J,AtN'. 6, 1917] DISEASES OF THE MIALE URETHIR. [x ,'4 3

6. Syphilitic keratodernmia demands a few observations. The lesions are characterized by an increase in thie horny layer of the epidermis of the palmiis and soles. They often ltrcturrze form gyrate figures of a dull coppery colour covered with ON a horny layer. They may be mistaken for chronic eczemla or psoriasis. In any case of doubt the blood should be DISEASES OF THE MA1LE liTRETHIIA. examined by the Wassermainn test. 1.1R 7. Syphilitic Alopecia.-In the first year after infection FRANK S. KIJDD, B.C., MI.B.CANITAD., LR.CS., the hair-tends to fall. In some cases all that is noticed is ASSISTANT SURGEON, LONDON HOSPITAL, AND SURGEON a general thinning of the lhair, but in others there are TO THE 0 ENITO-U*GINARY DEPARTMIENT. patches of baldness. These are often characteristic, tlhe bald areas being of small size, as if the hiair lhad come LECTUtBE I.-=RETHRITIS. out from numerous spots about the size of the tip of the ETIOLOG-Y. finger. IURETIMrITIS is in mnost instances establislhed by the diirect I have lhad cases of this type sent to lie as alopecia implantation of a specific bacterium, the gonococcus of areata. In the latter affection the bald areas are of round Neisser. Do not forget that it may be caused by. othler or ovoid form, quite smooth, and tend to spread peri- germs. such as colon bacilli, streptococ6i, staphylococci, and pherally. At tlle margin one is often able to demonstrate so fortlh. Investigate all uretlhral discharges under the hiairs thicker at the distal than the proximal end. mnicroscope. In a consectutive series of one hundred cases, 8. Pigmentary S philide.-As an aid to diagnosis I a gonococcus was fouind in eiglhty-four, a -streptococcus in specially desire to draw attention to a cul-ious pigmentary five, a staphylococcuis in eleven cases. affection occurring in the first two years of syphilis. It How-is-tlhe disease eont-acted by tlle male? It is con- consists of greyish or brownislh staining of thle neck, tracted in the majority of cases after connexion witlh an especially on thle lateral asp:?cts. From its situation it infected woman. Do not forget that a man may contract is billed. the *'Venereal- Collar." The margin of the the disease even though he has nsed a condom. I have 'pigmented area is ill defined, but the surface is studded known many instances of this. He-probably infects him- with white spots, with 'a slharp outline varying fromn a self by soiling the uriethira with the fingers after he lhas split pea to a shilling in size. The dappled appearance removed tlle condomi, or by wasliing the penis afterwards is striking and characteristic. It occurs almnost 'exclulsively in an infectedl utensil, or the condom may have broken.- in women. Arsenical pigmentation resembles it closely, Urethritis duie to other gel-ms than the gonococcus may be but is almost always fouind on the trunk-that' is, on contracted fromii a woman lwbo is menstruating, from a cove'red parts. woman wlho has non-specific vaginitis set up by causes 9. Certain drug eruptions may be diagnosed as syplhilis. such as an unclean pessary, or by rectal coitus. I have have known this occur in the case of copaiba, the associa- instances of all thiese. Before the warn hlad seen only a tion of gonorrlhoea witlh a rash leading to tlle error. Thie few undoubted ints-taiCes- of urothi-itis contracted from colaiba raslh is all of one type, resembling uirticaria or infected towels, bathing' diawers;, or water-iclsets. Sinice inorbilli, and there is itclhing. I have also known an the war I lhave seen a ijuinber of ca"es contractedl fiom eruption due to iodides dliagnosed as syphilis. Tlle iodlide thlese soutrces, as tle soldiers arc often thrown together at oruLption is bullous, and commlonly affects tie face and thle front or even' in ca'iiil at lioutie uin'der conditiong which neck. The vegetating syphilide may be nmistaken for favour sucll contagion. an iodide eruption. The history and general symptomns should help in thle diagnosis, and in any dloubtful ease Sp)ont(ouCo011aS or Ii-em^alttogeno6is reltthritl. the blood should be tested. I lhave on several occasions observed a man develop af Lcsions of Mucous Membrance.