A

cases, and came to the conclusion that gout was the efficient cause. Acton, in his "Reproductive Organs," refers vaguely to two cases of imperfect erection as "strange anomalies." Possibly these two cases were examples of the malady under consideration. H. J. Johnson* reports four cases as "chronic inflammation of the corpora cavernosa." Galligo describes these indurations as special tumors of the penis, in 1852. Demarquay refers to this malady as having been described under the names induration of the erectile tissue of the penis, nodes, ganglions of the corpora cavernosa, plastic induration, by many authors-Boyer, Patissier, Lerminier, Vidal (De Cassis), Ricord, and others. Cruveilhier believes the affection to be a fibrous transformation of the erectile tissues of the penis, but doubtless some of the authors above named have confused the results of fracture and traumatisms, gummata, tumors, and calcifications with the malady now under consideration. Gross, in his "Surgery" (1859), mentions an indurated tumor of the pectiniform septum, removed by operation, which may have been some analogous condition. Marchal (De Calvi) || gives a case occurring in a diabetic subject. Prescott Hewett reports two cases in 1866, calling the malady a spontaneous blocking of the corpus cavernosum, and ascribing it to gout as a cause. J. Mason Warren,◊ in 1867, gives three cases of apparently typical examples of this malady under the name of indurated tumor of the penis. He notes one case where the induration completely disappeared. Charles G. Smith, of Fall River, reported a case in 1874, and in the same year Howard Marsh, of St. Bartholomew's, brought out three cases. Eldridge gives a case in 1876. I have not attempted to put into print a dozen or more cases which I have encountered since the first edition of this treatise appeared, most of which were seen as private patients in my office, and a few presented at the New York Dermatological Society by several of its members. Hodgen,** of St. Louis, reported three cases in 1876 as "reflex induration of the penis." He thought that the influence of cold had a causal relation to his cases. Cameron (Medico-Chirurgical Society of Glasgow, October 8, 1879) read an essay on gouty tumors of the penis, reproducing Kirby's ideas as to the cause of these formations. Sir James Paget advocates the

*London "Lancet", November, 1851, p. 481.

"Gaz. Medicale," 1852, p. 440 (reference from "Gaz. Med. Italiana Toscana "). Op. cit., p. 344.

# "Anatomie Pathologique," tome iii, p. 594.

"Les Accidents Diabétiques," 1864, p. 401.

A "St. Bartholomew's Hospital Reports," 1866, vol. ii, p. 82, et seq.

◊ "Surgical Observations with Cases," Boston, 1867, p. 245.

"New York Medical Journal," June, 1874, p. 606.

"New York Medical Journal," Sept., 1874, p. 269.

"New York Medical Journal," 1876, p. 260.

** "Transactions of the Medical Association of the State of Missouri," 1876, p. 28.

same etiology. Finally, Verneuil,* in 1883, reports four cases, in which glycosuria coincided in three. He believes the condition to be noninflammatory, and analogous to the contractions of the palmar and plantar aponeurosis which are encountered among gouty subjects. He thinks the cause is gouty, and is interested in the fact that three out of four were also diabetic. Trélat, in the same meeting of the surgical society, reported that he had seen two cases, Monod one, and Le Fort three, none diabetic. I do not know that the urine was tested for sugar in the earlier cases seen by Dr. Van Buren and myself. None of the later cases examined were diabetic, or any of them, so far as I know. Some of the cases had the gouty diathesis, but this can not be affirmed of all of them. Tuffier, in an exhaustive article, while omitting a number of cases of which I have record, has collated thirty-five cases, in which no diathesis is noted in nine, fifteen were gouty, and eleven diabetic. The malady being far more common in advanced life than at any other time, he searched patiently among twenty-five hundred old men at Bicêtre and at Ivry without finding a single specimen of which to study the pathological anatomy after cutting it out, and mentions Cruveilhier and Ricord as having been equally unsuccessful in trying to find a case for dissection; but, after his article was finished, one of these nodosities was cut out by Verneuil, October 25, 1884, and Leloir reported that in its pathological histology it was composed of a tissue analogous to that of keloids-embryonic cells in clusters tending to fibrous transformation, few vessels, with fibrous planes resembling cicatricial tissue.

Prognosis. The prognosis is negatively good in that the malady never ulcerates or degenerates into anything malignant, may get spontaneously better, even possibly well, or may, and sometimes does, progress backward until it gets so low down toward the root of the penis that it no longer interferes seriously with upright erection. I have seen more than one patient who, at one time being debarred from sexual intercourse, has by a shifting of the position of the induration again become capable. In one case I believe this was due to an improvement in the condition of the induration without any change in its position-a change coming on spontaneously.

Treatment.-An effective treatment of this singular malady is yet to be discovered. Thus far only time has seemed to help it, while blisters, oleate of mercury, tincture of iodine externally, with mercury, the iodides of potassium, and sodium, and local electrolysis, have uniformly failed. Perhaps alkaline or anti-gouty remedies may have something more to offer in the future than the ineffective means now in use.

"Bull. de la Soc. de Chir.," 1883, tome viii, p. 826.

"Ann. des Mal. des Org. Genito-Urinaires," July and August, 1885.

CHAPTER II.

DISEASES OF THE URETHRA.

Anatomy.-Natural Curve of the Urethra.-Proper Curve for Instruments.-Catheterism; Obstacles to Catheterism in the Healthy Urethra.-Deformities of the Urethra ; Imperforation, Atresia, Hypospadias, Hermaphrodism, Epispadias.-Urethral and Sexual Hygiene.-Injuries of the Urethra.-Urethral Fever.-Foreign Bodies.-Polypi.

