especially after urination. There is commonly some feeling of pressure, weight, or discomfort, with possibly burning or mild pains in the perineum. Some sexual irritation is noticeable in practically all cases. Posterior urethritis is sometimes announced by a more or less sudden increase in the frequency of urination, the patient sometimes being compelled to urinate every few minutes from the beginning of the attack. At the same time the process in the anterior portion often subsides to a great extent, with marked diminution in the discharge from the meatus; and though the reverse may be true, yet the sudden cessation of a gonorrhoeal discharge should always lead one to suspect this complication. In severe cases the inflamed mucous membrane of the prostatic urethra becomes so sensitive and irritable that it will not tolerate the presence of the smallest amount of urine in the bladder, and but a few drops are required to excite an uncontrollable desire to urinate, the tenesmus often being excruciatingly painful. In other instances the patient has such poor control of this inflamed outlet of the bladder, or the desire to urinate comes on at irregular intervals and so suddenly and with such severe pain, that the urine escapes before he can reach a urinal. In still other cases there may be complete retention of urine.

A few drops of blood may appear at the close of each urination, or the hemorrhage may be considerable-sometimes sufficient to pass backward into the bladder and to color all the urine. The perineum may be the seat of severe burning or cutting pains which may radiate to the end of the penis, to the testicles, the groins, or the back. There is usually considerable irritation of the sexual organs, manifested in prolonged and painful erections at night, and in frequent seminal emissions, which may be mixed with blood.

The acute symptoms in a posterior urethritis may last from a few days to several weeks, but the process is often prolonged in a subacute form and shows a decided tendency to become chronic. In the severest cases the

sufferings of the patient from pain and lack of rest are extremely pitiful. When posterior urethritis complicates an old stricture or hypertrophied prostate, the condition is a very serious one. Fortunately, in most instances the disease runs a mild or but moderately severe course. The danger of further complications, such as prostatitis, epididymitis, etc., should, however, be kept in mind.

Diagnosis.-The occurrence, during gonorrhoea, of frequency of urination, tenesmus, hemorrhage, or the sudden cessation of the discharge, should lead one to examine for posterior urethritis. The finger in the rectum finds the prostatic and membranous portions of the urethra sensitive; slight pressure increases the pain and tenesmus, but the prostate is not enlarged. Examination with instruments in the urethra is contraindicated, but the urine should be examined carefully by Thompson's two-glass test. This test is based on the supposition that pus secreted in the prostatic urethra cannot pass the compressor urethræ muscle and find its way out through the pendulous portion; but, on the contrary, if more pus collects than the prostatic urethra can hold, it will pass back into the bladder and mingle with the urine, rendering the latter cloudy. If the patient passes the contents of his bladder in two glasses, the first glass will contain urine plus the washings of the urethra, while the second will contain the urine as it exists in the bladder. If this second portion is clouded by the presence of pus, the latter evidently comes from some portion of the genito-urinary tract back of the compressor urethræ muscle.

The exact localization of the source of pus in the bladder is often difficult and calls for careful microscopical examination, but the presence, during the course of gonorrhoea, of pus in the second glass, together with the occurrence of the above-described symptoms, will point strongly to posterior urethritis. If the urine is passed frequently, there may be times

when no more pus will accumulate than the prostatic urethra can hold (when it will all be washed out with the first urine), so that the urine in the bladder will remain clear and will appear so in the second glass. This occasional appearance of clear urine in the second glass will exclude cystitis. In less acute cases, since the amount of pus produced is small, the urine in the second glass may always be clear unless the urine has been retained in the bladder three or four hours. It is important, consequently, that the morning urine-also that passed at the time of the visit-be examined. The degree of cloudiness and the amount of pus in the urine of the second glass give some indication of the intensity of the inflammation. More accurate use of the twoglass tests may be made by first carefully and thoroughly irrigating the anterior urethra with a warm solution of boric acid. The first glass will then contain pus from the posterior urethra only, in case that portion of the canal is involved. If the amount of pus is small, it should be thrown down with a centrifuge and examined while fresh.

Treatment. The general hygienic management is that of gonorrhoea, except that rest is of still greater importance, and in severe cases with much tenesmus or hemorrhage rest in bed, or at least in the recumbent position, is absolutely necessary. Large quantities of bland fluids, such as flaxseed or slippery-elm tea, should be drunk, and the urine should be rendered sterile by the use of boric acid, salol, or salicylate of sodium, in doses of from 5 to 10 grains four times a day. Free dilution of the urine is preferable to the use of alkalies, which may increase the danger of ammoniacal decomposition

'The only cloudiness of urine considered in these pages is that produced by pus and mucus. The nature of the sediment in any specimen of turbid urine should be determined by the usual methods of urinalysis or microscopical examination. Gentle heat clears a turbidity due to the presence of urates; acetic acid, that caused by phosphates or carbonates; bacteria and pus can be removed only by filtration.

in the bladder. Such decomposition and the pus infection of the bladder, which is frequently present, can usually be controlled by the use of urotropin, in doses of from 3 to 8 grains four times a day. Copaiba and sandalwood are valuable in many cases, but they may prove irritating, and should then be stopped. If the urine is markedly alkaline and contains pus, it may be advisable to give benzoate of ammonium in small doses sufficient to keep the urine neutral, but if given too freely it will prove a source of irritation.

For the purpose of controlling the pain and tenesmus, suppositories containing morphine (gr. 4) and atropine (gr.) may be used in the rectum, or from 1 to 10 minims of the fluid extract of hyoscyamus may be given. every few hours. The use of a catheter is to be avoided if possible, and is rarely necessary if the directions. given for the treatment of retention of urine in gonorrhoea be faithfully followed. Allowing the patient to urinate while sitting in a tub of hot water will rarely fail to give better results than the catheter. If the posterior urethritis has come on during the declining stage of gonorrhoea, or if for any reason local treatment of the anterior urethra has been instituted, such treatment must be suspended at once. Local treatment should not be undertaken until the acute symptoms have subsided. The methods to be employed are described under treatment of the declining stage of gonorrhoea.

26

CHRONIC URETHRITIS.

Synonyms.-Chronic gonorrhoea; Gleet.

Before terminating in complete recovery every case of acute urethritis passes through a subacute stage with a muco-purulent and finally a mucous discharge. Following a first attack of gonorrhoea, in a healthy man under favorable hygienic surroundings, this muco-purulent stage tends to recovery without local treatment; but when following repeated infections, or an infection in an unhealthy individual or in one subjected to improper treatment or other injurious influences, this subacute stage may be prolonged indefinitely, as a chronic urethritis, known in popular parlance as "gleet."

Etiology. Chronic urethritis originates usually in gonorrhoea or other form of acute urethritis, but in the cachectic it may occur independently of an acute attack.

The influences which interfere with the proper recovery of gonorrhoea and which tend to prolong the disease in chronic form are numerous and vary widely in different individuals. The general health of the patient is an important factor. In gouty, rheumatic, strumous, syphilitic, tubercular, anæmic, or debilitated persons it is not unusual for gonorrhoea to be followed by chronic urethritis. It occurs frequently as a result of repeated infections, or after a first infection in which there have been a series of relapses.

Probably the chief factors in the production of chronic urethritis lie in the failure of the patient to observe a proper sexual hygiene during and after an attack of gonorrhea; and the most persistent and intractable cases are found in men who, in spite of their disease, are indulging in promiscuous sexual relations, or who are