.\\nIt is the more dangerous form, as it may extend into the peri-\\ntoneum.\\nAcute funiculitis in either form is treated as laid down under\\nthe lighter form of epididymitis. If the manifestations are so\\nsevere that the testicle is threatened, the funis should be incised\\nand drained.\\nGenekal Gonorehceal Infection. Some of the complica-\\ntions mentioned here can have their explanation only in con-\\nveyance of gonococci through the circulation. P. Colombini\\nreports a case which signally illustrates this\\nA mechanic, aged 28, had acute gonorrhoea in two weeks he\\nColombini Bakteriologische und experimentelle Untersuchungen iiber\\neinen merkwurdigen Eall von allgemeiner gonorrhoischer Infection. Cen-\\ntralblatt fur Bakteriologie, vol. xxiv., No. 25.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0083.jp2"}, "84": {"fulltext": "7\u00c2\u00b1 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ndeveloped an inguinal bubo, a week later an abscess of the epi-\\ndidymis, and eight days after that, suppuration of the parotid.\\nThe pus from all the abscesses, as well as the blood, was found\\nto contain gonococci, from which pure cultures were obtained.\\nColombini found a boy of twenty who had never had gonor-\\nrhoea and who willingly submitted to having his urethra infected\\nwith one of these cultures. A florid gonorrhoea resulted, which\\nrequired many months of assiduous and patient treatment for\\nits cure.\\nThurnmel, 1 of Leipsic, in commenting on this case, says that\\nthe culture experiments should have sufficed Colombini for cer-\\ntainty that the diplococci found in the various abscesses and\\nblood were true gonococci, and that humane sentiment should\\nhave forbidden imperilling the health and life of a young man,\\nby so infecting him. Thurnmel adds that if it seems necessary\\nto make any such tests, the experimenter should use his own\\nurethra for the purpose a sentiment with which all will agree.\\nIn a most explicit paper, which Berg 2 read before the Sec-\\ntion of Practice, New York Academy of Medicine, he recites\\nthe details of a case whose death, twenty-nine days after the\\nfirst symptoms of a gonorrhoea, was clearly due to systemic\\ngonorrhoeal infection of the heart and kidneys without any lesion\\nof the bladder or urethra. The author s deductions and literary\\nresearches are so instructive that justice to the reader requires\\ntheir entire reproduction.\\nA large number of cases of ulcerative endocarditis com-\\nplicating gonorrhoea have been reported. In the larger number\\nof cases the heart lesion was preceded by gonorrhoeal arthritis\\nthus Ricord and Hunter, according to See, 3 believed that gonor-\\nrhoeal rheumatism was sometimes complicated by rheumatic\\nendocarditis. Desnos, however, in 1877 performed the first\\nautopsy upon a case of endocarditis without rheumatism, com-\\nplicating gonorrhoea and other cases have since been reported\\nin which arthritis was not present. Such a case was reported\\n1 Thurnmel Centralblatt fur die Krankheiten der Harn- und Sexualor-\\ngane, July 15th, 1899.\\n2 Henry V. Berg: Pyelo-nephritis and Ulcerative Endocarditis as a\\nComplication of Gonorrhoea the Gonococcus found in Pure Culture upon the\\nDiseased Heart Valve. Medical Record, April 29th, 1899.\\n3 Le Gonocoque, 1896.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0084.jp2"}, "85": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 75\\nby Morel. 1 That inflammatory complications occur in gonor.\\nrhoea has always been recognized. Many of them are due to\\ndirect extension of the process from the urethra or vagina into\\nthe deeper tissues connected with these tracts. Others are the\\nresult of direct inoculation of distant structures with gonorrhceal\\npus, as, for instance, gonorrhceal ophthalmia. Neither of these\\nmethods of infection would account for the production of a gon-\\norrhceal endocarditis. Effects upon the nervous system and\\nthe manifestations of general sepsis could be explained by sup-\\nposing that a toxin produced by the gonococcus had been ab-\\nsorbed iuto the lymphatic and circulatory system, but the find-\\ning of the gonococcus in pure culture in the vegetations on the\\nvalves of a case of ulcerative endocarditis complicating gonor-\\nrhoea would seem to prove that the gonococcus itself has been\\ncarried to the site of the lesion, and has there produced the\\nulcerative manifestation.\\nFor some time it was believed, when such an infection oc-\\ncurred, that it was the result of a mixed infection. As is well\\nknown, the urethra is the habitat, even in the normal state, of\\nnumerous varieties of germs, so that, when the mucous mem-\\nbrane of the urethra has been thrown into a pathological condi-\\ntion through the action of the gonococcus, the pyogenic germs\\nwould find a ready means of entering the system and producing\\ndistant lesions of a septic character. Thus Weichselbaum 2 re-\\nports a complete autopsy, with bacteriological investigation of\\na case, which certainly proved that ulcerative endocarditis can\\ncomplicate gonorrhoea as a result of mixed infection, he having\\nfound gonococci and streptococci upon the valves. A similar\\ncase was published by Ely. 3\\nHis 4 and Wilms, 6 although they both published cases of\\nulcerative endocarditis complicating gonorrhoea, in which the\\ncocci found on the diseased valves had morphological charac-\\nteristics of the gonococcus, and behaved in the characteristic\\n1 Tl$se de Paris, No. 209, 1878.\\n2 Centralblatt fur Bacteriologie, 1887, 2, and Zur Aetiologie der acuten\\nEndocarditis, Ziegler s Beitrage, 1888, iv., 3.\\n3 Medical Record, March 16th, 1889.\\n4 Berliner klinische Wochenschrift, 1892, No. 40.\\n5 Miinchner med. Wochenschrift, 1893, No. 40.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0085.jp2"}, "86": {"fulltext": "76 THE IRRIGATION TREATMENT OF GONORRHCEA.\\nmanner toward Gram staining, yet considered that these cases\\nwere the result of mixed infection.\\nBut in the last few years, particularly since 1894, many ex-\\ncellent observers have reported cases in which there was found\\nat the site of lesions complicating gonorrhoea only the gono-\\ncoccus. Thus Bordone-Uffreduzzi obtained the gonococcus in\\npure culture by inoculations made with the fluid from a joint\\naffected by gonorrhceal arthritis. A gonorrhoea was produced\\nin a human subject by inoculation with the second generation\\nof pure cultures thus derived from the arthritic joint. Council-\\nman 2 reports a case in which he obtained pure cultures, in a\\ncase of gonorrhceal septicaemia, from the joints, the pleura, the\\npericardium, and the valves of the heart. Councilman also\\nquotes a case of Gluzinsky very similar to the case which my\\ncommunication recounts, and Winterberg 3 reports a similar\\ncase. One of the earliest cases of this kind was that of Ley den, 4\\nin which, as in my case, the gonococcus was found after death.\\nCultures from the blood during life, and from the left ventricle\\nafter death, remained sterile.\\nOne of the most valuable cases was reported by Thayer\\nand Blumer. 5 In this case, in addition to pure cultures of\\ngonococcus found in the valves, the blood cultures taken dur-\\ning life showed colonies of gonococcus which would seem to\\nprove that the gonococci passed by means of the blood cur-\\nrent to distant portions of the body, and there gave rise to\\ninfections.\\nI think that at present we may believe that septic infections,\\nsuch as occurred in my case, can be the result of the unaided\\naction of the gonococcus distributed through the body by the\\nblood channels.\\nThe first conclusive proof of the gonococcus causing peri-\\ntonitis was presented by Cushing, 6 whose exhaustive investiga-\\n1 Deutsche mecl. Wochenschrift, 1894, xx., p. 484.\\n2 Trans, of the Association of American Physicians, 1893, viii., p. 165.\\n3 Festsch. zum 25jahr. Jubil. d. Vereins Deutsch. Aerzte zu San Fran-\\ncisco, 1894, p. 40.\\n4 Berliner klinische Wochenschrift, January 1st, 1894, xxxii., p. 22.\\n5 Arch, de Med. experimental., November 1st, 1895, vii., No. 6, p. 701.\\n6 Harvey W. Cushing: Acute Diffuse Gonococcus Peritonitis. Bulletin\\nof the Johns Hopkins Hospital, May, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0086.jp2"}, "87": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 77\\ntions add evidence to the fact that gonorhceal processes are riot\\nlimited to mucous surfaces.\\nBesides the joints, heart, and kidney, the fourth ventricle of\\nthe brain has been found the seat of gonococcal invasion through\\nthe circulation.\\nFor detailed study of the gonococcus the reader is referred\\nto the writings of the authors mentioned, and more particularly\\nthose of Henry Heimann. 1\\nGleet. This term is used to designate any kind of per-\\nsistent discharge from the urethra. As it embraces no patho-\\nlogical or otherwise descriptive import, it should cease to have\\na place in medical nomenclature.\\nGout. It is well known that gout can evince itself in\\nurethritis, especially of the posterior urethra, in orchitis and\\nepididymitis, although these manifestations are rare. When a\\ngouty patient past middle age and given to high living, con-\\ntracts gonorrhoea, the possibility of the constitutional complica-\\ntion should not be left out of mind. The urine, besides con-\\ntaining pus, is very acid and heavy with uric acid and urates.\\nSuspicion is attracted to the possibility of a gouty diathesis by\\nthe presence of dry, scaly eczema, tophi, and ground-down teeth.\\nIn such cases irrigations must be followed out as in uncompli-\\ncated gonorrhoea, while the patient is energetically treated by\\nhis family physician for the gouty condition.\\nHemorrhage. While bleedings, from the meatus of other\\nthan urethral origin would be beyond the scope of this book,\\ntheir possibility must not be left out of consideration when they\\noccur with a gonorrhoea.\\nThe bleedings from posterior urethritis and urethrocystitis\\nare discussed under their respective heads.\\nBleeding from the anterior urethra may be provoked bj r vio-\\nlently employed strong injections, sharp syringes, catheteriza-\\ntion through an acutely inflamed, macerated urethral mucosa,\\nand the passage of small, rough calculi.\\nSometimes urethral bleeding is provoked by coitus while\\nthe patient has gonorrhoea, incredible as such an act may ap-\\n1 Heimann A Clinical and Bacteriological Study of the Gonococcus Neis-\\nser, Medical Record, June 22d, 1895. A Further Study of the Biology of the\\nGonococcus, Medical Record, December 19th, 1896. Further Studies, Third\\nSeries, on the Gonococcus Neisser, Medical Record, January 15th, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0087.jp2"}, "88": {"fulltext": "78 THE IRRIGATION TREATMENT OF GONORRHOEA.\\npear. S. Kof mann, of Odessa, reports such a case. A healthy-\\nlooking individual, aged nineteen, with anxious features, told\\nKofmann that for over an hour blood had been pouring from his\\nurethra in an uninterrupted stream. The patient confessed hav-\\ning gonorrhoea. Examination showed blood escaping from the\\nmeatus in jets as thick as a pencil, as from an artery transversely\\ndivided. Kofmann dipped a strip of gauze into a solution of\\nalumina acetate, mounted it on a long button probe, carried it\\nas deeply as possible into the urethra and packed it firmly.\\nThen he applied a pressure bandage about the penis, ordered\\nthe patient to go to bed, to avoid urinating as long as possible,\\nprescribed opium and forbade drinking. On the following day\\nthe patient looked better, but still considerably affected. On\\nremoving the pressure bandage and extracting the blood-soaked\\npacking, considerable bleeding resulted. The whole dressing\\nwas repeated and the patient ordered to return on the following\\nday. He did not do so until one and a half months later. He\\nthen related the history of gonorrhoea four years before, lasting\\none year. Later he had had chancroid, still later another gon-\\norrhoea and chancre, and a third clap a year before the last con-\\nsultation. The discharge was very copious and the patient\\nsuffered much pain, especially on urinating. Despite the dis-\\nease, the patient cohabited several times. During one inter-\\ncourse he experienced intense pain, and immediately thereafter\\nfound his linen blood-soaked and blood dripping from the\\nmeatus. Since then the bleeding had recurred frequently,\\nespecially after the abuse of stimulants. The bleeding then al-\\nways came on after passing clear urine, sometimes in bright red\\ndrops, sometimes in a stream. Compression of the penis for\\nsome time always arrested the bleeding this was followed by\\nitching in the urethra, from which the patient extracted a co-\\nagulum cast in the shape of the channel. Upon its withdrawal,\\nbleeding immediately recurred. On the day he consulted the\\nauthor the patient had drunk several glasses of tea and a con-\\nsiderable quantity of brandy. Bleeding, which then set in upon\\nurination, proved uncontrollable. On the day after the second\\ntamponing the patient removed the bandage and the packing.\\n1 Kofmann: Zur Tamponade der Urethra. Centralblatt der Chirurgie,\\nNo. 19, 1899, quoted in Monatsberichte tiber die Gesammtleistungen auf dem\\nGebiete der Krankheiten des Harn- und Sexualapparates, July, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0088.jp2"}, "89": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 79\\nThis was followed by a thick coagulum and several drops of\\nblood. Then the bleeding stopped the debility resulting from\\nthe loss of blood obliged the patient to remain in bed for two\\nweeks. The origin of this bleeding was doubtless gonorrhceal\\ninjury to a blood-vessel deep in the urethra, with subsequent\\nlaceration of the vessel.\\nSee also Foreign bodies and Traumatism.\\nHemospermia. Ked or brownish semen is due to the ad-\\nmixture of blood dependent upon very severe gonorrhoea or\\nacute seminal vesiculitis. It is occasionally produced by mas-\\nturbation, chronic orchitis, or chronic gonorrhoea. In vesicu-\\nlitis the spermatozoa are deformed, dead, or absent. The\\nmicroscopic specimens also show red blood corpuscles, pigment,\\ngranular detritus, epithelia varying in accord with the region\\naffected, and round cells.\\nThe most aggravated case of haemospermia that ever came\\nunder my notice was that of a man of twenty-eight sent to me for\\ncomplete loss of sexual desire, erections, and even nocturnal emis-\\nsions. Six months before he, for the amusement of some com-\\nrades of his own intellectual calibre, had four prostitutes perform\\nbuccal masturbation upon him in immediate succession. At the\\nfourth ejaculation he fainted, and remained unconscious for a\\nlong while. The physician who was called found blood oozing\\nfrom the meatus. This continued for several hours.\\nNo pathological conditions were discernible when I examined\\nhim. Under the use of tonics, galvanism, faradization and the\\npsychrophore, he undeservedly recovered his potencj^ in two\\nyears.\\nFor the treatment of haemospermia, see Vesiculitis and\\nDigital Palpation of the Urethral Adnexa.\\nHydrocele. When epididymitis, orchitis, or orcho-epididy-\\nmitis complicates gonorrhoea, the extension of the inflammation\\nis not rarely accompanied by acute hydrocele. The effusion is\\noften so slight as to be barely perceptible and, in the majority\\nof cases is resorbed, when the local inflammation subsides with-\\nout any treatment being directed to it.\\nWhen the swelling is very great and produces much painful\\ntension, it is necessary, for purposes of differential diagnosis,\\nto ascertain whether it is caused by serous effusion. The local\\npain, too severe to permit manipulation, is intensified when the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0089.jp2"}, "90": {"fulltext": "80 THE IRRIGATION TREATMENT OF GONORRHOEA.\\npatient is placed in the standing position to secure transillu-\\nmination of the scrotal sac.\\nIn such cases, the simplified urethroscope described on page\\n190 will fully serve, without in any manner increasing the pa-\\ntient s discomfort. The light is inserted into a large urethro-\\nscope tube its mouth is passed over the side of the scrotum\\nopposite the surgeon s eyes, while the patient, whose testicles\\nare elevated as described under epididymitis, is not disturbed\\nat all. If the swelling is due to acute hydrocele, the light will\\npass through the scrotal layers and the fluid, but not through\\nthe testicle, whose body can be clearly outlined.\\nIf the pain does not yield to the treatment directed against\\ngonorrhoeal epididymitis, relief may be promptly obtained by\\npuncturing the sac with a very fine narrow-bladed knife. At\\neach withdrawal of the knife, a few drops of the yellowish effu-\\nsion will squirt from the tumor. According to its size, fifteen\\nto fifty such punctures may be required. The pain is trifling,\\nand the reduction of pain immediate.\\nConsideration of hydrocele as an individual disease, result-\\ning from or preceding gonorrhoea, must be relegated to the\\nlarge, recent works on genito-urinary diseases.\\nLymphadenitis gonorrhceica (gonorrhoeal bubo) may com-\\nplicate gonorrhoea if the patient commits any kind of excesses,\\nindulges in violent or too prolonged exercise, or stands for\\nmany hours, as book-keepers, etc., must. Then one or more of\\nthe superficial glands in the subcutaneous cellular tissue, above\\nthe fascia lata, and immediately below Poupart s ligament, may\\nbe affected.\\nThe physician who makes it a rule to examine his cases at\\neach visit, is likely to discover and often abort lymphadenitis\\nbefore the patient becomes conscious of it. The first sign of\\nlymphangitis (see below) should direct attention to the groin.\\nIf a single or double hard swelling is found there, and even if it\\nis not painful or only slightly sensitive to pressure, it should\\nbe treated as mentioned below.\\nIf the patient s attention is attracted to these glands by pain,\\nit will be found that the pain is increased by pressure and by\\nstanding. Early in the involvement of these glands, they are\\nmovable under the skin. Soon, however, they become adherent\\nto it and the tissues around it. The region loses its hard con-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0090.jp2"}, "91": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 81\\ntour, becomes doughy and assumes a reddened and later on a\\npurple color. Even then, when properly treated, the inflamma-\\ntion may terminate in resolution, unless the patient s resistance\\nis weakened by dissipation, excessive work, malnutrition, or a\\nscrofulous constitution. Then the glands affected are likely\\nto suppurate.\\nAt the first sign of such glandular enlargement, prolonged\\nhot hip-baths, and mercurial ointment U. S. P. rubbed into the\\nregion twice daily may abort the case. Pressure upon the en-\\nlarged gland, with a well-applied spica of the groin, if the pa-\\ntient must be about, may assist in resorption of the swelling. Its\\neffect may be increased by neatly fitting a compressed sponge\\nover the gland, and wetting it after the spica is applied. If the\\npatient can remain abed, a stout bag containing three to iive\\npounds of bird-shot may be fixed upon the groin, so that its\\nweight exercises continuous pressure upon the gland.\\nIf in forty-eight hours the above course has not brought\\nabout marked relief, the enlarged gland or glands should be\\ndissected out. Ordinarily this can be very well done under\\ninfiltration anaesthesia by Schleich s method.\\nIf the patient is timorous or the physician of limited surgical\\nexperience, the region may be anaesthetized with ethyl-chloride\\nspray and the enlarged gland slit. After bleeding is arrested\\nthe cut must be irrigated with hot water or hot boric-acid solu-\\ntion, and then filled with antinosin. This is retained by a\\ncovering of gauze and a spica. After two or three daily repeti-\\ntions of this washing and dressing, the wound will be found\\nfilled with healthy granulations. Then nosophen dusted into\\nit and the spica applied will ordinarily result in prompt cicatri-\\nzation.\\nIf the case is not seen until the gland has become converted\\ninto an abscess, evacuation of its contents must be at once at-\\ntained by free incision and curetting the cavity, which then must\\nbe treated as above indicated, or by packing with iodoform or\\nnosophen gauze.\\nLymphangitis. Persons who have no idea of cleanliness, or\\nthose with a tight meatus, or those employing dressings of the\\nglans that invite retention of gonorrheal discharge, are likely\\nto suffer inflammation of the lymphatics of the penis.\\nAt the very inception one or two superficial, diffuse, faint,\\n6", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0091.jp2"}, "92": {"fulltext": "82 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nreddish lines show along the dorsum of the organ. They are\\nrarely, if ever, observed by the patient in this stage. A day or\\ntwo later this discoloration disappears and one or two distinct\\ncords can be felt beneath the skin. These cords may start near\\nthe frenum, pass like a bridle upward and backward behind the\\nregion of the corona to the dorsum and extend to the pubis. As\\nthe skin over this cord or cords becomes reddened again, pain\\nsets in, which increases with the thickening of the lymphatics\\ninvolved. This pain is much aggravated during erection. With\\nthe increase of pain, the skin that was freely movable over the\\nenlarged lymphatics sometimes becomes adherent and very sen-\\nsitive even to contact of the clothing.\\nIn most exceptional cases, a spot anywhere along the dorsal\\nlymphatics hardens, lies in the loose connective tissue, where\\nit enlarges, giving but little inconvenience. The lymphatics\\nbehind such a knot are then not enlarged. The knot itself\\neventually breaks down into an ordinary abscess.\\nWhen a case of gonorrhoea presents, showing the preliminary\\nlight red lines, they subside after one or two irrigations, with\\nall the precautions for cleanliness described under the technique\\nof irrigation.\\nIf thickening of the lymphatics has set in, in addition to\\nirrigations, the penis is kept enveloped in cloths wet with equal\\nparts of alcohol and lead water, renewed whenever they begin\\nto get warm. Severe cases may require the patient to keep\\nabed, to rise only for hot sitz-baths, or entire hot baths three\\nor four times daily. If erections are frequent and painful,\\neither monobromate of camphor or bromide of potassium gen-\\nerally controls them. These drugs failing, morphine may be\\nused. Throughout, attention must be given to free intestinal\\nevacuation.\\nIf the case has progressed to suppuration, the abscess must\\nbe promptly opened, curetted, and packed with iodoform or\\nnosophen gauze.\\nNeuroses (gonorrhoea!) While most diseases carry with\\nthem more or less marked nervous depression, there is none in\\nwhich it is more evident or more frequent than gonorrhoea. The\\ncause of nervous manifestations even at the inception of clap\\nmay be attributable to the consciousness of being physically\\nunclean, or of being a menace to others; or they may be at-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0092.jp2"}, "93": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 83\\ntributable to the deprivation from habitual sexual intercourse\\nor stimulants. More recent investigations, however, make it\\nappear that the gonococcus toxins directly attack the nervous\\nsystem. At all events Leleneff 1 reports the following disturb-\\nances of the nervous system produced by gonorrhoea\\n(1) Changes in the sensory nerves, causing anesthesia,\\nhyperesthesia, paresthesia, and pain in the nerves, in the skin,\\nin joints, in muscles, and in internal organs; (2) changes in\\nthe vasomotor nerves, causing hyperemia, anemia, paralysis of\\nvessels, and dermographism; (3) changes in the secretory\\nnerves, causing increased or diminished sweating, local sweat-\\ning, an increase in the flow of mucus from the urethra, etc. (4)\\nchanges in the trophic nerves, causing some forms of skin dis-\\nease, atrophy of the testicle, and muscular atrophy; (5) changes\\nin the motor nerves, causing paresis, paralyses, and twitchings\\n(6) changes in the skin reflexes and tendon reflexes. Gonor-\\nrhceal affections of the central nervous system give rise to a\\nvariety of symptoms, such as asthenic neuropsychosis, neuras-\\nthenia, hemiplegic phenomena, etc.\\nThese disturbances, however, seem to premise that gonor-\\nrhoea, to produce them, must be implanted upon an existing\\nneurotic tendency. Beard 2 has shown that Americans are more\\nprone to this complication than are patients of other nationali-\\nties. He attributes this to our unfavorable climate, overwork,\\nanxiety, excesses in tobacco and alcohol.\\nThis view is confirmed by my observations in European\\ngenito-urinary dispensaries and hospitals, where neurasthenia\\ncomplicating gonorrhoea is certainly far less frequent than it is\\namong us.\\nVon Krafft-Ebing 3 reports only eight cases in which local\\ngenito-urinary disease was manifest in one hundred and four-\\nteen cases of neurasthenia.\\nLowenf eld 4 is of the opinion that most of those afflicted with\\nleleneff: The Nervous System in Gonorrhoea. Wratch, No. 4, 1899,\\nexcerpted by Medical Record, July 15th, 1899.\\n2 Beard: Sexual Neurasthenia.\\n3 Von Krafft-Ebing Ueber Neurasthenia Sexualis beim Manne. Wie-\\nner medicinische Presse, No. 5 et seg., 1887.\\n4 Lowenfeld: Sexualleben und Nervenleiden, Bergmann, Wiesbaden,\\n1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0093.jp2"}, "94": {"fulltext": "84: THE IRRIGATION TREATMENT OP GONORRHOEA.\\nclap-neurasthenia are individuals with hypochondriacal predis-\\nposition, in whom the consciousness of suffering from a genital\\naffection evokes persistent mental depression and frequently\\nmost exaggerated worry regarding its possible consequences.\\nSuch a patient continually directs his thoughts to the condition\\nof his urethra, watches its secretions with anxious care, and sub-\\nmits to interminable attempts at curing it with astringents and\\ncauterizants. This author concludes that clap-neurasthenia is\\nmore frequently the result of chronic maltreatment of the ure-\\nthra than of its disease.\\nEvery practitioner, and particularly every specialist, has seen\\ninnumerable cases in which urethritis has been maintained in-\\ndefinitely by over-treatment, even when the methods employed\\ncorrectly met the indications while the disease existed.\\nNaturally then, when discharge and floaters in the urine are\\nmade to continue by urethral maltreatment, or continuance of\\ntreatment when it has become unnecessary, the neuroses pro-\\nvoked by the manifestations of apparent disease must continue.\\nThe more persistent these neuroses are, the more difficult their\\ncure becomes.\\nWhen all discharge has ceased, the presence of floaters in\\nthe urine, which may continue for several weeks after a gonor-\\nrhoea has subsided, may disturb the patient s mind. Some\\npatients, even when the urine is perfectly clear, acquire remark-\\nable dexterity in stripping the urethra, by which they can at\\nalmost any time produce a minute drop of normal secretion at\\nthe meatus, to which they point as evidence of their uncured\\ncondition.\\nWhen in such cases the urethroscope shows the absence of\\ndisease, it is the physician s duty to direct his treatment to the\\nmental condition, lest the patient be driven by its persistence\\nto the quacks, who will gratify the patient s desire for active\\nlocal maltreatment as long as he can pay for it. Arguments\\nand evidence of the microscope are only exceptionally of avail.\\nThe more palpable the physician s honesty is, the less he will\\nbe able, as a rule, to convince such a patient that the healthy\\nurethra must be left alone.\\nUnder such circumstances, it is perfectly justifiable to per-\\nsuade such a patient that the passed gonorrhoea has affected his\\nconstitution and that he requires constitutional treatment for", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0094.jp2"}, "95": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 85\\nits cure. Ordinarily the drugs administered must, to be effec-\\ntive, have a decided taste, such as tincture of nux vomica in\\nwatery solution. It will be well to warn such patients against\\nthe disastrous effects of squeezing out the perennial drop\\nwhile taking this drug or any other that may be used. (See\\nalso Chronic Gonorrhoea.)\\nIf the neurasthenia persists despite all suggestive treatment\\nthat the physician s ingenuity may devise to suit the special\\nmanifestations in each case, or the peculiar bent the mind has\\ntaken, the patient should be referred to a neurologist, because\\nthen it has gone beyond the field of general practice or the\\ngenito-urinary specialty.\\nIt must, however, never be forgotten that a very minute ure-\\nthral lesion can maintain a neurotic condition, even when not\\nthe slightest discharge can be brought to the meatus and the\\nurine remains perfectly clear. If such a lesion exists, it can be\\nfound. When it is properly treated, the neurasthenia subsides\\nwith or shortly after its disappearance.\\nWhen gonorrhoea has destroyed tissues or organs through\\nchanges in the trophic nerves, surgical intervention may be re-\\nquired, to restore the patient s nervous and mental equilibrium.\\nSeveral cases are reported in which an atrophied testicle was\\nsubstituted by a celluloid body, with satisfactory results, as far\\nas the patient s mental state was concerned.\\n(Edema of the skin of the penis may complicate gonorrhoea,\\nespecially in persons who. keep the organ in a filthy condition.\\nIt subsides with attention to cleanliness.\\nIn a number of cases, an immense oedema of all the tissues\\nof the penis sets in almost immediately after the first or second\\nirrigation. This is painless and disturbs the patient in no wise,\\nexcept by the sensation of a large bulk in the trousers. In the\\nmajority of cases, when this oedema occurs, the gonorrhoea will\\nbe aborted in a very short time, probably because then no parts\\nof the organ remain a favorable culture medium for gonococci.\\nOphthalmia, gonorrhoea!. Whenever a patient with gonor-\\nrhoea, or one who has come in contact with the disease, shows a\\nslight reddening of the conjunctiva, with an increased flow of\\ntears, the latter should be examined microscopically. Whether\\ngonococci are found or not, the patient should without a mo-\\nment s loss of time be referred to an ophthalmologist.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0095.jp2"}, "96": {"fulltext": "86\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nIf a specialist in eye diseases is not instantly accessible, the\\npatient should be put to bed and, until the ophthalmologist\\narrives, small compresses taken from a block of ice must be put\\nupon the eye, every two or three minutes, day and night.\\nSilver nitrate, as laid down in works on ophthalmology,\\nshould be employed as soon as the secretion becomes creamy.\\nThe healthy eye should be protected by an occlusive dressing.\\nBuller s dressing has the advantage of permitting continual in-\\nspection and conse-\\nquent early treat-\\nment, if the healthy\\neye has become in-\\nfected.\\nOECHI EPIDIDYMI-\\nTIS see Epididy-\\nmitis.\\nParaphimosis\\ncomplicating gonor-\\nrhoea does not fre-\\nquently assume a\\nsevere form, and it\\nusually subsides as\\nthe gonorrhsea im-\\npr o ves When,\\nhowever, a patient\\nattempts forcibly to\\nreduce a gonorrhceal\\nphimosis and man-\\nages to slip the fore-\\nskin beyond the glans, the preputial orifice soon becomes rigid,\\nconstricts the penis, which then swells, producing the familiar\\ndeformity. If the constriction and consequent oedema are not\\npromptly relieved, the penis presents three distinct swellings\\nand three more or less deep contractures, as shown on the ac-\\ncompanying drawing.\\n1. The margin of the corona is much swollen, forming a\\nthick ridge.\\n2. The coronary sulcus rendered deeper by the swelling\\naround it.\\n3. Glistening mucous fold sometimes overlapping the sulcus\\nFig. 18.\u00e2\u0080\u0094 Paraphimosis.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0096.jp2"}, "97": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 87\\nand glans, formed of that part of the preputial mucosa that lay\\nupon the posterior aspect of the corona.\\n4. A very deep, tight, constricting band; this is the pre-\\nputial cutaneo-mucous margin, and, beinj the real point of con-\\nstriction, is the cause of the trouble in this position. It is the\\nsurgical point of paraphimosis, the one that must be severed\\nwhen operation becomes necessary.\\n5. Behind the hard constriction is another thick roll, con-\\nsisting of preputial integument crowded back and held there by\\nthe constriction.\\n6. Another furrow, less deep and less tight than the former,\\nis formed by the swollen tissues crowding back upon those that\\nare not involved in the constriction before them.\\nThis general type of paraphimosis may suffer a number of\\nvariations the rolls of mucosa and skin may become so thick\\nas to cover the furrows beneath them the penis may be so con-\\nstricted at the second furrow as to make it look as if bent for-\\nward at a right angle upon itself; the constriction may be lateral,\\ngiving the penis a twisted appearance.\\nWhen dislocation backward of the prepuce is recent, it may\\noften be reduced by manipulation, after soaking the penis in a\\nhot antiseptic solution for twenty or thirty minutes. Then,\\nafter drying the organ, a little vaseline or lubrichondrin is ap-\\nplied within the second constricting furrow, but nowhere else,\\nlest it render the organ too slippery for manipulation. The\\npenis is then grasped and steadied by the index and middle\\nfingers of both hands,* passed from both sides so that the tips\\nof the indices touch each other on the dorsum, while the middle\\nfingers cross below. In this position the fingers compress the\\nthird roll, while the thumbs perform a species of massage upon\\nthe glans as they strive to crowd it back within the prepuce.\\nIf it will yield at all, it will do so in a few minutes of this\\nmanipulation.\\nIf the paraphimosis cannot be reduced by manipulation, or\\nif efforts to perform it are excessively painful, or if the constric-\\ntion has become too dense to yield, it will be promptly relieved\\nby incision in most cases.\\nNeglected cases usually end by necrosis at the central dorsal\\npoint of the second furrow. Following this indication, the\\nsurgeon passes a sharp-pointed, curved, narrow bistoury be-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0097.jp2"}, "98": {"fulltext": "88 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nneath the constriction, gathering it upon its edge as if it were\\na cord. In doing so, he takes care not to wound the corpora\\ncavernosa. In severing the cord it may impart quite a carti-\\nlaginous sensation to the knife. If the first cut is not successful\\nin relieving the tension, a second may be made.\\nIn case the swelling so overlaps or distorts the furrows that\\nthe second one cannot be found, a straight, narrow knife is used\\ninstead of a curved one. The penis is then rested in the palm\\nof the left hand while the thumb and fingers depress and render\\ntense the folds. Then the skin and mucous membrane are\\nincised firmly, holding the knife perpendicularly to the axis of\\nthe penis, but not cutting more deeply than the integumentary\\ncoverings. These incisions must be continued until the con-\\nstriction is felt to give way. In such case the incisions along\\nthe dorsum of the penis should be no longer than the length of\\nthe glans.\\nWhen the constriction has been severed, the foreskin can as\\na rule be easily drawn forward. It will then appear as if it had\\nbeen slit. Ordinarily the cut heals soon, leaving a dog s-ear\\nforeskin, which subsequently may be remedied by complete cir-\\ncumcision.\\nPeriarthritis see Rheumatism.\\nPhimosis. While many fine distinctions are made by au-\\nthors regarding irretractibility of the foreskin, Taylor s 1 defini-\\ntion embraces all practical requirements: Phimosis is that\\ncondition of the prepuce which prevents its retraction and the\\nexposure of the glans. It may be congenital or acquired.\\nMany boys are born with a redundant prepuce. With some\\nit is so tight that it cannot be withdrawn. It is debatable\\nwhether any boys are born with adhesions of the prepuce to the\\nglans at all events, in most of those whom I have circumcised,\\nthe prepuce had at least a few adherences. In some the adher-\\nence was so general as to oblige complete dissection of the\\ninner lining from the glans.\\nThe growth of the prepuce sometimes does not keep pace\\nwith that of the rest of the organ. The result may be an arrest\\nof development of the glans. In one case treated in my class\\nin the New York School of Clinical Medicine, the patient, a\\nBaylor: Venereal Diseases, Lea Brothers Co., Philadelphia, 1895.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0098.jp2"}, "99": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 89\\nnegro, aged thirty-eight, had a fully developed penis, except as\\nto the glans, which was no larger than that of a small boy of\\ntwelve years. After liberation of the glans by circumcision of\\na very small, tight, thick, unyielding foreskin, the glans began\\nto develop and in three months time attained almost its normal\\ndimensions.\\nA tight foreskin, even when not redundant, by its irritation\\nis likely to provoke masturbation. Normal secretions, or drops\\nof urine retained and decomposed within the preputial sac, may\\ncause ulcerations and heavy strong adhesions whenever these\\nulcerations heal. Concretions of smegma, sometimes quite hard\\nand friable, are often found lying about the glans, and especially\\nin the coronary sulcus. Urinary salts are sometimes deposited\\nin this region. All these substances act as foreign bodies erod-\\ning the delicate mucosa; by accretion they may become adherent,\\nembedded, and often produce extensive ulcerations.\\nLocal symptoms of phimosis may be entirely absent, the\\nmucosa accustoming itself to the irritation even of inspissated\\npieces of smegma or urinary concretions. They then will be\\ndiscovered only accidentally or when an infection obliges the\\npatient to seek professional advice. Ordinarily, however, there\\nis at least heat about the glans. More frequently all the local\\nevidences of balanitis or balanoposthitis with their conse-\\nquences new adhesions, venereal warts and fissures call for\\ntreatment.\\nPhimosis may lead to obstructive conditions due to the ad-\\nhesions, retained secretions, or subpreputial calculi mentioned\\nabove, or the preputial orifice may be so tight as to prove an\\nobstruction to the free emission of urine. Then vesical irrita-\\nbility, dilatation of the bladder, ureters, and renal pelvis may\\nobtain. Hemorrhoids and hernia may also result from the\\nheavy pressure required in attempts to force the urine through\\nthe obstacles.\\nThe liberal supply of nerves to the glans, when pressed\\nupon by a tight foreskin and its local results, often reflexly\\nevokes diseases such as convulsions in children, urinary re-\\ntention and incontinence, unduly frequent erections, excessive\\nseminal emissions, spastic paralyses, pseudo-hip-joint disease,\\nmuscular incoordination, etc. Naturally their presence with or\\ndeveloping in a phimosed patient does not make the tight fore-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0099.jp2"}, "100": {"fulltext": "90\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nskin the only etiological factor; still, its possibility must not\\nbe overlooked.\\nWhen phimosis develops from neglected gonorrhoea, it ordi-\\nnarily subsides shortly after beginning irrigations, unless heavy\\nFig. 19.\u00e2\u0080\u0094 Applying Constrictor.\\nlymph deposits have organized in the preputial tissues. In\\nsuch cases, or when phimosis precedes gonorrhoea, circumcision\\nshould be performed as soon as the more acute symptoms have\\nsubsided. But when the preputial orifice is so small as to pre-\\nvent exposure of the meatus, or when adhesions are so numerous\\nand tight that the glans cannot be cleansed, circumcision will\\nbe required despite the acute gonorrhoea.\\nThe objections that may be offered to circumcision during\\nacute gonorrhoea are\\n1. Possible infection of the wound, especially when the ure-\\nthritis is of a mixed character.\\n2. Difficulty of manipulation of the penis, as in irrigations,\\nbefore the circumcision wound has healed.\\nTo prevent infection of the cut, as far as possible while the\\npatient has acute clap, a continuous stream of mercuric bichlo-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0100.jp2"}, "101": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA.\\n91\\nride 1:30,000 should bo kept running over the entire field of\\noperation, from its beginning to its end.\\nThe other objection is easily overcome by the circumcision\\nI invariably practise, which may be concisely described in the\\nfollowing directions\\n1. Thoroughly scrub the penis, and especially as much of\\nthe mucous fold of the prepuce as can be reached, with soap\\nand hot water.\\n2. Irrigate the preputial sac with hot potassic permanganate\\nsolution 1 6,000 until the fluid that flows from it is entirely\\nclear.\\n3. Envelop the anterior four-fifths of the penis in absorbent\\ncotton soaked in mercuric bichloride 1:2,000.\\n4. Tie a rubber band as tightly as it can be drawn around the\\nroot of the penis (Fig. 19). As brutal as this precaution against\\nFig. 30.\u00e2\u0080\u0094 Freezing Tip of Foreskin.\\nhemorrhage may appear, it is quite painless, and its only result\\nis some ecchymosis of the penis, which subsides in a few days.\\n5. Pass a probe as large as the preputial orifice will admit\\ninto the sac and sweep it around all its parts to ascertain if the\\nprepuce is anywhere adherent.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0101.jp2"}, "102": {"fulltext": "92\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\n6. Freeze a small spot at tlie tip of the foreskin with ethyl\\nchloride (Fig. 20).\\n7. Inject into the frozen spot a drop of Schleich s 1 solution\\nNo. 1 (Fig. 21).\\n8. At the posterior margin of the bleb so produced inject\\nanother drop within the skin. Continue the line of drops along\\nFiG. 21.\u00e2\u0080\u0094 Injecting First Drop of Anaesthetic Solution.\\nthe dorsal aspect of the prepuce to a quarter of an inch beyond\\nthe point where the elevated margin of the corona is felt through\\nthe foreskin.\\n9. Inject a similar line of drops following the line of the\\ncoronary margin until the region of the frenum is reached on\\none side. Repeat this procedure on the other side.\\n10. Keep the syringe loaded for more infiltration, especially\\nwhen the preputial orifice is so tight that the mucosa cannot\\nbe exposed.\\n11. Pinch up the dorsal aspect of the prepuce with the left\\nthumb and index finger.\\n12. Insert the blunt arm of a pair of probe-pointed scissors\\nand carry it back as far as possible toward the corona. Drop the\\nprepuce upon the blade of the scissors inexperienced operators\\nSchleich: Schmerzlose Operationen, Springer, Berlin, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0102.jp2"}, "103": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA.\\n93\\nwill do well to sweep the scissors about under the foreskin,\\nwhile the left fingers feel it, especially in infants, to be sure that\\nthe scissors arm is not within the urethra (Fig. 22).\\n13. Draw back the skin and thus render it as tense as possi-\\nble. Cut through the part of the foreskin that lies between the\\nscissors blades. This will produce a large cut through the skin\\nand a disproportionately small cut into the mucosa (Fig. 23).\\n14. Grasp the cut angles of the skin and mucosa with artery\\nclamps, hold one in the left hand and give the other to an as-\\nsistant. While the mucosa is thus tensely held, infiltrate drops\\nof the Schleich solution along the mucosa as far as possible in\\na line toward the corona. Cut the mucosa as far as this line\\ngoes. Repeat the linear infiltration in the part that is now ex-\\nFiG. S3.\u00e2\u0080\u0094 Inserting Scissors.\\nposed. Continue cutting and infiltrating to within three-eighths\\nof an inch of the corona.\\n15. Repeat the entire procedure along the lateral lines reach-\\ning from the dorsum of the prepuce to the frenum, on both\\nsides, leaving a collar of mucosa three-eighths of an inch wide.\\nLet the prepuce then hang from the region of the frenum, to\\nserve as a convenient handle for further manipulations (Fig. 24).", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0103.jp2"}, "104": {"fulltext": "94\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nNo bleeding, beyond a slight oozing, will interfere with the\\nabove steps, if the rubber band about the root of the penis has\\nbeen firmly applied. Should bleeding to a disturbing extent set\\nin, another and tighter band around the root of the penis will\\nremedy the defect, or the bleeding vessels may be ligated.\\n16. Pass a needle armed with six inches of or 00 catgut\\nthrough the mucosa, at the centre of the dorsum of the penis.\\nA straight Gentile s (Fig. 26) modification of the Hagedorn\\nneedle will be found admirable for quick work. The needle\\nFig. 23.\u00e2\u0080\u0094 First Dorsal Incision.\\nshould transfix the mucosa at one-eighth inch from its cut margin.\\nTake up the skin in the same manner and tie the skin and mu-\\ncosa into neat, tight, but not wrinkled apposition, with a double\\nsurgical knot. Take care that the cut edges of skin and mucosa\\nembrace no cellular tissue. Grasp the free ends of the catgut\\nin the jaws of an artery forceps and lay it on the abdomen which\\nhas been covered with a sterilized towel. This will serve to\\nreadily distinguish it from the other sutures at the close of the\\noperation.\\n17. Apply similar sutures, each six inches long, to bring skin\\nand mucous membrane together around the entire cut edges,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0104.jp2"}, "105": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 95\\nFig. 24.\u00e2\u0080\u0094 Lateral Incision.\\nuntil within one-fourth inch of each side of the frenum. Always\\ntake care that no connective tissue is allowed to project between\\nthe lips of the wound, which would then not have the advantage\\nFig. 35.\u00e2\u0080\u0094 Inserting the First (Dorsal) Suture.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0105.jp2"}, "106": {"fulltext": "THE IRRIGATION TREATMENT OF GONORRHOEA.\\nof primary union. Wherever a bit of this tissue cannot be\\nforced back to remain, another suturing of skin to mucosa over\\nit will accomplish the desired end. After knotting each suture\\nat the wound lips, tie its free ends together in a\\nslip knot so that each pair of sutures can be easily\\nfound together at the conclusion of the operation.\\n18. Raise the prepuce where it hangs from\\nthe frenum and replace the skin and mucosa in\\ntheir original relative positions. While an assist-\\nant so stretches the foreskin, pierce its base along\\nthe frenum with a needle armed with six inches of\\ncatgut twice the thickness of that used before.\\n19. Give the ends of the suture to the assistant\\nwho stretches it at a tangent to the axis of the\\npenis. Take the prepuce in the left fingers, rais-\\ning the penis. Then, avoiding the suture held\\nby the assistant, cut off the foreskin neatly along\\nthe line of the frenum. Tie the ligature to bring\\nthe skin in coaptation with the exposed part of\\nthe cut frenum. Grasp the ends of the suture\\nwith an artery clamp, and place it upon the scro-\\ntum, which has been covered with a sterilized towel.\\n20. Examine the entire line of sutures, to be\\nsure that neat coaptation is everywhere obtained.\\nWherever connective tissue projects between the\\nlips it must be returned, and if it will not remain\\nbeneath the lips, an additional suture placed over it.\\n21. Slowly relax the rubber band that con-\\nstricts the root of the penis. In a few moments\\nthere may be some oozing from the lips of the\\nwound. If more than mere oozing results, addi-\\ntional sutures will control the bleeding.\\n22. Fold a strip of ten-per-cent. iodoform gauze\\nor three-per-cent. nosophen gauze, eight inches long\\nby one and one-half inches wide, into four smooth,\\nequal, longitudinal folds. Have it stretched by\\nthe assistant (Fig. 30) at right angles over the first suture,\\nwhose ends are held by the artery clamp lying on the abdomen.