URETHRA. 



1261 



stricturecl part, thus inducing a valvular ap- 

 pearance. Authorities vary as to the forma- 

 tion of this stricture. Some, as Ducamp and 

 Laennec, believe it to depend on the organ- 

 isation of false membrane thrown out on the 

 mucous surface. Amussat attributes it to the 

 healing of an ulcer, but there can be little 

 doubt that both causes may give rise to a 

 similar condition. Arutzenius considers it 

 due to a swelling of the mucous membrane, 

 and consequent loosening from the subjacent 

 tissue : thus the membrane becomes wrinkled, 

 and a fold is formed on its surface. 



Hunter attributes the origin of these stric- 

 tures to spasm of the circular muscular fibres 

 of the urethra. Sir C. Bell describes them 

 as occasionally splitting into branches, and 

 running in a longitudinal rather than a circular 

 direction. He considers them as the result of 

 inflammation of the mucous surface : to this 

 opinion most modern surgeons subscribe. 

 Sometimes two or more annular or bridle 

 strictures coexist at short intervals in the same 

 urethra. Hunter met with six, Lallemand 

 seven, and Calot as many as eight. 



The next variety of permanent or organic 

 stricture is that in which the urethra is nar- 

 rowed to a much greater extent of its course 

 than in the former case. In these cases half 

 an inch or an inch, or even the whole extent 

 of the spongy part of the urethra, is more or 

 less contracted. The stricture occupies one 

 or other side, or it completely encircles the 

 tube. It varies in consistence, from a soft, 

 yielding thickening of the membrane, to a 

 complete cartilaginous hardening. The dis- 

 ease in its most simple form occupies either 

 the mucous layer alone, or the submucous 

 elastic layer ; but it is not limited to this, for 

 in many cases the tissue intervening between 

 the submucous layer and the spongy body is 

 the seat of disease, whilst in others even the 

 spongy body itself, whose cells are obliterated 

 by the deposition of lymph, becomes thick- 

 ened and indurated, and thus encroaches on 

 the urethral tube. I regard genuine simple 

 stricture as dependent on hypertrophy of the 

 mucous or epithelial layer and the submucous 

 elastic lamina of the urethra. 



Stricture in its progress passes through 

 various stages, from simple thickening to 

 complete cartilaginous induration. The com- 

 plete cartilaginous conversion of stricture is 

 more frequently found where the stricture is 

 situated in the spongy portion. 



The most intractable stricture is that which 

 results from ulceration of the meatus ; it is 

 frequently associated with adhesion of the 

 prepuce to the glands; sometimes the stric- 

 tured part will not permit the passage of a 

 bristle. For the cure of this disease incision 

 is necessary. 



Among the most common attendants on 

 stricture of the urethra are hernial protrusions 

 of the mucous membrane of the bladder, be- 

 tween the columns of the dctrusor iirince, in 

 the form of sacculi. As a consequence of 

 stricture of the urethra, may be mentioned 

 rupture of the canal and of the bladder itself. 



It is probable that these are preceded by 

 interstitial absorption, and not unlikely by 

 sloughing or ulceration. And the straining to 

 overcome the impediment to the exit of the 

 urine leads frequently to the formation of 

 hernia at the groin, and has been attended 

 with rupture of the rectus abdominis muscle.* 



In old strictures the membrane of the 

 urethra is usually hypertrophied, the orifices 

 of the lacunae are enlarged, and the prostatic 

 ducts considerably dilated. The prostate 

 gland itself is frequently hypertrophied in 

 consequence of the general irritation of the 

 urethra. 



False passages. A false passage may be 

 formed in any part of the canal, according to 

 the seat of stricture ; there may be one only, 

 or several may co-exist. The under part of 

 the urethra usually gives way, owing to the 

 direction given to the point of the catheter. 

 Sometimes the catheter, passing beneath the 

 stricture, re-enters the urethra, and is then 

 directed into the bladder, or it may be forced 

 onwards through the prostate gland ; occa- 

 sionally the catheter penetrates but a short 

 distance, and on withdrawal enters the na- 

 tural passage. False passages through the 

 third lobe of the prostate gland not un r re- 

 quently result from unskilful attempts to re- 

 lieve retention of urine from enlarged pro- 

 state ; in this way the gland may be perforated 

 in three or four places. 



When false passages are maintained by the 

 frequent attempts to pass the catheter, they 

 become lined by a mucous membrane, and the 

 urine is in some ever afterwards discharged 

 through the newly formed canals. 



Fistulte in perinceo (urinary fisttilae) are 

 a common consequence of ulceration behind 

 a stricture ; they are generally preceded by 

 abscess, and sometimes by gangrene. Not 

 (infrequently they arise independently of any 

 obstruction, as after abscess from acute go- 

 norrhoeal inflammation. Urinary fistula? result 

 also from wounds of the canal, as after the 

 operation of lithotomy, or the extraction of 

 calculi from the urethra. Suppuration of the 

 lacunae sometimes leads to urinary fistula: 

 this happens occasionally to the lacuna magna. 



In urinary fistula there is sometimes a 

 single opening into the urethra, with many 

 external openings. These are found in various 

 situations : thus they occasionally exist anterior 

 to the scrotum, sometimes in the perinaeum, 

 and now and then they open into the rectum, 

 or even as low down as the tuberosities of 

 the ischia : the external and internal openings 

 do not always correspond, the intervening 

 tract taking a tortuous course. The walls of 

 the fistula are much thickened and indurated, 

 and this induration extends for some distance 

 to the parts around, and involves a large extent 

 of the cellular tissue and skin, so that the 

 perinaeum feels as hard as cartilage : the canal 

 of the fistula is lined by a mucous membrane. 



Sometimes the fistula passes upwards to- 



* See Dublin Journal of Medical Science, May 

 1842, p. 308. 



