Vascular Tumors of the Female Urethra With the Description of a Speculum Devised to Facilitate their Removal A. REEVES JACKSON, A. M., M. D. CHICAGO, ILL. REPRINT FROM VOLUME II CSjmecoloaical 1878 TRANSACTIONS OF The American Gynecological Society. VOL. 1., FOR THE YEAR 1876. 4.00 pages. Many illustrations. The Annual Address by the President, Dr. Fordyce Barker, of New York, and the following papers : I. Etiology of Uterine Flexures, with the proper mode of treatment indicated. By Thomas Addis Emmet, New York. 11. Cicatrices of the Cervix Uteri and Vagina. By Alexander J. C. Skene, M. D., New York. 111. Extirpation of the Functionally Active Ovaries for the Remedy of otherwise Incur- able Diseases. By Robert Battey, Rome, Ga. IV. On Central Rupture of the Perineum. By J. Matthews Duncan, M. D., Edinburgh, Scotland. V. Viburnum Prunifolium (Black Haw); its Uses in the Treatment of the Diseases of Women. By Edward W. Jenks, M. D., Detroit, Mich. VI. An Illustration of Xenomenia. By Theophilus Parvin, M. D., Indianapolis, In- diana. VII. Relations of Pregnancy to General Pathology. By Robert Barnes, M. D., Lon- don, Eng. VIII. The Spontaneous and Artificial Destruction and Expulsion of Fibrous Tumors of the Uterus. By W. H. Byford, Chicago, 111. IX. Case of Abdominal Pregnancy, treated by Laparotomy. By T. Gaillard Thomas, M. D., New York. X. Pneumatic Self-Replacement in Dislocations of the Gravid and Non-gravid Uterus. By Henry F. Campbell, M. D., Augusta, Ga. XL Hydrate of Chloral in Obstetrical Practice. By W. L. Richardson, M. D., Boston, Mass. XII. Labor Complicated with Uterine Fibroids and Placenta Previa. By James R. Chadwick, M. D., Boston, Mass. XIII. Latent Gonorrhea, with Regard to its Influence on Fertility in Women. By Emil Noeggerath, M. D., New York. XIV. Death from Urinemia in Certain Cases of Malignant Diseases of the Uterus. By Alfred Wiltshire, M. D., London, England. XV. Clinical Memoir on some of the Genital Lesions of Childbirth. By William Good- ell, M D., Philadelphia, Pa. XVI. Hermaphroditism. By Lawson Tail, F. R. C. S., Birmingham, England. XVII. Cases of Cystic Tumors of the Abdomen and Pelvis. By George H. Bixby, M. D., Boston, Mass. XVIII. Case of Solid Uterus Bipartitus; both ovaries removed for the relief of epileptic seizures ascribed to ovarian irritation. By E. Randolph Peaslee, M. D-, New York. XIX. The Origin and History of Calculi found in the Bladder after the Cure of Vesico- Vaginal Fistula by Operation. By Henry F. Campbell, Augusta, Ga. XX. Rare Forms of Umbilical Hernia in the Fetus. By James R. Chadwick, M. D., Boston, Mass. XXL In Memoriam Gustav Simon. By Paul F. Mundd, M. D., New York. Price of Volume 1., $5.00. As contributions to advanced gynecology they exceed in value anything which we have ever before seen collected in any one volume. —N. Y. Medical Record. This volume of Transactions is certainly superior to any book of the kind that has been issued by the American Press.— St. Louis Clinical Record. Now we have the first of, we hope, a long row of volumes which will bear comparison with the Transactions of European Societies. Indeed, these must look to their laurels in this noble emulation. Edinburg Medical Journal. This volume is one of the best collections of gynecological papers that has been published this year. —Annales de Gyntcologie. VOLUME 11. 650 pages, 12 chromo-lithographs and many other illustrations. Contains the following papers, with the discussions to which they gave rise : I. Annual Address, on Medical Gynecology. By the President, Dr. Fordyce Barker, of New York. 11. The Functions of the Anal Sphincters, so called. With two wood-cuts. By Dr James R. Chadwick, of Boston, Mass. 111. Excision of the Cervix Uteri; its Indications and Methods. With one wood-cut- By Dr. John Byrne, of Brooklyn, N. Y. IV. Report on the Corpus Luteum. With twelve chromo-lithographic plates. By Dr. John C. Dalton, of New York. V. The Pathology and Treatment of Puerperal Eclampsia. By Professor Otto Spiegel- berg, of Breslau, Prussia. VI. Dilatation of the Cervix Uteri for the Arrest of Uterine Hemorrhage. By Dr. George H. Lyman, of Boston. VII. The Principles of Gynecological Surgery applied to Obstetric Operations. By Dr. A. J. C. Skene, of Brooklyn, N. Y. VIII. On the Necessity of Caution in the Employment of Chloroform during Labor. By Dr. William T. Lusk, of New York. IX. The Present Status of the Intra-Uterine Stem in the Treatment of Flexions of the Uterus. By Dr. Ely Van de Warker, of Syracuse, N. Y. X. Supplement to the report of a case of Xenomenia made at the first Annual Meeting in 1876. By Dr. Theophilus Parvin, Indianapolis, Ind. XI. A Case of Vaginal Ovariotomy. By Dr. William Goodell, of Philadelphia, Penn. XII. Is there a Proper Field for Battey’s Operation? By Dr. Robert Battey, of Rome, Ga. XIII. Subsulphate of Iron as an Antiseptic in the Surgery of the Pelvis. By Dr. H P. C. Wilson, of Baltimore, Md. XIV. Tetanus after Ovariotomy. By Dr. Theophilus Parvin, of