\\n23. Eelease the suture from its clamp, separate its ends, and\\npass them around the gauze. Tie the gauze firmly against the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0106.jp2"}, "107": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 97\\nFig. 27.\u00e2\u0080\u0094 Disposal of First Suture.\\nFIG. 28.\u00e2\u0080\u0094 Lateral Sutures Applied.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0107.jp2"}, "108": {"fulltext": "98\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nfirst knot, by which the skin and mucosa were brought together.\\nRepeat this procedure with each suture, whose corresponding\\nends, though now all are matted together with blood, can be\\neasily found, because they were tied together with a slip-knot.\\nThe gauze must everywhere be laid smoothly upon the wound\\nlips its tension must be even.\\n24. When both ends of the gauze are hanging from the last\\nsuture at either side of the frenum, release the suture from the\\nFig. 29.\u00e2\u0080\u0094 Cutting Off Prepuce.\\nNote Two gentlemen assisted at the operation above depicted. When performed with one\\nassistant the upper end of the frenal suture can be held by the ring and little fingers of the hand\\nthat holds tbe clamp.\\nclamp lying on the scrotum and give its ends to the assistant,\\nwho stretches them apart while placing the penis on the pubis.\\n25. Take the gauze strip pendent from the left side and lay\\nit smoothly to the right side of the penis, upon the knot of the\\nsuture being stretched by the assistant. Then place the end of\\ngauze pendent from the right side and cross it to the left (Fig.\\n31) Firmly tie the two ends of gauze within the last suture.\\n26. Cut off the projecting ends of gauze and trim the catgut\\nsutures beyond their knots, leaving a smooth neat collar of\\ngauze, about a quarter of an inch behind the corona, firm enough\\nto press any ununited parts of the wound into coaptation, but", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0108.jp2"}, "109": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 99\\nFig. 30.\u00e2\u0080\u0094 Applying Gauze Collar.\\nnot tight enough to exert the slightest pressure upon the penis\\nor give pain during erection (Fig. 32).\\nA little blood will ooze into the collar. This will swell\\nJ\\nFig. 31.\u00e2\u0080\u0094 Closing Gauze Collar.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0109.jp2"}, "110": {"fulltext": "100\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nslightly, and in so doing press any little gapings of the wound\\nlips together.\\nA light gauze bandage will steady the ring in walking. It\\nshould be so applied as to leave the whole glans free, that none\\nof the dressing be soiled by urination. As the glans, so ex-\\nposed, would suffer from friction with the clothing, it must be\\ncovered thickly with vaseline, over which a wad of absorbent cot-\\nton is placed and tied around the penis with a strip of gauze.\\nFig. 32.\u00e2\u0080\u0094 Circumcision Completed.\\nAfter each urination, fresh vaseline and cotton are applied by\\nthe patient. In two or three days the mucosa over the glans\\nwill be sufficiently hardened to render this protection unneces-\\nsary.\\nIf the patient requires treatment for gonorrhoea, irrigations\\ncan be performed, and by using a little additional care in hand-\\nling the penis, without pain from the operation.\\nOrdinarily, i.e. when the patient requires no treatment for\\ngonorrhoea that moistens this dressing, the gauze ring will in a\\nday become as hard as stiff pasteboard. In from four to eight\\ndays the catgut holding the wound lips together will be ab-\\nsorbed; the ring will then drop off, leaving the line of primary", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0110.jp2"}, "111": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 101\\nunion in evidence of the care and neatness witH which the\\noperation has been performed.\\nIn circumcising children or unruly boys, general anesthesia\\nproves preferable to infiltration. When the latter is properly\\nemployed, it renders the entire operation absolutely painless.\\nWhen phimosis accompanies gonorrhoea, associated with\\nchancre or chancroid, the danger of sloughing of the wound\\nprohibits circumcision. As, however, the clap must be treated\\nand as the sores may produce large destruction of tissue, unless\\nthey receive attention, it becomes necessary to expose the glans\\nentirely. This is best accomplished by two lateral incisions,\\none on each side of the penis, half-way between the frenum and\\nthe dorsal median line of the foreskin. In most cases, Taylor s\\nphimosis scissors will be found useful; still as often very hard\\npreputial infiltrations may render its employment difficult, a\\nstout, slightly curved sharp-point bistoury will be found more\\neffective. It is passed upon a grooved director w r hich has been\\ninserted into the coronary sulcus, the preputial skin drawn back\\nas far as possible, the knife made to penetrate the mucosa, the\\nintervening tissue and to project from the skin, cuts a steady,\\nstraight line outward. This cut is repeated on the opposite side.\\nThe operation should be preceded by very thorough anti-\\nseptic irrigation of the preputial sac. After both sides of the\\nprepuce are slit, a large flap of foreskin projecting above and\\nanother hanging below will expose the entire glans for examina-\\ntion and treatment as soon as bleeding has ceased.\\nPollutions. There is no symptom in connection with gon-\\norrhoea that does less harm and creates more consternation than\\nan emission of semen, especially in a patient whose mind has\\nbeen misdirected by quack advertisements. It is often difficult\\nto persuade such a patient into appreciation of the essential\\nfacts, viz.\\n1. That in abstinence from sexual intercourse occasional\\nemissions of semen from the overfilled seminal vesicles are per-\\nfectly normal.\\n2. That the local irritation of gonorrhoea is likely to evoke\\nemissions more frequently than they would occur in health.\\n3. That no proximate or remote injury will come to the pa-\\ntient from such emissions, when they are not too frequent. Their\\nfrequency may vary widely within normal limits.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0111.jp2"}, "112": {"fulltext": "102 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n4. That only when the semen emitted is bloody, or when its\\nemission gives pain enough to awake the patient, is it indica-\\ntive of seminal vesiculitis and then requires attention.\\nIf the patient s intellect is too limited to permit him to grasp\\nthese ideas, the physician is perfectly justified in employing\\nsuch subterfuges as will best appeal to the patient s understand-\\ning. The one that succeeds most frequently is to felicitate the\\npatient on the occurrence of these pollutions and to offer him\\nremedies that will cause their continuance. The remedies\\nthen prescribed must naturally be only placebos.\\nAt the same time, a towel tied around the waist and heavily\\nknotted over the spine to prevent the patient sleeping on his\\nback, and light evening meals, will contribute to reducing the\\nfrequency of pollutions.\\nProstatitis. Wossidlo 1 insists that no case of gonorrhoea\\nbe dismissed as cured before the physician has assured himself\\nthat the prostate is free from invasion. If this advice were al-\\nways followed, there would be few, if any, cases of recurrent\\ngonorrhoea.\\nThe almost direct manner in which the prostatic ducts empty\\ninto the posterior urethra seems to invite infection from this\\nregion to the prostate, by continuity of surface. Bransford\\nLewis 2 supports his own studies of the frequency of infection of\\nthe posterior urethra, by the statistics of other authors, such as\\nLetzel, who found posterior urethritis in 92.5 per cent, of gon-\\norrhoeas, Jadassohn in 87.7 per cent., Eona in 79.7 per cent.\\nMy own observations have led to the views expressed in the\\nchapter on Acute Posterior Gonorrhoea.\\nLike posterior urethritis, gonorrhoeal prostatitis may give\\nbut slight or practically no manifestations of its presence. It\\nis therefore likely to be overlooked unless one makes it a rule\\nto follow Wossidlo s sage advice.\\nA slight discomfort about the perineum and rectum may be\\nthe only indication of the disease. If this does not receive at-\\ntention, pain referred more directly to the bladder may follow.\\n1 Wossidlo: Treatment of Chronic Prostatitis. Journal of the Ameri-\\ncan Medical Association, August 27th, 1898.\\n2 Lewis: The R61e of the Posterior Urethra in Chronic Urethritis.\\nRead before the American Association of Genito-Urinary Surgeons, June 21st,\\n1893 (reprint from Medical Record).", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0112.jp2"}, "113": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHCEA. 103\\nThe pain is accentuated by urination and defecation, especially\\nwhen efforts are necessary to expel hard faeces. The patient is\\nobliged to urinate frequently, but does not experience complete\\nrelief from the act. While the frequency may, in great degree,\\nbe caused by the coincident posterior urethritis, there is neces-\\nsarily an amount of urine retained in the bladder. The quantity\\nof residual urine is in proportion to the degree of prostatic\\nengorgement. This pushes that part of the bladder which lies\\nover the prostate upward into the vesical cavity. Behind this\\nelevation a trough is produced, from which the bladder con-\\ntractions do not suffice to force all the urine it contains above\\nthe hillock made by the enlargement. Sometimes the entire\\nlower part of the enlarged prostate juts into the bladder cavity\\nin such a manner as to form a species of valve. This is shown\\nafter such a patient has voided all the urine he can extrude by\\nirrigating his bladder with a potassium permanganate solution.\\nNo difficulty opposes the inflowing solution, because it forces\\nthe prostate back toward its place. But when the patient voids\\nall he can of the solution, it will be found decolorized by the\\nretained urine if it is normal, or rendered brown, muddy, in\\ncase the urine has become septic.\\nThe prostate in this condition may cause stammering\\nurination, as Guyon graphically describes it. The patient, by a\\nseries of contortions, invites the stream which, while he holds\\nhimself in a certain position, may flow freely; then suddenly\\nan untoward motion throws the enlarged prostate against the\\ninternal meatus and urination stops. The greater the efforts\\nmade, the more firmly is the bladder outlet blocked. Only after\\nsuccessful efforts at relaxation does the prostate fall back and\\nallow the urine to flow. But the bladder contractions may force\\nthe prostate up, and let it drop again, producing the character-\\nistic stammering. The end of urination may be painful and\\naccompanied by emission of pus and blood. When the conclu-\\nsion of urination is so disturbed, neither the pain nor extrusion\\nof pus and blood is as marked as in acute posterior urethritis.\\nNaturally, if the prostatic trouble accompanies posterior ure-\\nthritis in the fulminant form, the severe symptoms of the latter\\nwill overshadow those produced by the engorged prostate.\\nThe frequency with which acute prostatitis complicates pos-\\nterior urethritis is disputed. This may be due to the omission", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0113.jp2"}, "114": {"fulltext": "104 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nof prostatic examination and to subsidence of its severer symp-\\ntoms with the decrease of those of the urethritis.\\nOn examining the prostate per rectum, the ringer finds the\\ngut hot, more or less firm and tender to the touch, according to\\nthe degree of inflammation. The anterior wall itself bulges\\ndownward and backward into the rectal space. The enlarged\\nprostate, very tender to the touch, can be outlined through the\\nrectal wall. These findings are the only ones by which prosta-\\ntitis can be differentiated from posterior urethritis.\\nThe rational division of this complication into simple acute\\nprostatitis, acute follicular and parenchymatous prostatitis is\\nsufficiently explanatory of the varieties. Their detailed con-\\nFig. 33.\u00e2\u0080\u0094 White and Martin s Rectal Injector.\\nsideration is unnecessary in a book limited to treatment, which\\ndoes not materially differ in the several forms of the disease.\\nIf the case is seen at the inception of the prostatic involve-\\nment, the patient must be put to bed, with a sewing-board or\\nleaf of an extension table under that part of the mattress upon\\nwhich his buttocks rest. Upon this a thick hair pillow is placed\\nto elevate the pelvis. The intestinal discharges are kept soft\\nby skimmed milk to the exclusion of other food, and the urine\\nbland by alkaline diuretics. Irrigations of the urethra and\\nbladder are as a rule exceedingly well borne during acute prosta-\\ntitis, especially when the manifestations of posterior urethritis\\nare marked.\\nIf perineal pain and vesical tenesmus are severe, leeches to\\nthe perineum will furnish relief.\\nEectal irrigations, hot or cold, according to the local and\\ngeneral condition, often give very prompt relief. The most con-\\nvenient instrument for these irrigations is the rectal injector", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0114.jp2"}, "115": {"fulltext": "COMPLICATIONS AND SEQUELJE OF GONORRHOEA. 105\\ndescribed by White and Martin, who direct its use as follows\\nA quart of a seven-tenths-per-cent. salt solution is heated from\\n110\u00c2\u00b0 to 115\u00c2\u00b0 P., and the injection pipe is introduced into the\\nanus and its end tilted upward and forward so that the stream\\nwhen it is turned on shall flow directly on the prostatic tumor\\nas it bulges into the rectum. The exit pipe allows the fluid to\\nflow away as fast as it enters the bowel. This treatment should\\nbe repeated two or three times a day.\\nWhen using this rectal irrigator, I found that larger quanti-\\nties of hot water, two or even three quarts, gave more relief than\\none. After each rectal irrigation a suppository of\\nIodoform, pulv., gr. ss.-iss.\\nCodein. phosph., gr. |-i.\\n01. theobrom., q. s.\\nwill aid in resolution, and further assuage pain.\\nSome patients bear cold irrigations much better than hot\\nones. In the beginning of prostatic involvement they occasion-\\nally act better indeed, if used early enough, they often appear\\nto abort the case.\\nHot baths, and particularly hot sitz-baths, twice or three\\ntimes daily, of ten to twenty minutes duration each, will often\\ngive marked relief. In some cases a hot-water bag to the peri-\\nneum aids in making the patient s condition tolerable.\\nPersistent severe pain and tenesmus, both vesical and rectal,\\nmay oblige recourse to opium administered by the rectum or\\nmorphine injected deeply into the perineum.\\nWhen prostatic enlargement prevents urination and the oth-\\ner means suggested for relief fail, or when the emergency of\\nthe case demands, recourse must be had to catheterization. As\\nrepetition of the use of the catheter will be required, and is\\npainful, it will be well, when the urine is retained because of\\nprostatitis, to employ permanent catheterization (see Eetention).\\nIf the prostate has become the site of pus formation, no\\ntime should be lost by any of the above procedures. Palpation\\nthrough the rectum will reveal whether fluctuation points toward\\nthe bowel. If it does not, fairly moderate pressure may cause\\nthe pus to escape into the urethra; indeed, it is often so re-\\nlieved by nature. In case this effort fail, it may bo supple-\\nmented by the introduction of a Benique or Guyon sound, which", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0115.jp2"}, "116": {"fulltext": "106\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\noffers increased resistance, and performing massage while the\\nsound is held in the bladder. But unless the physician has\\nlarge experience in the use of genito-urinary instruments and is\\nendowed with great delicacy of touch\\nhe should certainly avoid the use of\\nthese sounds, es-\\npecially in acute\\ninflammatory con-\\nditions.\\nI f fluctuation\\ndoes not distinctly\\npoint rectumward,\\nand if nature or\\nmassage does not\\nempty the pus into\\nthe urethra, a me-\\ndian perineal\\nincision will be re-\\nquired for its evac-\\nuation and sub-\\nsequent thorough\\ndrainage.\\nWhen, how-\\never, pus distinctly\\npoints to the rec-\\ntum, it may be\\n111 considered as na-\\nture s indication of\\nthe most favorable\\nsite for evacuation.\\nM^ Acting upon this\\nj/^fr suggestion, I have,\\n^^jjjpr in eight cases,\\n^jJ||P^ opened prostatic\\n%J^^ abscess by a long\\nincision through\\nthe anterior rectal wall, packed the cavity with iodoform gauze,\\nand have not observed one case of general infection. It is true\\nthat in each of these cases the rectum was on the point of break-\\ning down when I operated.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0116.jp2"}, "117": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 10?\\nIn the above, termination of prostatitis by resolution or sup-\\npuration only has been considered. Prostatitis may also go\\nover into a chronic inflammation of the gland. Chronic prosta-\\ntitis may also be a sequel to chronic posterior urethritis or\\ncystitis, with no appreciable acute prostatitis preceding it. The\\ngland being predisposed by congestion, it is easily susceptible\\nto infection. Any disturbance producing pelvic engorgement,\\nirritating injections, continued sexual excesses, masturbation,\\nhemorrhoids, concentrated urine, habitual constipation, may\\nproduce congestion of the prostate.\\nThe symptoms of chronic prostatitis differ but little from\\nthose of chronic posterior urethritis. The most marked dif-\\nference is in a burning pain distinctly referred to a point almost\\nimmediately behind the fossa navicularis. Urination may be\\nfollowed by and defecation associated with an emission of a milk-\\nlike fluid, which on examination is found to consist of prostatic\\njuice, amyloid prostatic bodies, occasionally blood, epithelium\\nfrom the prostate and its ducts, and pus. The pain after urina-\\ntion and defecation or either may be severe, lasting sometimes\\nfor several hours. It may radiate from deep in the perineum to\\nthe rectum, testicles, and down the thighs, and is aggravated by\\nmotion or effort of any kind.\\nThe perineum is tender to touch. Rectal examination of the\\nprostate shows it to be irregularly nodulated or asymmetric.\\nAfter massage, the urine contains considerable pus.\\nThe mind and nervous system suffer perhaps more in chronic\\nprostatitis than in any other genito-urinary affection excepting\\nseminal vesiculitis. These sufferings are aggravated when ac-\\ncompanied by reduction or loss of sexual desire. The patient\\nthen becomes markedly neurasthenic and even melancholic,\\nwith the usual accompaniment of general depressed physical\\ntone.\\nThe constitutional treatment of such cases demands regular-\\nity in meals, consisting of nutritious, bland, easily digestible\\nfood; systematic exercise, preferably walking in the open air,\\nnot, however, to the extent of tiring the patient, and a sufficiency\\nof sleep.\\nLocally, rectal injections of a pint of hot water retained as\\nlong as possible and followed by a suppository of iodoform and\\ncodeine phosphate, twice or three times daily, will afford relief.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0117.jp2"}, "118": {"fulltext": "108 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nHot sitz-baths twice or three times daily will also aid in the\\ntreatment.\\nMassage of the prostate every second day will empty the\\norgan of pus that has accumulated, and will relieve congestion\\nif it contains no pus. The most beneficial manner of securing\\nthis end is by a complete intravesical irrigation with boric acid,\\nfour per cent., followed by filling the bladder with the same\\nsolution, after its first washing has been passed out. The\\nmassage is performed after the bladder has been almost filled\\nfor the second time. The fluid then passed will be found turbid\\nwith the substances expressed from the prostate. If the patient\\ncan stand a third intravesical irrigation, one of silver nitrate\\n1:5,000 or 1:3,000, according to his vesical tolerance, may be\\nadvantageously used (see also Rectal Palpation of the Urethral\\nAdnexa).\\nPatients with chronic prostatitis are liable to acute intercur-\\nrences. These must be treated as suggested for acute prosta-\\ntitis.\\nRetention op ueine is rare in gonorrhoea. It may occur in\\nvery hyperacute cases, or in those aggravated by alcohol, coi-\\ntus, masturbation, irritating injections, or the introduction of in-\\nstruments. Invasion of the prostate and the presence of even\\nlarge calibre strictures may produce retention of urine in gonor-\\nrhoea, by the urethrospasm they are likely to provoke.\\nWhen a patient with gonorrhoea cannot pass urine, he is\\nusually in such agony that the history of the case cannot be ob-\\ntained. It will be well, before attempting to unload the blad-\\nder, to examine the prostate. If the finger inserted into the\\nrectum feels the prostate to be enlarged, hot and sensitive to\\ntouch, the retention is attributable to at least congestion of this\\ngland. If the prostate be found normal, any or several of the\\nabove causes may be at the bottom of the retention.\\nThe patient should be at once placed in a hot bath, hot\\nenemata given him, followed by a suppository of iodoform and\\nopium. If these fail to relieve the emergency, the following\\nsteps for evacuating the bladder may be employed\\n1. Irrigate the anterior urethra with potassium permanganate\\n1:6,000 or boric acid four per cent. The solution should be\\nat a temperature of between 110\u00c2\u00b0 and 120\u00c2\u00b0 P. This irrigation\\nalone often suffices to relieve the spasm.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0118.jp2"}, "119": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 109\\n2. After using 750 c.c. (one and a half pints) of either of the\\nabove solutions, inject one or two drachms of a warm two-per-\\ncent, solution of eucaine into the urethra. Hold it there by com-\\npressing the sides of the glans with the left thumb and index\\nfinger. Stroke the urethra with the right fingers at first gently,\\nthen with increasing pressure, to force the eucaine solution\\nbeyond the site of the spasm, which is usually located in the\\nmembranous portion.\\n3. Kemove the nozzle from the irrigator tube and attach in\\nits place a sterilized semi-soft French conical, well-lubricated\\ncatheter.\\n4. Insert the catheter, and when its eye is beyond the meatus\\nlet the irrigating fluid pass through it.\\n5. Very gently glide the catheter onward, striving to reach\\nthe bladder before the entire contents of the irrigator have\\nescaped from the urethra. If the catheter in its onward course\\nmeets an obstacle which it cannot overcome without force,\\nwithdraw the instrument an eighth or a quarter of an inch and\\nendeavor to insert it in slightly different directions until the\\nlumen is found.\\n6. If the semi-soft catheter fails to enter the bladder, re-\\ncourse must be had to a silver catheter, employing all the pre-\\ncautions mentioned above.\\n7. When the catheter has reached the bladder, detach the\\nirrigator tube and allow about 90 c.c. (three ounces) of urine to\\nescape slowly by checking the stream with the finger over the\\nmouth of the catheter. When this amount has flowed off, inject\\n60 c.c. (two ounces) of four-per-cent. warm boric-acid solution.\\nAgain allow 90 c.c. to escape slowly from the bladder, and repeat\\nthe injection of 60 c.c. boric acid. Resume these alternate slow,\\nsmall emissions and injections until the fluid that flows from\\nthe catheter proves to be clear boric-acid solution. Then in-\\nject 60 c.c. of boric-acid solution and withdraw the catheter until\\nits eye is just beyond the compressor. This will be manifest\\nby cessation of flow from its mouth.\\n8. Ee-attach the irrigator nozzle and allow 250 c.c. (one-half\\npint) of warm boric-acid solution to run through the catheter\\nwhile it is being removed from the urethra.\\n9. Urge the patient to retain the boric acid left in his blad-\\nder for at least an hour.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0119.jp2"}, "120": {"fulltext": "110 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n10. If three hours later the patient cannot empty his blad-\\nder without assistance, catheterize again as above directed.\\nThe main purpose of the slowness advocated is threefold\\n(a) The continuous flow of the warm solution through the\\ncatheter, while it is being passed through the urethra, is in-\\ntended, as far as possible, to prevent carrying infection to the\\nbladder. At the same time its temperature may aid in over-\\ncoming the urethral tumefaction and such spasm as may exist.\\n(b) Slowly emptying the bladder gives it better opportunity\\nto regain its muscular tone, which may be seriously impaired by\\noverdistention.\\n(c) Rapidly emptying the bladder to relieve retention may be\\nfollowed by dangerous hemorrhage ex vacuo.\\nIn some very rare cases, great difficulty may be experienced\\nin inserting a catheter, when a second emptying of the bladder\\nbecomes necessary. The question of permanent catheterism\\nthen arises. It naturally involves the risk of impeding the\\nfree escape of pus from the urethra and of infecting the bladder.\\nEqually its omission may allow the congestion of the urethra\\nor of the prostate or both to increase, effectually shutting off the\\noutflow of urine, with all its dangers.\\nIn such a rare case it is advisable to provide continuous\\nbladder drainage, with a catheter too small to block the urethral\\ndischarge. The presence of the catheter in the urethra and\\nbladder will serve to reduce the thickening of the urethra and\\nof the prostate, if both are congested, as is shown by the free\\nvoluntary outflow of urine alongside the catheter in a very few\\nhours. Repetition of catheterization will then not become neces-\\nsary.\\nThe easiest and safest method of fastening the catheter in the\\nbladder is the one we owe to Guy on, 1 whose directions are con-\\ndensed as follows\\n1. Cut two pieces of firm knitting yarn each one metre\\n(about forty inches) long.\\n2. Fold them in half, and tie the free ends of each separately.\\n3. Place the strings in bichloride or boric-acid solution.\\n4. Insert the catheter and so place it that the urine comes\\n1 Guyon Lecons cliniques sur les Maladies des Voies Urinaires, vol. iii.,\\nBailliere, Paris, 1897.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0120.jp2"}, "121": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. Ill\\n5 9fc;\\nfrom its mouth in single drops. Watch this dropping for sev-\\neral minutes; if the urine is occasionally emitted in a little\\nstream, or if it stops entirely, move the catheter either a trifle\\nmore deeply into the bladder or an equal distance forward until\\npermanent dropping of urine is secured.\\n5. Take one of the doubled strings from the antiseptic solution,\\nfold it in half again, and tie it firmly around the catheter, exactly\\nat the level of the meatus (A) (Fig. 36). Then take its two double\\nends to the side of the penis, hold them together at the coronary\\nsulcus (B and tie another\\nknot there. Keep this knot\\nat the sulcus (B) exactly\\nhalf-way between the frenum\\nand the dorsum of the penis.\\nSeparate the doubled strings\\nand pass them around the\\npenis, to be tied in a firm\\nknot at the corresponding\\nside (B The double\\nstring collar thus tied about\\nthe neck of the penis must\\nnot be tight enough to cause\\neven inconvenience should\\nan erection occur.\\n6. Tie the second doub-\\nled string (which appears\\nas dotted line in Fig. 36) in\\nthe same manner as the first\\ndoubled string was attached\\nto the catheter. Place the first knot in the second doubled\\nstring immediately in front of the first string and directly op-\\nposite the first knot. Carry both ends of the second string\\nto the knot that completed the collar (B Tie a knot in the\\nsecond string there. Separate the cords that form the first\\nstring as it makes the collar at each side of the knot and pass\\neach end of the second string through the separations. Tie\\nthem in a knot upon the first string s knot (B Pass the two\\nends of the second string around the neck of the penis as those\\nof the first string were passed, but in the opposite direction,\\nforming another collar. Close the collar by a knot at B and\\nFig. 36.\u00e2\u0080\u0094 Fastening Catheter into Bladder.\\n(Guyon Voies Urinaires.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0121.jp2"}, "122": {"fulltext": "112 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nfasten the strings there in the same manner as they were fast-\\nened at B\\n7. Take up a bunch of hair at about an inch from the root\\nof the penis (C) and twist it into the shape of a moustache.\\nLay the string alongside of the penis like a rein, and where it\\ntouches the moustache, without stretching or moving the penis\\nfrom the exact median line tie it firmly about the root of the\\nmoustache. As this knot will envelop the base of a pyramid\\nof hair, it will be likely to slip off; therefore double the mous-\\ntache upon itself and with another knot fix the rein in place.\\n;^r~ -,^s\\ny-Rbussel;\\nFig. 37.\u00e2\u0080\u0094 Drainage Into Urinal.\\n(Guyon Voies Urinaires.\\nEepeat this procedure with the other rein that hangs from the\\ncollar at B attaching it to C, opposite the first moustache.\\nAfter so fastening the catheter in place, the condition of the\\nbladder must decide whether continued drainage or interrupted\\nevacuation should be employed. In a general way it may be\\nlaid down that if the bladder is infected, continued drainage with\\ncontinual washing will be necessary if the bladder is not in-\\nfected, interrupted evacuation is easily obtained by plugging the\\nmouth of the catheter with a wooden spigot. This spigot can\\nbe removed each time it becomes necessary to empty the bladder.\\nContinuous drainage of the bladder is best accomplished by\\nattaching a rubber tube eight inches long to the mouth of the\\ncatheter, and inserting it into the bottom of the tube (D) of a\\nDuchastelet antiseptic urinal, containing a solution of bichloride\\n1 1,000. A similar quantity of the same solution may be poured\\ninto the bowl of the urinal, through its opening C, after the\\nurinal is placed between the patient s thighs. The purpose of\\nplacing the urinal between the patient thighs is to protect the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0122.jp2"}, "123": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 113\\nbed, to allow the patient some latitude in motion and to pre-\\nvent the bending of the penis and the catheter it contains, thus\\ninsuring its continuous free action.\\nWhether it is determined to employ continuous or inter-\\nrupted vesical evacuation, the penis should be dressed in the\\nmanner laid down by Guyon. This dressing is made with three\\npieces of salicylated or carbolated gauze 25 cm. (about ten inches)\\nsquare. These are folded in half, from one angle to its opposite\\none, making a triangle of six layers of gauze. The base of this\\ntriangle is passed close to the penoscrotal angle, and the two\\nangles at the base are doubled over the penis so that the one\\nprojecting to the right of the penis reaches the left side of the\\npubis, where the strings holding the catheter are tied to the\\nhairs (see Fig. 37). It is firmly attached to this spot with\\nthe string that was left hanging there. The angle of the gauze\\ntriangle projecting from the left side of the penis is folded over\\nto the right tied moustache and attached firmly to it. The\\nmoustache strings are then cut off. The penis is thus com-\\npletely enveloped by the gauze. To prevent its slipping up-\\nward, the angle around the catheter is tied to it by another\\npiece of string.\\nWhile it is undoubtedly a grave violation of surgical prin-\\nciples to insert any instrument into an acutely inflamed urethra,\\nI must confess that I was driven to it in three cases. In each\\nof these the urethra was lacerated from attempts to pass cath-\\neters for the relief of retention. No aspirator or trocar was\\nwithin several hours reach, and the patients w r ere in acute suf-\\nfering, with high fever. I was fortunate enough to get cathe-\\nters into these bladders. One remained four hours, another six\\nhours, and the third eighteen hours. Naturally all possible\\nantiseptic precautions were taken. In none of the three cases\\ndid vesical infection result, nor was the gonorrhoea materially\\naggravated from the use of the catheter.\\nShould it be impossible to pass a catheter, after the prelimi-\\nnary efforts (hot baths, etc.) have failed, it will be necessary to\\neither aspirate or evacuate part of the bladder conteuts by a\\ntrocar through the suprapubic space. In many cases it will be\\nfound that after removal of perhaps one-fifth of the retained\\nurine, the patient will be able to empty the remainder through\\nthe urethra, owing to relief from the tension.\\n8", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0123.jp2"}, "124": {"fulltext": "114\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nIf prostatic congestion causes the retention, catheters of the\\nMercier curve will be found most useful. Guyon suggested\\nvarious lengths of beaks and angles at which the beaks are at-\\ntached to the shafts for easier introduction and more comfort-\\nable retention, according to the degree of prostatic swelling.\\nThose most frequently used are shown in Fig. 38. Their press-\\nure upon the prostate proves valuable, while placing the reten-\\ntion of urine under control. When, however, evidence of pus\\nFig. 38.\u00e2\u0080\u0094 Guyon Beaks of Mercier Catheters.\\nformation in the prostate presents, the abscess cavity must be\\npromptly emptied.\\nEheumatism (gonorrhceal).\u00e2\u0080\u0094 A somewhat extensive study of\\nthe literature of gonorrhoea makes Bransford Lewis appear the\\nfirst, at least among American writers, to show that infection of\\nthe posterior urethra is far more frequent than is ordinarily\\nassumed. This author, 1 in an interesting and instructive mono-\\ngraph, shows that posterior urethritis is almost invariably pres-\\nent in every case of prolonged or severe gonorrhoea. He further\\nasserts that the gonococci, instead of gradually progressing along\\n1 Lewis: The Role of Posterior Urethra in Chronic Urethritis. Read\\nbefore the American Association of Genito-Urinary Surgeons, June 21st, 1893 r\\nMedical Record.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0124.jp2"}, "125": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHCEA. 115\\nthe urethral mucosa to penetrate eventually the compressor in\\ntwo or more weeks after the onset of the disease, are promptly\\ncarried back through the lymphatics. About the same time\\nEona, of Budapest, made similar assertions, but his thoughts\\non the subject were presented more tentatively than were the\\nfindings of Lewis.\\nThe facts exposed by these authors emphasize the need of\\nintravesical irrigations (see page 29) even when gonorrhcea\\nseems to arlect only the anterior urethra. At all events, experi-\\nence shows that when irrigations are properly used, the posterior\\nurethra, if it does not escape invasion, does not show any mani-\\nfestations of the disease.\\nAccepting the above author s most reasonable explanation of\\nthe etiology of posterior gonorrhcea, it is not surprising that\\nremote regions and organs are often the site of the deposit of\\ngonococci. As mentioned elsewhere, there is hardly a soft\\ntissue of the organism in which modern investigation has not\\nbeen able to demonstrate gonorrhceal infection.\\nAmong the manifestations of remote gonorrhceal invasion,\\nrheumatism is at present the most frequently recognized. In\\nthe majority of cases it affects only one joint, and among these\\noftenest the knee. Less frequently the ankle, wrist, and elbow\\nare the site of gonorrhceal rheumatism.\\nGonorrhceal rheumatism is not distinguishable from rheu-\\nmatism of other origin. Neither does its appearance, while a\\npatient has gonorrhoea of the urethra, conjunctiva, vagina, or\\nrectum, prove that it is gonorrhceal. The fever and sweating\\nare usually higher in ordinary rheumatism, except when the af-\\nfected joint becomes the site of pus formation.\\nWhen rheumatism of any kind complicates gonorrhoea it\\nshould be treated as rheumatisms usually are. While this is\\nbeing done, irrigations must not be interrupted, so that the\\ngonococci, which may be the provokers of the rheumatism, be\\neliminated as soon as possible.\\nSkin Diseases.\u00e2\u0080\u0094 Taylor says that he has many times seen\\npatients with acute and declining gonorrhoea attacked by erup-\\ntions resembling scarlatina, measles, oedematous erythema, and\\nurticaria. In some instances he did not find that gastric dis-\\nturbances due to antiblennorrhagics was the exciting cause.\\nMany other eminent writers have reported such cases.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0125.jp2"}, "126": {"fulltext": "116 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nAmong these Finger 1 described three of gonorrhoea and cystitis\\ncomplicated by purpura rheumatica.\\nBuschke, 2 grouping his own observations and those of other\\nwriters, first mentions simple erythema, which usually appears\\nin connection with gonorrhoeal rheumatism, epididymitis, or\\nother localized inflammatory complication. Cases have been\\nrecorded, however, of a febrile erythematous rash in gonorrhoea.\\nThe second group is made up of urticaria and erythema\\nnodosum. The fact that the latter form of eruption may com-\\nplicate a febrile gonorrhoea shows that it is not a mere appanage\\nof polyarthritis, but is most likely due to the direct action of\\nthe gonococcus.\\nThe third division of Buschke is made up of hemorrhagic\\nand bullous eruptions.\\nThe fourth and last division consists of the hyperkeratoses,\\nand has hardly before been mentioned in literature. Buschke\\nhas found a record of four cases which he considers in this con-\\nnection. In a case originally described by Chauffard, for ex-\\nample, there were horny thickenings upon the feet, back, penis,\\nand insides of thighs, accompanying a general gonorrhoeal in-\\ntoxication.\\nAuthorities are still at odds as to the explanation of these\\ncutaneous manifestations of gonorrhoea, and several widely dif-\\nfering views are ably*maintained in controversy.\\nMy own studies of skin complications of gonorrhoea began\\nafter I had commenced the use of irrigations. None of the\\ncases so treated from the inception had any dermal trouble.\\nMany of those which had been treated before by internal medi-\\ncation or hand injections or both, had skin diseases. In those\\nin which the skin affections could not be traced to digestive dis-\\nturbances from antiblennorrhagics, they appeared to have no\\nconnection with gonorrhoeal infection, .except in some of those\\nconditions mentioned under neuroses.\\nSteictuee. Wossidlo 3 defines urethral stricture as a nar-\\n1 Einger Ueber Purpura rheumatica als Komplication blennorrhagischer\\nProzesse. Wiener medicinische Presse, Nos. 9, 10, and 11, 1880.\\n2 Buschke: Archiv fur Dermatologie und Syphilis, Band xlviii., No. 2,\\nmost admirably excerpted by the Medical Review of Reviews, July 25th, 1899.\\n3 Wossidlo: Die Stricturen der Harnrohre und ihre Behandlung, Nau-\\nmann, Leipzig, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0126.jp2"}, "127": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 117\\nrowing of the urethral lumen and reduction of its normal dila-\\ntability, produced by organic changes in the urethral walls.\\nSuch changes are usually brought about by a gonorrhoea\\nallowed to go on to chronicity through lack of proper treatment\\nor care. Congenital strictures, however, and those provoked\\nby traumatisms (such as the passage of a rough stone) may\\ncomplicate gonorrhoea as seriously as can acquired strictures.\\nThey can, moreover, by the same cicatricial tendency to con-\\ntraction, produce all the disastrous results that may follow the\\nlatter. Infantile lithiasis, evidenced by painful urination and\\npurulent discharge, containing no gonococci and afterward for-\\ngotten, may often be the cause of presumed congenital stricture.\\nWhen stricture from internal or external causes complicates\\ngonorrhoea, the disease will persist ordinarily until the stricture\\nis cured. Stricture itself is too vast a subject to be even outlined\\nin a small effort like this its influence on gonorrhoea, which is\\nprone to aggravate a pre-existent stricture and to produce new\\ncoarctations, is daily evident.\\nThe presence of stricture in no wise modifies the treatment\\nof gonorrhoea by irrigations. When the acute manifestations\\nof gonorrhoea have yielded, the stricture or strictures must re-\\nceive attention, as will be sketched under the head of Chronic\\nGonorrhoea.\\nTraumatisms of the Urethra. The injuries of the urethra\\nthat may complicate gonorrhoea are, besides those mentioned\\nunder Foreign Bodies and Hsematuria, such as may be pro-\\nduced by faulty circumcision.\\nM. A. Wasiliew, x citing Bergson, Ploss, and Joly, shows that\\nthis operation was performed by the ancient Egyptians and\\nPhoenicians. To-day ritual circumcision is done only by Jews,\\nMohammedans, and a number of savage tribes.\\nThe American and Bussian Jews cut off the preputial in-\\ntegument with a small knife, and tear the mucous fold with the\\nfingers. The knife may injure the glans and the part of the\\nurethra it contains; efforts to split a firmly adherent mucosa\\nwith the pulp of the index fingers and thumb nails may tear\\nopen the fossa.\\n1 Wasiliew Die Traumen der mannlichen Harnrohre, Hirschwald, Berlin,\\n1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0127.jp2"}, "128": {"fulltext": "118 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nIn Germany and Hungary, so I am informed, many ritual\\ncircumcisers maintain the right thumb nail long and trimmed\\nfor the operation; others use a silver ring-shaped attachment\\nwith a flat, finger-nail-like projection, to slip over the thumb\\nwhen the operation is to be performed.\\nAt least one of the native tribes, Los Lacantunes, of that\\nregion of Guatemala that has been but partly explored, use an\\nobsidian for the same purpose.\\nRamon Guiteras 1 is of the opinion that stricture of the\\nmeatus is most frequent with those circumcised in infancy.\\nSince having attention called to this point, I searched my\\nrecords and found that I performed far more meatotomies on\\nthose circumcised in early life than on others. If this is not\\na mere coincidence, it is hardly explicable by nature contracting\\nthe meatus to protect the urethra. It seems more likely to be\\nattributable to the crude methods employed by the Mohelim or\\nMauhelim (ritualistic circumcisers).\\nEvery physician who has circumcised many infants knows\\nthat the lips of the meatus are found pouting. As the ritualistic\\ncircumcisers cut or pinch off the foreskin close to the meatus,\\nit is readily appreciable how they can remove with it a part of\\nthe pouting lips. The resulting cicatrix naturally contracts\\nand so produces the stricture. Among those who present no\\ncontraction of the meatus, slight radiating marks suggest the\\npossibility of a small tip of the meatus having been removed.\\nDisregard for asepsis in ritualistic circumcision has caused\\nmany, and among them devout Jews, to inveigh against the op-\\neration. Erysipelas, syphilis, and tuberculosis are frequently\\nreported in support of this objection. In France a sanitary law\\nwas passed at the beginning of 1899 prohibiting circumcision,\\nexcept it be in the presence of a physician. While the intent\\nof this law is manifest, its execution is likely to fall far short\\nof its purpose, as must be evident to those who from sad ex-\\nperience know the difficulty of securing asepsis in even trained\\nassistants and nurses.\\nRegarding injuries to the urethra from circumcision, Sascke 2\\n1 Guiteras A Review of the Principal Features of Urethral Stricture.\\nMedical Review of Reviews, January 25th, 1899.\\n2 Sascke Betrachtliche Verletzung der Harnrohre. Schmidt s Jahr-\\nbucher, vol. lv., 1847.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0128.jp2"}, "129": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 119\\nreports a young Jew whose anterior half of the glans was miss-\\ning. The meatus was at the lower surface, and behind this a\\nsecond orifice emitted the urine. It seems, however, that in thi3\\ncase the mutilation complicated a pre-existing deformity.\\nA patient referred to me for chronic gonorrhoea had had\\nover four-fifths of the right half of his glans torn off during\\nritualistic circumcision. The left side of the fossa was exposed.\\nFrom the right coronary margin three fleshy projections hung.\\nThe consequence of this deformity doubtless contributed in\\nmaking his gonorrhoea most persistent.\\nA most aggravated case of urethral traumatism from ex-\\nternal violence was in a young man whose penis a prostitute\\nhad bitten while, as he said, both were drunk. Singularly\\nenough, the upper surface of the middle third of the penis\\nshowed only slight bruises from the teeth; the lower central\\nincisors had evidently been sharper, for they penetrated the\\nurethra and had sunk into the corpora cavernosa. Permanent\\ncatheterization was at once employed, but as the wound soon\\nmanifested syphilitic infection attempts at repair have thus far\\nproved futile.\\nInjuries to the urethra from within, such as follow violent\\ninstrumentation, false passages, tears of the mucosa, may com-\\nplicate gonorrhoea. When irrigations have reduced the inflam-\\nmation and discharge to a minimum, these injuries should be\\nsought by the urethroscope and treated as their especial char-\\nacter may require.\\nVesiculitis Seminalis (Gonocystitis).\u00e2\u0080\u0094 If Fuller 1 had done\\nnothing else than develop the pathology and rational treatment\\nof inflammation of the seminal vesicles, his studies of this dis-\\nease alone would suffice to place the profession under deep ob-\\nligations to him.\\nWith a view to refreshing memory on the precise location of\\nthese organs, whose infection is far more frequent than ordi-\\nnarily recognized, a schematic drawing may be borrowed from\\nStewart, 2 elucidated with Lewis 3 concise description of the\\nseminal vesicles which is here condensed The vasa deferentia\\n1 Fuller Disorders of the Male Sexual Organs, Lea, Philadelphia, 1896.\\n2 Stewart: Diseases of the Urethra. William Wood Company.\\n3 Lewis: Seminal Vesiculitis as an Obscure and Elusive Disease.\\nMedical Age, June 25th, 1897.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0129.jp2"}, "130": {"fulltext": "120\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\ncarry the spermatozoa from the testicles, through the inguinal\\ncanals, into the pelvic cavity, converging behind the bladder and\\nalmost touching each other behind the prostate. The seminal\\nvesicles lie against the posterior surface of the bladder, just\\nbeyond the convergence of the vasa, which conduct the sperma-\\ntozoa into the vesicles. There the fluid secretion of the vasa\\nkeeps them alive. At opportune moments (coitus or nocturnal\\nemission) the spermatozoa are thrown out of the vesicles through\\nthe ejaculatory duct, which perforates the prostate, into the pos-\\nFig. 39.\u00e2\u0080\u0094 Location of the Seminal Vesicles (from Stewart s Diseases of the Urethra\\nterior urethra, where they are mixed with prostatic juice, and\\nwhence they are ejected by the spasmodic contractions of ejacu-\\nlation.\\nIt consequently is clear that the finger inserted into the\\nrectum will feel the seminal vesicles immediately above the\\nprostate and projecting to either side of the bladder. In health,\\nhowever, these soft little pouches are difficult and often impos-\\nsible to find.\\nIn view of the fact that the ejaculatory duct is so short and\\nalmost straight, it is strange that seminal vesiculitis does not\\nmore frequently complicate gonorrhoea. As, however, acute\\ngonocystitis, as Gouley aptly calls the disease, fortunately tends\\nto resolution, it may be overlooked in very many gonorrhoeas.