These instruments may be passed down to the bulbous portion of the urethra; beyond this further investigation should be made with the ordinary sounds. By their use much may be determined in regard to prostatic tenderness, and the combined use of the sound in the deep urethra with the finger in the rectum will give more accurate information regarding the size of the prostate than can easily be obtained in any other way. Much reaction, however, may occur from the use of the sounds in this way, and it is a good rule never to introduce an instrument into the deep urethra without having ample reason therefor, and then doing it under antiseptic precautions; while, as a formal measure after it, the patient should be placed at absolute rest. This serious reaction, which occasionally follows instrumentation of the deep urethral passage, is commonly known as urethral fever. It is characterized by chills, elevation of temperature, and often by local indications, the constitutional features being sometimes pronounced, and in rare cases terminating fatally. Such serious symptoms are difficult to explain. Doubtless the use of the instrument opens up paths of fresh infection, and absorption rapidly follows, which may be limited to the surrounding tissues or cause widespread trouble. This may ensue after every precaution has been adopted, although doubtless many of these cases have been the result of carelessness and failure in antisepsis. Much may be done in the way of prevention when this condition is feared, for these cases are rarely so urgent but that the urine can be medicated and its quality improved, while a part of the procedure may consist in having the patient empty the bladder and then carefully washing it, or filling it with an antiseptic solution, which may be expelled before any instrument is used except the catheter, through which it may be necessary to introduce the bladder wash. The administration of 2 or 3 Gm. doses of urotropin, with or without quinine, previous to the exploration, may also be of great service. The surgeon perhaps does not always take these precautions, but he should when the history of the case shows that patients have already suffered in this way. In the presence of such a history the urethra should be explored with great caution.

When the rectal examination is made the intent should be to discover any enlargement, irregularity, or undue sensitiveness of the prostate, and then to pass the finger still farther and ascertain if there is involvement of the seminal vesicles. At the same time a species of manipulation described as “milking” may be conducted, by which the contents of the vesicles as well as of the prostatic utricle may be incited by gentle pressure, directed from above downward, to empty into the deep urethra, whence they may be promptly expelled or may be carried out by the urinary stream, or removed through the endoscope. The discharge of pus or catarrhal debris in any visible amount is suggestive, and indicates that these passages have participated in the infectious process. This act may be repeated at three or four day intervals; it should be so gently done as not to cause much pain, and will be found of great value in cases calling for it.

Treatment.

—The treatment of gleet is essentially treatment of the causes which produce it, and these should be carefully determined. In the urethra, as in all other tubular channels of the body, an abnormal constriction is accompanied by an area of excitement behind it, from which will issue more than the normal mucous discharge. We see this in stricture of the esophagus, intestine, or any of the ducts. This discharge is not to be subdued by mere applications nor by astringent and antiseptic injections, but the stricture itself, being the most important factor, must be suitably managed. In recent cases its gradual distention by the use of conical sounds will usually suffice.

In long-existing strictures more radical measures should be adopted, and they should be divided with one of the numerous urethrotomes in general use. Mere division, however, is not sufficient, but the patient should be impressed with the fact that cicatricial tissue tends invariably to contract, and that persistent dilatation is to be practised lest the stricture recur. The old saying used to be, “Once a stricture, always a stricture.” If this is to be disproved, it can only be by the frequent and long-continued use of sounds. Ignorance or indifference impel many a patient to return for further treatment, sometimes in a condition worse than at first, while occasionally the penalty paid for carelessness is life itself.

No routine in the treatment of gleet will give satisfactory results beyond this fact, that patients should be instructed to regulate their lives by absolute rules as regards indulgence of every description, and avoidance of intestinal inactivity and constipation. The urine will be found concentrated and irritating in many of these cases, and this should be overcome by the free use of water and diluent drinks. Hyperacidity should be corrected by suitable alkaline medication, and remedies administered, already mentioned, which are supposed to medicate the urine. Capsules may be procured containing salol, oleoresin of cubebs, balsam of copaiba, and pepsin, and except in cases where there is already great irritation of the urinary tract, these serve their purpose admirably.

When the anterior urethra alone seems to be involved, one of the milder injections already mentioned in describing the treatment of acute cases may be employed. When the deep urethra appears to be the site of continued irritation, it should then be treated extensively with deep irrigations and injections of suitable medicaments. The deep irrigations can be practised with or without the use of a catheter. The deep urethra may be flushed through a smaller catheter than the urethra will comfortably take, allowing the fluid to return through the urethral channel outside of the catheter itself. When this practice is adopted, hot water which has been made antiseptic should be used, preferably with one of the silver salts. The nitrate may be used in proportion of 1 to 500, and the citrate or lactate in strength of 1 to 300 or 1 to 400. Protargol is effective in 1 per cent. solution, or argyrol in 1 to 3 per cent. strength.

In the employment of irrigation in these cases a shield should be used, by which the end of the penis may be covered and all danger of spattering avoided. The simplest expedient for this purpose is one-half of an old atomizer bulb, which may be punctured and slipped over the catheter or irrigator tube.

