lymphatics along the dorsum or side of the penis. In chordee, great pain is felt from the stretching of the inflamed erectile tissue. This pain is measurably relieved by bending the penis so as to increase the bow, and in this way to slacken the string; and it passes off entirely . as erection disappears. Chordee is most frequent during the night and toward morning. It may render sleep impossible. The point of greatest curvature is situated anywhere along the pendulous urethra, most frequently near the glans-gland arqué (Ricord). The pernicious practice of "breaking the chordee," which consists in roughly straightening the penis when erect, gives rise to a hæmorrhage which may become excessive and be the starting-point of organic stricture.

After the disease has continued at its height for from one to three weeks under favorable circumstances, the pain on urination, which had traveled down to the root of the penis, ceases, the discharge becomes more watery, chordee infrequent. The discharge diminishes down to a drop in the morning, the meatus again sticks together, and finally even this ceases, and the patient is well.

During all this local inflammatory disturbance there is little if any constitutional sympathy. There may be some feverishness for a time, or, in nervous individuals, a real or fancied feeling of prostration during the continuance of the discharge.

THE DURATION OF GONORRHEA is variable. A well-managed case lasts from three to six weeks, as a rule; but the discharge may continue for months or even years. A first gonorrhoea is the most severe; but it is also the most certain to get perfectly well if carefully managed.

COURSE OF GONORRHEA.-The urethral inflammation commences at the meatus and travels slowly backward. According to Desormeaux,* on the eighth day of the discharge, the anterior half of the urethra has become invaded, its surface is congested, without polish, and covered with little bare spots, like those seen in balanitis, where the epithelium has exfoliated. There is no ulceration. When the discharge is older, the lesions are identical, but deeper seated. The disease tends to limit itself and to become localized at the bulb, in the fossa navicularis, or at some intermediate point, where there may have. been much chordee. At these points of localization, the surface is of a vinous red, the polish of healthy epithelium is absent, and there are perhaps a few granulations. The submucous tissue thickens, impairing the vascularization of the part, and this process may go on to the formation of organic stricture. Where the disease runs this course, instead of getting well, we have gleet.

GLEET. In gleet, whether due to forming stricture or not (the former condition is vastly more common), a certain amount of sticky,

* "De l'Endoscope et de ses Applications au Diagnostic et au Traitement des Affections de l'Urèthre et de la Vessie," Paris, 1865.

bluish fluid-often only a drop at the meatus in the morning-continues to be secreted after gonorrhoea-from altered patches of the urethra-or coming from the stretched and congested membrane behind a stricture.

Gleet, then, is a symptom of two structural lesions, and signifies that there are patches of congestion in the canal, covered or not by granulations, or that stricture exists, and that the discharge comes. from behind it. Granulations, analogous to those seen in granular lids, may be observed, when present, through a urethral tube, as may the little vegetations, or polypoid growths, which sometimes spring from altered patches of urethral membrane. Idiopathic gleet may come on in individuals of a strumous or gouty diathesis, the immediate cause being a broken-down constitution or acid urine. Prostatic congestion and enlargement are also liable to be attended by a slight gleet, as are also mucous patches in the urethra, etc. Of these varieties, the strumous urethritis, like other manifestations of the diathesis, is usually found in early life, while gouty gleet belongs more particularly to middle age. An explosion of gout may come on in this way, a distinctly purulent urethritis of some severity appearing suddenly in a gouty individual, after chilling of the legs or excess at table, especially in regard to drink. When an individual with a gleet. is found to be gouty, whether his discharge be idiopathic or not, it is particularly advisable to enforce urethral hygiene and general dietetics.

Gleet tends to last indefinitely, but is often so very slight as to be ignored. An individual so affected is a ripe subject for bastard gonorrhoea. The simple congested patches, without sensible thickening or granulations, which furnish the gleety discharge after an ordinary gonorrhoea, are kept from getting well by alcohol, malt liquors, sexual excess, fatigue, violent exercise, anæmia, gouty or strumous habit, etc. If one of these causes for the continuance of a discharge do not exist, it will usually get well of itself, or certainly with the help of some mild injection, or after a few introductions of the sound. Gleet is contagious when purulent-the more copious and creamy the discharge the greater its infecting power, but only if it contains gonococci.

COMPLICATIONS OF URETHRAL INFLAMMATION.-Of the complications of gonorrhoea, some have already been described: balanitis, inflammatory phimosis, chordee, possible retention, and hæmorrhage. Others will receive attention when considering the organs they affect -epididymitis, orchitis, inflammation of seminal vesicles, gonorrhoeal cystitis, catarrhal prostatitis, prostatic congestion, prostatic and periprostatic abscess. The others will be dealt with after the section on treatment-folliculitis, cowperitis, suppurating peri-urethritis, lymphangitis, and adenitis-all being extensions of inflammation from the

urethral mucous membrane; finally will be considered gonorrhoeal rheumatism, gonorrhoeal ophthalmia, and gonorrheal conjunctivitis. Treatment of Urethral Inflammation.-There are two methods of treating inflammation of the urethra :

1. The abortive-which seeks to strangle it at once.

2. The methodic-a treatment based upon the intensity and stage of the inflammation.

Injection of the urethra is a proceeding so often resorted to, both early and late, in inflammation of the canal, that the subject of treatment may be well introduced by a few words upon a proper method of performing this surgical manœuvre.

First, as to a choice of instrument. The nozzle of the syringe must be short, for fear of scratching and irritating the already inflamed membrane, and must expand suddenly, so as to be adaptable to orifices of all sizes. Any syringe more or less like the one shown in Fig. 19 is capable of enabling an injection to be made. without wetting the patient or scratching the inside of his inflamed urethra. Such a syringe should hold between three and four drachms, not that the whole of this quantity must be introduced at each injection, but because that amount may be necessary to properly distend the urethra in many instances.