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0130.jp2"}, "131": {"fulltext": "COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 121\\nMoreover, the close resemblance of its symptoms to those of\\nposterior urethritis and prostatitis may account for its relatively\\nrare discovery. If every patient with gonorrhoea were subjected\\nto digital examination per rectum, infection of the seminal ves-\\nicles would be better understood and its often disastrous con-\\nsequences avoided.\\nThe symptoms may be ushered in by a mere sense of weight\\nin or about the perineum. This soon changes to dull or throb-\\nbing pain in this region and that within the anus and the bladder.\\nRectal and vesical tenesmus may become very intense. All\\nthese symptoms increase while urine accumulates in the bladder;\\nthe pain then may be referred to the region of the glans or the\\nroot of the penis, or both. The constitutional disturbance is\\noften quite marked; anorexia, even nausea, may accompany the\\nbeginning of the disease, while decided chills and fever may\\ncause an error of diagnosis.\\nCertainty of differentiation, principally from posterior ure-\\nthritis, is obtainable only by rectal examination. The presence\\nof a swollen, painful prostate should not be accepted as conclud-\\ning a diagnosis. The ringer passed beyond this gland should\\nseek the seminal vesicles which, if involved, will be found\\nmuch enlarged in all directions in the shape of a distended\\nleech, hot, brawny, and exquisitely tender (Taylor).\\nFurther development of the disease can cause a pulpy con-\\nfluence of the vesicles of both sides, rendering their delineation\\nimpossible. They may then appear as if overhanging the pros-\\ntate like a large, flabby mass.\\nWith the progress of vesiculitis the patient presents all the\\nappearances of severe illness associated with acute sufferings.\\nThe pains in the perineum, rectum, and bladder become intensi-\\nfied, and extend to the sacrum, the coccyx, the hip-joint, down\\nthe sciatic nerve, sometimes up to the diaphragm, making even\\nbreathing painful. The local pains are increased by urination,\\nwhich is frequent but the pain, if there is any after urina-\\ntion, is not so severe nor so prolonged as that of posterior\\nurethritis.\\nExamination of the urine may be misleading, unless speci-\\nmens of the first morning urine or that passed at the end of\\ndefecation is used. At other times the urine may appear normal\\nThe properly selected specimen will contain, according to the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0131.jp2"}, "132": {"fulltext": "122 THE IRRIGATION TREATMENT OF GONORRHCEA.\\nintensity of the involvement, pus corpuscles, red blood corpus-\\ncles, epithelia from the ejaculatory ducts, epithelia from the\\nprostate, mucous casts, and spermatozoa. Among the latter\\nmany a one will be found with a rounded enlarged head whose\\npellucidity has changed to a granular appearance, making the\\ndiseased spermatozoon look like a tailed pus corpuscle. If the\\ngonocystitis is gonorrhceal, gonococci will be present in the\\nspecimen. The greater the chronicity of the case, the greater\\nwill be the number of the fat globules. Fuller (op. cit.) holds\\nthat in about one-third of the cases of seminal vesiculitis the\\ndisease is tuberculous. While all deference is due to Fuller s\\nwide researches, this large number of tuberculous invasions of\\nthe seminal vesicles does not coincide with the experience of\\nothers, that of the present writer included. Still, Fuller s\\nwarning should never be left out of mind.\\nHeitzmann {op. cit.) always finds prostatic epithelia with\\nmicroscopic evidences of gonocystitis, from which he deduces\\nthat the prostate is inflamed when the seminal vesicles are. For\\nself-evident reasons (see Fig. 39, page 120) it would be practically\\nimpossible for the prostate to escape such infection. But as\\nthe disease of the vesicles may overshadow the latter, it may\\nelude observation.\\nDefecation, in seminal vesiculitis, is often as painful as is\\nurination. It may be associated with intense tenesmus of the\\nrectum and of the bladder.\\nUnless sleep is disturbed by painful erections or emissions,\\nit may be very prolonged. Despite its length, the patient is as\\nfatigued when he awakes as when he retired.\\nIf the patient has nocturnal emissions, they may be bloody\\nor of a chocolate color, from the admixture of blood.\\nWhen the ejaculatory duct is not firmly agglutinated, the\\nseminal vesicle may be emptied of much or all of its pus by\\nstrippings through the rectum. The remainder of the treat-\\nment is necessarily similar to that advised for prostatitis.\\nIf acute vesiculitis does not go on to resolution or is not re-\\nlieved by treatment, it may go over into chronic gonocystitis or\\nabscess may form, with all the dangers of invasion of other\\nstructures.\\nAbscess of the seminal vesicles should be promptly emptied\\nthrough the perineum or the rectum. In making the long free", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0132.jp2"}, "133": {"fulltext": "COMPLICATIONS AND SEQUELS OF GONORRHOEA. 123\\nincision through the anterior rectal wall for extensive abscess,\\nas advised by Gouley, the cavity should be carefully packed and\\nasepsis of the region observed as cautiously as possible.\\nAn attempt to study chronic seminal vesiculitis in such brief\\nform as would be admissible here could not but prove mislead-\\ning. The reader is therefore referred to the more exhaustive\\nworks of Fuller, Gouley, Taylor, White and Martin, and others\\nfor clear, complete discussion of the subject.\\nThis perfunctory disposal of chronic seminal vesiculitis\\nshould not lead to a light consideration of the disease. The\\nvast array of symptoms, direct and reflex, which it produces\\nmakes it worthy of most serious attention, as do the dangers to\\nwhich it exposes the patient. Moreover, when due to gonor-\\nrhoea, as it very often is, it will explain many cases of apparently\\nfrequent recurrences of the disease. Indeed, when a presumably\\nfresh gonorrhoea presents in less than two or more than ten days\\nafter coitus, the physician would be derelict in his duty if he\\ndid not interrogate the seminal vesicles.\\nUeethbo-Pbostatic Infection by the Nogues- Wassebmann\\nDiplococcus.\u00e2\u0080\u0094 While this form of genito-urinary infection is\\nnot a complication of gonorrhoea, it is outlined here for con-\\nvenience of differentiation. This urethro-prostatic trouble may\\nbe mistaken for cystitis, urethrocystitis, and prostatitis. Paul\\nNogues and Melville Wassermann 1 describe the etiological\\nmicrobe which they discovered as resembling the gonococcus\\nin form, dimensions, staining and decolorization by Gram s\\nmethod so closely that many authors would not hesitate to class\\nit with Lustgarten and Mannaberg s pseudo-gonococci. They\\ninsist that all the diplococci so grouped can be differentiated by\\ncareful examination.\\nNogues and Wassermann describe the symptoms of urethro-\\nprostatic infection by their micro-organism in a case from\\nGuyon s service in the Hopital Necker:\\nThe patient, aged 42, had no disease except syphilis, con-\\ntracted many years ago. Eighteen months before being treated\\nat the Necker, he had had vague pains in the region of the peri-\\nneum and of the anus. Twelve days subsequently he observed\\n1 Nogues et Wassermann Infection Urdthro-Prostatique, due; a un micro-\\norganisme particulier. Annales des Maladies des Organes Gtenito-Urinaires,\\nJuly, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0133.jp2"}, "134": {"fulltext": "124: THE IRRIGATION TREATMENT OF GONORRHOEA.\\nan oozing from the urethra. This oozing never assumed the\\nproportions of a true blennorrhoea, he had no painful urination\\nnor nocturnal erections. The only functional symptom was the\\nanal pain mentioned above. For six months he was treated by\\nwashings with boric acid and santal oil internally. The next\\nphysician he consulted diagnosed prostatitis and employed irri-\\ngations of potassic permanganate and prostatic massage. No\\nchange in the condition resulted in the beginning soon, how-\\never, vesical^ manifestations appeared the patient urinated\\nevery two hours during the day and four times at night. In\\nthis condition he sought Professor Guyon s advice. The\\nurethral discharge was then minimal, but a few slightly colored\\nspots stained the shirt the urine was acid and clear, but the\\nfirst urine emitted contained numerous dense and heavy fila-\\nments. The urethra was found in good condition, the bladder\\nof nearly normal capacity. The prostate was in almost com-\\nplete health, but the urine voided immediately after massage\\nwas decidedly turbid. In this specimen Nogues and Wasser-\\nmann found their microbe.\\nAfter an instillation of silver nitrate into the prostatic por-\\ntion by Guyon s method, the urine almost recovered its trans-\\nparence; very careful microscopic examination did not reveal\\nany bacteria whatever, and two tubes of agar and of bouillon\\nsown with the specimen remained sterile. The cure was verified\\ntwo weeks later by a second bacteriological examination which\\ngave a negative result.\\nThe authors, after most exhaustive histological and bacterio-\\nlogical series of experiments, including cultures on all accepted\\nmedia of the turbid urine with an abundant whitish sediment,\\nsum up the characteristics of their microbe as follows\\nA diplococcus, within and outside the leucocytes, not in\\nspecific grouping, readily decolorizable by Gram s method;\\neasily and abundantly culturable on all the ordinary media ex-\\ncept on potato; does not liquefy gelatin, indifferent in the\\npresence of oxygen and of rapid growth in anaerobic condition\\napparently with no power to decompose urea.\\nThey conclude that the diplococcus they describe is the in-\\nfectious agent of a form of urethro-prostatitis and that it can be\\nthoroughly differentiated from the gonococcus by culture.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0134.jp2"}, "135": {"fulltext": "CHRONIC GONORRHOEA. 125\\nVIII. CHRONIC GONORRHOEA.\\nUnder the treatment pursued before irrigations were estab-\\nlished, six weeks was deemed the duration of an acute gonor-\\nrhoea. If it proceeded beyond six weeks, it was considered to\\nhave gone over into a chronic condition. This chronicity,\\nhowever, was often associated with all the symptoms of the\\nacute attack.\\nGoldberg s statistics (quoted on page 1) compiled from the\\nworks of all who wrote on irrigations, whether approvingly\\nor disapprovingly, show that ninety per cent, of the patients re-\\ncover within fourteen days. It is therefore equally proper to\\nhold that a case of gonorrhoea not entirely cured within two\\nweeks must be considered a chronic clap.\\nJanet, to whom all the credit is due for popularizing the\\nirrigation treatment, advises a second series of irrigations after\\nthe first series, when that has not succeeded. The second series\\nof irrigations with solutions of potassic permanganate as advo-\\ncated by Janet is as follows\\nFirst day, first visit, Anterior irrigation 1 3,000\\nFirst day, 7 p.m. Anterior irrigation 1 6,000\\nSecond day, 9 a.m. Intravesical irrigation 1 4.000\\nSecond day, 7 p.m. Anterior irrigation 1 4,000\\nThird day, 7 p.m. Anterior irrigation 1 2,000\\nFourth day, 9 a.m. Intravesical irrigation 1 3,000\\nFourth day, 7 p.m. Anterior irrigation 1 2,000\\nFifth dav 7pm i Intravesical irrigation 1 3,000\\nAnterior irrigation 1:1 ,000\\nSixth day, 7 p.m. Anterior irrigation 1 1,000\\nSeventh day, 7 p.m. Anterior irrigation 1 1,000\\nEighth day, 7 p.m. i Intravesical irrigation 1 3,000\\nAnterior irrigation 1 1,000\\nIn offering the above formulary, no thought is conveyed that\\nit will cure every chronic gonorrhoea. Even if the clap is un-\\ncomplicated, the solutions may have to be materially modified\\nto meet the individual peculiarities of each case. The solutions\\nadvised, however, meet the average cases.\\nFurthermore, this formulary will serve admirably in most\\ngonorrhoeas which appear without acute manifestations (chro-\\nniques d emblee, Guiard) and which are so often erroneously\\ncalled light attacks.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0135.jp2"}, "136": {"fulltext": "126 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThe majority of cases, however, require most scrupulous\\nsearch for the conditions that cause their progression into\\nchronicity.\\nIn an effort like this none but the barest outlines of pathol-\\nogy can be sketched, and indeed, none of these can find place\\nexcept those essential to an intelligent comprehension of the\\ntreatment advocated. The writers who have labored and are\\nlaboring so industriously and well in this, the most important\\ndepartment, of genito-urinary diseases, can receive but scant\\nattention. No lack of appreciation is conveyed thereby. As\\nOberlaender 1 said five years ago: The literature of chronic\\nurethritis has grown to monstrous proportions. The additions\\nto this literature since then are if anything greater in number than\\nthose which preceded Oberlaender s comment; hence the hope-\\nlessness of attempting even approximate justice to the authors.\\nThe principal conditions that predispose a patient to the\\nestablishment of a chronic gonorrhoea are reduced vital resist-\\nance, lax urethral mucosa, phthisis, diabetes, phimosis, agglu-\\ntination of the prepuce to the glans, tight meatus, a narrow\\nurethra, deformities of the glans, para-urethral fistuhe and re-\\nsidual defects from former gonorrhoeas, be they ever so minute\\nand often not evident to the inexperienced urethroscopist\\n(Oberlaender). In many instances none of these predisposing\\nelements are found to explain the progress into chronicity; in\\nany given case in which this occurs, cure is not likely to be ob-\\ntained until the cause is found and removed.\\nThe causes of the transition of gonorrhoea into the chronic\\nstate, are summed up by Guiard 2 in his brilliant and exhaustive\\nwork on the subject. With slight modification from this author,\\nthey may be cited as (1 congenital or acquired deformities (2)\\nthe patient s constitutional condition; (3) misdirected or in-\\nsufficient initial treatment; (4) infractions of hygienic precau-\\ntions (5) over-treatment.\\nThe two first-named have been briefly mentioned above.\\nThey are discussed somewhat more in detail in Chapter VII.\\n(Complications of Gonorrhoea).\\nOberlaender: Die chronischen Erkrankungen der mannlichen Harn-\\nrohre. Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., Vogel,\\nLeipzig, 1894.\\n2 Guiard Les urethrites chroniques chez 1 homme, 1898, Rueff, Paris.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0136.jp2"}, "137": {"fulltext": "CHRONIC GONORRHCEA. 127\\nAs outlined under the head of acute gonorrhoea, irrigations\\nto be effective, must be promptly and energetically instituted\\nas soon as possible after inception of the disease. But irriga-\\ntions will certainly be misdirected and thwart the object in\\nview if the physician were to mistake force and violence for\\npromptness and energy. The column of fluid, if bruskly sent\\ninto an exquisitely inflamed urethra, cannot but damage it;\\nlesions can easily be caused thereby, directly inviting invasion\\nof the deeper structures and thence of the adnexa and the entire\\norganism. Therefore, while all uncomplicated and most com-\\nplicated gonorrhoeas must and should be treated by the general\\npractitioner, none should touch them save those who are char-\\nacterized by innate and carefully cultivated delicacy of manipu-\\nlation. Only those so endowed are able to avoid misdirecting\\neven the best intended efforts.\\nInsufficient initial treatment is likely to obtain in the hands\\nof physicians whose delicacy of touch is above criticism, but\\nwho lack adequate firmness of purpose. While these will not\\nsin by injuring the inflamed urethra they, through timorousness,\\nare prone to allow the disease to gain mastery over the infected\\nregion. This extreme is quite as reprehensible as the other.\\nAn exceedingly frequent element for the production of\\nchronic gonorrhoea, entirely beyond the physician s responsi-\\nbility, is in the hygienic and dietary infractions which patients\\ncommit. In Chapter VI. (Constitutional and Accessory Treat-\\nment) an endeavor is made to outline the hygienic and dietary\\nprecautions that are necessary for the successful treatment of\\ngonorrhoea. If the physician, for any reason, cannot obtain\\nsuch control over his patient that the latter will follow these sim-\\nple instructions or appreciate the dangers of their infraction, he\\nwill wisely recommend to him the study of James Foster Scott s 1\\nbook. Should the patient s inferior intelligence or lack of ap-\\nplication not permit him to grasp the value of Scott s excellent\\nwork, he may be advised to read a small effort in the same\\ndirection. Its author 2 will not object if his name is erased\\nfrom the article before it is handed to the patient.\\n1 Scott The Sexual Instinct Its Use and Dangers as Affecting Heredity\\nand Morals, Treat, New York, 1899.\\n2 Advice to Gonorrhceai Patients. Philadelphia Medical Journal, July\\n8th, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0137.jp2"}, "138": {"fulltext": "128 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nExcessive treatment cannot only assure a gonorrhoea becom-\\ning chronic, but also tends to perpetuate a chronic clap indefi-\\nnitely. In Chapter XIV. (The Proofs of Cure of Gonorrhoea)\\nthe indications for discontinuance of treatment are detailed.\\nThe local pathological conditions which maintain a chronic\\ngonorrhoea have been and are made the objects of special in-\\nvestigations by an immense array of learned men. To even\\nquote their names and outline their results would require a\\nlarge volume.\\nFor the general practitioner s purpose it may suffice to be-\\ngin the study of chronic gonorrhoea by attaching its cause to\\n(1) epithelial disturbance; (2) infiltration of the mucosa; (3) in-\\nvolvement of the urethral glands (4) infection of the adnexa.\\nWhile precise distinction of the three first-mentioned condi-\\ntions is obtainable only by the urethroscope, it can hardly be\\nexpected that any but those with a very large general practice\\nwill avail themselves of this instrument of precision. Those\\nwho desire to instruct themselves in urethroscopy will find\\nelementary outlines thereof in Chapter XIII. (Urethroscopy).\\nA study of the symptoms of chronic gonorrhoea is, however,\\nopen to even the least experienced. An effort will be made to\\ndepict those that are most directly related to therapeutic sug-\\ngestions. For easy reference they are arranged in alphabetical\\norder. Necessarily, with a view to differentiation, this list must\\ninclude some symptoms not due to chronic gonorrhoea.\\nAbsence of Symptoms see Chapter XIY. (Proofs of Cure of\\nGonorrhoea).\\nAppaeent Aspermia.\u00e2\u0080\u0094 Quite a number of patients complain,\\nlong after external evidences of gonorrhoea have passed off, that\\nthey experience little or no sensation at the conclusion of the\\nsexual act, no matter how prolonged it was. When withdrawing\\nthe penis at the feeble conclusion of the act, nothing is seen to\\nescape from the meatus. Manifestly, unless the case be one of\\ntrue aspermia, swelling of the posterior urethra directs the\\nsemen into the bladder, instead as normally, through the com-\\npressor. The next urination then carries with it the semen that\\nshould have been forcibly ejected in coitus.\\nSome of these patients, who are called trompeurs (cheat-\\ners) in French literature, will confess to having employed arti-\\nfices to prolong the sexual act or to prevent pregnancy. These", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0138.jp2"}, "139": {"fulltext": "CHRONIC GONORRHCEA. 129\\nartifices embrace digital compression of the urethra, constriction\\nat the peno-scrotal juncture by a rubber band, or a species of\\nmental coercion by means of which the orgasm is arrested just\\nbefore ejaculation. The first urine passed after such coitus will\\nbe found to contain an abundance of semen.\\nDefecation and Urination Drop. Very many patients have\\nno discharge whatever, but during or after defecation or after\\nurination a thick white drop appears at the meatus. The man-\\nner in which this drop appears at once suggests a urination\\nor defecation spermatorrhoea. Indeed, these ma} coexist with\\nthe manifestation which I have named as above.\\nLike urination or defecation spermatorrhoea, this drop is\\nsometimes attributed to expression of a diseased prostate or\\nposterior urethra, by the pressure of lumps of hard faeces upon\\nthese organs in their passage through the lower rectum. The\\nanatomical relations of this region prevent a faecal bolus, which\\ncan at all pass the anus, from exercising sufficient pressure upon\\nthe prostate or posterior urethra to expel their secretions.\\nThe faecal mass, however, if hard, stimulates voluntary contrac-\\ntions of the rectal and urethral detrusors, and these, by forcible\\ncompression of the prostate and posterior urethra, cause them\\nto yield some of their contents.\\nMacroscopically, these drops differ from those of spermator-\\nrhoea in not proving tenuous i.e., they cannot be drawn out\\nin such long filaments. Moreover, they dry in concretions re-\\nsembling phosphatic calculi. When fresh, and pressed or\\nrubbed between two cover-glasses they convey a sensation as if\\nthey contained very fine sand.\\nMicroscopically, these drops show pus in minute quantity,\\nmuch mucus, epithelium, and occasionally gonococci. The grit-\\nlike substance has the appearance of little globules, resembling\\ncocci. If acetic or nitric acid is added to them, they dissolve\\nwith the escape of bubbles of gas.\\nIf spermatozoa are found, the case may be one of pure urina-\\ntion or defecation spermatorrhoea their presence, however, does\\nnot exclude the coincidence of gonorrhceal prostatitis or posterior\\nurethritis.\\nDischarge. In chronic gonorrhoea the discharge may vary\\nfrom a slight, glairy excess of moisture, expressible to the meatus\\nwith difficulty, to free, continual, or intermittent discharges.\\n9", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0139.jp2"}, "140": {"fulltext": "130 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThe discharge, whatever its character, may be the only symp-\\ntom which the patient observes. Some patients are singularly\\nindifferent to this manifestation of disease when it gives them\\nno inconvenience beyond filthiness; the majority, however, are\\nmentally distressed, and in consequence physically disturbed,\\nby an excess of moisture that does not even agglutinate the\\nmeatus. Whether this is on a purely aesthetic score or due to a\\nspecific lasting influence of gonococci toxins on the nervous\\nsystem, is one of the questions neurologists still have to solve.\\nWhatever the character of the discharge, its contents and\\norigin must be ascertained. Many microscopical examinations\\nmay be made without discovering any noxious bacteria. This\\ndoes not entitle the physician to assert that none exist in the\\npatient s genital apparatus (see Chapter XIV., Proofs of Cure\\nof Gonorrhoea). Whether gonococci, with or without other\\nbacteria, present in the slight or copious, permanent, intermit-\\ntent or recurrent discharge, or if none are found, the origin of\\nthe discharge, i.e., the diseased region or regions and the char-\\nacter of the disease, must be ascertained. The discharge itself\\nis not characteristic of its source. While it can be determined\\nby the kind or kinds of epithelia found, it is always well to give\\nequal weight to the clinical manifestations. These are outlined,\\nas are the methods for eliciting them, in Chapter VII., on the\\nComplications of Gonorrhoea.\\nFor convenient reference, and until a better arrangement is\\noffered, I submit the following description of urethral dis-\\ncharges, which may be continuous in the mornings only in-\\ntermittent during the day intermittent with several days weeks\\nor months interval (recurrent gonorrhoea) mixed with the last\\nportion of urine, or immediately after urination (gonorrhceic\\nand other prostatorrhcea)\\nIn regard to color and consistence, it may be: watery, al-\\nbuminoid, rice-water, grayish, thin white, thick white, thin yel-\\nlow, thick yellow, thick greenish-yellow, thick bloody.\\nThese discharges may be mixed, as for instance the grayish\\ndischarge may be mottled with spots of white, yellow, or green,\\nor it may be streaked with these colors.\\nI may be permitted to emphasize that this classification of\\nthe discharge of chronic gonorrhoea is offered solely for con-\\nvenience of recording.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0140.jp2"}, "141": {"fulltext": "CHRONIC GONORRHOEA. 131\\nA form of discharge characteristic of prostatic involvement,\\nand not mentioned above, has a tendency to be drawn out in\\nlong elastic filaments when taken between the fingers or when\\nremoved from the urethra with an instrument. When placed\\non a cover-glass it curls up into one or more glutinous heaps.\\nWhen one endeavors to spread these heaps, they drag after the\\ninstrument with great tenacity. They are difficult to crush be-\\ntween cover-glasses, and require considerable rubbing to spread\\nthem with sufficient thinness into a smear preparation (Stern-\\nberg) for microscopical examination. Moreover, they require\\nmuch more time for the air-drying than is usually necessary for\\nflame fixation prior to staining. The microscope shows them\\nto contain many prostatic epithelia and prostatic bodies, in\\naddition to the other elements that characterize the special kind\\nof infection.\\nDischarges Simulating Spermatorrhea.\u00e2\u0080\u0094 Guy on and Jamin\\nwere the first to point out this symptom of chronic posterior\\ngonorrhoea, which Guiard J compares to little ejaculations\\n(petites ejaculations). It is the sudden, intermittent appearance\\nof a large drop at the meatus. After the drop has passed to the\\nlinen, no more discharge can be expressed from the urethra,\\nunless by persistent milking some normal secretion is pro-\\nduced from the pendulous portion. If the patient is not in-\\nformed on the subject, he is likely to consider these discharges,\\noccurring at irregular intervals, indications of spermatorrhoea\\nor of urinary incontinence.\\nThe stains on the linen produced by these discharges differ\\nmarkedly from those made by anterior gonorrhoea. The occa-\\nsional sudden stains are fewer in number and much larger than\\nthose of chronic anterior gonorrhoea. Both kinds of spots may\\nappear together. Those ejected from the posterior urethra at\\nirregular intervals generally have yellowish- white centres, with\\nclearer and starch-like peripheries, when they have dried on the\\nlinen.\\nOrdinarily the emission of these drops is not accompanied\\nby any sensation; their presence is then not noted except by\\nthe moisture at the meatus or on the shirt, which the patients\\noccasionally feel. In some very rare cases the emission of this\\nGuiard: Op. cit, p. 161.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0141.jp2"}, "142": {"fulltext": "132 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ndrop is associated with a very brief, somewhat pleasurable sen-\\nsation along the urethra, suggesting that produced by the ejacu-\\nlation of semen.\\nGuyon emphasizes that the compressor will not yield to\\npressure from within until a sufficient degree thereof is exercised,\\nand then urethroprostatic discharge is prevented from flowing\\ninto the bladder by the sphincter vesicae. The discharge so re-\\ntained, distending the posterior urethra, evokes reflex contrac-\\ntions of the ejaculatory muscles. This view is opposed by\\nmany authors, but Guiard s 1 observations fully support it.\\nWhile this seems the most rational explanation of this\\nsymptom, it cannot, however, be compared to the emptying of\\nthe posterior urethra in ejaculation of semen. During this act\\nthe posterior urethra is suddenly filled with semen, and while\\nthe ejaculatory muscles are stimulated to spasm thereby, the\\ncompressor in this spasm ordinarily yields intermittently, in\\nconcordance with their contractions. As opposed to the normal\\nejaculations the little ejaculations, as Guiard designates them,\\nappear to premise an extraordinary development of tonicity of\\nthe sphincter vesicae, preventing the urethroprostatic accumula-\\ntion from entering the bladder, which ordinarily is the point of\\nleast resistance. This extraordinary condition may explain\\nthe rarity of the symptom under discussion.\\nThe extrusion of these drops from the posterior urethra\\ncertainly proves that a posterior gonorrhoea can persist after\\nthe anterior clap has subsided. It is undoubtedly important\\nwhenever they are present that their origin be ascertained. In\\nthis, aside of their macroscopic characteristics mentioned before,\\nthe microscope will give the final decision concerning their,\\nsource, whether they proceed from anterior gonorrhoea, pos-\\nterior gonorrhoea, seminal emissions, or the after-dribbling of\\nurine.\\nExcessive Moistuee. In many cases, long after a gonor-\\nrhoea is cured, a watery or slightly gelatinoid excess is visible\\non opening the meatus, or can be stripped or milked from the\\nurethra. If repeated microscopical examinations of this excess\\nof normal moisture proves it to contain only mucus and normal\\nepithelium, and if no other symptom of disease presents, it\\n1 Guiard: La Blennorrhagie chez Thomme, p. 266, Rueff, Paris, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0142.jp2"}, "143": {"fulltext": "CHRONIC GONORRHCEA. 133\\nwould be exceedingly unwise to subject the patient to any local\\ntreatment, no matter how persistently he may implore it.\\nThe excessive moisture, unaccompanied by other manifesta-\\ntions of disease, may be due to a slight catarrhal condition or\\nto constitutional depression. The latter is often caused by the\\nneurotic state that so frequently is associated with and follows\\ngonorrhoea.\\nSome patients acquire remarkable dexterity in expressing\\nmoisture from a perfectly healthy urethra at all times. In do-\\ning so, they keep the channel in an irritated condition, which\\nceases as soon as their thoughts can be diverted from continual\\nconcentration upon their genitalia.\\nIf careful examination positively reveals complete absence of\\nany local ailment, constitutional remedies will be required.\\nAmong these, the mixture of tr. cantharid. and iron, recom-\\nmended many years ago by that eminent teacher Otis, will be\\nfound effective in the majority of cases.\\nWith a view to facilitating the study of excess of moisture,\\nits characters are here offered, preliminary to a better arrange-\\nment which doubtless will be made later.\\nIn volume, the excess may be: expressible with difficulty,\\ni.e., slight in quantity; easily expressible, i.e., in quantity not\\nsufficient to form a drop, but enough to be visible as an excess\\nwhen the meatus is opened.\\nIn color, the excess may be: thin watery; thick watery;\\nalbuminoid, like raw albumen; gelatinoid; grayish; thin white\\n(like milk and water) thick white, like cream rice-water yel-\\nlowish-white yellow; watery, white or yellow spotted or\\nstreaked; mixtures of any one or more of the above.\\nI repeat that this classification has no other purpose than\\nease of description.\\nExcessive Sexual Desire. While the prostate or seminal\\nvesicles or both are in a deteriorated condition from chronic\\ngonorrhoea, or while the urethra still suffers from the disease\\nor its effects, some patients may be annoyed with what they\\ncall a teasing or nagging impulse to indulge in sexual in-\\ntercourse. This may occur without provocation, or in the pres-\\nence of women who in no wise evoke sensuality, as in a public\\nvehicle. Perhaps it may be well to call this symptom genesic\\nhyperesthesia, in order to concisely describe it. An extreme", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0143.jp2"}, "144": {"fulltext": "134 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ncase thereof manifested the following conditions While at col-\\nlege, the patient, then aged twenty, contracted gonorrhoea, of\\nwhich he was apparently cured. At twenty-eight he married,\\nand became the father of three healthy children during five\\nyears. His wife was not infected by him. From the time of\\nhis only gonorrhoea, he was obliged to undergo continual mental\\nstruggles to master the sexual impulse. His business required\\nmuch dictation to stenographers. In selecting these employees,\\nhe gave preference to those least likely to suggest lascivious\\nthoughts. Imagining that the presence of any woman under\\npropitious surroundings aggravated his condition, he eventually\\nemployed only men, but soon found that the sexual obsession\\nwas ever present, detracting materially from the mental concen-\\ntration his business demanded. A long vacation from his work,\\nand devotion to athletic exercise, brought no relief. He finally\\nhad recourse to bromides with but temporary relief, and the re-\\nsult that he became a bromide-habitue. When he was thirty-\\nfive years old, he was brought for consultation. The urethra\\nshowed a slight, hard infiltration close behind the posterior\\nboundary of the fossa; the prostate was somewhat enlarged.\\nUnder dilatations of the urethra and prostatic massage for\\nabout six months, the conditions materially improved. When\\nthe genesic hypersesthesia had subsided so far that it but rarely\\ntroubled him, and then only for a few moments, he unfortunately\\nwas misled into drinking too much champagne at a dinner. The\\nnext day the condition returned in an aggravated form he re-\\nverted to large doses of potassium bromide and passed from\\nobservation for three months. He then wrote that he could not\\nsummon the courage to discontinue the bromide, which he knew\\nwould be required of him if he resumed treatment.\\nThe majority of cases do not, however, terminate in so un-\\nhappy a manner, but yield to the treatment elsewhere discussed.\\nGONORRHOEAS THAT ARE CHRONIC FROM THE INCEPTION. In\\nsome cases the manifestations of gonorrhoea are so slight, and\\ntheir progress is so insidious, that they appear to have been\\nchronic from the very beginning. These Guiard calls urethrites\\nchroniques d emblee. The only symptom may be so slight an\\noozing from the meatus as barely to attract attention. The ap-\\n1 Guiard Les Urethrites chroniques chez l homme, Rueff, Paris, 1898.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0144.jp2"}, "145": {"fulltext": "CHRONIC GONORRHCEA. 135\\nparent insignificance of this discharge has no relation to the\\nrelative number of gonococci it may contain, nor is the patient\\nany the less exempt from complications and sequelae of gonor-\\nrhoea than if it manifested itself in the hyperacute form.\\nI have not observed a case, however, in which a patient s first\\ngonorrhoea began with this sole symptom of chronicity. This\\nmay explain the fact that the gonorrhoeas apparently beginning as\\na chronic disease are more tenacious and resistant to treatment.\\nWhen the patient denies previous attacks, it may be accepted\\nthat his memory may be fallacious in this regard. Therefore it\\nwill be well to explore the urethra and adnexa as soon as pos-\\nsible for residua of previous trouble. These must then be\\npromptly and thoroughly treated, however slight they may ap-\\npear to be.\\nItching or tickling is one of the most annoying and often\\none of the most persistent symptoms of chronic gonorrhoea.\\nWhen a focus or several foci of inflammation or infiltration can\\nbe discovered by the urethroscope, the condition can be relieved\\nby direct applications of silver nitrate or cupric sulphate. When\\nitching or tickling oscillates with varying intensity between spots\\nin the anterior and posterior urethra, it may be due (1) To both\\nthese regions having diseased foci then temporary greater irrita-\\ntion in a focus or foci in the anterior or posterior urethra may\\nobscure that of the less disturbed region; (2) involvement of the\\nseminal vesicles, prostate, or Cowper s glands, from which the\\nirritation is reflected forward. In the latter case urethroscopy\\nmay show a perfectly normal channel; (3) fissure of the anus,\\nhemorrhoids, or rectal disturbances.\\nWhen tickling or itching besets the posterior urethra, it is\\noften referred to the rectum or anus. Such cases are frequently\\ntreated for a presumed rectal disease and even operated, natur-\\nally without result. On the other hand, a fissure of the rectum,\\nespecially when near the raphe, may cause urethral tickling or\\nitching. Urethral treatment must then necessarily be fruitless.\\nIt is necessary, therefore, most searchingly to explore the\\nurethra, its adnexa, the anus, and rectum when itching or tick-\\nling in the urethra presents. This sj^mptom is so harassing\\nthat the local disturbance seriously affects the patient; if long\\ncontinued, it so influences his general condition as to unfit him\\nfor his vocation.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0145.jp2"}, "146": {"fulltext": "136 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nWhen the cause is in th eurethra, it often is so minute that\\nits location is difficult, even by the most careful urethroscopy.\\nThen if all other causes can be excluded, dilatations and irriga-\\ntions fortunately relieve the condition.\\nMeatus, Agglutination of. In some cases the only mani-\\nfestation of chronic gonorrhoea is a cohesion of the lips of the\\nmeatus. More frequently still the lips are agglutinated, requir-\\ning a little force to separate them. When the urethral secretion\\nis a trifle greater than necessary to produce cohesion or aggluti-\\nnation, a little transparent pellicle or even a brownish crust may\\nform from the secretion as it dries between and upon the lips of\\nthe meatus. This crust must not be confounded with the one\\nfound upon the meatus of uncleanly persons.\\nIf the incrustation persists, it may make the beginning of\\nurination, especially that of the first morning bladder evacua-\\ntion, quite painful. The urinary stream tears the crust from\\nthe meatus and carries epithelium with it.\\nAgglutination and incrustation can be avoided in all cases\\nby keeping the meatus covered with absorbent cotton soaked in\\nbichloride 1 10,000 to 1 6,000, or boric acid four per cent. The\\ncotton so prepared is applied after each urination as described\\nunder the head of Anterior Irrigations, in Chapter III.\\nThe avoidance of this symptom, however, by no means im-\\nplies its cure. A diagnosis is as necessary here as elsewhere.\\nTo ascertain its character, a small quantity of the substance\\nthat agglutinates the meatus is taken with a sterilized (flamed\\nand cooled) platinum loop and placed upon a cover-glass. If\\nthe substance is so dry and hard that it cannot be spread very\\nthinly upon the glass, a drop of distilled water added to it will\\nquickly soften it, so that it can be spread, dried, flamed, stained,\\nand examined in the usual manner (see Chapter XIV., Proofs\\nof Cure of Gonorrhoea)\\nThe microscopical examination of a specimen so prepared will\\nshow, in simple urethrorrhoea, epithelium, mucus, and perhaps an\\noccasional leucocyte; in chronic gonorrhoea, all the above, de-\\nformed or thinned epithelia, or normal epithelia, pus cells, gon-\\nococci, and perhaps other bacteria in stricture, when it causes\\nthe persistence of a gonorrhoea, all the above, and epithelia with\\nloss of granulation of the epithelial nuclei or epithelia entirely\\nwithout nuclei; in uncleanliness, mucus, epithelium from the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0146.jp2"}, "147": {"fulltext": "CHRONIC GONORRHCEA. 137\\nmeatus, pus, dirt, and all kinds of bacteria; in consequence of\\nerections, mucus, epithelia from several parts of the urethra,\\nand spermatozoa.\\nMorning Drop. This term, like its French congener goutte\\nmilitaire, is unfortunately used by many authors as a synonym\\nfor chronic gonorrhoea. In reality it is only a symptom, and by\\nno means a constant one, of chronic gonorrhoeal inflammation.\\nWhen, in this disease, the discharge is continuous, there can be\\nno drop that appears at the meatus, in the morning or after\\nmore or less prolonged intervals between urination; nor is a\\nmorning drop ordinarily found when the only symptom of\\nchronic gonorrhoea is a stain on the linen.\\nThe persistent presence of this drop after a night during\\nwhich the patient has not urinated, by no means implies that\\nthe drop contains gonococci. On the other hand, the absence\\nof gonococci from the drop does not prove that the patient is\\nfree from these bacteria. Therefore the appearance of this\\nsymptom, which may vary from a clear, colorless, to a gelati-\\nnoid, gray, mottled, white or yellow drop, demands not only\\nmicroscopical examination, but also a thorough exploration of\\nthe entire urethra and its adnexa.\\nIf the patient with no other symptom of disease than the\\nmorning drop cannot come to his physician s office before uri-\\nnating, he should be instructed in the proper manner of taking\\nthe specimen on a cover-glass. This he then brings with him\\nfor examination.\\nNumerous observations of cases in which the morning drop\\nfree from gonococci was the only symptom of urethral dis-\\nease, have led me to the opinion that its presence is due to the\\neffect of gonococci held in some part of the lower urinary ap-\\nparatus. The most painstaking and exhaustive examination may\\nnot reveal the focus of inflammation nor the site where the\\nbacteria are residually held. To establish the presence or ab-\\nsence of gonococci it will be well, in such a case, to irrigate the\\nurethra with silver nitrate 1 1,000 or 1 500, or mercuric bichlo-\\nride 1:10,000. The discharge produced thereby can then be\\nexamined for gonococci. But whether they are or are not pres-\\nent, there will be no use in attempting to conquer the morning\\ndrop with any of the astringent injections of which so many are\\nrecommended. Even in the absence of any special focus of dis-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0147.jp2"}, "148": {"fulltext": "138 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nease, the case must be treated by internal massage of the ure-\\nthra, as directed when describing the treatment of chronic gon-\\norrhoea by dilatations and irrigations.\\nPainful Ejaculations. In those not due to the ejaculatory\\nspasm drawing upon nerve terminals compressed in infiltrations\\nof the anterior urethra, the pain may be due to irritation of the\\nchronically inflamed posterior urethra, just as urine, the normal\\nstimulant to vesical contraction, gives pain in cystitis, and as\\nlight, the normal visual stimulant, gives pain in iritis. These\\npainful ejaculations, however, are by no means essentially of\\ngonorrhceal origin. In character they may be lancinating,\\nburning, extending from the meatus to the rectum, or radiating\\nto the testicles and lasting some time after coitus, which may\\nbe followed by scalding on urination. They are most frequent\\nin excesses, such as are likely to be committed by middle-aged\\nmen in sexual relations with very young women. A most\\naggravated case in which painful ejaculation was the exclusive\\nsymptom of chronic anterior and posterior gonorrhoea, was that\\nof an otherwise normal man, who screamed at the moment of\\nejaculation and fainted before entire conclusion of the act.\\nUsually the patients with chronic anterior urethritis complain\\nof no pain during ejaculation, or only a slight burning. When\\nthe pain is sharp, lancinating, stabbing, and extends to the region\\nof the anus or rectum, chronic posterior urethritis is prob-\\nably associated with disturbance of the anterior urethra, with\\nor without involvement of the seminal vesicles or prostate, or\\nboth.\\nPainful Eeections. These are comparatively rare when ac-\\ncompanied by sufficient genesic impulse to overshadow the pain.\\nBut there are cases in which erections without sexual desire are\\nprovoked by the presence of chronic localized inflammation;\\nthey then stretch the tense areas or draw upon them, producing\\nexquisite pain, while increasing the inflammation. Many a man\\nhas mere mechanical erections from an overfilled bladder.\\nWhen the urethra harbors a chronic gonorrhea, the erections\\nare, as a rule, more or less painful. They subside, however,\\nas soon as the bladder is emptied.\\nPainful ubination may be frequently evoked in chronic\\ngonorrhoea by abnormally irritating urine, as in oxaluria, from\\nerrors of diet, alcohol, coitus, or overexertion. The irritation", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0148.jp2"}, "149": {"fulltext": "CHRONIC GONORRHCEA. 139\\nproduced may cause reawakening of the dormant inflammation\\nand with it recrudescence or increase of the discharge.\\nPainful urination in chronic gonorrhoea may also be caused\\nby agglutination or incrustation of the meatus, produced by a\\nsmall quantity of discharge drying upon or between the lips.\\nWhen sealing of the meatus is very firm, the first urine forced\\nfrom the bladder may distend the urethra most painfully, until\\nthe incrustation is torn off by the stream. This tearing away\\nof the crust is necessarily also painful. With repetition of the\\nact it rends epithelium from the meatus, leaving the lips\\ndenuded, and increasing the painfulness through the heavier\\nincrustation and greater denudation that follow. Decided\\nulceration of the entire meatus can result, if the condition is\\nneglected.\\nWhen alcohol or coitus or both have provoked the irritation,\\nthey must naturally be forbidden; when oxaluria is the cause,\\nthe diet must be regulated in all cases, the patient should be\\nordered to drink large quantities, three or four quarts, of boiled\\nwater daily to dilute the urine.\\nIncrustation of the meatus can be entirely and easily pre-\\nvented by causing the patient to keep the meatus continually\\nwet with cotton soaked in bichloride or boric-acid solution as\\ndirected where irrigations are described. When the incrustations\\nhave formed, pain on urination can be avoided by soaking the\\npenis in hot bichloride or boric solution until the crusts are\\nsoftened and can be easily removed.\\nPost-Coital Seminal Dkibbllng. In some cases, in which\\ncoitus is normal, it is followed by more or less copious dribbling\\nof semen from a but partially evacuated posterior urethra.\\nThis symptom is likely to occur as an independent manifesta-\\ntion of urethritis ex libidine. When sexual excesses take place\\nduring chronic urethritis, they are the more likely to provoke\\nthe same condition.\\nPkematuke ejaculations frequently overshadow the chronic\\ngonorrhoea that causes them, and often indeed are the only\\nsymptom of the disease. The local symptom may be merely\\ntoo brief intercourse before the ejaculation. A more marked\\nform is that in which the emission occurs before intromission,\\nwith subsidence of the erection as the penis touches the external\\nfemale genitalia. In still more aggravated cases, accidentally", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0149.jp2"}, "150": {"fulltext": "1-iO THE IRRIGATION TREATMENT OF GONORRHOEA.\\nbrushing against female garments suffices to provoke the emis-\\nsion, while the penis obtains but momentary turgescence, which\\nmay be so evanescent as to pass unobserved.\\nIn addition, these patients are usually depressed by fear of\\nconsumption from the frequent seminal losses, the dread of the\\npermanent destruction of their sexual powers, and the fear of\\ninsanity, which they have cultivated mainly from charlatans\\nadvertisements. The despair of these patients is not often over-\\ncome by the physician s assurances. They regain hope only\\nwhen they observe the beginning of relief from mechanical treat-\\nment. While this is pursued, the closest attention must be given\\nto the accessory treatment mentioned in Chapter VI.