Indianapolis, Ind. XV. Sarcoma of the Ovaries. By Dr. Washington L. Atlee, of Philadelphia, Penn. XVI. The Value of Electrolysis in the Treatment of Ovarian Tumors, as seen in the Light of Recent Experience. By Dr. Paul F. Mundd, of New York. XVII. Congenital Absence and Accidental Atresia of the Vagina; Mode of Operation to Establish the Canal, and to Evacuate retained Menstrual Blood. With three wood- cuts. By Dr. Thomas Addis Emmet, of New York. XVIII. Case of Sarcoma of the Kidney in a negro child. With Heliotype. By Dr. W. H. Geddings, Aiken, S. C. XIX. The Hystero-Neuroses. By Dr. George J. Engelmann, of St. Louis, Mo. XX. Cases illustrating Important Points connected with Ovariotomy. By Dr. Gilman Kimball, of Lowell, Mass. XXI. The Radical Treatment of Dysmenorrhea and Sterility by Rapid Dilatation of the Canal of the Neck of the Uterus With one wood-cut. By Dr. Ellwood Wilson, of Phil- adelphia, Penn. XXII. Dr. Uvedale West’s Views of Rotation, as illustrated by the Contrast between the Mechanism of Simple Occiplto-Posterior Positions and those of the Bregmato-Coty- loid Variety. By Dr. John P. Reynolds, of Boston, Mass. XXIII. Vascular Tumors of the Female Urethra; with the Description of an Instru- ment devised to Facilitate their Removal. By Dr. A. Reeves Jackson, of Chicago, 111. XXIV. Lying-in Hospitals; especially those in New York. By Dr. Henry J. Gar- rigues, of Brooklyn, N. Y. XXV. The Simpler Varieties of Perineal Laceration; their Consequences and Treat- ment. By Dr. Thaddeus A. Reamy, of Cincinnati, Ohio. XXVI. The Cyclical Theory of Menstruation. By Dr. John Goodman, of Louisville, Ky. XXVII. In Memoriam Charles E. Buckingham. With a Heliotype Portrait. By Dr. George H. Lyman, of Boston, Mass. Index of Obstetric and Gynecological Literature of all Countries, from July i, 1876, to January 1, 1877. The price of Volume 11. is $6.50. The 2 volumes will be sent by mail or express, post-paid, for $lO.OO. Address, HOUGHTON, OSGOOD & CO., Boston. VASCULAR TUMORS OF THE FEMALE URETHRA: WITH THE DESCRIPTION OF A SPECULUM DEVISED TO FACILITATE THEIR REMOVAL. BY A. REEVES JACKSON, M. D., Chicago, 111. Sixty years ago Sir Charles Clarke, in his work on “ Dis- eases of Women,” called attention to a disease affecting the meatus urinarius of the female, characterized by the pres- ence of red elevated spots, or wart-like growths, exceed- ingly sensitive to the touch, and accompanied by dysuria, frequent micturition, and various other local and sympa- thetic symptoms. Prof. James Y. Simpson subsequently brought the disease into more prominent notice and named it “urethral caruncle.” Since that time it has,received the attention of almost every writer on gynecology, and, under the various names of vascular excrescence, caruncle of the urethra, vascular tumor, urethral polypus, etc., it is now a well-recognized disease. Its comparatively frequent oc- currence and its very distressing character justify all the consideration that has been bestowed upon it. It having been my lot to see a number of these cases, I have deemed it expedient to make brief mention of a few of them, especially those which seem to possess features of more than usual interest. It has been stated that these vascular growths are not supplied with nerves, and that the seat of their great sensi- tiveness is not any part of their own tissue but that portion of the mucous membrane to which they are attached, I feel convinced that this opinion is erroneous, for not only 2 VASCULAR TUMORS OF THE FEMALE URETHRA. has Dr. Reid 1 affirmed the existence in them of numerous nervous filaments, but I have on more than one occasion caused a patient to scream with pain by simply touching one of these growths in the most gentle manner with a camel’s hair brush, in such a way as not to influence at all the underlying membrane. The remarks I may have to make, and the cases intro- duced to illustrate them, will have reference to the disease only as it occurs within the urethra. Those cases in which it appears at the meatus, or in the parts externally adjacent, are much more easily diagnosticated and treated, although even in these localities it has sometimes, from lack of simple inspection, existed for a long period without recog- nition. There are no diseases that come within the province of the gynecologist that show more pointedly the necessity for thoroughness of physical investigation than do those of the female urethra. This arises from the fact that the subjec- tive symptoms present in these cases frequently do not lead to even the suspicion of disorder in that organ ; and, hence, nearly every writer upon the subject relates instances of grave blunders, both of omission and commission, on the part of himself and others. And, indeed, this is what we might naturally expect; for, as already stated, while these growths, for example, are readily discoverable when situated externally to the meatus, it is quite the reverse when they are confined to the interior of the urethra. In this latter local- ity they are very certain to be overlooked if, as is often the case, other neighboring organs, as the uterus, vagina, or rec- tum, present such abnormal conditions as may reasonably be supposed sufficient to account for all the symptoms. And blame should not be imputed to a physician who might deem it unnecessary to dilate the urethra, in order to inspect its in- terior in a case furnishing, as. prominent symptoms, frequent painful micturition, leucorrhea, and dysmenorrhea, he having found, on making a vaginal examination, an anteflexed or 1 Simpson, Diseases of Women, p. 276. A. REEVES JACKSON. 