9th August, when his weight was 9 stone 10 lbs.; the decrease was steady and uniform and appeared quite uninfluenced by any of the circumstances of his illness. On the 5th of May he saw a physician in consultation with me; by this time his countenance had acquired a haggard worn look, and he complained of a dull aching pain immediately above the pubes. The urine now contained more pus, but still no casts, and there had not for some time been any blood passed. The opinion given was that it was a case of cystitis depending probably on some malignant disease of bladder. No chest mischief could at this time be detected. On the 25th of August the bowels which up to that time had been confined became much relaxed, and continued so in spite of medicines for ten days; this greatly prostrated him, he also now began to suffer from nausea, vomiting and pain at stomach after food, and for the first time complained of distress in the lumbar region.

At the end of November another attack of diarrhoea occurred and was accompanied by such excessive prostration that the patient and his friends were counting the hours of his life, and it seemed impossible that he could last from day to day. After taking two doses of Apis the diarrhoea stopped, the appetite, which had completely failed, returned, and the patient recovered sufficient strength to move about the house and even to go out for a short walk. When the diarrhoea ceased the bowels again became much confined, the motions now assuming quite a new character, being hard round lumps coated with blood and slime, causing great pain in passing. An examination by rectum which gave excessive pain revealed no enlargement, but intense tenderness in the region of the prostate. The improvement lasted for a fortnight, when the appetite again failed, and he lost his newly acquired strength. At the beginning of last month cough came on and I found some dulness over the upper part of the right lung, by the middle of the month this had increased, and the cough was now accompanied by a greenish expectoration streaked with blood. Up to the present time the emaciation has con

tinued to progress, so that now he lies a perfect skeleton. Takes but little food, which is more often vomited than retained, bowels much confined, and when relieved the motions are hard balls with much blood and pus, water scanty, depositing about one third of muco-pus, sp. gr. 1012, acid, the deposit insoluble in acetic acid. The state of the lung is much the same, the cough not very troublesome, profuse night perspirations, and hectic fever night and morning.

I believe this to be a case of tubercular disease commencing in the upper part of the prostate, extending from there to the bladder and kidney, and now invading the lower half of the prostate and causing ulceration into the rectum. I had fully expected before the time for reading this paper arrived that I should have been able to verify my diagnosis by a post-mortem examination; failing that I will state briefly the reasons which have led me to this conclusion. That it is tubercular disease I think the family history, the excessive wasting, the comparative absence of pain, and the occurrence at the close of symptoms of pulmonary phthisis, prove or at least make it exceedingly probable. That its primary seat was the prostate and its course that I have described is evidenced to my mind by the following facts: that the pain at the commencement of the disease was always referred to the position of the prostate, and was accompanied by the passing of streaks of blood, which as the disease progressed ceased, the gradual increase of the purulent deposit with the supra-pubic pain showed its extension to the bladder, and the lumbar pain and gastric disturbance its further progress to the kidney, while the ulceration into rectum proves the last step of the process.

Sir Henry Thompson in his work on prostatic disease, speaks of tubercular affection of that gland as very rare, and instances but eighteen recorded cases. He also says that it probably never is limited to the prostate and that the kidney is generally its primary seat, next to that the testicle; in my case for the reasons I have given, I believe it commenced in the prostate, and there has been no sign of any affection of the testicle.

Dr. Roberts, speaking of tubercle of the kidney, says, that in males it not unfrequently affects also the genital organs, and most frequently the prostate, but that in the female, tubercular diseases of the urinary do not spread to the genital organs, and vice versa.

Hitherto I have not mentioned the treatment pursued, for no medicine seemed to have any influence in stopping the progress of the disease. The list is a long one, and includes most, I had nearly said all the remedies which are credited with an action on the bladder and prostate or on the tubercular diathesis. The temporary rally after the use of Apis almost made me hope that I had found the specific medicine, though, having at that time fully made up my mind as to the nature of the disease, I could not endorse the sanguine expectations of the patient's friends; its failure to continue forced me to conclude that it was a post and not a propter hoc fact, and in this idea I am confirmed, for I find Dr. Roberts recording an almost similar instance of sudden improvement in a woman apparently dying of tubercle in the kidney, for the occurrence of which improvement he confesses himself quite unable to account. medicine which always appeared to me to cover most of the symptoms and to be most indicated by the location of the disease was Thuja. I tried it in various dilutions, but without result; had I, however, another case to treat, I should give that medicine a more extended trial at an earlier stage of the disease, should I be so fortunate as to recognise the malady with which I had to cope sooner than I did in this instance.