-The mucous miiembrane slight uretlhritis at the onset of mieasles, no germs.bein-g lesions of syplilis are usually very lhelpful in making distinguishable in the discharge, but only pus and epithelial a diagnosis, and on no account slhould an eixamination cells. 'These discharg,es have cleaired up without treata of the fauces, buccal mucosa, tongue, and anal region be mnent. I have also observed a case of mumps that began omitted. The following points are worthy of niotiee: with orchitis and slighlt putrilent urethral dischalre. I Aphthae are rounded yellow, painfLul superficial lesions lhave-also observed several cases of spontaneous urethnitis occulrring on the gums and buccal miucosa. Herpetic cdue to the colon bacilluts in Dien 'whro were very run down, lesions in the mouth are also painful. Neitlher are asso whio had not been exposed to infection, and who deve- ciated with an eruption on tlhe skin nor witlh generalized loped trethlitis with or Witht]io1t simultaieous attacks of indtration of the lymphatic glands. Ervtlhenma muulti- haematogeuotus pi-ostatitis and pyclitis. forme, with extensive lesions in the imoutll, may be diagnosed as syplhilis. The skin eruption especially SUCRGICAL ANAT0QMY OF TIIE URETHFRA. affects the 'extremities -over bony prominences. 'There .An ndertanding or thiejsirgical an'atomy of thle urethra^ is no general enlargement of the glands, and there is is essential in the stud(y of it'thr-itis (Fig. 1). often -a history of previous attacks. Condylomata lhave been migtakein for piles, but the error is due to want of care in examination. SOME CONCLUSIONS. I would remind you that syphilis, as iutceiinson taughlt us, is a great imitator. Always have syphilis in yVou mind, and particularly when youi see what looks like a common variety of eruption with unusual distribution, and where there is an erLuption of several types co-existing. Do not make a diagnosis on the raslh- alone; look for con- firmatory signs in the glands and the mucous membranes. r Do not pay too much attention to the history, and in any $fprss4-VetV doubtful case take a specimen of the blood and send it to an expert for tlhe "1 Wassermann " test. Here let me give iou' some figures as to my own experience with this test. For some years I lhave sent cases, some hundreds, to Drs. Fildes and McIntosh for "'Wassermlann" examination. Of cases in wlichl I was clinically certain of syphilis the P.i.Poasterior UretAre following results were obtained: FIC:. 1---Diagra of the male urethra. Primary syphilis ... W.R. po0sitive in 90 per cent. Thle first conception to get into your minds is that the tSecondary syphilis ... WV.R. positive in 99 per cent. ureXthra is dividedl into two0 portions, the anterior ulrethira Tertiaray syphilis ... Wv.R. positive in 95 per cenlt. and the posterior urlethra. Cong6enital syphilis ... WN.It psositive in 100 per cent. The point of division is the compressor uIrethlrae muscle ("Ceut off" muscle) whlichi sui'roulnds the membranoule (To bce con tinnZed.) portion of the urethlra. Tiuz BRITISI 1 4 tii DICAL JOURNAL I DISEASES OF THE MALE URETHRA. [JAN. 6, 1§~I7 Tr I The Anterior Urethra. and cavernous tissues of the corpus spongiostum. Directly In fronit of tlhe mnus-cle lies tlle anterior uretlhra, 6 in. underneatlh tlle submucous coat is a well-defined layer of long. Tljis consists of: unstriped muscle fible disposed in circular riings. These 1. The nica/us, whliclh is the narrowest portion of tlle rings are very obvious on urethroscopic examuination. canal, the calibre being 24 Charriiere in average Underneatlh this layer lies the cavernous tissue of the individuals. corptus spongiosumn. The lymtuplhatics of tlhe front portion of thje urethlra lead to of on 2. The Jossa navicularis, 1 in. lona and containing theglands th1e-glroin bothi sides. The lymplhatics of deep and prostate lead usually one large gland on the roof,-the lacuna tlle uretlhra to mag;na. (Calibre 30 to 35 ClWarriere.) tlhe hypcogastric ancd externial iliac glands, and so to the 3. The penile or pendulous portion distal to the scrotum, lumi-bar glanids. upon the as a containiug ou thle roof numerous glands or follicles, Look uretlhra, tlhen, tube di#ided into two and being very resistant to dilatation. (Ca.libre 28 parts: to 30 Cliarriere.) 