brane highly vascular. Microscopic examination of lungs showed no inflammatory cells or other products except in the bronchi. Heart contracted; both sides contained blood; the right side was not remarkably full. The blood was particularly apt to stain, its coagulation was very imperfect. There were soft black, but no white clots; some bubbles were seen in the right ventricle. On microscopic examination many small white masses were seen, just large enough to be visible to the naked eye; these appeared to be clots containing a great number of colourless corpuscles. Liver and kidneys perfectly healthy. Spleen small and hard, its Malpighian corpuscles were very evident. Brain anæmic and dry, its sinuses very empty, not many puncta vasculosa. The symptoms during life in this boy, and the mode of his death, were closely similar to those observed in the case at St. George's, but the post-mortem phenomena were very different. The lungs in the former were but slightly congested, the brain absolutely pale, and the heart well contracted, without any notable accumulation of blood on either side. In the elderly man all this was reversed; the only point of resemblance is the uncoagulated state of the blood, and its tendency to allow the colouring matter to escape from the red cells. It seems plain that some less visible alteration must have existed which was common to the two cases.

It may be mentioned here that meningitis is occasionally the result of exposure to the sun, even when the head is covered. I have seen one such case myself, and another occurred a year or two ago at St. Bartholomew's (I think).

I proceed to cite some cases of minor severity, which, nevertheless, appear to me of very great value, and capable of indicating to us the true pathology of the malady perhaps even more clearly than those where the events are more numerous, more complex, and on a larger scale. A well-known physician related to me once his personal experience of sun-stroke. It did not affect him notably in any other way except that he slept almost continuously for forty-eight hours. He suffered, in fact, a moderate coma. Dr. Strange, in a highly interesting paper in the British Medical Journal, 1868, August 29th, relates the following case :-A stonemason, a strong, muscular man, working at a short distance from the hospital one hot day early in the season, was brought in in a state of partial collapse, the result of sudden sun-stroke while at work. He stated that he had suffered from the heat for the previous two or three days. Having recovered from his collapse, he exhibited the next day the following symptoms, viz.-considerable dulness of apprehension, loss of memory, hesitation of speech, with defective sensation and motion over the whole of the body. The skin was cool, and had been so all along; the pulse slow and small; there were sleeplessness and anorexia. With cold shower-bath, aperients, nourishing diet, and afterwards quinine, he slowly improved, but was unable to leave the hospital on account of the defective sensory and motor power of the limbs. He was Faradised, and after three months was discharged pretty well. In a second case the patient, a slim youth of 18, after exposure to a broiling sun, suffered collapse. In the evening he had vomiting, smart fever, rigors, with preceding pain in head and hot skin. The next day the vomiting continued, the thirst was excessive, he had pain down the spine and in all the muscles, and at night delirium, which continued to recur, and was exceedingly violent on the fourth night. A tendency to syncope was occasionally present. With ice to the head and internally, tepid sponging of the surface, and beef tea with brandy every three hours, the patient became rapidly convalescent. In a third case a man, æet. 48, energetic and muscular, after much exposure to the heat, suffered with weariness, pain in back of head or down spine, inability to sleep after two a.m., and great and causeless anxiety. He was speedily cured by bromide of potassium. Dr. Buller (British Medical Journal, Aug. 22nd, 1868) relates the case of a lady, æt. about 30, strong and unused to illness, who, while walking in the street

on a very hot day, was suddenly seized with pain in the head, giddiness, faintness, and a sensation as if she should die. She looked so ill when seen as she was returning home, that she was with difficulty recognised. For nearly fourteen days she remained very ill, suffering with sleeplessness, disturbed nights, anxious fearful days, with occasional aggravated attacks of pain in the top of the head, which was hot, confused vision, vertigo, sickness, loss of power in her limbs, palpitation of the heart and irregular quick pulse, with a sensation of coldness of the body, and often a distressing anxiety as if she were going to die. Quiet, cold to the head, aperients, and bromide of potassium were serviceable; and subsequently much seems to have been effected by a combination of small doses of calomel, tartar emetic, and muriate of morphia given repeatedly. In a case at present under my care in St. Mary's Hospital, the prominent symptom of the first seizure which the patient had in England (he had had one previously in Japan) was loss of sight, which lasted a few minutes. In a third attack he became unconscious, as he did in his first.