The

My next case is one of hæmorrhage from the urethra with expulsion of fibrinous cast. In the evening of the 7th of March last I was summoned to visit a man, who the messenger, his brother, stated had come home about an hour previously bleeding profusely from the urethra, and had passed just before he started to fetch me a mass looking at first sight like a globular lump of flesh about an inch or an inch and a half in diameter. Directing the man to be placed on his back and ice to be applied to the genitals, I promised to follow as quickly as possible. On washing the

lump from grit I found after the clotted blood had separated from it that it consisted of a fibrinous cast, resembling in shape more closely than anything else a segment of a ball enema with the tube attached; the circular part was, as before stated, about an inch and a half in diameter, whilst the pipe was about an inch in length and of the diameter of a wheat straw; its structure was evidently fibrinous. I much regret that I have not now the specimen by me, but at the time I did not think of bringing the case before this society, and I gave it to a professional friend to exhibit at the Pathological Society.

On my arrival at the house I found the patient, a man about thirty, lying on his back, perfectly blanched, pulse very slow and thready, countenance expressive of great terror and anxiety; the bleeding had been in a measure checked by the application of the ice, but blood was still dripping from the urethra. I at once passed a No. 12 silver catheter into the bladder, and noticed that the water which came through the instrument was unstained with blood. The pressure of the instrument almost immediately stopped the hæmorrhage. I fastened the catheter in, cautioning the patient to lie perfectly still on his back and to have the ice applied if the bleeding recurred. I left him Arnica and China to take alternately. The next morning I found that there had been no more hæmorrhage, and on removing the instrument the urine passed per urethram was only slightly tinged with blood. He was kept quiet in bed for two or three days and made a good recovery. The history given by him was as follows: that a week before the evening I saw him "he was larking," to use his own words, with a woman previous to having connection with her, when a sudden gush of blood from the urethra took place; this lasted some ten minutes and then ceased. Four days after, under similar circumstances, there was a recurrence of the hæmorrhage, but in a slighter degree. On that evening on which I saw him he was walking to his home at Brixton, and whilst crossing St. James's Park had an erection, and at once there was again a rush of blood from the penis; this continued till he reached home and, increasing in quantity, they sent

for me. Of the amount of blood lost it is difficult to form an estimate, but it must have been very considerable, as it continued for more than two hours, and the bed and bedding were quite saturated. Neither on passing the catheter nor by subsequent examination along the whole course of the urethra could I find any tender spot, and I confess that I have not been able to decide to my own satisfaction the source nor the real cause of the hæmorrhage. The man at the time was suffering from a slight gleet for which he subsequently came under treatment and soon recovered. I ordered him to abstain at least for a time from all sexual excitement, and I think for a little while he obeyed the injunction, but being of a very erotic temperament he soon lapsed into his former habits, but had not when I last heard of him, a month or two since, had any return of the hæmorrhage.

The last case with which I shall trouble you to-night will be stated in a very few words. A young man who had been under treatment for gonorrhoea returned in about a month with a profuse crop of warts on the glans penis and prepuce, the largest being of the size of a pea; he was ordered a lotion of Thuja 0 and Thuja 1st centesimal internally; at the end of the week he reported himself much the same. Medicine and lotion repeated; at the end of the second week there was still the same report. I now swept the surface of the warts with strong Nitric acid and gave him Nitric acid 1st centesimal, internally; on his next visit the largest of the warts were reduced in size, but the number was not diminished. The treatment was repeated for another week, but still very slight progress was made. I then gave him the Thuja lotion again and Thuja 12 internally. At the end of the first week of this treatment many of the small warts had disappeared and the larger ones were reduced in size. Thuja 12 was repeated but without the lotion; next time a very marked improvement was manifest; the whole of the warts save the largest were quite gone; he received another week's medicine and ceased to attend. He has since been under treatment for another attack of gonorrhoea, and tells me that all the warts had entirely disappeared