tumor of the urethra; it is, however, rare as a primary growth. It is seen most often as an epithelioma of the squamous celled type, originating, when primary, from the mucosa of the meatus, as a rule. The malignant character of the growth may be recog nized by its tendency to infiltrate, by superficial necrosis, and by the pain which accompanies it, though the parts are generally not very sensitive locally. As a general thing the gross appearance of the growth is such as to leave little doubt as to its nature. Carcinoma of the urethra is in our experience most commonly confused with syphilitic ulcerations. Differential diagnosis must rest on response to syphilitic treatment and on microscopic examination. Sarcoma of the urethra is very rare except in general or local sarcomatosis. Treatment. The treatment in malignant tumors of the urethra is early extirpation in all cases whenever this is possible. The incision should include as much of the surrounding tissues as practicable, and we strongly advise the application of the x-ray after the surgical removal of these growths. Care must be taken in the use of this agent, however, and it should not be employed about these delicate mucous membranes except in the hands of an expert. Innocent Tumors.--The most frequent innocent tumors of the female urethra are condylomata. They appear as more or less pediculated papillomatous masses, generally in groups and more or less symmetrically arranged, for they are autoinoculable. They probably bear a direct relationship to uncleanliness and in many instances are the result of venereal inoculation. They are ordinarily painless except in secondary inflammation; they grow rapidly, particularly under conditions of moisture and filth, and may develop to tumors of considerable size. The treatment consists in removal, and the surgeon should be particular to fully excise the base of the growth, and the wound should then be cauterized with strong silver nitrate solution. Urethral caruncles are tumors developing from the lips of the external meatus. They are deep purple in color, due to the large number of blood-vessels which enter into their structure. They may be either pediculated or sessile. They are covered over by a delicate reflection of the mucous membrane, bleed readily, and are exquisitely tender. They cause great distress, especially on urination or from chafing or pressure. They may further become intensely inflamed. Microscopically they are made up of a delicate connective-tissue stroma which supports a very abundant number of large, thin-walled blood-vessels. The tumors are probably inflammatory in origin; they do not recur on removal and never grow to be of large size. The treatment consists in removal, which must be done under efficient local or general anesthesia. In nearly all cases removal by the knife is to be greatly preferred to cauterization, both because the pain during and after the operation is less and also because the resulting scar after excision is much smaller and better placed than when removed by cautery. Polypoid fibroma are occasionally found attached to the urethral lips or projecting from the tissues immediately internal to the meatus. The mass of the tumors is made up of myxomatous or embryonal connective tissue and they are covered in by a reflection of the urethral mucosa. Blood-vessels are not numerous. The tumors may cause considerable obstruction of the urethra at times, but unless they become much inflamed they are generally painless. Treatment consists in removal by cutting them away at the pedicle or by twisting them off at this place. They do not recur. CHAPTER XXIV THE PENIS INJURIES OF THE PENIS Treatment. Generally speaking, injuries or wounds of the penis have a tendency to heal rapidly. It is not deemed necessary to enumerate here the various injuries or wounds of this organ that have been recorded from time to time. The organ may be completely or incompletely severed or portions of it may be torn away. When completely a severed, the ordinary surgical measures for arresting hemorrhage should be adopted and a good stump made. When incompletely severed, the aim should be to preserve the integrity of the urethra as much as possible by means of deep and superficial sutures, placing the organ on a splint, and establishing either perineal or suprapubic drainage and adopting such other measures as will give the injured organ a chance to heal. An astonishing amount of the outside skin may be torn away and repair still take place. If much of the skin surrounding the penis has been destroyed, autoplastic measures may be attempted. These may be divided into two classes: First, when a large portion of the skin has been lost and scrotal tissue can be used, and, second, when a large portion of the skin has been lost. Fig. 182.-Operation of Bessel-Hagen for the plastic repair of denudations of skin of the penis where a scrotal flap cannot be obtained. First step, bridge is taken from the abdominal wall and penis inserted through it (redrawn from Berger and Hartmann). and scrotal tissue cannot be used. When the skin on the inferior Fig. 183. The second step in the Bessel-Hagen operation. Eleven days after first operation the line ab and a' b' is cut through to recover the denuded penis. Then a flap L is made following on lines a a'c with which the denudation at the base of the penis is covered (Berger and Hartmann). surface of the penis, extending to the scrotum, is lost, the foreskin, if intact, may be split, and a portion of this may be used. Reich's method, shown in fig. 184, consists of making a bridge from the scrotal tissue. Twenty days afterward the bridge is freed by making an incision on each side. When possible, the skin from the scrotum is used. Bessel-Hagen's method is illustrated by figs. 182, 183. When skin from the scrotum is lacking, the penis is made to pass under a bridge cut from the belly. Fig. 184. Operation of Reich for the plastic repair of denudations of the skin of the penis by means of a bridge of scrotal tissue, a and a', b and 6' representing the upper and lower borders of the incision; lower, about 9 centimeters, slightly the longer. The flap having been freed, the surface of denuded shaft of the penis having been freshened is slipped through as though a ring and fastened with a few sutures through top and bottom to the flap. After about twenty days the ring is freed by incising line c b (redrawn from Berger and Hartmann). Eleven days after he cuts each side line, a b and a' b'. He uses the sides of the bridge and recovers with it the shaft of the penis; then he takes another flap and recovers with that, line a a' c, the base of the penis. Fracture of the organ may take place; this is in reality a fracture of the corpora cavernosa. The injury is accompanied by pain and sometimes by fainting; the organ becomes flaccid and enormously swollen. Occasionally this is complicated by a rupture of the urethra. As a rule the injury is followed by disturbance of the sexual functions, as after healing the posterior portion of the organ may become rigid at times, the anterior generally remaining flaccid. Probably the best treatment, if the case is seen early enough, is to cut down on the organ, remove any clots, and, by means of fine sutures, sew the fractured portions well together, applying splints, and preventing, so far as possible in the after-treatment, the formation of cicatricial tissue. GROWTHS AND UL- Saddle-shaped nod Fig. 185.-Epithelioma of the foreskin. (Natural size.) ules occasionally form Tumors of the organ, with the exception of carcinoma, are rare. Horny excrescences and cysts of varying size occasionally form, |