The second case is shown in Fig. 15. In both cases a pavement epi thelioma had undoubtedly started from the urethral mucosa. In the second patient, who had urethral and vesical calculi, and soon died of urxmia, the pelvic connective tisssue contained no cancerous nodules; there was present a fistula urethro-vaginalis carcinomatosa as well as secondary carcinoma vesicie.
I have seen one case of lupus perforans vulvw, in which a hole was eaten through the right labium minus; and another in. which the disease ex tended from the base of the clitoris to the urethra, whose wall was much swollen and was filled with nodular thickenings and condyloma-hke growths of the mucous membrane. The latter case Inul obstinately with stood all manner of anti syphilitic treatment for years, and the urethra, was much dilated.
L. Mayer has seen destruction of the urethra from elephantiasis of the vulva. (L. c. case 9.) Symploms.—Many of the new growths that we have described may exist without causing a single symptom save a slight burning. This is apt to be the case with small condylomata, fibromata, retention cysts, and mucoid polypi. If they grow to any size, besides the pain caused by their traction, a disturbance in the excretion of urine is the first symptom that attracts attention. The patients feel an itching and burning in the urethra, together with frequent desire to micturate, and dysuria. The symptoms may become very marked. Simpson tells of a woman having a vascular tumor of the urethra, who, when she desired to urinate, used t,o leave the house, so that she could groan and cry out undisturbed. Ile also mentions the case of a girl sixteen years old, who retained her urine twelve hours so as to avoid the frightful pain. As the growths enlarge, the urethra is dilated, and its mucosa becomes irritated, hyperEe mic, and catarrhally inflamed. Thereupon follow erosions, fissures, and sores. The pains now radiate to hips, back, and thighs, even to the feet; they are increased by standing, by motion, and sometimes by menstruation. In spite of the urethral dilatation the stream of urine is often very small, or it may be forked; often the urine is tinged with blood.
If the tumors occur in little girls, the troublesome itching may drive them to masturbation. Reid says that varicosities of the urethra increase the sexual desire, though its satisfaction almost invariably causes pain. In fact the polypoid angiomata of the urethra usually render cohabitation impossible from their pain, since the slightest touch of the finger, and even that of the chemise, causes excessive pain, and leads to a spasmodic contraction of the sphincter cunei and levator ani, which renders ad rnissio penis impossible, and produces sterility' as certainly as does vagi.
nismus. Nevertheless such tumors have been found in pregnant women.
Later on the pains may be so gre,at as to lead to convulsive attacks, and to insomnia; while the catarrh and hemorrhage have a very deleterious influence upon the general condition. In consequence of the retention of urine, inflammation of the bladder and the ureters and kidney disease may ensue. This, though happily rare, has happened Pledoro, Barden hener.) The following complications deserve mention: uterine and vaginal catarrh, vaginal polypi (Macdonnell), polypi of the vestibule (Simpson), and calculi in the bladder and the urethra.
Besides the tendency to continuous growth, there is, especially in the angiomata, a great predisposition to a return. After extirpation these latter usually appear again in 1+ to 2 months. This has been observed by almost all authorities, even when the application of ferrum candens and energetic cauterization has followed the operation. (Biwisch, Medoro.) One symptom of the malady which I have had an opportunity to observe for years at a time, and which is not mentioned by any author that I know of, is the hypertesthesia3 vulvaa in the neighborhood of the tumor, which render sitting almost absolutely impossible to the patient. I had one case in which the tumor was repeatedly removed by me with the scissors, and followed by energetic cauterization with nitrate of silver. But the malady was occasioned by a myoma of the posterior uterine wall, dislocating the organ, so that it pressed upon the neck of the bladder; and it always grew again. This patient could not possibly sit on a chair in the ordinary way; she only sat upon one tuber ischii, and had been engaged for years in attempting to arrange a chair to fit herself. Finally she spent nearly the entire day either standing, or lying upon a sofa. She could not go into society, since she could only sit upon the edge of a chair for a few minutes at the most; and she always eat standing. Coitus was absolutely impossible; she was nearly sixty years old, and though married thirty years, still virgin. She could not on account of her ad vanced age make up her mind to undergo an application of ferrum eAndens under narcosis; and the only relief she could obtain was always gotten by cauterization of the flat tumor with nitmte of silver or the lapis mitigatus.