Apart from mere irrigation it is well to deposit within the depths of the urethra, in the membranous portion, by means of a deep urethral syringe, a drop or two of a fresh solution of silver nitrate in distilled water, in strength of ¹⁄₂ to 1 per cent. This should be deposited behind the “cut-off” muscle, where it will cause a burning sensation for a short time. The strength of the solution is to be regulated by this complaint, as no benefit is derived from using it too strong.

Of all the medication that has been suggested, nothing gives better results for this purpose than this silver nitrate.

For ordinary urethral injections, besides those already mentioned, formalin may be used, but in weak solution (1 to 2000, or stronger if the patient can tolerate it); while picric acid has been recommended by Belfield and others in strength of 1 to 1000 or 1 to 2000.

Some surgeons believe that patients can learn to flush the deep urethra, or even the bladder itself, without the use of the catheter or internal tubing of any kind. The procedure may have to be learned in the sitz bath, the pelvis being immersed in warm water; the nozzle of the irrigator tube is inserted into the urethra and the patient is told to make an effort as if to void his urine. This will so relax the “cut-off” muscle as to permit the passage of fluid into the bladder, and this, which is most desirable in many cases of cystitis, where the bladder washing is an essential feature of the case, is to be avoided when the gonorrheal infection has travelled backward beyond the prostate; no attempt should be made to pass the solution into the bladder, but simply to wash out the urethra. The better plan is to teach the patient the proper use of a small soft catheter, which may also be used in the sitz bath, inserted to the proper extent.

Recent strictures should be treated by sounds after the urethra has been thoroughly cleansed. For this purpose a conical cylindrical sound should be selected, whose urethral end will comfortably enter the stricture. Gentle force should then be brought to bear to pass it beyond the stricture. If gradual dilatation be aimed at, it is well not to go beyond the point of drawing a drop or two of blood; even this may be avoided. On the other hand, should it be decided to use sufficient force, the dilatation should be done thoroughly and at one sitting, in order to avoid repetition of the irritation. The instrument generally in use in this country for this purpose is the Otis dilating urethrotome, by which the degree of dilatation and the size of the cicatricial ring can be estimated and the extent of the division and the effect gained also regulated. (See Operative Surgery of the Urethral Canal.)

The divulsion of strictures, formerly in vogue, is now abandoned for the more accurate division performed by this instrument. The strictures having been thus divided, sounds should be passed at intervals of from three to five days, by which the urethra is distended to its full caliber and the divided surfaces not allowed to contract. This is an important part of the treatment, and gives opportunity for widest discretion in their employment. Ordinarily they should not be carried farther back than the lesion calls for, as the deep urethra is best let alone. On the other hand, there are many cases where the stimulus of the cold metal passing the entire length of the urethra and the effect which it seems to have in expressing from the various follicles any retained contents seem beneficial. It has been stated that instrumentation sometimes leads to epididymitis or “swelled testicle;” should this take place in a case undergoing treatment for gleet it may necessitate a temporary cessation of the mechanical treatment. It is not good surgery to introduce any instrument into the urethra when one or both testicles present this complication.

In the local treatment of these lesions, cocaine or one of its substitutes should be employed. It is questionable whether the full benefit of applications is obtained when the surfaces are so anesthetized; on the other hand, the treatment can be made more endurable by its use.

This is true, also, of the use of the endoscope, and applications which may be made through it to inflamed or hypersensitive patches. When these are recognized or exposed, they are best treated by a probang moistened with silver nitrate solution, in 5 to 10 per cent. strength, or by the solid stick or crystal of copper sulphate, pure or mitigated, as used by the oculists.

One of the most important features in the consideration of gonorrhea is to determine, if possible, when a given case has ceased to be dangerous to others. In theory the danger passes with the disappearance of the gonococci, but it is so difficult to determine when this has occurred that it is almost impossible to fix a time limit in any given case. An excellent method of determining the matter in a reasonably accurate way is by having the patient void urine in two different glasses; a small quantity in the first, which will contain, then, the washings of the urethra. In this glass will be found those chains of gonococci clustering around masses of epithelial cells or debris which have been especially described as “clap threads” (tripper-faden of the Germans), upon which, by careful examination, gonococci can often be recognized. As long as these threads are in evidence it may be held that the infection still persists, and might be either brought into activity again by excitement or convey the disease in the sexual act.

Gonococci have been found in clap threads years after the last known infection, and this will illustrate why they are such a source of danger, and how an innocent woman has been made to suffer when it was supposed that all danger of infection had passed away.

GONORRHEA IN WOMEN.

This naturally assumes the type of a specific vaginitis, usually with active participation of the mucous membrane of the vulva and of the vulvovaginal glands, the urethra and bladder being sometimes secondarily involved, while the role of the lymphatics is about as described in the male. In the young, especially in young girls upon whom rape has been attempted, the mucosa is extremely susceptible. In adults, particularly in those who have borne children, the vaginal walls offer more resistance. The nature of the parts permits of more violent chemosis of the mucous membrane, while in serious cases there will be well-marked edema of the labia. The urethral orifice is usually inflamed and chemotic, even though the infection travel no farther in this direction.

