URETHRAL EXCRESCENCES, CARUNCLES OF THE URETHRA, VASCULAR TUMORS OF THE URETHRA.

BY J. H. WOODBURY, M.D.

AMONG the many and distressing ailments incident to middle and advanced female life, those in which dysuria and strangury are prominent form by no means an inconsiderable part, and few are more distressing. Many of these are due to irritation or sensitiveness of the urethra due to certain qualities of the urine, others to a hyperesthesia of the nervous filaments of the mucous membrane of the urethra in sympathy with and dependent upon the general hyper-sensitiveness of the entire nervous system, and especially of the sexual organs. This is especially noticeable about the period of the menopouse, or "turn of life"; indeed, it may be safely said that a majority of women suffer from dysuria at that time, and many most exquisitely. Most of these cases yield with tolerable promptness to homœopathic treatment, and there is no occasion to make any kind of physical examination, the sensations of the patient furnishing a sufficiently accurate guide in the selection of the remedy.

But occasionally we find a case which does not yield to treatment, and in which the sufferings of the patient are of the severest character, and when the lack of our usual success, if no other reason, leads us to make a more thorough examination. We call to our aid, in making our diagnosis, the assistance of our touch and sight. In many cases these will reveal to us as the chief cause of all this suffering, the existence of those little tumors whose appropriate names form the subject of this paper. They arise from the mucous membrane of the vulva immediately around the urethral orifice or meatus urinarius, or from the urethra itself. They are generally solitary, but occasionally there are several. Also they are usually sessile and look like a fold of mucous membrane, which renders them sometimes difficult to discover; occasionally, however, they are polypoid in their attachments, and may be found just slightly projecting from or hidden within the urethral orifice; when thus situated, they are intensely red, or even purple, and resem

ble a small, ripe cherry. They vary in size from that of a pinhead to that of a common red cherry, that of a small pea being perhaps about the average of the polypoid class of these neoplasms, while the sessile variety exists more as a hypertrophied fold of existing tissue than as a distinct formation, and therefore is more difficult to describe accurately as to its dimensions. They do not, as a rule, differ in color from the mucous membrane from which they arise, although, as above remarked, they are sometimes very red, almost scarlet, very soft, and easily broken. down. They are formed mostly of capillary blood-vessels and loops of nerves; they are a morbid development of existing tissues, instead of an independent growth of abnormal tissue. They give rise not only to the most excruciating symptoms locally, but also to the most remote general nervous affections as well as functional disturbances in all the organs with which the sexual organs are in nervous connection. The deep-red variety produces the most intense local suffering, while the paler ones produce the most general remote and obstinate complications. Within a few days I have seen one of the deep-red polypoid variety just depending from the urethral orifice, having its attachment within the urethral orifice. It was not larger than a very small pea, but it produced the most agonizing pain in urination, and severe tenesmus continuing for many minutes after the discharge of urine was completed. The slightest touch also caused the most intense pain.

The only proper and satisfactory method of diagnosing these tumors is the ocular one. The labia should be carefully separated while the patient is lying on her back, with the legs drawn up and in a strong light: these little tumors and great torments are then clearly revealed. They exist frequently in connection with and are the cause of one of the most distressing varieties of nervous irritation, that of the bladder and urethra. In bad cases the sufferings are simply horrible: there is not only the usual amount of heat, burning, pain, pressure, fulness, and weight, but also the constant tormenting desire to urinate every five or ten minutes or without ceasing for hours together. The patient feels as if the attempt to pass the urine must be repeated every minute, and persists in the attempt for half an hour, or

even longer, yet but a few drops are passed after the prolonged efforts and agonizing pains, simply because there is none in the bladder; but the moment that a few drops have accumulated, then this agonizing effort for its expulsion is repeated. These efforts are frequently accompanied by the most violent spasms of the urethra, bladder, vagina, rectum, and the levatores ani muscles, all aggravating the patient's sufferings to the highest degree. The patient cannot sleep, she cannot even lie down ; for the moment she does so the terrible demand to urinate is repeated. I saw a patient at Lawrence about a year since who had abandoned her bed altogether, saying that it was useless to lie down, as the moment she did so the irritation of the bladder and the irresistible desire to urinate compelled her at once to rise again. She therefore passed her entire nights in her chair, a victim to the most intense distress and suffering for almost the entire time.