\\nSimulated Anterior Gonorrhoea. In some cases the com-\\npressor allows the secretion behind it continually to leak into\\nthe anterior urethra, giving the appearances of anterior ure-\\nthritis. The first urine then coming from the bladder may\\nwash out the entire urethra and thus be rendered turbid the\\nurine following, if it detaches no secretions, may be clear. But\\nthe last ounce of urine, forcibly ejected by the concluding efforts,\\nmay be rendered as turbid as the first, or more so, by the de-\\ntrusor s compression of the diseased organs. If such a patient s\\nanterior urethra is gently irrigated and then examined with the\\nurethroscope, it will prove to be perfectly healthy. Therefore\\nwhen a case of apparently chronic anterior urethritis does not\\nyield to irrigations, the cause may be found in the posterior\\nurethra.\\nIn an extreme case of such a condition, the urethroscope\\nfound the compressor bulging forward. Slight pressure upon\\nit with the distal end of the tube caused it to extrude enough\\nsecretion to nearly fill one fifth of the tube (30 F.).\\nStains on Linen. Numerous patients present stains on the\\ngarments as the only evidence of chronic gonorrhoea. When this\\nis the case, in most instances, all endeavors to strip a discharge\\nfrom the urethra either fail, or bring to the meatus, but not ex-\\npressible from it, only a slight excess of transparent moisture.\\nAlmost invariably these stains on the garments produce more\\nmental distress than the discharge did when it was copious, or\\nthe morning drop when it persisted.\\nA patient whose garments become the seat of such stains\\nuses every possible means to impress the physician with their", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0150.jp2"}, "151": {"fulltext": "CHRONIC GONORRHOEA. 141\\nimportance as evidence of grave disease. One patient, a not at\\nall ignorant practitioner, whom I had treated for chronic gonor-\\nrhoea, on returning from a visit at midnight, found several spots\\non his shirt flap when he undressed. He awoke me an hour\\nlater, and to prove that he was not cured produced the shirt,\\nwith assurance that he intended to commit suicide in my office.\\nThe color, shape, and appearance of the stains were utterly at\\nvariance with those that come from urethral disease. My pa-\\ntient was not convinced, however, until a microscopical examina-\\ntion, made at once, proved a complete absence of bacteria in the\\nstains, which, however, contained an exceedingly large number of\\nwell-formed spermatozoa. He subsequently married the lady\\nwith whom he had spent the evening; her exceedingly good\\nhealth and frequent pregnancies finally dispelled the doctor s\\napprehensions.\\nSome patients bring a formidable laundry bundle to show\\nthe harassing spots. One wore a shirt an entire week, during\\nwhich he examined it hourly while awake whenever he found a\\nstain, he encircled it with indelible pencil and in the circle marked\\nthe date and hour of its discovery. Other patients cut the\\nstained portions from the shirt flap and attach labels thereto,\\non which they write the same information. Impatience or\\nderision will not relieve the sufferer s mental distress; reassur-\\nances regarding eventual cure are equally fruitless. The pa-\\ntients will not obtain mental tranquillity until they cease to\\nfind the stains.\\nWhen the stains are due to an excess of urethral secretion\\nthey probably are expelled whenever the secretion has accumu-\\nlated in sufficient quantity to evoke slight, unperceived urethral\\ncontractions. The excess of urethral secretion may be due to\\nslight post-gonorrhceal urethrorrhcea, to infiltration of the mu-\\ncosa or of glands, or to stricture.\\nThe gross clinical differences between the stains on the gar-\\nments may be roughly tabulated as follows\\nStains from urethral Stains from drops of urine Seminal stains\\ndischarge: (as in after-dribbling,\\nfrom enlarged prostate, or\\nstricture)\\nCircular or ovoid. Irregularly shaped diffuse. Shred-shaped or band-\\nlike.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0151.jp2"}, "152": {"fulltext": "142 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nSmall, with sharply de- Large, with undefined edges. Elevated edges.\\nfined edges.\\nColor same throughout. Centre darker than periph- Varying thickness gives\\nery. deeper color in spots.\\nAs Diday has shown, the stains from urethral discharges,\\nvery soon after they escape, assume another color than that\\nwhich they had when leaving the meatus. In the little table be-\\nlow I have added my observations to those of Diday\\nA colorless discharge produces a starch-like stain.\\nAn opaline\\na\\na\\ngrayish\\nA white\\nu\\na\\nyellow\\nA yellow\\nn\\nn\\ngreen\\nA green\\nn\\na\\nreddish-brown\\nA red\\nu\\nu\\nmottled dark-brown stain\\nWhatever the origin of the stain, microscopical examination is\\nnecessary, not only for the patient s mental peace, but for diag-\\nnostic purposes as well. The stained spot is moistened with a\\ndrop of distilled water and rubbed upon a cover-glass. The\\nstain so transferred is air-dried, flamed, colored, and mounted\\nin the usual manner.\\nEven the most minute stains may contain gonococci there-\\nfore thej r should not be lightly considered.\\nThe treatment of the condition producing stains on the linen\\nmust be directed to its cause. The stains themselves, however,\\ncan be prevented from soiling the linen by keeping the glans\\ncontinually covered with cotton, as directed under anterior\\nirrigations.\\nUrethroscopic Findings. The conditions of the urethra\\nthat sustain chronic gonorrhoea are sketched in the Outlines of\\nUrethroscopy, Chapter XIII.\\nThe urine in chronic gonorrhcea is made the subject of\\nexhaustive discussion iD very many large scientific volumes.\\nManifestly, then, no more can be attempted here than very\\nrough outlines of the coarser manifestations that are accessible\\nto the beginner in practice and available for rapid office work\\nin large practice. The latter, however, cannot be complete or\\nsatisfactory without at least one assistant continually devoted\\nto microscopical research.\\nThe urine used for examination should be passed in the\\nphysician s office. For convenience, tubes should be kept in", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0152.jp2"}, "153": {"fulltext": "CHRONIC GONORRHCEA. 143\\nquantity as mentioned elsewhere (page 25). Previous to pass-\\ning the urine, the patient s prepuce, glans, and meatus should\\nbe cleansed with absorbent cotton soaked in boric acid, so that\\nthe urine first passed does not carry into the tube the secretion\\nof balanitis or the diversity of foreign bodies that are some-\\ntimes found about the glans. Among these Professor Guy on 1\\nenumerates mineral dust, coal, wool, silk, linen, hemp, cotton\\nthreads, bits of hair, feathers, grains of starch, etc. Some of\\nthese, by their presence, may prove decidedly misleading in\\nmacroscopical and microscopical examination of the urine.\\nThe presence of some of these objects, as visible to the un-\\naided eye as are the floaters mentioned on page 67, become of\\ndeep concern to a patient, who, like the majority, observes that\\nat each visit the physician carefully notes them. When they\\ndo not proceed from the urethra, they are easily eliminated by\\nthe preliminary cleansing mentioned above.\\nMalodorous Urine. This is frequently the first symptom\\nwhich patients observe. It sometimes has a fishy odor in\\nchronic posterior urethritis and in tumors of the bladder; an\\nexcessively aromatic odor after taking balsams (e.g., santal oil);\\na violet-like odor almost a perfume after taking turpentine\\npreparations, etc.\\nTurbid Urine. If the first urine is turbid it is generally re-\\ngarded as evidence of anterior urethritis. This, however, is\\nopen to error, as mentioned in connection with a consideration\\nof simulated anterior gonorrhoea. If washing out the anterior\\nurethra produces only clear wash-water and the first urine then\\npassed is turbid, disease of the posterior urethra is fairly well\\nestablished. If all the urine passed is turbid, it may be due to\\nan inflammatory disease of any part of the urinary tract, except\\nthe anterior urethra, whose pus is generally washed away with\\nthe first 150 cgm. of urine.\\nDonne s Test. If the turbidity is caused by pus, the addition\\nof a saturated solution of caustic potash and then twirling the\\ntube, will soon provoke that ropy separation which Donne, who\\ndevised the test, called snotty. This forcible term (rotzig)\\ndoes not seem to have yet found a more elegant and equally de-\\nscriptive English equivalent.\\n^uyon: Maladies des Voies urinaires, vol. i., p. 293, Bailliere, Paris,\\n1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0153.jp2"}, "154": {"fulltext": "144 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nIf bacteruria causes the turbidity, caustic potash will not sepa-\\nrate the clear urine, as above described.\\nPhosphaturia can show the urine just as turbid as in either\\nof the preceding conditions. A little nitric, hydrochloric, or\\nacetic acid will, especially after boiling the urine, clear it with\\nthe formation of bubbles, causing it to resemble champagne.\\nThis excess of phosphates may accompany the act of digestion,\\nespecially in dyspeptics it may follow mental exertion, anger,\\nfright, or apprehension; it is almost always present in prostatic\\nenlargement.\\nPerfectly clear and brilliant urine by no means proves absence\\nof disease. Centrifuging the specimen may reveal slight but\\npositive evidence that some part of the urinary apparatus is\\naffected.\\nShreds, fakes, f laments, granules in the urine are the symp-\\ntoms which bring patients to us long after other manifestations\\nof disease have passed. Roughly these substances found in\\nclear urine or in urine not so turbid as to conceal them, become\\nsmaller with approaching restoration to health. With Guyon\\nMaladies des Voies Urinaries and Guiard Les Urethrites\\nChroniques I deem the following general classification of\\nthese substances carried in the urine the most convenient for\\nordinary practical purposes\\nPurulent Filaments. Muco-Purulent Filaments. Mucous Filaments.\\nShort. Very much longer. Uniformly transparent.\\nMultiple. Less numerous, often have\\nends rolled into a ball,\\nor are serpentine.\\nOpaque. Yellowish. Not homogeneous, but No opaque spots,\\noften consist of thicker\\nspots, held together by a\\nmore transparent sub-\\nstance.\\nFall rapidly to bottom Sink slowly and remain Light; remain in the up-\\ndissolve readily and coherent a long time. per part or float on sur-\\nincrease turbidity. By twirling the tube face of the urine,\\nthey can be made to rise\\nfrom bottom.\\nEasily removable from More difficult to fish as Still more difficult to fish,\\nthe urine with plati- proportion of pus di-\\nnum loop. minishes.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0154.jp2"}, "155": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 145\\nPurulent Filaments. Muco-Purulent Filaments. Mucous Filaments.\\nEasily spread upon Tendency to roll into a Tendency to roll into a\\ncover-glass no ten- thick slippery heap or clear, thick mass on\\ndency to curl. serpentine mass upon cover -glass, where it\\ncover-glass. dries very slowly and\\nthen is barely recog-\\nnizable.\\nMicroscopically: Large Microscopically: Leuco- Microscopically: Never\\nmasses of leucocytes, cytes, often with equal exclusively mucus al-\\nfew epithelial cells, quantity of altered epi- ways have some epithe-\\nno mucus. thelial cells, englobed in lial cells, often also a\\na substratum of mucus. few leucocytes.\\nThe omission of bacteria from the microscopical findings in\\nthe above table is intentional. They require separate extensive\\nstudy. It must not, however, be forgotten that the heaviest,\\ncoarsest shreds may be free from gonococci, while the finest of\\nshort filaments may envelop an abundance of them.\\nThe other salient symptoms of chronic gonorrhoea are men-\\ntioned under the Complications of Gonorrhoea, on page 38.\\nIX. TREATMENT OF CHRONIC GONORRHOEA. 1\\nConsistent with the character of this little book, theoretical\\nconsiderations will here be entered into only so far as is neces-\\nsary to outline the principles upon which treatment is based.\\nFor the same reason, space cannot be given to even mention of\\nthe many authors names who have worked and are working so\\nefficiently for the clearer comprehension of chronic gonorrhoea.\\nNaturally no thought can be devoted to those who hopelessly,\\nfrom preconceived notions or from lack of energy and persist-\\nence, deem chronic gonorrhoea incurable.\\nIt seems in place here clearly to establish my position in\\nregard to what is called by very many practitioners the Valen-\\ntine method. The success obtained by those who followed my\\n1 This and the preceding chapter are somewhat elaborated, in accord with\\nthe results of two years increased study and experience, from my article\\non Chronic Gonorrhoea published in the Clinical Recorder for January,\\n1898.\\n10", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0155.jp2"}, "156": {"fulltext": "146 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nwritings on the subject makes this designation doubly flatter-\\ning to me. But those who employ the term, even for mere con-\\nvenience, do an injustice to others, principally Oberlaender of\\nDresden and Janet of .Paris. To Oberlaender belongs all credit\\nfor initiating and systematizing the use of dilators to Janet is\\ndue all credit for methodizing and popularizing irrigations in\\nthe profession. The study of and experience with both meth-\\nods led me to simplify and combine them. Since early in 1895\\nI began to teach the combination, but always emphasized the\\nfact that it is based upon combination and a series of modifi-\\ncations of the methods advocated by the gentlemen whose names\\nare mentioned above.\\nFor practical purposes it is convenient to detail the treat-\\nment of chronic urethritis, of which less than ten per cent, are\\nof other than gonorrhceal origin, in describing the instruments\\nemployed. The finer pathological considerations upon which\\nthe treatment is based can be studied in the more extensive\\nworks on the subject.\\nThe local treatment to be followed in a given case is pre-\\ndicated upon the conditions that present.\\n1. If the affection is superficial it will yield to irrigations,\\nas described on page 18. Ordinarily one series, requiring\\neight days of such irrigations, will suffice to cure the case. Oc-\\ncasion ally a repetition of this series of irrigations will be re-\\nquired.\\n2. If the urethritis causes structural changes of the mucosa,\\nor involves the deeper tissues, or has invaded the ducts of the\\ncrypts, glands and follicles of the channel, dilatations will be\\nrequired for their own effect. The manner in which these dila-\\ntations are performed is described on page 160 et seq.\\n3. If the urethritis depends upon invasion of the crypts,\\nglands and follicles, these will have to be slit, curetted, or de-\\nstroyed by electrolysis before the materies morbida they con-\\ntain can be liberated. Similar treatment is required when\\ndiverticula or false passages complicate the case.\\n4. If neoplasms are the cause of the urethritis, they must\\nbe removed in accord with modern surgical principles.\\n5. If the urethral adnexa are involved, they must be treated\\nas outlined under complications (Chapter VII.).\\nThe urethroscopist has a decided advantage over the phy-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0156.jp2"}, "157": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA 147\\nsician who does not use this instrument, which exposes to sight\\nthe urethral disturbance. The patient has still greater advan-\\ntage, for when the urethroscope is used treatment can at once\\nbe directed to the conditions found.\\nUntil the physician has familiarized himself with the ure-\\nthral appearances, his methods will necessarily be tentative.\\nThe diagnosis, then, being by a slow process of exclusion, is\\nobtained by successive failures in treatment.\\nSuperficial Invasions of the Mucosa. The quantity, color, and\\nconsistence of the discharge, the presence or absence of specific\\nbacteria, do not indicate the depth of the structural invasion.\\nThe epithelia contained in the discharge and in the urine, how-\\never, are valuable guides thereto but their differentiation pre-\\nmises a degree of special microscopical training whose acquisition\\ncannot be too highly recommended. The microscopical findings,\\nit must be remembered, are subject to great variability, often\\ndue to extraneous circumstances. Recognizing this, the most\\nexperienced microscopist will not decide on the absence of gono-\\ncocci, in a given case, before making at least ten examinations\\nof specimens, each taken at one or more days interval.\\nThe presence of many gonococci in a case of chronic ure-\\nthritis does not necessarily convey that the disease has made\\ndeep ingression, or that serious structural changes exist, or\\nthat the adnexa are involved. Obversely, a specimen containing\\nbut few gonococci does not bear evidence that the case is a light\\none, or that it will respond readily to treatment.\\nOrdinarily a patient, the superfices of whose urethra are the\\nsite of the disease, may be expected to recover promptly after\\none, or at most two series of irrigations. These failing, the\\nphysician who has not assured himself of the coudition by\\nmeans of the urethroscope must conclude that deeper tissues\\nare invaded, a fact which he could have established weeks be-\\nfore, had he examined the urethra. He will then proceed, as he\\nwould have done at once, to dilatations.\\nStructural Changes of the Mucous Superfices, the Deeper Tis-\\nsues, or the Gland Ducts. Despite the marked pathological differ-\\nences between the conditions here placed together, their grouping\\nis warranted by the fact that their efficient treatment is almost\\nidentical. As long as men have written on urethral diseases,\\ndrugs of all kinds have been proposed for the treatment of", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0157.jp2"}, "158": {"fulltext": "14:8 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nthese conditions and the others that maintain urethral dis-\\ncharges. The absurdity of expecting remedies injected into the\\nurethra to cure changes in its structure does not seem to be yet\\nquite evident to all. Indeed, even to-day a medical journal\\nrarely appears without at least mention of one drug or formula\\nadvocated to cure chronic gonorrhoea. Occasionally, in con-\\nsequence of vigorous advertising by the manufacturer, a drug\\nacquires considerable vogue for a while. Soon it sinks into\\nmerited oblivion, to which it is relegated even by those who\\nstrenuously urged it.\\nMechanical methods, too, have their advocates, and have had\\nthem for a long time. Many proved utopian, but most of these\\nhave the merit of leading to the use of dilators, which for fully\\nfifteen years have proven effective in the hands of those who\\nconscientiously employ them.\\nRegarding the dilatation treatment of chronic urethral dis-\\neases, Oberlaender 1 says: As to the principle itself, upon\\nwhich instrumental treatment is based, all agree that the pur-\\npose thereof is to stretch or burst infiltrations, be they hard or\\nsoft, by means of superficial or subcutaneous injury thereof.\\nHe further says that the end in view can hardly be attained\\nwith sounds, owing to the very frequent disproportion between\\nthe calibre of the meatus and the urethra. Moreover, the in-\\nsertion of sounds sufficiently large to produce an effect upon\\nthe diseased areas is often painful indeed even after the widest\\npossible meatotomy it is frequently infeasible.\\nSome of the above facts which Oberlaender mentions, led\\nhim to work for a number of years with insufficient spring in-\\nstruments. Accidentally an Otis divulsor then fell into his\\nhands in the course of time Oberlaender constructed a number\\nof modifications thereof, suited for every zone of the urethra.\\nWhile a sense of justice compels unsparing credit to Ober-\\nlaender for his modifications of the dilators and his systema-\\ntization of the treatment of chronic urethritis, and while he\\nmust be unqualifiedly acknowledged as the founder of the\\nmodern and rational treatment of this most frequent and erst-\\nwhile obstinate disease, an honest difference of opinion regard-\\n1 Oberlaender Die chronischen Erkrankungen der mannlichen Harn-\\nTohre. Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., Vogel,\\nLeipzig, 1894.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0158.jp2"}, "159": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 149\\ning the principle on which it is based may be allowed. Experi-\\nence and careful observation do not seem to make it necessary,\\nnor is it at all obvious from his practice and writings, that the\\neffect of dilatations is due to the stretchings or bursting of infil-\\ntrations. Their effect, on the contrary, seems due to the dynamic\\ninfluence which Guyon so graphically attributes to sounds that\\nlie loosely in a strictured or infiltrated urethra. It is within\\nthe experience of every practitioner that a urethra which\\neasily admits a No. 1, 2 or 3 E. sound will, if the sound is\\nleft in situ, allow a No. 5, 6, or larger calibre to pass readily in\\ntwenty -four hours. After the same interval the patient finds\\nthat he emits a larger urinary stream, with less need of aid from\\nabdominal pressure than before. The presence of the small\\nsound lying loosely in the stricture therefore must induce a\\nspecies of retrograde metamorphosis, if this term may be so\\napplied to the changes in the infiltration itself, that permit a\\npart of it to be carried off. Inadequate and elementary as this\\nexplanation is, it is offered as an introductory to the study of\\nthe dynamic influence (Guyon) of instruments in the urethra\\nand to the effect of dilators in chronic urethritis, as established\\nby Oberlaender. His terms to stretch and burst infiltrates\\nare thereby materially modified, as are whatever of violence or\\npainfulness they may convey. Indeed, he does the same thing\\nin urging gentleness in instrumentation and very gradual in-\\ncrease in dilatations.\\nThe gentleness necessary in dilatations is practically em-\\nphasized when a very narrow canal or urethral hyperesthesia\\nprohibits the introduction of a dilator. Either condition must\\nthen be overcome by the preliminary use of flexible bougies,\\nalways selecting one that will readily glide through the urethra\\nwithout producing pain. The limit of usefulness of these\\nbougies is reached, usually at 18 or 20 F. when an Oberlaender\\ndilator can be readily and painlessly inserted.\\nThe preparatory treatment of the urethra by flexible bougies\\nis subject to the same rules that govern the use of dilators. The\\npractitioner will do well, however, to recall the precautions\\nnecessary for aseptic and thorough, albeit painless work with\\nthese instruments.\\nPrevious to the introduction of any instrument, every effort\\nshould be made to prevent carrying with it infection into and", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0159.jp2"}, "160": {"fulltext": "150 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nfrom one part of the urethra to another. Naturally, in the light\\nof our present knowledge, no pretence can be made to rendering\\nthe urethra aseptic; yet every precaution must be employed\\nto reduce the danger of infection. CleansiDg, preliminary to\\nurethral instrumentation, is most easily performed by irrigation\\nof the channel as described on pages 12 and 18. When, as at a\\ndistance from the office, no irrigator is at hand, urethral wash-\\nings may be performed with large hand syringes, such as are\\nknown as the Guy on or Janet syringes.\\nDilators are inserted into the urethra in the same manner as\\nare most other instruments. The penis, held erect in the left\\nhand, causes the pendulous portion of the urethra to form an ap-\\nproximate right angle to the mesian line of the body. The fossa\\nnavicularis (scaphoid fossa) forms an obtuse angle with the ure-\\nthra. Therefore an instrument to easily enter the canal should\\nbe guided first through the fossa in the direction of its lumen,\\nthen turned upward, to pass into the urethra. It may meet an\\nexcessively developed lacuna magna, which may receive the\\npoint of the instrument, and, if violence is employed, expose the\\npatient to the dangers of urethral laceration. This danger is\\nthe greater the smaller the instrument employed. The lacuna\\nmagna is situated in the upper urethral wall therefore, to avoid\\nit, the instrument should here be guided along the floor of the\\ncaaal. All works on surgery that have been searched on the\\nmatter of urethral instrumentation, except a paper by Murcell, 1\\nurge that the passage of an instrument throughout the anterior\\nurethra must be along its roof, where it will meet with few or no\\nrugosities. In theory this course seems correct. But the sur-\\ngeon s concentration being directed to the roof of the urethra,\\nhe can allow the rugse of its floor to escape the attention of the\\ninstrument which at the time is prolonging his tactile sense.\\nMinute study and extended experience will make plain the great-\\ner safety and ease of adopting a diametrically opposite course.\\nThe smallest damage that can then be done is an interference\\nwith the easy passage of the instrument. This can be at once\\nremedied, and it will be almost automatically done, if the tip of\\nthe instrument is made to hug the floor of the urethra. Then\\nJ H. Temple Murcell: Some Points in the Diagnosis and Treatment of\\nUrethral Stricture. Treatment, July 27th, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0160.jp2"}, "161": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 151\\nthe most minute impediment to its onward course causes the\\nsurgeon to withdraw the instrument ever so slightly and point\\nits tip toward the roof enough to easily override the obstacle.\\nIn this manner urethrospasm, which would interfere with the\\nwork, is avoided, as is laceration of the urethra.\\nWe are also urged to avoid the floor of the bulbous portion\\nand the region beyond, as it is the urethra s least supported\\npart, and therefore the one most exposed to injury. Again, in\\nthis regard a difference in opinion and practice from that of our\\njustly most honored colleagues in the specialty, may be per-\\nmitted. Greater safety to the region lies certainly in seeking\\nit, with that exquisite gentleness which must characterize all\\ngenito-urinary work. Thus, if it be kept in mind that the sinus\\nof the bulb may be quite a pouch and this obstacle to the in-\\nstrument s progress be carefully sought, a slight withdrawal of\\nthe instrument and raising its point to override the opening of\\nthe pouch are more likely to lead to success than timorous\\navoidance of the region. When the compressor is passed, how-\\never, the point of the instrument must hug the roof of the pos-\\nterior urethra, which here is the channel s true surgical wall,\\nto avoid contact with the sensitive caput gallinaginis and the\\nmouths of the ducts that open in this region.\\nAll dilators, except those provided with an irrigating device,\\nare clothed with a rubber cover before their insertion into the\\nurethra. Excellent covers for all the dilators are made accord-\\ning to my directions, by the Miller Kubber Manufacturing\\nCompany, of Akron, Ohio. These covers differ from those of\\nEuropean manufacture essentially in being about one millimetre\\ngreater in calibre and in being finished with a smooth, instead\\nof a ribbed, surface. The greater calibre permits their easier\\nadjustment to and removal from the dilators; their smooth sur-\\nface makes the insertion of a dilator as painless as the correct\\nintroduction of a solid instrument with a highly finished,\\nnickelled surface.\\nClothing dilators with these new covers is performed by\\ngrasping the mouth of the cover with the left fingers and drawing\\nthe cover over the dilator. This can always be done with ease\\nif the cover is thoroughly dry. No attempt should be made to\\napply a cover if it retains the slightest moisture from steriliza-\\ntion.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0161.jp2"}, "162": {"fulltext": "152 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nAlthough the element of expense has no weight in aseptic\\nconsiderations, it is well to remember that the price at which\\nthese covers are furnished makes it quite an economy to throw\\nthem away after one use, in preference to devoting the time,\\nlabor, and cost of materials to their resterilization.\\nBut, unless the covers are bought in a sterilized condition\\nand enclosed in glass tubes, they should be sterilized before\\neach use. To this end they must be scrubbed in boiling water\\nwith soap, each one then wrapped in a sterilized gauze napkin\\nand boiled seven minutes in a one-per-cent. carbolic-acid solu-\\ntion. They may then be left to dry for use. Easier still is dry\\nsterilization in formalin fumes, after scrubbing with soap and\\nhot water. After sterilization and drying, if the wet method is\\nemployed, the covers must be placed in a long shallow glass\\nor porcelain tray, closed with a tight-fitting lid of the same ma-\\nterial. Beneath and upon each layer of sterilized covers a\\nliberal quantity of finely powdered, sterilized talcum is dusted.\\nIf the gauze napkin is left open at the orifice of the cover,\\nenough talcum will enter to keep its inner surface dry and facili-\\ntate its gliding upon and from the dilator.\\nAfter a dilator is clothed with its cover, the instrument is\\nstruck several times upon the gauze napkin that enveloped it.\\nThe napkin is folded or crumpled in the left hand to receive these\\nblows by means of which any talcum adhering to the cover s\\nouter surface is removed.\\nAfter clothing the dilator smoothly and assuring himself\\nthat folds are nowhere formed, the operator violently turns the\\nscrew at its handle, as if to forcibly burst the cover. When the\\nbranches of the dilator are so expanded to their fullest extent,\\nevery part of the cover is carefully examined for minute orifices.\\nIn new, well-made covers these will not be found. It is mani-\\nfestly better that, if a cover contains holes or can be burst by\\nthe dilator, this be learned before it enters the urethra. A de-\\nfective cover inserted would permit urethral secretions to enter\\nthe delicate joints of the dilator, and, what is far more impor-\\ntant, endanger the urethral mucosa to being grasped and injured\\nby the dilator s branches.\\nWhen the above tests of the cover s good condition are com-\\nplete, it is lubricated from its point to half an inch along its\\nshaft. The material experience has shown most useful for this", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0162.jp2"}, "163": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA.\\n153\\npurpose is lubrichondrin, made according to Professor Bangs\\ndirection. It is composed of the gelatinous substance of chon-\\ndrus crispus (Irish moss) to which eucalyptus oil 1:1,000 and\\nformaldehyde 1:1,500 are added. Lubrichondrin is sold in\\ncollapsible tubes and in glass-stoppered salt mouths. The\\nformer can be resterilized by boiling the closed tube in water.\\nIn using a tube its bottom is compressed to force out the con-\\nFig. 40.\u00e2\u0080\u0094 Lubricating the Meatus.\\ntents, of which the necessary quantity can be placed directly\\nupon the dilator cover. When the bottles are used, about a\\nsixth of a drachm of lubrichondrin is poured into a sterilized\\nPetri dish, whence it can be readily taken upon the point of the\\ndilator.\\nUnless the physician is ambidextrous, it will be well for him\\nto stand at the right side of the table upon which the patient\\nlies. The meatus being cleansed with cotton and bichloride,\\nand the urethra washed as directed in this chapter, the penis is\\nheld as before suggested, and a part of the lubricant smeared\\nupon and between the opened lips of the meatus by drawing\\none side of the covered dilator over them. Then the dilator", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0163.jp2"}, "164": {"fulltext": "154 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nmay be inserted. In doing this, no force whatever should be\\nemployed. When a dilator for the anterior urethra is used, it\\nis best held as if it were a pen grasped for writing. While fol-\\nlowing the suggestions before made, until the posterior bound-\\nary of the fossa navicularis is passed, the right hand exercises\\nFIG. 41.\u00e2\u0080\u0094 Oberlaender Anterior Dilator.\\na species of restraining force to prevent the weight of the in-\\nstrument violently plunging it into the urethra.\\nThe selection of a dilator is necessarily predicated upon the\\nlocation of the disease and the calibre of the urethra. If the\\nanterior urethra alone requires treatment and the urethral calibre\\nis still small, Oberlaender s anterior dilator is used. This in-\\nstrument has a slight curve near its tip, to readily accommodate\\nit to the normal curve of the anterior urethra. The tip is rather\\nsmall, permitting its insinuation through a stricture so narrow\\nthat it will let no instrument beyond 10 F. pass. The smallness\\nof the tip should be well kept in mind when using this instru-\\nment if the greatest of gentleness is not employed, it may en-\\ngage in a mucous fold, a wide open duct mouth, or a previously\\nmade false passage. The instrument will then not proceed.\\nThe slightest force employed is likely to produce serious ure-\\nthral laceration. When an obstacle of any kind impedes the\\neasy progress of the dilator, the instrument must be immedi-\\nately withdrawn and a successive systematic series of other\\ndirections given its point. With well-developed tactile sense,\\nhowever, the surgeon is enabled by gently touching all parts of\\nthe obstacle to form a clear mental picture of its character.\\nWhen the point of the instrument has found the correct urethral\\nlumen, it will easily, smoothly glide to its destination, unless\\nagain impeded by further obstacles. These then will have to\\nbe overcome in the same manner as the first.\\nGreater safety from injury to the urethra is obtained by in-\\nserting the Oberlaender anterior dilator by a technique similar\\nto that employed in introducing dilators for the posterior ure-\\nthra, which will be detailed in discussing these instruments.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0164.jp2"}, "165": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA.\\n155\\nThe curve of the Oberlaender anterior dilator being the nearest\\napproach to that of the anterior urethra therefore exercises the\\nmost direct pressure upon its roof and floor without distorting\\nthe canal. This consideration of the urethral curve is unneces-\\nsary when the channel is or has become sufficiently capacious\\nto easily admit the Kollmann anterior dilator, which is described\\nbelow.\\nThe steps of inserting the Oberlaender anterior dilator are\\nas follows\\n1. The patient lies on a firm table with his legs extended\\nand a sterilized towel placed upon his abdomen covering the\\npubis, another over his testicles and thighs. The penis rests\\nupon the latter towel.\\n2. After the penis has been cleaned, the glans is taken be-\\ntween the left thumb and index finger.\\n3. The penis is gently placed in the direction of the right\\nthigh, in a line continuing the left Poupart s ligament.\\n4. The clothed Oberlaender anterior dilator is then taken as\\nManner of Holding Dilator.\\nbefore described, like a pen, with the face of the dial resting\\nupon the interspace between the right thumb and index finger.\\n5. The tip of the instrument is inserted into the meatus.\\n6. After overcoming the angle at which the fossa stands to\\nthe urethra, the penis is drawn over the dilator, as a glove is\\ndrawn over a finger, but far more gently. The tip of the instru-\\nment is so guided along the floor of the urethra until the bulbous", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0165.jp2"}, "166": {"fulltext": "156 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nportion is reached. The surgeon then experiences a sensation\\nof reduced resistance at the instrument s point.\\n7. Without increasing the pressure, but keeping the tip im-\\nmobile, the surgeon carries the penis containing the dilator in\\nabout a three-quarter circle in the same plane, around and be-\\nyond the patient s left side, until the dial of the dilator faces\\nthe linea alba at its commencement above the pubis.\\n8. Keeping the tip within the bulbous portion, the dilator is\\nnow gently tilted from the floor to the roof of this region, and\\nFig. 43.\u00e2\u0080\u0094 Patient in Position During Dilatation.\\nthe penis with the dilator raised until it stands at right angles\\nto the body.\\n9. The patient s elbow, either right or left, is rested against\\nhis side to steady his arm. He is then asked to grasp the\\ndilator, where its cover projects from the meatus, and hold it\\nin this position.\\n10. If the dilatation is to be in prolonged session it will\\nmaterially contribute to the patient s comfort to raise the back\\nof the table to about forty-five degrees and elevate its feet. I\\nfind the tables made by the Allison Company most convenient\\nfor the purpose, as well as for all other genito-urinary work\\ndone in the office.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0166.jp2"}, "167": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA.\\n157\\nFurther manipulations with the Oberlaender anterior dilator\\ndo not differ essentially from those to be described in discuss-\\ning the other dilators.\\nKollmann s four-branched dilator for the anterior urethra is\\nintended for use when the urethra s capacity\\nis, or when previous dilatations have brought\\nit to 21 F. The technique of its employ-\\nment is the simplest of all\\ndilators. After the dilator\\nis clothed with its cover\\nand lubricated, the penis\\nis held in erect position\\nby the left hand. The di-\\nlator is slowly inserted,\\nobserving the general rules\\nbefore mentioned. The\\ndial may be placed in any\\ndirection, as the instru-\\nment when closed is per-\\nfectly round. The one of\\nchoice will naturally be\\nthat in which the light\\nstrikes the dial, so that\\nthe figures thereon can be\\neasily read.\\nOberlaender s Benique-\\ncurve dilator exercises\\npressure only within the\\nposterior urethra. The\\ntechnique of its insertion\\nis as follows\\n1. Follow all the steps,\\nfrom 1 to 8 inclusive, laid\\ndown for the introduction of the Oberlaender\\nanterior dilator.\\n2. When the tip of the instrument has been raised to the roof\\nof the bulbous portion, guide it gently through the compressor,\\nwhile letting the handle sink between the patient s thighs.\\nIn this motion, contact of the tip with the delicate and sensitive\\nstructures at the floor of the posterior urethra is avoided.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0167.jp2"}, "168": {"fulltext": "158\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nUndeniably brilliant results are obtained in affections of the\\nposterior urethra from the use of this dilator, without disturbing\\nthe anterior urethra. In the premature ejaculations due to\\nirritability of the posterior urethra from\\nmasturbator s chronic hyperemia, it often\\nexercises a decided salutary effect. But it is\\nnot an instrument that can be recommended\\nto any save those whom large experience\\nhas made familiar with intra-urethral work.\\nThe very great Benique curve, alarming\\n2 as it may appear to the patient, allows the\\ninstrument to lie very easily in the urethra,\\n1 without making any traction whatever upon\\n3 its normal bend. But this very curve and\\nits small tip make its introduction safe only\\nin trained hands.\\nKollmann s four-branched dilator for the\\n2 bulb and posterior urethra is a much safer\\ninstrument to use. It cannot, however, be\\nemployed through an anterior urethra whose\\ncapacity is less than 21 F. Its large tip ex-\\ns eludes the danger of injury, unless violence\\ni is employed. Its Guy on curve, about one-\\nhalf of that of the Benique, does not exer-\\ng cise any appreciable traction upon the ure-\\nthra, while its great weight adds to the\\nease of its introduction. The technique\\no thereof is the same as that laid down for\\nthe Oberlaender posterior dilator.\\nOberlaender s curved dilator for the pos-\\nterior and anterior urethra is used when\\nboth these regions require dilatation. The\\ntechnique of its introduction is identical\\nwith that directed for the Oberlaender Be-\\nnique-eurve dilator. The angle at which it\\nis depressed between the thighs governs\\nthe dilatation that is to be done within the bulbous portion or\\nbeyond. Dilatation of the anterior urethra is accomplished at\\nthe same time.\\nKollmann s four-branched Guyon-curve antero-posterior", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0168.jp2"}, "169": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA.\\n159\\ndilator is applicable when both urethras require treatment and\\npermit the passage of an instrument over 21 F. The technique\\nof its insertion does not differ from that before described for the\\ninstruments intended for these regions.\\nKollmann, whose ingeniousness seems to have no limit, also\\ndevised irrigating dilators (Fig. 49 and 50). They are used\\nwithout rubber covers. Surgical cleanliness of these irrigating\\ndilators is obtained, according to the author s directions, as\\nfollows", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0169.jp2"}, "170": {"fulltext": "160 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n1. Place the dilator into absolute alcohol for an hour before\\nuse then pass it over a flame, burning off all the alcohol that\\nadheres to it.\\n2. When the dilator has grown cool, stand it upright in a tall\\nvessel and force boric acid through its canals.\\n3. Previous to inserting it into the urethra, pass a sound\\nand leave it there for a few moments.\\n4. Anoint the dilator freely with glycerin before inserting it.\\n5. After use, scrub the dilator vigorously with soap and\\nwater. After having dried it, cleanse with benzin applied by\\nmeans of a tooth-brush, and then with absolute alcohol.\\nThese dilators, when inserted, have a short rubber tube at-\\ntached to one of their nipples and a long one to the other. The\\nshort tube is connected to a syringe by means of which the\\nirrigation fluid is forced through the dilator into the urethra and\\ngathered by outflow channels to the long rubber tube, which\\nconducts it to a vessel below the table.\\nIn exceptional cases this immediate combination of dilatation\\nand irrigation proves useful. But the instruments, from their\\nvery construction, require the hands of the specialist for their\\nuse.\\nThe technique of dilatations is the same for all dilators, viz.\\n1. After the instrument is in the necessary position, so that\\nthe region known to be diseased embraces the branches of the\\ndilator, it is held motionless long enough to allow the discom-\\nfort of its presence to pass off, if such discomfort is experienced\\nat all. This varies from a few seconds to half a minute. Dur-\\ning this time the penis is held steadily by the left hand and\\ndrawn out its full length, while the right hand keeps the dilator\\nimmovably in its position.\\n2. Grasp the penis with the four left fingers and palm, and\\nextend the left thumb to the ring at the dilator s handle, thus\\nholding both the penis and the dilator immovably together.\\n3. With the right thumb, index and middle fingers take the\\nlarge screw-head or disc at the handle of the dilator and very\\ngently turn it to the right. Continue this until the first slight\\nresistance to its easy progress is felt.\\n4. If the patient is not extraordinarily timorous, it will then\\nbe well to entrust the dilator to him for a few moments. It\\noccupies his attention and remeves any apprehension he may", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0170.jp2"}, "171": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 161\\nhave of pain that may be produced. At the same time it\\navoids cramping the surgeon s fingers which would interfere with\\nfurther delicate dilatations. The patient may be instructed to\\navoid cramp by holding the dilator with the other hand, when\\nthe one grows fatigued.\\n5. At the first seance leave the dilator at the first point of\\nresistance for from three to five minutes, unless an especially\\nspongy mucosa, as evidenced by bleeding, urethrospasm, hyper-\\nesthesia, or fear of pain, obliges its removal before.\\n6. Close the dilator s branches by very slowly turning its\\nscrew-head to the left. In doing so, watch the dial and turn\\nthe screw-head no further than to leave it open one-half or one\\nnumber E. to preclude the very remote and most unusual, but\\npossible, accident of a collapse of the rubber cover permitting the\\nbranches, if closed entirely, to grasp the urethral mucosa.\\n7. Kemove the Kollmann anterior dilator by drawing the\\npenis back with the left hand and at the same time drawing the\\ndilator from the urethra with the right. Kemove any one of the\\nother dilators by tilting the anterior margin of the instrument\\nas if to dip it into the umbilicus the penis will then drop be-\\ntween the legs, after the urethra has painlessly slid from the\\nrubber cover.\\n8. After each dilatation, irrigate the region that was invaded\\ni.e., after an anterior dilatation, irrigate the anterior urethra;\\nafter a posterior dilatation, irrigate the bladder. The solution\\nmost frequently employed for this purpose is potassium per-\\nmanganate 1 6,000. In some cases this proves quite irritating\\nafter dilatation; then it may be used at one-half this strength,\\nviz., 1 12,000 or four-per-cent. boric-acid solution may be sub-\\nstituted. When the urethra harbors many other bacteria besides\\ngonococci or without them, silver nitrate 1 5,000 or 1 3,000, or\\nstronger if it can be borne, will be found effective.\\nIrrigations should never be omitted after dilatations or in-\\ndeed any urethral instrumentation. Without them, the dis-\\ncharge is materially increased and often persists several weeks.\\nPain on and even between urinations may become quite severe\\nand all the appearances of a new gonorrhoea may set in. The\\ncause thereof is evident. If gonococci are squeezed from the\\nmouths of ducts or from structural interstices, they may infect\\nurethral regions that had returned to the normal state or that\\n11", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0171.jp2"}, "172": {"fulltext": "162 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nhad remained free from infection. The results of omission of\\nirrigations after instrumentation, if they portend nothing further,\\nwould entail a delay in dilatations until the reawakened acute\\ncondition has yielded to additional treatment.\\nBut another greater and more immediate danger attends\\nomission of irrigations that is, urethral fever catheter fever\\nIt will suffice to say here that since making it an inflexible rule\\nto irrigate after each instrumentation, not a single case of ure-\\nthral fever has resulted.\\nFrequently on the morning after a dilatation followed by\\nirrigation, the patient will find a slight increase of the discharge.\\nIf this continues until the second morning, the urethra should\\nbe again irrigated on that day rarely will a third irrigation be\\nrequired.\\nThe frequency of dilatations, the amount of dilatation and\\nits duration at each seance, must necessarily be governed by the\\ncondition of each case, the toleration of the patient, and the\\nresults of the preceding dilatations.\\nA good average working rule to keep within the limits of\\nsafety is (1) Begin with two dilatations weekly (2) increase\\neach dilatation one-half number F. over the preceding num-\\nber reached; (3) prolong each seance two minutes. The\\nlongest seance, however, a patient can generally endure is\\nforty -five minutes. Therefore when the seances have reached\\nthis limit, the dilatation desired must be attained within this\\ntime.\\nVariations from the above may become necessary\\n1. When the increase of discharge persists, as it may in\\nvery rare cases, beyond three days. It must then be controlled\\nby irrigations.