A system of practical medicine. By American authors. Vol. 4

by Unknown

It is a well-known fact that the first stage of vesicle prolapsus is apt to be marked by as great discomfort as the third, for after a while the organ seems to become accustomed to its altered relations. The treatment of this condition is difficult. The bladder should be replaced and kept there. As this usually necessitates the reposition and maintenance of the displaced uterus, it is extremely difficult, and in case of existing adhesions it is impossible. A great variety of mechanical means have been tried to furnish an artificial support to keep the parts in position. If the bladder alone is prolapsed, the pessary used for anteversion of the uterus will sometimes answer. The instruments devised by Thomas, Grailly Hewett, and myself are most commonly used.

Acute Urethritis; Inflammation of the Urethra.

This affection may be simple or gonorrhoeal, and it is often difficult to tell the one from the other. There is a difference in history when we can get correct testimony from the patient. Simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease, while gonorrhoea comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. The chief symptom is painful urination. Sharp scalding is produced by the urine passing over the tender surface. There is often a frequent desire to urinate, but not so urgent as in cystitis. In some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. In quite a number of cases I have noticed hemorrhage, the source of blood being evidenced from the fact that it was not intimately mixed with the urine, and after micturition it oozed from the meatus urinarius.

An examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. Occasionally there is a discharge seen coming from the urethra, but if the parts have been recently bathed this may not be apparent. Introducing the finger into the vagina and pressing upon the urethra from above downward will cause a discharge, unless the patient has passed water immediately before. The appearance of the discharge corresponds to that of gonorrhoea in its various stages.

Cystitis, which is liable to be confounded with urethritis, may be excluded by using the catheter, and, after letting urine flow for a time, collecting the remainder for examination. The mucous membrane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. The instrument cannot be used in all cases, owing to the acute tenderness of the parts. Bleeding is very likely to occur in the examination, simply from the contact of the endoscope.

The TREATMENT of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. This will suffice in most cases of acute disease, but when it assumes the subacute form from the beginning, then the use of injections becomes necessary. I have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. For this purpose I use a catheter made like the fluted roller of a crimping-machine. The catheter conveys the water to the rounded point of the instrument. Behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. By this arrangement the water, as it flows back through the grooves, is brought in contact with every portion of the mucous membrane. The instrument is passed up to the neck of the bladder, and a fountain syringe attached to it, and the water as it flows away is caught in a cup.

The injection of solutions of nitrate of silver and sulphate of zinc will often prove useful. It must be borne in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where very slight force is employed while injecting. I use a large syringe, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. When the case is of long standing, and the neck of the bladder appears to be involved also, I use a weak injection of one or two grains of nitrate of silver to the fluidounce, and inject it through the urethra with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. In old cases which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. While the bougie is passed once or twice a week, I apply to the vaginal portion of the urethra oleate of mercury or the unguentum hydrargyri. This will often suffice to stop the gleety discharge, as well as remove the thickening of the urethral walls.

Inflammation of the Urethral Glands.

These glands rarely, if ever, take on inflammation primarily, but vulvitis and vaginitis, especially if gonorrhoeal, often extend into them. When they do become inflamed, the disease usually remains without any tendency to subside. More than that, when a gonorrhoea affects these glands the inflammation will remain there after all traces of the disease have left the vagina, vulva, and urethra, and in time the discharge from these glands will light up the original vaginitis and vulvitis again. The symptoms of this inflammation are not diagnostic. The physical signs are the swelling and redness around the mouths of ducts which are located just within the labiæ of the meatus urinarius. This give a general redness to the meatus. By pressure made upon the urethra from above downward a purulent discharge from the ducts will be produced and can be seen escaping. The only effective treatment is to lay open the glands their whole length. They run upward in the posterior wall of the urethra, so that by passing a fine probe-pointed scissors they can be laid open on the vaginal surface. Care should be taken to prevent the incision from reuniting, and if the inflammation does not promptly subside applications should be made, as in the ordinary treatment of inflammation.