(To be continued.)

CASES OF SYPHILITIC DEPOSIT IN THE

HEART.

(See Engraving.)

With Observations thereon

By JOHN MORGAN, F.R.C.S.I., Professor of Practical Anatomy in the Royal College of Surgeons in

Ireland and Surgeon to Mercer's Hospital.

THE insidious and not infrequent formation of gummata on late syphilitic deposits in the various internal organs has always been a point of interest in the history of the later stages of the disease, their formation having been observed in the osseous system and viscera, both thoracic and abdominal; and many anomalous symptoms have been explained by post-mortem detection. Their occurrence as in the subjoined case on the heart is remarkable. In this instance death was gradual and slowly produced, contrary to most of those hitherto recorded, where death occurred suddenly, and without warning of any pre-existing cardiac lesion. In this instance, also, there can be no question as to the saturation of the system with the syphilitic poison, and its external evidences at the time of death.

S. B. (Ward No. 1, Bed 6) was admitted June 8, 1868, suffering from leucorrheal discharge and general debility. Has been upwards of twenty years unvirtuous, and eighteen years ago was treated in hospital for genital sores. She was then hardly seventeen years of age, and had ever since led an unvirtuous life, with its concomitant evils of dissipation, exposure to cold, &c.; having been five or six times affected by sores, the dates of which it is not easy to obtain with any reliability, and two or three times by gonorrhoea, about ten years ago she had a "rash," not to such an extent as, she remarked, to disfigure her, and which was cured out of hospital. She had never observed any other results of the primary sores, nor till lately suffered in any way from pains, sore throat, or other well-marked constitutional affections. She never took mercury in any form. On admission she presented the appearance of one considerably advanced in age, looking fully twelve or more years older than she really was. The limbs were very thin; the neck and face slightly puffed and of a dingy hue; the lips blueish. She suffered much from coldness and lassitude. breathing was 22 per minute. The pulse was remarkably feeble, but regular, varying from 56 to 66 according to position. The area of cardiac dulness was considerably diminished; the impulse also was less perceptible both to the eye and touch. There was no abnormal sound, but diminished intensity of the first. There was no

The

evidence of disease of the lungs; the other viscera seemed healthy, and the liver was not enlarged. She was now suffering from pains in the shoulder and knee joints, thickening of the periosteum of the left tibia, and the formation of three gummy tumors on the thigh and one on the shoulder, the latter having nearly proceeded to ulceration. She was ordered generous diet, stimulating mixture, with cinchona, wine, &c., freely.

June 11, 1868. She complained a good deal of palpitation and precordial uneasiness, and of increasing debility; could not rest. There was no orthopnoca, but the breathing was at times greatly hurried. There was some dilatation and slight pulsation of the right external jugular vein, and a faint bruit over the heart and great vessels. The subsequent history of the case is that of gradually increasing debility. The pulse became feeble, till for several days preceding death it was hardly perceptible, feeling as a mere wave or undulation under the finger. The semicongested appearance of the face increased notably, but not to an inordinate degree. The heart sounds became more indistinct. There was much irritability of stomach at times, and notwithstanding an abundant use of stimuli and nutrition, finally the patient "died out," without suffering from any special or overwhelming symptom, on July 24, 1868, six and a half weeks after admission. Two of the gummata had nearly ulcerated, and the pains in the joints had diminished.

