To establish the location of the trouble in the male urethra, the patient reports to you, having retained his urine for three or four hours; we then, use what is known as the irrigation test, which consists in inserting a soft rubber catheter to the cut-off muscle, and by means of a 100 c.c. syringe attached to the outer end of this catheter, flush out the anterior urethra with cold, clean water, catching up the washings at the meatus, which will contain the contents of the anterior urethra.

Now have the patient pass his urine in two glasses, and the first portion will be the contents of the posterior urethra, plus bladder, while the second portion will be purely bladder contents. Should this second portion be cloudy, it does not necessarily denote a cystitis, but denotes the presence of pus in the bladder, which may be (as it often is) due to pus flowing from an over-distended posterior urethra back into the bladder and clouding the entire urine in the bladder. In these cases, the bladder may be perfectly healthy and still give this cloudy urine, the intensity of this cloudiness depending, of course, on the interval since last urination.

This test is generally only necessary in subacute and chronic cases, as the two-glass test alone will satisfactorily establish an acute anterior urethritis.

Having established the location of the trouble, your treatment must now be outlined.

Acute gonorrhea is treated symptomatically. First, try to reduce the hyperemia of the urethral mucosa. In order to reduce the inflammatory condition, you must get rid of the exciting cause, which is the gonococcus. This must be done with anti-bacterial measures, which will not harm the urethral mucous membrane.

The preparations used for this purpose are divided into two groups: the first group, or antiseptics, and the second group, or astringents. Among the most desirable agents in the first group may be mentioned protargol, largin, argonin, argyrol, albargin and novargan. Those of the second group are silver nitrate, argentamin and ichthargan.

In acute gonorrhea the gonococci first invade the orificium urethræ, then the fossa navicularis. They travel over these parts for a more suitable soil, which they find in the cylindrical epithelia of the remaining urethra; here they multiply on the upper cylindrical epithelia and grow into the deeper parts of the surface of the urethra to the cubical epithelia and deeper connective tissue, where are situated the blood vessels, through which in turn there occurs a transudation of serum and phagocytes, which latter attempt to throw the gonococci off. There occurs here a proliferation of epithelia and infiltration of serum, then a leukocytosis and the gonococci wander into these. Pus cells are pushed to the surface of the mucous membrane and appear in the discharge from the urethra.

At the end of about the second week of this process, the gonococci. have been thrown off from the connective tissue. Now you get a pro

liferation of the epithelia to replace those thrown off and what gonococci remain are in the superficial layers, where they may multiply. This is the critical time for your patient, because should there occur an exacerbation due to excesses, or a pollution whereby the hyperemia is increased and the occurrence of tears in the mucous membrane of the urethra, the gonococci go deep into the tissues again, and the above process repeats itself, maybe several times, and with every repetition the gonococci become deeper implanted in the connective tissue, and you thus get a chronic from an acute gonorrhea.

If the mucosa urethræ had no glands, it would be easier to handle the gonorrhea, but owing to the glands of Littré and their ducts into which the gonococci wander, it makes them hard to reach.

The antiseptics act only on the superficial mucosa, and are therefore insufficient, so you must follow them up with astringents or irritants which bring out the gonococci from the deep.

If the acute symptoms of a fresh gonorrhea cause mechanical obstruction, as phimosis, paraphimosis, or severe inflammation of the glans, you had better not start with injections, but use antiphlogistics and give internally the essential oils.

The latter, however, are only to be used when you can not use local treatment, which should be begun as soon as you have thus subsided any inflammatory conditions.

In your local treatment you may choose any one of the before-named antiseptics, but you must order your patient to obtain a syringe which should hold not less than ten to twelve c.c. The patient should be told to inject enough, say of a 4% protargol solution, until the distension of the urethra becomes painful. The object of this is to distend the urethra so there are no folds, and so that your medication reaches all parts of the mucous membrane. The solution should be used cold and the fluid should be held in the urethra five minutes three successive times, every eight hours. You should increase the strength of your solutions, starting with 4% protargol for two to four days, then 2%, then 1%, each for the same length of time, increasing according to the appearance of the urine.

After about eight days your patient will be much improved and may think he is well; you must then warn all patients not to stop treatment, as this is their most critical time. The antiseptics having now killed off the gonococci from the urethral surface, and all acute symptoms having disappeared, you now give your patient an astringent solution, preferably a 4% ichthargan, or 4% silver nitrate solution. This the patient injects once every eight hours, and holds in for four minutes until the urine clears up. Should there be a terminal catarrh manifested by a cloudy urine after withdrawal of medication, give a 2% bismuth subnitrate solution, to be injected for a few days.

Always have your patient report to you about a week after you discharge him, to note whether through drink, pollution, protracted erection or coitus, any latent gonococci have been brought to the surface.

In acute posterior urethritis at the onset where the inflammatory symptoms are severe and the patient has a terminal hematuria, stop all local treatment and use sedatives until the severe inflammatory symptoms subside, then use Janet's irrigations preferably, with a big hand syringe, using your solutions warm. Use either one-quarter of 1% protargol, potassium permanganate 1-4000 to 1-1000, silver nitrate 1-500.

Begin with mild irrigations until the intensity of irritation and cloudiness of urine decreases, then use instillations of protargol 5 to 10%, ichthargan 1/40% to 14%, or silver nitrate 1⁄2 to 2%. If the urine becomes cloudy, however, go back to the washings.

While treating the posterior urethra with instillations, the patient should also inject mild antiseptics into the anterior urethra and should take internally sodium salicylate in fifteen-grain doses three times daily.

Catarrhal prostatitis is a very common complication of posterior urethritis. It is shown by the presence of pus cells and gonococci in the prostatic secretion. This examination should be made in every case of posterior urethritis.

