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.