The therapeutic measures applicable to these anomalies are naturally very restricted. All that surgery can aim at is the removal of defects, the opening of fused parts, and the closure of clefts by plastic measures.
In case of fusion, a sound is inserted into the canal which from its direction suggests the vagina, and the united parts separated by the knife. To prevent re-union it suffices to insert a piece of carbolized cotton be tween the separated layers. Before using the knife an endeavor should be made to cause disunion by means of the sound and thus to avoid hem orrhage. In case of labor we ought not to wait too long before interfer ence. In many cases of union and atresia the simple force of the labor pains will suffice to effect separation, but it is better to make a slight in cision in order to limit the extent of the resulting trauma.
Hypertrophied labia and enlarged clitoris are to be remedied by the knife or by the scissors. Hemorrhage is only profuse when the corpora cavernosa are wounded. The galvano-cautery had better not be used for removal; in case of hemorrhage the vessels need only be tied. For extir pation of the clitoris, the organ Is seized in a forceps and drawn out. It is then separated on each side and finally from its base. Anesthesia is necessary, although the operation is short, since the organ is especially sensitive. After excision a simple suture is sufficient to secure union and to arrest hemorrhage.
In case of epispadias Roger operated as follows on his patient: He re moved a crescentic piece from between the everted halves of the clitoris, the convexity of the denuded portion being forward, and extended the incision downward along the crura of the clitoris to meet in the mid line the centre of the meatus urinarius. The skin of the symphysis and the pubic rami between the margins of this incision was loosened as far up ward as the meatus, and he then made a horizontal incision extending from the ends of the crescentic incision through the middle of the meatus, loosened the lower border of this horizontal incision, turned in the edges of the crescentic flap, and brought together, on each side, the urethral opening with the button suture. Thus then the lacking anterior urethral
wall was made out of the mucous membrane of the symphysis and the patient's condition relieved, so that during the day urine was retained but at night there was dribbling. To relieve this the urethra was cauter ized with nitrate of silver, and after three applications cure resulted.
In Testelin's case cauterization with caustic potassa caused closure of the canal which existed above the urethra.
In the case described by Moricke and operated upon by Schroder, a somewhat different operative course was pursued. An artificial canal was made extending underneath the symphysis. It would seem as though the urethra in this case was much shorter than in the other reported in stances. The opening into the bladder was denuded laterally, and the flaps brought together from each side, above and forwards. There re sulted a urethra about inch long, and with retentive power. The left flaps retracted somewhat, and a number of operations were necessary be fore complete retention was possible.
In the two cases of Schroder, described by Frommel, the urethral de fect was not so extensive. The anterior urethral wall only existed to the extent of about of an inch, but on the posterior wall (possibly pro lapsed) there was sufficient tissue. Two right-angled incisions were made, the bases of which subserved the purpose of lengthening the urethra, while the apices met at the mons veneris. After suture one long side of each denuded portion formed the surface underneath the symphysis, and the external edges were united outside. The resulting urethra was over f of an inch long and recovery was perfect.