The principles and practice of modern surgery

by Roswell Park

Fig. 29

Urethrometer.

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.