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Although widely regarded as a mild disease (the clap), gonorrhoea was a cause of much debility and its treatment by urethral washouts was widely detested by servicemen. The complications of arthritis, iritis and chronic prostatitis were severe and difficult to treat. Surprisingly, although the Wasserman test for syphilis was available, soldiers with gonorrhoea were not routinely tested for a concomitant syphilitic infection.

Vaccines were widely used in these pre-antibiotic days and their use is described in detail in this article taken from "The Practitioner's Encyclopaedia of Medical Treatment", 1915 Edition, published by Oxford Medical Publications. The author was Mr J. E. R. McDonough, FRCS., Surgeon to the Outpatients, The London Lock Hospitals..

Dr M. G. Miller


1. Abortive Treatment.--The abortive treatment should only be attempted if the patient comes , for advice within four days after contracting the disease, and provided the subjective symptoms are slight only. The treatment should consist in washing out the anterior part of the urethra twice a day with about a pint of a 5 per cent. solution of protargol, or a 25 per cent. solution of argyrol, or a 1 per cent. solution of hegonon. The treatment should not be continued for more than three days, and if it has been successful no gonococci should be present on the fourth day.

Unfortunately patients seldom come for advice soon enough, but if a case can be obtained before the discharge is copious or the patient has a burning pain on passing water the abortive treatment will almost invariably prove successful. Putting the patient to bed during the course will materially assist the treatment.

Practical Differences between Anterior and Posterior Urethritis The great difference between acute anterior and posterior urethritis rests in the fact that, owing to the collection of pus in the prostatic portion of the urethra and its passage along the path of least resistance, which is over the neck of the bladder into the bladder itself, so much irritation is set up, that in acute posterior urethritis the patient is always requiring to pass water, and has to get up three or four times or more in the night to do so.

If the two-glass test is used, owing to the pus mixing with the urine in the bladder both iportions will be thick. E the pus collects in the urethra only, then the urine passed in the first glass will be thick, while that passed in the second glass will be clear.

If both portions are thick and the patient does not have to get up in the night to micturate, the thickness is either due to phosphates or urates: the former will disappear on adding acetic acid and the latter on heating.

The two-glass test is not of much use in chronic cases, because, in whichever part of the urethra the lesion is situated, the threads brushed away there from will only appear in the first glass. If threads are seen in the second glass, they usually come from the prostate.

Speaking generally, long threads are urethral, short threads and dots are prostatic. A urethroscopic examination will show in which part of the urethra there is inflammation.

Treatment of Acute Urethritis

1. Hygiene.--First of all rest, both to the part--by wearing a suspensory bandage--and to the person. Bed is seldom necessary, but active exercise must be forbidden. Alcohol should be strictly avoided, and hot foods and condiments--mustard, pepper, sauces, etc.-- should not be taken. Excessive smoking has not infrequently aggravated the disease.

2. Symptomatic.--Pain on passing water can generally be diminished by diluting the urine by drinking more milk and water, or barley water and alkaline mineral waters, Evian water in particular. Decreasing the acidity of the urine by drinking lime water often affords relief. For the acute pain caused by spasm of the compressor urethrae muscle, nothing is better than a warm hip bath or a hot opiate fomentation, which at the same time relieves the retention, if present. If there is haematuria the patient should remain in bed until haemorrhage has stopped, and cold evaporating lotions should be applied to the penis, and sodium salicylate given internally.

3. Local.--Two courses are open: giving by the mouth such drugs as are excreted through the urethra and direct application of drugs to the urethra itself. The drugs usually given internally are resins and balsams like cubebs, copaiba, sandal-wood oil, etc., the last being the best; but all are of very little value and less useful than the well-known mistura alba, which keeps the bowels well open--a most important point in the treatment of gonorrhoea. In acute posterior urethritis nothing is better than sodium salicylate.

A mixture which finds favour with some is the following:

When this mixture is given, thrice daily injections of a 1 in 10-20 solution of perhydrol (Merck) should be ordered. The theory is that the Hydrogen Peroxide liberates the iodine from the potassium iodide, and allows the free iodine to exert its destructive action upon the gonococci.

