TYPICAL OASES ILLUSTRATING THE ADVANTAGES 
OF THE USE OF NITRATE OF SILVER IN THE 
DEEP URETHRA. * 
By George E. Brewer, M.D., 
Clinical Assistant in Genito- Urinary Diseases at the Colleye 
of Physicians and Suryeons, New York. 
Case I.-E. S., aged 28, single, called upon me in 
March, 1888, suffering from hsematuria, frequent 
micturition, pain in the glans penis, and marked 
prostration. He stated that he had had a severe 
attack of gonorrhoea six months ago, which was ac- 
companied by an acute cystitis, which confined him 
to bed for several weeks. 
For the past four months he has been obliged to 
pass water every twenty minutes during the day, and 
from six to eight times during the night. A slight 
hemorrhage always occurred at the close of each act 
of urination, and not infrequently the entire amount 
of urine passed would be so deeply colored as to re- 
semble pure blood. The pain in the glans penis was 
often so severe as to cause the patient to violently 
squeeze the part to deaden its exquisite sensitiveness. 
He had been treated by several physicians of 
prominence, and had been the inmate of at least two 
hospitals. The diagnoses which had been made at 
different times were cystitis, vesical calculus, tumor 
of the bladder, and tubercular ulceration. 
* Reprinted from the International Journal or Surgery, July, 1885). 2 
The circumference of the penis was three inches, 
the meatus admitted a 24 F., urethra was free to 
30 F. from bulb to meatus. The deep urethra was 
excessively tender and bled freely after the passage 
of the sound. The urine was cloudy, alkaline, had 
a specific gravity of 1024, and contained one-fourth 
per cent, of albumen. The sediment consisted of 
pus, a few urethral epithelial cells, and crystals. 
The first specimen examined contained small urethra 
casts of blood, the second a large amount of blood 
and pus. Examination for stone proved negative. 
The diagnosis of granular prostatic urethritis was 
made, although the presence of a new growth could 
not be excluded until a satisfactory cystoscopic ex- 
amination had been made. 
The treatment consisted in absolute rest, the 
internal administration of boracic acid in five grain 
doses four times daily, and the use of a solution of 
nitrate of silver in the deep urethra by means of an 
Ultzmann's syringe. The strength of the solution at 
the beginning was grains to the ounce, which 
was increased by 2% grains at each application. 
This treatment was repeated every second day. 
After the third or fourth injection the hemorrhage 
entirely ceased, and the intervals of urination were 
increased from twenty minutes to four hours. The 
urine became clearer and acid in reaction. This 
treatment was continued until six applications had 
been made. One week later his meatus was divided 
to 30 F., and a 30 F. steel sound passed to his 3 
bladder every third day for two weeks. The patient 
has since been in perfect health. 
Case II.-L. IL, aged 18, suffered in the third 
week of his first attack of gonorrhoea from symptoms 
of so-called cystitis. He had painful and frequent 
urination and often passed blood at the close of the 
act. On one occasion he passed a membranous cast 
of the deep urethra, and several times small frag- 
ments of mucous membrane. His treatment for 
some days had consisted in washing out the bladder 
and the internal administration of morphine and 
boric acid. 
This case was seen in consultation by Dr. F. N. 
Otis, who advised the immediate injection of a 5 
grain to the ounce solution of nitrate of silver into 
the deep urethra and the use of a morphine and 
belladonna suppository-the injection to be repeated 
on the following day. 
The relief was immediate and permanent. Before 
the injections were used the urine had been passed 
involuntarily by spasmodic muscular effort every five 
to ten minutes, each expulsion being accompanied 
by great pain. On the following day he was able to 
hold his urine for one or two hours, and after the 
second injection the urine was retained from three 
to five hours, and its passage was not attended with 
pain. There has since been no recurrence of his 
symptoms. 
Case III.-P. II., aged 45, single, gave no history 
of venereal disease. lie had indulged in masturbation 4 
and sexual excesses in early life. He complained of 
a " weak bladder and backache," and was compelled 
to urinate from twenty to twenty-five times in the 
twenty-four hours. Duration of these symptoms 
sixteen years. The patient states that he has been 
unable to work for the past two years. He has been 
treated by many physicians and at several hospitals, 
without obtaining relief. Examination of the urine 
showed it to be clear, of a specific gravity of 1020, 
and free from albumen, sugar or pus. 
The circumference of the penis was inches, the 
meatus admitted a 32 F., the urethra was free to 
36 F., from bulb to meatus, and a 32 F. passed into 
the bladder. There was marked tenderness in the 
deep urethra. 
An injection of silver nitrate, 5 grains to the ounce, 
was made in the deep urethra. Two days later the 
patient reported that he had urinated but six times 
during the past twenty-four hours. Another injection 
of silver, 8 grains to the ounce, was now made, after 
which he passed his urine only four times in the 
twenty-four hours. He also stated that the pain and 
weakness with which he had been troubled had en- 
tirely disappeared. 
