A plan which has proved efficacious in some instances is the pro longed use of hot water in combination with the acetate of lead, the patient being instructed to inject the urethra for fifteen or twenty minutes, night and morning, with water as hot as can be borne. The treatment is to be concluded by syringing the canal with fifteen drops of a saturated solution of the acetate of lead in an ordinary teacupful of hot water. This is to be thrown into the canal four or five times iu succession. In a few instances of catarrhal gleet the author has succeeded in checking the discharge by the use of a watery solution of ordinary alum, in the strength of a drachm to eight ounces, night and morning.
It may be considered absurd to advocate a change of climate for patients with this form of chronic nrethritis, yet, when the general condition seems to demand it, this plan may be advised, and will be found to be productive of marked benefit.
The rheumatic, gouty, syphilitic, and tubercular diatheses will be found to be responsible for some cases of chronic urethritis. These conditions require the same remedies as under other circum stances ; the combinations of mercury, iodide of potassium, and col chicum are apt to be particularly serviceable in the three former conditions. The various balsamic preparations may be continued during the course of treatment for chronic urethritis, providing the stomach and kidneys are tolerant of these drugs.
Stricture of the urethra is the most frequent cause of chronic ure thritis. Its treatment will be considered in a subsequent section.
Congested and granular patches require local applications by means of the endoscopic tube. It should be remembered in this con nection that general and powerful applications to the canal are apt to be productive of injury. It is an unfortunate fact that the surgeon seldom localizes his efforts to cure the complaint, but continues the use of caustic and astringent applications, " shot-gun" fashion— sometimes hitting the disease, but more often the normal memlganc —and the internal administration of the balsams, in a futile effort to relieve something that perhaps a single well-directed application would cure. It is necessary to determine the precise location of the offending spot and to measure accurately its distance from the meatus, with or without ocular inspection of the part. The passage of a steel sound upon alternate days for a few weeks will cure a large proportion of these cases by crushing the minute granulations, emptying pus-distended follicles, producing local absorption of the infiltrated material in the mucous membrane, toning up the latter, and stimulating repair. When this method of treatment has been proven to be ineffectual, strong applications of the nitrate of silver or the sulphate of copper may be made directly to the diseased spot through the endoscope. The pure crayon of sulphate of copper or nitrate of sil ver is safe, if very cautiously used. The silver may be fused upon the end of a blunt probe and touched to the spot very lightly. In lieu of the pure caustic, strong solutions of copper or silver may be used, thirty to sixty grains to the ounce being admissible, but great care is necessary not to leave an excess of the caustic fluid upon the mucous membrane. When the diseased point is within three inches
of the meatus, the urethral speculum is often serviceable in making applications. The meatoscope may also be useful. It is in cases of chronic urethritis that the methods of treatment by soluble bougies and retro-injection are apt to prove of the greatest service.
One of the oldest methods of treatment of gleet consists in the in jection of astringents of gradually increasing strength. This Ricord's old formula consists in the injection of one part of red wine to three of water, each syringeful of the injection being replaced by wine, so that after a time the patient is using the pure red wine. Bumstead speaks highly of strong solutions of the persulphate of iron.
Experience has shown that many cases of urethritis are perpetu ated by a contracted meatus, behind which urine and inflammatory products accumulate and produce irritation. It is advisable to per form meatotomy as a matter of routine in every case of chronic ure thritis in which the meatus will not admit a full-sized sound. The incision should be made with a straight blunt-pointed bistoury and kept open by the frequent introduction of a short sound or a fossil Bougie.
In some cases of gleet, dependent upon congested and granular patches of mucous membrane, there exists a slight thickening of the underlying mucous membrane, hardly of sufficient importance to be denominated a stricture, yet requiring the same treatment, and even tually terminating in a constriction of the lumen of the canal. These patches of tough and resilient infiltration are usually found iu the pendulous portion of the urethra, and in such cases the gleet is abso lutely resistant to all measures of treatment, until a urethrotomy is made and the thin layer of thickened tissue divided. When this process extends entirely around the circumference of the canal, it necessarily constitutes a stricture of large calibre, but it is well to remember that the relation of the thickened tissue to the gleet is precisely the same in those cases in which, on account of the circum scribed limitation of the process, no pronounced narrowing of the canal is evident, as it is in those in which an acknowledged stricture exists. It is to be remembered, furthermore, that iii many cases which are denominated " stricture of large calibre" there is really not a stric tured condition of the canal, but as the instruments pass over a thick ened, granular, and hypermsthetic patch there occurs, just at the location of the lesion, spasm of the accelerator uriu and com pressor urethrae muscles, which gives rise to the same objective symptoms as stricture. It is probable that urethrotomy is performed many times for the relief of strictures of large calibre in which true organic stricture does not exist, and there is only the condition of affairs just described to explain the obstruction to the introduction of instruments and the grasping of the bulbous bougie as it is with- • drawn from the canal. This fact, however, is no argument against the necessity for urethrotomy.