than three times a week, and at lengthening intervals as the strength of the solution is increased. If this method is suitable, each injection produces a more or less pronounced effect upon the discharge; if improvement is not manifest after two or three injections, it is useless STOHLMANN, FFARRE&CC. FIG. 24. to continue the course. Occasionally a fifty-per-cent solution in water of the glycerole of tannin will arrest a deep urethral discharge after the nitrate of silver fails. I have experimented with many other substances only to discard them. The deep urethral syringe has almost entirely displaced in my practice the use of the various medicated soluble bougies and the cupped sound with tanno-glycerin paste. Another kind of injection, called isolating, highly praised by Caby,* is still occasionally resorted to. It consists in throwing in bismuth, or calamine, or chalk, suspended in a sticky fluid, or as soluble suppositories-the object being to coat over the walls of the urethra with one of these insoluble powders. They sometimes act effectively, but often cause a good deal of discomfort from the collection of little hard lumps of bismuth and mucus along the canal. The following is a good type of this style of injection, combined with a mild stimulant: Milton is loud in praise of blistering the penis externally, combined with mild astringent injection; but this treatment is altogether too severe for general adoption. Electricity, both the continued and the induced currents, internally and externally applied, has been vaunted for the cure of gleet. In my hands it has proved of no value. Gleet, unconnected with serious urethral lesions, gets well under treatment by injection. If the discharge remains gleety a fortnight or more, even if there be no urethral lesion of importance, a well-oiled, conical, smoothly-polished sound, as large as the meatus will comfortably admit, should be passed into the bladder, with the utmost gentleness and slowness, and withdrawn at once with the same deliberation and care. This simple operation, repeated every third or *“Nouveau Mode de Traitement de divers Affections génitaux chez l'Homme et chez la Femme par l'Emploie de Sous-nitrate de Bismuth." Thèse, Paris, 1858. fourth day, will rarely fail to cure the discharge. The sensibility of the canal becomes blunted by contact with the instrument, its irritability overcome by the slight distention to which it is subjected, while the tonic effect of the cold metal is also probably a factor in producing the good effect. A steel instrument is much better than a soft bougie. There is no object in leaving the instrument longer in the canal than it takes to pass it slowly into the bladder and as slowly withdraw it. The instrument must fill without stretching the meatus. The meatus may be congenitally small, and this alone may keep up a discharge. In such a case a little pouch can be felt with a bent probe, formed behind the lower commissure of the meatus. Such a condition may be promptly relieved by incising the meatus. This simple operation occasionally cures a gleet of long standing. Finally, in regard to instruments, the greatest care and gentleness should be employed. Used too often or clumsily, they do harm by increasing the grade of inflammation, or possibly bringing on an attack of epididymitis. In the cases under consideration, no instrument should be reintroduced until all irritation and temporary increase of discharge, produced by its previous use, have subsided for twenty-four hours. Where patches of urethral congestion keep up a discharge, they may be detected by passing a full-sized bulbous bougie into the bladder. When the head of the instrument reaches the altered spot, the patient will complain of slight pain, which will disappear as the bulbous head of the instrument passes on to the healthy urethra beyond. Any little thickening in the walls of the canal is recognized at the same time. Furthermore, if a patient with one of these patches makes water into a glass vessel, and the fluid be held up to the light, one or more thready filaments may be seen gradually sinking through the urine. If one of these be caught and placed under the microscope, it will be found to consist of pus-corpuscles adhering together; in other words, it is a soft scab, and indicates that a portion of urethra is not covered by healthy epithelium, but is abraded (not ulcerated), and covered by soft, round leucocytes. These shreds are always found in cases of forming stricture, in every stage of the