3 anteverted uterus with granular erosion of the os, because these conditions are fully adequate to the production of the symptoms named. But, if the dysuria should persist, in such a case, after the abnormities of the uterus had been remedied or removed, no one would be longer justified in delaying the examination of the urethra and bladder. The first case of urethral tumor which came under my notice nearly sixteen years ago —was of very instructive character in many respects. The patient was a woman forty-eight years of age, the mother of a large family of children. Her health had been unimpaired until about six months prior to the time of consultation. Her youngest child was seven years old and the result of her last preg- nancy. Menstruation had been irregular for the past two years both as to quantity of discharge and times of recur- rence, but presented no unusual features considering her time of life. Six months before, after exposure to inclement weather, she had observed an uncommonly frequent desire to urinate, with sharp pain attending the effort. These symptoms increased in severity, and to them were added the appearance of a mucous discharge, a feeling of heat and throbbing about the genitals, loss of appetite, headache, sleeplessness, and other evidences of deranged' nervous ac- tion. The physician to whom she first applied regarded the symptoms as due to the climacteric period, and prescribed various remedies for her without, however, any material bene- fit. I, too, prescribed for her in an aimless sort of way, for two or three weeks, when on one occasion she informed me casually that the stream of urine was sometimes suddenly stopped, the stoppage being attended by excruciating agony. This led me to think that she might be suffering from cal- culus, a suspicion which was strengthened by her telling me, further, that during the violent tenesmus accompanying the stoppage of the flow, and also at other times when void- ing the last drops of urine, she had noticed the escape from the urethra of a few drops of blood. These new features of the case induced me to make an examination of the blad- 4 VASCULAR TUMORS OF THE FEMALE URETHRA. der. The introduction of a sound into the meatus was im- mediately followed by a considerable discharge of blood, and the pain caused by the procedure was so unbearable that I was obliged to desist before reaching the bladder. On the following day the attempt was renewed under anesthesia. Again, so soon as the sound was passed into the urethra, a smart gush of blood appeared and the instru- ment encountered an obstruction which- was passed with some difficulty. No stone was detected and the sound was withdrawn. On separating the sides of the meatus with the blades of a dressing forceps, a florid granular mass could be seen fairly blocking up the urethral canal. Here was evidently the hitherto hidden source of the poor wom- an’s sufferings, and although unprovided with suitable in- struments for the purpose, I resolved to take advantage of the anesthetic condition of the patient and attempt its removal. Stretching the urethra open as widely as possible with a pair of forceps, I seized the growth with another pair and drew it down so as to bring it partly outside the meatus, and then proceeded to cut away all the visible part of it with scissors. Other portions were removed from the in- terior by tearing with the forceps until I succeeded, finally, in removing four-fifths, perhaps, of the entire growth. A good deal of bleeding attended the operation, but it had al- most ceased when I had finished. It was a very badly-per- formed piece of surgery, and only temporarily successful, for, although the patient was greatly relieved during the suc- ceeding few weeks, the tumor returned, and I was called upon again to remove it at the end of about three months. The second operation was more successful. After ether- izing the patient, I dilated the urethra by means of a bivalve ear-speculum and was able to bring the growth clearly into view. Commencing just within the meatus, it extended inwards about half an inch and projected about a quarter of an inch from the surface of the membrane. It had a sessile attachment. In structure it was so friable that I A. REEVES JACKSON. 