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Medical Societies.MEDICAL SOCIETY FOR THE STUDY OF

VENEREAL DISEASES.

A MEETING of this Society was held at the rooms ofthe Medical Society of London on May 30th, ColonelL. W. HARRISON, the President, being in the chair.A discussion took place on the subject of

Epididymitis. that though theMr. KENNETH WALKER said that though the

gonococcal was the form of epididymitis chieflyconcerned, it would be necessary for him to refer tosuch other forms as those due to the tubercle bacillus,B. coli, and other pyogenic organisms. It was thegeneral belief that infection of the epididymis fromthe urethra was effected through the lumen of thevas, the exciting cause being a wave of reversedperistalsis which drove infective material downwardstowards the epididymis. He did not deny this, butwas convinced that another route was open to theinfecting organisms. In some experiments he made14 years ago with B. prodigiosus he was able toprove that organisms could reach the epididymis fromthe urethra even after the vas had been tied anddivided. The epididymis was infected 10 to 24 hoursafter inoculating the urethra, and the infection wasnot blood-borne, as blood cultures were always ’,negative. Later work suggested that the organismstravelled along the lymphatics in the sheath of thevas. It was known that infection descended the cord,and that the chief producer of epididymitis wasirritation of the posterior urethra, trauma of thelatter, in his view, opening up the lymphatics toinfection. A factor of equal importance in theproduction of epididymitis was direct trauma of thetestis ; there was often a history of the latter in thecases. He was sure that gonococci were often presentin tissues without producing symptoms ; and if theywere in the epididymis even the trauma associatedwith exercise would suffice to precipitate epididymitis.During the war, epididymitis was most frequentwhere irrigation was carried out at too great a pressureand where it was the habit to place subjects ofposterior urethritis on to fatigue duty.

Preventive treatment was very important, and allirritation of the posterior urethra must be avoidedduring the acute stages of the disease. The tendencyof the present day was towards over-treatment andover-instrumentation. Rest was very important ;the cases would be halved if all acute gonorrhoeacases were kept in bed. Failing this, patients shouldwear suspensory bandages and take a minimal amountof exercise. He had not found atropine or belladonnadefinitely helpful, though they should reduce peri-stalsis in the vas. To prevent epididymitis occurringafter prostatectomy, many surgeons ligatured thevas at the neck of the scrotum. Some Frenchurologists had advocated that for many years, andMr. Clifford Morson in this country favoured thepractice.

Z)Mt</Mo.s.s.&mdash;With regard to diagnosis, he said thecommon conditions from which a gonococcalepididymitis had to be distinguished were attackswhich occurred secondary to urinary infections byother organisms, such as B. coli, acute attacks ofepididymo-orchitis associated with blood infections,such as mumps and typhoid, and from tuberculousepididymitis. Epididymitis could complicate a

staphylococcal prostatitis as easily as it could a

gonococcal one. The differentiation of the gonococcalfrom the tuberculous condition was not always easy,especially as the method of spread was the same inboth. In the majority of both tuberculous andgonococcal cases, a lesion of the prostate or vesiclescould be detected by rectal examination. In 22 outof 24 cases of genital tuberculosis sent to him for i

examination ne tound signs 01 prostatitis or vesiculitis.In early days it might be necessary to wait for acertain diagnosis.

T?’g6()!MM<.&mdash;When the condition had developed, twoobjects were aimed at in treatment: (1) the relief ofpain, (2) the hastening of resolution. A third, andimportant, one he regarded as the prevention ofsubsequent sterility. All inter-urethral treatmentshould cease and the patient be kept in bed, whichhe was usually glad of, owing to the acuteness of thepain. In some, the pain was felt along the cordrather than in the testicle itself, sometimes leading tothe diagnosis of acute appendix, especially if vomitingalso occurred. Hot fomentations, supported by hotbaths and rubefacients might give sufficient relief,especially if backed up by morphia suppositories.The form of heat application he favoured was thatby diathermy, the whole testicle enwrapped in a zincsheet which had been well padded with lint soakedin saline. This treatment was applied daily. Thepressure pain could be much reduced by puncturingthe swollen epididymis with a hypodermic needle,drawing off a little blood-stained serum. Americans.favoured doing more : opening the tunica vaginalisand incising the swollen epididymis. Owing to thedanger of dividing the epididymal canal, resulting instricture and sterility, he did not approve of thismore heroic measure.