It has been stated that 80 per cent. of deaths from pelvic disease in women are due directly or indirectly to gonorrhea, as well as one-half of the cases of involuntary sterility.

As in the male, there may be different types of so-called gonorrheal infection of the vagina, varying from the pure gonococcus type to that in which the preponderating bacteria are of the ordinary pyogenic varieties. The detection of gonococci in the discharges sometimes assumes medicolegal importance, and upon it has depended the guilt or innocence of more than one individual.

The intensity of the vaginitis will vary with that of the infection. In the worst cases the discharge is profuse and acrid. It may amount to 50 Cc. or even 100 Cc. in twenty-four hours. The burning pain will be extreme, while backache and pelvic soreness will be bitterly complained of. In mild cases the disease assumes the clinical form of a low-grade vaginitis with abnormal discharge, such as may be characterized as a severe case of “whites.”

In these cases of either type the question is, whether infection has already travelled upward beyond the vagina into the uterine cavity or through it into the tubes.

Gonorrhea is the most common, and some believe almost the sole, cause of pyosalpinx with its attendant complications and dangers. Even when not severe, vaginitis may permit of such extension, and so not only induce sterility, but compromise the physical welfare of the patient; while in acute cases the activity is so great that it occasionally terminates in peritonitis, primarily of gonorrheal origin. When both tubes have become involved, the patient is almost invariably sterile.

In nearly all of these cases strings of mucopus will be found hanging out, or beads of it presenting at the external os, and when examined this exudation will afford a fair test as to the character and degree of the infection. Here, as in the male, there are so many follicles difficult of access, and so many recesses in which germs may lurk, that a complete disinfection of the parts is almost impossible. For this reason, then, latent gonorrhea is a frequent outcome of the disease when once it has existed, and a possible and more or less constant source of danger to others.

Treatment.

—A case of acute gonorrheal vaginitis with its accompaniments will present a difficult problem. The discharge is so great that the danger to others, and especially to the eyes, is pronounced, while the exquisite tenderness of the parts makes radical treatment difficult. The treatment should consist of antiseptic douches, which in serious cases should be made as nearly continuous as possible. The water used for the purpose should be as warm as the patient can tolerate, and contain an antiseptic, of which corrosive sublimate, in strength of 1 to 2000, silver nitrate in the same strength, or formalin in double this strength, are the most serviceable. The irrigating tube should be carried to the upper end of the vagina and the stream made to flow outward. In milder cases a douche at intervals through the day may suffice. The vaginal surface should later be exposed through a speculum and the entire mucous surface treated with nitrate of silver solution in from 6 to 10 per cent. strength. Should the surface be tender, this will be painful, and might justify the use of an anesthetic, especially of nitrous oxide.

If the disease extend upward and there is an endometritis or a salpingitis, external applications of ice may be used to lull the pain; but probably hot poultices or some application of external heat might afford greater comfort to the patient. Byford has used succinic dioxide in the treatment of specific vaginitis with great satisfaction. It is sold in the open market under the trade name “Alphozone.”

The edema of the vulva will subside with the general improvement of the case. Abscesses in the vulvovaginal glands are not uncommon. These are easily recognized, are often painful, and should be incised early or as soon as recognized, cleaned out thoroughly, the interior of the cavity cauterized to prevent the result of fresh infection, and then packed and left to heal by granulation.

Urethritis and cystitis may be treated as when they occur in the male. There is the same liability in women as in men to lymphatic involvement, with the consequent bubo, which may perhaps suppurate. They are less liable to the widespread manifestations of postgonorrheal infections of the joints, etc., although they are even more liable to infection of the endocardium, and, as will be readily understood, more so to infection of the peritoneum. It will then be seen that the treatment of the disease is essentially the same in either sex, certain differences in method rather than in principle having to be made in accordance with anatomical requirements.

As to the rectal mucous membrane participating in gonorrheal infection, under ordinary circumstances it would escape. In the treatment of any of these cases by the sitz bath, the question might arise whether there would be danger of extending the contagion in this direction. It does not appear that much fear need be felt, for two reasons: the grasp of the sphincter is usually sufficient to prevent entrance of fluid, and, furthermore, the rectal mucosa is itself extremely resistant to the gonococcus. Gonorrheal proctitis is an exceedingly uncommon infection, and one rarely seen, except in extreme cases of sexual perversion. It should be treated in about the same manner as gonorrheal vaginitis, i. e., by continuous irrigation with hot water, and stretching the sphincter in order to overcome the spasm into which it would be thrown by reflex activity.

Gonorrheal urethritis in women is best treated with local applications of argyrol or one of the other silver compounds. These can be made with a syringe or with a small swab. Cystitis is to be treated in the same manner as when it occurs in the male.