\\n2. When marked improvement in the general and local con-\\ndition shows that the intervals between dilatations may be ex-\\ntended. Experience has shown that recurrences are most likely\\nto result when the intervals between treatments are too sud-\\ndenly made. Therefore the extension must be gradual. Thus,\\nfor instance, if a patient was treated on Mondays and Thursdays,\\nand it be determined on a Monday to extend the intervals be-\\ntween his visits, a risk would be incurred by asking him to omit\\nthe treatment for a week. Therefore the next appointment is\\nmade for Friday. If then he is found in continued improve-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0172.jp2"}, "173": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 163\\nment, the following visit is set for Wednesday, and each inter-\\nval increased by one day in this manner.\\n3. When it is found that the usual increase of dilatation by\\none-half F. over the preceding number, or even the preceding\\nnumber itself cannot be reached without producing even slight\\npain, the patient may explain the condition by an intercurrent\\ndigression into the paths of Yenus or Bacchus or both. With-\\nout such an occurrence the preceding dilatation may have pro-\\nduced a temporary swelling of the mucosa, which readily sub-\\nsides. The physician, when such an impediment presents,\\ncontents himself by dilating as much as possible, without pro-\\nducing any discomfort. He may confidently reassure the pa-\\ntient that the time lost by delay in progress or even in decrease\\nof the progress will be regained in a few sessions.\\n4. When a spongy mucosa, as shown by blood oozing from\\nthe meatus, a reawakened hyperesthesia or urethrospasm com-\\nmand the removal of the instrument before the time required\\nfor the day s dilatation, the latter must be abbreviated.\\n5. When a dilatation is followed by oozing of blood from\\nthe meatus, bloody urination, or pain, the subsequent dilatations\\nmust be increased by but a quarter number at each session. If\\neven this slow procedure is still followed by any of or all the dis-\\nturbances mentioned, it will be well to substitute flexible bougies\\nfor the dilator until the use of the bougie no longer produces\\nthe objectionable symptoms. The bougie selected must be five\\nnumbers F. less than the last dilatation. Thus if the number\\nreached by the dilator was 25, the bougie to take its place\\nmust be 20, or a size as much smaller as will glide through the\\nurethra easily and painlessly.\\nWhile, as a rule, the increase of dilatation at each session of\\none-half number F. is not interrupted, this increase should never\\nbe obtained by force. Nor should the beginner attempt to ex-\\nceed this, even when no resistance whatever presents thereto.\\nThose most experienced in dilatations prefer the slow progress,\\nbecause of the greater safety it assures.\\nThe best practice is to stop dilating at the number last\\nreached or at the first slightest resistance, and then at from three\\nto five minutes intervals to dilate at no more than half numbers,\\nor up to slight resistance, until the number desired for the day\\nis attained.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0173.jp2"}, "174": {"fulltext": "164 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nWhen a patient observes his improvement under dilatations,\\nhe is likely to urge more rapid advances than above directed.\\nSuch patients, when not watched, are tempted to surreptitiously\\ngive the dilator s screw-head a rapid turn. Those most prone\\nto thus viciously maltreat their urethras are physicians afflicted\\nwith chronic gonorrhoea. Until a locking device is invented\\nthat will prevent such patients endangeriDg their urethras, it will\\nbe well in their protection to refuse a continuance of treatment,\\nunless they pledge themselves not to interfere with the case.\\nBleeding to quite a considerable extent sometimes follows\\ndilatations, especially in the beginning of treatment. Such a\\nhemorrhage is usually of very short duration; if it threatens\\nto become excessive, the penis may be compressed by a bandage\\nuntil it ceases. Obstinate cases may require the pressure of a\\nsound within the urethra in addition to the bandage. This\\nfailing, very cold water passed through a psychrophore will, in\\nthe majority of instances, arrest the bleeding. In extreme cases,\\nsuch as are cited on page 77 (Complications), the urethra may be\\npacked in the manner there described. When bleedings to any\\nextent follow dilatations, it will be well to endeavor to control\\nerections by the treatment mentioned on page 47 (Chordee), lest\\nthe erections cause the bleeding to recur at night.\\nAs mentioned before, one of the results of dilatations is an\\nincrease of discharge on the morning following treatment, or its\\nrecurrence if no discharge existed. Oberlaender looks upon\\nthis as an evidence of the melting of infiltrations. However\\nthis may be interpreted, the discharge in a case that proceeds in\\nthe ordinary manner is less in quantity, thinner in consistence,\\nand lighter in color at each recurrence, until it ceases entirely.\\nThe products of inflammation that are carried off in the urine\\nbecome smaller and less in quantity. With these manifesta-\\ntions the general condition of the patient improves and local as\\nwell as reflex manifestations of disease fade away.\\nThe limits of dilatation and irrigation are reached when no\\nmore evidences of disease exist or can be evoked by the tests\\nmentioned in Chapter XIY. (The Proofs of Cure of Gonorrhoea)\\nThere are but few conditions in which dilatations are contra-\\nindicated. Decrepit persons, those in acute febrile conditions,\\nthose with large vesical tumors or with genito-urinary tuber-\\nculosis, or those in whom a severe posterior urethritis persists", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0174.jp2"}, "175": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 105\\nmust not be dilated. The last mentioned must be treated by\\nirrigations, or by Guy on s instillations of silver nitrate, until\\nthe condition of the posterior urethra ceases to be an impedi-\\nment to dilatations.\\nInvasion of the crypts, glands, and follicles was alluded to in\\nthis chapter under the third class of causes upon which the\\nchronicity of a gonorrhoea may depend. In such a case dilata-\\ntions and irrigations\\nwill have no appreci-\\nable or lasting effect\\nwhile these recesses\\nharbor infectious bac-\\nKollmann s Urethral Gland Syringe. teria. Any attempt\\nto treat such cases,\\nexcept locally, by means of the urethroscope, must be\\nabjectly hopeless.\\nAmong the many inventions for which the profession\\nis indebted to Kollmann are instruments for treating these\\ncases. His urethral gland syringe is the first to be con-\\nsidered. By means of this little instrument silver nitrate\\ncan be injected directly into the invaded glands, as they\\nare exposed by the urethroscope. These injections fail-\\ning to effect a cure, the glands can be evacuated by his\\nsharp curette. If curettage does not accomplish the de-\\nsired end, his electrolytic needle will effectively destroy the\\ninvaded urethral adnexa. For this purpose, the needle\\nis attached to the negative pole of the galvanic battery\\nthe positive electrode is placed firmly upon the thigh.\\nThe needle is then carefully inserted into the gland as deeply\\nas is possible without force the current is turned on very slowly.\\nAt two or three milliamperes, white bubbles will be seen rising\\nfrom the gland about the needle; as the instrument is sunk\\ndeeper and swept about the gland, these bubbles increase. The\\nsurgeon will have to estimate the manipulations required to\\nentirely destroy a gland. The time necessary varies from five\\nto fifteen seconds. The pain of electrolysis is easily borne by\\nmost patients. An exceptionally sensitive case may require\\ncocainization. To minimize the pain the current should not\\nbe made before the needle is inserted, nor should the needle\\nbe removed until the current is gradually reduced and finally", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0175.jp2"}, "176": {"fulltext": "166 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nbroken. Ordinarily not more than three or four glands can be\\ndestroyed at one seance even if the patient is willing to bear\\nthe prolonged pain, more such work would be inadvisable,\\nowing to the excessive reaction that would thus be produced.\\nThe greater ease and safety with which the glands can be de-\\nstroyed by electrolysis makes this method preferable to the\\nintraglandular injection and curettage before described. The\\nintensity of the reaction can be very much reduced, and often\\nFig. 52.\u00e2\u0080\u0094 Kollmann s Electrolytic Needle for the Destruction of\\nDiseased Urethral Glands.\\nentirely obviated, if each electrolytic seance is followed by an\\nirrigation, as should be every instrumental invasion of the ure-\\nthra.\\nNeoplasms of the urethra, mentioned in this chapter as the\\nfourth class of conditions that maintain a urethritis chronic,\\nare not amenable to treatment except by aid of the urethroscope.\\nWhen they take the form of growths upon the urethral surface,\\nthey must be removed, as directed under Complications (page\\n50) When they are interstitial as well as superficial, they ap-\\npear as dry, gray-looking cicatricial masses. Oberlaender\\nrecommends splitting these with his urethroscopic knife. The\\nnecessity of resorting to such incisions has not presented in my\\nexperience. Successive punctures of such infiltrates with Koll-\\nmann s electrolytic needle, each seance followed by an irriga-\\ntion, have thus far sufficed to gradually overcome them. The\\nobjective point is usually best attained by treatment twice each\\nweek, one seance devoted to electrolysis and the other to dilata-\\ntion.\\nInvasion of the urethral adnexa, placed in the fifth group of\\ncauses that maintain the chronicity of gonorrhoea, may present\\nas Cowperitis, vesiculitis, or prostatitis, or two or all of these.\\nTheir treatment is sketched under Digital Palpation of the\\nUrethral Adnexa, page 173-.\\nOver- Treatment. This cause for the continuance of a chronic\\nurethritis has not been considered in the foregoing groups.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0176.jp2"}, "177": {"fulltext": "TREATMENT OF CHRONIC GONORRHOEA. 167\\nYery few of the best-known authors give it more than casual\\nmention. Among these Furbringer emphasizes the fact that\\nthe urine will contain filaments as long as the urethra is dis-\\nturbed by instruments.\\nIf a urethra that had never been infected were subjected to\\npersistent instrumentation, even under the strictest aseptic\\nprecautions, it would sooner or later resent the intrusion, obedi-\\nent to the maxim ubi irritatio, ibi afftuxus if not otherwise\\nthan by irritative urethritis.\\nA urethra that was diseased and has recovered is necessarily\\nat least as prone to be affected by unnecessary treatment. If\\nall the tests advocated in Chapter XIY. (The Proofs of Cure in\\nGonorrhoea) yield a negative result, the physician will be justi-\\nfied in discontinuing treatment. But the exigencies of general\\npractice, among other reasons, prevent many physicians from\\nbecoming sufficiently expert urethroscopists, microscopists, and\\nchemical analysts of urine for this purpose. The test that then\\nmight suggest itself, would be to risk discontinuance of treat-\\nment, with intentions to resume it should evidences of disease\\nagain present. This would be as dangerous to the patient s\\nhealth as it would be to the physician s reputation. I believe\\nthat I have devised a fairly effective means of covering such cir-\\ncumstances this means is suggested when discussing the inter-\\nvals between dilatations (page 162). Naturally it will apply\\nonly when, for any reason, the direct and decisive tests of cure\\ncannot be made.\\nThis suggestion is that when marked improvement shows\\nitself, the intervals between treatments be prolonged one day\\neach. On the third day of the second month after instituting\\nsuch extension, the patient would have been eight days without\\ntreatment. If he continues to improve during this interval, the\\nnext one could safely be made twelve days. The improvement\\nstill continuing, the next interval could be eighteen days. This\\nwould bring the case to the third day of the third month of in-\\nstituting the prolongation of intervals. Thus increasing the\\nintervals between treatments by one-half each, after the eight\\ndays interval has been reached in the ordinary course, would\\nbring the next day of treatment twenty-seven days, or nearly\\na month from the preceding one.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0177.jp2"}, "178": {"fulltext": "168 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThen it will be found that\\nIf the Urethra is still Diseased If the Patient has Recovered\\nOn the day after treatment the discharge Recrudescence of the discharge may\\nmay become evident again. This continue, but not as many days as\\nmay continue several days. it would in a still diseased condi-\\ntion.\\nThe floaters in the urine may increase Floaters appear in the urine that was\\nin dimensions and numFer on the hitherto clear. They are, however,\\nday or for several days after treat- fine and few. They disappear soon.\\nment then they grow less in number\\nand smaller in dimensions, but do not\\ndisappear.\\nToward the end of the interval be- The discharge does not reappear, nor\\ntween treatments or before, the dis- does any abnormal moisture pre-\\ncharge or excess of moisture may re- sent at the meatus the floaters do\\nappear; the floaters in the urine not reappear.\\nbecome more numerous and more\\ngross.\\nFor the sake of emphasis it may be repeated that this means\\nof establishing the need of continuance or cessation of treatment\\nis exceedingly crude and prolonged, but it is offered to take the\\nplace of the other correct, scientific method when the latter is\\nnot available.\\nX. RECURRENT GONORRHOEA.\\nA deliberately intentional misnomer heads this chapter, for\\nthe purpose of grouping under it the recurrences of apparently\\ncured gonorrhoea without new infection.\\nA recurrence, with or without an exciting cause, soon or\\nmany years after a clap has ceased to produce any manifesta-\\ntions, is but a symptom of residual gonorrhoea. Until the loca-\\ntion of the residual (latent, quiescent) affection is ascertained,\\nthe disease cannot be cured, nor the patient relieved from its\\ndangers. It is this phase of gonorrhoea that has misled some\\ngood men to deem it an incurable disease.\\nRecurrent gonorrhoea certainly offers great menaces to the\\npatient and others, mainly because of the fancied security in\\nwhich the former lives. Deeming himself cured, he may marry\\nand infect his wife, or, with or without infecting her, the disease\\nmay recur in him so many years after the first or last attack\\nthat it had become but a dim shadow of the past. Unless it can", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0178.jp2"}, "179": {"fulltext": "169\\nbe made evident that lie reinfected himself, a family disruption,\\nbecause of the presumption of infidelity on part of either hus-\\nband or wife, with all its sad consequences, is prone to result.\\nThis is especially likely to be the case if gonococci are found\\nin the wife s genital secretions.\\nFew physicians indeed there are, in general practice or in\\nthe specialty, who have not seen such recurrences of gonorrhoea.\\nThey present the appearances of a new infection with some of\\nor all its symptoms and expose the patient to all its complica-\\ntions and sequelae.\\nThe recurrence of such an uncured gonorrhoea may be, as\\nsaid before, weeks, months, or many years after all manifesta-\\ntions of the disease have ceased.\\nThe exciting cause maybe: (1) Keduction of the patient s\\nresistance by a debilitating disease, by exposure to inclement\\nweather, by deprivation from proper food, by physical or mental\\noverwork, by prolonged grief or anxiety (2) prolonged excite-\\nment of the genitalia, or excessive intercourse (3) dietetic irregu-\\nlarity, such as drinking more beer or other stimulants than was\\nthe patient s custom; (4) a traumatism of the genitals, provok-\\ning an inflammatory condition; (5) examination of the prostate,\\nseminal vesicles, or Cowper s glands, when urinary disturbance\\ncauses the patient to seek professional advice (6) examination of\\nthe urethra, as, for instance, when a stricture has sufficiently\\nadvanced to impede the urinary stream; (7) marital reinfection.\\nWhatever the exciting cause, the gross manifestations of the\\ndisease may be so marked and the appearance of gonococci so\\ncharacteristic that the physician, unless he knows the patient\\nvery well, might believe, even if the patient is a colleague, that\\na new gonorrhoea has been recently contracted. While it is\\ntrue that the infectious incident may have been forgotten, it is\\nbetter to err on the side of charity and give the patient the bene-\\nfit of the doubt.\\nIrrigations, as described in Chapters III. and V., will, in the\\nmajority of such cases, bring about an abatement of the disease,\\nand often in a very few days. But the cause for its recurrence\\nremains and is likely to reproduce it at any time. Therefore it\\nbehooves us to study these causes now as far as is compatible\\nwithin the limits of this book.\\nWhen the recurrence is provoked by reduction of resistance", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0179.jp2"}, "180": {"fulltext": "170 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nfrom any cause, proper nutrition, protection from exposure to\\natmospheric inclemencies, abstinence from overwork must be\\nprescribed in addition to local treatment. Grief and anxiety\\nare, however, beyond the sphere of professional advice, unless it\\nbe in that sympathy and encouragement by which the physician\\nexercises his noblest duty.\\nIn addition, these cases will require tonics. After several\\ndays of treatment, microscopical examination of the discharge\\nand of the urine will serve as excellent guides to the locality of\\nthe residual infection. When the local manifestations have\\nsubsided or are reduced to a minimum, exploration of the ure-\\nthra and its adnexa will usually confirm the microscopical diag-\\nnosis. Before the case can be dismissed, these must be treated,\\nand after the proper interval, the patient submitted to the tests\\nmentioned in Chapter XIV. (The Proofs of Cure of Gonorrhoea).\\nThe second group of exciting causes of a gonorrhoeal recur-\\nrence are perhaps the most difficult to ascertain. Few married\\nmen, except those lacking culture or refinement, will confess to\\ngenital dalliance with a partly willing female, such, for instance,\\nas a well-developed, sensual-appearing servant. Yet some in\\nwhom the sexual sense, or lack of sense, is strongly pronounced\\nare guilty of such acts, in which they perhaps preserve them-\\nselves from the possible consequences of infection or the woman\\nfrom impregnation by abstaining from gratification of the so\\nstimulated impulse. A step further in this class is shown by\\nthose who indulge in psychic masturbation. They give way to\\ninvoked phantasms of sexual relations with women they see in\\npublic or even with creatures of the imagination. Whether\\nthese practices lead to appreciable ejaculation or only to its\\nverge, the effect of the hyperemia is the same.\\nThose who had sexual intercourse onceoftener than was their\\nhabit in a night can similarly produce an emptying of gono-\\ncocci that long have lain residual upon the urethral mucosa, or\\nstimulate them to renewed activity by the urethritis ex libidine\\nthat resulted.\\nThe irritated condition of the urethra which often obtains\\nfrom the excesses committed shortly after marriage may pro-\\nvoke a recurrence of gonorrhoea, if the husband s urethral ad-\\nnexa hold gonococci. An illustrative case may here be cited\\nA gentleman, aged 34, acquired gonorrhoea in his eighteenth", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0180.jp2"}, "181": {"fulltext": "171\\nyear. When he was twenty-eight he married, having had no\\nmanifestation of the disease for ten years. Shortly after his\\nmarriage, as so often happens, he had what appeared to be a\\nvery severe fresh attack of gonorrhoea. His wife was similarly\\naffected. Conscious that for six months before he had not ex-\\nposed himself to infection, and his wife but recently having been\\na virgin, he attributed their illness to that mysterious, albeit\\noften quoted cause, a strain, for which he sought no treat-\\nment until violent orcho-epididymitis bound him to his bed.\\nIt progressed to suppuration, which caused the destruction of\\none epididymis and testicle.\\nAfter this he had no acute evidence of disease until five\\nyears later. His wife then had returned home after an absence\\nof several weeks. Their first coitus was, within four days, fol-\\nlowed by acute gonorrhoea in both. Never having been guilty\\nof infidelity, he suspected her, with the usual result of a family\\ndisruption. This lasted until it was shown him that either or\\nboth could harbor gonococci for years without any appreciable\\nmanifestation thereof. In both, the disease yielded rapidly to\\nirrigations. The wife, on subsequent examination, was found\\nto be free from the disease. The husband, however, three\\nweeks after responding negatively to all tests, when examined\\nurethroscopically, showed some enlarged, gaping glands. Their\\ncontents being expressed with Kollmann s spatula, showed gon-\\nococci, which, with an adequately exciting cause, would have\\nsufficed to produce an apparently fresh clap. After electrolysis\\nof these glands the patient resumed relations with his wife and\\nhis usual mode of high living. Examination of the entire gen-\\nito-urinary apparatus six months later showed no abnormal con-\\ndition, except, of course, the destroyed testicle and epididymis.\\nThe third group of causes for the recrudescence of residual\\ngonorrhoea are those attributable to dietetic irregularities. A\\nglass of beer or wine in excess of the usual quantity drunk, or\\ningestion of the vegetables that provoke oxaluria or phosphaturia\\nin susceptible cases, may set up enough urethral irritation to\\nreproduce the discharge. In Germany the urethral irritation\\nfrom young white wine and beer is well-known to the laity,\\nwhence arose the familiar designation of Biertripper. In all\\nthe cases of this Biertripper I could examine gonococci were\\nfound; each of these patients, however, acknowledged having\\nhad gonorrhoea. No doubt can obtain but that such a distinct\\nurethritis occurs in cases that have never had gonorrhoea; it\\nhas, however, not been my fortune to meet one.\\nWhen such a urethritis db ingestis provokes gonorrhceal re-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0181.jp2"}, "182": {"fulltext": "172 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ncurrence, success in treatment naturally is predicated upon pro-\\nhibition of all irritating food, stimulants, and carbonated waters.\\nTraumatisms, mentioned before as the fourth class of causes\\nfor the recurrence of gonorrhoea, explain themselves. It is not\\nnecessary that the traumatism to the genitals be applied directly\\nto the region which harbors gonococci the inflammation result-\\ning can readily extend to it and there provoke the recurrence.\\nThe fifth division of cases in which a recurrence of gonor-\\nrhoea is provoked is distinctly due to the physician s inevitable\\ndiagnostic procedure, as shown by the following typical outline\\nA gentleman beyond middle life experiences gradually dimin-\\nishing propulsive ability in expelling urine. The physician\\nexamines his prostate, and in so doing makes pressure upon it.\\nWhile having his finger in the rectum, he completes his work\\nby examining the seminal vesicles and Cowper s glands. If any\\nof these adnexa harbor gonococci, from an infection of possibly\\nmany years ago, some can be emptied into the urethra by the\\nmanipulations necessary for a thorough examination. Ordi-\\nnarily the urethra is not infected thereby but if there be a point\\nof weakened resistance in the urethra, acute gonorrhoea can re-\\nsult from this mode of infection.\\nThe length of time in which gonococci can be harbored within\\nthe prostate, without in any way manif estating their presence\\nto the patient, is well demonstrated by the following extreme\\ncase\\nA gentleman had an attack of gonorrhoea in his eighteenth\\nyear. At twenty-six he married. His wife bore him two healthy\\nchildren. When he was forty-three years old, his wife, who\\nhad not become pregnant for ten years, was taken with salpin-\\ngitis at about the same time that he became affected with evidence\\nof prostatic enlargement, such as diminution of the force of the\\nstream, frequent nocturnal urination and inability entirely to\\nempty his bladder. Examination of the enlarged gland brought\\nforth a very small quantity of grayish muco-pus, which was\\nfound replete with gonococci.\\nSo here is a case in which, for twenty -five years, the prostate\\nheld gonococci without any manifestation whatever, not even\\npreventing the procreation of two healthy children.\\nIn the sixth class of cases auto-infection, from the use of an\\nexploring instrument to discover a stricture or a catheter to re-\\nlieve retention, is far more readily comprehensible. The instru-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0182.jp2"}, "183": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 173\\nmerit can impinge upon or scrape the mouth of an infarcted\\ncrypt, gland, or follicle and thus cause gonococci that have long\\nlain residual therein, to be set free upon the mucosa.\\nThe seventh set of cases, those in which gonorrhoea is due\\nto marital reinfection, are mentioned here only to remind the\\nstudent of such a possibility. The importance thereof will bet-\\nter be considered more in detail under Residual Gonorrhoea in\\nWomen (Chapter XII.).\\nThe means for the diagnosis of these conditions and their\\ntreatment are outlined under the respective heads.\\nNote The cases cited in this chapter are quoted from my\\nreport in the Atlanta Medical and Surgical Journal, for Sep-\\ntember, 1898.\\nXI. DIGITAL PALPATION OF THE URETHRAL\\nADNEXA.\\nAs has been mentioned under the Complications of Gonor-\\nrhoea, the posterior urethra, the prostate, and the seminal vesicles\\nfrequently become involved in gonorrhoea. Cowper s glands\\noften escape. If infection of one or more of these adnexa is\\nunheeded, the case is likely to be interminable, from uninter-\\nrupted or occasional reinfection of the channel, as gonococci are\\ncarried to it from the organs mentioned.\\nA greater part of each of these adnexa can be reached only\\nthrough the rectum by the finger, not alone for diagnostic, but\\nfor therapeutic purposes as well.\\nDigital exploration of the rectum, disagreeable and even\\npainful as it sometimes is, cannot be avoided in the diagnosis\\nand treatment of diseases of the seminal vesicles, the prostate,\\nthe base of the bladder, Cowper s glands, and the posterior\\nurethra.\\n1. Preparation of the Patient. Whenever possible, the ex-\\namination should be made soon after the patient has evacuated\\nhis rectum. The presence of fecal masses or of a column of\\nfaeces renders the examination more disgusting than necessary.\\nIt also has a tendency to divert the physician s attention from\\nhis objective points. Many patients, especially if they have\\nnot defecated on the day of the examination, at once have a", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0183.jp2"}, "184": {"fulltext": "174 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ndesire for stool when the finger is inserted. The straining in-\\ncidental thereto may thwart the effort at examination. This\\nmay go so far as to oblige an interruption of the examination,\\nthat the patient may go to the closet. The immediate resump-\\ntion of digital exploration thereafter is only a renewal of every-\\nthing unpleasant connected with the procedure. In such a case,\\nit is generally advisable to defer further examination to the fol-\\nlowing day. Of course such prorogation cannot be considered\\nwhen dealing with an acute case, or one* requiring immediate\\ntreatment, as in periprostatic or prostatic abscess.\\n2. When possible the patient empties his bladder, preferably\\ninto two or three twelve-inch ignition tubes. Into one tube he\\npasses 150 c.cgm. (about fl. 3 v.), which is estimated to carry\\nwith it all the washings from the anterior urethra that can be\\ndetached by the stream. The second, third, or more tubes,\\naccording to the capacity of the bladder and the time that has\\nelapsed since the last urination, should then be filled. The last\\n25 or 30 c.cgm. (about an ounce) should be voided into a sepa-\\nrate tube, to ascertain whether the final expulsive efforts cause\\nejection of the contents of the prostate or seminal vesicles, as\\nin urination-spermatorrhoea. As has been said before, separa-\\ntion of the urine in this manner does not serve for absolute\\ndiagnostic accuracy, but it often proves a valuable aid thereto.\\nNaturally, if the patient is severely strictured, or has incon-\\ntinence from any cause, or retention from a much enlarged pros-\\ntate, this preliminary step is omitted.\\n3. Distending the Bladder. When no contraindication\\nthereto exists, the bladder may be filled with a warm four-per-\\ncent, boric-acid solution. Besides distending the bladder for\\nthe purpose of facilitating prostatic examination, this is the\\neasiest means of ascertaining vesical capacity. Except where\\na large prostate acts as a dam for residual urine, the catheter\\nand hand syringe (such as the Guy on or Janet syringes) are\\npreferable for such measurement.\\nThe use of boric acid for this purpose has other advantages,\\nwhich will be mentioned further on (see 14).\\n4. Position. The method often advocated, of bending a pa-\\ntient over a chair or the end of a table, is unsatisfactory. It\\nobliges the surgeon to fix the pelvic viscera with his left hand,\\nadding to the severe labor by the then necessary support of the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0184.jp2"}, "185": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 175\\nabdomen. As many of the cases requiring examination and\\nmassage of the prostate are quite corpulent, their management\\nin this position becomes impossible. Moreover, in painful pros-\\ntatic conditions, it may cause a patient to faint, or in epileptics\\nmay provoke an attack during examination.\\nFor the above reasons and for convenience as well, it is best\\nto examine all cases with the patient lying on his back on a\\ncouch or table, the knees somewhat raised, and the heel of the\\nright foot resting in the hollow of the left. When the trousers\\nare then drawn down to the ankles, there will be no difficulty\\nin extending the knees as far apart as possible. A cushion\\nunder the buttocks is objectionable, as it throws the weight of\\nthe abdomen upward, which draws with it the pelvic viscera.\\nIn so doing it naturally renders the distance between the anus\\nand the prostate greater, and thus unnecessarily enhances the\\ndifficulty of examination.\\nInstead of a cushion, a towel should be placed under the\\nbuttocks and left there, while the shirt is drawn up to beyond\\nthe hips. Most prostatic patients are very susceptible to change\\nof temperature the towel will protect their bared nates from\\ncoming into contact with the cold leather of the table or sofa.\\nThe same towel should be used by the patient for cleansing\\nhis anus of the lubricant employed in the examination. The\\nmajority will appreciate this care for their comfort and the\\ncleanliness of their linen. They will also appreciate it highly if\\na clean towel is placed under their heads, so that the hair is pro-\\ntected from contact with the place where other patients have lain.\\nThe preference for a sofa over a table for prostatic examina-\\ntion lies partly in the fact that the familiar piece of furniture\\ninspires less dread than does the more strictly surgical imple-\\nment; consequently there is less likelihood of spasm of the\\nsphincter ani, which fear of pain is prone to induce. Again,\\nthe surgeon, being in the bent posture, can exercise greater\\nthoroughness with less manifestation of physical effort than he\\ncould if the patient were on a table.\\nIt is well to cover the lower third of the sofa with a tough\\nrug, as the position of the patient with his knees drawn up and\\nextended as widely apart as possible exposes his feet to slip-\\nping, and the sofa to being cut or at least mutilated by the\\npatient s heels.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0185.jp2"}, "186": {"fulltext": "176 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n5. Preparation of the Finger, For some time I used espe-\\ncially thin rubber cots to protect the index from contact with the\\nrectum. No matter how thin, they always, by their presence,\\nobtund sensation. Then, too, the thickened band at the open\\nend constricts the finger, and this, producing some numbness by\\nvenous stasis, also renders the touch less acute.\\nIn addition to thus reducing the finger s sensitiveness, these\\ncots are difficult to remove. Even slitting them with a probe-\\npointed knife does not prevent the fecal soiling one sought to\\navoid by their use, for it is but crowded down their slippery\\nsurface to the root of the finger.\\nAfter discarding the finger-cots I for a while used short\\ncondoms rubber caps, Eichelcondome, capotes anglaises).\\nThe touch through them was somewhat better than through the\\nequally thin cots. But their looseness about the finger often\\ncaused them to be swept off and left just within the sphincter\\nani. Attempts to fasten them with rubber bands produced the\\nsame constriction and consequent numbness which led the finger-\\ncots to be discarded. Moreover the manufacture, importation,\\nor sale of short condoms is forbidden by law therefore there is\\nsomething disagreeable in the necessarily surreptitious manner\\nof obtaining them.\\nThe use of common soap for the finger approaches perfec-\\ntion in rectal examination. The points most requiring protec-\\ntion are the sulcus beneath the nail and the matrix at its base.\\nOf course no one in active genito-urinary work thinks of begin-\\nning his day s labors without filing and pumice-stoning his nails\\nas close to the skin as possible. Still, a minute subungual\\nfurrow is inevitable, and it is in this furrow that the slightest\\ntrace of fecal odor makes itself so unpleasantly distinct, even\\nafter the most vigorous scrubbing. The rival of this spot for\\nfecal defilement is the slightly overhanging skin at the matrix\\nof the nail, which, despite the most assiduous trimming, cannot\\nbe kept down or even. Most genito-urinary practitioners who\\ntreat many cases daily, wash and scrub their hands very many\\ntimes during office hours. It is true that at one of the large\\nEuropean clinics I saw a gentleman with a little bowl before\\nhim, containing about eight ounces of 1 1,000 mercuric bi-\\nchloride solution. After each patient he dipped the tips of his\\nfingers into this bowl and dried them on a towel the one towel", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0186.jp2"}, "187": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 177\\nserving him for perhaps a hundred cases. That he did not\\ninfect himself or carry infection from one patient to another\\ncould have been but a matter of luck. The matrices of his nails,\\ntoo, were just as ragged as if he had used as much hot water\\nand soap as do others.\\nWhen soap is used to protect the finger, the cake should be\\nslightly moistened and then scraped with the index, in such a\\nmanner as to fill the matrix, as well as the interval between the\\nnail and the skin at the tip of the finger. But after this is\\nscrubbed off ever so vigorously and thoroughly, a match or\\ntoothpick scraped through these spaces will acquire a decided\\nfecal odor. This is possibly due to some of the excremental\\nconstituents penetrating the soap.\\nWhen soap is used for this purpose, the finger can be rid of\\nits bad smell by first thoroughly scrubbing it in intensely hot,\\nrunning water then crushing a few grains of potassic perman-\\nganate about the finger with the left hand. After the ozone-\\nlike smell of the permanganate becomes evident, the stain is\\nremoved with oxalic acid and numerous rinsings. The slight\\ncuts and chaps one occasionally acquires despite the greatest\\ncare then become too painfully evident to pass unobserved.\\nSince January, 1899, 1 have used flexible collodion for finger\\nprotection in rectal examinations of the genito-urinary adnexa.\\nIt covers the finger tip with a pellicle which, if properly ap-\\nplied, does not break within the rectum. It in no wise obtunds\\nsensation. The fingerfe els through it as acutely as if it were\\nnot covered at all. Only after the examination, when the finger\\nis vigorously scrubbed with soap and very hot water, does the\\ncollodion separate and then in large flakes. These flakes are\\nve or six times thicker than elsewhere, at the subungual space\\nand at the matrix, the very points most easily invaded by rectal\\ncontents. Any bits of collodion that may remain are quickly\\nremoved by a little ether, which also dissolves the fats that hold\\nthe minute fecal masses adherent to the finger. Thus cleanli-\\nness after rectal exploration is easily obtained.\\nThe best manner of securing a desirable coat for the finger\\nis by dipping it into an ounce salt-mouth containing the flexible\\ncollodion. As soon as the first coat has dried, a second and\\nfinally a third may be applied in the same manner. This will\\ngive additional security and not interfere with sensation.\\n12", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0187.jp2"}, "188": {"fulltext": "178 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nSpecial care should be exercised in not attempting to insert the\\nfinger before all parts of its collodion covering are perfectly dry.\\nIt may require several minutes to insure solidity of the little\\nblebs that form between the finger and the collodion. If these\\nare overlooked and the finger is inserted while they still exist,\\nthey will break in the rectum and produce severe burning as the\\nether of the collodion touches the mucosa. Besides the un-\\nnecessary suffering thus inflicted upon the patient, the points at\\nwhich the collodion has so been broken will cause it to peel off\\nin shreds and leave the finger exposed to contamination by the\\nfecal odor.\\n6. Protecting the Genitals. The patient being in position,\\nwith his trousers and drawers well drawn down to his ankles,\\nas described under 4, the surgeon raises the scrotum with his\\nleft hand, so that the genitalia be not unnecessarily soiled with\\nthe lubricant that is now applied to the collodion-covered finger.\\n7. Lubricating the Finger and Anus. When the entire right\\nindex finger is coated with collodion, as much lubrichondrin as\\ncan be taken up by it is placed upon the anus.\\n8. Inserting the Finger. Most of the works I have been able\\nto search are exceedingly meagre in their description of the\\nentire technique of rectal digital examination. The most ex-\\nplicit are Hoffmann, Guterbock, and von Frisch.\\nThe first says The examining index finger, its vola turned\\nupward, well oiled, is slowly inserted with gyrating motions,\\ninto the anus, after a thorough evacuation of the rectum.\\nGuterbock 2 offers but little more detail The oiled, care-\\nfully inserted finger feels, after traversing the excavation of the\\nrectum that lies closely over the anus, first the bulb which offers\\nsomewhat increased resistance.\\nThese directions certainly suffice for surgeons who have been\\nwell instructed. But not all have had the educational advan-\\ntages that make further details superfluous.\\nProfessor von Frisch, 3 who describes the lower rectal findings\\nEgon Hoffmann: Die Krankheiten der Prostata. Zuelzer and Ober-\\nlaender s Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., p. 3,\\nLeipzig, 1894.\\n2 Paul Guterbock Die Krankheiten der Harnrohre und Prostata, p. 203,\\nLeipzig and Vienna, 1890.\\n3 A. von Frisch Die Krankheiten der Prostata, Holder, Vienna, 1899.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0188.jp2"}, "189": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 1 1 9\\nmore in detail, offers the valuable advice that the hairs about\\nthe auus be separated before attempting to insert the finger.\\nThis additional precaution against giving the patient pain by\\ndragging the hairs into the rectum will be especially appreci-\\nated by those who have been examined before without this care.\\nMoreover, the examination will be easier to the physician be-\\ncause of the absence of the pain which dragging upon the hairs\\nwould produce and the anal rigidity it would evoke.\\nIt is hardly necessary to call attention to the need of care-\\nfully avoiding any fissures or erosions about the anus, lest pain\\nbe given and aggravation of these conditions produced thereby.\\nThe examiner s index finger, protected with flexible collodion,\\npenetrates the mass of lubricant he has placed upon the anus.\\nAt the moment of an interval between expiration and just before\\nbeginning inspiration, he allows the finger to glide into the\\nrectum. Any hesitation, gyration, or force will cause the pa-\\ntient to contract the sphincter and violently clasp the thighs to-\\ngether. The patient will certainly esteem more the efforts of\\none who, causing less or no pain, consequently performs better\\nand more thorough work.\\n9. Releasing the Scrotum. The left hand now being required\\nto fix the pelvic viscera, it allows the scrotum to fall gently\\ninto the space between the right thumb and the extended rignt\\nindex finger.\\n10. Fixing the Pelvic Viscera. The left hand is curved, the\\nouter margin of the thumb placed about half an inch above and\\nparallel to the pubis. By increasing pressure downward and\\nbackward, the pelvic contents are rendered as immovable as\\npossible and approached, as far as can be, to the finger within\\nthe rectum.\\n11. Raising the Perineum. When the index finger is about\\nto approach the mass of lubricant on the anus the middle, ring,\\nand little fingers are flexed when the index penetrates the rectum,\\nthe other fingers are tightly closed upon the palm. The dorsal\\naspect of their basilar phalanges presses against the perineum\\nas the index ingresses more deeply into the rectum. Mean-\\nwhile the forearm is depressed between the thighs until the\\nelbow almost touches the couch upon which the patient lies. As\\nthis is being done the perineum is crowded upward, the surgeon\\navoiding contact with the tip of the coccyx.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0189.jp2"}, "190": {"fulltext": "180 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n12. Position of the Thumb. If the thumb is doubled with\\nthe other fingers, it will be arrested by the ascending ramus of\\nthe pubis and thus materially limit the upward progress of the\\nindex within the rectum. When the hand is turned to avoid\\nthis, the knuckle of the thumb will impinge upon the anterior\\npart of the perineum and give the patient unnecessary pain. It\\nis therefore well to pass the thumb as high up as possible along\\nthe scrotum, while the index finger glides into the rectum.\\n13. Palpation. The index finger, as it progresses into the\\nrectum, ordinarily finds (a) the excavation of the rectum, almost\\nimmediately above the anus (b) the bulb which offers a some-\\nwhat increased resistance; (c) the pars nuda urethrse; (d) the\\napex of the rectal surface of the prostate; (e) the lobes of the\\nprostate.\\nEven a short index finger, when the proper technique is\\ncarefully followed, can pass its tip about the topmost margins\\nof the prostate and even beyond them, as in health the extreme\\nupper curves of the prostatic lobes are between 7 and 8 cm. from\\nthe external anal margin.\\nWith increasing practice the physician will learn to seek for\\nthe seminal vesicles and the ampullae of the vasa beyond the\\nprostate, and Cowper s glands below it, during the same rectal\\nexploration. Ordinarily these adnexa cannot be found in health.\\nIf prostatic enlargement always proceeded in its rectal direc-\\ntion alone, digital palpation would suffice for diagnosis. But\\nas the diseased prostate can increase in size in any direction,\\nother palpatory means than that furnished by the finger will be\\nrequired.\\nIn this a silver catheter with a short curve or with the\\nMercier beak will prove of valuable aid. If, the finger being in\\nthe rectum, such a catheter is inserted into the bladder, its tip\\nis distinctly felt as it passes through the bulbous portion and\\nwith equal distinctness as it penetrates the pars nuda. It then\\ndisappears until its tip proceeds just beyond the prostate. A\\ntight rubber band may then be slipped over the catheter just\\nwhere it emerges from the meatus, while the penis is crowded\\nas far back toward the pubis as possible. Then withdrawing\\nthe catheter, its point is concealed by the prostate from the\\nfinger in the rectum. Still further extracting the catheter, an-\\nother rubber band is slipped over its shaft at the moment when", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0190.jp2"}, "191": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 181\\nthe finger within the rectum first feels it in the pars nuda, be-\\nneath the prostate. The distance between the two rubber bands\\nwill give a sufficiently precise measurement of the length of the\\nprostatic urethra. This consequently will also reveal increase\\nin the length of the prostate.\\nThe thickness of the prostate and variations therein are dis-\\ncernible in the same manner. An aid to this is in close obser-\\nvation of the shaft of the catheter. Grossly it may be said that\\nthe less the prostate crowds into the bladder, the more will the\\nexternal end of the catheter point upward, and the larger the\\nprostatic ingression of the bladder, the more will it be inclined\\ndownward between the patient s thighs. Naturally this applies\\nonly when the shaft of the catheter has passed the prostatic ure-\\nthra.\\nThe cystoscope is doubtless the most valuable instrument\\nfor prostatic examination, when its encroachment is principally\\ntoward the bladder. But as cystoscopy is not within the prov-\\nince of the present effort, we may rest at its mention.\\n14. Emptying the Bladder. The discomfort at least, if there\\nbe no severe pain incidental to rectal palpation, ordinarily\\naffects the patient very much. Often the pupils will be found\\nquite dilated, the pulse weak, and respiration disturbed. Some\\nmen grow very pale and are suffused with perspiration in con-\\nsequence of the examination. It is well to have the patient\\nremain in the position of the examination, but with extended\\nlegs, for at least five minutes, or at all events until all symp-\\ntoms of the disturbance have passed off. He is then allowed to\\nrise, and, in order to divert his attention, he is ordered to cleanse\\ncarefully the region about his anus of the lubricant lest it soil\\nhis linen.\\nIt will be unwise to ask the patient to empty his blad-\\nder at once. The examination ordinarily produces a pro-\\nlonged spasm of the compressor, which does not subside for\\nfive or ten minutes, and only then can the patient void the blad-\\nder contents.\\n15. Microscopical Examination. When boric-acid solution or\\nsterilized water has been used to dilate the bladder, it shows by\\nits turbidity, when passed, that the prostatic contents or those\\nof the seminal vesicles have been pressed out during the ex-\\namination. If the palpation has been prolonged, the water", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0191.jp2"}, "192": {"fulltext": "182 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nmay also contain a little urine. Shreds from the bladder or\\nurethra may also float in the liquid. To complete the diag-\\nnosis, the fluid should be sedimented or centrifuged and ex-\\namined microscopically. By this means a guide to the organ\\naffected will be obtained.\\nIf the prostate is not so much enlarged as to preclude sepa-\\nrate examination of the other urethral adnexa that can be reached\\nthrough the rectum, these should be examined preferably a day\\nor two after each other. While their shape and gross changes\\ncan be elicited at one examination when extreme prostatic en-\\nlargement does not prevent, the contents expressed from them\\nare mingled in the urethra, and therefore the specimens obtained\\nmust be examined together.