The Treatment of Chronic Urethral Discharge

BENJAMIN TENNEY
1907 Boston Medical and Surgical Journal  
Surgeon to the Boston Dispensary. THEORY. Considering how difficult it is to grow them outside the body, how short their natural life is in the incubator, and how easily their artificial growth is stopped by slight accidents of various sorts, it has always interested me to theorize as to how the gonococcus can exist so long and so prolifically in a canal which is thoroughly flushed Avith urine every few hours. The most reasonable explanation to my mind is that within a very short time after
more » ... hort time after infection, probably within a few hours, some of the bacteria Which are very motile have penetrated some tiny duct where they are safe from the frequent flood of urine and can increase and spread to other ducts between urinations. In other words that there is a para-urethritis almost from the start. Starting with the proposition that it is a possibility for a man in ideal health and surroundings and with a urethra of proper sort to acquire a specific urethritis for the first time and be free of all symptoms within three weeks, we are immediately faced by the fact that he has many brethren Avho are less fortunate, and the conclusion is plain that there must be a chemical or mechanical factor to account for the difference or else a combination of the two. Either the body fluids are lacking in the power to throw off the bacteria faster than they form or, in modern language, " the opsonic index is Ioav " or else there is some mechanical obstruction to their escape. That the former condition obtains with some patients I like to believe, because occasionally symptoms persist after weeks of attempt to smooth the Avay for the most remotely hiding diplococci to float away. That the second is the almost universal cause for persistent urethral discharge as it is for persistent discharge from other and unnatural sinuses, I do believe, and so do most men if 1 understand their treatment correctly. A sliver, a silk ligature, a bit of necrotic bone or other tissue may keep up a continuous small discharge because the opening is not large enough for it to float out bodily. Enlarge the sinus or make a new opening through Avhich the irritating foreign body escapes or remove it by pressure and the sinus closes and the discharge stops. The analogy is not solely with the urethra which serves as a grand canal for the hundreds of little canals leading to the para-urethral glands, but with these canals and the ejaculatory ducts, the prostatic ducts, and the canals from Cowper's glands all of which drain into the same channel. At the beginning of any of these canals the desquamated cells destroyed at the first invasion by bacteria may form necrotic masses too large to pass through the natural exit without greater force than the gentle urging of the leucocytes which are themselves of a size to pass out and attract attention. The idea of a vaccine by which the removal of bacteria may go on more rapidly than their increase is fascinating. Could the masses of dead and dying cells be rendered sterile, the blood currents would doubtless build a wall about them or carry them away ; but the essential element in the new therapy is the handicapping of a definite bacterium by a vaccine prepared from the dead bodies of his own kind, and it is by no means certain that any one bacterium is the cause of all the long-standing para-urethral inflammations. It is not very uncommon to find a smear without Gram decolorizing diplococci and Dr. Charles Duval assures me that many intracellular Gram decolorizing diplococci Avili show luxuriant growth on agar. After the well-meant efforts of ourselves and our patients and considering the varied and abundant flora of the normal urethra it would not be surprising to find that some other organism was trying to fill the place once occupied by the gonococcus, and can we have a vaccine for each infection? Until we do we must continue to work along lines which have given results satisfactory though often sIoav in coming. With the chemical treatment of chronic urethral discharge in the way of dnigs SAvallowed or used by the patient, this paper has nothing to do because 1 seldom order them, and in my office I only use silver nitrate in very weak solutions, hot salt solution, and occasionally cocaine and adrenalin. PRACTICE. The first ground to cover is to find the highest point from which the discharge can come and the rectal examination is the first one to be made after inspection of the urine. Rarely does one of these patients fail to show some signs of a past acute and present chronic inflammation in prostate or A'esicle or both. The nodular feel of an infected vesicle, and the masses of cells, cell membranes, and motionless spermatozoa in the washings after gentle massage are evidences which cannot be mistaken. The unilateral enlargement, difference in consistency between the two lobes, and the smaller plugs and shreds with large numbers of mononuclear leucocytes in the expressed contents are the main points in locating the prostate as a constant source of discharge. If either of these conditions has been present for six months or more avc may expect to find the membranous urethra contracted. I was taught that stricture formation never followed the first infection. This is a mistake. Stricture formation is often very slow. In one case of mine
doi:10.1056/nejm190704041561403 fatcat:cedtyasq6rhkjcdkfhtqxxfsum