We now come to the pendulous portion, which, except for that part within the glans, is uniformly of a pale rose color, the radiations or depressions between the folds being of a slightly darker shade. (Fig. VIII.) Here on the anterior surface are seen the little openings of the glands of Littré, little depressions or dark spots, varying in size from as small as a needle's point to as large as a needle's eye. The smallest ones are, of course, invisible. These are frequently the seat of inflammation, and then become easily demonstrable, either as a dark spot surrounded by a red areola, or as a pouting papilla, exuding a drop of clear mucous, or milky, or purulent secretion. Or the opening may have become sealed, imprisoning the secretion, thus forming a miniature abscess, which if undiscovered would increase in size and cause considerable trouble later on.

The follicles or lacunæ of Morgagni, are also very easy of demonstration in this region. Their openings are larger than those of Littré's glands, and more elliptical than round in shape. The sizes of these orifices may be compared approximately to the various sizes of the eyes of ordinary sewing needles. These follicles may be the seat of simple inflammation, or form acute purulent pockets. They may become ulcerated, dilated, and the seat of chronic processes, which are often the cause of protracted gleets, or they may be the origin of sinuses and fistulas, which burrow deeply into the tissues and finally find a vent at the surface of the skin.

These follicles, or lacunæ, are more numerous as we approach the glans' portion; and here, also, they have wider openings with shallower pockets. Some of these are anatomically constant, or nearly so, especially the lacuna magna in the glans' portion, called the valve of Guerin, situated about 11⁄2 cm. above the meatus. This lacuna magna, however, is not always present, and on the other hand, we often find a number of other lacunæ just as large, situated not only here but also higher up in the urethra. It is the folds of these lacunæ, all of whose openings are directed towards the meatus, which catch the points of small instruments.

Within the glans the mucous membrane is smooth, having no folds, of very pale pink color, and presents for observation the lacunæ just referred to and the fossa navicularus; the lumen of the

canal again changes in shape here, gradually forming an anteroposterior slit as seen at the meatus.

Pathologic conditions encountered in the penile urethra consist principally of circumscribed areas of inflammation, which are situated most often just within a relatively small meatus, or in the vicinity of the peno-scrotal junction. They may occupy any site within the canal. They are denoted by a deeper red color, combined with a dullness of the membrane, where the surface epithelium has been destroyed. Papillæ and condylomata are found here, and also specific and chancroidal ulcers. The occurrence of vesicles as well as hard and soft infiltrations in this region, should also be mentioned.

The lacunæ are particularly liable to gonorrheal infection, and may then form para-urethral fistulæ. Such conditions are discovered by the urethroscope, and appropriate treatment promptly applied through the same instrument. The lacunæ, as well as the glands of Littré, are also frequently found dilated and in a condition of simple inflammation.

I have been able to give only an outline of the use of urethroscopy in the time alloted me. Many of the diseased conditions which 'have been barely mentioned in passing, would require many pages for a proper discussion of their etiology, pathology, and treatment.

One or several lesions may exist in the same urethra, and we must see and treat each of them surgically, according to its special requirements. Therefore, in any case of urethral disease which has assumed a subacute or chronic character, we cannot expect to effect a cure until we recognize the lesion. And to this end the only means of exact diagnosis is the urethroscope.

DISCUSSION.

Dr. P. Duncan Littlejohn (New Haven): Mr. President and Gentlemen: I was very much interested to hear Dr. Stern's explicit description of both the normal and pathological urethra. Although this branch is mentioned in nearly all text books, nevertheless the detail with which any of them go into the subject is very limited, and therefore his descriptions were very instructive to me; both from a scientific standpoint as well as from its value in treating and diagnosing many conditions. I was somewhat disappointed, however, in not hearing Dr. Stern describe the technique of the urethroscope's use, and also the instrument which he prefers. There has

been so much written recently about the value of air dilatation in the examination of the urethra, that I had hoped to hear him touch upon that method. The instrument which he showed, I think, perhaps can be improved upon, because of the fact that whenever one attempts to use a cotton swab through this instrument the cotton is very apt to become entangled in the lamp. If one uses an endoscope, with an auxiliary tube for the lamp, the latter is out of the field of vision and therefore does not encroach upon the field in which the operator is at work. Also, the megaloscope is a very useful addition to the urethroscope, as it magnifies about twenty diameters the picture one sees, and in consequence one is able to discover many pathological changes which he might originally overlook.

In two cases I have seen, the urethroscope has been of exceptional value in finding the opening of eccentric strictures where ordinary means had failed. In both of these cases when the endoscope was introduced into the urethra, the opening of the stricture was found with comparative ease. A visual examination, therefore, saved a great deal of time.

