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membrane. Further chronic inflammation goes on in the SUMMARY OF parts still left congested. The loss of epithelium from small areas form shallow erosions, from which, in some cases, spring up granulations which appear as uneven red Lectures often them with adherent The ON areas, dotting grev pus. rows of granulations stretch obliquely or transversely along SOME AFFECTIONS OF THE GENITO- the urethra, ultimately leaving a palish grey streak of fibrous tissue, or rising into fibrous ridges, and thus forming URINARY ORGANS. the so-called bridle stricture. These terminations are in some Delivered at the Royal College of Surgeons, usually permanent; patients they may disappear and their sites become indistinguishable; especially may BY MATTHEW BERKELEY HILL, F.R.C.S. the erosions disappear altogether and leave the tissue elastic as before. After the catarrh the mucous PROFESSOR OF CLINICAL SURGERY IN UNIVERSITY COLLEGE. dies, membrane is often left paler than before, or with patches of brown pigmentation. Over the generally pallid surfaces, LECTURE I. large bloodvessels can sometimes be seen. In the of the and lacunae the first CHRONIC URETHRITI!. changes glands glands appear as little red dots; around these red dots, owing to BEFORE describing the conditions caused by chronic the shrinkage of submucous infiltration, little white areas urethritis the lecturer briefly enumerated the conditions and develop. The ducts sometimes, owing to the wasting of variations of the healthy urethra when tested by the meter their walls, give cup-like greyish-brown depressions, with and examined the The natural condition of yellow pus lying in their floor. Gradually the redness by endoscope. disappears from these dots, and they become indistinguish- the urethra when at rest is that of a tube with its elastic able from the red areas in which they have been placed. walls closely contracted, capable of yielding to the flow of The deep infiltration of the mucous membrane and under- urine and to the passage of a sound much larger than any lying erectile tissue causes changes of more serious character; stream of urine. This expansibility varies in different among which is the conversion of the parts affected into parts of the canal, being greatest in the prostatic portion. ordinary scar tissue without ulceration. The changes may reach considerable development before the superficial con- There it reaches to fifty or sixty millimetres in circumference. gestion and bright colour of the patch undergo diminu- At in it from the aperture the triangular ligament ranges tion. The redness then subsides to a purple and greyish- about twenty-five to forty millimetres; most commonly it lilac hue, slowly becoming grey or yellowish grey. The is about thirty millimetres. At the bulb the expansibility surface of the grey patches is often rough, and the lnstre of the urethra is sometimes forty millimetres, when the rest small, owing to the imperfect epithelium which covers them. A leading characteristic of these deeply spreading inflam- of the penile portion is only thirty millimetres. The meatus mations is their abrupt limitations. The superficial in- millimetres the common varies greatly, twenty-five being dnrations shade gradually away into the surrounding non- size. inflamed mucous membrane; the deep ones, on the contrary, When seen through the endoscope, the colour of the are quite isolated nodules. Their presence is indicated by mucous membrance is pink or bluish pink, varying in their uncontracting nature causing the lumen to wriggle different individuals, but identical with the hue of the from side to side as the inspecting tube passes them. some the surface of the scleroses buccal mucous membrane. The surface has a fine gloss or After months’ duration or instead of brilliancy given to it by a thin lubricating layer of mucus. becomes irregular ridged. The lumen, being Along the floor two fine furrows course forwards, and transverse or linear, is pushed into various positions, arched, or nodules towards the deeper part minute carmine-tinted papillae are sinuous, guttered. Probably these deep of ones doubtless are visible. The openings of ducts can be seen in health in scleroses are not absorbed; the superficial the prostatic portion, but seldom or never in the part frequently cleared away, but the deeply spreading ones anterior to the triangular ligament. The lumen is generally remain to form fibrous stricture of the urethra. linear when closed, and the penile part transverse, except The symptoms of chronic urethritis were dwelt upon, at the fossa navicularis, where it is vertical and lozenge- being little more than a milky-white drop of muco-pus shaped. At the membrano-prostatic portion the lumen is I oozing occasionally from the meatus or forming shreds and in cases was due to saddle-shaped or arched. flakes the urine. This in most patches The morbid changes seen in the urethra in chronic of granulations at the bulbous or membrano-prostatic por- urethritis were illustrated by drawings taken by Mr. Frank tions of the urethra. These were shown to be the source Collins, and by diagrammatic enlargements of them. of frequent recurrence of scalding and free discharge during the course of chronic urethritis if the patient departed from MORBID CHANGES IN URETHRITIS. his r6gime or discontinued the use of his injections. The Inflammation may invade the tissues in several ways. uncertainty of the length of time during which contagious First, simple mucous catarrh; next, inflammation of the power continues in a discharge was remarked upon, and it whole substance of the mucous membrane and submucous was acknowledged to be impossible to lay down a hard-and- tissue, and even the erectile tissue; lastly, the glands of fast rule as to the time when liability to communicate disease Littre and lacunae of Morgagni are chiefly affected. Near is lost. It was suggested that the discharge produced