INFLAMMATORY AFFECTIONS OF THE URETHRA.
Inflammation of the female urethra is a disease of much greater frequency than is usually suspected or diagnosed. The explanation of this lies in the fact that patients complaining of characteristic in flammatory symptoms are not often subjected to a painstaking en doscopic examination.
Numbers of cases of urethritis are diagnosed from their symp toms as cystitis and persistently treated as such for long periods of time. I have at present under my care a patient who was treated in a hospital for some months for irritable bladder, where examination revealed the fact that she had an inflammatory disease limited to the anterior part of the urethra and a small area near the internal orifice.
Inflammation of the urethra is due to infection, and must be dis criminated from hyperemia due to a mechanical or chemical irritant.
The most common cause of inflammation is the gonococcus. In the aggravated form of gonorrhoeal inflammation of the urethra, ulceration may also be present.
The urethra may also be the seat of syphilis, tubercular ulcers, and diphtheritic patches.
A mild form of urethritis not infrequently exists in women where there has been no opportunity for infection by contagion, and where there can be uo suspicion of gonorrhoia. The disease is apt to be most marked in the anterior and posterior parts of the urethra. The mucous membrane becomes swollen and deep-red, and the vessels are injected. Upon examination, unless the speculum is handled with extreme care, the mucosa is injured and a little bleeding results. The glands of the urethra stand out prominently, appearing as oval yellow spots a few millimetres long. In the anterior part of the urethra a little secretion is often discharged from one of the crypts, as it comes into view in the lumen of the speculum. This looks like pus, but may be nothing more than epithelial debris. The tenderness throughout is very marked.
Treatment of this form of trouble is both simple and satisfactory. The inflamed parts are touched once in four or five days with a weak solution of nitrate of silver, usually not more than three per cent. in strength. From five or six to a dozen applications will usually clear up the trouble.
In gonorrhceal urethritis, the mucosa of the urethra becomes so swollen that there is no longer room for it in the urethral canal, and it pushes down and prolapses at the external orifice, where it pouts out of a deep red color, at a later stage to be bathed in pus. The parts
are so exquisitely tender that they cannot be handled, much less can a speculum be introduced, without amosthesia. Bleeding is often spontaneous and is sure to occur upon the introduction of an instru ment. An examination of the secretion under the microscope shows gonococci. The urethral ducts described by Skene are often involved, and, long after the disease has subsided in the rest of the urethra, may remain in the state of chronic inflammation, secreting pus. This pus, as has been pointed out, may become the source of repeated relapses by reinfecting the mucous membrane after the disease has been cured elsewhere, in a manner entirely analogous to the similar inflammation of the ducts of Bartholini's glands. It is important, therefore, always to watch for this complication, and in cases which have survived an attack of specific urethritis, to investigate the con dition of these glands. This is done by milking their contents down through the orifice opening into the urethra, while pulling the urethral orifice open and exposing the duct. The anterior vaginal wall just under the symph3-sis is stroked downward ou one side from a point about three centimetres to the inner side of the urethral orifice. The position of the finger in thus emptying the ducts is shown in the illustration (Fig. 86) . The appearance of the urethral orifice with a drop of pus on one side issuing from the right duct is drawn from life and is entirely characteristic.
The treatment of gonorrhoeal urethritis is by rest, hot vaginal douches, the application of lead-water and laudanum to the external parts, if swollen and tender, and the administration of such reme dies as are used in the male, together with sedative suppositories if necessary.
In the more chronic condition, the passage of a No. 10 speculum and the application once every five to seven days of a two- to three per-cent. solution of nitrate of silver to the part most affected will be of great benefit. The general supporting tonic treatment of the patient must also not be forgotten.