Allow me once more to express my sincere appreciation of Dr. Stern's very able paper.

Dr. Edward S. Moulton (New Haven): Mr. President and Gentlemen of the Society: I think Dr. Stern is to be congratulated on the very thorough way in which he has shown us what can be seen through the urethroscope, and the Society is also to be congratulated on having such a scientific paper read to them. As Dr. Stern has treated the subject, he has left very little to those who discuss his paper, because there is practically nothing to add, as he has not gone in any way into the usage, except to show us what is to be seen. The lesson to be drawn from this paper is one which I think most of the profession have neglected, and that is the use of the endoscope. It has not been used as much as the other "scopes " which the other specialists have brought out, yet, it seems to me, in subacute and chronic gonorrhea, that it is as essential to look into the urethra with the endoscope, as it is for the laryngologist to use his laryngoscope to see what is the condition of the vocal cords. Also in the treatment of these cases, an endoscope enables you to put upon the granular patches, and upon circumscribed inflamed areas, very much stronger solutions than could possibly be used through a syringe where you would have to go over normal tissue. You can go down and touch a granular spot with nitrate of silver in a 20 per cent. solution, and then put in salt solution, and it doesn't affect anything but just the spot which you are touching. My own personal preference in these cases is the Otis instrument, where the light is thrown in by an electric light entirely outside, and you can use a larger tube. You have thus more room for making applications and there is absolutely no danger (the tube being absolutely smooth and of polished silver) of the swab coming off from the applicator.

Dr. Charles S. Stern (Hartford): Dr. Littlejohn refers to the micro

spectroscope and air dilatation, and his remarks are very timely. I don't know whether it will ever come into general use. He claims very much for it, and it may be better, but still I don't see how you are going to make your applications so well through it, because you have got it bulged out with air. If you open it you are going to let the air out. Of course the cotton will catch on the lamp, if you use a big swab of cotton, but generally the lamp holds closely to the tube, as you will see in this instrument, and there is plenty of room alongside of it to put the swab through. In fact, after you have found the spot, you can remove the lamp and put the swab in. However, the suggestion is a good one.

The instrument spoken of by Dr. Moulton is a good one, but I don't think the illumination is as perfect where you get it from a distance. Dr. Moulton also spoke of touching the spots with a 20% solution. I have frequently touched very bad areas with a 50% solution, and without using any salt after it, and have had no difficulty thereafter.

The important point which I desire to emphasize is, that one or several distinct and separate lesions are present in some part of the urethra in all inflammatory cases that have existed for any length of time, and that these can be discovered only through the urethroscope. I have not attempted to take up the therapeutical value of the instrument in this paper.

The main point which I desire to emphasize is, that one or several distinct and separate lesions are present in some part of the urethra in all inflammatory cases that have existed for any length of time; and that these can be discovered only through the urethroscope. I have not attempted to take up the therapeutical value of the instrument in this paper.

Acne.

MARK S. BRADLEY, M.D., Hartford.

Acne is a disease of the sebaceous glands. The sebaceous glands are racemose glands, simple or compound, and lined with round cell epithelia. They secrete an oily substance, called sebum, which is produced by slow fatty degeneration and ruptures of the cells lining each lobule. The ducts are short and open in the hair follicles or directly on the surface of the skin. The glands found in the so-called non-hairy parts of the skin or those portions supplied with lanugo hairs, are large in size and more complex than those of the hairy parts. They are especially large on the nose, at the labionasal fold and on the cheeks.

Symptoms.-Acne appears in small and slightly elevated red papules, with or without infiltration, which are followed by spontaneous resolution or by central pustulation. This form of eruption does not leave scars. In connection with this, we may have a papulo-pustular eruption arising from the deep connective tissue layers of the skin, a tubercle or a true dermic abscess. These are destructive in their action and slow in their evolution and chronic in their course, and if untreated, leave scars. The location of the eruption is on the face, neck, shoulders, and chest. It is very rare to find it on any other part of the body. The smaller eruptions are rarely tender. The larger, nearly always, are on deep pressure. Comedoes are usually abundant. Beyond the disfigurement and the tenderness of the large pustules, the eruption produces little inconvenience. It is not accompanied by itching.

Etiology. The active agent producing acne is, without doubt, a certain micro-organism and claimed by Sabouraud as identical to the dipplococci of seborrhoea. It is certainly true that a large percentage of the cases of acne have seborrhoea, but it is also true that few cases of seborrhoea, which are over thirty years of age,