b. Partial dilatation of the female urethra, diverticulum urethrfe, urethrocele, affects the posterior wall of the organ a few lines from the meatus. I know of but four cases so far recorded. The first, that of Foucher (1857), occurred in a woman twenty-seven years old, who had had dysuria for four years, and in whose anterior vaginal wall, inch from the orificium urethrte, there was a tumor which became smaller on pressure, urine exuding from the meatus. On introduing a catheter, it entered this cavity, and only after traversing it attained the bladder. Foucher treated it as Jobert would a cystocele. He incised the vaginal wall the whole length of the tumor, dissected up a strip of ith of an inch wide on either side, cut off the loosened portions, and sutured the edges of the wound. The patient was cured when cicatrisation had oc curred. Gilette's case is very similar. A woman thirty-one years old, confined three times, was cured by the excision of a triangular piece from the vaginal wall.
The third case has been described by G. Simon. The woman was forty four years old, had borne eleven children, and had had involuntary urina tion on vigorous motion for sixteen years. In the last three years the incontinence had so increased, that at certain times all her urine flowed off continuously in any position, even when lying down. In the anterior vaginal wall there was a tumor as large as a hen's 'egg, reaching from the region of the meatus urinarius to the vesical neck. The catheter or the finger introduced into the orifice entered a wide sac, which was continu ous, without any line of demarcation, with the bladder. Only the meatus was normal in size, and had its proper muscular tonicity. This dilata tion had been caused by large varicosities in the urethro-vaginal septum, which were so near to the urethral mucous membrane that a brisk hem orrhage followed catherization. They projected as dark blue coils. In two sittings Simon cut ten veins, double ligaturing four of them, and cauterized the wound with chloride of iron. The patient did not even have to keep to her bed. The tumor visibly diminished in size, through the cicatricial contraction of the wound. The woman no longer lost urine while lying, sitting and standing, and during ordinary motions. Six months later she had remained well, but Simon did not regard the relief as permanent, believing that the dilatations would reappear, or that other neighboring veins would become varicose. I have often seen con siderable varicosities of the bulbus urethrte and of the anterior vaginal wall, but have never seen such a partial dilatation of the urethra result therefrom.
The fourth case was observed by Priestley. He found an elastic tumor, half the size of a hen's egg, in the vulva, springing from the upper part of the posterior vaginal wall; it disappeared on pressure, pus and urine flowing out of the meatus. Priestley applied a Barnes dilator, the pressure of which prevented the tumor from refilling, and relieved the patient.
In another similar case Priestley found a urethral cyst with atheroma tons contents; a condition that might well be confounded with urethro cele. But in these cases the urethral canal will hardly be dilated, and the tumor will simply open into it. Since 1877 I have encountered two cases like these, which were indubitably affections of the urethral follicles. In the first the tumor was of the size of a walnut, was placed upon the lower part of the posterior urethral wall; pressure caused the appearance of pus at the meatus. The patient improved by frequent compression of the tumor with her finger, and a lead-water lotion. In the second case, however, the tumor, hazel-nut in size, was the source of great pain during cohabitation, and caused bearing-down feeling when the patient was standing. I therefore excised it. It was situated under the urethral mucous membrane, near the external orifice, and contained abundant greenish, slightly foul-smelling pus. Its walls were muscular, its inner surface being covered with pavement epithelium. These cases, I think are not urethroceles; they are cases of inflammation of urethral lacunEe. They have doubtless often been confounded with urethroceles and urethral cysts.
We must also remember that other openings may be found in an other wise normal urethra, which must be distinguished from an urethrocele. Thus, as in the above-mentioned case of Debout, (page 29), the vagina may open into the urethra, so that a catheter introduced into the urethra may reach the uterus. Cusco has mentioned a case in which there was in the posterior urethral wall an opening itir of an inch in diameter, which led into a blind sac a few lines deep, the iudimentary vagina. Besides this, this servant girl, who was eighteen years old, had a uterus duplex rudimentarius solidus, and a hernia ovarialui simistra. Incarceration of the latter led to operation, and she died of peritonitis. Such adnexa may be dilated by the pressure of the urine, may deform and dilate the urethra, and may cause catarrh. Most often the differential diagnosis can hardly be made during life. Compression of the sac, as soon as it is proven that it has no other opening above, in the manner described by Foucher, will be our best method of examination.