1. T7he anterior portion, non-absorptive and easily 4. The bulbouts porti6n extending to tlhe- comupressor accessible. muscle, containing only a few large glands usually 2. The postcrior portion,-very sensitive,and lard to on the roof anid being very dilatable (calibre 40 to get at. 45 of Cowper's Charri6re). The mxioutlhs glands Look upon these two portions of tuibe not as cylinders on cau open the floor of the bulb. but these lhardly witlh smootlh walls, but as cylinders witlh num-erous perfora- ever be seen by the ure.lIiroscope, anad in my tions in their walls, tlese perforations leading to blind experietnce are only found infected on tlle very tuLbes or glands of varying lengtlh and complexity. rarest occasions. T7'he comhpi-essor wrethrae is a powerful voluntary URETEIRITIS (GONOCOCCAL). musele which passes into spasm on the slightest provoca- PATHOLOGY OF THE LiVING AS OBSERVED CLINICALLY. tion, as by the stimulus of antiseptics or instruments on incubation Period. mucous can the membrane. It only be relaxed by an After implantation in the fossa navicularis, the gono- effort of will or desensitizing thie mucous by mem-brane coccus lies apparently dormant for a period of two- to seven with novocain or stovaine- days, during wlich time it is in itself no opening reality multiplying Thereare gland of any importaniee into the until it becomes many -inyriads of germDs. III 180 cases membranous urethra, and this part of the eanal hardly the average incubation period was se.ven days, tlhe shortest ever acts as a reservoir of latet uretlwitis, though it is one day and the longest twenty one days. ometimes the site of tronblesome strietures, soft and hard. Developzent of the Disease. .-- The Posterior Urethra. At the end of the incubation period the gerius, now This is between Qne- and two inchies long, and is one of present in vast quautities, elaborate' poisonous bodies the most hIighly sensitive and highly absorptive mucous wlhichlirritate the tissues and set up iniflammation. As a membranes in the body. Half a grain of cocaine in the result an exudation is poured out of the blood vessels atot deep uretlhra is absorbed in a few minutes and way kill a the urethra, whielh exudationi appears at the opening of patient. A few bacteria carTied into thie deep uretlhra by the uretlhra as a yellow purulent dis 1iarge. The urine an unclean inst-rument will set up a rigor and may even passing over the iniflamied urethracauses pain. Thsese two lead to death from septicaemia. Treat- the deep uretlira facts informn the victimi that he lhas contracted the disease. withi the .litmst care, gentleness, and respect. Thje deep Dturing the incubation period the victim does not know urethra lhas a calibre of 35 to 40 Charri6re. The roof- and that hie or slhe has any infection, and in many of my cases sides are seldom provided with glands. On the floor lies I lhave records that connexion with otfier persons have the vernmontanum-a sensitive erectile structure on the taken place during this period, with consequent spread of apex of wlich open the ejaculatory ducts guarded eaclh by the disease. In tllis way married men or women who powerful splhincter muscle. On each side of the veru- have gone astray lhave given the disease to their wives or montanuin open numerous ductules of the prostatic husbands by going witlh thiemu during the incuibation peridd glandular tubules. The aterns masculinus lies in- the before they have realized that they are in fact infected or centre of the verumontannum, and is a bogey often cited infectioun. In 180 cases 24 married men were found, siL