5 was unable to elevate it or even to steady it with a tenacu- lum, the hold of the latter tearing out repeatedly, I there- fore seized it with a nasal-polypus forceps, and raising it up, cut smoothly through its base with scissors. The bleeding surface was freely mopped with a diluted solution of persulphate of iron, and a sigmoid catheter left in the bladder forty-eight hours. To the great delight of both the patient and myself, the distressing symptoms all ceased and the tumor never returned. The second case occurred in a woman twenty-two years old. She had been married four years, had one child two years of age, and had not been pregnant since its birth. For the past year menstruation had been regular as to time, but rather profuse. During the period of gestation she had suffered from both internal and external hem- orrhoids, and since her parturition had constant leucorrheal discharge. When pregnancy was about three months ad- vanced, and at times ever since, she suffered from irritable bladder, micturition being both frequent and painful. For a year past the vesical pain had become much more in- tense, was aggravated at the menstrual periods, and re- cently had become so excruciating that she would post- pone the act of urination until the bladder could be felt distended far above the pubes. Coition, too, had become so intolerable that it had not been attempted for several months. On making a digital examination of the vagina, I dis- covered that considerable pain was produced when even slight pressure was made against the urethra. The uterus was anteverted and somewhat flexed, and the vaginal por- tion large and congested. An attempt to replace the uterus by drawing the cervix forward and pressing the fundus backward at the same time through the hypogas- trium gave severe pain. The introduction of the specu- lum was likewise very painful, especially when the point of the instrument was passing the vaginal entrance. The in- terior of the vagina was of a deep-red color, as was also 6 VASCULAR TUMORS OF THE FEMALE URETHRA. the visible portion of the uterus. The os uteri was patu- lous and purplish, but free from erosion. As I withdrew the speculum I observed a small quantity of blood upon the instrument, and, on examining for its source, I dis- covered a drop at the meatus urinarius, caused, doubtless, by the pressure which had been made against the urethra, either by the finger or the speculum. On wiping away the blood, the edge of the meatus presented a red and swol- len appearance. Passing my finger again into the vagina and pressing it against the urethra drawing the fin- ger downwards at the same time several drops of blood were squeezed out of the passage, and the lower portion of a dark-red fleshy-looking mass came plainly into view. This was enough to establish the diagnosis, a diagnosis again made in an accidental manner. Within the next hour the patient was fully anesthetized with sulphuric ether and the tumor removed. Here, I di- lated the urethra with Molesworth’s instrument so that the finger could easily pass into the bladder. The growth, which was as large as a currant, was found to be attached to the side of the urethra by a pedicle the size of a crow- quill. I experienced no difficulty in reaching the latter, and cutting through it with a pair of blunt-pointed scis- sors. The stump was then seared with nitric acid applied on a piece of pine wood, which was held against the base for about one minute. The cure was perfect. In a few days the patient urinated without pain or inconvenience, and there was no return of the disease. The foregoing cases have served to put me on my guard, and now, as a rule, I never treat a patient more than a few days for frequent or painful micturition unsuccessfully with- out examining the urethra. A third case, presenting some features of interest, oc- curred in an unmarried woman, eighteen years of age, who was admitted to the Woman’s Hospital of the State of Illinois. She complained of burning pain while urinating, and had such an amount of uneasiness in walking as to A. REEVES JACKSON. 7 cause her to adopt, frequently, a straddling gait. Urination was not frequent, however, and her general health was un- impaired. An unusual degree of redness about the vulva was the only symptom revealed on examination. There was neither uterine, vaginal, nor rectal disease discoverable, nor was any pain or tenderness complained of during the investigation. As she had been over-working, rest in bed was enjoined, and cooling sedative applications were made to the vulva. Her symptoms not improving under the use of these means, she took, in addition, successively, copaiva, uva ursi, buchu, etc., with some degree of relief. But so soon as these rem- edies were suspended she suffered as greatly as before. On obtaining the foregoing history from the resident physician, I determined at once to explore the urethra and bladder. The patient, accordingly, having been placed fully under the influence of ether, the urethra was dilated and I dis- covered an outgrowth of granular scarlet