A post-mortem examination was made 18 hours after death. The body was emaciated, and rigor mortis well marked. There was slight puffiness about the neck and face. The pericardium was healthy, and contained a few drachms of fluid. The right side of the heart was distended, and the organ itself was small, weighing but five ounces, indicating chronic failure of nutrition, as occurs in phthisis, cancer, and other wasting diseases. On opening the right ventricle a large clot nearly filling the cavity was to be seen (as shown in the illustration) entangled in and forming around the carne columnæ, whitish, very firm, dense, and fleshy-looking. When torn away from the lining membrane, to which it was adherent but not covered by, it came in shreds, or lamina, and in section was solid. Its formation must have been altogether antemortem, and by its increase and density it encroached on the cavity to a very great extent. The infundibular portion of the ventricle was quite free from coagulum and empty. The right auricle was distended with a soft, gelatinous, and coloured post-mortem clot, extending into the superior vena cava. The left ventricle was of small size and apparently healthy, but towards the apex on the anterior aspect presented one smaller, and two larger elevations or nodules, both being raised about half a line over the level of the ventricular wall, as shewn in the illustration, accurately drawn by Mr. Grey. To the touch they felt firm, and on section were found to penetrate one-fourth into the substance of the ventricular wall. The colour was not the yellow tubercular hue depicted by Ricord in his case (plate 29), but was more of a very pale flesh or cream colour. On making a section the edge of these deposits was tolerably defined, but at the deeper part, where imbedded in the fleshy substance, not so plainly discernible. On the posterior aspect of the left ventricle another smaller deposit, but more distinctly marked, was also seen embedded in like manner. The cavity contained a small, dense, whitish blood concretion, entangled amongst the carnæ columnæ. The wall of this ventricle was half-an-inch thick, while that of the right was thinner and denser than usual, as shewn in the section. There was no valvular lesion whatever. The lungs were healthy and contained no deposits. There were a few old adhesions. The liver was rather small and pale, not indurated, and presented on the under part and towards the thin edge three deposits, hardish, slightly yellow, raised over the surface, and about the superficies of a sixpence. The other viscera were healthy. The head was not opened.

the

The occurrence of syphilitic deposit or gummy tumor in the heart itself, though recognised by Virchow, Ricord, Haldane, and others, is rarely demonstrated. The forma tion of these tumors in the tongue as the prelude to tubercular ulcers, and in the muscles themselves, is undoubted, having been seen in many of the large voluntary muscles, such as pectoralis major, sterno-mastoid, vastus, glutæns maximus, trapezius, etc., exactly analogous to the wellknown gumma of the cellular tissue,-one of the latest, but by no means the least troublesome manifestations of constitutional infection, commencing as a hard nodule cellular tissue, gradually leading to ulceration, and consisting microscopically, according to Robin, of "rounded nuclei belonging to fibro-plastic cells, or cytoblastions,' of a finely granular, semi-transparent, or amorphous substance, and finally of isolated fibres of cellular tissue, a small number of elastic fibres, and a few capillary blood vessels." Bouisson remarks, speaking of syphilitic tumors in the muscles :-" It is difficult to determine whether the earliest change takes place in the muscular fibrils or in the intervening cellular tissue, although analogy would lead us to believe that it is the fibro-cellular element connecting the fleshy fibres or serving as their sheath that is first involved." On microscopic examination of the tumors in this case, the muscular fibres could be seen around the section of their natural appearance; in the interior they were few, and surrounded by a homogeneous, dense, structureless material, in which I did not detect any granules. To the feel these tumors were firm, and felt to the knife dense and easily sliced.

The case related and illustrated by Ricord ("Iconographie," plate 29) presents a history, as in this instance, of a longstanding constitutional infection, and its manifestation by the formation of gummata or external deposits. The patient received his first sore in 1824, another in 1826; between 1829 and 1834 he had several sores. In 1834 he got a sore, followed by swelling of the inguinal glands, succeeded by mucous patches. He remained apparently cured till 1845, when" tubercules " formed, followed by ulceration, both on the shoulder and penis. While under treatment, and apparently going on favourably, he suddenly died. On post-mortem examination the heart was found hypertrophied, the right ventricle containing soft coagula, and its endocardial lining thickened; not so in the left. The walls of both ventricles contained deposits of a yellowish matter, dense, "criant," to the knife, and in some places of a squirrhoïde" consistence and in others like tubercular matter in process of softening; "in a word, of syphilitic tubercules, a tertiary evidence often found in the subcutaneous and submucous cellular tissue." "Around these morbid products there was no disturbance, 'refoulement,' of the muscular fibres, for the degeneration was in the substance of the muscular fibre itself."

