gland, which is increased until swallowing becomes painful. On examination there will be seen upon the tonsil a superficial, greyishwhite erosion, with indurated base. The exact amount of induration in different cases is difficult to make out; for the induration depends upon the amount of hypertrophy of the tonsil-the greater the hypertrophy, the greater the induration, and vice versa. More or less marked, and an early submaxillary adenopathy on the affected side. is another prominent sign. These swollen glands are more painful than those which follow a genital chancre and sometimes become extremely large, but are always resolved without suppuration.

The tonsil erosion may assume the phagedenic form of a deep sloughing ulcer with great tumefaction and induration of the neighboring parts, though this would seem to be a new complication of tonsil chancre.

The functional symptoms of tonsil chancre are general but slight. An outbreak of a roseola being the first intimation the patient has of his trouble. As a rule there is pain on deglutition and Rollet declares that of all the chancre of the mouth those back of the anterior pillar are the most painful. When the ulcer becomes phagedenic the pain is very great, swallowing impossible and there is great prostration.

As may be seen the positive diagnosis of hard chancre of the tonsil is beset with many difficulties. It is to be differentiated from epithelioma, from tuberculous ulceration (according to Cohen); from psoriasis of the mouth, the milky patches of smokers; from mucous patches, whose favorite seat when in the fauces would seem to be upon the tonsils, and from the perforating ulcer of tertiary syphilis. Pivaudran thinks tonsil chancre may be mistaken for diphtheritic deposit and for a gangrenous throat angina; it must not be confounded with an ulcerating gummy tumor of that gland.

In general we may say that, if the tonsil lesion is unilateral, superficial greyish-white, with indurated base and hypertrophy of the gland itself; if there is a history or even a suspicion of syphilitic exposure; if there is glandular enlargement in the affected side; if the angina appeared for ten days to three weeks after exposure and there is absence of chancre in other parts; if the patient has not been subject to tonsillar angina; if the pain and soreness has lasted some time and has not excited febrile reaction; and finally, if an outbreak of secondary syphilis developes in due time, we may be safe in our diagnosis of the lesion upon the tonsil as a hard chancre.

STRICTURE OF THE URETHRA, WITH CASES AND

SPECIMENS.

BY J. H. BRANHAM, M.D.

Visiting Surgeon to Bayview Hospital, etc.

To avoid inflicting a lengthy and tedious paper on this Society (which would necessarily be largely a recapitulation of facts and opinions already repeatedly published), I have concluded simply to note a few cases, and to show some specimens, which, with a few brief comments, I hope will be of interest.

About a year ago I was requested to see A. D., white, aged 19; machinist. His history was as follows: He had never had gonorrhoea or any injury to his penis; formerly masturbated, but claims to have quit this over two years ago. For the past two and a half years, he has suffered from frequent, painful and often difficult urination, severe pain in the loins, seminal emissions, slight discharge from meatus, great mental depression and general debility, so, that lately, he had almost entirely stopped work.

He had been treated by sundry druggists, and by eight or ten physicians, including two of the leading genito-urinary specialists of this city. His meatus measured 23 mm., and about half an inch back of it was a contraction to the same size. The remainder of the canal would readily pass a 32 (F). The anterior part of the urethra was divided freely and he was given a short straight steel sound, with instructions to pass it twice a week at first, and then less frequently. He improved rapidly, soon returned to work, and nine months afterward reported himself entirely well.

Four months since a physician, aged 32, came under my care, suffering with the following symptoms: Two months previously he had contracted a gonorrhoea, which under very active treatment soon disappeared, with the exception of a very slight discharge, which seemed to come from just behind the meatus, where the canal was sensitive.

This had continued in spite of various methods of treatment, and was accompanied by frequent painful micturition, genito-crural neuralgia, and hyperæsthesia of the scrotum and perineum.

Although his genitals were well developed, his meatus would only admit a No. 12 (F) and he stated that it had never been larger. The same treatment as in the previous case was followed by rapid improvement of all his symptoms. He left town a few days afterward and has not since been heard from.

From these and a number of similar cases which have come under my observation, I think we may draw the following conclusions: Ist. The nearer the meatus a stricture is situated, the greater the reflex symptoms.

2d. Natural contractions of the urethral canal, which under ordinary circumstances are of no moment, may in certain conditions, give rise to symptoms of stricture, and must be treated accordingly. These contractions are not limited to the meatus.

By examining a large number of men who had never had urinary troubles, Belfeld has demonstrated that they may be situated in any part of the canal and may be as much as 12 mm. (Diseases of the Urinary and Male Sexual Organs, P. 89, Wm. Wood & Co., 1884.) This is explained by the fact that during inflammation the action of the muscular coat of the canal is impaired, and that after passing water a drop of urine lodges behind the obstruction and decomposes. This will cause a gleet, and, if not relieved, will induce the formation of connective tissue, and, in time, a fibrous stricture.

