unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. But in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means.

TREATMENT.-When a case is first seen it is well to remove any inflammation or other complicating conditions. The prolapsed membrane should be replaced, and the patient kept quiet in bed to favor the retention of the parts in situ. Astringents, such as tannic acid, alum, or persulphate of iron in a weak solution, should also be used. Should these fail, the prolapsed portion of the membrane should be removed. The methods of doing this (by excision and the thermo-cautery) have already been described.

Stricture of the Urethra.

PATHOLOGY.-Obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. Still, it occurs sufficiently often to demand attention. There are some facts in the pathology of urethral stricture peculiar to women which we will first notice. Passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end. in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. Stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of 'vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal.

SYMPTOMATOLOGY.-Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. In almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. The previous

history of cases in which stricture is suspected will aid in settling the diagnosis and etiology.

DIAGNOSIS.-A digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be detected in the same way. The use of the sound will determine the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascer

tained.

The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations.

PROGNOSIS.-Stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state.

TREATMENT. The treatment of stricture will depend upon its location and cause. If it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. When due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. Dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as the stricture has given way dilatation should be suspended.

Incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively.

In contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation, and pass the sound from time to

time to see if there is any tendency of the stricture to return. The brilliant results obtained in the treatment of stricture in the male with electrolysis by Robert Newman should warrant a more extended trial of this method.

Stricture at the Junction of the Urethra and Bladder.

This form or location of stricture is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations have been limited, but sufficient, I think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal. The causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. The point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. Contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. This is contrary to the history of stricture of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. It is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ.

The symptoms presented in this form of stricture are difficult urination and in some cases complete retention. I have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder.

In this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. Our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal.

Having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. To distinguish these from the stricture, the catheter should be passed when the bladder is well

distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. On the other hand, in paralysis and atrophy the stream is slow and without force-so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diagnosis may be confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. There is a slight yielding at all points except at the stricture, where a decided resistance is met.

Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. Rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present that is all that I have to offer on this subject.

DISEASES OF THE VAGINA AND VULVA.

BY EDWARD W. JENKS, M. D., LL.D.

DISEASES OF THE VAGINA.

THE subject will be considered in the following order: Anatomy, Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina, Growths, and Vaginismus.

Anatomy.

The vagina is a musculo-membranous canal extending from the neck of the uterus-which it embraces-to the vulva. It is usually attached to the uterine neck at a point midway between the os internum and the os externum. This canal is composed of three layers or coats: the outer one is of fibrous and elastic tissue; the middle, of unstriped muscular fibre and fibre-cell; the inner coat or lining is mucous membrane, composed of connective tissue and elastic fibre and covered with squamous epithelium. The outer and middle coats spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. One of the peculiarities of the middle coat is that during utero-gestation it becomes much hypertrophied like the same structure in the uterus, and following labor undergoes a similar process of involution. The inner or lining coat extends to the fourchette.

Savage has described the general form of the vagina as similar to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. The ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum; it is about two inches long, while the posterior wall or posterior column is twice that length. The anterior column or cord causes the investing mucous membrane to be puckered and thrown into folds or ruge which run transversely toward the posterior column. "This mucous membrane is studded with papillæ which are covered with pavement epithelium. The papille of the vagina, which were first fully described by Franz Kilian, were regarded by him as having for their function the transmission of sensation. He represents them as being thread-like and filiform."2

Anatomists have differed regarding the existence of muciparous glands 1 Anatomy of the Female Pelvic Organs, London, 1870. 2 Thomas on Diseases of Women, Philada., 1880.