great strength or in unsuitable conditions of the urethra, may certainly cause a return of the discharge. It happens not infrequently that the patient, by his unceasing efforts to cure his disease with one remedy after another, keeps up a congested state of the urethra sufficient to furnish a little mucus every time he presses the canal. Such a discharge will often cease if he lets it alone, and diverts his mind for a week or two at the sea-side. Again, the oftener the discharge is reproduced, whether this happen through neglect or unsuitable treatment, or through fresh contagion, the more difficult it is to cure.

Variations in the course of Urethritis.-The foregoing description applies to the majority of well-marked cases, but from this typical representation there are often departures: for example, the discharge is sometimes the first notification to the patient that he has contracted the disease, for the swelling and pain are sometimes very slight for a day or two. In other cases, the tenderness, scalding, and swelling occasionally continue for a few days before the discharge appears. The intensity of the inflammation varies very much. The first attack is commonly the most severe one, but the severity is dependent in some measure on other circumstances, especially on individual peculiarity. The patient's habits with regard to temperance in alcoholic and venereal indulgence, and his state of health at the time of infection, greatly influence the intensity of the inflammation. Middle-aged men generally have gonorrhoea less acutely than youths, and persons who suffer from acne usually have the disease severely and obstinately.

Terminations.-There are several ways in which urethritis subsides. The first and most frequent is gradual disappearance of the symptoms of the chronic stage. In a certain number of patients the discharge soon becomes very much lessened, but the scalding on micturition and chordee remain. In such cases the mucous membrane is generally bright red, and the urethra is tender if pressed between the finger and thumb. If the patient be questioned, some irregularity on his part will generally be admitted. He has been riding, playing cricket, or has not been sufficiently abstemious in respect of wine and spirits. In another patient the discharge may remain abundant and thick without pain or scalding for months, and in very rare cases even for years, before it subsides. This form is mostly found in persons of gouty constitution.

Gleet.—A common termination of gonorrhoea is termed gleet, by which is meant the persistence, often in spite of various treatment, of a scanty, thin, pale white discharge from the urethra. Sometimes the quantity is sufficient to afford a drop whenever the urethra is pressed, at others a drop of matter is obtained only in the

morning, on rising from bed, or there may be only a little continual moisture with a drop of pus now and then. A very characteristic sign of the condition of the deeper part of the urethra, when the discharge is too scanty to appear at the meatus in the ordinary way, is the presence of little threads of clotted discharge in the urine. The sensations felt by the patient at this stage of his disease rarely exceed a little occasional itching and smarting. A slight but obstinate discharge is often the only outward sign of the formation of an organic stricture, which, growing slowly and imperceptibly, will eventually cause much trouble. There is another danger, too: the state of the patient's mind induces him to constantly examine his genital organs; he grows morbidly anxious about himself, becoming, it may be, hypochondriacal and unable to pursue his occupation in life, or enjoy society: he is rendered miserable by the dread of various evils, real and imaginary; and in this condition he becomes desperate, and a willing victim of quacks and charlatans.

The anatomical changes in the urethra which give rise to gleet may be classed as follows:-1. Excoriations or shallow ulcers. 2. Inflammatory patches. 3. Simple vegetations or warts. 4. Inflammation of the glands and follicles of the urethra. 5. Certain conditions of the prostate.

The exact nature of the lesion which may be present can, in some cases, only be ascertained with certainty by means of the instrument called the urethroscope, or endoscope. Of late years the inspection of the urethra has been much facilitated by the improved construction of this instrument. Its more recent modifications have been simplified, so that the light can be thrown to the bottom of the tube by the ordinary frontal mirror. These simpler forms have now superseded the earlier and more cumbrous contrivances of Desormeaux, Cruise, Warwick, and others. Grünfeld, who has written an exhaustive treatise on the endoscope, uses a simple straight tube. Auspitz has invented a dilating endoscope. The glowing platinum wire has been also used for illuminating the urethra and bladder. This is the source of illumination in the complicated apparatus known as the Nitze-Leiter endoscope, which is fully described in Grünfeld's work.

1. Excoriations or shallow ulcers are occasionally seen in the fossa navicularis, or in the neighbourhood of the bulb. They are always very superficial, and present the ordinary appearance of similar lesions elsewhere. They are very sensitive, and the passage

1 Grünfeld: Die Endoscopie der Harnröhre und Blase. Lieferung 51.

23

1881.

Billroth's Deutsche Chirurgie.

2 Auspitz: Vierteljahresschrift für Derm. und Syph. 1879, p. 14.

of the endoscopic tube usually causes more or less bleeding from their surface.

2. Inflammatory patches.-These are the commonest cause of gleet. If the urethra be examined with the endoscope, the greater part of the mucous membrane will be seen to be pale pink, but at one or more parts there is a patch of deep red colour. The most common position for such patches is the bulbous portion, that is, about 4 to 6 inches from the meatus. There may be a patch also in the fossa navicularis, or, less commonly, in the portion of the urethra between this and the bulb. The red patches are less elastic than natural, and yield to the endoscopic tube less readily than other parts of the canal; consequently a little oozing of blood is frequently caused, and when this is wiped away the surface looks rough or raw. When gleet has lasted some months, the redness is not so deep in colour, and arborescent marking of the urethra with tortuous bloodvessels near the bulb is very common. This condition of the urethra is one that it is very important to ascertain, for the patches just described are really one of the early stages of stricture, and time only is needed for their conversion into fibrous contractile tissue. The surface of these inflamed patches sometimes becomes elevated into prominent granulations which are exceedingly difficult to cure. A granular condition of the urethra was formerly described by Thiry1 and Desormeaux 2 under the name of urethritis granulosa, and was considered by them to be always due to specific contagion. This view, however, was never generally accepted.