by the meatus long ducts open, which occasionally become a few granular patches on the surface of the urethra would inflamed and are very slow to heat. These ducts are most no longer provide a contagious discharge; but so long as easily seen in persons who have slight hypospadias as small discharge came from crypts and ducts of glands, there was a dots, from which muco-pus comes by light squeezing, and probability that it contained the power of communicating through which a probe can be passed for half an inch. gonorrhoea. " ,... Further down the canal the inflammation may extend I 1,T,,,rro,,. ess of the meatus was shown to be a common along the ducts into the glands of Cowper; and further cause of the maintenance or prolongation of discharge, and, still, by the ducts into the body of the prostate. moreover, that symptoms of much greater importance Further forms may be classified as (1) superficial granular might be produced by this abnormal condition of the outlet, induration of the mucous membrane ; (2) infiammation of such as difficultyin micturition, and spasm at the deeper part the glands and lacunae ; (3) areas of deeper induration with of the urethra during the passage of a sound, so great as to proliferation of cells, ultimately converting the mucous suggest the presence of real stricture. The localities where tissue into fibrous tissue; and (4) patches of fibrous tissue granular patches and indurated areas were most commonly penetrating into the submucous and erectile tissue. The met with were pointed out, being the bulbous portion and readiness with which these forms relapse makes it not about three inches from the meatus. uncommon to have them present together in the same The occurrence of inflammation in the glands and closed urethra. ducts, causing small abscesses and nstuipe, and a source of In general inflammation of the mucous membrane itself gleet, was explained. The occasional extension of catarrhal the membrane is bright red, with an absence of mucus, and inflammation to Cowper’s glands was indicated by circum- is so swollen that the lumen becomes circular or oval. Later scribed perineal swelling away from the mesial line and on, the red congestion changes to isolated dark-red patches, near the crus penis, by the sudden disappearance of the around which the natural colour reappears in the mucous swelling and the inconvenience caused by it, with simul- 1292
taneous abundant discharge of pus during an act of micturi- irritation caused by this injection is unimportant. The tion. The occasional formation of large abscess and effect passes off in a day or two, and must be repeated perineal fistula, instead of evacuation of the Cowperitic every third or fourth day until the granular patches no abscess along the ducts of the gland, was mentioned. The longer exist. Where induration of the submucous tissue frequency of acute prostatitis or of acute epididymitis exists as well as granular patches, these unyielding parts occurring at any period of the existence of a chronic are stretched in the passing of the bougie before the urethritis was also mentioned. instillation of the nitrate of silver. The nitrate of bismuth has but a restricted value as an astringent. In some cases it does good, in others none. LECTURE II. For the value of chloride of zinc as an injection forty- TREATMENT OF CHRONIC URETHRITIS. three cases were analysed. In seventeen of the forty-three the ceased after its in nine others it diminished. The different methods of treatment were and discharge use; compared, Extract of belladonna and extract of used the effects of these demonstrated by means of an opium, long analysis the lecturer as to have but small of cases for the In 110 cases this by sedatives, appear prepared purpose. analysis influence in that direction. showed that one at least of the four conditions following Cocaine in solution, before the was small meatus; (b) stricture, 5 per cent. applied injec- present:-(a) Abnormally tion is thrown is a efficient anaesthetic when much or (c) of inflamma- in, very single, or multiple, slight tight; patches is caused the it was tion ; (d) granular areas. Though other conditions might pain by injection. Parenthetically, be without of in the remarked that during the acute stages of gonorrhoea, when present production strictures, great is the of 10 cent. solution of of cases stricture was In of scalding severe, injection per majority present. thirty-five cocaine into the urethra the the 110 cases there were but one and in entirely prevented scalding stricture, seventy- of micturition. live more than one. The strictures were most numerous pain After a few remarks on the effects of between the third and fourth inch from the next to injurious certain meatus ; articles of the lecturer described his method of in the first inch and a half. Stricture is not in- diet, treating that, to in for the maintenance of the chronic the granular patches-this being first pass bougies order dispensable discharge. to dilate the contracted areas. Observation on the effects of ’in a who had had for patient discharge twenty-five months, found this to be the not to No. 27 millimetric on the first examina- bougies always same-viz., stretch, bougie passed easily to The the fibrous areas and tion. On the other whose affections have but split. splits pass through do hand, patients not affect the elastic membrane. The continued for a few weeks or months have not naturally endoscopic infrequently tube is then down the and a areas which form into strictures. The passed through split part, mop unyielding average in nitrate of silver solution is to the duration of the treatment in cases was two months applied ninety soaked and to the areas as the tube is withdrawn; and a half, but this includes treatment in many different patches split the granular condition of the membrane or prostatic part ways. also treated at the same the instillation of Soluble the remedies used were soluble being sitting by .BoM