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.