anterior chamber recovers its ordinary condition, but the iris sometimes forms permanent adhesions and deformity; this is rare, usually the vision is perfectly restored.

Fournier has collected the various recorded cases of rheumatoid ophthalmia, and added them to thirty-nine cases of his own. He finds that in nearly all of them the patients were attacked in the joints as well as in the eye. In a small number of cases the eye was alone attacked and the joints escaped; generally many joints and synovial sacs were affected when the eye was also inflamed; and not infrequently the pain and congestion passed from the eye to the joints, and vice versa, showing that all these structures were attacked by the same disorder. Or, again, a patient suffering several attacks of gonorrhoea may have the eye inflamed in one attack, and in another, swelling of some of the joints. Fournier records a case where a man had four attacks of gonorrhoea in five years with the first attack he had double ophthalmia, and no articular rheumatism; with the second, first the eyes and then the joints suffered; with the third, first the joints and then the eyes; with the fourth attack, he had articular rheumatism only.

The treatment of the rheumatoid ophthalmia seldom need be very severe. In light cases the patients need not be confined to a dark room, they may go about if their eyes are protected by a shade, and not employed. The eyes should be bathed three or four times a day with a belladonna lotion, and if the inflammation is slow to subside, a few flying blisters may be applied to the temples. The diet should. be mild and moderate in quantity, while all stimulants must be avoided. The bowels should be well purged with saline and hydragogue purges; sulphate of magnesia, compound extract of colocynth, with a small quantity of gamboge, will

Blennorrhagie, p. 249. See also Rollet: Mal. Ven. Paris, 1866.

cause several watery stools, and thereby relieve the con gestion of the eye. The purgative should be repeated two or three times according to the progress of the case.

When the iritis is severe the treatment must be more active. Free purgation and local depletion by leeches should be first alministered, and the pain assuaged by warm belladonna lotions, with low diet and confinement to a dark room. No time should be lost in dropping atropine into the eye to date the pupil The patient should also take frequent doses of sizes with colchicum wine after the preliminary Fangation. If this does not arrest the inflammation, the patient must be quickly brought under the influence of may. The tendency to relapses, and even sometimes the progress of the disorder, is often checked by the balsams of pera, espaita, or cubebs, for these medicines appear to have & specific effect on the rheumatoid complications of gonorraza as well as over the urethral discharge. If the patient remains in a feeble condition, cubebs with iron will greatly beneft him, with change of air.

Flewatoid Arthritis-A certain proportion of gonorrhœal patients have rheumatoid inflammation of the synovial and Abrens membranes. Of 2423 persons with gonorrhoea,1 one in 27 had also acute arthritis. The symptoms of this diserder so closely resemble ordinary rheumatism, that doubt still remains respecting the distinctions to be drawn between the two disorders. The swelling and inflammation has been observed in nearly all the joints, though, in this differing from ordinary rheumatism, it frequently attacks only one joint in the same person, and has great predilection for the kuce. The sheaths of the tendons, the plantar and palmar fascis, the sclerotic, and the iris, are also attacked, but less frequently, than the joints. Of the nerves, the great sciatic

1 Rollet Traité des Maladies Venériennes. Paris, 1865.

Rollet

appears the only one liable to this inflammation. alludes to cases, and I have notes of two cases, where the pain in the sciatic nerve was particularly obstinate. The heart and other serous membranes are probably exempt from gonorrhoeal rheumatism, as no record of their being attacked exists.

Gonorrhoeal arthritis is exceedingly rare in women. This exemption is supposed to be owing to the fact that rheumatoid gonorrhoea only follows urethritis, and the urethra frequently escapes in women when the vagina is inflamed.