appearance, about three fourths of an inch within the meatus, occupying, ap- parently, the entire upper part of the canal. Its attach- ment was by a broad base involving more than half the calibre of the urethra. It was removed, but the removal was attended by a good deal of difficulty, caused, chiefly, by the very fragile texture of the growth. The base was then thoroughly cauterized with nitric acid, and a suppository containing two grains opium and one fourth of a grain extract belladonna placed in the rectum. No subsequent treatment was necessary, and the patient left the hospital cured, at the end of a week. The remedy for this disease is complete removal; nothing short of this is effectual. This may be accomplished either by ligature, excision, or caustics. The ligature is now rarely used, from the fact that removal by this means is seldom thorough ; and even excision, whether performed by the knife or scissors, is far more likely to be certain when followed by efficient caustic applications. The latter alone 8 VASCULAR TUMORS OF THE FEMALE URETHRA. especially in the form of the galvanic cautery is an ad- mirable remedy in those cases in which the disease is read- ily accessible. But the expensiveness of the necessary apparatus must always be a bar to its general employment. And, besides, the use of this agent has no advantage what- ever over the method of removal by the scissors or knife with subsequent cauterization by nitric acid, in the manner which I will describe presently. Although I have spoken of this disease only as “tumor,” it must be borne in mind that it does not always take the form of an outgrowth, but is frequently seen as a flat or slightly elevated red patch. Indeed, this latter is, perhaps, the most frequent form of its existence within the urethra, for the opposing pressure of the walls of this canal has a tendency to repress excrescent growth. In such cases ex- cision is quite unnecessary ; the complete application of nitric acid alone being usually sufficient to insure a per- manent cure. There are two sources of annoyance in dealing with these tumors of the urethra. The one arises from the difficulty of inspecting the interior of the canal and bringing the ex- crescence fairly into view, and the other, from their loose structure, this being frequently so flimsy as to permit them to break down on the application of the least degree of force. In order to overcome both of these difficulties, I have devised a simple instrument which I have latterly found of the greatest service. It consists of a tapering glass tube, closed at one end, and provided with a flare or flange at the other end, and having a fenestrum on one side ; being similar to, although much smaller than a much-used form of rectal speculum. The instrument is made of glass sufficiently thick to insure against breaking while in use. It is two and a half inches long, and a half inch in outside diameter.1 With this spec- 1 I have found it convenient to have several of these specula of dif- ferent sizes, and with different sized fenestra, although the one de- scribed and figured will be suitable for most cases. A. REEVES JACKSON. 9 ulum not only may the most complete inspection of the urethra be made, but such tu- mors as those I have described will bulge up through the fenestrum, and may then be grasped and excised with the greatest ease and celerity. CODMAN & SHURTLEFF, BOSTON. Urethral Speculum (half-size). Likewise, its use affords the most perfect means of cauteriz- ing the base of the growth with nitric acid, or other means, without in the least endangering other portions of the ure- thral canal. This is highly important, for unless such appli- cation be made subsequent to excision, repullulation is almost certain to ensue. The part should not be simply touched with the caustic. This is not enough. A mass of cotton- wool, previously made thoroughly wet with water, should be squeezed between the fingers until it is merely damp. Then, holding it with a pair of dressing forceps, it should be dipped into fuming nitric acid and applied firmly against every part of the raw surface for at least one minute double the time would do no harm and then the superfluous acid may be neutralized by pouring into the speculum a solution of bicarbonate of soda. If the operation be done in this way, and so completely, there will be very slight prob- ability of a return of the disease. Bleeding will occasionally be rather profuse, but it is easily controlled. Usually, the application of the acid will suffice to check it. Where it seems necessary to do so, I have found it a good expedient to rotate the speculum suf- ficiently to remove the fenestrum of the instrument from its correspondence with the bleeding surface. The pressure against the bleeding part resulting from this change of position has always checked the hemorrhage in a few min- utes. Then, bringing the cut surface again into the field of the fenestrum, the acid may be applied as already directed.