rectum, thus making an opening that reaches to the fistula. The latter is then dissected up from the rectal side and left attached to the urethra. The rectum and urethra are next separated transversely well above the fistula, so that the anterior rectal wall can be dragged down over the fistula to the anal margin. The mucous membrane is then dissected from the anal margin on each side of the wound and trimmed off, so as to form a crescent with the edge of the gut that has been separated from the urethra above the fistula. A soft rubber No. 22 F. catheter is now passed from the meatus into the bladder. The edges of the fistula are

the muscular wall of the gut at this point, and back through the perineal tissues and skin on the opposite side, the ends being left. untied. The anterior wall of the rectum is then brought down and sutured to the margin of the anus, from which the mucous membrane was dissected, thus forming an impervious layer between the sutured urethra and the rectal canal. Finally, the silkworm-gut suture, which acts as an anchor to the rectal wall, dragging it down and preventing tension on the marginal sutures, is tied firmly over a small roll of gauze, so that it will not cut into the skin. The perineal wound is then packed, and the catheter fastened at the meatus, so that it cannot slip out. The catheter is left in situ ten days or more. When it is taken out, a perineal fistula remains that usually heals in about three weeks.

CHAPTER XXIII

THE FEMALE URETHRA

ANATOMY

The female urethra is considerably shorter than that of the male and it virtually represents but the posterior portion of the male passage. It is about one and one-half inches in length, but varies considerably in this respect in different subjects. Its walls are ordinarily in immediate apposition, but when its longitudinal corrugations are distended the passage is about one-fourth inch in diameter. The tube can be greatly dilated, however, sufficiently so as to permit the introduction of a palpating finger.

The organ lies embedded in the anterior vaginal wall and its external orifice is found about one inch posterior to the glans clitoris. It passes upward and backward, joining with the walls of the bladder and draining this cavity at its most pendent portion, the trigone. The internal or cystic orifice is stellate in the resting condition and the external orifice or meatus presents itself between the nymphæ as a vertical slit with slightly raised margins. The urethra penetrates the triangular ligament and is attached to the pubic arch by the pubovesical ligaments. The body of the tube is inclosed by the compressor urethræ muscle. The ducts of Skene enter the urethra just within the meatus. These gland tubules are of considerable importance, since in infectious diseases of the female urethra they afford lodgment for microorganisms which may later infect the bodies of the glands and excite a persistent inflammatory disease with sporadic outbreaks of adjacent infection.

The walls of the urethra are made up, beginning from within, of a thick layer of transitional epithelium, continuous with that lining the bladder and like it in its appearance; at the external meatus this epithelium becomes transformed into a form like that making up the external genital mucosa. At the vesical

extremity of the channel many mucous glands are found, the ducts of which enter the urethra at this point. The mucous membrane of the urethra is laid down on a delicate basement membrane which is in turn applied to a thick and very highly vascular connective-tissue coat which is further characterized by the presence of many elastic connective-tissue fibrils. The connective-tissue layer is inclosed by an inner longitudinal and an outer circular layer of smooth involuntary muscle which acts as and receives the name of the compressor urethræ muscle. The muscular coat is united to the surrounding structures by a layer of connective tissue which blends with the surrounding stroma.

The lymphatics of the upper portion of the urethra drain into the internal iliac nodes, but the lower ones enter into the channels of the external genitals and so pass to the inguinal nodes. blood-vessels and nerves are very abundant and are derived from the same sources as those supplied to the vagina.

CONGENITAL MALFORMATIONS

Congenital malformations of the female urethra are more rare than in the male. They are usually found associated with accompanying malformations of the genitals. Atresia is the most frequent congenital malformation with which the obstetrician and general practitioner meets. Its treatment is obvious and the severity of measures necessary depends on the degree of the atresia. Occasionally the urethral meatus is indicated and the septum separating it from the bladder can be perforated by a probe or sound. When no such landmarks exist and where the tube cannot be felt, it may be necessary to open the bladder suprapubically or through the vagina, following later with a reparative or constructive plastic operation such as is indicated by the associated lesions of the particular case under question. Hypospadias and epispadias are very rare and exstrophy of the bladder is also less frequent than in the male. The treatment of these conditions has been sufficiently discussed under the like conditions in the male.

Traumatisms of the urethra are much less common in the female than in the male on account of the protected location of the canal. As a rule, they result from direct violence, and the

chief difficulties presented in their treatment follow from their close proximity to the genital tract and the rectum, from which infections are likely to arise.

Treatment is directed mainly toward surgical repair, when necessary, and toward the prevention of septic infection. On account of the great vascularity healing generally takes place rapidly.

EXAMINATION OF THE FEMALE URETHRA

On account of the short length of the channel, its dilatability, and its accessible position, examination of the female urethra is a much more simple matter than that of the male. Palpation of practically the entire length of the passage can be usually satisfactorily performed through the anterior vaginal wall, the index or examining finger being introduced for that purpose into the vagina. In this manner, calculi lodged in the lumen may be readily detected, and in most cases the location and extent of strictures or new-growth formations can be ascertained.

Examination of the mucous membrane can be best accomplished by the introduction of a small sized Kelly cystoscope, and as the instrument is slowly withdrawn the walls of the canal fall together over the open end of the instrument, when they can be closely inspected bit by bit as the tube is slowly withdrawn. A strong light is necessary and the best results are obtained when light reflected by means of a head mirror is employed. Where Kelly's instrument is not available examination can be quite satisfactorily accomplished with an ordinary urethral endoscope of large size. In the withdrawal of the tube one must particularly inspect the openings of the gland tubules, which appear normally as minute, yellowish, slightly pink spots. Inflammatory and ulcerative processes are especially apt to be seen at these points. The entrance of the ducts of Skene's glands appears just as the instrument is about to escape from the urethra. Where infection of these glands is suspected, massage along their course may force a droplet of discharge into the urethra, from which it may be collected for examination by means of an applicator. Absolute asepsis is, of course, requisite in every step of the examination.