g. But the most important of all urethral tumors are the so-called vas cular tumors or polypi, or papillary polypous angiomat,a. These are new growths that vary from a pea to a hazel nut in size, and form pale cherry or raspberry colored tumors at the orificium urethrie. Their surface is usually granular; they may be more or less pedunculated, and they bleed readily. G. Simon found them microscopically composed of vascular loops, which had proliferated among the papilhe and the connective tissue layers of the mucous membrane. Wedl also found enormously developed and tortuous vessels; he compared them to the vasa vorticosa of the choroidea, and designated them as dendritic papillary connective tissue new growths with thin-walled vessels. " They are related to telan giectases, inasmuch as a very large number of vessels enter into their com position. But they differ in that the vascular wall is not thickened, and is not usually ectatic. The surface of the growth is covered with pavement epithelium; the basis is a soft mucoid or connective-tissue. Glands are infrequent; occasionally they are dilated or cystic, with mucoid contents." (Virchow.) Not all tumors of this kind are covered with pavement epithelium; Verneuil found one covered by a thick layer of cylindrical epithelium. Medoro long ago noticed that they occasionally increased in size, and were to be included in the class of erectile tumors, and Scanzoni has observed this in one of them during menstruation.
As a rule but one tumor is present; but 2 or 3, or even more, have been found. Besides this there occur, though not so frequently as West con cludes, small similar excrescences in different parts of the vestibule. Simp son has given us an instructive drawing of such a case. West says that cases have been known in which almost the whole length of the urethra was the seat of these growths. These tumors being extremely sensitive, nerve fibres have been sought in them; but Verneuil found none, though Dr. John Reid, according to Simpson, for whom he examined one, found " very rich distribution of nervous filaments " in it. The most frequent seat of these neoplasms is near the orificium urethrEe externuni, on the posterior wall, a few lines from the entrance.
h. Lupoid and carcinomatous neoplasms are of extremely rare occurrence in the female urethra, and when they do occur, they have usually spread from the external genitals or the vagina. Rayan says that the meatus urinarius may be affected by cancerous and syphilitic disease. The de scriptions of urethral carcinoma in the female, which we find scattered in the literature' are such as to render doubtful the correctness of the diagnosis. Though affection of the bladder is extremely common in car cinoma uteri, Gusserow finding it 128 times in 311 cases; though fis tulle are frequent, being present 56 times in the above 311 cases; it is very rare for any portion of the urinary apparatus save the trigonum colli and the posterior bladder wall to be involved. It is evident enough that death is close at hand by the time that perforation of the bladder occurs; and carcinoma of the external genitals is itself too rare to be frequent cause of the appearance of urethral cancer. Schlesinger has recently
described a case of the latter kind, when a woman fifty-eight years old, who had long suffered from prolapsus uteri, had a long rounded tumor in the vulva 1 inch long, which extended from the root of the frwilulum clitoridis down to the meatus. The urethra was shorter than usual, and its entire posterior wall was enclosed in a chestnut-sized tumor, which Klob decided to be a pavement-epithelium cancroid.
More recently 5 cases of peri-urethral carcinoma have been published; 4 by Melchiori and 1 by Riberi in 1869. These observers found that peri urethral cancer in woman appeared as nodules in the vestibule near the urethra, and extended thence in the cellular tissue along the urethra, without, however, affecting the walls or the mucous membrane of the canal. Secondary ulceration of the meatus from extension of the growth, may however occur. The nodules are at first hard, painless, and non ulcerating; in fact it is only the occurrence of occasional lancinating pains that leads to their discovery. They are often not noticed until they have grown to a considerable size and have ulcerated. Finally the entire vestibule is occupied by the new growth. In the earlier stage the can cerous nodules do not extend downwards to the depth of more than half the length of the urethra, about an inch; in the second stage they reach the pelvic fascia and the neck of the bladder; in the third stage they extend over the symphysis and the rami descendentes pubis.
In Badenheuer's case the exulcerated tumor was the size of a hazel nut,.embraced the orificium urethrm, and extended through the urethra to the bladder. In 1877 Thomas removed by galvano-cautery a peduncu lated carcinoma of the urethra in a patient twenty-nine years old.
I myself chanced to see in July, 1878, in a single day, two very rare cases of primary urethral cancer, which I have described in my atlas. In the firsecase I extirpated the still isolated urethral tumor, and cured my patient. The growth removed was inches long, of an inch thick, and contained in its mass the urethra with an ulcerated mucous membrane. In one place near the meatus, the vaginal mucous membrane allowed a plain transition to the greyish-white, warty tumor mass. Solid plugs of pavement epithelium were divided from one another by bundles of mus cular fibres. Towards the urethra breaking down had begun; and at the free surface, turned towards the lumen of the urethra, a brownish granular pigment lay upon the degenerated c,ancroidal processes. The tumor was separated from the vaginal epithelium by the vaginal mucosa, which was normal save for the existence of a large number of leucocytes. Only in the neighborhood of the anterior portion of the urethra could any par ticipation of the vaginal epithelium in the growth be noticed. There its lower surface showed deep inter-papillary depressions, some forked; and many were only separated by a narrow btrip of connective tissue from the neighboring cancroidal processes. The patient was fifty-eight years old, and had been delivered naturally eight times.