Gonorrhea in women localizes itself in three places: Most often in the urethra, next in the cervix, and lastly in the Bartholin glands, of which latter the left is more often affected than the right, for some unknown reason. The female urethra is four to five cm. long and separated from the bladder by the sphincter vesicæ internus, so the inflammation is very often limited to the urethra; women develop cystitis, but not as often as men.

Alongside of the female urethra there are two paraurethral ducts, which become very readily infected in gonorrhea.

The symptoms of a simple urethritis in the female are mostly burning on micturition, but if the bladder is involved, the symptoms of cystitis, extreme pain and frequency of micturition are marked.

The gonococcus does not attack, nor grow on the mucosa of the vagina of an adult. In children, however, you may have a gonorrheal vaginitis, as here the vaginal mucous membrane is made up of cubical epithelia, while in the adult there has been a transition to squamous epithelium on which gonorrhea will not develop.

Bartholinitis is either an inflammation of the ducts of the glands alone, or of involvement of the ducts and glands. You may have abscess formation in which the entire gland breaks down, or you may have a walling off, or cyst formation, which may get to be the size of a walnut and may remain for years.

For Bartholinitis gonorrhoica, first massage the gland, and try to express the gonorrheal pus, then inject a 1% silver nitrate solution if

possible through the duct with a blunt needle, or a 15% protargol solution may be used.

The most dreaded complication of female urethritis gonorrhoica is an involvement of the glands of Skene. This is a condition that is difficult to reach for treatment, and the gland should be removed in toto. This occurs in about 2% of female gonorrheas. Cervicitis gonorrhoica sometimes occurs alone, without involvement of the endometrium. This, however, occurs but seldom; still Finger claims that the cervix should always be treated separately, beginning with silver nitrate, 10%, or tincture iodine, or 5% trichloratic acid, the latter acting nicely in erosions about the cervix.

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GENERAL HINTS ON THE DIAGNOSIS AND TREATMENT OF SKIN DISEASES.

BY G. W. SPENCER, M. D., Cleveland, Ohio.

[Written for the MEDICAL BRIEF.]

The almost universal opinion among medical men that the diagnosis and treatment of skin affections is both difficult and unsatisfactory, is born of the fact that the students of this branch of medicine have adopted a nomenclature and treatment both complicated and unscientific.

In the diagnosis of diseases in other organs of the body, the names have been largely coined from the name of the tissues involved, and from some pathological changes produced in the structure or derangement of some function of the organ affected, as for example, pericarditis, endocarditis, cerebritis, hepatitis, myelitis, neuritis, etc., preceded or followed by some qualifying word to more clearly express the condition found as acute, chronic, subacute, hypertrophic, senile, etc.; only a few old and meaningless names are left to indicate some known or unknown diseased process.

In skin diseases not only has the old nomenclature been preserved, but equally ridiculous names for skin affections are being constantly added to the now far too voluminous list.

Every ambitious dermatologist thinks that, in order that his name may be written upon the roll of honor, he must coin some new word to describe a variation in some very common skin disease; or, because the disease attacks some particular region of the body, the name must be modified, or some qualifying word added to indicate the location, for example, eczema capitis, plantaris, facialis; or to indicate some variation in the manifestations of the disease, as rubrum, madidans, seborrheicum, etc., or dermatitis caloricum, exfoliativum pustulare, papulare, or a name lately coined by a distinguished dermatologist in Cleveland, Ohio, "prurigineous

eczema." Many more examples might be added, but it is unnecessary, because the above hint indicates the common custom.

The flights of imagination indulged in by the older dermatologists and some of the modern, surpasses the conception of a normal mind. A distorted mental vision likens one eruption to blisters and calls it pemphigus, when in reality the lesions are pus sacs of varying size.

Another imagines a papular disease to resemble a species of plant called lichen, and then in addition uses the name lichen in connection with eczema or some form of tinea of the skin.

Still another has applied the name ichthyosis to a scaly form of skin disease, because he imagined the appearance resembled fish scales. The parasitic diseases and infections are not so mixed with the imagination, thanks to the development of the microscope and culture media.

The above hints give an idea of the reason this class of diseases is so difficult to diagnose and classify in accordance with the literature of the subject.

When we consider that at least 60% of the diseases of the skin are inflammatory, it should simplify the diagnosis; some writers have very appropriately classified the inflammatory cutaneous diseases as catarrhs.

When inflammations affect certain special structures, the diagnosis becomes less difficult; for example, eczema, which constitutes about 47% of all skin diseases, is a special inflammation of the rete mucosum, hence its exudative character, especially in the acute forms. The presence of an exudate of serum into the skin is the one point always to be borne in mind in the diagnosis, notwithstanding such an exudate may occur in other forms of disease, but it is not so constant a factor.

Inflammations or catarrhs may occur in appendages of the skin, namely, the seborrheic glands, sweat glands, or even in the hair follicles; therefore, the only necessity is to locate these inflammations and you have a name thoroughly applicable to the disease.

When these diseases become subacute or chronic, the difficulty of diagnosis may be increased. Then the only way by which to work out a diagnosis is to get a full and complete history of the course of the disease and mark the pathological changes that have taken place during the course of the affection, and from these changes you can coin your own name. To illustrate again, take the common disease eczema: eczema rubrum is so called because of the red, bleeding surface left after the epithelial layer of the skin has been destroyed; weeping or eczema madidans is so called because of the weeping surface, drops of serum appearing on the skin; eczema squamosum, a chronic dry scaling form of the disease; eczema seborreicum, characterized by an involvement of the seborrheic glands.

Any name which expresses the condition is equally as scientific and acceptable as the classical names.