FIG. 19.

To inject elegantly, the patient encircles his penis behind the corona with the thumb and first finger of his left hand, uncovering the glans penis in part or wholly. In the right hand he holds the syringe between his thumb and last three fingers, placing the top of his index-finger within the ring. He now inserts the blunt nozzle into the flaring meatus, and, pulling the penis forward with his left hand, he pushes the blunt nozzle well into the gaping urethra, and at the same time slowly causes the piston to descend. He continues this manoeuvre until a positive feeling of distention in the deep urethra warns him that the urethra will hold no more. Then, tightening the encircling grasp of the left hand, he removes the syringe and holds. some convenient vessel in front of the penis. Now relaxing the pressure upon the urethra, the injected fluid spurts out without soiling clothing or hands. It is always well to pass urine immediately before using an injection, that the canal may be thus freed from pus.

ABORTIVE TREATMENT.-The idea of aborting gonorrhoea by the internal use of balsams has been abandoned. The old idea of abortive treatment was to irritate the urethra, substituting a simple for a poisonous inflammation. The modern idea is by hot irrigation to soothe the membrane and wash out the poison, or by antiseptic or antipara

sitic drugs to destroy the gonococcus. Nitrate of silver and chloride of zinc, formerly in great repute, are no longer relied upon, and this is fortunate, for they often did harm, and rarely, if ever, any good in true gonorrhoea, the only one of the class of maladies we are considering really worth a serious effort at producing its abortion. Iodoform has been tested and abandoned, and the present favorites are prolonged irrigation and varying strengths of the bichloride of mercury. If the abortive treatment is to be tried as such, it should be used within the first twenty-four hours of the commencement of an attack.

The bichloride of mercury in solution has been used at varying strengths up to one in one thousand-nearly half a grain to the ounce. This, however, is not capable in my hands of aborting gonorrhoea. Even a sixteenth of a grain in the ounce often produces severe pain, and greatly increases the grade of the inflammation in a fresh, young case of true gonorrhoea. I have never, with the bichloride of mercury, been able to entirely arrest a true gonorrhoea at once or to kill the gonococcus-using it weak or strong, at long or short intervals.

The irrigation method has had some ardent advocates. There are two ways of using it-one deep, the other superficial. By the deep method a small, soft catheter is gently inserted up to the hole in the triangular ligament, and a pint or more of very hot water is run through the urethra one or more times a day. Sometimes a strong astringent injection, as of tannin, is used once a day after the injection. This method I believe to be dangerous in some cases. It will abort urethritis and bastard gonorrhoea, but in my hands it has always failed to modify a virulent attack in any way except to aggravate it, and I have treated a number of cases in which cystitis, prostatic congestion-even abscess-epididymitis, etc., had been directly caused by this abortive method of deep urethral irrigation early in an attack at the hands of other surgeons. I think this method often useful in old cases or late in an attack-not in the beginning. Dr. Holbrook Curtis and Dr. Brewer think highly of it in the early stages, and have advocated it in the journals.

The method by anterior irrigation is more rational, since the virulence of the malady confines itself at first to the anterior segment of the urethra. This method combines irrigation with a very mild antiseptic action. Its introduction in New York is largely due to Dr. Halstead and the Roosevelt Dispensary. The method is simply to put a quart of tepid or hot water, at a strength of half a grain of bichloride of mercury in twenty-two ounces (about 1 in 20,000), into a fountain syringe, the rubber tube of which is armed with a nozzle of glass shaped like Fig. 20. This blunt nozzle is simply crowded into the urethra, and then the fluid is allowed to flow. Soon the canal is distended, after which

FIG. 20.

*

the whole quart of fluid is allowed to run through the anterior urethra by slightly letting up the pressure on the orifice so that the water shall trickle out slowly alongside of the glass nozzle. L. F. Keifer has devised a hard-rubber nozzle for irrigation (Fig. 21). The nozzle is kept crowded into the meatus, the fluid runs in through one arm and out at the other, the urethra being kept ballooned out, and a constant irrigation being kept up by regulating the amount of outflow with the finger over the orifice of outflow in the arm of exit. This irrigation is repeated three times a day, and the malady, if treated within twenty-four hours of the beginning of the attack, may be sometimes aborted, it is said. This is true for urethritis; if the gonorrhoea is

A

FIG. 21.

virulent, it can nearly always be moderated in violence and sometimes cured in the second week-at the earliest. This is my present view; others claim better results.

Instead of the fountain syringe, I now generally get the patient to use for himself a little red soft-rubber irrigator called the universal injector (Fig. 22). I direct the patient to dissolve one fifth of a grain of bichloride of mercury in eight ounces of water (or to make the solution even much weaker if this strength causes pain), and to practice irrigation of his urethra with it in the manner described above about three times a day. A speedy diminution in the discharge often follows, but not invariably. I rely upon it, in the beginning of all acute attacks, with growing confidence.

FIG. 22.

This treatment, even if it fails, has yet the enormous advantage that it can not possibly do harm, and that stricture can not be caused by it, a statement which could not be made of the old abortive treatment by strong injections of the nitrate of silver.

METHODIC TREATMENT OF URETHRAL INFLAMMATION.-This is the rational treatment for all forms of urethral discharge, whatever their nature, based upon the quantity and quality of the discharge and the grade of the inflammatory action.

The hygienic part of the treatment is of the utmost importance. If it be disregarded, the best-directed efforts may fail to arrest the discharge. Many cases of simple urethritis and bastard gonorrhoea require little else than the hygienic treatment. The hygiene of gonorrhoea is as follows:

"Medical Record," April 9, 1887.