to explain tailure to cure. Actually it is very seldoma a of whlom had thus given it to their wives. Of thiese 2 factor of importance in keeping up a disclarge. married men, it was known that 15 lhad contracted it from- The posterior urethra is cut off from the bladder by a women other than thipir wives. Thje remainder had weak involuntary muscle, the internal sphincter of the undoubtedly got it from their wives who lhad gone astray. bladder. It used to be taught tlhat the bladder and deep Do not be (deceived because the- incubation period seeins- uretlhra were practically one; and that thle internal to liave been unduly prolonged. lif reality the patient hias spiiincter did not keep the urethra shut off from the had a mild dischiarge and has niot noticed it, anid only a bladder. I am convinced from practical observation that bout of alcohol or excessive coitus or some dJebilitating this is not the fact, and that in the majority of cases tlle factor has br ouglht on a more profuse and therefore internal sphlinlcter is a potent cause in keeping uretlhritis obvious discharge. from spreading to the bladder. The bladder nmucous Rtate of Ascent. memnbranie also seems to be hiighly resistant to the goIno- In cases of uretlhritis thie germlis ascend the uretlhra at coccus. In practice, therefore, consider the deep uretlhra varying rates. If thie germs ate very virulent or if tlhe as dlistinct fromi the bladder. patient is very -riun dowvn in hiealtlh and indulges in ex- The uretlhra is niot a simple tube; if it were, uretlhritis cessive alcolholic or sexual excitemnent, then tlhe germs may wouild be a simple dlisease. Theo tube nieeds to be kept ascened quickly anid reachi the deep uretlhra in a few days. moist so that tle walls, naturally in a state of collapse, Il the average case it is ten days to a fortnighlt before they cani be separated widely during the passage of urine get as far as the deep uretlhra, and in some cases tlhree or witliout tearinig. For this purpose mucus-secreting glands four veeks. How tlJe gonococcus ascends we do not know. of variolas sizes are provided in the walls of the tube, All we kniow is tlhat if we use the uretlhroscope during tlhe "glands of Littre," " follicles," " lacunlae of Morgagni," early acute stage (a p)ractice I do not advise) we can see "prostate glanids,' " vesiculac seminales." Tlle moutlhs of quite clearly liow hliglh the inflammttliation lhas spread. We the glands point forwards. see the walls of the tiibe highlly inflamed for soniie inclhes If the hjealtlhy uretlhra is inspected by means of the aind tlhen quite suddenlly ve see the imiucous nmembrane unetlhroscope the mnouthls of thte secretinlg glands glisteningy pale anid lhealtlhy. Evidetntly the gern gi-ows steadily up- with inucus cati be seen clhiefly on tlle roof of tthe canal. wards in tlhe ordinary cases; but in hyper-acute cases it The gland(is serve to keep tlhe walls of tlhe canal mnoist ascends by somue process- the nature of wlliclh we do lnot and gliSLellillt. In exceptional cases glands botlh small exactly kniow. and large are founid on the floor or sides of the canial. As ttie golnocoCcus spreads up the canal it siiilis into the The muicous meiDb)rane is lined by epithelial cells moutlhs of the glands and also 'siimks into tlle areolar and stratified in the fossa, but further back columijnar. Under- muscular tissute beneathl tlhe bas6iient mliewbrane. and in neatli is foniud a submiucous areolar coat, richl in elastic severe cases it reaches. tlle dor.;sal lymplhatics and the fibres and blood vessels. Nvhich merges with the muscular glands of the groin. The bl'ood" vessels dilate and pour JAN. *C,, THE f T.r fIRrTIeT 1917i DISEASES OF MALE URETHRA. UiLflWcALJOURN.AL 5 forth plasma and pus cells (inflammation). The inucous -Daring this stage off ante deep urethritis tlhe pationt is membrane can be seen to be red andswollen and bathed in a hlyper-sensitized state, and it is -very eay to ujet in pun; and pus can be seen pouring out of the glands of the equiiibriuimnbetwo)en