\\nThe technique of separate examination of each of the other\\nurethral adnexa is performed as follows\\n16. Seminal Vesicles. All the steps for examination of the\\nprostate are taken. The finger passes the prostate without\\nmaking any pressure upon it. Above the prostate and some-\\nwhat external to its sides, the vesicles project along the bladder.\\nIn health the vesicles cannot often be felt in disease they pre-\\nsent as somewhat enlarged sausage-shaped, soft or hard bodies.\\nOccasionally distinct knots are felt in them. Their stripping\\nor milking is performed by strokes similar to those used in\\nmassage of the prostate. Fuller s excellent work on Disorders\\nof the Male Sexual Organs (Lea, 1895) is devoted to the study\\nof diseases of the seminal vesicles, and to this work the reader\\nis referred for exhaustive information.\\n17. The Posterior Urethra. For examination of as much of\\nthe posterior urethra as can be reached through the rectum, the\\npatient s bladder is first irrigated until the boric acid used is\\nreturned perfectly clear. Then the bladder is filled with dis-\\ntilled water, and the patient prepared as for a prostatic examina-\\ntion. The examining finger, however, leaves the prostate without\\npressing upon it, and exercises all its pressure on such parts of\\nthe urethra as are exposed, endeavoring at each stroke to com-\\npress the urethra more closely against the pubis. The distilled\\nwater then passed will contain such shreds, flakes, filaments,\\nand granules as the urinary stream and irrigation could not de-\\ntach from the walls of the posterior urethra. While the pres-\\nence of gonococci in this expression fluid will serve to assist", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0192.jp2"}, "193": {"fulltext": "DIGITAL PALPATION OF THE URETHRAL ADNEXA. 183\\nin diagnosis, differentiation is not complete without urethro-\\nscope examination.\\n18. Gowpers Glands. Although these glands are not fre-\\nquently involved, their examination should not be omitted. In\\nhealth they are so minute as to be barely or not at all percepti-\\nble to the examining finger in the rectum. When it is engaged\\nbetween the internal and external sphincter, somewhat doubled\\nupon itself and carried forward in the direction of the perineal\\nraphe, at either side thereof, these glands will be found.\\nIn many cases of prostatic enlargement, of acute vesiculitis\\nor cystitis, the bladder will not tolerate the preliminary disten-\\ntion mentioned above. The examination then must be made\\nwithout this valuable assistance, and it consequently becomes\\nmore difficult.\\nIt is particularly when the bladder is dilated that some\\nof the contents of the adnexa escape from the meatus when\\npressure is made upon them. The discharge so obtained is\\nthen easily taken upon a cover-glass, and prepared for micro-\\nscopical examination.\\nMassage of the prostate and stripping the seminal vesicles for\\ntherapeutic purposes are performed in practically the same man-\\nner. The tip of the finger engages, as high up as possible,\\nthe organ to be treated. At first gentle, slow strokes downward\\nand toward the mesian line are made these strokes are gradu-\\nally increased in firmness and continued until the flattening of\\nthe organs shows that their removable contents are expressed, or\\nat least as long as the patient can bear the manipulation.\\nIn many cases the efficacy of prostatic massage can be en-\\nhanced by steadying the vesical side of the prostate by means\\nof a sound, preferably of the Guy on curve. It requires, how-\\never, some dexterity to so incline the sound laterally within the\\nbladder that it rests upon and thereby to a degree fixes the\\nprostatic lobe that is being treated through the rectum.\\nThe student need hardly be reminded that the first rectal\\nmanipulation is likely to be quite painful. Therefore extreme\\ngentleness is as requisite here as it is in all other genito-urinary\\nwork. The relief patients experience is in most instances so\\ngreat that they willingly submit to what soon grows to be a\\nmere inconvenience. Indeed, many of them urge its repetition\\nat shorter intervals than the judgment of the physician prescribes.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0193.jp2"}, "194": {"fulltext": "184: THE IRRIGATION TREATMENT OF GONORRHOEA.\\nOnly rarely can these organs bear massage or stripping oftener\\nthan twice or at most three times weekly. In exceptional cases\\ndaily massage may be required.\\nXII. RESIDUAL GONORRHCEA IN WOMEN.\\nGynecologists have, in recent years, well exposed the dis-\\nastrous consequences of gonorrhoea when it invades the womb\\nand the organs beyond. They have also shown how amenable\\nthe disease is to treatment before it has passed beyond the\\nvagina.\\nMany a woman, however, subjected to the older methods of\\ntreatment is only apparently cured. In consequence, she may\\nat any time near or remote, infect a man, if the circumstances are\\npropitious therefor. This form of the disease, which seems to\\nbe best denned by the term residual gonorrhoea, has appar-\\nently not received the attention in literature that its importance\\nmerits.\\nIn considering residual gonorrhoea in women, the disease\\nadulterously acquired by the husband or wife may, in certain\\ncases, be within the range of possibility. But adultery does not\\ncontribute to the understanding of residual gonorrhoea, unless\\nthe infection of the husband occurs long after all manifestations\\nof the attack have subsided.\\nAgain, the possibility of auto-infection on the part of the\\nhusband, who had gonorrhoea before marriage, as outlined in\\nChapter X., can explain a gonorrhoea in his wife, who may, if\\nthe husband is ignorant of such a possibility, be unjustly ac-\\ncused of infidelity.\\nThe field for speculation and theorization in this connection\\nis extremely wide, and most frequently no conclusions can be\\nreached therefrom. Certain facts, however, are known. Among\\nthese are the not inconsiderable number of women who marry\\nmen while the latter are not cured of gonorrhoea. Many of\\nthese women, for at least a period of their lives, enjoy a species\\nof immunity. Their resistance to gonorrhceal infection may at\\nany time become impaired by slight causes. If the case re-\\nceives prompt and energetic treatment, no residual gonorrhoea\\nwill result.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0194.jp2"}, "195": {"fulltext": "RESIDUAL GONORRHOEA IN WOMEN. 185\\nMany practitioners have been obliged to treat vaginitis in\\nrecently married women. Often this is so slight that it subsides\\nwith the employment of an antiseptic wash, a lead and opium\\nlotion, or injections only of hot water. Since familiarity of prac-\\ntitioners with bacteriological staining has become greater, many\\nof these cases are found to contain gonococci. Anti-gonorrhceal\\ntreatment being employed, the patients recover.\\nThe majority of brides, however, do not inform any one of\\ntheir ailments, which they conclude are the natural consequences\\nof sexual intercourse. In very many cases, especially if the\\nhusband is considerately abstinent for a while, the infection ap-\\nparently yields to the vis medicatrix naturce.\\nIn some cases the inflammation is so slight and its resultant\\ndischarge so scanty that, when gonococci are found in the mi-\\nnute excess of normal secretion, Guiard s blennorrhagie cJironique\\nd emblee is suggested.\\nMost Avomen, when brought for examination under suspicion\\nof having infected their husbands, will unhesitatingly acknowl-\\nedge having had leucorrhcea once or oftener in their lives.\\nSome, however, have had so slight vaginal discharges that they\\nattracted no attention because of that marvellous carelessness\\nregarding the genitals which so widely extends in all classes of\\nsociety. Whether these discharges were the result of gonor-\\nrhoea! infection or were leucorrhoeas due to other causes, is of\\ncourse impossible to determine after they have passed off.\\nThe cases that must be considered as residual present no ex-\\nternal manifestations whatever. The urethra, the labia, the\\nvagina, the cul-de-sac, and the os all appear perfectly normal.\\nIf consideration of the woman s health stops here, and the hus-\\nband is cured, he is likely at any time to again contract the dis-\\nease from his wife, without any crass evidences of the disease\\nbecoming manifest in her.\\nTo illustrate as graphically as is possible to me, the condi-\\ntions above outlined, I transcribe several typical cases from my\\nrecords\\nJ. B aged 35, banker, in apparent good health, with no\\nfamily or personal record of disease of any kind, was sent by\\na colleague on November 5th, 1897. The patient said that\\nfor three years he had been cohabiting with but one woman,\\nof whose fidelity he had no doubt. Three weeks before, he had,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0195.jp2"}, "196": {"fulltext": "186 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nfour days after intercourse, experienced slight burning on uri-\\nnation; soon a slight mucoid excess set in. The discharge\\nrapidly became yellowish, then greenish-yellow, mixed with\\nblood. With the increase of the discharge the pain on urination\\nincreased painful erections were almost continual every night\\nthe right epididymis was enlarged, not much hardened, but ex-\\nquisitely sensitive. The last-mentioned complication caused\\nhim to be referred to me. The patient had been treated by the\\ninternal administration of balsams and various hand injections.\\nOn examination of the discharge it was found to contain\\nvery little mucus, few leucocytes, few epithelial cells, and most\\nof these from the second layer of the urethra. Everywhere the\\nfield was thick with pus cells, of which many seemed ready to\\nburst from their repletion with gonococci. There were also\\nmany extracellular gonococci between the pus cells and some\\nattached to the epithelial scales.\\nIn brief, it was a distinct case of gonorrhoea. Irrigations\\nand strapping the testicle enabled the patient to be dismissed\\nfrom treatment on November 23d, 1897 i.e., eighteen days after\\nhis first visit. Beer and champagne did not reproduce the dis-\\ncharge injection of silver nitrate produced a non-microbic dis-\\ncharge lasting ten hours; coitus with a condom showed the\\nsemen to be normal; expression of the prostate and seminal\\nvesicles proved freedom from infection of these organs; these\\ntests were made a week apart. Then, a week later, a urethro-\\nscope examination showed a healthy urethra.\\nOn March 20th, 1898, the patient was again sent to me with\\nsome pain on urination, slight mucoid discharge easily express-\\nible from the somewhat tumefied lips of the meatus. The first\\nurine was turbid and contained coarse filaments, which sank\\nrapidly to the bottom. The second urine was clear.\\nMicroscopical examination of the discharge showed it to con-\\ntain several groups of intracellular gonococci.\\nThe patient assured me that he had cohabited with no other\\nwoman. His last intercourse had been four days previously,\\nbeing two days before she began to menstruate, at which epoch\\nshe was more than ordinately sensual. They had not committed\\nsexual excesses.\\nUnder irrigations this discharge and all other symptoms\\nceased in five days.\\nDuring this time he told me that his mistress confessed to\\nhaving been unfaithful to him about six months before, with a\\nmarried man, whom he knew. The one-time partner of his\\nmistress s favors confirmed her confession, but averred that he\\nnever had had any venereal disease.\\nI suggested that if my patient had never been infected be\\nfore, possibly his mistress had, previous to their acquaintance,\\nand that she might unconsciously be carrying a residual gonor-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0196.jp2"}, "197": {"fulltext": "RESIDUAL GOXORRHCEA IN WOMEN. 187\\nrhoea, which from the hyperemia incidental to the pre- and\\npost-menstrual days would become manifest. He then wrote\\nher, severing their relations. She came to his office and in tears\\nviolently protested against being cast off. In the heat of her\\nasseverations, she confessed to having cohabited with a number\\nof men, whose names she revealed, so that he might assure him-\\nself that none of them had been infected by her.\\nOn her insistence that she be examined in his presence, he\\nbrought her to me.\\nTo safeguard my pos-ition regarding what might otherwise\\nimply a violation of professional confidence, I asked whether\\nshe were willing that I tell him my findings in her presence.\\nTo this she promptly consented.\\nOn examination, I found her genitalia in apparently per-\\nfect health. Careful scrapings from the introitus, Bartholini s\\nglands, the meatus, the vaginal walls, the cul-de-sac, the cervix,\\nall showed normal epithelium, some mucus, and the usual vaginal\\nbacteria.\\nI then carefully irrigated the genitalia with hot boric-acid\\nsolution, sterilized ray hands, and packed the vagina with steril-\\nized cotton tampons soaked in sterilized glycerin. On re-\\nmoving these forty -eight hours later, I found a slight excess of\\nwhitish discharge upon the small tampon that had rested in the\\ncul-de-sac and some slight oozing from the os. Examination of\\nthese discharges, so evoked from the submucous layers, was\\nfound to contain distinct groups of gonococci.\\nThe patient then told her lover, in my presence, that about\\na year before she first knew him, she had had a slight vaginal\\ndischarge, which had been diagnosed as leucorrhcea; this had\\npromptly yielded to treatment. As an explanation for infecting\\nhim and not others, she offered that he was the only one with\\nwhom she experienced an orgasm, while she merely submitted\\nto the others for the sake of financial gain.\\nA similar case was brought me three years ago.\\nA young married woman infected her lover. She confessed\\nto having been cured of gonorrhoea acquired as a result of her\\nfirst adultery, while her husband was on a long voyage. He\\nwas never infected by her. She said that though her husband\\nwas sexually more potent than her lover, and physically better\\ndeveloped, he never produced an orgasm in her. This she at-\\ntributed to her dislike for him. Each coitus with her lover,\\nhowever, was complete.\\nExamination revealed an exceedingly slight endocervicitis\\nwhich, however, contained no gonococci. Only upon curetting\\nthe cervix, some discharge was obtained containing Neisser s\\nspecific microbe of gonorrhoea. In this case it seemed safe to", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0197.jp2"}, "198": {"fulltext": "188 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nsay that the spasm of the orgasm discharged in this instance\\ngonococci, which reached the lover s meatus.\\nIn a third case, seen with a colleague, the patient was a\\nyoung woman, who claimed to suffer from occasional eroto-\\nmania. When the condition was severe she assumed the part\\nof a prostitute. Frequent cohabitation did not relieve the de-\\nsire, unless the man s physique or mentality especially pleased\\nher. Then coitus produced an orgasm. She was sure, when-\\never this occurred, that she had infected the man. Her phy-\\nsician told me that she had sent him a number of patients, for\\nwhose treatment she had paid, whenever the patient would per-\\nmit it. She unhesitatingly related that she had had gonorrhoea\\nfour years previous to consultation.\\nExamination evinced no excess of secretion, but a thorough\\ncurettage revealed that the deeper uterine mucosa harbored\\ngonococci. This young woman, though continuing her course,\\nafterward infected no others.\\nA number of similar cases could be thus sketched to warrant\\nthe following deductions\\n(1) A woman can have residual gonorrhoea, without any ex-\\nternal manifestations. (2) A woman with residual gonorrhoea is\\nmore likely to infect a man cohabiting with her during the hy-\\npersemia immediately preceding or still remaining after men-\\nstruation. (3) The likelihood of infection is probably greater if\\nthe coitus produces an orgasm in the woman. (4) Packing the\\ncul-de-sac, as employed in the first case cited, may produce a\\nslight discharge, revealing the submucous habitat of gonococci.\\n(5) A submucous intra-uterine habitat of gonococci can be\\nreached only by thorough curettage. (6) No woman should be\\npronounced cured of gonorrhoea until the osmosis test men-\\ntioned above (4) has proved negative, and until expression of\\nthe urethra and Bartholini s glands, and scrapings from the\\ncervix and uterine lining are proven to be free from gonococci.\\nNote This chapter is elaborated from an article I contrib-\\nuted to the American Journal of Surgery and Gynecology (St.\\nLouis), May, 1898.\\nXIII. URETHROSCOPY.\\nAs has been repeatedly observed in the preceding chapters, a\\ndiagnosis of a chronic urethral disease cannot be even approxi-\\nmately complete without visual examination of the channel.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0198.jp2"}, "199": {"fulltext": "URETHROSCOPY. 189\\nObedient to surgical principles, no instrument may be in-\\ntroduced into the urethra while it is acutely inflamed. The only\\nexceptions thereto are when a foreign body requires removal or\\nwhen retention demands relief by the catheter, after other means\\nof voiding the bladder have failed.\\nIn Chapter VIII. (Chronic Gonorrhoea) mention was made\\nof the fact that without the aid of the urethroscope, all treat-\\nment of chronic urethral diseases must be tentative. With its\\nassistance, the diagnosis can be made early, the treatment di-\\nrected to the cause, and recovery expedited.\\nBut as easy as urethroscopy is, and as simple as its tech-\\nnique has become, it can be acquired only most laboriously\\nfrom written descriptions. The certainty of diagnosis it gives,\\nhowever, is worth all the efforts devoted to acquiring it. In\\nthis it does not differ from other instruments of precision, such\\nas the ophthalmoscope, the laryngoscope, etc., except that its\\nmanipulations are less difficult.\\nThe technique of urethroscopy can be most readily acquired\\nby a few lessons from a colleague, who has been properly in-\\nstructed. A recognition of the multifarious conditions seen and\\ntheir diagnostic interpretation can come only with experience.\\nAll efforts to pictorially present the urethral conditions have\\nhitherto failed, at least, in being of use to the beginner. The\\nessential difficulty seems in the reproduction of the colors,\\nwhich are seen in the urethra under electric illumination. The\\npictures lithographed all appear too lurid, when an attempt to\\nreproduce them is made. Exceptions thereto are the sectional\\ncolored pictures illustrating Oberlaender s 1 work, but as they are\\nschematic, showing the walls of the urethra in section, they are\\nof use only, and of most valuable use, to the urethroscopist of\\nsome experience. Kollmann s black and white photographs of\\nthe urethra are also invaluable to the advanced urethroscopist;\\nit would certainly be desirable if the method of photographing\\nthe urethra devised by him were in the hands of all genito-uri-\\nnary specialists, whose records and reports would be vastly en-\\nhanced in value thereby.\\nThe reasons wherefor the urethroscope is not more generally\\nused seem to be because: (1) Of the complicated character of\\n1 Oberlaender: Lehrbuch der Urethroskopie, Thieme, Leipzig, 1893.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0199.jp2"}, "200": {"fulltext": "190 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nthe instruments for direct illumination; (2) of defective light-\\ning; (3) of the high cost of the instrumentarium.\\nThe consequence is, that the treatment of chronic gonorrhoea\\ncontinues to be with some the most unhappy guesswork. To\\nothers it is a hopeless task, undertaken with misgiviDgs and\\ndiscarded in desperation. What wonder then that the quacks\\nmake this their favored field, to begin with promises, to end\\nwith the patient s purse The immense number of men whose\\nlives are rendered miserable and abbreviated by chronic gonor-\\nrhoea, make all efforts on their behalf, and on behalf of their\\nwives and children, worthy of most serious consideration.\\nManifestly then, an instrument is necessary to show the\\npractitioner the exact location and precise character of the dis-\\nease. The instrument must effectively do its work, must be\\nsimple in construction, easy of use, not prone to get out of order,\\nand always reliable.\\nIf the opinion of those who honor me by calling me their\\nfellow-specialist is a guide, as it is on other matters, all these\\nends are accomplished by the urethroscope I had the privilege\\nof publicly demonstrating for the first time before our Genito-\\nurinary Section of the New York Academy of Medicine on\\nMarch 14th, 1899.\\nThis instrument, made for me by the Electro-Surgical Com-\\npany, consists of urethrosbopic tubes, running from Nos. 24 to 32\\nFig. 53.\u00e2\u0080\u0094 Urethroscope Tubes.\\nF. In general appearance they differ little from the Nitze-Ober-\\nlaender tubes with burnished ends as modified by Kollmann.\\nThis modification permits urethral examination from behind for-\\nward as well as from before backward. The disc at the visual\\nend is, however, larger, to safely hold the spur for easy and firm\\nattachment of the light-carrier and the megaloscope.\\nEach tube is provided with an obturator, stamped on the\\nhandle to correspond with the tube to which it belongs. The\\ndistal end closes the urethral tube to permit its easy introduc-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0200.jp2"}, "201": {"fulltext": "URETHROSCOPY.\\n191\\ntion, and lias a deep slit corresponding with a similar slit in\\nthe handle. This slit permits air to readily enter the tube,\\nfacilitating the removal of the obturator by then preventing any\\nsuction upon the urethral mucosa.\\nFig. 54.\u00e2\u0080\u0094 Obturator.\\nThe light-carrier is a delicate but very firm strip containing\\nthe insulated wires that illuminate the lamp which is enclosed\\nin a glass capsule. By this means bright light is brought\\ninto almost immediate contact with the spots to be examined, be\\nthey ever so small. At its proximal end the light-carrier has\\nan expansion, which can readily be attached to the spur on the\\ndisc of the urethroscopic tube. From the expansion the in-\\nsulated connections for the conducting wires project, but are so\\nFig. 65.\u00e2\u0080\u0094 Light-Carrier.\\ncurved that they do not encroach upon the visual orifice of the\\nurethral tube.\\nThe light-carrier in general appearance resembles the one\\nused in the Nitze-Oberlaender urethroscope. It differs essen-\\ntially, however, in that the lamp gives no appreciable heat, and\\nconsequently requires none of the cumbersome water-cooling\\narrangements that are necessary when an uncovered light is used.\\nFurthermore, the lamp being fixed permanently at its end, is\\nnot exposed to twisting and short-circuiting, as happens almost\\ncontinually with what hitherto was the best instrument for direct\\nillumination. Nor is this lamp likely to burn out, unless the\\nmost gross carelessness is employed.\\nMoreover, the light being enclosed in glass, permits the lamp\\nto remain in place while swabbing the secretions from the urethra,\\nperforming cauterizations, slitting infiltrated glands, electrolysis,\\nfinding the opening of devious strictures, and every other diag-\\nnostic and remedial procedure, all under the guidance of sight.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0201.jp2"}, "202": {"fulltext": "192 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThe megaloscope is a series of lenses combined in a short\\ntube, attachable by a ring to the spur on the disc. By\\nmeans of the megaloscope, whose focus is easily changed, the\\nview of every part of the urethra can be im-\\nmensely magnified. The interspace between\\nthe visual orifice of the tube and the objective\\nend of the megaloscope is three-fourths of an\\ninch, to allow the introduction of instruments\\nfor operative procedures within the urethra.\\nThe urethroscope, with all the appurte-\\nnances described, is enclosed in a case, whose\\ntotal weight is about ten pounds. At the price\\nat which the fresh dry cells are furnished, the\\ncost of each urethroscopy is within half a cent.\\nThe foregoing shows that I have devised\\nonly improvements upon and mainly simplifica-\\ntions of existing instruments. This urethroscope\\nin its entirety, however, differs from the Nitze-\\nOberlaender apparatus in being easily transport-\\nable, thus making it unnecessary to reserve a\\nroom in the office suite for this purpose, or of having an urethro-\\nscope outfit for each room.\\nWhen science and benefit to humanity are objective points,\\nthe question of priority is of no importance. Still it may be\\nwell to sketch the history of this instrument. In 1894 1 expressed\\nto my friend and fellow-student, Dr. Henry Koch, the opinion\\nthat urethroscopy by direct illumination would not find favor\\nwith the profession unless the water-cooling arrangement could\\nbe dispensed with and the apparatus further simplified as to the\\nsource of illumination and in other regards. It seemed to me\\nthat the first step in this direction would be in the production\\nof a sufficiently small encapsulated light. Late in 1898 Dr.\\nKoch found that Mr. W. C. Preston could make such a light.\\nExperiments with it led me to suggest the construction of the\\napparatus above described. 1\\nThe technique of urethroscopy, as suggested before, is exceed-\\nFlG. 56.\\n1 As this book is going to press, Messrs. George Tiemann Company, of\\nNew York, are placing before the profession a urethroscopic apparatus embrac-\\ning all the improvements that continued study and experience have demon-\\nstrated to be necessary for aseptic, effective, and convenient work.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0202.jp2"}, "203": {"fulltext": "URETHROSCOPY. 193\\ningly simple. One demonstration usually suffices to impart all\\nits details. As, however, all cannot avail themselves of such\\npersonal instruction, an attempt is here made to substitute it,\\nas well as my descriptive powers will allow.\\nAnterior Urethroscopy. 1. Have the patient lie on an oper-\\nating-table, or sit on a high chair. The former is always pref-\\nerable, especially when an intra-urethral operation is to be per-\\nformed or when remedies are to be applied. When a chair is used\\nthe patient should sit as far forward as possible upon its front\\nedge, its back supporting his shoulders, and his legs wide apart.\\n2. Cleanse the foreskin, glans, and meatus thoroughly with\\nabsorbent cotton soaked in bichloride 1 6,000.\\n3. Select the urethroscopic tube that will readily pass the\\nmeatus. Those experienced in urethroscopy will have no diffi-\\nculty in doing this. The novice will do well to employ a Piffard\\nmeatometer, which often reveals that a meatus which appears to\\nbe very tight is rapidly, painlessly extensible so that it will\\noffer no resistance to a very large tube. On the other hand, it\\nwill often show that quite a large meatus is no guide to a very\\ntight posterior boundary of the fossa navicularis. In the latter\\ncase, a much smaller tube must be used or a preliminary deep\\nmeatotomy performed.\\n4. After cleansing the tube and obturator, pass each one\\nseparately through the flame of an alcohol lamp or Bunsen\\nburner. Then insert the obturator into the tube and pour gly-\\ncerin upon them until the tube, and especially the projecting\\ntip of the obturator, is thoroughly lubricated.\\n5. Take the penis in the left hand as for anterior irrigations\\nand wipe upon the meatus some of the excess of the glycerin\\nfrom the tube in the same manner as was recommended before\\n(insertion of a dilator, vide page 153).\\n6. Insert the tube gently, without any gyrating motions,\\nuntil it is arrested by the compressor urethrse or the anterior\\nlayer of the triangular ligament. If it does not proceed so far\\nwithout the employment of force, stricture or some other abnor-\\nmality obstructs its progress. Then a smaller tube must be\\nused. Only exceptionally is there any practical value in em-\\nploying a tube smaller than a 24 F., save by urethroscopic ex-\\nperts. A tube so large as to give pain or to produce excessive\\nbleeding thwarts the purposes of urethroscopy.\\n13", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0203.jp2"}, "204": {"fulltext": "194 THE IRRIGATION TREATMENT OF GONORRHOEA.\\n7. Withdraw the obturator, after giving it a slight turn in\\neither direction.\\n8. Dry the urethra of excessive secretions by gently mop-\\nping it through the tube by means of applicators wrapped with\\nabsorbent cotton. Uncut match sticks will be found most con-\\nvenient for this purpose.\\n9. Insert the light-carrier, and fasten it to the spur on the\\ndisc.\\n10. Attach the megaloscope when required.\\n11. Draw the tube slowly out of the urethra. As this is\\nbeing done all its parts fall into view. When one requiring\\nspecial investigation or treatment is met, bend the penis over\\nthe tip of the tube in the direction opposite to the side at which\\nthe point to be examined appears. This stretches the mucosa\\nat such a point for better examination or treatment. The fourth\\nor fifth finger of the left hand holding the penis can push the\\nurethra still further into view.\\n12. As an additional safeguard, it is well to irrigate the an-\\nterior urethra after a urethroscopy, as after any other instru-\\nmentation.\\nPosterior Urethroscopy. (a) Place the patient in the posi-\\ntion for perineal section.\\n(b) Perform the steps indicated above (1 to 6). When the\\ntip has reached the compressor make gentle pressure against it;\\nat the same time depress the tube between the thighs. Then,\\nwatching for the end of an expiration, gently thrust the tube\\ninward and slightly upward. Usually the grasp of the com-\\npressor is felt upon the tube for an instant immediately there-\\nafter it can be drawn forward and backward. This should not\\nbe done bruskly lest the tip injure the very sensitive posterior\\nurethra.\\n(c) Withdraw the obturator. This is usually followed by\\nsome urine.\\n(d) Dry the posterior urethra as much as possible with ab-\\nsorbent cotton wrapped about applicators, taking more care than\\never to use no violence. A little blood upon the cotton is, how-\\never, not unusual.\\n(e) Insert the light-carrier. Even if urine trickles into the\\nposterior urethra and out through the urethroscope, it will not\\nextinguish the light, as it would were an uncovered, incandescent", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0204.jp2"}, "205": {"fulltext": "URETHROSCOPY. 195\\nwire employed. The posterior urethra can consequently be\\nmost deliberately examined, its secretions mopped up, and ap-\\nplications made under the guidance of sight.\\nAn intravesical irrigation of potassium permanganate\\n1:6,000, or of boric acid four percent., should be used after\\nposterior urethroscopy.\\nUrethroscopic Diagnosis. The recognition of urethral dis-\\nturbances, like a knowledge of the urethra in health, cannot be\\nacquired, except most laboriously, from mere descriptions. Even\\nsuch graphic details as those furnished by Oberlaender, Koll-\\nmann, and Wossidlo are of use only to the urethroscopist\\nwhose eye has received some training. They then are invalu-\\nable.\\nStill, those who are prevented from obtaining personal in-\\nstruction in the urethroscopic appearances are entitled to such\\nguidance as is within the writer s power. To this end the fol-\\nlowing attempt is made.\\nTlie Urethra in Health. Even when observing most scrupulous\\nasepsis no physician will insert an instrument into a urethra\\nwhich he knows to be in health. But the practitioner may avail\\nhimself, for the purpose of studying the normal urethra, of a\\nclass of neurasthenics to whose general condition urethroscopy\\nacts as a most grateful placebo. No matter how perfect the\\ncondition of their urinary channels, nor how firm the physician\\nis in assuring them of that fact, they are satisfied and believe\\nthemselves improved with each urethroscopic examination.\\nThe study of urethroscopy on cadavers is absolutely useless.\\nCirculation having ceased, the natural color and consistence of\\nthe mucosa are gone and offer no means for comparisons.\\nA first glance into the normal urethra shows a red glare, re-\\ncalling one s initial effort at ophthalmoscopy. After some prac-\\ntice one learns to distinguish brilliancy, colors, folds, and striae.\\nThe normal central figure, as Oberlaender calls that part of the\\nurethra which presents when the tube is held in the exact axis\\nof the canal, merits study, as do the mouths of the crypts which\\nlater on become evident to the investigator. Under the megalo-\\nscopic attachment the submucous blood-vessels become visible\\ntheir normal or excessive tortuousness should receive heed.\\nEven with these premises it will be found that the urethra,\\nlike other organs, varies exceedingly within the limits of health.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0205.jp2"}, "206": {"fulltext": "196 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nThe Normal Anterior Urethra.\\nThe normal brilliancy of the urethra varies in its different\\nparts. The cavernous portion is so brilliant that it suggests\\ndisturbing reflexes. The fossa is perhaps almost as brilliant,\\nbut the paleness of its submucous tissues makes the whiteness\\nthereof more apparent.\\nThe normal color varies considerably. It may be ansemic,\\npale, or light pink; moderately hypersemic, roseate to red; hy-\\npersemic, intensely red.\\nThe normal folds vary with the calibre, thickness, and con-\\nsistence of the urethra. A narrow ansemic urethra shows slight\\nfolds or none at all while a wide, thick, coarse urethra contains\\nfive to eight more or less deep folds of mucosa.\\nThe normal strim appear as fine yellowish- white marks, radi-\\nating from the central figure upon the eminences of the folds.\\nThis striation is not found in all urethrse.\\nThe normal central figure suggests the opening of a rubber\\nspring tobacco pouch, where the distal end of the tube presses\\nagainst the mucosa by its weight. Ever so slightly drawing\\nthe penis out gives this region a funnel-like appearance, leaving\\nthe central figure somewhat smaller, and differing in various\\nparts of the urethra. Just behind the glans it appears as a\\nsmall round or oval opening, deeper within the urethra it looks\\nlike a closed dimple, and at the bulb its lower half arches for-\\nward.\\nThe Morgagnian Crypts.\u00e2\u0080\u0094 When drawing the tube out of the\\nurethra five to ten little shallow depressions fall into view, most\\nof them centrally located toward the upper two-thirds of the\\ncanal. These are the openings of the Morgagnian crypts.\\nThe megaloscopic attachment will considerably augment the\\napparent size of the above-described parts.\\nThe Normal Posterior Urethra.\\nThe caput gallinaginis (veru montanum, collicnlus seminalis)\\nis usually first seen in the posterior urethra. It is about the\\nsize of a split pea, semiglobular in shape, sometimes flattened\\nand smooth, sometimes elevated and with a furrowed surface.\\nIt is of the same red color as the surrounding mucous mem-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0206.jp2"}, "207": {"fulltext": "URETHROSCOPY. 197\\nbrane. Depressions suggesting crypts may sometimes be seen\\nabout it. These are the openings of the prostatic sinus, and of\\nthe prostatic and ejaculatory ducts.\\nThe sinus pocularis (uterus or utriculus masculinus) opens at\\nthe anterior declivity of the caput gallinaginis as a fine slit.\\nIt is a little sac, of a lengthened pear shape, which passes up-\\nward and backward to the base of the prostate and ends between\\nthe ejaculatory ducts. It may be materially enlarged, so much\\nso as to catch and arrest the progress of an instrument toward\\nthe bladder, if the instrument is not guided along the roof of the\\nposterior urethra.\\nThe posterior urethral funnel is very short.\\nThe lustre of the posterior urethral mucosa is less than that\\nlining the anterior urethra.\\nThe posterior urethral folds are so shallow as often to convey\\nthe impression of their entire obliteration.\\nThe anterior boundary of the posterior urethra is naturally the\\nposterior boundary of the anterior urethra. The withdrawal of\\nthe tube marks it clearly, not only by release from the tight grasp\\nof the compressor upon the tube, but also by the appearance\\nof the marked folds of the bulbous portion.\\nBleeding during posterior urethroscopy is not at all infre-\\nquent,^ especially when it is made for the first time.\\nUrethroscope Appearances.\\nFor the student s convenience, the appearances of the ure-\\nthra are here alphabetically arranged. No pretence to any-\\nthing more than a mere introduction to the study of urethro-\\nscope diagnosis is made.\\nBleeding in the posterior urethra occurs more readily than in\\nhealth from mere contact with the tube in the soft infiltration of\\nchronic posterior urethritis.\\nBleeding Spots. Where epithelial denudations have been\\nfollowed by slight granulations, these bleed easily.\\nBlood-vessels not visible in hard infiltrations.\\nBrilliancy (see Lustre).\\nCaput gallinaginis pale, yellowish color, lacks lustre, does\\nnot project, is not wrinkled, but is flat and smooth in hard in-\\nfiltration of the posterior urethra.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0207.jp2"}, "208": {"fulltext": "198 THE IRRIGATION TREATMENT OF GONORRHCEA.\\nCentral figure appears as a wide, often distorted passage in\\nhard (dry) infiltrations.\\nColor, dull gray in hard infiltrations.\\nCyanotic, purplish color of posterior urethra evidences soft\\ninfiltration.\\nDenudation, epithelial, in advanced inflammatory processes\\nand in superficial traumatisms of the mucosa.\\nDesquamation, epithelial, distinct, in hard infiltrations.\\nDesquamation, epithelial, slight, in somewhat advanced in-\\nflammation.\\nDull, dry epithelium with lack-lustre appearance, indicates\\nsubepithelial inflammation of the glands. Their orifices are\\nthen not visible.\\nDull, uneven mucosa, when in the first stage of inflammation\\nthe cellular infiltration is denser than ordinarily.\\nEpithelial denudation, in advanced inflammatory processes.\\nEpithelium desquamating (see Desquamation, epithelial, dis-\\ntinct and slight).\\nFolds absent in hard, dry infiltrations.\\nFolds grosser, thicker, coarser, broader and from four to\\nsix in number instead of from eight to twelve, in more dense\\ncellular infitration than usual in the early stage of inflamma-\\ntion.\\nGaping Glands. The orifices of Littre s glands and of the\\nMorgagnian crypts gape and are surrounded by a puffy, red,\\nprominent wall, forming a distinct boundary from the healthy\\ntissues, in the more severe forms of chronic gonorrhoea, with\\nconsequent infiltration around the crypts. Occasionally some\\nsecretion oozes from the orifices in this stage of urethritis\\nmucosae or soft infiltration.\\nGlands and crypts are always visible in first degree of hard\\ninfiltration as red inflamed spots.\\nGlands and crypts are not visible, or but very few appear, in\\nthe second variety of infiltration (dry infiltration), as their\\norifices are covered by epithelia and connective tissue.\\nGlandular Orifices. More are visible than in health, when\\nthe mucosa is diseased. When the epithelial layer of the mu-\\ncosa is destroyed, then the more deeply the mucosa is invaded,\\nthe greater is the exposed part of the glands. They appear\\nas minute red specks, mostly in groups. When the megalo-", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0208.jp2"}, "209": {"fulltext": "URETHROSCOPY. 199\\nscope is used, the glandular form and ducts are made plainly\\nvisible.\\nGranulations appear on spots that have been denuded of\\ntheir epithelium. They often bleed readily at contact with the\\nmargin of the tube.\\nGray Color. In hard, dry infiltrations the mucosa has a\\ngray color.\\nGrayish opaque veil covers mucosa in hard infiltrations.\\nHard infiltration is rare in the posterior urethra.\\nHard infiltration is the outcome of transformation of cellular\\ninto fibrous infiltration. Its urethroscopic manifestations nat-\\nurally vary as this transformation progresses.\\nHillocky mucosa is sometimes seen in hard infiltrations.\\nThe mucosa has lost its brilliancy and may distinctly des-\\nquamate.\\nInfiltration, hard, rare in posterior urethra.\\nInfiltration, soft, frequent in chronic posterior urethritis.\\nLittre s glands are grouped about the Morgagnian crypts.\\nThey are ordinarily not visible in health. The experienced\\nurethroscopist, however, employing the megaloscope, in many\\ncases can see the mouths of the normal Littre s glands and even\\npart of their ducts as they descend beneath the epithelium of\\nthe mucosa. The mouths of these glands may remain visible a\\nlong time after the urethra has returned to health. They may\\nalso be invisible in disease, if the pathological process occurs\\nsubepithelially. The form of disease affecting these glands,\\nwhether visible or not, shows its results upon the Morgagnian\\ncrypts.\\nSmall red points are the mouths of Littre s glands in simple\\nswelling.\\nLarge red points, projecting into the urethra, show that\\nLittre s glands are in a state of infiltrative inflammation. The\\nfibrillary connective tissue, always present in chronic gonor-\\nrhoea, is then formed about the ducts and bodies of Littre s\\nglands. This fibrillary connective tissue is caused by the finely\\ngranular infiltration of the acute inflammation.\\nLittre s glands are not visible in the dry form of hard infiltra-\\ntions. In this condition the epithelium looks dull (lack-lustre)\\nand dry, and desquamates in spots.\\nLustre apparently increased by liquid (glycerin, cocaine,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0209.jp2"}, "210": {"fulltext": "200 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nmucus, urine) left on mucous lining. To prevent error, the\\nsurgeon should attempt to remove the excessive lustre by care-\\nful use of absorbent cotton attached to applicators.\\nLustre decreased with increased infiltration and in epithelial\\ndesquamation, with or without infiltration. The brilliancy is\\nentirely lost in hard infiltrations.\\nLustre gone in epithelium covering glandular orifices, with\\ndull, dry appearance of mucosa, indicates subepithelial inflam-\\nmation of the glands.\\nLustre increased in subacute superficial urethritis. The mu-\\ncosa is congested and swollen from cellular infiltration.\\nLustre of posterior urethra increased in soft infiltration.\\nThe Morgagnian crypts are visible in all chronic diseases of\\nthe urethra, and are modified according to the intensity of the\\ndisease of Littre s glands. The mouth of a crypt is larger than\\nthose of the surrounding Littre s glands, often appearing as a\\nquite evident dark-red slit. The variations from simple swell-\\ning to infiltrative inflammation are similar to those which take\\nplace in Littre s glands. When the megaloscope is used, and\\nslight pressure made upon an opening of a crypt by bending\\nthe urethra, pus may be seen welling from the red slit. Its\\npatency gaping will then become more evident and show\\nthat it is not a tear in the urethra, but really a widely open\\nemunctory duct.\\nNeoplasms. The most frequent tumors of the urethra are\\npapillomata and fibrous polypi. Carcinoma of the urethra is\\nvery rare. Before Oberlaender diagnosed a primary carcinoma\\nof the urethra in 1893, the disease was only accidentally dis-\\ncovered in its advanced stages during an operation. Ober-\\nlaender s early discovery of this carcinoma enabled the patient\\nto be operated upon promptly. A year later no evidence of the\\ndisease had recurred.\\nOpaque grayish veil covers mucosa in severer forms of in-\\nfiltration.\\nPosterior urethroscopy is not permissible in acute or sub-\\nacute posterior urethritis, in tuberculosis, or in acute prosta-\\ntitis.\\nProminence, reddish, within the mucosa, with a central\\ndimple and invisible lumen, is seen when the inflammation has\\nbecome follicular. The finger can feel these encapsulated crypts", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0210.jp2"}, "211": {"fulltext": "URETHROSCOPY. 201\\nas small hard nodules. Their breaking down may produce\\nperi-urethral abscess.\\nPsoriasis mucosce iirethralis (Oberlaender) see White Patches.\\nPurple color, of posterior urethra see Cyanotic Color.\\nRed specks with swollen, puffy surroundings, occasionally\\nexuding a watery, milky, or purulent discharge, show in-\\nflammation of the Morgagnian crypts. See also Glandular\\nOrifices.\\nResistance to urethroscopic tube as it is being introduced is\\nfelt in hard infiltrations.\\nRigid Urethra. The denser the fibrous tissue in dry, hard\\ninfiltration, the more rigid does the urethra become in its fully\\ndeveloped form it shows white cicatricial tissue, spotted witli\\ngroups of red orifices of Littre s glands.\\nScaly and uneven epithelial layer in severe infiltrations.\\nSmoothness of epithelium lost in severer forms of infiltration\\nof the mucosa.\\nSpecks, red see Glandular Orifices.\\nSpecks, white\u00e2\u0080\u0094 see White Patches.\\nStria y almost or quite obliterated in dense cellular infiltra-\\ntions no vestige of them remains in hard, dry infiltration. In\\nsome normal urethrse the stria3 are absent.\\nSwelling of mucosa of posterior urethra in soft infiltration.\\nTransparency lost in hard infiltrations.\\nTumors see Neoplasms.\\nUlcerations due to epithelial denudations of inflammatory\\norigin are usually longitudinal. They may result from trauma-\\ntism produced by excessive or violent dilatation. Ulceration of\\na circular tendency may be chancre or chancroid.\\nUneven and dull mucosa in denser cellular infiltration, at the\\nfirst stage of inflammation.\\nUneven and scaly epithelial layer, in severe infiltration.\\nVeil,\u00e2\u0080\u0094 A thin veil seems to cover the urethra in hard infiltra-\\ntion in spots elevated scales present. These gradually heal.\\nWhite patches, irregular in shape from small specks to large\\npatches, called psoriasis mucosae urethralis by Oberlaender.\\nKollmann found these psoriatic pellicles to consist of cumuli of\\nfirmly agglutinated epithelial cells, whose nuclei stained dis-\\ntinctly with Bismarck brown. These epithelia were of polygonal\\npavement shape, rounded epithelia, and some high cylindrical", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0211.jp2"}, "212": {"fulltext": "202\\nTHE IRRIGATION TREATMENT OF GONORRHOEA.\\nepithelia as are found in the prostate. The course of this\\npsoriasis is very chronic.\\nNote This chapter is elaborated from the report of my first\\npublic demonstration, in the Journal of Cutaneous and Genito-\\nurinary Diseases for April, 1899, and from my article in the\\nJournal of the American Medical Association for September 7th,\\n1899.\\nXIV. THE PROOFS OF^ CURE OF GONORRHOEA.\\nTo secure a patient who no longer presents any tangible\\nevidences of gonorrhoea against auto-reinfection and possible\\ninfection of others, no case should be dismissed from treatment\\nuntil all the tests at present known have resulted negatively in\\nhis case.\\nFig. 57.\u00e2\u0080\u0094 Stripping TJretnra.\\nWhile most of these have been mentioned incidental to\\nother matters, all are here placed together for the practitioner s\\nconvenience. In describing them, a note is added to each test\\nof the errors that may thwart its purpose.\\nStripping the Urethra. Patients, especially those anxious to", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0212.jp2"}, "213": {"fulltext": "THE PROOFS OF CURE OF GONORRHOEA. 203\\ndemonstrate that they have recovered, squeeze the penis, some-\\ntimes quite violently, to prove the absence of a discharge. The\\nconformation of the organ renders this method futile in bring-\\ning to view any evidence of disease, even when the urethra has\\nan appreciable quantity that can be produced with the proper\\ntechnique, as follows\\n1. Best the four left fingers upon the outer side of the left\\ncorpus cavernosum, and the left thumb upon the opposite side,\\nthus endeavoring to approximate the corpora cavernosa to each\\nother and exercising a pressure, as if to squeeze the urethra\\nfrom between them.