The other form of hypospadia may be regarded as persistence of the sinus uro-genitalis. There is an orifice between the clitoris and the peri neum which leads into a canal, and thep divides into two passages, one being the bladder, and the other the vagina. Willigk (O. Heppner) has given us the best description of this monstrosity: A woman forty-six years old died of a phlegmon. Her penis-like clitoris was 21 inches long. The uro-genital canal was of the thickness of a catheter at its entrance, mn in bow-shape under the arch of the symphysis, and inch behind its opening in the skin it divided into an anteriorly placed urethra 1 inch long, and vagina 2 inches and 10 lines in depth. In this class we must place the cases of Debout (S. Ffirst), Hug-uier, Jumn6, Coste, Debrau, and Engel. There was atresia vaginte, and the passage opened into the urethral canal.
Symptoms of these malformations. —The most important consequence of a total urethral defect is the inability to hold water. According to Heppner's reports those persons who with the defect have stricture of the vagina are better situated than those that otherwise than it luive normal genitals; since very probably the bulbo-cavernosus muscle that encircles the sinus uro-genitalis is capable of voluntary contraction. The patient's condition is a miserable one if. there is permanent incontinence of urine. (See symptoms of vesico-vaginal fistula.) .
If the atresia urethra3 has occurred within the uterus, there is usually hydropsy of the bladder, the ureters, and the kidneys, together with ascites. The stomach of the fcetus is enormously swollen, and may form a serious obstacle to delivery, so that sufficient force to rupture the ab dominal walls, or tapping, is necessary before the child can be born. Examples of such cases have been recorded by Paul Portal, Delborier, Moreau, Freund, Hecker, and others. (See Rose, 1. c.) Such children of course are usually born dead. Very different is the case, however, when from the tension of the bladder the urachus has opened, and a urachus-fistula been established. The urine then issues from the region of the navel continuously, the orifice being surrounded with comb-like outgrowths. (See Cabral's case.) In Bonnett's very interesting case ' the urine issued in numerous hair-like streams from the urachus-fistula, which WM about nine inches long, as soon as the prolapsed uterus was replaced, and with it the bladder carried upwards. Oberteufer knew a woman forty-two years old, who had since birth only urinated through the navel. Vagina and menstruation was normal; the urethra was wanting.
If the persistent sinus uro-genitalis is large enough, coitus may be effected, and conception occur. But if the vagina is narrowed, the penis
may penetrate the urethra, and each coitus be followed by dysuria and temporary incontinentia Jumn6 (Heppner, 1. c.) has described such a case. We must be careful not to mistake these cases for instances of hermaphroditism, as Smith did.
More than simple inspection is usually necessary for the diagnosis of malformations of the urethra. The inner surface of the labia minora and the space between the clitoris and the rectum must be carefully looked over, and then all orifices must be explored with the finger, or, where that is impossible, with elastic and metallic catheters and sounds. The external genitals should then be carefully palpated; and the existence of any hard resisting body is to be carefully searched for in the labia majora, since they might be testicles or ovaries. This is necessary, since in child hood we are not aided by the presence of menstruation or the female habitus. In the above-mentioned case of Debout, there was a hernia ovarialis si n istra. • A persistent uro-genital sinus may be mistaken for atresia hymenis, and acquired atresia vulvw. In either case conjoined vesical and rectal examination will inform us whether there is a tumor or only a thin mem branous septum between the two organs. If with finger, sound, or cathe ter, two openings can be demonstrated, the diagnosis is not difficult. If the entrance of the sinus uro-genitalis is very narrow, rapid dilatation with Simon's urethral specula may be tried, and an ocular examination made for another opening. Finally the secretion must be examined chemically for urea, and microscopically for pavement and cylindric,a1 epithelium.
may be palliative or radical. When there is com plete absence of the urethra, and the bladder opens into the vagina by a fissure; and also when the urethra is partially developed and the sinus uro-genitalis persists, the construction of an artificial urinal canal might be attempted. From either side of the vagina, a flap about half an inch broad is t,o be stripped up to the symphysis, and, with its mucous surfa,ce tiu-ned in, is to be united above to the pared margins of the vesical cleft, and at the middle is to be united to its fellow of the opposite side. Heppner considers the operation difficult, but possible. It is doubtful, however, whether the possession of a urethra devoid of muscular fibres and incapable of voluntary contraction, would better the patient's condi tion. Nevertheless, the formation of the new channel would prevent the urine flowing into the vagina, and would facilitate ret,ention and the ap plication of a suitable receptacle. Lebedeff has successfully performed the operation.