the germs anid the tissues, amid to Littre, the glauds thetmselves being swollen so that their set up blood infectiorn. -This explains whty consideraible bodies project into the lumen of the canal. wisdom, clinical -know]iledge, and judgement are requliriel in When thle gerTns reacll the deep urethra (58 per cent. i* the treatment of acufte deep uretliritis, anid wlhy sucl good 180 consecutive cases that came up to be examnined, but results are obtained iff tlle patient can be confined to Lis almsat invariably in. untreated cases) they peuetrate the bed. ttubules of tlle prostatq gland and the sem-inal vesicles. so that these glands can be felt- by -a finger in the rectumii as lhot Chroi,nic Stage: Carriers. and swolleni. In 15 per ceit. of posterior cascs the germIs At the end of tllis period of five to eight weels thie -spread to .lte 'testicles, but they very seldom reach the inflammation suddeul;y dies down, and -the patient seems bladder, and hardly ever tlle kidneys. The only evidene to develop partial immn unity; tlht is to say, ihe is no 4onger of bladder infection is greatly incireased freqencey of in a hiyper-sensitized eptate, and, he eases to pritdue very micturition. Most cases labelled as gonococcal eystitis are much pus. It thien 1becomes -possible to employ strong really cases of deep urethritis. The bladder, unlike the treatment for tfhedeec p Urethl, -and it is niuchltiharer to uretlhra, is hliglhly resistant to the gonococcus. upset the balance by iiuwise treatrment. It is then safe for If a case comes to us before tlhe disease has spread to thle patient to get about, take exercise, anld try to get fit. the deep uretlhra, and if we at once institute irrigation or At the same period the -gonococcus clea-liy becomes injection treatni-ent, tleln it is rmost exceptional to find the modified also-tlhat iis to say, it ceases to prodieo all disease spreading at a later date to the cleep urethra. It intense irritant poisoiu, and does not easily invade the is most imiportant to recognize this fact. If a large blood stream and irrittate the body into producing a large number of cases in tle early acute stagoe are observed amount of discharge. clinically it will be noted that on tlhe average it takes A few -ases undergo natural resolution at this stag,e, but about ten days to a fortniglht before the germs reach the only a fewv. The paticent often tliniks lie is ctiredl, as all deep uretlhra and prostate, tlhouglh tlhere are exceptions to burning and pain ceaseDs, and urethral discharge is hardly., the rule in lhyperacute cases. noticeable. All the sai,me, this state of m-ind is only due to Tlis is' a fact of vital iuip)ortaiice. lack of close observattion. A careful observer will iiote a little gleety discharge in tme mornin, on iisi'g, or will Treatment of Lairly Aniterior Urethlritis. notice threads in tlle urine, or even a slight turbi(lity of During tlle early stages the germs, beingf confined to the pus ini the ulrine. A r eally careful, scientific, trained anterior uretlhra, arceasily got at by means of antiseptic worker can soon dete4ct the fact that a inman is iiot cured applicationis, and can be got un(ler control and prevented btut lhas passed into thae clhronic stage; or, iii otlher wordts, from spreading to thle deeper parts. The disease caln then hias become a "1 gunoco4ccus carrier." If lie examines thle be cured in a few wveeks often, iiLdeed, in a week.' Thliis is will find pu:s cells and a few gonococci in tlhem. a fact that has inot been widely appreciated. A fatal tIrleasIf lie examineshe the pr )static secretion micieroscopically lie doctrine lhas beeni tauglht in many of the Eniglislh sclhools- will find pus cells and figonococci. If lie ulses tle turetliro- namely, tlhat in the early acute stages injectionls slhould scope lie will find infe,eted glands of Littre or patchles of not be used. This is a niost pernicious fallacy aild needs sibmucous infiltrationL, wlhere the gonococci are still to be eradicated fronm the miid of tlle profession. Evi(lence