TREATMENT OF CHRONIC URETHRITIS.
The treatment of chronic urethritis requires more radical meas ures than are warrantable in the acute stages of the affection, and incidentally a greater variety of remedies, these being necessitated by the varying character of the special causes which tend to the per petuation of the inflammation.
The first step to be taken is to explore the urethra, and thus de termine, if possible, what particular local condition is keeping up the difficulty. For ordinary purposes the bulbous, flexible French bougies will be found to be all that is necessary for this purpose, for in the majority of instances a knowledge of the existence of a local ized spot of inflammation or stricture is all-sufficient, ocular inspec tion being of little or no advantage. In the hands of the expert the bulbous Bougie readily determines with a great degree of accuracy the condition of the urethra. Otis' acorn-tipped metallic sounds may be used, but the soft instruments are preferable.
The endoscope bears a somewhat similar relation to urethral ex ploration that the stethoscope does to the diagnosis of disease of the thoracic viscera. The physician who becomes expert in physical diagnosis finds that the unaided ear is all-sufficient for practical pur poses in the exploration of the chest, the stethoscope becoming nec essary only in very obscure cases, or those in which critical and hair-splitting differentiation of objective signs becomes necessary. There have been numerous elaborate encloscopes devised, but for practical purposes the ordinary straight, hard rubber or silver tubes, with the addition of a strong light reflected from a laryngoscopic re flector, or from one of the modern small reflecting electric lamps, are sufficient. The panelectroscope of Leiter is valuable where it is practicable to utilize it. The author has found that his own endo scopic tubes, which are much larger than Leiter's, are more useful than the latter in most cases in which he uses the panelectroscope. It is well to have a series of these tubes, in order that an instrument may he selected which is as large as the capacity of the urethra will permit.
In case stricture exists, preliminary dilatation may always be practised prior to eudoscopy, and it thus becomes possible to use relatively large tubes for explorative purposes. The mistake is often made of having these tubes made too long ; by crowding the penis well down around the tube, a short tube can be used much more effectively than larger ones.
We will first consider those cases the chronicity of which depends chiefly upon constitutional conditions or a general predisposition to catarrhal fluxes of various kinds, and in which exploration fails to detect any local condition that will explain the discharge. Cases frequently arise in which all forms of internal and local treatment fail of their object because of inappreciation of the constitutional pecu liarities of the patient. Debilitated and strumous subjects, and those who are cachectic from any cause whatever, require the admin istration of tonics, such as quinine, iron, cod-liver oil, and various preparations of nux vomica. In cases of this kind the tincture of the chloride of iron or the mineral acids sometimes accomplish wonderful • results by improving the general systemic condition, toning up the relaxed and flabby mucous membranes, and inhibiting excessive secretion. It is in these cases, too, that we are apt to have excellent results from the internal administration of vegetable astringents, ergot, etc. Turpentine in moderate closes is occasionally of decided advantage to these patients ; the tincture of cantharides may also be of service.
Local measures of treatment are often unnecessary. In fact, it will be found that it is in just such patients that the prolonged use of injections and balsamic preparations are inclined to perpetuate the gleet. In some instances, however, in conjunction with measures to improve the general health, it will be found advantageous to make local applications. One of the best preparations is the pure fluid extract of hamamelis, applied by a cotton-wrapped probe through the endoscopic tube. This will never be found to be too strong, and it is a singular circumstance that patients who are unable to bear an ordinary injection, in the strength of one part of hamamelis to four of water, make no complaint of the application of the pure fluid ex tract in this manner. It is sometimes necessary to alternate the applications of this astringent with the use of an ointment of nitrate of silver, ten grains to the ounce, in combination with stramonium or belladonna, by means of the cupped sound. Tannin may be used in the same manner. In making all these applications the patient should first be directed to urinate; a full-sized sound should then be passed to press out the contents of the dilated follicles of the urethra, after which the medicated application is made.