The causes of rheumatoid arthritis are obscure. It is very possible that the rheumatic diathesis exists in those who are attacked by it during their urethritis, though certain French surgeons deny any connection between the two, and insist that the patients, who have gonorrhoeal arthritis, do not suffer from ordinary rheumatism. They strengthen their argument by pointing out that exposure to damp and cold does not excite sudden inflammation of the joint during gonorrhoea; and that the medicines efficacious in ordinary rheumatism are often quite valueless in the gonorrhoeal form, which is controlled by the specifics against urethritis. At present the matter is undecided. The pain and swelling of the joint or eye are not produced by metastasis of the disorder, for the discharge from the urethra does not cease during the swelling in the joint, and return when that subsides, but the inflammation is apparently uninfluenced by the condition of the discharge. Of late there has been much discussion concerning the nature of these rheumatoid complications of gonorrhoea. By Grisolle,' Fournier, and others, it is maintained that they are not rheumatism, and quite distinct from it, being, according to Fournier, possibly due to some reflex influence of the gonorrhoea on the

1 Gazette des Hôpitaux, July 3, 1866.

urethra. Others again, conceive it possible (Texier1) the: the gonorrhoeal poison is more than a local irritant; that it infects the system somewhat similarly to scarlet fever; and that the suppuration of mucous membranes excited by it corresponds to the cuticular eruptions produced by the latter malady. In their opinion, arthritic and other affections occurring in gonorrhoea are simply the ordinary sequelæ of a gonorrhoeal diathesis. Lorain, and with him many others, maintain that the joint and eye affections are purely rheumatic in nature; that people with the rheumatic predisposition are more likely to be attacked if they contract gonorrhoea than others; that the gonorrhoea, in short, is the exciting cause of the rheumatic inflammation. These views are all too speculative to be accepted until supported by further observation; the known facts on which all are agreed being, that the arthritic and ophthalmic inflammations of gonorrhoea have certain points of difference from rheumatism excited by ordinary causes.

Symptoms.-Premonitory symptoms of chills and heat are usually wanting, the first indication being the swelling and aching of the joint attacked, which soon becomes severe pain. The amount of effusion is often considerable, and the skin shines and even grows red over the distended joint. The constitutional disturbance is seldom great, usually the local pain and swelling are the only important symptoms.

The duration extends from six to eight weeks, and the termination is nearly always resolution; in very few instances have either ankylosis or suppuration taken place. It is however, prone to relapse, especially if a repetition of gonorrhoea takes place, and the relapses are as tedious as the first attack.

1 Union Medicale, Dec. 1866.

Ibid.

For the joints, local treatment is most efficacious. Fomentations, leeches, and presently blisters, in the form of small ones repeated several times. In the after stages, pressure by strapping and bandages is useful. Internal remedies are uncertain; it is best to continue to treat the gonorrhoeal discharge, for the joint recovers itself when the gonorrhoea yields in the urethra. Colchicum, iodide of potass, and liquor potassæ in moderate doses, with Dover's powder to relieve the pain, are serviceable.

SUMMARY.

Balanitis is inflammation of the surface of the glans penis; posthitis, inflammation of the inner surface of the prepuce; they are common in uncleanly persons with a narrow foreskin when attacked by gonorrhoea. They are easily allayed by frequent syringing underneath the foreskin, and relieving constriction if necessary. Phimosis is inflammation in a foreskin which is too narrow to be drawn back. Paraphimosis is the same condition in a foreskin which has slipped behind the glans, or is too short to be drawn forwards. Both these conditions excite congestion, suppuration, even sloughing of the foreskin. Warts not unfrequently grow in the furrow behind the glans, and on the inner aspect of the prepuce, in long continued gonorrhoea. They may be snipped off, or made to wither by strong astringents, liq. plumbi being very effectual for this purpose. Retention of urine may come on at any time; it is due to violent congestion of the urethra. In the early stages of gonorrhoea it is generally simply this congestion, but in the later stages there is usually some permanent stricture also. Sedatives, warm baths, and purgation should be tried, and a catheter passed, if speedy emptying of the bladder is imperative; recourse being had to other measures if a catheter cannot be introduced into