Epididymit’&Iacute;8 and Sterility.-Mr. Walker said it wasprobable that gonorrhoea was responsible for at least40 per cent. of all barren marriages, and if sterilityin the male alone were taken, the figure would beeven higher. Of 30 husbands sent to him by gynaeco-logists, he found seven cases of azoospermia, three ofwhich were the result of previous gonococcalepididymitis, two of mumps. When epididymitiswas bilateral, the chances of sterility were very great.Cunningham and Cook (in America) found that outof 22 patients upon whom they had performed doubleepididymectomy, 12 subsequently showed spermatozoain their semen ; in five they were absent. No exami-nation of the semen was made in the case of theremaining five. Finger, following the expectanttreatment, found that 207 out of 242 cases ofgonococcal epididymitis suffered subsequently fromazoospermia. Thus incision of the inflamed epididymisseemed to lessen the risk of sterility.

- DCMSSOM.

Major A. T. FROST confirmed what Mr. KennethWalker said as to the method of direct infection. Hehad been looking into the records of over 300 casesand had been struck by the fact that the urethranever showed a posterior infection. In the army acrop of epididymitis cases in the winter usuallymeant that there was a football team, and strenuousgames were played. The sudden exertion causedeither injury or a reflex disturbance which spread thedisease up the vas. In the army it was rare for a caseof epididymis to last beyond ten days, though slightenlargement of the organ might be left longer. Littlewas done for it except resting the patient in bedand injecting sulpharsenol, though he did not regardthe latter as a specific. It had no effect when thepatient was at his worst, but was useful on the upwardrise and when the infection was clearing up. It wasan excellent analgesic. Secondary infection, mostlystreptococcic, probably found its way in by irrigation.He relied on vaccine-therapy as much as ever, and acombination of this with sulpharsenol he regarded asthe best non-drastic method of attacking the disease.

Mr. CLAUDE MiLLS said cases did best which wereput on to vaccines as a routine measure. Patientsshould wear a suspensory bandage from the date thegonorrhoea started ; it lessened the risk of subsequentepididymitis. Often the fluid in the tunica vaginaliscontained gonococci, though the patient might have nosymptoms of epididymitis, showing, he thought, thatthe gonococci probably got through the lymphatics.

Captain CABMiow DOBLE said he had foundatropine very helpful in epididymitis, and the samewas true in his experience of sulpharsenol.

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Major DAWSON was able amply to confirm thestatement as to the harmful effects of football inthese cases of gonorrhoea in producing epididymitis,for in certain hospitals in France during the warthere was a high epididymitis rate, but it came downat once when football was stopped.

Mr. H. M. IIArtscr3r:r L spoke of the good effect ofsimple rest in bed and the keeping up of gentlewarmth, such as by the application of thermogenewool. The two-glass urine test he did not regard asof real value as showing posterior urethritis, unlessit was so severe that there was a coincident cystitis.

Dr. B. B. SHARP referred to a case of what appearedto be anterior urethritis, which, after washing outuntil the fluid became clear, and the prostate andvesicles seemed normal, was regarded as cured.Three days later the patient slipped in his bath andinjured his testicles, and when next seen by thespeaker, after having rested in bed, the man hadposterior urethritis. Possibly the infection had spreadvia the lymphatics from the anterior urethra to theepididymis, and the posterior urethra had been infectedfrom the epididymis and perhaps by lymphatics.

Mr. E. R. T. CLARKSON said that although this wasnot an ethical society, there was one feature of thediscussion which he would like to ventilate. It was ’,as to whether, when consulting his medical adviserand found by him to have dual epididymitis, such apatient should, without putting the question, beinformed that there was a danger that he might besterile in marriage, and that a prospective wifeshould therefore be advised as to that possibility.Did the meeting agree with him that the subject wassufficiently important, as regards both parties, for thatcourse to be justified ? To allow the prospective wifeto enter into a union with such a man in ignoranceseemed scarcely to be

"

playing the game." If such aman did marry, without himself knowing lie was liableto be sterile, he could, it seemed, justly feel he had amoral claim against his medical adviser for not havingdone his duty in this respect. If the patient askedhis doctor the direct question, the course was clear andthe matter much simplified.

Mr. C. MILLS said it was his view that the medicalman should in every such case point out the danger ofsterility, whether directly asked by the patient or not.It would not be fair to allow such a man to enter intomarriage blind as to the likely consequences.

Dr. J. DONALD spoke of the kind of cases in whichthe infection seemed to have been via the lymphatics,not from the posterior urethra.