The local application of the proprietary preparation known as "Iodex" is now under trial, and would appear to give favourable results. For direct application to the urethra, potassium permanganate 1 in 4000, or until the solution is the colour of red blotting paper, is the best drug. If a silver salt is desired, preference should be given to 0.1 to 0.3 per cent. solution of hegonon It should always be remembered that every salt of silver should be freshly prepared, and that whatever drug is employed more harm can be done by using too strong than too weak a solution.

No injections should be given until the pain on micturition as well as all redness and oedema of the penis have disappeared. They should then be employed twice daily until every trace of the discharge has ceased, and for at least ten days after. In quite a large number of cases this will result in cure. The old fear of driving the disease back by using injections is not supported by practical experience. In anterior urethritis the solution injected goes only as far back as the triangular ligament and returns through the meatus.

Acute Posterior Urethritis.--In order to wash out the whole of the urethra and bladder, which is necessary in acute posterior urethritis, either the column of fluid to be injected must be raised higher, or the return opening in the glass tube must be stopped up. It is far better to wash out the urethra and bladder with a cannula just inserted into the meatal orifice, than by passing an instrument directly into the bladder, because it is so easy to injure an inflamed mucous membrane, and through the abrasion so caused, the gonococci may reach the systemic circulation.

Chronic Urethritis.--The anterior part of the urethra is rarely affected alone; when such is the ease, twice daily injections of a 0.1 - 0.3 per cent. solution of albargin will speedily effect a cure; if it does not, then the presence of a para-urethral canal must be considered. These canals may or may not communicate with the urethra internally, but they usually open externally in the region of the corona glandis or in the glans penis just external to the meatal orifice..They may be unilateral or bilateral and are usually about 3 cm. or more in length They can only be closed by electrolysis, which is accomplished by inserting a fine platinum needle attached to the negative pole, and passing a current through it of 1-2 m. amps, for one to two minutes.

Another cause of chronic or recurring anterior urethritis is inflammation of the bulbo-urethral glands. The secretions should be expressed by massage and then an mjection of a 0.5 per cent solution of silver nitrate given per urethrum. Chronic or recurring urethritis is most commonly posterior and dependent upon either inflammation of the prostate or the seminal vesicles. Massage per rectum of these structures, continued with instillations per urethram by means of an Ultzmann's syringe of 1 or 2 cc. of a 0.5 per cent. of silver nitrate, or 5 per cent. solution of copper sulphate will sometimes result in a cure. It must be remembered that the mere presence of threads in the urine does not always signify an active or even latent gonococcal infection because many patients who have had frequent attacks or who have been treated with too strong solutions may have threads in the urine for the remainder of their days. A cure cannot be ascertained by searching for gonococci, since in many cases a chronic urethritis may be kept up by the diphtheroids, staphylococci and streptococci, which have long since exterminated the gonococci. These secondarily infected cases are usually made worse by the injection of fluids which have a specific anti-gonococcal action, and only clear up when the silver salts are supplanted by very weak solutions of biniodide or perchloride of mercury. The best method of diagnosing a chronic gonococcal urethritis is to give a large dose of a potent gonococcal vaccine, and if there are gonococci latent, the injection will quickly stir them up, with the result that within forty-eight hours the patient will either have had an increase in the urethral secretions on rising or even profuse discharge. The further administration of vaccines may cure such a case, especially if the prostate or the seminal vesicles are affected. Many a case of urethritis is kept up by a stricture, and no treatment short of gradual dilatation or urethrotomy will effect a cure.

Gonococcal abscesses along the penis should be treated as long as possible with cold evaporating lotions and rest; the knife should only be used when they actually point, and then only the smallest incision should be made just sufficient to let out the pus. A urinary fistula may result, but it will almost invariably close of its own accord in time, and operative interference is seldom called for.

Many a case of acute prostatitis will resolve by merely putting the patient to bed and inserting a psychophore per rectum, through which runs a stream of cold water. A prostatic abscess frequently bursts into the urethra and brings about a spontaneous cure; if it points into the rectum, only a tiny incision should be made to evacuate the pus. Resolution is rapid and a fistula is extremely rare.

Gonococcal Cystitis so rarely occurs, and when it does the infection becomes so quickly superseded by the bacillus coli that the treatment does not differ from that which is described elsewhere.

