recognize that the little tumor between the labia mi nora and under the clitoris belongs to the urethra, and is not simply a tu berculum vagina, it is first necessary to find the urethral canal. In cir cular prolapses it is a slit or round opening in the middle of the tumor; in crescent-shaped ones it is situated at its upper margin. A catheter is now introduced and reposition attempted.
In a case published by Guersant in 1852 in which an emaciated and sickly girl had a prolapse of the mucous membrane nearly one inch in length cut sway with the scissors, he found after liar death, which oc curred from tuberculosis, that her urethra, of normal length and diame ter, was only covered with mucous membrane over its posterior (lower) third. This would go to prove that the meatus may occasionally be found at the lower portion of the tumor. Exactly defined the condition is not a simple prolapse, but is an invagination with prolapse. Inversio cum prolapsu mucosa urethra.
The tumor and the difficulties it causes incre,ase in time; and the pro truded portion may be dry, smooth, soft, and undergo the change of the mucous membrane described in prolapsus vagina (Reid and Streubel). But this is rare, and the malady is painful, obstinate, and debilitating. The cure, though slow, is sure and radical, and the prognosis, therefore, not unfavorable.
must first try to replace the part. It must be carefully compressed with three fingers, assisted by the well-oiled and blunt end of a thick catheter. After reposition the causes of the disorder must be remedied; such as vesical tenesmus, etc. It is a good plan to rinse out the bladder several times a, day by means of llegar's funnel, using a 1 '000 solution of salycilic acid. In the milder cases, when the prolapse remains reduced, involution of the mucous membrane and narrowing of the lumen of the urethra may be helped by the use of mildly caustic and astringent remedies, such as arg. nitrat., decoction of oak bark, sulphate of copper or zinc, tannin, etc. If the inverted portion is eroded or ul cerated we must proceed to more vigorous cauterization, and may use the lapis mitigatus in substance. Reposition must be effected immediately after each cauterization.
If in spite of this the prolapse returns, it has been proposed to treat it radically by ligature. the actual cautery, or ablation with subsequent ap plication of chloride of iron. (Sc,anzoni.) We may discard the method of ligature over the metallic catheter, since it is slow and painful. The knife should be used. A large metallic catheter is carried into the blad der, fixed by an assistant, and a sharp hook inserted into the tumor on each side of the staff so as to prevent too great retraction of the mucous membrane. The mucous membrane is now dissected up from without in
wards, beginning at the edge of the meatus, so that it can be cut off cir cularly. Scanzoni recommended the use of chloride of iron as a styptic. It seems to me to be easier and better to unite the cut edge of the mucous membrane to the edge of the wound at the meatus with a few silver liga tures. The stitches may remain in 5-6-7 days. There is no danger of pushing eschars caused by the caustics with the catheter into the bladder.
If serious hemorrhage is feared a wooden staff may be introduced into the urethra, and the prolapse taken off with the galvano-caustic wire.
b. Malplacement of the whole urethra is of more common occurrence than the partial dislocations that we have been so far considering, since it is usually secondary and unimportant, following changes in position of the blad.der. Still, one primary dislocation of the female urethra alone may be cursorily mentioned here. We refer to its dislocation by the pre senting part of the child, which bends the urethra at an acute angle. We then see it as a dark, bluish red tumor under the symphysis, together with the tuberculam vagime. Both the bending and the swelling of the vaginal and urethral walls are of importance in connection with retention of urine. Another and more frequent cause of this trouble is believed by Mattei and Ohlshausen to be the sudden descent of the uterus after de livery. The puerperal ischuria that occurs therefrom is exactly analogous to that so very often seen after the puncture of large ovarian tumors. The bend in the urethra forms an obstacle to catheterization which is very liable to be mistaken for vesical spasm. An attempt to fcrrce the catheter into the bladder may injure the urethral mucous membrane, and cause hemorrhage. But if the tuberculum vaginae be first pushed up out of the way, and the catheter carefully introduced two or three times, the urethra will be sufficiently stretched to obviate the retention. But in all these changes of position, with or without changes in the bladder, the urethra is lengthened, and its walls may be thickened and infiltrated, or they may be atrophic. So that even in the later days of the puerperium there may be deficient contractility of urethra and incontinentia mime after such contusions. I had recently such a case, in which repeated cauterization of the urethral mucous membrane with solid lapis infernalis soon restored continence.