66

From inspection of M. Ricord's plate, the heart contrary to the condition in this case, was very considerably hypertrophous, and the deposit more abundant and tubercular in appearance.

Mr. Haldane has given a case of syphilitic deposit in the heart, but without the co-existence of other indications of the disease, and where death ensued suddenly. Here also the heart was largely hypertrophous (Edinburgh Medical Journal),

Dr. Walshe remarks, page 355:-"Some years ago opened an individual cut off by tertiary syphilis, whose heart presented appearances suggesting the possibility of productions similar to subcutaneous gummata being found therein," but no mention is made as to the condition of the heart's substance, whether hypertrophous or not.

With regard to this case, it is curious, and illustrative of the modifying effects of the system, that signs of constitutional syphilis showed themselves but once in apwards of twenty years, and that not till a few months before decease did well-marked signs of general infection develope themselves.

ON RAPID DILATATION WITH THE SCREW DILATOR, WITH CASES.

BY CHARLES OWEN ASPRAY, M.D., Fellow of the Royal College of Surgeons, Edinburgh; Honorary Consulting Surgeon to the Islington and North London Provident Dispensary.

BEFORE Commencing the use of any instruments for the cure of stricture there are many points, such as the state of the general health and the condition of the urine, that should be considered. If the uric acid or oxalic acid diathesis be present it should be removed by the appropriate remedies. I have observed that in old men strictures which formerly were very tight have relaxed considerably, and in these cases I have generally found the mucous membrane peculiarly flaccid, and puckered into folds. These, by acting as valves, produce the symptoms of stricture. Under these conditions the use of small instruments is contra-indicated, and the free injection of oil will be of great advantage in facilitating the passage of an instrument. When the stricture is suspected to be tight, the patient should be requested to make water in the presence of the surgeon, who would then be guided by the size of the stream as to the sized instrument he ought to attempt. If the stream jets straight out from the penis an instrument of the same size may be passed, but if on the other hand the stream only trickles without force we should begin with an instrument of not more than half its size. When the urine passes only by drops the soft filiform bougies (not catguts) should be used, if the stricture is at the bulbous portion. Before commencing the treatment of a deep stricture we should always attempt to pass a full-sized instrument; when, if there is an obstruction at the orifice, it should be removed by the dilator before proceeding further. Without this preliminary precaution the case may easily be mistaken for one of deep stricture with deviation, as the same want of improvement will follow the passage of instruments in both cases. An orificial stricture may allow a No. 7 or 8 bougie to be passed and yet produce retention. I have always treated a stricture at the orifice first, even if there was evidence of another obstruction further along the canal. Unless removed, the orificial stricture interferes with manipulation, and it obscures the symptoms of progress in the deep stricture. I have frequently seen patients treated for stricture at the bulb, when dilatation of the canal has been carried up to No. 7 without materially increasing the size of the stream. On trying then to pass a No. 8, a stricture has been found at the orifice, the existence of which was previously unrecognised. Dilatation with the large-sized screw dilator will work wonders, as opposed to the usual method with ordinary instruments. The meatus should be made larger than the natural size, as there is sure to be some contraction after the operation. Strictures in the penal portion of the urethra partake more or less of the resilient character of those at the orifice, often producing retention, especially after the

passage of instruments, which is very rarely the case with strictures at the bulb. As I shall hereafter show, retention is very rare after dilatation with the screw dilator, whereas it is a common occurrence after the passage of a small instrument. Thus it will be safer to dilate rapidly up to No. 6, than to pass a No. 1 metallic instrument, and withdraw it directly. The reports of two cases of stricture will be found further on, in which ordinary dilatation failed totally, but recovery was rapid with the use of the screw dilator.

The instrument below was first introduced to the notice of the profession in the Lancet, August 11th, 1866. It has the following advantages. It will dilate from No. 1 to No. 6, 9, or 12 quicker than any instrument yet produced. Little pain is caused, and there is seldom any abrasion of the mucous membrane. As soon as No. 1 is passed, dilatation can be commenced without withdrawing the instrument, which is often replaced with great difficulty. A soft catheter may be passed over the guide and allowed to remain, the guide being removed.