Dr. M. KORN referred to a series of cases whichwere treated at London Hospital, under Mr. H. Lett,by the injection of contramine for epididymo-orchitis. There was definite benefit from this method,for they recovered in about a fortnight, or in half thetime compared with the cases in which it was not used.He had found that a prolific cause of epididymitiswas the use by the patient of strong solutions of suchfluids as permanganate.The PRESIDENT was particularly interested in the

question of trauma of the urethra and of the testiclein the matter of the prevention of epididymitis.During the war he had a unique opportunity of- definitely associating a high onset of the conditionwith the playing of football, or the use of ungentlemethods of treatment, such as having a strong headof fluid from placing the irrigation apparatus at toogreat a height ; also vigorous or too early massage ofthe prostate. He fully supported what Mr. KennethWalker said in regard to the usefulness of diathermyin the disease. He did not think one could be surethere was no pus in the posterior urethra, even aftergetting clear urine from the washing out, unlesscentrifugalising was carried out. With regard to theuse of atropine, he related a case with very severerelapsing urethritis, with hard prostate and vesicles,which had immediate testicular swelling whenmanipulation was attempted, but the use of atropinethe night before intended treatment enabled manipula-tion to be carried out without enlargement of thetesticles.-Mr. KENNETH WALKER briefly replied.

The Question of Neuro-Recurrence afterArserioberazol Treatment.

The PRESIDENT gave a statement on the male casesof syphilis at the St. Thomas’s Hospital V.D. centre,numbering 2638. In this number the cases withclinical symptoms of syphilis of the central nervoussystem were 168 (including 123 of tabes, 12 of generalparesis, 6 of tabo-paresis). Of the 168, five hadpreviously had arsenobenzol treatment, prior to theonset of the nerve symptoms, and he gave the detailsof these, which showed that only one patient hadreceived the intensive course which was employedat the military hospitals during the war.

Gonococcal Infection from Sebaceous Follicleto Prepuce.

Mr. C. MILLS showed a young man who, a weekafter exposure to infection, had a small " blindpimple " on the skin of his prepuce, and three dayslater had a second of these lesions, the skin beingintact over both. There was no urethral discharge.The follicles were opened, and, as a routine, slideswere made of the pus, which yielded pure gonococci.The urethra remained sterile.

ROYAL ACADEMY OF MEDICINE INIRELAND.

A MEETING of the Surgical Section was held onMay 23rd, Mr. R. A. STOXEY being in the chair.

Mr. W. PEARSOX showed a case of

Atrophic Dermatitis Follozciog " Trench Feet "

treated by periarterial sympathectomy. He saidthat this condition was a rare sequel to trench feet ;this was the second case he had seen. The trouble hadstarted in 1915 with swelling and pain in the feet, sincethen there had been recurring attacks of vesication ofthe dorsum of the feet associated with coldness andtingling. He had performed periarterial sympath-ectomy over three weeks ago, and so far the patienthad greatly improved, but it was too early yet to knowwhether a cure had been effected. The patient saidhis feet had been quite warm since the operation, andhe had not any vesication. It was a very simpleoperation to do. In the other case which Mr. Pearsonhad seen the patient had had a great deal of localtreatment without benefit, and so he came to theconclusion that surgery was the only possible chance.A dermatologist who was consulted called the conditionatrophic dermatitis, and said it was a conditionresembling X ray burns, being very unresponsive totreatment. Mr. Pearson had operated and thepatient was completely cured.The PRESIDENT thought that Leriche’s operation

would be of great help in many cases, as it wasapparently a possible cure for such conditions.-Mr. H. STOKES suggested the applicability of thisoperation to chronic ulcers.-Mr. PEARSON, in replying,said that Leriche’s operation was at first advocatednot for vascular conditions, but for reflex contractionsand paralysis, in which the wounds occurred in theneighbourhood of large blood-vessels and nerves. Hepersonally did not think that the operation would curesuch cases. It had been used with benefit in thetreatment of callous ulcers.

Mr. A. K. HENRY read a note on an investigation of a]}Iechanisrn of Sudden Death in Caebral Tumours,

illustrated with lantern slides. He dealt in particularwith tumours of the posterior fossa, giving rise toincreased intracranial pressure. It had been knownfor nearly a century that when intracranial pressurewas increased the brain tended to herniate through allpossible openings. Notable among these was theforamen magnum, and the hernia here consisted of thepart of the cerebellum known as the tonsils andportions of the biventral lobes. In two of Cushing’scases the hernia, wluch he called the foraminalpressure cone, reached the level of the posterior archof the atlas and compressed the medulla. The