3d. As all observers agree that the meatus does not yield to dilatation, the proper method of treatment is free division.

About eight months ago I had under treatment J. S., colored, age 40, who had had several attacks of retention of urine. He had been drinking, and was unable to pass a drop of water, and his bladder was greatly distended. After vainly attempting to pass several soft catheters, all of which were arrested at the deep urethra, I took a medium sized steel sound and, by making steady gentle pressure against the obstruction, succeeded in getting it into the bladder. When it was withdrawn, he urinated freely. A firm stricture was found at three inches from the meatus, which would only pass a 22 (F). This was divided by Otis' instrument. He would not carry out the after treatment, only having a sound (32) passed twice; nevertheless he remained free from urethral trouble for five months, when, after drinking freely, a similar inability to urinate occurred and was re

lieved in the same manner. On making a careful examination no re. contraction could be found. By the old method of examining, the true seat of this man's trouble would have been entirely overlooked, and, on account of the great difficulty of passing an instrument, and from the obstruction occurring in the membraneous part of the canal, a perineal section would in all probability have been done.

Such cases illustrate how much we owe Dr. Otis for demonstrating the proper size of the urethra. They also show that we may have complete stoppage of the flow of urine by spasm and congestion of the urethra, when there is not the slightest organic contraction in any part of it.

Four years ago Dr. Bevan divided for a patient of mine, a stricture which was situated in the membranous part of the urethra. It was only after patient effort that a filiform instrument could be gotten in. This was followed by a Maissonneuve, and afterward the canal was divided to full size by Otis' method. This patient was 64 years old, had had the stricture for over twenty years; his urine had several times completely stopped, and gradual dilatation had been practiced repeatedly. He had just recovered from a peri-urethral abscess. At present this patient is entirely well.

I have recently operated by this method on stricture of the membranous urethra accompanied by fistula and scrotal abscess, and although it is too soon to give the final result, the patient has improved very much and passes nearly all of his urine out of his meaWhen we remember that Otis gives external urethrotomy the preference in such conditions, the value of the above cases will be better understood. The advantages of the former method over the latter are (1) That instead of cutting all the structures of the penis, we divide very little besides cicatricial tissue; (2) We avoid the formation of artificial fistula which may prove troublesome; (3) the tendency to contract is very much less. The hemorrhage which sometimes follows internal urethrotomy on the deep urethra may be readily controlled by the introduction and retention, for a short time, of a full sized sound.

The specimens which I present are from the Museums of the College of Physicians and Surgeons, and the Johns Hopkins University. They illustrate nearly all the important pathological points of this disease. On closing the canal we see that the contraction is not sufficient to obliterate it. Now, from the condition of the other organs and from the history of the cases, complete retention occurred.

What, then, is the additional factor which evidently was present? Most probably, this was inflammatory engorgement of the mucous membrane, which on account of elasticity of the walls, disappeared after death. In many instances, this is, no doubt, assisted by contraction of the muscular coat.

The changes which we see in the bladder are great hypertrophy of the walls, and a tendency to pouching.

The orifices of the ureters remain small and the valvular action is intact, while the rest of the canals are dilated and the walls are thickened. The pelves of the kidneys are greatly dilated, the proper renal structure in one instance is almost entirely gone, and what remains is tough and fibrous.

In another specimen we see the cavities of minute abscesses which were scattered throughout the organ.

Our understanding of the mechanism of these changes has been much enhanced by the publication of Beck's excellent article on this subject in Reynolds' "System of Medicine."

The cystitis and secondary suppurative inflammation of the ureters and kidneys are due to retention and decomposition of urine. In one of these specimens this has extended to the parenchyma of the organ and produced abscesses noted above. The dilatation of the ureters while their mouths remain intact is due not to regurgitation from the bladder, but to the collection of urine which cannot escape into that overloaded viscus. Pressure on the kidneys from the collection of fluid in the pelvis by acting directly on the venous circulation produces obstructive hyperæmia of these organs. This results in increased secretion of watery urine, connective tissue hyperplasia, and, by the contraction of the latter, absorption of the proper structure of the kidney, and degeneration into dense fibrous substance. This latter change prevents rupture of the thinned organ. Now, according to Beck, if, during this condition, an operation is done which removes the pressure from these blood vessels which have long been accustomed to it, they readily dilate, intense hyperæmia of the organ follows, and suppression of urine and death results. This is that "bug bear" long known to the profession as "Surgical Kidney."