The instrument is composed of a No. 1 catheter (A), having a small handle (B), which can be removed when a screw is loosened. When this handle is withdrawn, the dilator (C), having the conical screw (D) at the end, can be passed over the catheter, and worked by the handle (E). The dilator may be the size of No. 6, 9, or 12, and has a thin metallic cover reaching from the handle (E) to the screw (D), working smoothly over the tube beneath. This is for the purpose of steadying the penis while the screw works in the stricture; it also prevents any abrasion of the anterior portion of the urethra. The soft catheter (F) may be passed over the guide into the bladder after the dilator is withdrawn, and allowed to remain. The metallic rod (G) screws into the guide (A), so as to lengthen it while the dilator and soft catheter are passed over.

The method of using the instrument is as follows The catheter No. 1 is first passed into the bladder (which of course should be made certain by the urine passing through it); the handle being removed and the metallic rod screwed in, the screw of the dilator is freely oiled and passed down the urethra until the obstruction is felt, when the penis should be grasped firmly with the left hand, and pulled down over the dilator while it is screwed through the stricture. The operator must be careful during this part of the proceeding, not to push the guide catheter with the hand; and next to unscrew the dilator when withdrawing it. If this be attended to, the operation is done without pain, but if the instrument be pulled without any rotary motion it will require some force to disengage it, and be painful to the patient. The dilator being withdrawn, the soft catheter is pushed into the bladder over the guide, which is then taken out, and the gum catheter allowed to remain. I have found a soft catheter one or two sizes smaller than the dilator to be of equal benefit with one of the same size; it is less trouble to pass, and produces no pain or abrasion. The

D

A

B

nstrument will afford a very rapid means of cure in cases of urinary fistula, and in such cases the soft catheter should be used. In the majority of cases it will not be necessary to leave in the gum catheter, and an instrument should not be used for some days after the operation, when probably a catheter the size of the dilator used will pass with ease. The way of telling when the screw has passed the stricture is very simple. As long as any part of the screw remains in the stricture it will be felt to be held by turning the handle, but when it has passed quite through and the stricture presses on the metallic cylinder only, then it is clear that the screw and handle will be freely moveable and the cylinder be held firmly.

In tight irritable strictures, when a No. 1 is introduced for the first time and is obliged to be withdrawn, from the irritation produced or from the inability of the patient to stop in bed, retention frequently follows, and the same difficulty as at first, is experienced on each attempt to introduce an instrument of the same size. Where the No. 6 dilator is used under these conditions the gum catheter should be kept in one night, and in the morning the stream will be the size of No. 5 or 6. On the other hand if a catheter can be retained, in two days we may get in a No. 3, but the patient has all the pain and inconvenience of lying in bed with the catheter in the bladder for that time. From the above it must be apparent that great advantages attend the use of the dilator.

We should always be sure that the guide catheter is in the bladder, otherwise it is impossible to use the dilator properly, especially when the stricture is situated in the bulbous portion of the urethra. When the dilators, Nos. 6, 9, and 12, are used in succession a week at least should be allowed to intervene between the operations, no instrument being passed in the meantime. In case No. V., given at the end, gradual dilatation up to No. 12 catheter had been employed eight months previously; the cure took fifty-two days to effect, out of which he was in hospital fifty-one days. With the use of the dilator, a No. 10 bougie was passed in eighteen days, but urine was passed in a good stream five days after the treatment was commenced; the patient did not keep his bed a single day, and he now keeps perfectly well with the occasional passage of a bougie.

In most cases I use the No. 6 dilator only, and it must be remembered that half the full dilatation is accomplished with that instrument, and by far the most difficult half. It may also be observed from the following reports that all the symptoms which are of any inconvenience to the patient disappear directly after its use; the next day the bladder is quite emptied, and that quickly and with ease; there is no dribbling after making water, the urine if it has been thick previously becomes clear, and the patient does not get up at night to micturate. From this local relief, and the consequent freedom from anxiety of mind the general health rapidly improves, and the patient, with the occasional use of the bougie, will remain free from symptoms of stricture for the rest of his life.