complaint. When these signs of urethral lesion exist, the gentle use of the steel sound becomes the first requisite of treatment. The balsams may be discontinued, and injections become of secondary importance. Urethral hygiene (p. 43), and the gentle, persevering use of a full-sized conical steel sound, will often effect a cure. In some cases the "coldsound" (Winternitz*), a closed silver tube like a catheter, with a partition running down centrally within, nearly up to the tip, so that water injected into one of the compartments, after circulating through the instrument, runs out from the other compartment, is worth a trial. I use iced water for about five minutes, and reapply about every second * "Berl. klin. Wochenschrift," July 9th, 1877. day. In some cases of urethral neuralgia and of pollution also, this instrument yields good results. The endoscope is of some service in treating obstinate cases, but its aid is very rarely required. Thompson's remark about its usefulness is a fair criticism: "If a man has a good and tolerably practiced hand, with a fair share of intelligence, I do not think he will gain a great deal by the endoscope; and, if he has not, I think it will be of no use at all." Yet the altered spots of urethral membrane can be very clearly seen through the endoscope, granulations can be detected where they exist, and local applications of considerable strength made, which could not be applied with safety by any other means. The expensive and complicated instruments of Desormeaux, Cruise, and modifications of the same, are but little if at all better than a simple straight urethral tube of black, hard rubber furnished with an obturator. The silver tube known as Klotz's endoscope answers well. All the illumination required for these tubes may be obtained by reflection from a concave mirror strapped to the forehead. For examining the deep urethra, however, direct sunlight or a strong artificial light is necessary for illumination. To make a thorough inspection, the tube should be introduced well into the membranous urethra, the obturator withdrawn, the oil and mucus wiped away from the membrane presenting at the bottom of the tube, and then, the illumination being brought to bear, each successive portion of membrane may be inspected as the tube is withdrawn. The healthy mucous membrane has a pale-pink color, and contrasts strongly with congested spots, which are of a vinous red without polish. Such spots can be plainly seen as they come across the end of the tube, and any granulations upon them are readily recognized by the practiced eye. The topical remedy for granulations suggested by Desormeaux, and which can be very accurately applied through the tube by means of a little cotton twisted upon a long probe, is a solution of nitrate of silver of from 3 ij to the 3j up to the saturated solution. The latter should be only used in the case of large granulations, and then is to be very sparingly applied. Iodine, sulphate of copper, tannin, carbolic acid, etc., used as local applications, give fair results. The advantages of treating by the endoscope are, that the spot to which an application has been made may be inspected from week to week, and the effect of treatment critically observed. This topical treatment is to be repeated at first twice a week, then weekly for several months. W. T. Belfield,* of Chicago, has an excellent chapter on endoscopy. He is the exponent in this country of the views of Josef Grünfeld, of Vienna, whose work and instrument he extols. The electric cys "Discases of the Urinary and Male Sexual Organs," New York, 1884, p. 69. "Die Endoskopie der Harnröhre und Blase," one of the volumes of Billroth and Lücke's "Deutsche Chirurgi." toscope of Nitze, made by Hartwig, of Berlin, is an analogous instrument for inspecting the bladder. It has a visual field, it is claimed, of considerable size. Leiter, of Vienna, makes also an admirable endoscope and cystoscope illuminated by an electrical lamp. SEQUELE OF GONORRHEA. Certain unusual sequelæ of gonorrhoea may be mentioned here before entering into a detail of its complications. After discharge has absolutely ceased, the patient is usually as well as he was before; but there are exceptions. Among the most frequent of these is pain on passing water, ranging from an itching up to an absolute burning; and this neurosis may last from a few months up to many years. * The pain may be confined to erections and ejaculations, the latter depending upon some disturbance at the prostatic sinus. There