As before remarked, the nervous centres are disordered in their functions, and we have nervous symptoms of almost every description. The mind is sometimes affected by it to irascibility, despondency, peevishness, and purposeless instability. Sometimes there is palpitation of the heart; headache, usually occipital but frequently in the vertex and temples, is common. The stomach is deranged to a considerable extent and in a variety of ways. Sometimes there is real dyspepsia, with pain and aversion to food. The bowels are almost universally constipated, in fact the cases are rare where this is not so, -a condition probably produced by the constant tenesmus or state of contraction into which the uterine walls are thrown by the reflex irritation from the urethral nerves. The treatment is in some cases very simple and the cure very prompt and satisfactory; in others it is very difficult and tedious. Of the first class are all those cases where no important constitutional disturbances exist, and where the tumors are polypoid. Here we have only to remove the tumor by snipping it off with the scissors, or, if large, cutting it through with the eccrascur, or destroying it with chromic acid, or even in some cases with the fluid extract of Thuja. The removal of the tumor in these cases is followed by a prompt disappearance of all the unpleas

ant symptoms from which the patient has suffered. Where the tumors are sessile in form, with broad bases involving the meatus and considerable portions of the surrounding tissue, they cannot be so readily removed. Here the best plan is to hook a tenaculum into the tumor, and having raised it as much as possible, carefully dissect away the abnormal tissue. The parts should then be kept dressed with liut, soaked in a solution of the fluid extract of Thuja, or what I have found in practice to be better, the Eucalyptus globulus. Indeed, in two most obstinate cases -the one at Lawrence above mentioned, and another in Allston Street in this city-I have been able to entirely cure the patients: perfect cures have been produced by the use of the Eucalyptus without a resort to any surgical measures whatever. A glycerole was prepared, and the parts kept constantly dressed with it, the patient remaining meanwhile in as near a recumbent position as possible, usually upon the ordinary reclining-chair. A few weeks faithful treatment greatly mitigated the intense pain from which the patient suffered and reduced in an equal degree both the bulk and sensitiveness of these tormenting little tumors. A strong decoction from the dried leaves of the Eucalyptus was made and this was mixed with an equal quantity of glycerine. With this, lint was saturated and kept constantly applied to the parts. Internally the same medicine was given in the first decimal attenuation. The case at Lawrence was treated by Dr. C. W. Scott, the one in Allston Street by myself. In two other cases this treatment could not be tolerated for a moment, the sensitiveness of the little tumors being so great that the contact of any foreign substance produced the most exquisite torture. The patients were therefore etherized, and the tumors removed by the knife or scissors. It is proper to state that all these cases had been under treatment for a long time for strangury, and one of them had suffered untold tortures at the hands of an eclectic physician in this city, by the repeated injection into the bladder of a strong decoction of hydrastin.

The hyperesthesia existing in these cases seems to be akin to, if not identical with that existing in cases of vaginismus, and as a general rule is almost as little amenable to medical treatment. In closing let me call your attention to the import

ance of a physical examination in all cases of dysuria or painful urination, for thereby you may be saved from the mortification of a mistaken diagnosis and a failure in treatment. It is but a few years since these little tumors have come to be recognized as distinct pathological products, but in that time more has been done to render their treatment accurate and efficient than ever before, thus showing that they are no exception to the general rule in medicine that in all curable diseases increased accuracy in diagnosis has always been followed by a corresponding accuracy and success in treatment.

ACUTE NEPHRITIS.

CALLED April 19, 1875, to see Mary E. G—, æt. 16, of dark complexion, medium size, stout frame; has menstruated regularly three times. She is the child of laboring people living in third story of a tenement house in Boston, and a dispensary patient. Has enjoyed good health since childhood until the last few weeks, during which time, as her mother expresses it, she has grown lazy and peevish; has had no exanthema for

years.

About three weeks ago a puffiness of eyelids and general swelling of the face were observed, which has since partially disappeared; she now complains of restlessness at night, dyspnoa, and general malaise, but is still able to be about and aid somewhat in the general housework; has no appetite for plain food, no abnormal thirst; looks pale and anæmic; mucous membrane of mouth and conjunctiva pale; lips nearly colorless. Sounds of heart and action of digestive organs normal, but the patient is nervous and irritable.

Examination shows hands, legs, and feet highly oedematous, abdomen much distended, and labia majora at least four times their natural size; could detect no effusion in thorax. Administered Arsenicum3 dec. trit., one powder daily, and took some of the urine for examination.

The urine is normal in quantity, of dirty appearance, brownish red color, and deposits a plentiful cloudy sediment. Boiling