lurliing under tlhe mIucouIs membrane and setting uip gathered by mo(letrn clinical observers goes to disprove patches of clhronic if ammation (=- early stricture or soft this fallacy. Clinical experience slhows that it is inl the Stricture). These facts can readily be detected by a early stages that antiseptics properly applied in suitable trained clinical obser'ver, but are usuially coniveniently strength1s can cure'C th1e disease quickly. Antiseptics used ignored by those who are after short cuts to cure-a very to be applied in unsuitable strengths, andl that is why this fatal thing for progress fatal doctrine grew up. In other woids, thetre is a clhronic stage i-n nretthritis: Pace Almroth Vriglit no disease illustrates better than vwhich lhas been largelly ineglected- in the past botli by acute urethriti tAhe favourab.e reaction of purulent patient and doctor, so tthat the patient is told that lie is tissues to the application ot suita;ble antiseptics, and this cured and goes about slpreading the disease to other people. reaction cani be used as a constant and living proof of the If this chro'nic stage diid not exist, the gonocoeus would fallacy of somne of Wright's statements or "ipostulates lhave died out long ag,o. Very few pe:ople will copulate for example, " Tlhese general trutlhs are firmully based upon willilngly when sufferihig from profuse uretlhal dischlarge, experiment. It can be demonstrated tlhat nione of our but they are only too ready to return to their okl ways ordinary antiseptics extirpate miiicrobes . . . in purulent whien they lhave entereed the chronic stagc of urethritiss, discharges." especially if they have been told by their medical advisers Anterior uretbritis if left alone or treated by vaccines that they need not wo)rry about a sliglht gleet or a few or irrigated only witli salt solutioni, spreads rapidly tlhreads, or -lhave been told to " let it rip "-lthat classicil upwards. If in tlhe same puutilent stage potgssium per- plirase of the mentally inert. muanganate in suitable sttiengthis is applied to the ;sup- purating mucous mucmtibranec of tlhe anterior urethra by N or the SYMPTOMS AND SI(.S. injections irrigations, diMhlarge is at once lessenied, Ndo. no propose in tI lectures to and in a few days disappears, and with it-the-germs that the ordinary symptoms hese (lescribe iii deetail caused tlhe inflamination. In otlher words- and discar a soms of acute uretlritis, SuLChi as burniug "It can be dfemnionstrated eve--ry day tliat ani ordinary known bothi to doctfforth, as they are sLflficiently well antiseptic, potassinui perwanganate, in suitable concentra- lvai thle ,or and to the layiman. Witat I (lo tions can extirpate microbes (gon:ococci) in uretlhral t to emphasize here is that these are (nly the sig,ns purulent d sc iarges." a symptoms o e early acute stages (five to eigllt These "general trutlhs " may be firinly based ulpon I to bring to yotur nlotice is the iun- experiments in thle laboratory, but they are found not wreekas). ofWhnatnot eglectiwantiting the signs and symiiptomiis of the to lhold in tlle out-patieilt de)artment. clrOlliClortancestage.g Spread to Posterior Urethra.I Gleet. alone stage thliere may be a slight gleet noticed If a case is left or treatedl c,simply bv rest in becl, In thleclmronic 7outte milita ire," ';1)on;jonlr drop"), medicines or vaccines, wlhat happens? Or if a case comes or there may be nothingX more than a few tllreads in the to us in which tihe disease lias ali-eady spread to the deep urine. A man in the clhronic stage may pass perfectly urethra, what iappeiis? If we observe a large number of clear urine for weeks at ca.ses wewfind that almost invarlablvy thie disease snreads to clearI)iA fowLLe eks at a time, contaiuing not a trace of the d in course of a such a case if we massage the the deep uretlhra an(t prostatep tthe ten days and vesicles wea may find the secretioni full of pus; to three weeks, sets up acute iniflammation in this ~~~~~~~~~~~~prostate structure, andt cells and gonococci. T'his is particularlv trite-'wlen tlhe disease is confined only to one resicle. Thle mijouitlh of tlhe The inflammuation in the deep urethlra remains acute for vesicle tends to become at least five weeks the of occluded and the gonococci mnay fromn firsL Sign uretlral discharge, only come out during exncessive coitus or after an excess of and very often for as long as seven or eiglht weeks. alcohol. G 6 mc4LBJOURNAL TREATMENT OF MALARIA BY TARTAR. EMETIC. [JATA . 