The treatment depends partly upon the cause. Stenoses due to vesico vaginal flstulw, and those due to cedema of the urethral mucous mem brane, may be completely cured by repeated careful catheterizations.
If it be caused by cicatrices in the introitus and the vagina, we can follow Scanzoni and use lukewarm vaginal injections, followed by an iodide of potassium salve applied to the anterior vaginal wall, and by re peated introduction of bougies of gradually increasing sizes. Thus Gold schmidt almost entirely cured in four weeks a syphilitic urethral stricture by catheterization and the removal of a tumor that pressed on the ex ternal meatus. But in more serious cases this will not suffice. We must then carefully cut the chief cicatricial band at its point of greatest tension from without, and then undertake methodic urethral dilatation after Simon's method. (Page 13.) For stricture caused by chancre Scanzoni used first a course of treat ment with sublimate, and then for three weeks a daily inunction of iodine ointment, which was warmed and poured into the catheter, and then blown into the urethra by means of a syringe filled with air. The treat ment was successful. Boucher's patient had been once completely cured in six weeks by means of gradual dilatation; but the strictures returned, and had t,o be redilated. In such cases incision together with dilatation is certainly indicated. The urethra should be dilated with the urethral specula, until the little finger could be passed through the stricture; then a short knife is to be introduced flat under the finger, and. then returned and pressed against that part of the cicatricial ring that feels hardest. No especial hemorrhage need be anticipated; but if it did occur, the ap propriate urethral speculum might be left for a few hours in the canal. Then bougies, medicated with iodide of potassium or salycilic acid, could be employed. The patient should be warned to return as soon as the least difficulty in urination occurred, or, if that be impracticable, she should use elastic bougies of gradually increasing sizes herself to prevent a recidive.
3. Change of position of the urethra, partial or total, may occur in any direction, above, below, sidewards, or anteriorly. Again the entire urethnt, or only its mucous membrane, may be disloc,ated. This latter is the most important displacement, and will be first considered.
a. Prolapse of the urethral mucous membrane in females was acci dentally found twice during autopsy by Morgagni nearly 100 years ago. Since then such cases have been seen by Seruin, Solingen, Hain, Lee, Ki wisch, Burns, Streubel, Ried, Scanzoni, Patron, Basler, Day, Hudson, In gerslev, and Olivarius. It must be rare, since the author has seen but one
c,a8e, though small partial protrusions of the mucous membranes of the lower part of the urethral wall occur often enough. The entire mucosa can only protrude at the external orifice where it has been loosened from its base and forcibly- torn or pushed out. The protruded part is pea, walnut, or pigeon-egg-sized (Basler), bluish or dark red, and round, half moon-shaped, or globular. At its middle or towards its upper border is the orifice of the canal. Thus the condition is exactly similar to that of prolapse of the rectum. As in the latter case the mucous membrane can usually be easily replaced; and like it also it may recede of itself, but in some cases may be difficult or impossible to reposit. The surface of the tumor sometimes bleeds, and may be sore and suppurating; in long standing cases it grows and becomes cedematous and may appear con stricted. (Patron's case.) It is usually very sensitive.
The causes of this malady are partly those of urethral dilatation (see ob. 5), partly diseases of the bladder, and partly constitutional affections. As a rule, the patients have already long suffered from urinary difficulties, dysuria, and vesical catarrh; and it is especially the catarrhal condition that predisposes the mucosa to a prolapse. In 15 sick persons suffering from this affection, were 7 girls between the ages of 8 and 15 years, weak, chlorotic, and relaxed individuals. Of Streubel's 4 patients three were " much used prostitutes with vaginal gonorrhcea, dilated meati urinarii and hyperzemic urethral mucous membranes." Displacement of the geni tals, such as prolapsus uteri, cystocele vaginalis (Scanzoni), have repeatedly caused the affection. On the other hand there do occur cases like those of Basler, when a young women twenty-two years old had a urethra so dilated five weeks after her first an4 normal delivery, that he could intro duce his finger, and bring to view a prolapse of the mucous membrane, the size of a pigeon's egg, the other genitals remaining normal. Excit ing causes are contractions of the bladder with marked desire to urinate, expressing the mucous membrane; abdominal and vesical muscles here working together. It has been claimed that calculi may cause it (Scan zoni); I know of no such case. Solingen's one case had bad a number of severe confinements, had suffered blows upon the abdomen, and in con sequence thereof suffered from difficult urination and defcecation. Larger growths in the urethra cause prolapse of the mucus membrane, but usu ally only to a small degree.