CASE I.-February 24th.-C. W. H., æt. thirty-one; married. Very tight double stricture at the bulb of two years and a-half standing. He was sent to me by a patient on whom I had operated with the dilator. Stream very small and without force; micturates frequently during the day, and is obliged to get up for the same purpose at night; feels pain during coitus. He has had a gonorrhoea once and gleet for six months after; he is very anæmic; urine normal. On attempting to pass an instrument he became faint.

February 26th. Passed an instrument through the first obstruction, but was stopped by a second.

March 5th.-Again passed a No. 1 into first stricture. Tr. ferri sesquichlor., mxx. ter die sum.

March 10th.-Passed No. 2 into first stricture.

March 24th.-Passed No. 2 into first stricture. Cannot attend oftener.

March 31st.--Passed No. 1 guide into bladder, but he became faint. Tr. opii, mxx. h.s.s.

April 7th.-Passed No. 1 guide, and used a No. 6 dilator. The dilator passed easily through the stricture and there was only a trace of blood. Left in a No. 4 gum catheter. 14th. Used a No. 9 dilator and left in a soft catheter. He kept in the catheter all night after the last operation. Micturates only four times in the twenty-four hours, and does not get up at night.

21st. Passed No. 9 steel, sound; stream of natural size and he has no trouble in any way.

28th.-Passed No. 10 steel sound; thinks his stream is larger than it was before he had stricture. His health is better than it has been for years, and he has no pain during coitus.

May 5th.-Passed No. 11 steel sound.
19th.-Passed No. 12 steel sound. Cured.

CASE II.-R. J., æt. 60; stricture at orifice, which he has had many years. He passes a No. 5 gum catheter very frequently, but still the stream is very minute, and he constantly suffers from retention.

June 1st.-Passed No. 5 steel sound.

6th.-A No. 3 guide was passed and a No. 12 dilator screwed through the stricture. The instrument was very tightly held.

20th.-Passed No. 11 olivary bougie. Is to use a No. 10 himself. Stream full size. Cured.

CASE III.-R. W., æt. twenty-six; pale and care-worn. Had a gonorrhoea eight years ago, and was discharged from the navy a year after. He was at Haslar Hospital when he first noticed that he could not hold his water, which ran from him all day. He has worn a urinal now for a long time, but can pass a very minute stream for a second or two, if he strains very hard. The bladder is always found distended, reaching above the pubes. He has never had any instrument used. The stricture is situated three inches from the orifice.

June 11th. The point of a small catgut was passed

into the stricture.

13th.- No better.

16th.-Has a bougie passed down to the stricture daily. 26th. The smallest catgut was passed through the stricture. A catgut was passed on the 2nd and 4th of July, but finding that a larger instrument could not be passed it was determined to use the screw dilator.

July 9th.-The No. 6 dilator was used, about half the screw going through the stricture.

10th. He has had no dribbling in the night, and has done without the urinal for the first time; stream larger. 11th. No. 6 dilator passed into stricture.

12th. Stream much larger, does not dribble at all. 14th.-No. 3 steel sound passed.

16th.-No. 3 steel sound passed through, and No. 4 into stricture. Holds urine four hours.

18th.-No. 6 dilator was passed through the stricture. 19th. No. 7 steel sound passed.

30th. No. 8 steel sound passed.

He now has No. 10 steel sound passed once a month; he is free from symptoms of stricture and his general health is good. Cured.

CASE IV.-E. F., æt. 24. Had gonorrhoea six years ago, and gleet for six months after. Has had frequent attacks of retention, for which he went to the Charing cross and Middlesex Hospitals, but no instrument was passed.

July 25th.-Found a stricture three inches from orifice, but could not pass an instrument.

August 6th.-Passed a small catgut through first stricture, but was stopped by another at the bulb. I passed a No. 6 dilator over the catgut, and dilated the first stric