6, '917 Chronic Prostatitis and Neurasthenia. Another very important fact to note is the effect of DISAPPEARANCE OF MALIGNANT TERTIAN chronic prostatitis on thle general healtlh. A man with CRESCENTS FROM THE BLOOD FOLLOWING clhronic prostatitis may lose a stone or mnore in- weight, may becoine severely neurasthenic, and so dprepsed as to THE -1NTRAVENOUS INJECTION OF be suicidal. This neurasthenic condition i'soften aggravated. TAIRTAR EM LiETIC. by a low meat free diet, whlich tle patient hlas- adopted on the advice of his doctor. 'All this vanishes witlh the cure of BY the prostatitis. Probably a clhronic toxaemia is respoiisible, SIR LEONTARD ROGERS, M.D., F.R.C.P., F.R.S., I.M.S., or it may be that subconscious irritation of thie complex PROFESSOR OF PATHOLOGY, CALCUTTA. nerves of the prostate with their close emotional conulexion' in the mid-brain, may be the cause of the nervous depres- [PRELIMINARY NOTE.] sion. Remember that nothing helps so much in the cure THE discovery of tlle value of cinclhona and cquinine in of a clhronic prostatitis as clieerful suggestion and atten- rnalaria has' been' of incalculable value. Nevertheless, tion to the general hlealth. Sea air, a generous diet, anid even quinine is not an ideal drug for' tle disease, because, open-air exercise are the most important elements in although it rapidly kills'the intracorpuscular'stage of the success in treatment. iparasiteo 'nd brings' iib&ut 'tle cessati6n 'of tlie febiile paroxysnms, yet it co6mp!)lete,ly fails to destro6y 'the" extia- "Sciatica,' ".4xunbag," " Chrvniea Rkheuratis'." corpuscular cyc'16, wlich --is. responsibiee botlh for 'the Another clinicalflact-sliould be -emphasized.: I find that frequent ielapses of the. ague, naud, stil' more important, a very large number of cases labelled as' clronic sciatica, for the infection of mosquitos, -andftiroiugi them of Qther chronic lumbago, cbronic rheumatism, have their origin in persons. The difficulty in comipletely eradicating a an unsuspected gonococcal focus in tlie prostate or seminal malarial infection is -well kniown. T'hlius Normian Chevers vesicle. 'In' sucl cases the doctor is often content to relates tlhat lhe suffered froim attacks foxeigrt&n years in squeeze the uretlhra and if no dischlarge is obvious then he India after contracting the disease in Chittagong, and for dismisses gonorrlhoea as a possible cause.- More careful six years more after hie returned to England, and that hIis observers may eve'n look at tlle urine. But here again in friend,- Sir Ranald Martin, hiad frequent attacks of ague niost cases not even threads are to be seen, let alone pus. thiroughout his long Indian service, and for no less tih&n The only way to exclude 'chronic gonorrlhoea as a cause of thirty years more in England, althjouglh both of them took obscure rlheumatism is to massagethe prostate and vesicles quinine freely for the attacks. Prolonged daily doses of and exafmine the secretion under the microscope. If pus quinine for montlhs at a time will often prevent relapses, is detected, then the cause has probably been found. If but even this measure mav Jail. A drug whichi will really treatment directed to the cause is instituted, in six weeks cure malaria and destroy the infective extracorpuscular to thlree months all the pains vanish and a brilliant cure stage of the parasite is, tlheretore, still much to be desired. is obtained. The uniform success wlich I have already reported, in the cure of kala-azar bv tartar emetic intravenously, now Ferer. amlounting to over twenty conisecutive cases in