solutions; in others it requires a solution four times as strong to check the discharge, and restore the urethra to a healthy condition.

Besides prescribing an injection, the patient should always be instructed in the method of using it, for if untaught, he often derives little benefit from its use. The syringe should be made of glass, and should be short and wide, that one hand may work it easily. The nozzle, half an inch in length, should be bulbous at the extremity, that the meatus may be readily closed against it. When the injection is to be used, the patient makes water to clear out the discharge that has collected in the passage, that the membrane may be freed from mucus before the injection comes in. This precaution taken, the patient inserts the nozzle into the canal, but not too far, and pinches the penis with the thumb and fore-finger of the left hand on each side of the nozzle, not above and below, that he may not compress the fossa navicularis against the nozzle, and prevent the flow of the injection over the part where it is most wanted. All being ready, he depresses the piston with the right thumb until the injection is thrown in. Unless the discharge comes from the prostatic part, it is not necessary to inject more than about two tea-spoonsful at a time, but that much should be retained about two minutes before it is allowed to escape; if it has properly distended the passage, the fluid returns with a spirt from the meatus.

The drugs employed in injections are of various kinds; some suitable to one condition, some to another. If the discharge is thick and tolerably plentiful, but scarcely any scalding remains, two drachms of a solution of nitrate of silver (of one-third or half a grain to the ounce of distilled water) injected thrice daily for three days, will usually produce great diminution of the discharge. Where this fails of effect, but does not excite pain and irritation (in which case

injections must be postponed), it should be changed for some other astringent. The chloride or the sulphate of zinc, in solutions of similar strength, or the acetate of lead in solutions of one to five grains, should be used, beginning with the weaker solution first.

A very useful formula in these cases is the "Four Sulphates," alum, zinc, iron, and copper, ten grains of each being dissolved in eight ounces of water. The solution is not used at full strength at first, but the first day is diluted with three times its bulk of water. If severe smarting follow its injection, it may be even further diluted before it is used again. The strength of the injection is gradually increased till the full strength is used or the discharge stops. This being attained, the injection should be diminished in strength, step by step, until plain water is reached. In this plan ten days should be employed, and a pause allowed before any other treatment is adopted should that prove necessary.

Various other drugs, such as oxide of zinc suspended in mucilage and water, have been employed, but their use does not give better results than those obtained by the beforementioned preparations. The injection of copaiba into the urethra is an old remedy, and often successful, but its action is very uncertain. An injection containing from one to two drachms of copaiba to the ounce of thin mucilage, is the most usual form of application. A useful injection for a serous discharge from a relaxed mucous membrane is made of three scruples of white bismuth rubbed up with four drachms of glycerine, and suspended in five ounces of water. This injection should be employed three times daily, for three or four days, and then gradually discontinued. Tincture of steel, of the strength of five to twenty drops to the ounce of water, or protiodide of iron, eight grains to the ounce, form injections that are best employed by commencing with a dilute strength, and increasing them day

by day, till the discharge ceases, when they should be gradually discontinued by successive steps of dilution. Rough red wine, such as Burgundy or port wine, used as injection, is often very beneficial and successful where other means have failed. It should be diluted with once or twice its bulk of water. Occasionally watery solutions of tannic acid, of tincture of rhatany, and other vegetable astringents are beneficial, but they are uncertain, and tannin is apt to cause much painful irritation of the urethra. In old gleets the glycerine of tannin of the British Pharmacopoeia, diluted with four times its bulk of water, is very effective when the discharge depends on a general relaxed condition of the mucous membrane.

When the discharge comes from the bulbous or deeper parts of the urethra only, the injections can be best applied by passing them through catheters directly to the part affected. The catheter employed for this purpose should be gilt, perforated with fine holes near the beak for about one and a half inch, and have a small elastic bottle fitted to the mouth. The bottle is filled with a solution of nitrate of silver, or sulphate of zinc, about 20 to 30 grains to the ounce, and screwed on to the catheter, which is then passed into the urethra short of the bladder. If the bottle is compressed, the fluid flows slowly into the membranous part and distends that with caustic injection; after one or two minutes the instrument may be withdrawn and the fluid allowed to escape. This active treatment sometimes excites smart inflammation, and perineal abscess may follow; but when the precaution is taken of keeping the patient quiet in bed a few days, this hardly ever happens. The following plan of Diday's ensures that the posterior part of the canal shall be thoroughly bathed by the injection. A catheter, to which an elastic bottle, capable of holding six or eight ounces and fitted with a stop-cock and nozzle, can be applied, is passed

into the bladder. The urine is at first withdrawn, and then six ounces of solution of sulphate of zinc of two-thirds of a grain to the ounce are injected slowly; when the fluid has entered the bladder the catheter is to be withdrawn, and the patient told to void the contents of the bladder in a natural manner; by this means, the urethra is distended during some seconds by the injection passing through it, and every part of the mucous membrane is washed by the fluid. The operation should be repeated daily, unless it cause irritation at the neck of the bladder, which is the chief objection to adopting this method. It is successful in obstinate cases of discharge from the prostatic part of the canal, and may be tried when other means have been exhausted.

Again, a catheter of similar construction, but with larger holes, is filled with powder of equal parts of nitrate of silver and starch, and passed to the site of the discharge. The powder is then blown through the holes on to the mucous surface by means of an air syringe fitting the outer end of the catheter. Ricord1 has lately used with success in obstinate gleet the injection of powdered astringents-bismuth and phosphate of magnesia, by means of a straight catheter open at both ends, in which slides another tube formed at one end into a spoon-like trough, the other end screws on to a small caoutchouc ball. The catheter is introduced to the neck of the bladder, the powder put in the trough, which is passed along the catheter till it projects beyond it in the urethra. The whole instrument is then slowly withdrawn while the ball is compressed, and the air it contains. blows the powder out of the trough in a cloud that reaches throughout the lining of the urethra.

The regular introduction of bougies is a very efficacious

1 Bulletin de l'Académie de Médicine, xxxi. 1866.

plan of curing certain obstinate gleets.

Discharges from

slight stricture, and from indurations of the mucous membrane, are most successfully treated by this plan. A bougie, or sound, large enough to fill the canal, should be passed every day, and kept in the urethra ten or fifteen minutes. The bougies usually excite some irritation and increase the discharge after the third or fourth time of passing, when they may be left off. After the irritation is at an end, the discharge sometimes ceases completely; but it is generally necessary to have recourse to a mild astringent injection to complete the cure. If the bougies fail to cause reaction, they may be passed twice a day, or exchanged for a flexible catheter, and tied in for three or four days. This soon sets up a smart discharge, when the catheter should be removed, and the irritation allayed by demulcent drinks and a few warm baths. If a discharge remains after this, it may be arrested by injections or a few doses of cubebs.

and steel.

The irritating power of the simple bougie has been increased by covering it with stimulating ointment, of red oxide of mercury, nitrate of silver, and other similar preparations. They are sometimes beneficial, but very uncertain in their effect. Bougies, dipped into solutions of gum and nitrate of silver and allowed to dry, are useful to introduce into the bulbous part when that is the source of the discharge; the gum dissolves in the mucus of the passage, and sets free the nitrate at the place where it is required. Bougies so prepared are difficult to introduce, because the gum rarely dries evenly, but leaves the instrument rough on the surface. Bougies of cocoa butter, which become liquid at the temperature of the body, have been suggested by Sir Henry Thompson' for introducing

"Lancet," May 12, 1866.