\\n2. With the bent right index finger press the peno-scrotal\\nangle backward as far as possible to the lower margin of the\\npubic arch. Firmly pressing the so bent finger upward and\\ncarrying this pressure steadily forward, any moisture thus ob-\\ntainable will be brought to the meatus. It is not at all rare that\\na large yellow, purulent drop replete with gonococci can be so\\nstripped from the urethra long after all discharge has ceased.\\nA great many patients, as anxious as the first mentioned,\\nbut in the opposite direction namely, to prove that they are not\\ncured acquire remarkable dexterity in maintaining an urethror-\\nrhcea by frequent strippings of the urethra. These can, at al-\\nmost all times, produce a transparent or translucent drop at the\\nmeatus. Its microscopical examination reveals mucus, urethral\\nepithelia, and occasionally some leucocytes.\\nIn either case, urethroscopic examination is required to de-\\ntermine the region or gland whence the drop comes, or to elicit,\\nin the second category of cases, whether the drop the patient\\nmilks from his urethra is due to general excessive juiciness of\\nthe canal. In the former the treatment mentioned in Chapter\\nIX. is applicable. But a patient who maintains the irritability\\nof his urethra by continual milkings is more difficult to manage.\\nArguments and persuasion are ordinarily of little avail; the\\nconviction that he is incurable is usually deep-rooted in his\\nmind, and is reinforced by each milking, wherein he persists\\nuntil the convincing drop is brought forth. A good method for\\nthe treatment of such cases is to irrigate the urethra with four-\\nper-cent. boric-acid solution and to order the patient, with a view\\nto diverting his attention from persistent milkings, to inject a\\ndrachm or two of the same solution several times daily, if he", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0213.jp2"}, "214": {"fulltext": "204 THE IRRIGATION TREATMENT OF GONORRHOEA.\\ncannot be otherwise dissuaded from the milking habit. One\\ncase, after all else had failed, was cured by the cruelty of paint-\\ning the lower half of his penis with cantharidal collodion. The re-\\nsultant blisters prevented his handling the organ for two weeks\\nthen they were permitted to heal. He did not resume the milk-\\nings, but persists in the firm belief that the blistering cured him.\\nPossible Errors. Stripping the urethra may fail to produce a\\ndrop or an excess of moisture from a diseased anterior urethra, if\\nthe patient has urinated within a few hours. In many cases it can-\\nnot be made evident at all, unless the examination is made in the\\nmorning, if the patient has not urinated since the night before.\\nIf the drop cannot be stripped out during the day, and if for\\nany reason the patient cannot be examined while his bladder\\nholds the night s urine, the patient should be given several\\ncover-glasses and be instructed to catch a small quantity of the\\nmorning drop upon one and press another cover-glass upon it.\\nThus the drop can be brought to the office for microscopical ex-\\namination. The fact that one specimen is found to be free from\\n1 gonococci does not prove their absence. It will always be best\\nto make ten such examinations, two or three days apart, before\\nfinally concluding that the morning drop contains no bacteria.\\nEven then it is by no means safe to declare the patient unable\\nto infect others or to reinfect himself. Gonococci may be resid-\\nual in some part of the urethra, and by their presence pro-\\nvoke the non-bacterial drop. Therefore this test cannot be\\naccepted as final, nor can the case be pronounced cured, until\\nall the tests here recited have proven the absence of gonococci\\nand the healthy condition of the urethra and its adnexa.\\nThe Urine. Whenever possible, examination of the urine\\nfor evidences of urethral disease should be made before the\\npatient has passed any part of his night s accumulation in the\\nbladder. Ordinarily 1 it is assumed that the first 50 c.c. passed\\nin the morning suffice to wash out the anterior urethra. This\\nquantity, however, does not seem sufficient in all cases. There-\\nfore it is best always to have the patient pass first 150 c.c. into a\\ntube as directed (on page 25) in Chapter IV. and to pursue the\\nother steps there directed.\\nPossible Errors. On centrifuging clear urine, a deposit may\\nPosner: Diagnostik der Harnkrankheiten, Berlin, 1895.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0214.jp2"}, "215": {"fulltext": "THE PROOFS OF CURE OF GONORRHCEA. 205\\nbe obtained. If not, a few drops of alcohol added to the speci-\\nmen will, on second centrifuging, throw down a slight deposit.\\nIn case this deposit, microscopically examined, shows thinned\\nepithelium with very faint nuclei or none, the patient should\\nbe warned that an infiltration is at least beginning, and that he\\nmust be at once treated by dilatations lest he become a victim\\nof stricture and all it portends.\\nFilaments, flakes, etc., have been discussed in other parts of\\nthis book (see page 144).\\nRamonage. The great master Guy on suggests this method\\nof obtaining specimens from the deeper urethra for microscopic\\nexaminations. It consists in anointing with glycerin as large a\\nbougie-a-boule as can be easily introduced. Immediately upon\\nits withdrawal from the urethra, the substances that adhere,\\nespecially to its shoulder, are removed for examination.\\nThis bougie may, however, fail to bring with it any patho-\\nlogical products. Owing to a possible excess of glycerin or an\\nover-juicy urethra, evidences of disease may be swept from the\\nbougie before it is entirely withdrawn. Still, in the majority\\nof cases it will be well to examine the substances adhering to\\nthe bougie, even when the purpose of its use was only to search\\nfor infiltrations, stricture, etc.\\nScraping the urethra is performed by holding a platinum\\nloop in the alcohol or Bunsen flame until it is red hot, and,\\nwhile not permitting its sterility so obtained to be impaired\\nby contact with anything, to allow it to cool. Then, holding\\nthe penis as for stripping (vide Fig. 57) the cooled loop is gently\\npassed into the urethra. As it is drawn out it is pressed against\\nthe urethral walls sufficiently to detach some of the adherent\\ncontents. They will at least fill the eye of the loop. Striking\\nit upon a slide or upon a cover-glass furnishes a specimen for\\nmicroscopical examination.\\nAfter each such scraping the loop must be thoroughly re-\\nsterilized by flaming, lest by it the next case so examined be in-\\nfected, or, at least, the specimen taken from him be vitiated.\\nSwabbing the Urethra. When the urethral excess is too\\nminute to be obtained by ramonage or scraping, sufficient moist-\\nure can be swabbed therefrom for examination. The swab is\\nmade by tightly wrapping a small quantity of borated cotton\\nupon a sterilized platinum loop then lighting the cotton in the", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0215.jp2"}, "216": {"fulltext": "206 THE IRRIGATION TREATMENT OF GONORRHOEA\\nflame and instantly blowing it out. A light rap with the handle\\nof the loop upon a finger will cause the charred parts of the\\ncotton to drop off. This swab may then be used without a\\nlubricant to obtain a specimen. Its employment is naturally\\nlimited to the anterior third or half of the urethra.\\nResidual Posterior Gonorrhoea see Chapters IV., VIII.,\\nand X.\\nExpression Urine. The patient is laid upon a table and the\\nindex finger, prepared as directed in Chapter XI., is well an-\\nointed and inserted into the rectum. Avoiding the prostate,\\nthe pulp of the finger presses upon the posterior urethra by\\nstroking it firmly from above downward against the pubis.\\nThe urine accumulating during this process will contain as\\nmuch evidence of posterior urethral disease as can be detached\\nby this method.\\nInfection of the Prostate, Seminal Vesicles, or Cowper s Glands.\\nStripping these adnexafor the purpose of obtaining specimens\\ntherefrom is described in Chapter XI.\\nPossible Errors. No attempt should be made to obtain speci-\\nmens from the posterior urethra or the prostate, seminal vesi-\\ncles, or Cowper s glands, at the same examination, lest their\\ncontents intermingle in the urethra and thus give no positive\\nindications regarding the region infected.\\nBeer Test. A week after all evidence of gonorrhoea has\\nceased the patient is ordered to drink, in the evening, double\\nthe quantity of beer or champagne he was in the habit of con-\\nsuming before they were forbidden him. This may, within\\ntwelve to thirty-six hours, produce a discharge, if any disturb-\\nance exists. Microscopical examination of the discharge will\\ndecide its character.\\nSilver and Bichloride Tests. When the beer- test fails to pro-\\nduce a discharge, an irritant irrigation of the anterior urethra\\nwith silver nitrate one per cent, or corrosive sublimate 1:5,000\\nwill evoke one, lasting from eight to thirty-six hours. If the\\ndischarge so established contains gonococci, they most probably\\nbut not positively are located in the anterior urethra.\\nCondom Test. The other tests having resulted negatively,\\nthe patient is advised to use a condom at his next sexual inter-\\ncourse and to bring it with its contents for microscopical ex-\\namination. It is most likely to contain, in addition to semen,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0216.jp2"}, "217": {"fulltext": "THE PROOFS OF CURE OF GONORRHOEA. 20T\\nsome of the contents of the urethral mucosa and its glands, as\\nwell as any bacteria the reproductive apparatus may harbor.\\nThe various local tests suggested must then be employed to de-\\ntermine the region in which the bacteria are held.\\nIt would go beyond the province of this effort to discuss the\\nmorality of advising a patient to cohabit or to use a condom.\\nThe majority during the acuity of their sufferings invariably\\nforswear sexual relations during the remainder of their lives.\\nAs a rule, the more vehement their asseverations in this regard\\nthe sooner will they again seek sexual gratification, often during\\nthe period when it is still positively forbidden. With or with-\\nout permission, when evidences of the disease have passed and\\nthe tests before mentioned have yielded negative results, these\\npatients will have coitus. Is it not best to avail one s self of their\\nimmorality for their own good and the protection of their pro-\\nspective wives by asking for a condom specimen?\\nWhen even the condom test has proven negative or when the\\nphysician s conscientious scruples cause its omission the final\\nresort is\\nTlie Urethroscope (see Chapter XIII.). If a healthy urethra,\\nis found, and its adnexa are proven to be normal, the case may\\nbe discharged.\\nPreparation of a Specimen for Microscopical Examination.\\nFor the convenience of those not rendered familiar with the tech-\\nnique, by daily examination for gonococci, the method that is\\neasiest and most reliable is here recapitulated\\n1. Spread as thinly as possible upon a cleaned cover-glass\\nthe discharge, drop, filament, urinary sediment, or specimen\\ntaken with a sterilized platinum needle from the contents of a\\ncondom.\\n2. Let the specimen dry under a bell-glass, to protect it\\nfrom dust or air microbes. This usually requires about three\\nminutes.\\n3. Pass it three times through the opened Bunsen flame,\\nwith an even motion, to fix it.\\n4. Drop eosin (saturated solution in alcohol) upon the cover-\\nglass and hold it over the closed Bunsen jet until a slight,\\nvisible evaporation results.\\n5. Hold it under a stream of water until all the eosin that\\ncan be washed away is carried off. If the cover-glass stood on", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0217.jp2"}, "218": {"fulltext": "208 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nedge over filter paper gives the paper ever so slight a tinge, the\\nwashing has been insufficient, and must be repeated until noth-\\ning but clear water comes from the glass.\\n6. Drop two per cent, methylene blue upon the glass and let\\nit rest there, covered, for five minutes.\\n7. Wash as described under 5, let it dry, and then mount it\\nfor examination.\\n8. Unstain by the Gram method.\\nPhysicians who cannot devote the ten or twelve minutes to\\nthis preparation of a slide will do well merely to take the speci-\\nmen on a cover-glass, place another cover-glass upon it, and\\nsend the specimen to a colleague or a bacteriological laboratory\\nfor examination.\\nFor positive assurance culture experiments are necessary.\\nThese, however, cannot be made save by a physician provided\\nwith a laboratory fitted for the purpose.\\nXV. THE MARRIAGE OF GONORRHCEICS.\\nThe question that most frequently confronts the general\\npractitioner, as well as the specialist, concerns the marriage of\\nthose who have had gonorrhoea, and the resumption of matri-\\nmonial relations by married infractors who acquired the disease\\nextra domo.\\nAdvice in this regard cannot be lightly given. In support\\nhereof a slight historical digression may be permitted.\\nE. Noeggerath, 1 of New York, in 1872 asserted, as Ricord\\nhad before him, that eight hundred men of every one thousand\\nliving in large cities had gonorrhoea. The recently deceased\\neminent gynecological surgeon, Mr. Lawson Tait, went further\\nin this, claiming that every man at least once during his life\\nacquired clap. While observation and experience compel ac-\\nceptance of Tait s estimate as nearer the facts, the author can\\npositively assert that at least one man, now almost fifty years\\nof age, has not been so unfortunate.\\nNoeggerath, in the same dissertation, and in the light of\\nthe treatment then employed, asserted that men infected with\\n1 Noeggerath Die latente Gonorrhoe irn weiblichen Geschlecht, Bonn,\\n1872.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0218.jp2"}, "219": {"fulltext": "THE MARRIAGE OF GONORRHCEICS. 209\\ngonorrhoea never recovered. He further insisted that ninety per\\ncent, of these men, when they married, infected their wives.\\nThe eminent surgeon s views were fiercely combated, yet\\nstanch in his convictions he, four years later, summarized his\\nconclusions in a paper on the subject, 1 as follows:\\n1. Gonorrhoea in the male, as well as in the female, per-\\nsists for life in certain sections of the organs of generation, not-\\nwithstanding its apparent cure in a great many instances.\\n2. There is a form of gonorrhoea, which may be called\\nlatent gonorrhoea, in the male as well as in the female.\\n3. Latent gonorrhoea in the male, as well as in the female,\\nmay infect a healthy person either with acute gonorrhoea or\\ngleet.\\n4. Latent gonorrhoea in the female, either the consequence\\nof an acute gonorrhoeal invasion or not, if it pass from the latent\\ninto the apparent condition, manifests itself as acute, chronic,\\nrecurrent perimetritis or ovaritis, or as catarrh of certain sections\\nof the genital organs.\\n5. Latent gonorrhoea, on becoming apparent in the male,\\ndoes so by attack of gleet or epididymitis.\\n6. About ninety per cent, of sterile women are married to\\nhusbands who have suffered from gonorrhoea, either previous to\\nor during married life.\\nNoeggerath s conclusions were based purely upon clinical\\nexperience. They were in no wise essentially controverted\\nAvhen three years later Neisser 2 published his epoch-making\\ndiscovery of the gonococcus.\\nIf Noeggerath s note of alarm needs further confirmation it\\nis found in the statistics of the German empire for 1894. These\\nshow that of the women who died of diseases of the womb, or\\nof its adnexa, eighty per cent, were proven to have succumbed\\nto gonorrhoeal infection. They further show that of all chil-\\ndren who became hopelessly blind after having been born with\\nhealthy eyes, eighty per cent, went into a life of darkness from\\ngonorrhoea. Since 1894, the Crede method of swabbing the\\neyes of the new-born with two-per-cent. silver-nitrate solution\\n1 Noeggerath Latent Gonorrhoea in the Female. Transactions of the\\nAmerican Gynecological Society, 1876.\\n2 Neisser: Eine der Gonorrhoe eigenthiimliche Mikrokokkenform.\\nCentralblatt fiir medicinische Wissenschaften, No. 28, 1879.\\n14", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0219.jp2"}, "220": {"fulltext": "210 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nhas saved many eyes. And since the irrigation treatment and\\na clearer understanding of the dangers of gonorrhoea have be-\\ncome more generalized, doubtless many women are saved from\\ninfection.\\nIt cannot for a moment be assumed that the men who caused\\nthe death of their wives or the blindness of their children mar-\\nried with the knowledge that they could produce such disastrous\\nresults. If there is one among the thousands who did so, no\\npunishment known to any modern criminal code could ade-\\nquately expiate his iniquity. With the ever-increasing atten-\\ntion given by the profession to the appreciation of the dangers\\nof gonorrhoea, it is to be hoped that this menace to human hap-\\npiness will be eventually stamped out.\\nIt is perfectly true that many men to-day, uninformed of the\\nseriousness of clap, boast of having had innumerable attacks of\\nthe disease and of having relieved themselves therefrom by\\ntrifling medication or advertised nostrums. It is exceedingly\\ninteresting to note that none of these boasts are made while the\\npatient has gonorrhoea, and that he does not employ the vaunted\\npreparations when he acquires a new attack.\\nThe physicians and those of the public who make clap a\\nsubject of witticism are not without their influence upon the\\npeople in general. All men, however, when they have gonor-\\nrhoea, know that it was contracted from a woman, and it would\\nbe the extreme of pessimism to assert that a man, knowing that\\nhe can infect a woman, would marry. Still, it is difficult to\\nconvince such a man, after he perceives no evidence of the dis-\\nease, that the danger of infecting his future wife may continue.\\nFor such it will be well to cite a typical case, couched in lan-\\nguage within the reach of his intelligence.\\nFive, ten, or more years after a man had gonorrhoea, time\\nhas almost if not entirely effaced the disagreeable incident from\\nhis recollection. He marries a girl, strong and healthy. The\\nyoung wife soon begins to fade. Yague pains set in. If her\\nfriends love her, she will be twitted with advice and congratula-\\ntions regarding the presumed coming maternity. Her form,\\ntoo, suggests such possibility. But by the time, or before, the\\nchild that is to make her still more loved by her husband is ex-\\npected, it is found necessary to seek professional advice.\\nA cyst of the ovary, a Fallopian tube filled with pus, or", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0220.jp2"}, "221": {"fulltext": "THE MARRIAGE OF GONORRHCEICS. 211\\nsome other dangerous disease is discovered. An operation,\\nperilous to life, must be performed to save her. If she survive,\\nshe will no longer be a woman, for she cannot become a mother.\\nThe light of modern microscopy brought to bear upon the\\ntumor, cyst, or other substance removed reveals gonococci.\\nEemember that this wreck, but a few short months ago a vigor-\\nous, healthy girl, was as chaste as ice, as pure as snow.\\nRemember, too, that, her husband presented no sensory evidence\\nof the disease that killed his cherished wife. Killed the word\\nis advisedly employed for, though she live, she is worse than\\ndead; she is not only unsexed, but also physically and often\\nmentally destroyed.\\nIf a patient is morally so debased that such an argument\\ndoes not appeal to him, he should be made to understand what\\nat least some of the complications and sequelae of gonorrhoea\\nportend to him. He will listen to the fact that gonorrhceal pus\\nin ever so minute a quantity entering the conjunctivae can irre-\\nmediably destroy his sight within twenty-four hours. Equally\\nwill he appreciate that his testicles can be invaded, rendering\\nhim impotent to further disseminate the disease. Little as he\\nmay care for the lives of others, he can be made to understand\\nthat even long after he observes any evidence of disease, he may\\ndie from the consequences of gonorrhoea.\\nAll these facts, impressed upon such a man, will induce him\\nto submit to the tests that will prove whether he is cured (Chap-\\nter XIV. and to seek treatment for the ailment, if it is discov-\\nered that he still carries the death-dealing microbes.\\nIgnorance of the dangers of gonorrhoea is not limited to the\\nmentally uncultured. The highest literary universities in our\\nland do not teach their students even the veriest rudiments of\\ngenital physiology and pathology. The editor of one of our\\nforemost American magazines, a man of wide general scientific\\nattainments, expressed surprise when informed of the origin,\\nprevalence, and dangers of gonorrhoea.\\nThe task of instructing and warning the public regarding\\nthe dangers of this ever-prevalent disease is left almost wholly\\nto the medical profession. But such teaching can appeal only\\nto those whose intelligence is of a grade sufficient to grasp its\\nimportance. Others can be reached only by the law.\\nAll honor must be tributed to the legislators of Michigan,", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0221.jp2"}, "222": {"fulltext": "212 THE IRRIGATION TREATMENT OF GONORRHOEA.\\nwho in their session of 1899 enacted that Any person who\\nhas been afflicted with syphilis or gonorrhoea, and has not been\\ncured of the same, who shall marry shall be deemed guilty of a\\nfelony, and upon conviction thereof in any court of competent\\njurisdiction shall be punished by a fine of not less than five\\nhundred dollars or more than one thousand dollars, or by im-\\nprisonment in the state s prison at Jackson not more than five\\nyears, or by both such fine and imprisonment in the discretion\\nof the court.\\nWhile an adulterer or anadultress might by perjury succeed\\nin throwing the odium of this law upon an innocent party, the\\nfact remains that Michigan stands in the front of the world in\\nrecognizing the dangers of uncured syphilis and gonorrhoea.\\nNaturally this enactment must have been prompted by the phy-\\nsicians of that State therefore the credit thereof belongs to our\\ncolleagues. But medical men are accustomed and satisfied to\\nsee the glory of their public work go to others, when humanity\\nat large and individuals are benefited and protected thereby.\\n1 Michigan Monthly Bulletin of Vital Statistics, June, 1899.\\nThis little book has been written to place before those phy-\\nsicians who may not be thoroughly familiar therewith\\n1. The rationale and technique of irrigations in acute gon-\\norrhoea.\\n2. The advantages of dilatations and irrigations in chronic\\ngonorrhoea.\\n3. The dangers of uncured gonorrhoea, and the means of\\nlocating the foci of the disease, especially after its external\\nmanifestations have subsided.\\n4. To urge physicians to use their influence for the dissem-\\nination of a better understanding of the disease.\\nIf in but one instance these purposes are accomplished, my\\nefforts to that end will be amply rewarded.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0222.jp2"}, "223": {"fulltext": "INDEX.\\nAbortion of acute manifestations, 11\\nAbscess, follicular and peri-urethral,\\n38\\nAbsence of gonococci from one speci-\\nmen not conclusive, 130, 137,\\n207\\nor reduction of sensation on ejac-\\nulation, 128\\nAccessory treatment, 34\\nAction of potassium permanganate, 8\\nAcute anterior gonorrhoea, 8\\nanterior gonorrhoea alone, rare, 8\\nposterior gonorrhoea, 19\\nAdenitis, gonorrhceal, see Lymphade-\\nnitis\\nAdhesions, preputial, 41, 88, 90\\nAdnexa invaded from posterior ure-\\nthral infection, 21\\nAgglutination of the meatus, 136\\nAlbarran instillator, 28\\nAlbuminuria, 42 in posterior gonor-\\nrhoea, 22\\nAlcohol, 36\\nAmusements aid in opposing neuro-\\nses from gonorrhoea, 34\\nAnsemia, 42\\nAnaesthesia of urethra not necessary\\nin irrigations, 18\\nAnaesthetizing urethra, 109\\nAnterior irrigations, 12; technique\\nof, 14\\nAntinosin in inguinal adenitis, 81\\nAntrophors, 20\\nAnuclear epithelium in urine evi-\\ndencing infiltration of urethra, 205\\nApparent immunity from gonorrhoea,\\n187, 208\\nArtificial oedema produced by irri-\\ngations, 11\\nArtificial prolongation of coitus, 129\\nurethritis induced to ascertain\\npresence of gonococci, 137, 206\\nAsepsis of shield and nozzles, 14\\nof urethra, 108\\nAspermia, apparent, 128\\nAthletics, 37\\nAuto-reinfection in gonorrhoea, 170\\nAvoidance of carrying infections to\\npatients by the irrigator, 7\\nBacteruria, 144\\nBalanitis, 42\\nBalanoposthitis, 42\\nBallooning urethra, 16\\nBangs lubricator, 153\\nBartholin s glands a frequent site of\\nresidual gonorrhoea, 8\\nBathing, 34\\nBeard on sexual neurasthenia, 83\\nBeck, radiography of arteriosclerosis,\\n55\\nBed, 35\\nBeer test, 206\\nBeer-tripper, 171\\nBe nique sound, 106\\nBerg on general gonorrhceal infec-\\ntion, 74\\nBergson on ritual circumcision, 117\\nBeverages, 35\\nBicycling, 37\\nBirch-Hirschfeld on epididymitis, 57\\nBladder-drainage, continued, 111 in-\\nterrupted, 112\\nBladder, excessively strong solutions\\naccidentally entering, 14, 16\\ninflammation of, see Cystitis\\nin health, immune to gonorrhoea,\\n22", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0223.jp2"}, "224": {"fulltext": "214\\nINDEX.\\nBleeding after urination in posterior\\ngonorrhoea, 21, 23\\nat or after dilatation, 163, 164\\nsee Hemorrhage\\nBlind fistulse, 45\\nBlindness from gonorrhoea, 209, 211\\nBloody emissions, 122\\nBougie-a-boule, 205\\nBracket irrigator, 6\\nBubo, see Lymphadenitis\\nBuller s dressing in gonorrhceal oph-\\nthalmia, 86\\nBuschke on skin diseases complicat-\\ning gonorrhoea, 116\\nCalculi, urethral, 71\\nCarbonated drinks prohibited, 35,\\n172\\nCarcinoma of urethra, 200\\nCare of irrigator, 5\\nCasper ointment, in epididymitis, 61,\\n65 suspensory bandage, 64\\nCatheter-fever prevented by irriga-\\ntions, 12, 162\\nCatheter for washing urethra is repre-\\nhensible, 20\\nCauses of chronic gonorrhoea, 126\\nCaustic potash test for pus in urine,\\n11, 144\\nCavernitis, 45\\nCentrifuging urine, 204\\nChancre, 47\\nChancroid, 47\\nChocolate-color emissions, 122\\nChordee, 47\\nChronic gonorrhoea, 125 treatment\\nof, 145\\nCircumcision, 91 ritual, dangers of\\ntraumatism by, 117 in France not\\npermitted except in presence of a\\nphysician, 118\\nClap-threads, 68, 145\\nCleanliness in irrigations, 13, 17\\nClear urine not a positive evidence\\nof health, 144\\nClothing dilator, 151\\nClots following urine, 21\\nin urine, 23\\nCocaine before irrigations, not neces-\\nsary, 18\\nCohesion of lips of meatus, 136\\nCoitus, incomplete, 46\\nCollodion to protect finger in rectal\\nexploration, 177\\nColombini on general gonorrhceal in-\\nfection, 73\\nColor of discharge and color of stain,\\n142\\nCombined rectal and vesical examina-\\ntion of the prostate, 180\\nComma filaments as evidence of pros-\\ntatic disease, 69\\nComplications of gonorrhoea, 38\\nof posterior gonorrhoea, 22\\nCompressor as a protection to posterior\\nurethra, 19\\nCondoms, a cause of auto-infection,\\n16\\nCondom test, 207\\nCondylomata, 48\\nCongenital strictures, 117\\nConstitutional infection, 73\\nsymptoms of gonorrhoea, 22\\ntreatment, 34\\nCovers for dilators, 151\\nCowperitis, 50\\nCowper s glands, examination of, 183\\nCrede method to protect the new-born\\nfrom gonorrhceal ophthalmia, 209\\nCulture experiments, 208\\nCure, proofs of, 202\\nCurette for urethral glands, 165\\nCushing on gonorrhceal peritonitis, 76\\nCystitis, 53\\nCystoscopy in enlarged prostate, 181\\nDaily examinations necessary, 58, 80\\nDangers of irrigation, 14\\nDeath from gonorrhoea, 76, 211\\nDefecation drop, 129\\nDefective irrigation apparatus, 1\\ntechnique, 1\\nDe Keersmaecker on chronic urethri-\\ntis, 19\\nDiday on stains from urethral dis-\\ncharges, 142", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0224.jp2"}, "225": {"fulltext": "INDEX.\\n215\\nDietetic irregularities producing re-\\ncurrences of gonorrhoea, 171\\nDigital palpation of the urethral\\nadnexa, 173\\nDilatation, contraindications, 164\\nDilatations, amount of, 162 forcible\\nnot permitted, 164; frequency of,\\n162 length of each, 162 not pain-\\nful, 149 technique of, 160\\nDilator covers, 151 their steriliza-\\ntion, 152\\nDilators, manner of holding, 151\\nDischarge in chronic gonorrhoea, 130\\nincreased after dilatation, 162 in\\nposterior gonorrhoea, 22\\nDischarges of gonorrhoeal pus from\\nthe posterior urethra, 131\\nDisturbed digestion in gonorrhoea, 12\\nDiverticle, see Urethral diverticulum\\nDonne s caustic potash test for pus in\\nthe urine, 55, 144\\nDressing glans after irrigation, 16\\npenis, 113\\nDribbling of semen after coitus, 139\\nDrinking away a clap, 36\\nDrop expressible from healthy ure-\\nthra, 84\\nDuchastelet urinal, 112\\nDynamic influence of instruments in\\nthe urethra, 149\\nDysuria in posterior gonorrhoea, 24\\nEarly symptoms of gonorrhoea, 10\\ntreatment necessary, 11\\nEjaculatio praecox, 139\\nEjaculations of semen, painful, 138\\npremature, 139; suppressed, 129\\nElectrolysis of infiltrated urethral\\nglands, 166\\nElectrolytic puncture of infiltrations,\\n166\\nEmissions, bloody or chocolate color,\\n122 painful, 138 premature,\\n139; seminal, 140\\nin posterior gonorrhoea, 23 from\\nirritable posterior urethra, 140\\nEnglisch on foreign bodies in the\\nurethra, 71\\nEosin counter-stain for microscopic\\nspecimens, 207\\nEpididymitis, 55\\nEpispadias, 65\\nEpithelium in the urine, 66 thinned,\\nan evidence of stricture, 66\\nErections in posterior gonorrhoea, 23\\npainful, 82, 138\\nEucaine before irrigation not neces-\\nsary, 18 in retention, 109\\nEvacuating bladder gradually in re-\\ntention, 109, 110\\nExcessive moisture at meatus, 132\\nsexual desire, 133\\nExercise, 36\\nExpressing urethral secretions, 202\\nExpression urine, 204\\nExtra-genital gonorrhoea, 9\\nEye, gonorrhoeal inflammation of, see\\nOphthalmia\\nFailures in irrigation treatment;\\nprobable causes thereof, 1\\nFainting during irrigation, 14\\nFelicke on irrigations, 1\\nFever, urethral (catheter-fever), obvi-\\nated by irrigations, 12, 162\\nFig-warts, see Condylomata\\nFilaments in the urine, 144\\nFinger on the frequency of posterior\\ninvasion, 19; on purpura rheuma-\\ntica as a complication of gonor-\\nrhoeal processes, 116 on urethro-\\ncystitis, 53 on epididymitis, 56\\non prostatic filaments, 69\\nFistula, urethral, 66\\nFlakes in the urine, 144\\nFlexible sounds to prepare the urethra\\nfor dilatations, 149\\nFloaters in the urine, 67, 144\\nFollicular abscess, 38\\nFolliculitis, see Abscess\\nvon Frisch on examination of the\\nprostate, 178\\nFood, 37\\nForce never permissible in dilatations,\\n164\\nForeign bodies in the urethra, 70", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0225.jp2"}, "226": {"fulltext": "216\\nINDEX.\\nForeskin, tight, irrigation of, 15\\nFrank on irrigations, 1\\nFrenum, short or rigid, 73\\nFricke s method of strapping testicle\\n(author s modification), 61\\nFuller on seminal vesiculitis, 119;\\non tuberculosis of the seminal vesi-\\ncles, 122 on examination of the\\nseminal vesicles, 182\\nFulminant type of posterior gonor-\\nrhoea, 27\\nFuniculi tis, 73\\nFiirbringer on floaters in the urine,\\n67 on prostatic filaments, 69 on\\nover-treatment, 167\\nGenesic hyperesthesia, 134\\nGentleness essential in dilatations, 149\\nGerman statistics on death and blind-\\nness from gonorrhoea, 209\\nGerson, scrotal elevating strips, 64\\nGin, 38\\nGlands, urethral, infiltrated, syringe\\nfor their injection, 165 curette and\\nelectrolytic needle for their destruc-\\ntion, 166\\nGlans, dressing, after irrigation, 16\\nGleet, 77\\nGoldberg on results of irrigation\\ntreatment, 1\\nGonococci proliferate by segmenta-\\ntion, 10\\nGonococci cidal action of hot water,\\n11\\nGonococcus, an anaerobic microbe, 11\\nGonocystitis, 120\\nGonorrhoea and marriage, 208\\nbags, a cause for auto-infection,\\n17\\nrecurrence from marital excesses,\\n169\\nGonorrhceal ophthalmia, 85, 209\\nGouley on gonocystitis, 120; on in-\\ncision through the rectum for ab-\\nscess of seminal vesicles, 122\\nGout, 77\\nGoutte militaire, 137\\nGranules iu the urine, 142\\nGuiard on causes of chronicity, 126\\non classification of substances in\\nthe urine, 144; on floaters in the\\nurine, 67 on gonorrhoeas that are\\nchronic from the inception, 126,\\n135, 185; on little ejaculations,\\n132 od mechanism of gonorrhceal\\ndischarge from posterior urethra,\\n132\\nGuiteras on stricture of meatus, 118\\nGumma of frenum, 39\\nGuterbock on prostatic examination,\\n178\\nGuy on on classification of substances\\nin the urine, 144 classification of\\nurinary filaments, 70; curved pos-\\nterior dilator, 158; on discharges\\nsimulating spermatorrhoea, 131 on\\ndressing penis, 113 on the dynamic\\ninfluence of instruments in the ure-\\nthra, 149 on foreign bodies about\\nglans, 143; on instillations, 29; on\\nirrigations, 1 on mechanism of\\nemission of gonorrhceal discharge\\nfrom posterior urethra, 132 modi-\\nfication of Mercier catheter, 114\\non normal mucous filament, 68 on\\nramonage, 205; retention-catheter,\\n111; sound, 106; on stammering\\nurination, 103\\nHematuria in posterior gonorrhoea,\\n23\\nHemorrhage, 77 ex vacuo, from rap-\\nidly emptying the bladder, 110\\nHemospermia, 79, 122\\nHairpin in urethra, 72\\nHatpin in urethra, 72\\nHeiman on the gonococcus, 77\\nHeitzmann on epithelia in urine, 66\\non filaments, 70; on gonocystitis,\\n122\\nHoffmann on examination of the pros-\\ntate, 178\\nHorand suspensory bandage, 64\\nHorowitz on Cowperitis, 50\\nHorseback riding, 37\\nHydrocele, 79", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0226.jp2"}, "227": {"fulltext": "INDEX.\\n217\\nHydrogen peroxide not a gonococci-\\ncide, 11\\nHyperesthesia, 149\\nHypospadias, 65\\nImmunity, apparent, to gonorrhoea,\\n187, 208\\nImperious urination in posterior gon-\\norrhoea, 24\\nIncrease of discharge after dilatation,\\n162\\nIncreasing intervals of treatment to\\ntest progress of case, 167\\nIncrustated meatus, 136\\nIndications for irrigations, 12\\nInefficient sounds, 148\\nInfection by apparatus, precautions\\nagainst, 13\\nfrom a sound, 9 from a water-\\ncloset, 9\\nInfiltration-anaesthesia, see Schleich\\nInfusions in posterior gonorrhoea, 27\\nInguinal adenitis, antinosin in, 81\\nInstillations of silver nitrate in pos-\\nterior gonorrhoea, 29\\nInstrumentation of acutely inflamed\\nurethra, 20\\nof the urethra or bladder, followed\\nby irrigations, 12, 162\\nIntervals between dilatations, 162;\\nbetween irrigations, 19\\nIntravesical irrigations, impediments\\nto, 31 technique of, 29\\nIntromission not necessary for acqui-\\nsition of gonorrhoea, 8\\nInvasion of organism from posterior\\nurethra, 20\\nIrrigation in recumbent posture, 14;\\nin standing posture, 14\\nIrrigation-treatment, statistics of re-\\nsults, 1\\nIrrigations, conditions in which they\\ncan exercise no effect, 165 cure\\nninety per cent, of gonorrhoeas with-\\nin fourteen days, 1 indications for,\\n12 prevent urethral fever, 12, 162\\nIrrigator, care of, 6 cleansing of, 6\\ndescription of, 2\\nIrritative urethritis from treatment of\\nhealthy urethra, 69, 167\\nItching in urethra, 135\\nJadassohn on posterior gonorrhoea,\\n19, 102\\nJamin on discharges simulating sper-\\nmatorrhoea, 131\\nJanet on irrigations, 2, 18 solutions\\nemployed, 125 treatment of chron-\\nic gonorrhoea, 146\\nJoly on ritual circumcision, 117\\nKlotz on the effect of carbonated\\ndrinks, 36\\nKobner on prevention of catheter fe-\\nver, 28\\nKofmann on urethral hemorrhage, 78\\nKollmann on cavernitis, 46 electro-\\nlytic needle for the destruction of\\nurethral gland, 166 four-branched\\nanterior dilator, 157 four-branched\\nposterior dilator, 158; Guyon curve\\nantero-posterior dilator, 159; irri-\\ngating dilators, 159 photographs\\nof the urethra, 189 on psoriasis\\nmucosae urethralis, 201 syringe for\\nurethral glands, 165\\nLaceration of urethra avoided, 150,\\n154\\nLacuna magna may arrest instrument,\\n150\\nLanglebert suspensory bandage, 64\\nLatent gonorrhoea, 168\\nLeleneff on gonorrhoeal neuroses, 82\\nLetzel on posterior gonorrhoea, 102\\nLewis on posterior gonorrhoea, 102\\nits frequency, 102; infection\\nthrough the lymphatics, 115 semi-\\nnal vesiculitis, 119\\nLight attacks of gonorrhoea, 126\\nLimits of dilatation and irrigation,\\n165\\nLinen, stains on, 131, 142\\nLittle ejaculations, 131\\nLbwenfeld on sexual neuroses, 83\\nLowered physical condition predis-\\nposes to gonorrhoea, 8", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0227.jp2"}, "228": {"fulltext": "218\\nINDEX.\\nLustgarten and Mannaberg on pseudo-\\ngonococci, 123\\nLydston on athletics in genito-uri-\\nnary diseases, 37\\nLymphadenitis gonorrhoeica, 80\\nLymphangitis, 81\\nMalassez and Terrillon on epididy-\\nmitis, 56\\nMalodorous urine, 143\\nMarital reinfection, 169\\nMarriage of gonorrhceics, 208\\nMassage of prostate, 183\\nMasturbation, psychic, 170\\nMasturbator s premature ejaculations,\\n158\\nMeasuring size of prostate, 180\\nMeatometer, Piffard s, 193\\nMeatus, agglutination of, 136 exces-\\nsive moisture at, 132 swollen, 4, 10\\nMechanism of gonorrhoeal infection, 8\\nof symptomatology of posterior\\ngonorrhoea, 21\\nMegaloscope, 192\\nMercier curve catheters, 114\\nMercuric bichloride test, 206 in pos-\\nterior gonorrhoea, 26\\nMethylene blue in differentiation be-\\ntween anterior and posterior gon-\\norrhoea, 25; stain for gonococci,\\n208\\nMichigan s law on the marriage of\\ngonorrhceics, 211\\nMicroscope, preparing specimen for,\\n207\\nMilking urethra, 133 maintains ure-\\nthrorrhoea, 203\\nMoisture, excessive, at meatus, 132\\nMorgagnian crypts, 196, 200\\nMorning drop, 137\\nMuco-purulent filaments, 144\\nMucous filaments, 144\\nMucus, urethral, augmented early in\\ngonorrhoea, 10\\nMurcell on urethral rugosities, 150\\nNeisser on the gonococcus, 209\\nNeoplasms in the urethra, 166\\nNervous patients, irrigations of, 14\\nNeuroses evoked by gonorrhoea, 26\\nby normal filament, 69\\ngonorrhoeal, 82 in prostatitis,\\n107\\nNitze-Oberlaender tubes, 190\\nNoeggerath on gonorrhoea in women,\\n208\\nNogu^s-Wassermann diplococcus, 123\\nNormal filament, its discovery as a\\ncause for neurasthenia, 69\\nNosophen in balanitis and balanopos-\\nthitis, 43 in scrotal erosions from\\nstrapping, 63\\nNozzles for various sized meatus, 4\\nmode of attachment, 5\\nNuclei of urethral epithelia thinned\\nor absent in stricture, 66\\nOberlaender anterior dilator, 154\\nantero-posterior dilator, 159 B\u00c2\u00a3-\\nnique curve posterior dilator, 157\\non carcinoma of the urethra, 200\\non cavernitis, 46 on chronic ure-\\nthritis, 126 on the treatment of\\nchronic gonorrhoea, 146 on dilata-\\ntions, 148; on melting infiltra-\\ntions, 164 on splitting infiltrations,\\n166 on psoriasis mucosae urethra-\\nlis, 201\\nObstacles to dilatation, 154, 164\\nOdor of urine changed by drugs, 143\\n(Edema, artificial, induced by irriga-\\ntions, 11 by gonorrhoea, 85\\nOffice arrangement, 33\\nOrcho-epididymitis, 55\\nOrgasm suppressed, 129\\nOphthalmia, gonorrhoeal, 85, 209\\nOtis on catarrhal urethritis, 133 di-\\nvulsor, 148\\nOver-treatment, 84, 166\\nPacking urethra to arrest bleeding,\\n78, 164\\nPain after urination in posterior gon-\\norrhoea, 23, 24; connected with an\\nattack of gonorrhoea, relieved by ir-\\nrigations, 11 increased when local", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0228.jp2"}, "229": {"fulltext": "INDEX.\\n219\\nanaesthetics have worn off, 18 on\\nurination after dilatations, pre-\\nvented by irrigation, 161\\nPainful erection, 82\\nurination, 10 absent in gonor-\\nrhoea, 11\\nPainlessness of irrigations, 17\\nPalpation of urethral adnexa, 173\\nParaphimosis, 86\\nPatient, preparation of, for irriga-\\ntions, 12\\nPeriarthritis, see Bheumatism\\nPeriod of incubation, 9\\nPeritonitis, gonorrhoea^ 76\\nPeri-urethral abscess, 38\\nPermanent catheterization, 112\\nPhimosis, 88\\nPhosphaturia, 144\\nPhysician s urethra infected from mi-\\ncroscopic specimen, 9\\nPiffard meatometer, 193\\nPloss on ritual circumcision, 117\\nPollutions, 101\\nPosner on condylomata, 50 on poste-\\nrior gonorrhoea, 19\\nPosterior gonorrhoea, acute, 19\\navoided by irrigations, 20; causes\\nof, 20 diagnosis of, 25 evoking\\nneurosis, 26 fulminant type, treat-\\nment of, 27 presumed recovery\\nwithout treatment, 21, 26 strength\\nof irrigation solutions in, 26 symp-\\ntoms, 20\\nPosterior irrigations, technique of,\\n29; urethra, examination of, 196\\nPostures in irrigation, 13\\nPotassium permanganate, strength of\\nsolutions, 18\\nPremature discontinuance of treat-\\nment, 167 ejaculations from mas-\\nturbator s or other irritable poste-\\nrior urethra, 139\\nPremonitory symptoms of gonorrhoea,\\n10\\nPreparation of patient for irrigation,\\n12\\nPrepuce, adhesions of, 41, 88, 91\\ntight, irrigations of, 15\\nPrevention of pregnancy, 129\\nProlongation of coitus, 129\\nProofs of cure of gonorrhoea, 202\\nProstate, massage of, 183 aided by\\nfixing prostate with a sound, 183\\nProstatic examination by sound in the\\nbladder and finger in the rectum,\\n180 filaments, 69\\nProstatitis, acute, 102 chronic, 107\\nPsoriasis mucosae urethralis (Ober-\\nlaender), 201\\nPsychic masturbation, 170\\nPsychrophor to arrest urethral bleed-\\ning, 164\\nPurulent filaments, 144\\nPus in urine, caustic potash test for,\\n11, 55, 144\\nPyuria, 11, 144\\nQuiescent gonorrhoea, 168\\nRamonage, 205\\nRectal irrigations in prostatitis, 104\\nRecumbent posture, irrigating in, 14\\nRecurrent gonorrhoea, 168\\nRelapse of acute symptoms from dila-\\ntations avoided by irrigations, 161\\nRelative sizes of bougies and dilators,\\n163\\nResidual gonorrhoea, 168 in women,\\n184\\nRetention catheter, 111\\nof urine, 24, 108\\nRheumatism, gonorrhoeal, 114\\nRona on posterior gonorrhoea, 102, 115\\nRugosities on floor of urethra, 150\\nSantal oil in posterior gonorrhoea, 27\\nSascke on urethral injuries from cir-\\ncumcision, 118\\nSchleich s infiltration in circumcis-\\nion, 92 in removal of inguinal\\nglands, 81\\nScott on the dangers of gonorrhoea,\\n127\\nScraping urethra, 205\\nScrotal erosions from strapping, 63\\nSecond urine turbid, not an infallible\\nevidence of posterior urethritis, 25", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0229.jp2"}, "230": {"fulltext": "220\\nINDEX.\\nSemen, bloody or chocolate color, 102,\\n122 ejaculation of, 132 premature\\nemission of, 139\\nSeminal dribbling after coitus, 139;\\nemissions, 101 in posterior gonor-\\nrhoea, 23 vesicles, examination of,\\n182; stripping of, 183; vesiculitis,\\n119\\nSenn on tuberculosis of the genito-\\nurinary organs, 56\\nSequelse of gonorrhoea, 38\\nSexual desire, excessive, 133\\nShield, cleansing of, 7\\nShreds in the urine, 144\\nSimulated anterior gonorrhoea, 140\\nspermatorrhoea, 131\\nSilver nitrate in posterior gonorrhoea,\\n26 test, 206\\nSkin diseases complicating or follow-\\ning gonorrhoea, 115\\nSounds, inefficient, 148\\nSpermatic cord, inflammation of,\\n73\\nSpermatorrhoea, simulated, 131\\nStaining for gonococci, 207\\nStains on linen, 131, 142\\nStammering urination (Guy on), 103\\nSterilization of dilator cover, 152\\nSternberg, smear preparation, 131\\nStewart, location of seminal vesicles,\\n120\\nStone in urethra, 71\\nStopcock, author s, 4\\nStrain producing gonorrhoea, 171\\nStraining in posterior gonorrhoea, 24\\nStrapping testicle, 61\\nStricture, evidenced by thinned ure-\\nthral epithelium in urine, 66, 117\\ntight, 149\\nStripping seminal vesicles, 183\\nStrong injections as a cause of poste-\\nrior gonorrhoea, 20\\nSuppositories in prostatitis, 105\\nSuspensory bandages, 38 as a preven-\\ntive of epididymitis, 57\\nSwabbing urethra, 205\\nSwinburne on irrigations, 1\\nSymptoms of acute gonorrhoea, 10\\nSyphilis, prevention of infection by\\nnozzles, 8\\nSyringe, Kollmann s capillary, for\\nurethral glands, 165\\nTait on the frequency of gonorrhoea,\\n208\\nTamponing urethra, 78, 164\\nTaylor on extragenital infection, 9;\\non the frequency of posterior infec-\\ntion, 19 on gonocystitis, 121\\ndefinition of phimosis, 88; phimo-\\nsis scissors, 44 on skin diseases in\\ngonorrhoea, 115; on slitting fore-\\nskin, 44\\nTechnique of dilatations, 160\\nTenesmus in posterior gonorrhoea, 24\\nThummel on the impropriety of infect-\\ning a healthy urethra for purposes\\nof investigation, 74\\nTickling in urethra, 135\\nTight foreskin, irrigations in, 15\\nstrictures, 149\\nTime consumed in irrigations, 18\\nTobacco, 38 poultices in epididymi-\\ntis, 65\\nTraumatisms of the urethra, 117\\nTreatment of chronic gonorrhoea, 145\\nTripperfaden, 67\\nTrompeurs, 129\\nTuberculosis of the geni to-urinary or-\\ngans, 56, 122\\nTurbid urine, 11, 143\\nUrethra, female, frequent site of re-\\nsidual gonorrhoea, 8\\nmust not be washed with a cathe-\\nter, 20 traumatisms of, 117\\nUrethral adnexa, palpation of, 173\\nbleeding, control of, 164\\ncalculi, 71\\nfever prevented by irrigations,\\n12, 162\\nfistula, 66\\nglands, Kollmann s syringe for,\\n165\\nneoplasms, 166\\nrugosities, 150", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0230.jp2"}, "231": {"fulltext": "INDEX,\\n221\\nUrethritis ab ingestis, 171 ex libi-\\ndine, 170; irritative, from treat-\\nment of healthy urethra, 69\\nUrethrocystitis, 53\\nUrethroprostatic infection, 123\\nUrethrorrhcea maintained by milking\\nurethra, 131\\nUrethroscope, author s, 190\\nUrethroscopy, 188 technique of, 192\\nUrethrospasm, avoided, 150 imped-\\ning dilatations, 103\\nUrinal, Duchastelet, 112\\nUrination drop, 129\\nUrination, increased frequency early\\nin gonorrhoea, 10 painful, 10, 11\\npainful at beginning, from incrus-\\ntated meatus, 136 painful from local\\nand constitutional disturbances, 139\\nUrine, brought in bottles useless for\\nexamination of floaters, 70 urine,\\nclear, 144 in chronic gonorrhoea,\\n142 examination of, in posterior\\ngonorrhoea, 25 of gonorrhoeic\\nshould be examined daily, 24 mal-\\nodorous, 143; retention of, 11, 24\\n108; scalding, 10, 11; tubes, 25;\\nturbid, 11, 143\\nUrotropin, 36\\nVerhoogen on posterior urethritis,\\n19\\nVesical tenesmus, 24\\nVesiculitis, 119\\nWaiting for acute stage to pass off, a\\nserious error, 11\\nWasiliew on ritual circumcision, 117\\nWeichselbaum on condylomata, 48\\nWhite and Martin on the early symp-\\ntoms of gonorrhoea, 10 on posterior\\nurethritis, 20 on albuminuria in\\nposterior urethritis, 22; on balani-\\ntis, 42; rectal irrigator, 104; sus-\\npensory bandage, 64\\nWhite wine, young, producing ure-\\nthritis, 171\\nWife, danger of infecting from resid-\\nual gonorrhoea, 168\\nWomen, residual gonorrhoea in, 184\\nWossidlo on the need of rectal exam-\\nination, 20 on prostatitis, 102 on\\nstricture, 116\\nvon Zeissl suspensory bandage, 64", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0231.jp2"}, "232": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0232.jp2"}, "233": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0233.jp2"}, "234": {"fulltext": "", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0234.jp2"}, "235": {"fulltext": "MEDICAL PUBLICATIONS\\nOF\\nWILLIAM WOOD COMPANY.\\nAbney, Capt. W. de W., C.B., D.C.L., F.R.S.,\\nLate Royal Engineers.\\nCOLOUR VISION, being the Tyndall Lectures delivered in 1894 at\\nthe Royal Institution. One volume, 8vo, 241 pages, illustrated by\\na chromo-lithographic plate and numerous diagrams, muslin, $1.75 net.\\nAdams, Francis, LL.D., Surgeon.\\nTHE GENUINE WORKS OF HIPPOCRATES. Translated from\\nthe Greek, with a Preliminary Discourse and Annotations. 8vo, 766\\npages, gilt top, extra muslin, $5.00 net.\\nAllen, Charles Warrenne, M.D.\\nTHE PRACTITIONER S MANUAL, a condensed system of medical\\ndiagnosis and treatment. Arranged alphabetically, and containing many\\nhundreds of formulae, especially furnished for this work by leading med-\\nical authorities in the United States and abroad. Complete Index.\\nOne volume of 855 pages, octavo. Muslin, $6.00 net; half morocco,\\n$7.00 net.\\nAllen and\\nSbbel, Jacob, M.D.\\nHANDY BOOK OF MEDICAL PROGRESS. A Lexicon of the\\nRecent Advances in Medical Science. One volume, 8vo, muslin, $2.00\\nnet.\\nAllingham, William, F.R.C.S. Lond.\\nand\\nAllingham, Herbert W., F.R.C.S. Lond.\\nTHE DIAGNOSIS AND TREATMENT OF DISEASES OF THE\\nRECTUM. Being a Practical Treatise on Fistula, Piles, Fissure and\\nPainful Ulcer, Procidentia, Polypus, Stricture, Cancer, etc. New Edi-\\ntion in preparation.", "height": "4122", "width": "2428", "jp2-path": "irrigationtreat00vale_0235.jp2"}, "236": {"fulltext": "4 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nBuck, Albert H., fl.D.,\\nClinical Professor of the Diseases of the Ear, in the College of Physicians and Surgeons, New York\\nConsulting Aural Surgeon, New York Eye and Ear Infirmary.