Two weeks later he was able to hold his urine from 
four to six hours during the day, and was obliged to 
rise but once at night. 
Case IV.-F. B., aged 36, had contracted gonor- 
rhoea in early life. He had been married several 
years. During the past two years he had noticed a 5 
gradual failure of his sexual power, and for the past 
four months had been unable to have connection 
with his wife, owing to the entire absence of erections 
or sexual desire. 
The urine was examined and found to be normal. 
The circumference of the penis measured inches. 
The meatus admitted a 28 F., the urethra was free 
to a 32 F., from bulb to meatus. The deep urethra 
was very tender, and the passing of the sound caused 
a "peculiar weakness." 
The meatus was divided to 32 F., after which deep 
urethral injections of nitrate of silver were used three 
times a week, beginning with a solution of 2y£ grains 
to the ounce and increasing until 15 to 20 grains 
were reached. A 32 F. sound was afterwards passed 
once a week to the bladder. In two months he 
reported that he was able to have connection two or 
three times a week ; and aside from a slight relapse 
which was caused by an attempt to pass a sound on him- 
self, he has since remained well-now about one year. 
During the past three years it has been my privi- 
lege to employ deep urethral injections of nitrate of 
silver upon upwards of 200 cases of genito-urinary 
disease. The symptoms for which this treatment was 
undertaken have been chiefly those of disturbances, 
more or less marked, of the function of urination, 
such as frequency, pain, hemorrhage, etc., or of the 
sexual function, such as frequent nocturnal emis- 
sions, persistent priapism, genuine spermatorrhoea, 
diminution or annihilation of the sexual function. 6 
It has also been employed for the treatment of 
chronic urethral discharges. 
The success which has attended the method of 
treatment has varied considerably, not only in the dif- 
ferent classes of cases, but also in individual cases of 
the same class, in which the symptoms from a clinical 
point of view at least appeared to be identical. This 
variation I believe to be due to the degree to which 
the symptoms were occasioned by lesions in the deep 
urethra. These lesions may be the result of inflam- 
mation, new growth, or simply of an abnormal 
peripheral hypersesthesia of that portion of the ner- 
vous system which is concerned in the operation of 
these functions. 
In Case IV., the impotence complained of by the 
patient was undoubtedly due to local troubles in the 
deep urethra, and, therefore, yielded to the treat- 
ment employed. In the majority of these cases, 
however, the symptoms are not occasioned by a lesion 
of the deep urethra, but are rather due to nervous 
exhaustion, the result of prolonged sexual excesses, 
and are consequently not relieved by local treatment. 
It is, moreover, often impossible to determine the 
degree to which the symptoms depend upon local 
lesions, except by the results of treatment. The four 
cases whose histories have been briefly outlined above 
were selected as affording examples of the class of 
cases in which the best results might be expected by 
the employment of this method. They also illustrate 
the promptness with which symptoms, often of the 7 
greatest severity, will yield to therapeutic measures. 
In general terms it may be stated that the acuter 
the symptoms the more prompt will be the relief. 
I have no hesitation in saying that no method of 
treatment has, in my hands, proved so universally 
successful in the so-called "cystitis" occurring in 
the course of an acute gonorrhoea (which in reality is 
only an extension of the inflammation to the deeper 
portions of the urethra). I have frequently seen 
such an attack aborted by a single injection. In the 
non-inflammatory conditions, as in Cases III and IV, 
relief, though less prompt, is often striking. This 
class comprises a large number of cases, including 
various conditions of irritation which have been de- 
scribed by Civiale under the name of neuralgia of 
the vesical neck, and also the numerous conditions 
comprised under the term sexual neurasthenia. 
There are other conditions which often show 
marked improvement when treated by this method, 
among which may be mentioned prostatorrhcea, re- 
curring epididymitis, reflected neuralgias, chiefly 
those affecting the branches of the genito-crural 
nerve, and the irritation often present in senile en- 
largement of the prostate. Brilliant results are 
occasionally obtained in the treatment of these affec- 
tions, but in a large majority of such cases the relief 
is uncertain and often but temporary. 
As the object of this communication is simply to 
call attention to that class of cases most likely to be 
benefited by this treatment, a description of its ap- 8 
plication, together with the theory of its action is 
purposely omitted. For this the reader is referred 
to the works of Ultzmann1, Keyes2, and Otis3. 
(1) Pyuria, by Robert Ultzmann, M. I). Trans- 
lated by Walter B. Platt, M. D., 1884. 
(2) Chapter on Genito-urinary Diseases, by E. L. 
Keyes, M. D. Sajou's Annual for 1888. 
(3) The Male Urethra, by F. N. Otis, M.D., 1888. 
118 Madison Ave.