Epididymitis, on the other hand, is an extremely common complication, and, as when bilateral it is a frequent cause of sterility, may call for special and energetic treatment. Some few cases will resolve under rest in bed and local applications of Lotio Plumbi or Ichthyol, with sodium salicylate internally, but if a case is seen early it is better to employ either of the following two methods of treatment--preferably the former.

1. Take the scrotum into one hand, make the skin tense over the epididymis and plunge a scalpel into its substance, in its long axis, in two or three places; the pain is momentary, but the relief which so quickly sets in is enormous. Then treat in the usual way with lotions, etc.

2. Inject into the epididymis 1-2 cc. of electrargol. The epididymis reaches its normal size in one to three days, and only occasionally is a second injection necessary.

Paraphimosis occurs mechanically and is not due to the patient having drawn back his foreskin and being afterwards unable to draw it forwards again. Attempts at reposition frequently fail, then the treatment is either to divide the constricting band or better to remove the macerated portion of skin and stitch the edges together. If necrosis has already occurred the less done the better; the parts should be kept clean with antiseptic lotions and powders should be freely used to keep the necrosed area as dry as possible, leaving the rest to nature.

Systemic Complications.--The commonest are iritis and arthritis, and it is in such conditions that vaccines are most useful, but local treatment should never be omitted, and special attention should be paid to the genital tract. In the case of iritis, atropine should be used, in the case of arthritis, sodium salicylate with potassium iodide should be given internally, and a 10 to 40 per cent. guaiacol ointment should be applied externally. Atophan (a uric acid solvent - Ed.) is sometimes very useful and can be prescribed as follows--

One cachet be taken before every meal.

The addition of guaiacol. carbonate may be helpful.

Venereal Warts, gonorrhoeal warts or condylomata acuminata, are hypertrophic masses of epithelium produced by inflammation in the corium. The inflammation is not caused by the gonococcus, but by the bacterial flora which collects and flourishes in the corona glandis. Keeping the area perfectly dry with powders will often result in their spontaneous disappearance; this is the best treatment when there are many. If there are only a few, it is best to scrape them away with a Volkmann's spoon and to paint the base with silver nitrate stick, which both sterilises the surface and stops the bleeding.

Gonorrhoeal Ophthalmia.

(1.) Infantile.--Prophylaxis is the chief point, and that can only be effected by keeping the mother's genitals as clean as possible, and by bathing the baby's eyes immediately after birth with a 2 per cent. solution of silver nitrate, or a 10 per cent. solution of argyrol. It is well to wash out the silver solution by some normal saline.

(2). Adult.--The affected eye must be protected at once with a Buller's shield, which is an ordinary watch glass retained in position by a piece of adhesive plaster. The eye should be frequently washed with a solution of a silver salt, atropine drops must be used to prevent adhesion of the iris, and leeches applied to the temple to reduce inflammation.

Vaccines.--A vaccine to be potent must be prepared, without the employment of heat, from a fresh culture, or the first sub-culture which has not been allowed to grow for more than forty-eight hours. The vaccine should be fresh, as it begins to deteriorate after the tenth day, even when kept in the dark at freezing point. No evidence is forthcoming that an autogenous vaccine is to be preferred to a heterogeneous. There are three different methods of employing vaccines:

(1) Ordinary vaccine given subcutaneously or intramuscularly;

(2) Autolysed vaccine given intravenously;

(3) sensitized vaccine given subcutaneously or intramuscularly.

Of these three the last is the best, because, provided the immune serum used for sensitization contains anti-endotoxine, no negative phase follows its employment and the patient does not suffer from toxic symptoms (for full details see Journ. Path. and Bact., 1913, Vol. XVII, 559).

The sensitised vaccines are most useful in acute cases treated early, and speedily effect a cure. Chronic cases may often be improved enormously by vaccines, but after they are stopped the disease remains latent for a time, only to break out again; therefore a cure should not be guaranteed.

In eases of arthritis where there is much fluid in the joint, tapping is often necessary, after which a Martin's bandage should be applied to prevent refilling. Injecting the fluid drawnoff subcutaneously has often been advised, but it seldom does much good..

Autogenous vaccines made from the organisms which have been grown from the expressed secretion from the prostate, which contain staphylococci, streptococci and diphtheroids, may occasionally be beneficial when the gonococcal vaccines have failed.

J. E. R. McDonough.

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