THE urethra is always a shut canal throughout its whole course, except when distended by some foreign substance. Commencing at the neck of the bladder, it tunnels the upper part of the prostate, perforates the triangular ligament, and terminates at the end of the penis. Its size varies greatly, and, like the penis and testicles, it remains comparatively very small until after puberty. Its length has been estimated at all points between five and fourteen (Pitha) inches. The length varies with the condition of erection or flaccidity of the organ. Its mucous membrane, according to Robin and Cadiat,* is manifestly richer in elastic fibers than any mucous membrane of the body. It may be lengthened by disease (enlarged prostate). In round numbers, the length of the urethra of a well-proportioned adult is eight inches, six lying in front of the triangular ligament (spongy portion), a little less than one inch between this and the apex of the prostate (muscular or membranous portion), a little more than one inch surrounded by the prostate (prostatic portion).

The spongy portion is surrounded throughout by the erectile corpus spongiosum, terminating below in the bulb. Here the canal pierces the triangular ligament-that firm, fibrous fascia, stretching across the space bounded by the ischio-pubic rami-and, becoming membranous, is covered (besides the muscular fibers of organic life) by voluntary muscular tissue which entirely surrounds it. This' muscle has had special names given to different portions of it by Guthrie, Müller, and Wilson. In this muscular group, described as one muscle by Cruveilhier (transverso-urethral), is often the seat of spasmodic stricture; and it is here that muscular contraction may oppose the passage of an instrument into the bladder for several minutes, even when there is no evidence of urethral disease. These are the muscles which constitute the voluntary "cut-off," over which every healthy individual has full control. To allow the urine to pass, these are voluntarily relaxed, with the vesical sphincter, and then the detrusor expels the urine by its tonic tendency to contraction, over which the individual has no *"Structure intime de la muqueuse et des glandes urethrales," "Journ. de l'Anat. et de la Physiologie," September, 1874, p. 514.

control. If a catheter be introduced, so as to do away with any effect of the "cut-off" muscles, no voluntary effort of the individual can arrest the stream of urine, nor indeed cause it to flow with greater force unless the abdominal muscles or diaphragm be called into action. This cut-off" then controls urination in health relaxed, the urine flows; voluntarily contracted during any part of the act, the stream is cut off as sharply as if by a knife.

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Some erectile tissue and a good deal of unstriped muscle are found. around this as well as around all other portions of the urethra, but the function of the cut-off muscle must be kept clearly in view, on account of its bearing upon catheterism and spasmodic stricture.

The membranous urethra is, of all parts, the most positively fixed. There is no marking on the mucous lining of the canal to indicate any division between it and the spongy portion. The separation into parts is arbitrary. The prostatic urethra bores the prostate, sometimes barely covered by that organ above, sometimes surrounded by a considerable thickness of the same.

Unstriped muscle, of which the prostate is mainly composed, surrounds the urethra from one end to the other, and enters largely into the erectile structures of the penis as well.

The diameter of the normal urethra varies even more than its length-it has been estimated at from two to six lines. A fair average is not larger than three tenths of an inch-about No. 27, French scale. But, whatever its size, the urethra is not a tube of uniform caliber from end to end. It has naturally three points of physiological narrowing-one at the meatus; the second commencing about one inch back, and being most pronounced somewhere in the third inch, sometimes at three and a half inches; the third point of narrowing being the point of entrance into the triangular ligament. The meatus is normally the narrowest

point. The two points of enlargement are the fossa navicularis (so called from its supposed resemblance to a boat), which is situated just inside the meatus, and the bulbous urethra, occupying a position immediately in front

FIG. 7 (Thompson).

a, b, and c represent the prostatic, membranous, and spongy portions.

of the triangular ligament. Of the two, the latter is the larger. The urethra enlarges again in the prostate (prostatic sinus). Fig. 7, from Thompson, shows these points in diagram.

In the fossa navicularis lies the valvule or lacuna magna (Fig. 8), a little mucous flap on the roof of the urethra about half an inch from

the meatus, shutting in a fossa about two lines deep. In this valvule the points of small instruments are liable to become engaged. There are other blind pouches or lacunæ of variable size scattered along the

urethra, chiefly on its roof, and known as the sinuses of Morgagni. They run parallel with the urethra for perhaps half an inch, and terminate in a cul-de-sac. Cruveilhier found one an inch long. The openings of these sinuses all look toward the meatus, and are often large enough to receive the points of filiform instruments, a fact to be remembered in manipulating with fine bougies (see Fig. 31). Another lacuna in the urethra, which may catch the point of a fine instrument, is the sinus pocularis (Guthrie) or utriculus of the prostate, a deep little depression running down in front of and underneath the veru montanum.

The mucous glands of the urethra are small clusters of minute follicles, very abundant, opening either on the free surface of the membrane or into the sinuses of Morgagni.

Sp

Cowper's glands are small, round, lobular bodies about the size of cherry-stones, lying just behind the bulb of the urethra in the transverso-urethral muscle. Their ducts are sometimes very long, but average a full inch, and open into the floor of the urethra. Their fluid is supposed to aid in diluting the sperm. The urethra has about the same amount of sensitiveness in health as the conjunctiva. In the membranous. urethra, however, sensibility is exaggerated. The color of the membrane is a pale pink. In a state of rest its walls lie in contact, obliterating the cavity of the canal, so that a cross-section presents a slit instead of an opening (Figs. 9, 10, and 11).

D

FIG. 11 (Cruveilhier). Transverse section of center of prostate. D. Ejaculatory ducts. Sp, Sinus pocularis.