ABNORMAL SHAPE AND POSITION OF THE FEMALE URETHRA.
1. Abnormal dilatation of the urethra may affect its entire length, the surrounding tissues giving way upon all sides: Dilatatio urethrte totalis; or it may be limited to a portion of the canal, usually the central part, while the orificia extersum and internum are of normal calibre; dilatatio partialis, diverticulum urethrte, urethrocele.
a. Total dilatation of the urethra is usually caused by the penis, in cases where the vagina is closed or is unusually narrow. I have seen it twice, and in both cases in married women, who had practiced coitus for years, but who suffered from atresia vaginte with defectus uteri. With a little trouble the index finger could be introduced into the bladder. There were no erosions or lesions near the urethra, and both women could retain their urine perfectly. Scanzoni asserts that when dilatation is caused by the frequent introduction of a foreign body, the mucous mem brane is the seat of a catarrhal inflammation, with more or less secretion. IIyrtl mentions a like case, which he believes to be unique. They- are, however, not rare. Lachapelle has described one in a puella publics; Scanzoni one in a young girl who was in the habit during her daily acts of masturbation, to introduce a small wax candle 3 lines thick into the urethra; and Willemin (1864) one with defectus uteri and rudimentary vagina. In all these cases the forefinger could be passed through the urethra into the bladder. C. Knight (1860) has reported such a case; and Freund (1866) had a patient who practiced coitus for ten years per urethram, and never had incontinence, though she did suffer somewhat from ischuria at the beginning. Wegscheider has published a similar case. J. Sixinger has met a case in which a girl suffering from atresia vaginw and htematometra had a urethra so dilated by coitus, that two fingers could be introduced into the bladder; yet incontinentia urinte wsa not present.
The urethra may also be gradually dilated from within by new growths, or from the direction of the bladder or the vagina. Hyrtl's case is well knom II. in which a calculus 7 lines in diameter, escaped spontaneously from a woman's bladder. Scanzoni bad a patient with stone in 1850 upon whom he intended to perform lithotrity; she was suddenly seized with severe bearing-down pains, and a calculus larger than a pigeon's egg ap• peared at the meatus, whence it was extracted with a polypus forceps. Here the urethra remained so dilated for several days, that the bladder could easily be reached with the finger. I myself had a case of papilloma
of the bladder, who before the operation spontaneously evacuated a por tion of the growth over 7 lines in diameter. Ponfick's case belongs also in this category; she had atresia vaginw, luematometra, and cystitis with stone in the bladder; and her urethra was so dilated that various physi cians mistook it for the vagina, and ascribed the incontinence from which she suffered to a supposed communication between the vagina and the bladder. With the lax, dilated, and displaced vagina caused by frequent child-bearing at short intervals, we usually find the urethra dilatable and enlarged, especially in young persons. • If total urethral dilatation does not give rise to incontinence, it causes no special trouble. Patients who have used the urethra for coitus, are naturally unaware of that fact, and consult the physician because they have never menstruated, or because they have no children. As a rule they suffer at most from a transient dysuria, and can generally fulfill their marital duties. It would, therefore, be useless to attempt to reduce the calibre of the urethra. It is different, however, when vesical continence is affected by total dilatation. Kinny claims to have cured three cases by cauterizations with clu•omic acid; but since I have not seen the original article, I cannot tell whether pure or diluted acid was used. Cauteriza tion with solid lapis mitigatus would probably do as well. If, however, this is insufficient, I would reconunend Jobert's urethrocele operation, which will be described later on. Astringent and tonic injections, and the sitz-bath, as well as scarification of the mucous membrane has been ree,ommended; but Scanzoni reports that in an old case with relaxed genitals, all his efforts were in vain. He obtained most satisfaction from an ointment containing tannin or ergotin, to be applied partly to the vaginal walls, and partly in the urethra. In one of his cases, where the dilatation was caused by onanism, and resisted all methods of treatment, it yielded almost completely to injections of sulphate of copper. If all these means fail to restore continence, we must excise a strip 1 to 14 inches long, from the urethro-vaginal septum from the external to near the in ternal opening. Its base in the vagina should be fth in the urethra ith of an inch broad. The edges of the wound should then be carefully sown together over a metallic catheter. The operation is easy, and its results are good. We will retinal to it when we come to consider incontinence and urinary fistulie.