Europeans, There is another clinical sign to wlhich I would like to led me to lhope that the drug, once it is able to kill the call attention. So long as tlje disease is confined to the Leishman-Donovan parasites, wlichl are so higlhly resistant anterior urethlra we seldom, if ever, find fever. It seelmls to quinine, miglht possibly also be inimiiical to tlhe quiinine- c ear that tlje anterior urethra is a highly resistant surface resisting stages of the mialarial parasites, of wlhich tlle and does not allow the passage of fever-producing poisons malignant tertian crescents are the most characteristic. into the blood. Once the disease has spread to the deep It is well known tllat once tljey appear in the blood they urethlra fever is quite common, especially if the patient is remain present for montlhs on end quite uniinfluienced by not at rest in bed. The deep uretlhra is a highly absorp- quinine. Thlanks to the kinidness of imy friend Captain tive surface and lets through at once the fever-producing N. H. Hume, I.M.S., I have recently lhad an opportunity of poisons. Over and aver again I have met witlh patients testing the effect of the drug in tlle following two cases suffering from a deep uretlhritis who have been allowed to showinig numerous crescents in the blood. get -about by their doctors with a temperature of 1030 or 1040 F. It has not cc,urred to their doctors that it is CASE I.-Apyrexial Case shoointq Numilerouis Crescents inb the necessary to take their temperature. In the case of any Blood treated weith ITartar Emetic Intrarentiously. otlher acute disease the temperature would be taken as a A Russian sailor, aged 20. admitted for general debility, but matter of routine, and no patient would be allowed to be without fever. Numerous malignant tertiain. crescents found in the finger bloo(d, one in every few fieldls of the microscope. up and about with such a high temperature. It -should The followiug tabular stateheint will best brinig out the becoite-a rontine practice to take the temperatture in cases treatment and its effects: of acute--posterior urethritis, and if the temperature is raised above the normal the patient should be ordered to bed.. Blood Exaimination. Treatment. Another interesting fact is that in cases of chronic posterior uretlhritis wlich are not doing well a persistent First day ...... Very numerous cresceents subnormal temperature can -often be- noted. Wlhen tle Second day ... disease takes a turn for the better, simultaneously' the temperature rises to normal and remains there. Third day... Fourth day ...... Tartar emetic 4 eg. in- travenously. Hac?naturia. Fifth day .Very few crekcents Tairtar emnetic 8 cg. in- traveuously. Haematuria is not an uncomlmon symnptom at the onset Sixth day ...... t, of an acute posterior uretliritis. Usually a few drops of blood are squeezed out at the end of micturition. If strong Seventh day , No crescents found irrigations are exhibited in such cases a profuse haema- Eighth day One crescent found Tartar emetic 8 cg. in- turia may be set up. In such cases use oily the mildest travenously. injections, for example, ;ff pptassium permaanganate, and Ninth day.. No crescents found above all do not use a sound or a cystoscope. - Tenth day ..., Eleventh day ...... Tarter emnetic 12 eg. ini- travenously. Retention of Ur'ine. Twelfth day ... This is quiit comnon at the onset of a lhyperacute posterior' urethritis. In suchl- cases rectal examination Thirteenth day ... ., always reveals a large abscess of one or both lobes of tlle Fourteenth day ... prostate. Gentle pressure with the finger will empty the abscess a little?, and thle retenltion may at once be relieved. T'he patienlt left hlospital two dlays later much imnproved [nl his general. health, an(l havinug gainled 10 la,. inl weighlt. Hlis REFERENCE., tern perature was nlormal wrhile inl hospital excep)t for a: rise to I Trea.tinent Of infected Wrounds, BsmTIsnX MEDICAL JOURNAL. Juno 100.20°on the evening after the inljection of 12 cg. of tartar 3rd, 1916, 11, 793." etnetic.