Course and Prognosis. —Most neoplasms of the female urethra, as con dylomata, fibromata, mucous membrane polypi, and cysts can be easily and safely extirpated; they cause but little trouble, and their prognosis is pod. Oce,asionally, as Spalderer has noticed, the polypi pass off spon taneously with the urine, their bases having necrosed. On the other hand the venous and capillary angiomata not only cause numerous and very painful symptoms, but they also show a very great tendency to re turn, and their prognosis is not nearly so good. It is true that operative removal is an easy affair; the hemorrhage is usually unimporta,nt; but they begin to grow again in six or eight weeks, and the hemorrhage during and after the operations, both externally (Biegel) and into the bladder (Lisfranc-Forget) does impair the patient's strength. And there are cases in which the patient's life is imbittered and endangered by every new return of the malady, in spite of the most energetically radical treatment. Happily, these cases are the exceptional ones; and, save as regards the lupous, elephantiatic, and carcinomatous growths, a radical cure can be effected within a short time.
Therapy.—If the urethral tumor causes no trouble, there is no reason to interfere with it; but if it e.auses uneasiness, pain, or disturbance of function, energetic and speedy a,ction should be taken. The following methods of removal have leen employed: 1. The ligature: Guersant, Reid, Guerin.
2. Extorsion: Streubel.
3. Ablation with knife or scissors: Velpeau, Schfitzenberger, Espezel, Forget, Kiwisch, Normann, Simpson, Englisch, Reid, Macdonnell, Neu &der, and others.
4. Ferrum candens: Medow, Lee, Dalamin, Retzius, Simpson.
5. Excision and energetic cauterization of the base with arg. nitrat. or lapia mitigatus, or acid. nitr. or ferrum candens, or the galvano-cautcry: Velpeau, Macdonnell, Reid, Wetzer, Schuh, Thore, Berard, Simpson, Guerin, Veit, West, Baker-Brown, Menetrez.
6. Severe cauterization alone, with arg. nitrat. in substance, with con centrated sulphuric acid: Graem, with chromic acid: Edis.
In the larger and more deeply situated ones the urethra has been incised before extirpation; \Varner, Schuh, Wetzer, Macdonnell.
According to the most recent authorities No. 5 is the best of these methods; No. 1 (ligature), and No. 2 (torsion), being obsolete. The patient is deeply narcotized and placed in the dorsal position. The as sistants exposing the urethral orifice fully, the tumor is to be drawn for ward with a tenaculum, and cut off at its base with knife or scissors. The base is then cauterized thoroughly for several seconds with ac. ni tr. concentr., or ac. chromic, or with a small, pointed, red-hot iron. The bleeding is usually inconsiderable; if it is too free the repeated application of the ferrum candens, or the use of the liquor ferri sesquichlorati will stop it, or pressure may be made upon the urethra from the vagina first with the finger and then with tampons. If the tumor be situated high up in the urethra, and cannot be dragged down to the meatus, the urethra may be dilated; if it still cannot be drawn out, the galvanocaustic wire must be passed around its base. If the prominences in the urethra should
be so flat as not to be seizable by the wire, we can dilate the urethra, and use Simon's spoon to curette them.
In the retention-cysts of young children the use of bougies and catheters would necessarily precede excision.
In hemorrhoidal tumors of the urethra dilatation by the dilatator urethra or by tampon is indicated. If this method involves too much trouble and pain, the tumor may be drawn down, the veins tied off, a,nd the tumor excised. Finally, the actual cautery, or the galvano-caustic wire may be used to remove them. Richet has cured them by the use of a dilatator, shaped like the Frere-Come lithotome.
Finally, in epitheliomata of the urethra caustics are always contra indicated. Bardenheur used the sharp spoon upon his patient. Excision is the best remedy, so long as the tumor is small and isolated.
Melchiori has even operated in the second and third stages, to ease the patient's sufferings. He made a sickle-shaped cross-cut, with its convexity directed upwards, separated the soft parts with the exclusion of the urethra, and, after severing all adhesions, drew down the tumor. He then cut through the exposed urethra at the place fixed upon, closed every spurting artery by ligature or torsion, and stilled the oozing by means of ice-water and styptic solutions. Only when the bleeding was obstinate did he use catheter and tampons; and he removed them at latest in 24 hours. Healing took place by the contraction of the neighboring soft parts around the urethral stump, so that finally only traces of a ves tibule were left. Incontinence is not to be feared so long as the neck of the bladder is not injured; and thorough cleanliness will prevent any difficulty with tbe urine. If operative treatment is no longer possible, a symptomatic treatment of the pain, dysuria, and foul odor, by means of narcotics, catheterism, and antiseptics must be carried out. In the ex tirpation of a urethral carcinoma the size of a walnut I passed a catheter into the bladder, and then passed three needles from the vaginal mucosa under the catheter, drew them together with strong thread, and dissected out the urethra underneath them. Five bleeding arteries were tied with catgut, and then the urethral mucous membrane was united to the edge of the wound by means of seven deep-seated silk sutures. The catheter was left for several days in the bladder. Primary union took place rapidly.
Internal remedies have never effected anything in the maladies that we are considering; and even the local palliative treatment, such as dilute hydrocyanic acid (1:4), aconite, chloroform, and morphine in salve form, and warm sitz-baths (Simpson), have given no relief.
To prevent a recidive, energetic cauterizations every 3 to 4 days are to be recommended. We may use undiluted lig. plumbi. (West), liquor hydrargyri nitrici (Veit), argentum nitricum in substance, zincum muria ticum (Mettenheimer); but better than any is the actual cautery.