The condition of the urethra which has just been described may usually be diagnosed with sufficient accuracy without the use of the endoscope. The patient should lie down, and a bullet-headed flexible bougie of a size that will just enter the meatus without pain, and with a slender graduated stem, should be passed slowly down the urethra. When it reaches an inflamed patch, a slight resistance will be felt by the surgeon, and the patient will complain of a smarting or burning until the bullet-head has passed the tender spot. The bougie should be pushed gently onwards into the bladder, any other tender spots being noted during its progress, and also during its withdrawal. The exact position of the patch is easily ascertained by noting the numbers on the stem of the instrument, or, if that be not graduated, by marking the bougie with the nail and afterwards measuring the distance on a rule.

3. Vegetations or warts of the urethra.-These are commonly situated at or just within the meatus. Less frequently they are

1 Thiry: Presse Médicale Belge. 1858. And Recherches Nouvelles sur la Nature des affections blennorrhagiques. Bruxelles. 1864.

2 Desormeaux: De l'Endoscope, &c. 1865.

met with in the fossa navicularis, especially about the lacuna magna; but in some cases they extend along the whole length of the urethra. Near the meatus the growths are often branched or arboriform, but lower down they form sessile or slightly pedunculated projections, identical in structure with those that grow on the external genitals. (See Accessory Venereal Disorders.)

4. Inflammation of the glands and follicles of the urethra.-This sometimes remains long after gonorrhoeal urethritis has subsided. When the follicles in the anterior portion of the canal are affected, the discharge rarely comes from more than one or two of them. The lacuna magna is perhaps the commonest seat. In the prostatic portion, however, many of the crypts may furnish a discharge. Unlike the inflamed patches, these irritated follicles do not give rise to stricture. The only complication likely to arise is that the sinus or duct may close, and the pent-up secretion form an elastic swelling, which is easily felt in the penile portion. A small abscess is sometimes produced, which ultimately discharges into the urethra if not opened externally.

Gleet in patients who have hypospadias is very difficult to cure. This, in most cases, (depends on the number of crypts or ducts about the end of the urethra, into which the inflammation extends. There is usually one on each side of the fissure just where, in the normal organ, the frænum is attached. They are sometimes threequarters of an inch long, in which case they are quite capable of secreting a sufficient amount of discharge to stain the linen.

5. Prostatic gleet.-This will be considered under the head of Chronic Prostatitis.

The preceding description of the several conditions of the urethra which are observed through the endoscope, or found post-mortem, is not considered sufficiently exact by some authors, and the several forms of urethritis have been divided into a number of separate groups. In our experience, however, these distinctions cannot be drawn with such precision as to warrant a more minute classification than has been given above.

Finally, it must be remarked that more or less gleety discharge is sometimes present when nothing abnormal can be made out, either by the passage of instruments or by direct inspection with the endoscope. In such instances the mucous membrane is generally pale and flabby, and the discharge is due to debility, either from some constitutional cause, or, in some cases, from the employment of a

For a full description of the endoscope, and the lesions of the urethra rendered visible by its aid, see Grünfeld: loc. cit. Also, Desormeaux loc. cit. Tarnowsky, Venerische Krankheiten. 1872, viii. Vorlesung. Gschirhakl: Endoscopie, &c. Mittheilungen des Wiener Med. Doct. Collegiums. 1879, Bd. 5, No. 25. Fenger and Hinde: Chicago Med. Review, Dec. 5, 1880.

too severe and lowering course of medication during the preceding urethritis.

Diagnosis. The presence of urethritis in the acute stages is easily ascertained; the white or yellow or greenish matter which exudes from the orifice, the pouting lips and red mucous membrane of the meatus, are sufficient indications, without reference to the turgid condition of the organ, the smarting and aching pain, and other signs which frequently mark the course of acute gonorrhoeal urethritis.

In the later stages, when the discharge has reached the minimum, the presence of urethritis is not always so easy to determine. Much assistance is gained from the patient's account of his disorder. There has been acute urethritis more or less remotely, and often of late he has observed a drop of matter at the meatus on rising in the morning or the lips of the meatus are glued together by the dried discharge or again, shreds of inspissated mucus are present in the urine. This scanty urethral discharge may depend upon the presence of chronic prostatitis, urethral fistula, stricture or some other sequel of gonorrhoea. These various conditions are to be distinguished by their history and symptoms.

Pus may ooze from the urethra in many affections, and thus cause them to be mistaken for urethritis.

Urethral chancre.-This form of chancre is close to the meatus, and can be seen either with or without the aid of a small aural speculum, as a well-defined sore. The discharge is sanious, and general congestion and painful erections are absent.

The initial lesion of syphilis is usually situate at the meatus, and from the swelling and redness which it causes, combined with a sero-purulent discharge, this affection has at first sight considerable resemblance to urethritis; but the firm induration, the blanching of the red swollen part when pressed, and the almost total absence of soreness, sufficiently distinguish an initial sore of the meatus from urethritis. In rare cases the sore is situate a short way down the passage, leaving only the discharge to indicate its existence: but it may be detected as a hard tender spot, seldom more than half an inch away from the meatus. This circumstance, and the multiple enlargement of the neighbouring lymphatic glands, distinguish the discharge it excites from that of urethritis.

A sero-purulent discharge without sore is occasionally met with in early syphilis. Such an affection is unlike acute urethritis in its scanty discharge and painlessness; but it may be difficult to distinguish it from a chronic gleet unless the urethra be searched with the endoscope. The syphilitic discharge is attended by very slight general congestion of the mucous membrane of the urethra, and soon subsides spontaneously.