\\nA TREATISE ON DISEASES OF THE EAR. Together with a\\nBrief Sketch of the Anatomy and Physiology of this Organ. Third\\nRevised Edition. One volume of 604 pages, octavo, profusely illus-\\ntrated by 147 wood-engravings. Extra muslin, $3.50 net.\\nA VEST-POCKET MEDICAL DICTIONARY. Embracing those\\nterms and abbreviations which are commonly found in the medical liter-\\nature of the day, but excluding names of drugs and many words which\\nmay more properly be found in a general dictionary of the English lan-\\nguage. A most complete little book of 536 pages, less than one-half\\ninch in thickness, 321110, bound in flexible leather. Price, $1.00 net.\\nCabot, Richard C, M.D.,\\nBoston, Mass.\\nA GUIDE TO THE CLINICAL EXAMINATION OF THE BLOOD\\nFOR DIAGNOSTIC PURPOSES. Third edition. One volume of\\n464 pages, octavo, illustrated by numerous wood-engravings and by\\nchromo-lithographic plates, muslin, $3.25 net.\\nTHE SERUM DIAGNOSIS OF DISEASE. This book aims to bring\\ntogether in convenient form the results of the immense amount of\\nwork which has been done upon serum diagnosis since 1896. In one\\noctavo volume of 154 pages, illustrated. Price, $1.50 net.\\nCampbell, Harry, M.D., B.S. Lond. (London).\\nRESPIRATORY EXERCISES, in the Treatment of Disease, Notably\\nof the Heart, Lungs, Nervous and Digestive Systems. An essentially\\npractical work, dealing with a means of therapy which is not always\\nappreciated at its full value. One volume of 208 pages, 8vo, muslin,\\n$2.00 net.\\nCarpenter, Wm. B., C.B., n.D., LL.D.\\nTHE MICROSCOPE AND ITS REVELATIONS. 8vo. Vol. I.,\\n388 pages; Vol. II., 354 pages. One colored, twenty-six plain plates,\\nand five hundred and two wood-engravings. Two volumes in one.\\nMuslin, $3.00 net.\\nCheyne, W. Watson, M.B., F.R.S., F.R.C.S. Lond.\\nTHE OBJECTS AND LIMITS OF OPERATIONS FOR CAN-\\nCER, with special reference to Cancer of the Breast, Mouth, and Throat,\\nand Intestinal Tract. Being the Lettsomian Lectures for 1896. 8vo,\\n146 pages, muslin, $1.50 net.\\nClarke, A. Campbell, M.D., F.F.P.S.Q.,\\nMackintosh Lecturer on Psychological Medicine, St. Mungo s College, Glasgow; Medical Superintend-\\nent of Lanark County Asylum, Hartwood.\\nCLINICAL MANUAL OF MENTAL DISEASES FOR PRACTI-\\nTIONERS AND STUDENTS. One volume, 502 pages, illustrated,\\nmuslin, $3.50 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0236.jp2"}, "237": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 5\\nClarke, J. Jackson, M.B. Lond., F.R.C.S.,\\nSurgeon to Out-Patients at the North- West London and City Orthopaedic Hospitals, etc.\\nORTHOPAEDIC SURGERY, a text-book of the Pathology and Treat-\\nment of Deformities. One volume, 8vo, 473 pages, illustrated by 309\\nillustrations. Price, $3.00 net.\\nColeman, Warren, M.D.,\\nProfessor of Materia Medica, Cornell University Medical School, etc., etc.\\nA SYLLABUS OF MATERIA MEDICA. This book is an attempt to\\nassist the memory as much as possible by condensing the facts, repeat-\\ning the doses, and by grouping the drugs in various ways. It is in-\\ntended to supplement, not to take the place of, other and larger works\\non the subject. One volume i2mo, 175 pages. Price, $1.00 net.\\nCollins, Joseph, M.D.,\\nProfessor of Nervous and Mental Diseases in the New York Post-Graduate Medical School Visiting\\nPhysician to the New York City Hospital.\\nTHE TREATMENT OF DISEASES OF THE NERVOUS SYSTEM\\nA HANDBOOK FOR PRACTITIONERS. One volume of 616\\npages, 8vo, illustrated. Muslin, $5.00 net.\\nCory, Robert, M.A., M.D. Cantab., F.R.C.P. Lond.,\\nPhysician-in-Charge of the Vaccination Department of St. Thomas Hospital Teacher of Vaccina-\\ntion in the University of Cambridge, etc.\\nLECTURES ON THE THEORY AND PRACTICE OF VACCINA-\\nTION. 122 pages. 14 full-page colored plates, muslm. Price, $3.25 net.\\nDana, Charles L., A.M., M.D.,\\nProfessor of Nervous and Mental Diseases in the New York Post-Graduate Medical School, and in\\nDartmouth Medical College Visiting Physician to Bellevue Hospital, etc.\\nTEXT-BOOK OF NERVOUS DISEASES. Being a Compendium for\\nthe Use of Students and Practitioners of Medicine. Fourth edition,\\nrevised and enlarged. 8vo, 640 pages, 210 illustrations, $3.50 net.\\nDelafield, Francis, M.D.,\\nProfessor of Pathology and Practical Medicine, College of Physicians and Surgeons, New York.\\nSTUDIES IN PATHOLOGICAL ANATOMY. Volume I., treating\\nof the following subjects Phthisis, Peritonitis, Pleurisy, Pneumonia,\\nEmpyema, Hydrothorax, Bronchitis, and Tuberculosis. Illustrated\\nwith ninety-three full-page and double-page plates made by the follow-\\ning processes Wood-engravings of Original Drawings on the Block,\\nEtchings on Copper, Lithographs from Original Drawings on the Stone,\\nand Photographs of Specimens. Royal 8vo, bound in half morocco,\\ngilt top, plates hinged on linen guards, $20.00 net.\\nVolume II. Broncho-Pneumonia, Chronic Phthisis, Lobar Pneumonia,\\nAcute Bright s Disease, Chronic Bright s Disease. Illustrated with one\\nhundred and thirty-three full and double-page plates hinged on linen\\nguards, similar to those of Vol. I. Royal 8vo, bound in half morocco,\\ngilt top, $20.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0237.jp2"}, "238": {"fulltext": "6 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nDelafield and\\nPrudden, T. flitchell, fl.D.,\\nProfessor of Pathology and Director of the Laboratories of Histology, Pathology, and Bacteriology,\\nCollege of Physicians and Surgeons, Columbia College, New York.\\nA HANDBOOK OF PATHOLOGICAL ANATOMY AND HISTOL-\\nOGY. With an Introductory Section on Post-Mortem Examinations\\nand the Methods of Preserving and Examining Diseased Tissues. Fifth\\nRevised and Enlarged Edition. One volume of 846 pages, 8vo, illus-\\ntrated by engravings in black and many colors, and a chromo-litho-\\ngraphic plate. Muslin, $5.00 net; leather, $5.75 net.\\nDe Meric, H., Paris.\\nDICTIONARY OF MEDICAL TERMS. (English-French.) This\\nis the first part of the work, which is completed by the publication\\nof the second part; French-English Medical Terms. It can-\\nnot fail to be of the greatest value to all who have occasion for\\nsuch a book. The two volumes will be sold separately at $1.75\\nnet, or together at $3.00 net. One volume of 402 pages, octavo.\\nMuslin, $1.75 net.\\nDICTIONNAIRE DES TERMES DE MEDECINE. (Frangais-\\nAnglais.) This is the second part of the work one volume of 248 pages,\\noctavo. Muslin, $1.75 net. The two parts together at $3.00 net.\\nDraper, John C, M.D., LL*D.,\\nProfessor of Chemistry in the Medical Department, University of New York, and of Physiology\\nand Natural History in the College of the City of New York.\\nA PRACTICAL LABORATORY COURSE IN MEDICAL CHEM-\\nISTRY. One volume of 80 pages, printed on one side only, oblong,\\nfor laboratory use. Muslin, $1.00 net.\\nDwight, Thomas, A.fl., fl.D.,\\nInstructor in Topographical Anatomy and Histology in Harvard University Fellow of the\\nAmerican Academy of Arts and Sciences Surgeon at Carney Hospital.\\nFROZEN SECTIONS OF A CHILD. Fifteen full-page lithographic\\nplates, drawings from nature by H. P. Quincy, M.D. One volume,\\nroyal 8vo, 66 pages, muslin, $2.50 net.\\nEccles, A. Symons, M.B., London.\\nMember Royal College of Surgeons, England Fellow Royal Medical and Chirurgical Society, etc.\\nTHE PRACTICE OF MASSAGE THE PHYSIOLOGICAL EF-\\nFECTS AND THERAPEUTIC USES. One volume, 8vo, 386\\npages, $2.50 net.\\nDIFFICULT DIGESTION DUE TO DISPLACEMENTS. One vol-\\nume, octavo, illustrated. Extra muslin, $1.25 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0238.jp2"}, "239": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nEinhorn, Max, M.D.,\\nAdjunct Professor Clinical Medicine, New York Post-Graduate Medical School Visiting Physician\\nto the German Dispensary, and to the Montefiore Home for Chronic Invalids.\\nDISEASES OF THE STOMACH. Second revised edition. Complete\\nin one volume of 502 pages, post-octavo (uniform with other volumes\\nof the Medical Practitioners Series). Muslin, $3.25 net; flexible\\nmorocco, $3.75 net.\\nEllis, George Viner, fl.D.,\\nProfessor of Anatomy in University College, London and\\nFord, G. H., Esq.\\nILLUSTRATIONS OF DISSECTIONS. In a series of original colored\\nplates, representing the dissections of the human body, with descriptive\\nletterpress. The drawings are from nature by Mr. Ford, from direc-\\ntions by Prof. Ellis. Containing fifty-six full-page chromo-lithographic\\nplates. Two volumes in one, 8vo, 459 pages, muslin, $3.00 net.\\nEwart, William, M.D. Cantab., F.R.C.P. Lond.,\\nM.R.C.S. Eng.,\\nPhysician to St. George s Hospital, and to the Belgrave Hospital for Children formerly Assistant\\nPhysician and Pathologist to the Brompton Hospital for Consumption, etc., etc.\\nTHE PULSE SENSATIONS: A STUDY IN TACTILE SPHYG-\\nMOLOGY. 8vo, 510 pages, profusely illustrated, muslin, $3.25 net.\\nGOUT AND GOUTINESS AND THEIR TREATMENT. One\\nvolume of 601 pages, 8vo, muslin, $4.00 net.\\nFinger, Ernest, fl.D.,\\nDocent at the University of Vienna.\\nGONORRHOEA: being the translation of Blennorrhea of the Sexual\\nOrgans and its Complications. With seven full-page plates in colors\\nand thirty-six wood engravings in the text. Third revised edition, 8vo,\\n330 pages, muslin $2.50 net.\\nFox, George Henry, A.M., M.D.,\\nProfessor of Diseases of the Skin in the College of Physicians and Surgeons, Columbia University,\\nNew York, etc., etc.\\nSKIN DISEASES OF CHILDREN. The work is based upon a series\\nof papers originally contributed, to the America?i Journal of Obstetrics,\\nin 1896, and has been elaborated and a large formulary added. 8vo,\\nprofusely illustrated by photogravure plates, chromo-lithographic plates,\\nand half-tone cuts. Muslin, $2.50 net.\\nFreyer, P. J., M.A., M.D., M.Ch.,\\nSurgeon Lieutenant-Colonel, Bengal Army (retired).\\nTHE MODERN TREATMENT OF STONE IN THE BLADDER\\nBY LITHOLAPAXY. A description of the operation and instruments,\\nwith cases illustrative of the difficulties and complications met with.\\nSecond edition. One 8vo volume, illustrated. Muslin, $1.25 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0239.jp2"}, "240": {"fulltext": "8 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nGarrigues, Henry Jacques, A.M., M.D.,\\nObstetric Surgeon to the Maternity Hospital Physician to the Gynecological Department of rhe\\nGerman Dispensary Fellow of the American Gynecological Society Fellow of the New York\\nObstetrical Society, etc.\\nDIAGNOSIS OF OVARIAN CYSTS BY MEANS OF THE EX-\\nAMINATION OF THEIR CONTENTS. 8vo, 112 pages, illus-\\ntrated, muslin, $1.00 net.\\nQemmell, Q. H., F.I.C., F.C.S. Ed.\\nCHEMICAL NOTES AND EQUATIONS, INORGANIC AND OR-\\nGANIC. One volume of 254 pages, 1 2mo. Muslin, $1.75 net.\\nGowers, W. R., M.D.,\\nAssistant Professor of Clinical Medicine in University College Senior Assistant Physician to\\nUniversity College Hospital Physician to the National Hospital for the Paralyzed and Epileptic.\\nEPILEPSY AND OTHER CHRONIC CONVULSIVE DISEASES.\\nTheir Causes, Symptoms, and Treatment. 8vo, 366 pages, muslin,\\n$1.00 net.\\nDIAGNOSIS OF THE DISEASES OF THE BRAIN AND SPINAL\\nCORD. 8vo, 301 pages, muslin, $1.00 net.\\nGrandin, Egbert H., M.D.,\\nChairman Section on Obstetrics and Gynecology, New York Academy of Medicine Obstetric\\nSurgeon, New York Maternity Hospital Obstetrician, New York Infant Asylum, etc. and\\nGunning, Josephus H., M.D.,\\nInstructor in Electro-Therapeutics, New York Post-Graduate Medical School and Hospital\\nGynecologist to Riverview Rest for Women Electro-Gynecologist, Northeastern Dispensary, etc\\nPRACTICAL TREATISE ON ELECTRICITY IN GYNECOLOGY.\\nIllustrated. 8vo, muslin, 180 pages, $1.75 net.\\nHamilton, Frank Hastings, A.M., M.D., LL.D.,\\nProfessor of the Practice of Surgery, with Operations, and of Clinical Surgery, in Bellevue Hospital\\nMedical College Visiting Surgeon to Bellevue Hospital Consulting Surgeon to Bureau of\\nSurgical and Medical Relief for the Out-Door Poor, at Bellevue Hospital to the Central\\nDispensary and to the Hospital for the Ruptured and Crippled Fellow of the New York\\nAcademy of Medicine, etc.\\nTHE PRINCIPLES AND PRACTICE OF SURGERY. Illustrated\\nwith four hundred and sixty-seven engravings on wood. Royal 8vo.\\n954 pages. In muslin, $4.00 net.\\nHeitzmann, Louis, M.D. (New York).\\nURINARY ANALYSIS AND DIAGNOSIS by Microscopical and\\nChemical Examination. One volume of 271 pages, octavo, illustrated by\\n108 original wood engravings, 28 of which are full-page in size, from\\ndrawings by the author from actual specimens. Extra muslin, $2.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0240.jp2"}, "241": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 9\\nHelferich, H., M.D.,\\nProfessor at the University of Greifswald.\\nAN ATLAS OF FRACTURES AND DISLOCATIONS. Translated\\nfrom the Third Revised German Edition by Jonathan Hutchinson,\\nJr., F.R.C.S., London. This volume deals with fractures and disloca-\\ntions in all their details and is beautifully illustrated by 68 superb full-\\npage colored plates. 130 pages of text, containing 126 illustrations.\\n8vo (5%x8)4 inches). Muslin, uniform with other volumes of the\\nseries, $3.00 net. (Wood s Medical Hand Atlases.)\\nHerman, Q. Ernest, fl.B. Lond., F.R.C.P.,\\nObstetric Physician to and Lecturer on Midwifery at the London Hospital Consulting; Physician-\\nAccoucheur to the Tower Hamlets Dispensary Examiner in Midwifery to the Universities of\\nLondon and Oxford Late President of the Obstetrical Society of London and of the Hunterian\\nSociety Formerly Physician to the General Lying-in Hospital and to the Eastern District of the\\nRoyal Maternity Charity, and Examiner in Midwifery to the Royal College of Surgeons.\\nDISEASES OF WOMEN; A CLINICAL GUIDE TO THEIR\\nDIAGNOSIS AND TREATMENT. Octavo, 886 pages, profusely\\nillustrated. Extra muslin, $5.00 net j leather, $5.75 net.\\nDIFFICULT LABOR A Guide to its Management for Students and\\nPractitioners. 460 pages, demi-octavo, including complete index, mus-\\nlin, $2.00 net.\\nHerrick, Clinton B., M.D., Troy, N. Y.\\nLecturer in Clinical Surgery, Albany Medical College; Attending Surgeon to the Troy Hospital and\\nthe House of the Good Shepherd; Consulting Surgeon to the Leouaid Hospital; Surgeon to the\\nDelaware and Hudson, and the Fitchburg Railways; President of the New York State Association\\nof Railway Surgeons, etc., etc.\\nRAILWAY SURGERY. A handbook on the management of injuries.\\nThe only book on the subject. There has long been a demand for a work\\ndevoted to the surgery of cases resulting from railway accidents. This\\ndemand the present volume will, it is believed, supply. The book is\\nclear, concise, and practical. The very numerous illustrations, which\\nhave all been made specially for the work, are from photographs taken\\nunder the author s supervision, and are of remarkable excellence. One\\nvolume, octavo, profusely illustrated by numerous line and half-tone\\nengravings. Muslin, $2.00 net.\\nHolden, Luther, n.D.,\\nEx-President and Member of the Court of Examiners of the Royal College of Surgeons of England\\nConsulting Surgeon to Saint Bartholomew s and the Foundling Hospitals assisted by\\nShuter, James, F.R.C.S., H.A., fl.B. Cantab.,\\nAssistant Surgeon to the Royal Free Hospital late Demonstrator of Fhysiology, and Assistant\\nDemonstrator of Anatomy, at Saint Bartholomew s Hospital.\\nHUMAN OSTEOLOGY. Comprising a Description of the Bones, with\\nDelineations of the Attachments of the Muscles, the General and Micro-\\nscopic Structure of Bone and its Development. Sixth edition. With\\nsixty-six full-page lithographic plates, and eighty nine wood -engravings.\\n8vo, 285 pages, muslin, $1.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0241.jp2"}, "242": {"fulltext": "io PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nHousehold Practice.\\nSee WOOD S HOUSEHOLD PRACTICE.\\nHudson, E. D., Jr., A.m., H.D.,\\nProfessor of General Medicine and Diseases of the Chest in the New York Polyclinic Physician to-\\nBellevue Hospital, etc.\\nA MANUAL OF THE PHYSICAL DIAGNOSIS OF THORACIC\\nDISEASES. 8vo, 162 pages, profusely illustrated. Muslin, $1.25 net.\\nHutchinson, Jonathan, F.R.S.\\nTHE PEDIGREE OF DISEASE. Being Six Lectures on Tempera-\\nment, Idiosyncrasy, and Diathesis. Muslin, $1.00 net.\\nIngals, E. Fletcher, A.M., M.D.,\\nProfessor of Laryngology and Practice of Medicine, Rush Medical College Professor of Diseases of\\nThroat and Chest, Northwestern University Women s Medical School Professor of Laryngology\\nand Rhinology, Chicago Polyclinic, etc.\\nLECTURES ON THE DIAGNOSIS AND TREATMENT OF DIS-\\nEASES OF THE CHEST, THROAT, AND NASAL CAVITIES.\\nIncluding Physical Diagnosis and Diseases of the Lungs, Heart, and\\nAorta Laryngology and Diseases of the Pharynx, Larynx, Nose, Thy-\\nroid Gland, and GEsophagus. Third edition (1898), revised and en-\\nlarged, and with revisory appendix, 8vo, 736 pages, 240 illustrations,\\nincluding colored plate of stained tubercle bacilli. Muslin, $4.00 net.\\nKaposi, Dr. floriz,\\nProfessor of Dermatology and Syphilis, and Chief of the Clinic and Division for Skin Diseases in the\\nVienna University.\\nPATHOLOGY AND TREATMENT OF DISEASES OF THE\\nSKIN. For Practitioners and Students. Translation of the latest Ger-\\nman edition. 8vo, 684 pages, 84 illustrations, and a colored plate, mus-\\nlin, $4.00 net; leather, $4.75 net.\\nKellogg, Theodore H., A.M., H.D.,\\nNew York, Late Superintendent, Willard State Hospital former Physician-in-Chief of the New Yoric\\nCity Asylum for the Insane, etc., etc.\\nA TEXT-BOOK ON MENTAL DISEASES, for the Use of Students\\nand Practitioners of Medicine. One large octavo volume, of 792 pages,\\nillustrated by engravings and charts. Muslin, $5-\u00c2\u00b0\u00c2\u00b0 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0242.jp2"}, "243": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. u\\nKeyes, Edward L., M.D.,\\nConsulting Surgeon to the New York City Hospital Consulting Surgeon to Bellevue Hospital, etc.,\\netc.\\nand Chetwood, Charles H., M.D.,\\nVisiting Surgeon to Bellevue Hospital, etc.\\nVENEREAL DISEASES. Their Complications and Sequels.\\nOne volume of 364 pages, 8vo, illustrated by numerous drawings and\\neight full-page plates in black and colors. Muslin, $2.75 net.\\nKirchhoff, Dr. Theodore,\\nPhysician to the Schleswig Insane Asylum and Privat-Docent at the University of Kiel.\\nHANDBOOK OF INSANITY FOR PRACTITIONERS AND STU-\\nDENTS. Illustrated with eleven plates. 8vo, 362 pages. Muslin,\\n$2.25 net flexible leather, gilt top, $2.75 net.\\nKirkes Handbook of Physiology.\\nHANDBOOK OF PHYSIOLOGY. By W. Morrant Baker, F.R.C.S.,\\nand Vincent Dormer Harris, M.D. Lond F.R.C.P. Fifteenth\\nAmerican Edition.\\nThoroughly revised by Warren Coleman, M.D., late Professor of\\nPhysiology in the Woman s Medical College, New York; Instructor in\\nMateria Medica and Therapeutics and in Clinical Medicine, Cornell\\nMedical College, New York; Physician to the City Hospital, New\\nYork, etc., etc., and Charles L. Dana, A.M., M.D., Professor of\\nNervous and Mental Diseases in the New York Post-Graduate Medical\\nSchool, and in Dartmouth Medical College Visiting Physician to\\nBellevue Hospital Neurologist to the Montefiore Home ex-Presi-\\ndent of the American Neurological Association, etc. r\\nOne volume of 856 pages, 8vo, illustrated with a colored plate and five\\nhundred and sixteen illustrations, in black and numerous colors, muslin,\\n$3.00 net leather, $3.75 net.\\nKnies, Max, M.D.,\\nProfessor Extraordinary at the University of Freiburg.\\nTHE EYE AND ITS DISEASES, IN RELATION TO THE DIS-\\nEASES OF OTHER ORGANS. Translated and edited by H. D.\\nNoyes, M.D. 8vo, 470 pages, illustrated, muslin, $3.50 net\\nLandau, Prof. Dr. Leopold, and\\nLandau, Dr. Theodor,\\nBerlin.\\nTHE HISTORY AND TECHNIQUE OF THE VAGINAL RADI-\\nCAL OPERATION. Translated by B. L. Eastman, M. D. Berlin, and\\nArthur E. Giles, M.D., London. One volume, octavo, with numer-\\nous original illustrations. Muslin, $2.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0243.jp2"}, "244": {"fulltext": "12 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nLing, P. He.\\nSYSTEM OF MANUAL TREATMENT AS APPLICABLE TO\\nSURGERY AND MEDICINE. By Arvid Kellgrek, M.D. Edin.\\n8vo, 151 pages, with 79 illustrations, muslin, $1.00 net.\\nLiveing, Robert, A.M. and M.D. Cantab., F.R.C.P. Lond.\\nLecturer on Dermatology to the Middlesex Hospital Medical School lately Physician to the\\nMiddlesex Hospital; Author of Notes on the Treatment of Skin Diseases, Elephantiasis\\nGraecorum, 1 etc.\\nA HANDBOOK ON THE DIAGNOSIS OF SKIN DISEASES.\\nOne volume, i6mo, 266 pages, muslin, $1.00 net.\\nNOTES ON THE TREATMENT OF SKIN DISEASES. One\\nvolume, i6mo, 127 pages, muslin, 75c. net.\\nLoomis, Alfred L., M.D., LL.D.,\\nProfessor of Pathology and Practical Medicine, in the Medical Department of the University of the\\nCity of New York Visiting Physician to Bellevue Hospital, etc.\\nA TEXT-BOOK OF PRACTICAL MEDICINE. One handsome 8vo\\nvolume of 1,147 P a es illustrated by two hundred and eleven engravings.\\nEleventh edition. Muslin, $5.00 net leather, $5.75 net.\\nLESSONS IN PHYSICAL DIAGNOSIS. Eleventh revised edition.\\nRevised by Alexander Lambert, M.D., New York. One volume,\\n353 P a g es 8vo, illustrated by numerous engravings in black and colors,\\nmuslin, $2.50 net.\\nLuff, Arthur P., M.D., B.Sc, F.R.C.P. Lond.\\nGOUT; ITS PATHOLOGY AND TREATMENT. The subject of\\ndiet has been carefully dealt with, and a classification of the various\\nmineral waters is given according to their therapeutic value in the\\ntreatment of the various forms of gout. One volume, 256 pages.\\nMuslin, $1.75 net.\\nMacfarlane, A. W., M.D.,\\nFellow of the Royal College of Physicians, Edinburgh Fellow of the Royal Medical and Chirurgical\\nSociety of London Examiner in Medical Jurisprudence in the University of Glasgow, etc.\\nINSOMNIA AND ITS THERAPEUTICS. 8vo, 302 pages, muslin,\\n$1.50 net.\\nMacnaughton= Jones, H., M.D., M.Ch.\\nPRACTICAL MANUAL OF DISEASES OF WOMEN AND UTER-\\nINE THERAPEUTICS, for Students and Practitioners. Seventh\\nrevised and enlarged edition. One volume of 933 pages, small 8vo,\\nillustrated by 565 wood-engravings. Muslin, $4.00 net.\\nManson, Patrick, M.D., LL.D. Aberd.\\nPhysician to the Seaman s Hospital Society, attached to the Branch Hospital; Lecturer on Trop-\\nical Diseases at St. George s Hospital and Charing Cross Hospital Medical Schools, etc., etc.\\nTROPICAL DISEASES: A MANUAL OF THE DISEASES OF\\nWARM CLIMATES. Octavo, 623 pages, illustrated, and with full-\\npage colored lithographic plate. Muslin, $3.50 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0244.jp2"}, "245": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 13\\nMatthieu, A.,\\nPhysician to the Paris Hospitals.\\nTREATMENT OF THE DISEASES OF THE STOMACH AND\\nINTESTINES. 8vo, 285 pages, muslin, $2.00 net flexible leather,\\ngilt top, round corners, $2.50 net.\\nMauthner, Ludwig,\\nRoyal Professor of the University of Vienna.\\nTHE SYMPATHETIC DISEASES OF THE EYE. Translated\\nfrom the German by Warren Webster, M.D., James A. Spaulding,\\nM.D. i2mo, 220 pages, muslin, $1.50 net.\\nMay, Charles H., M.D.,\\nInstructor in Ophthalmology, New York Polyclinic and\\nMason, Charles F., M.D.,\\nLate Assistant Surgeon, U.S.A.\\nAN INDEX OF MATERIA MEDICA. With Prescription Writing,\\nincluding Practical Exercises. 321110, muslin, $1.00 net. (Wood s\\nPocket Manuals.)\\nMcGillicuddy, T. J., A.H., fl.D.\\nFUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN\\nWOMEN. One volume, 8vo, uniform with the Medical Practitioners\\nLibrary, 373 pages, illustrated by forty-five wood-engravings and two\\nchromo-lithographic plates. Extra muslin, $2.75 net flexible leather,\\n$3.25 net.\\nMcKay, W. J. Stewart, M.C., M.Ch., B.Sc. Lond.\\nLAWSON TAIT S PERINEAL OPERATIONS and an ESSAY ON\\nCURETTAGE OF THE UTERUS. One volume, 8vo, illustrated.\\nMuslin, $1.00 net.\\nMedical Record.\\nA WEEKLY JOURNAL OF MEDICINE AND SURGERY. Sub-\\nscription price, $5.00 per year.\\nMedical Record Visiting List.\\nSee VISITING LIST.\\nMillard, H. B., M.D.\\nA TREATISE ON BRIGHT S DISEASE OF THE KIDNEYS;\\nITS PATHOLOGY, DIAGNOSIS, AND TREATMENT. Third\\nedition, revised and enlarged. 8vo, 322 pages, numerous original\\nillustrations, muslin, $2.50 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0245.jp2"}, "246": {"fulltext": "H PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nMiller,\\nSTUDENTS HISTOLOGY. A course of normal histology for students\\nand practitioners of Medicine.\\nRe-written and enlarged by\\nHerbert U. Williams, M.D.,\\nProfessor of Pathology and Bacteriology, University of Buffalo.\\nOne volume of 273 pages, octavo, profusely illustrated. Extra muslin,\\n$2.00 net.\\nMoore, John William.\\nA TEXT-BOOK OF THE ERUPTIVE AND CONTINUED\\nFEVERS. 8vo, 535 pages, illustrated with lithographic plates and\\ntemperature charts, muslin, $3.25 net.\\nMorris, Henry, M.A., M.B. Lond., F.R.C.S.,\\nSurgeon to and Lecturer on Surgery at the Middlesex Hospital Member of the Council and of the\\nCourt of Examiners of the Royal College of Surgeons, England Examiner in Surgery in the\\nUniversity of London.\\nINJURIES AND DISEASES OF THE GENITAL AND URINARY\\nORGANS. One volume of 494 pages, 8vo, illustrated by 96 wood en-\\ngravings, muslin, $3.25 net.\\nMorrow, P. A., A.M., M.D.,\\nClinical Professor of Venereal Diseases Consulting Surgeon to the Bellevue Out-Door Depart-\\nment, etc.\\nVENEREAL MEMORANDA. A Manual for the Student and Prac-\\ntitioner. Second edition. 32mo, muslin, $1.00 net. (Wood s Pocket\\nManuals.)\\nATLAS OF SKIN AND VENEREAL DISEASES. One volume,\\nhalf morocco, $25.00. (Subscription.)\\nDRUG ERUPTIONS. A Clinical Study of the Irritant Effect of Drugs up-\\non the Skin. 8vo, 206 pages, one lithographed plate, muslin, $1.50 net.\\nMoullin, C. W. ManselL\\nSPRAINS, THEIR CONSEQUENCES AND TREATMENT. 8vo,\\n221 pages, muslin, $1.25 net.\\nMurreil, William, M.D., F.R.C.P. Lond.\\nA MANUAL OF MATERIA MEDICA AND THERAPEUTICS.\\nBy Special Arrangement with the Author, Revised to Conform with\\nAmerican Practice by Frederick A. Castle, M.D., New York. One\\nvolume of 522 pages, 8vo, with complete index. Muslin, $3.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0246.jp2"}, "247": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 15\\nNoman, Dr. D. Van Haren,\\nProfesseur e. o. de clinique dermatologique et syphiligraphique a la Faculty de Medecine d Ams-\\nterdam.\\nCASUISTIQUE ET DIAGNOSTIC PHOTOGRAPHIQUE DES\\nMALADIES DE LA PEAU. Consisting of photographic plates,\\nwith descriptive text. This work is to be in ten parts, unbound.\\nPrice complete, $20.00. Subscription. (Seven parts are published so far.)\\nNoyes, Henry D., fl.D.,\\nProfessor of Ophthalmology and Otology in Bellevue Hospital Medical College Executive Surgeon\\nto the New York Eye and Ear Infirmary recently President of the American Ophthalmologics!\\nSociety, etc.\\nA TEXT-BOOK ON DISEASES OF THE EYE. Royal 8vo, 832\\npages, richly illustrated with chromo-lithographic plates and 269\\nengravings. Second edition. Muslin, $5.00 net sheep, $5.75 net.\\nPaget, Stephen, F.R.C.S. Lond.\\nESSAYS FOR STUDENTS. This little work is intended to illustrate\\ncases which occur in hospital work and in private practice. It includes\\ncases of strangulated and umbilical hernia, with operations, results, etc.\\ncancer of the breast very interesting run-over cases, describing the\\nresults of heavy weights passing over different parts of the body- treat-\\nment and results aural and nasal cases. One volume of 180 pages, 8vo,\\nmuslin, $1.00 net.\\nParkes, E., n.D.\\nA MANUAL OF PRACTICAL HYGIENE. Edited by F. S. B.\\nFrancois de Chaumont, M.D. Sixth edition. With an Appendix,\\ngiving the American practice in matters relating to hygiene. Pre-\\npared by and under the supervision of Frederick N. Owen, Civil and\\nSanitary Engineer. Two volumes in one, 8vo, 946 pages. Illustrated\\nwith nine full-page plates and fine wood-engravings, muslin, $4.00 net.\\nPartridge, Edward L., fl.D.,\\nNew York City.\\nTHE OBSTETRICAL REMEMBRANCER. Profusely illustrated\\nwith miniature wood-engravings. (Wood s Pocket Manuals.) 321110,\\nmuslin, $1.00 net.\\nPaschkis, Heinrich.\\nCOSMETICS. A Treatise for Physicians. A complete translation from\\nthe German edition. 204 pages, paper, 50c. net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0247.jp2"}, "248": {"fulltext": "16 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nPictures for Physicians Offices and Libraries.\\nEdward Jenner, the first Inocula-\\ntion of Vaccine, May 14, 1796.\\nAndrew Vesalius, the Anatomist.\\nSpoonful Every Hour.\\nThe Sick Wife.\\nAmbrose Pare Demonstrating the\\nUse of Ligatures.\\nThe Young Mother.\\nThe Village Doctor.\\nProf. Charcot s Clinic at the Salpe-\\ntnere Hospital, Before the Oper-\\nation.\\nThe Rebellious Patient.\\nStudy in Anatomy.\\nWilliam Harvey Demonstrating the\\nCirculation of the Blood.\\nThe Anatomical Lecture.\\nThe Accident.\\nThe Doctor.\\nAnaesthesia.\\nSize of each, 19x24 inches. Price, each $1.00 net. Illustrated catalogue\\nsent upon application.\\nProf. Billroth s Clinic, Vienna, size 24x32, $2.00 net.\\nPiffard, Henry G., A.fl., fl.D.,\\nProfessor of Dermatology, University of the City of New York Surgeon to the Charity Hospital,\\nA GUIDE TO URINARY ANALYSIS FOR THE USE OF PHY-\\nSICIANS AND STUDENTS. 8vo, 88 pages, illustrated, $1.00 net.\\nPilcher, L. S., M.D.\\nTHE TREATMENT OF WOUNDS. Its Principles and Practice,\\nGeneral and Special.\\nIt is in every way a credit to American scholarship. New York Medical\\nJournal, April 1st, 1899.\\nOne volume, 8vo, 465 pages, profusely illustrated. Price, $3.00 net.\\nPorter, William Henry, il.D.,\\nLate Professor of Clinical Medicine and Pathology io the New York Post-Graduate Medical School\\nand Hospital Curator to the Presbyterian Hospital.\\nA PRACTICAL TREATISE ON RENAL DISEASES AND URI-\\nNARY ANALYSIS. 360 pages, one hundred illustrations, muslin,\\n$2.50 net.\\nPozzi, S., M.D.,\\nProfesseur Agrege a la Faculte de Medecine, Chirurgien de PHopital Lourcine-Pascal, Paris.\\nTREATISE ON MEDICAL AND SURGICAL GYNECOLOGY.\\nTranslated from the third French edition, under the supervision of\\nBrooks H. Wells, M.D., Lecturer on Gynaecology at the New York\\nPolyclinic Fellow of the New York Obstetrical Society and the New\\nYork Academy of Medicine. One royal 8vo volume of about 936 pages,\\nillustrated by 600 fine wood-engravings. Muslin, $5.50 net leather,\\n$6.25 ?iet.\\nRabagliati, A.,\\nHonorary Gynecologist, Late Senior Honorary Surgeon, Bradford Royal Infirmary.\\nAIR, FOOD, AND EXERCISE. AN ESSAY ON THE PREDIS-\\nPOSING CAUSES OF DISEASE. Second edition. Small 8vo,\\n236 pages, $2.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0248.jp2"}, "249": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 17\\nReference Handbook of the Medical Sciences.\\nBy various authors. Edited by Albert H. Buck, M.D., Clinical Pro-\\nfessor of the Diseases of the Ear, in the College of Physicians and Sur-\\ngeons, New York; Consulting Aural Surgeon, New York Eye and Ear\\nInfirmary. Nine volumes, imperial 8vo, muslin, $6.00 per volume;\\nleather, $7.00 per volume; half-morocco, $8.00 per volume. (Subscrip-\\ntion.) Circular on application.\\nReynolds, Edward,\\nFellow of the American Gynecological Society; of the Obstetric Society of Boston, etc.; Assistant\\nin Obstetrics in Harvard University; Physician to Out-Patients of the Boston Lying-in Hos-\\npital, etc.\\nPRACTICAL MIDWIFERY. A Handbook of Treatment. Third\\nrevised edition. 8vo, 427 pages, small octavo, 121 illustrations. Mus-\\nlin, $2.25 net.\\nRinger, Sidney, n.D., F.R.S.,\\nProfessor of Clinical Medicine Holme University College Physician to University College Hospital\\nand\\nSainsbury, Harrington, H.D., F.R.C.P.,\\nPhysician to the Royal Free Hospital, etc., etc.\\nA HANDBOOK OF THERAPEUTICS. Thirteenth edition. 8vo,\\n757 P a es muslin, $4.00 net.\\nRobson, A. W. Mayo, F.R.C.S.,\\nLeeds, Eng.\\nDISEASES OF THE GALL-BLADDER AND BILE DUCTS.\\nOne volume, octavo. (New edition in press))\\nRockwell, A. D., A.M., M.D.\\nTHE MEDICAL AND SURGICAL USES OF ELECTRICITY.\\nEntirely rewritten from the former book by Beard and Rockwell. One\\nlarge 8vo volume of 628 pages, profusely illustrated. Muslin, $3.75\\nnet; sheep, $4.50 net.\\nRose, William, M.B., B.S. Lond., F.R.C.S., and\\nCarless, Albert, M.S. Lond., F.R.C.S.\\nA MANUAL OF SURGERY FOR STUDENTS AND PRACTI-\\nTIONERS. Second Revised and Enlarged Edition. One volume,\\n1,190 pages, profusely illustrated. Octavo, muslin, $5.00 net; leather,\\n$5.75 net. The smallest complete surgery published.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0249.jp2"}, "250": {"fulltext": "18 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nRoosa, D. B. St. John, fl.D., and Ely, Edward T., n.D.\\nOPHTHALMIC AND OTIC MEMORANDA. (Wood s Pocket Man-\\nuals.) Fourth edition. One volume, 321110, 298 pages, muslin, $1.00 net.\\nRoosa, D. B. St. John, n.D.,\\nProfessor of Diseases of the Eye and Ear in the University of the City of New York Surgeon to\\nthe Manhattan Eye and Ear Hospital Consulting Surgeon to the Brooklyn Eye and Ear\\nHospital formerly President of the Medical Society of the State of New York Corresponding\\nMember of the Medico-Chirurgical Society of Edinburgh Member of the Medical Society of the\\nCounty of New York, etc.\\nTEXT-BOOK ON DISEASES OF THE EYE. Including a sketch\\nof its anatomy. Illustrated by 178 engravings and 2 chromo-hthb-\\ngraphic plates. Muslin, $4.50 net; leather, $5.25 net.\\nA VEST-POCKET MEDICAL LEXICON. Being a Dictionary of the\\nWords, Terms, and Symbols of Medical Science. Collated from the\\nbest authorities, with the additions of words not before introduced into\\na Lexicon. With an Appendix. Third revised and enlarged edition.\\nOne volume, 64mo, roan, 75c. net; or tucks, $1.00 net.\\nTHE OLD HOSPITAL, AND OTHER PAPERS. Being the second\\nrevised and enlarged edition of A Doctor s Suggestions. 8vo, 320\\npages, gilt top, uncut, dark olive cloth, $3.00 net.\\nRoth, Otto.\\nTHE MATERIA MEDICA OF MODERN MEDICINE. Second\\nedition. Translated from the revised German edition and adapted to\\nthe U. S. Pharmacopoeia. 8vo, 467 pages, muslin, $1.75 net.\\nSachs, B., n.D.,\\nProfessor of Mental and Nervous Diseases in the New York Polyclinic Consulting Neurologist to\\nthe Mt. Sinai Hospital Neurologist to the Montefiore Home for Chronic Invalids Ex-President\\nof the American Neurological Association.\\nA TREATISE ON THE NERVOUS DISEASES OF CHILDREN.\\nFor Physicians and Students. 8vo, 688 pages, profusely illustrated with\\ncolored plate, muslin, $4.25 net.\\nSalomonsen, C. J., and Trelease, William.\\nBACTERIOLOGICAL TECHNOLOGY FOR PHYSICIANS. Au-\\nthorized translation from the Second Revised Danish edition. 8vo, 163\\npages, 72 illustrations, muslin, $1.25 net.\\nSavill, Thomas, D., M.D.,\\nPhysician to the West End Hospital for Diseases of the Nervous System, London Examiner in\\nClinical Medicine in the University of Glasgow Formerly Medical Superintendent of the\\nPaddington Infirmary Assistant Physician to the West London Hospital, etc. etc.\\nCLINICAL LECTURES ON NEURASTHENIA. One volume, 8vo,\\n156 pages, muslin, $1.50 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0250.jp2"}, "251": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 19\\nSchmidt=Rimpler, Dr. Herman,\\nProfessor of Ophthalmology and Diseases of the Ophthalmoscopic Clinic at Marburg, Germany.\\nOPHTHALMOLOGY AND OPHTHALMOSCOPY. A Complete\\nTreatise upon Diseases and Injuries to the Eye, for Students and Prac-\\ntitioners of Medicine. Revised and edited by D. B. St. John Roosa,\\nM.D., Professor of Diseases of the Eye and Ear in the New York Post-\\nGraduate Medical School Surgeon to the Manhattan Eye and Ear\\nHospital, etc. Royal 8vo, 571 pages, illustrated by 183 wood-engravings\\nand by three colored plates. Muslin, $5.00 net.\\nSchreiber, August.\\nGENERAL ORTHOPEDICS, INCLUDING ORTHOPEDIC SUR-\\nGERY. Complete translation from the original German edition. 8vo,\\n357 P a es 388 illustrations, muslin, $1.75 net.\\nSchroeder, Aimee Raymond, M.D.\\nHEALTH NOTES FOR YOUNG WIVES. 121110, 218 pages, fancy\\nhalf cloth, Si. 00 net.\\nSemeleder, Dr. Friedrich,\\nFormerly Physician in Ordinary to his Majesty, the Emperor of Mexico Member of the Royal\\nMedical Society of Vienna and of the Medical Society of Pantheon in Paris Formerly Member\\nof the Medical Faculty of the University of Vienna, and Surgeon to the Branch Hospital at\\nGumpendorf.\\nRHINOSCOPY AND LARYNGOSCOPY: THEIR VALUE IN\\nPRACTICAL MEDICINE. Translated from the German by Edward\\nT. Caswell, M.D. With woodcuts and two chromo-lithographic plates.\\n8vo, 191 pages, muslin, $2.50 net.\\nSexton, Samuel, M.D.,\\nAural Surgeon to the New York Eye and Ear Infirmary Fellow of the American Otologica\\nSociety Fellow of the New York Academy of Medicine Member of the Medical Society of the\\nCounty of New York, and of the Practitioners Society of New York.\\nTHE EAR AND ITS DISEASES, BEING PRACTICAL CONTRI-\\nBUTIONS TO THE STUDY OF OTOLOGY. Edited by Christ-\\nopher J. Colles, M.D. 8vo, 473 pages, illustrated, muslin, $3.25 net.\\nSmart, Chas., M.D., Major U.S.A.\\nA HANDBOOK FOR THE HOSPITAL CORPS OF THE UNITED\\nSTATES ARMY AND STATE MILITARY FORCES. New edi-\\ntion, revised and enlarged (1898). 358 pages, illustrated, extra muslin.\\nPrice, $2.25 net.\\nSpencer, Walter Q., M.B., M.S., F.R.C.S., London.\\nOUTLINES OF PRACTICAL SURGERY. This is not only the\\nnewest book on Surgery, and therefore indispensable to the progressive\\nsurgeon, but it is of much value for other reasons. For ready consul-\\ntation it is probably unsurpassed, since theoretical discussions and dis-\\nputed points find no place in its pages, which are devoted to a practical\\nconsideration of purely practical matters. One volume of 704 pages,\\n8vo, well illustrated by wood-engravings. Extra muslin, $5.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0251.jp2"}, "252": {"fulltext": "20 PUBLICATIONS OF WILLIAM WOOD COMPANY\\nStarr, M. Allen, M.D., Ph.D.,\\nProfessor of Diseases of the Mind and Nervous System College of Physicians and Surgeons, New\\nYork.\\nFAMILIAR FORMS OF NERVOUS DISEASE. With illustrations,\\ndiagrams, and charts. 8vo, 350 pages, muslin, $2.50 net.\\nBRAIN SURGERY. 8vo, 306 pages, illustrated, muslin, $2.50 net.\\nSteel, J. H., M.D.\\nOUTLINE OF EQUINE ANATOMY. A Manual for the use ot Veteri-\\nnary Students in the Dissecting Room. i2mo, 312 pages, muslin, $2.50\\nnet.\\nStewart, R. W., H.D., M.R.C.S.,\\nPittsburg.\\nTHE DISEASES OF THE MALE URETHRA. One volume of\\n229 pages, post-octavo, illustrated by numerous wood-engravings. Mus-\\nlin, $2.25 net j flexible morocco, $3.00 net. {Medical Practitioners\\nLibrary.\\nSternberg, George M., M.D., F.R.M.S.,\\nSurgeon-General U. S. Army Director of the Hoagland Laboratory, Brooklyn, N. Y. Honorary\\nMember of the Epidemiological Society of London, of the Royal Academy of Medicine of Rome,\\nof the Academy of Medicine of Rio de Janeiro, of the American Academy of Medicine, etc.\\nA TEXT-BOOK OF BACTERIOLOGY. One volume, large 8vo, 693\\npages, illustrated by heliotype and chromo-lithographic plates and two\\nhundred engravings in black and colors. Extra muslin, $4.50 net; brown\\nsheep, $5.25 net.\\nIMMUNITY: PROTECTIVE INOCULATIONS IN INFECTIOUS\\nDISEASES AND SERUM-THERAPY. Post 8vo, 332 pages, muslin,\\n$2.00 net; flexible morocco, $2.75 net.\\nStevenson, W. F., A.B., M.B., M.Ch. Dublin Univ.,\\nSurgeon-Colonel (Army Medical Staff, British Army) Professor of Military Surgery, Army Medi-\\ncal School, Netley.\\nWOUNDS IN WAR; THE MECHANISM OF THEIR PRODUC-\\nTION AND THEIR TREATMENT. One volume, 8vo, 450 pages,\\nprofusely illustrated by half-tone plates, etc., muslin. Price, $4.00 net.\\nStewart, T. Grainger, M.D.,\\nFellow of the Royal College of Physicians Physician to the Royal Infirmary Lecturer on Clinical\\nMedicine; formerly Pathologist to the Royal Infirmary; Lecturer in General Pathology at\\nSurgeons Hall, and Physician to the Royal Hospital for Sick Children Extraordinary Member\\nand formerly President of the Royal Medical Society of Edinburgh.\\nCLINICAL LECTURES ON ALBUMINURIA. 8vo, 261 pages,\\nmuslin, $2.00 net.\\nSupplement to the International Encyclopedia of\\nSurgery.\\nOne imp. 8vo volume, of 1,136 pages, illustrated. Muslin, $6.00 leather,\\n$7.00; half morocco, $8.00. Circular on application.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0252.jp2"}, "253": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 21\\nSurgery, International Encyclopedia of.\\nBy Various Authors. Edited by Dr. John Ashhurst, Jr. Seven volumes,\\nincluding Supplement, imp. 8vo, of about 950 pages each, muslin, $6.00\\nleather, $7.00 half morocco, $8.00. Send for circulars. (Subscription.)\\nTait s, Lawson, Perineal Operations, see ricKay.\\nThomas, John J.\\nRevised and Enlarged by WILLIAM H. S. WOOD, Esq.\\nTHE AMERICAN FRUIT CULTURIST. Twentieth edition. Post\\n8v0, 784 pages, illustrated by 800 wood-engravings. Muslin, $2.50.\\nTreves, Frederick, F.R.C.S.,\\nConsulting Surgeon to and Emeritus Professor of Surgery at the London Hospital.\\nINTESTINAL OBSTRUCTIONS. Its varieties with their Pathology,\\nDiagnosis, and Treatment. One volume, 8vo, 576 pages. Illustrated by\\n118 half-tone cuts. New and Revised Edition. Price, muslin binding,\\n$4.00 net.\\nTurner, Dawson, V.A., M.D.,\\nLecturer on Medical Physics and Electro-Therapeutics, Surgeons Hall, Edinburgh.\\nA MANUAL OF PRACTICAL MEDICAL ELECTRICITY. One\\nvolume, 8vo, 351 pages, profusely illustrated by wood engravings and\\nfull-page half-tones, $2.50 net.\\nTwentieth Century Practice.\\nAN INTERNATIONAL ENCYCLOPEDIA OF MODERN MEDICAL\\nSCIENCE. By Leading Authorities of Europe and America. Edited\\nby Thomas L. Stedman, M.D., New York City. To be completed in\\n20 volumes, royal 8vo, published one every three months. Muslin,\\n$5.00, leather, $6.00; half morocco, $7.50. Nineteen volumes now ready.\\n(Subscription.) Circulars on application.\\nValentine, Ferd. C, M.D.,\\nProfessor of Genito-Urinary Diseases, New York School of Clinical Medicine, etc., etc.\\nTHE IRRIGATION TREATMENT OF GONORRHOEA, ITS\\nLOCAL COMPLICATIONS AND SEQUELAE. One volume, 8vo,\\n230 pages, profusely illustrated. Muslin, $2.00 net.\\nVest Pocket Hedical Dictionary, see Buck.\\nVeterinarian s Visiting List and Call=Book.\\nBy D. P. Yonkerman, D.V.S. Twenty pages of closely printed matter\\nessential to the veterinarian, and blank pages, specially arranged, for\\nfull record of cases, etc., etc. Bound in black morocco cover, with flap\\nand pocket pocket-book style, $1.25 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0253.jp2"}, "254": {"fulltext": "22 PUBLICATIONS OF WILLIAM WOOD COMPANY.\\nVisiting List (Medical Record), or Physician s Diary.\\nContaining, besides the diary, much useful information on many subjects of\\ndaily interest to the physician. Prices For thirty patients a week;\\nhandsome red or black leather binding, with or without dates, $1.25,\\nfor sixty patients a week, same style, with or without dates, $1.50.\\nRemovable, fitting into black sealskin and calf wallets, from $2.50 to $4.00.\\nSend for a circular. Prices all net.\\nWalker, Norman, M.D.,\\nFellow of the Royal College of Physicians of Edinburgh Assistant Physician for Diseases of the Skin\\nto the Royal Edinburgh Infirmary.\\nAN INTRODUCTION TO DERMATOLOGY. One volume of 263\\npages, 8vo. With a- frontispiece and 29 exquisite chromo-lithographic\\nplates, besides 34 illustrations in the text. Price, muslin, $3.00 net.\\nWalsh, David, M.D.,\\nEdinburgh. Physician, Weston Skin Hospital, Loudon Honorary Secretary, London Roentgen\\nSociety, London.\\nPREMATURE BURIAL FACT AND FICTION. 8vo, 49 pages,\\n50 cents net.\\nEXCRETORY IRRITATION, AND THE ACTION OF CERTAIN\\nINTERNAL REMEDIES ON THE SKIN. One volume, 8vo, 76\\npages, 75 cents net.\\nROENTGEN RAYS IN MEDICAL WORK. One volume, 8vo, pro-\\nfusely illustrated by wood engravings and a great number of full-page\\nhalf-tone plates, $2.25 net.\\nWalsham, W. J., H.B., C.H. Aberd., F.R.C.S. Eng.,\\nSenior Assistant-Surgeon, Lecturer on Surgery, and Surgeon-in-Charge of the Orthopedic De-\\npartment, St. Bartholomew s Hospital, etc.\\nNASAL OBSTRUCTION; THE DIAGNOSIS OF THE VARIOUS\\nCONDITIONS CAUSING IT, AND THEIR TREATMENT. 362\\npages, profusely illustrated, 8vo, muslin, $2.50 net.\\nWalsham and\\nHughes, Wm. Kent, il.B. Lond., fl.B. flelb.,\\nfl.R.C.S. Eng., L.R.C.P. Lond.,\\nOrthopedic Surgeon, St. Vincent s Hospital Assistant Surgeon, Children s Hospital, Melbourne.\\nTHE DEFORMITIES OF THE HUMAN FOOT, WITH THEIR\\nTREATMENT. 558 pages, post 8vo, profusely illustrated by 296\\nengravings, muslin, $4.00 net.\\nWarren, J. Collins, M.D.,\\nAssistant Professor of Surgery, Harvard University Surgeon to the Massachusetts General\\nHospital Member American Surgical Association Honorary Fellow Philadelphia Academy of\\nSurgery.\\nTHE HEALING OF ARTERIES AFTER LIGATURE IN MAN\\nAND ANIMALS. 8vo, 184 pages. Superbly illustrated with twelve\\nfull-page plates in black and colors. Muslin, $2.75 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0254.jp2"}, "255": {"fulltext": "PUBLICATIONS OF WILLIAM WOOD COMPANY. 23\\nWhittaker, J. T., M.D., LL.D.,\\nProfessor of the Theory and Practice of Medicine, Medical College of Ohio, etc., etc.\\nA PRACTICE OF MEDICINE, PREPARED FOR STUDENTS AND\\nPRACTITIONERS. 8vo, 700 pages, illustrated, muslin, $4.75\\nnet leather, $5.50 net.\\nWendt, Edmund C, M.D.,\\nCurator of St. Francis Hospital Pathologist and Curator of the New York Infant Hospital, etc.\\nA TREATISE ON CHOLERA. Edited and prepared in Association\\nwith John C. Peters, M.D., New York John B. Hamilton, M.D.,\\nSurgeon-General U. S. Marine Hospital Service, and Ely McClellan,\\nM.D., Surgeon U. S. Army. 8vo, 503 pages, illustrated with maps\\nand engravings, muslin, $2.50 net.\\nWilliams, J. W. Hume,\\nOf the Middle Temple, Barrister-at-Law, London.\\nUNSOUNDNESS OF MIND IN ITS LEGAL AND MEDICAL\\nCONSIDERATIONS. A complete reprint of this important work.\\n8vo, 166 pages, muslin, $1.50 net.\\nWitthaus, R. A., A.M., M.D.,\\nProfessor of Medical Chemistry and Toxicology in the University of Vermont Member of the\\nChemical Societies of Paris and Berlin, etc.\\nTHE MEDICAL STUDENT S MANUAL OF CHEMISTRY.\\n(American Series of Medical Text-Books.) Fourth revised edition.\\n556 pages and 62 woodcuts, muslin, $3.25 net.\\nESSENTIALS OF CHEMISTRY AND TOXICOLOGY. For the\\nUse of Students in Medicine. Twelfth edition. (Wood s Pocket\\nManuals.) 321110, 319 pages, muslin, $1.00 net.\\nGUIDE TO URINALYSIS AND TOXICOLOGY. For Students\\nand Practitioners. Fourth revised edition. Oblong i2mo, interleaved,\\nmuslin, $1.00 net.\\nWitthaus, R. A., M.D., and Becker, T. C, Esq.\\nWith a staff of Collaborators.\\nMEDICAL JURISPRUDENCE AND TOXICOLOGY. Four vol-\\numes, 8vo, bound in muslin and leather, at $5.00 and $6.00 respectively.\\n(Subscription.) Circulars on application.\\nWood s Household Practice of Medicine, Hygiene, and\\nSurgery.\\nA Practical Treatise for the Use of Families, Travellers, Seamen, Miners,\\nand others. By Various Authors. 8vo, 765 pages, illustrated by\\ncolored lithographic plates and five hundred fine wood-engravings.\\nMuslin, $5.00 net.\\nWood s Index Rerum.\\nThe finest arrangement yet devised for all ready record and reference\\npurposes. For professional use in recording your cases, or in grouping\\nyour cases from your case books. Patent index. Vowel arrange-\\nment. Bound for permanency in ledger binding, $5.00 net.", "height": "4474", "width": "2428", "jp2-path": "irrigationtreat00vale_0255.jp2"}, "256": {"fulltext": "i H3JH-\\n24 PUBLICATIONS OF WILLIAM WOOD JOMP.\\nn\\nWood s Pocket Lexicon\\nSee ROOSA.\\nWoodburn, W. D., L.D.S.,\\nGlasgow, Scotland.\\nON EXTRACTION, WITH NOTES ON THE ANATOMY AND\\nPHYSIOLOGY OF THE TEETH. One volume, i 2 mo, 104 pages,\\nprofusely illustrated. Extra muslin, $1.25 net.\\nYonkermail, D. P. See Veterinarian s Visiting List.\\nZiegler, Ernst,\\nProfessor of Pathological Anatomy and of General Pathology in the University of Freiburg.\\nTEXT-BOOK OF GENERAL PATHOLOGY. Translated from the\\nNinth German edition, under the editorship of Albert H. Buck, M.D.,\\nNew York, by a select corps of specialists. Royal 8vo, 618 pages, with\\n542 illustrations in black and numerous exquisite tints, and a chromo-\\nlithographic plate. Muslin, $5.00 net leather, $5.75 net.\\nZiemssen, H. von, M.D. Munich.\\nCYCLOPAEDIA OF THE PRACTICE OF MEDICINE. By Vari-\\nous Authors. Complete in twenty volumes, royal 8vo. A few sets\\nleft. 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