may be urethral pains independent of erection or urination, sometimes severe in character-perhaps paroxysmal-and known as urethral neuralgia. These different kinds of pains disappear, as a rule, in a few weeks or months. No treatment, except the observance of urethral hygiene, seems to be of much service. If they persist, there is probably some lesion of the canal, even although there be no discharge. Where there is no lesion, a resumption of the physiological exercise of the organ tends greatly to reduce the abnormal sensibility of the urethra. The judicious use of steel sounds at intervals, and the local employment of electricity, seem to hasten a cure. Where the trouble persists, a careful search should be made for stricture or deep urethral congestion. A condition of irritability of the neck of the bladder is sometimes left behind by gonorrhoea, attended by frequent desire to urinate, and sometimes a spasmodic action of the detrusor during micturition (neuralgia of the vesical neck). The urethra sometimes remains inelastic, causing a little dribbling. Both of the above sequelæ are overcome by hygiene and the steel sound. Castelnaut mentions a singular condition of prostatic and urethral anæsthesia-the patient having no orgasm, and being unconscious of the passage of semen-left behind by gonorrhoea, and coinciding with an inflammatory engorgement of the urethra. The normal sensation returned after several months. Various other unimportant functional troubles have been mentioned as sequelae of gonorrhoea. * The disease formerly known as "dry gonorrhea" is simply urethral neuralgia, coming on alone without any antecedent gonorrhoea-the canal not being inflamed, nor the malady, in any sense, a gonorrhoea. "Observation de Blennorrhagic suivie de Douleurs et d'Abolition de la Sensation agréable pendant le Coit," "Ann. des Mal. de la Peau et de la Syph.," 1843-'44, tome i, pp. 148-151. CHAPTER IV. COMPLICATIONS OF GONORRHEA. Folliculitis. Inflammation of Lacuna Magna.-Cowperitis.-Peri-urethritis.-Adenitis.-Lymphangitis.-Gonorrhoeal Rheumatism; Hydrarthrosis, Inflammatory, affecting Sheaths of Tendons; Bursa.-Diagnostic Table of Simple and Gonorrhoeal Rheumatism.-Gonorrhoeal Ophthalmia.Gonorrhoeal Conjunctivitis.-Diagnostic Table of Gonorrheal Conjunctivitis and Gonorrheal Ophthalmia. FOLLICULITIS.-During the acute stage of gonorrhoea, sometimes there appear along the urethra, especially in the region of the fossa navicularis, one or more small, round tumors, slightly sensitive to pressure, varying from the size of the head of a large pin to that of a pea. These tumors are cysts by occlusion of the mouths of the lacunæ of Morgagni. Inflammation seals the orifice of the follicle, and the lacuna is converted into a cyst containing pus. As the latter continues to be produced, the cyst enlarges. The pain accompanying it is insignificant, and the little lump is detected by accident. It feels like a hard ball moving under the skin and attached by a pedicle. This pedicle is the obliterated neck and orifice of the follicle. The little tumor tends to remain stationary for some time, and then suddenly to enlarge, soften, involve the integument, open externally (very rarely into the urethra), and, after discharging, remain fistulous for a long time; not, however, communicating with the urethra. These tumors have been compared by Ch. Hardy,* who has described them very accurately, to wens of the scalp. The best treatment consists in incising the skin and enucleating the cyst entirely, or excising a considerable portion of its wall, allowing the wound to heal by granulation. Another form of lacunal inflammation is where the lacuna magna in the roof of the urethra continues inflamed, perhaps after all the lining membrane of the urethra has returned to its normal condition. The mouth of this lacuna is too large to become obliterated, and the result is a gleety discharge, which tends to run on indefinitely. This condition may be relieved by introducing a fine director along the roof of the urethra until it is caught in the lacuna, and slitting open the pouch as recommended by Phillips. † COWPERITIS.-Inflammation in and around Cowper's glands is rare. It seems to occur only in connection with urethral inflammation. Gubler has written exhaustively on the subject. Cowperitis "Mémoire sur les Abcès blennorrhagiques," Paris, 1864. "Maladies des Voies urinaires," Paris, 1860. "Des Glandes de Méry (vulgairement Glandes de Cowper), et de leurs Maladies chez l'Homme." Thèse, Paris, 1749. |