Diagnosis.—Ocular inspection of the meatus is never to be neglected when women complain of painful micturition, of frequent desire to uri nate, of pain on sitting, or of any irregularity in making water. Any tumors of the urethra, if present, will then be seen. Condylomata will be recognized by their painlessness, by their bluish-grey, caulifloWer surface, which does not bleed when touched, etc.; and usually analogous growths will be found in other portions of the vestibule to confirm the diagnosis. Fibromata and cysts are painless, have a smooth surface, and are elastic; varices are bluish and compressible, and usually very sensitive. Sarcomata and angiomata are excessively painful, of a brilliant red color, and char acteristic,ally bleed when toucheszl. They could only be mistaken for vaginismus if inspection or palpation of the parts has been imperfectly accomplished; for in that disease the hymen or its remains are usually so sensitive that the mere attempt to introduce the tinger causes severe spasm, while with urethral angioma an examination can be quite freely made if only the meatus be avoided. Only in cases where these tumors lie hidden within the canal can a mistake be made. In sensitive patients narcosis is required for the recognition of grorths in the upper part of the urethra; vaginal pressure will then usually cause the tumor to appear, or it may be dragged out with a pair of forceps. If this does not suffice to render the diagnosis clear, the urethra must be dilated, either with Espezel's instrument, shaped like an ear speculum, or with Simon's specula. There is some danger of confounding some of these tumors with prolapse of the urethral mucous membrane (see page 38); but it may be avoided by carefully noting the position and shape of the meatus, and by endeavor. ing to reposit the tumor, finding out whether it is sessile or not. Of course a tumor and a prolapse may coexist.
The want of proper ocular inspection often causes non-recognition of the malady upon the part of the physician; other trouble, or the radiating pains of so many uterine affections, may be supposed to explain the symp toms. A very exact examination of the affected part ought to render a mistake in diagnosis impossible.
Etiology.—The neoplasmata of the urethra occur at all ages. Eng lisch, Hennig, and I have found them in young children, and at birth. blettenheimer has seen them in a girl 6 years old, and Denuc6 in 4 girls from 7 to 13.ye,ars. West records one case under 20, 5 between 20 and 30, 6 between 30 and 40, 4 between 40 and 50, and 5 over 50; and I hare had one at 60, one at 70, and one at 92 years.
The small number of cases renders it impossible to say whether single or married women are more prone to them. Besides the above recorded cases of congenital urethral polypus, I have seen 20 cases of urethral neoplasm; all but one of these were in married women, and the one ex ception had had a child; 5 were sterile, and 5 had been 5 times confined. Scanzoni remarked that, as a general thing, other affections of the genital apparatus were present at the same time as these tumors; he found only 2 out of 13 cases in which this was not the fact, and I found it to be so in every one of mine. But Scanzoni went further. Since in almost every case there was some chronic catarrh of the urethral mucous membrane, he claimed that this catarrh was the etiological moment of the new growth& My experience is opposed to this. Velpeau also thought that syphilitic:,
(more correctly gonorrhceal) infection was their most frequent cause, and Schiitzenberger and Kiwisch agree with him. But Simon, Normann, Streubel, and I believe that as a rule (with the exception of course of the condylomata), the new growths are not the result of infection, and the mucoid flow from the urethra occurs simply in consequence of their pres ence. The same holds true of masturbation; it is just as likely to be an effect as a cause. (Englisch, Normann, against Mettenheimer.) There can hardly be any doubt that catarrh of the vagina may lead to urethral catarrh, and may thus be the cause of certain new growths. Nor is it difficult to understand that cohabitation, pregnancy, childbed, and the puerperal state, causing frequently, as they do, urethral lesions, are predisposing causes of these affections. This Richet has especially em phasized for venous angiomata. Both my cases of primary urethral car cinoma occurred in multipara3 (8 and 9 pregnancies respectively) aged thirty-six and fifty-eight years, and without any history of heredity. Winiwarther did uot find a single case of urethral affeetion among 258 cancerous viomen. In rarer cases tumors of the uterus, ovaries, and other pelvic organs cause these neoplasms by the active and passive hyper's!, mia they set up. Verneuil observed a case of uterine fibroid, and in the same category belongs the case that I have described. The patient was ninety-two years old, and had hi3ematometra senilis. Old, relaxed, and scrofulous individuals with phlebectasies of the genitals are predisposed to urethral tumors.
If gonorrhceal affections were really the moot important causes, men, who rarely suffer from these new growths, should have them very often. Virchow here cites Goulard, already mentioned by Morgagni, as his authority. More recently Plum found a vascular polyp in the male urethra.' In A. Martin's (Stechow) second case gonorrhcea was said to be the cause.
It is especially in regard to etiology that the above-mentioned case of Neudiirfer is of interest. There was hypertrophy of the clitoris and of its prepuce, and below that the five pyramidal projections from the ure thra. It is possible that the latter might be due to the permanent irrita tion caused by the former.
Hutchinson's published case of a polypoid papillary angioma in a woman of thirty-three, who belonged to a family of bleeders, is of interest here. There was undoubtedly in this case a hereditary predisposition; but nevertheless most new growths are due to local irritation. And we are by no means agreed as to which kind of irritation is the most frequent agent. The exact etiology is not very clear. Biegel claims that there are but few women who are not affected with one or other of the growths under consideration. I have not found them so frequently. Hyper trophy of the lower portion of the urethra is extremely common in women; but true tumors are not of everyday occurrence. In 2700 puerperal women, whom I carefully examined myself at the time of discharge, I found 493 or 18 per e,ent. with erosions, fissures, or cicatrices in the im mediate neighborhood of the urethra; but only 18 showed varices, pointed condylomata, or small polypi of the urethra. Prolapse of the urethral mucosa was present, however, in 10 per cent. of all cases.