X CASE OF PAPILLOMATOUS URETHRITIS. BY F. M. BRIGGS, M.D. Reprinted from the Boston Medical an 1 Surgical Journal of October 24, r88g. BOSTON: DAM KELL & UPHAM, Publishers, 283 Washington Street 1889. e S. J. PARKHILL & CO., PRINTERS BOSTON A CASE OF PAPILLOMATOUS URETHRITIS. BY F. M. BRIGGS, M.D. The patient, male, age twenty-five, unmarried, con- sulted me in August, 1887, giving this history: He stated that every coitus was followed by a discharge from the urethra. This discharge was purulent and profuse, but was not accompanied by acute inflamma- tory symptoms. Injections of permanganate of -pot- ash always stopped it in a few days ; but if left un- treated, it went on indefinitely. At one time he had tried leaving it alone, but there being no improvement at the end of three weeks he had returned to injections and it was easily checked in a few days. There was never any thin, gleety discharge, and he had no trouble while he remained continent. He had had his first attack of gonorrhoea seven years before, and the condition above described had existed as nearly as he could remember, for about three years. He regarded himself as the possessor of a peculiar " gonorrhoeal diathesis," and looked upon each attack as a fresh infection. His father died of phthisis, but the patient himself was perfectly healthy aside from this trouble. He had a large meatus. Rectal examination showed a normal prostate. I examined for strictures with Otis' olive-pointed bougies but found nothing until No. 30 was reached, which showed a number of obstructions in the anterior urethra. The sensation to the hand was precisely that of urethral strictures. The bulb of 1 Read before the Boston Society for Medical Observation, April 1, 1889. 2 the instrument went smoothly for a short distance and became slightly engaged, -passed the obstruc- tion to again go over smooth mucous membrane, and was stopped as before. This was the condition for some four to four-and-one-half inches. I regret, in the light of subsequent events, that I did not make a care- ful endoscopic examination at that time. My diagnosis was strictures of large calibre, and I began to dilate. The passage of a sound always caused a good deal of bleeding and made it rather a troublesome case to handle, but I did not look upon the bleeding as of any clinical importance. The patient discontinued coming after a few visits and I saw no more of him until the following Novem- ber, when he again came, and wished to go through a thorough course of dilatation. He came regularly for two months. I could then pass a No. 40 sound without difficulty, and told him 1 had dilated all that I thought necessary. Although there was no discharge, I could not place this to the credit of the sounds ; for during treatment he had remained continent, and while con- tinent he had always been free from trouble. The treatment by sounds was not a success. About ten days later he came to me again as badly off as ever, having had intercourse two days before - in spite of the urgent advice I had given him to abstain from all indulgence and to lead a regular life for three months at the shortest. I thought it useless to attempt anything further with sounds, and saw no more of him until the fol- lowing July, (1888). He then reported that he had been in his usual condition since his last visit in Feb- ruary, but that once or twice the discharge had been streaked with fresh blood. He was sure this blood was in the discharge and not in the urine, nor were there any symptoms pointing to the bladder as its 3 source. I passed a No. 36 olive-pointed bougie. Its withdrawal was followed by bleeding, and upon the upper rounded surface of the bulb of the instrument, I noticed a small gelatinous mass, which a hasty examination under a low power showed to be a branch- ing growth. A later endoscopic examination showed that the mucous membrane of the urethra for nearly five inches was simply studded with similar growths of various sizes. The larger ones occurred singly, the smaller in groups, and in some places they were clustered to- gether, making a considerable mass and looking like the outside of a raspberry (Fig. 1). They were grayish-white in color, branching, and evidently vas- cular, for slight pressure with the end of the endo- scope caused bleeding. In short they were warty growths or condylomata, and their presence within the urethra accounted satisfactorily for all the symptoms. Fig. I. The growths as they appeared through a No. 34 endoscope. I found it very difficult to decide upon the best method of removing these growths, and could get but little assistance on the subject from the various author- ities on genito-urinary surgery. Griinfeldt,2 speaking of urethral polypi, advises their removal, through an endoscope, with a snare or with special endoscopic instruments of which he has « Endoscopie der Harnrohre und Blase, pp. 187-192. 4 three, namely, forceps, scissors, and a combined endo- scope and guillotine. But the growths which he de- scribes occurs either singly, or, at most there are two or three. His method of treatment would be efficient where a few isolated polypi are to be removed, but is useless where the urethra is the seat of such extensive distribution of growths as is the case in papillomatous urethritis. In the Annual of the Universal Medical Sciences 1888, vol. ii, pp. 212-13, E. L. Keyes gives a brief resume of an article by Oberlander of Dresden, and upon consulting the original3 1 found a most complete description of just such cases as the one in point. Oberlander writes at length on the subject and goes very thoroughly into all its details. He discards all methods of treatment other than the one which he originated, and which, as I understand it, is as follows : He uses cotton tampons. The cotton is twisted firmly on the ends of tampon holders. Having introduced an endoscope to the seat of the growths, he passes down two tampons one after the other, partially withdraws the endoscope and presses the two tampon holders well against each other. The penis is stretched out, and the tampons, by an up-and-down, slightly twisting, motion, ought to catch and pull off the growths. The tampons are withdrawn one after the other, and some papillomata will be found adhering to the cotton. Fresh cotton is re-introduced to the same spot to re- move the growths still there, and this is repeated at the various diseased points of the urethra, until as many growths as possible have been removed. One week later he examines again, and during this time many of the growths which were loosened by the tampons but were not removed, will have been carried out by the stream of urine. If any are left, he re- 3 Vierteljahresschrift fur Dermatologie und Syphilis, 1887, p. 1077, (4 Heft 2 Halfte.) 5 peats his operation (which he calls " tampon ecrase- ment") and, if necessary, does so a third time. In re- gard to these cotton tampons, I translate his directions for making them as follows :4 " In order to get a sure result, the tampons must have a definite size, and in- deed such, that in the movements among the condy- lomatous masses they take hold, that is, they can be passed through only with distinct pressure. They ought not to go through too easily or one removes too little; nor should they pass through with too much difficulty, for then one has not room enough in the urethra for two tampons going side by side." As regards after-treatment he says that if symptoms persist after all the growths are out, they are to be treated on the principles of treatment for chronic urethritis, by sounds or by topical applications. ' This is Oberlander's treatment and I decided to adopt it; but if not successful with the method, to scrape the urethra with a small curette. loperated on the 17th of August, 1888, Dr. G. W. Allen kindly assisting me. Tampon ecrasement was a total failure in my hands. My experience with it was, that where the tampons were small enough to be freely moved about they had no effect on the warts. When I got them large enough to exert pressure, they were moved with great difficulty ; so much so that I was afraid they would " bind " and tear the mucous membrane ; and, although I made a number of attempts, I was unable to strike a happy medium. I, therefore, determined to curette. My fear of this was haemorrhage. The tendency to bleed upon passing sounds had been so marked, even with the most gentle manipulation, that I was doubtful as to 4 Vierteljahresschrift fiir Dermatologie und Syphilis, 1887, p. 1096, (4 Heft 2 Halfte.) 6 the effect of scraping the urethra over the extent of surface that was necessary. But I could see no other rational method of treating the case, and thought that by scraping over a small surface first, and noting the result, I could decide as to whether further efforts in that direction were advisable or not. I introduced a small sharp curette through an en- doscope and scraped off an isolated growth. It came away easily and with only a trifling bleeding. I curetted farther without trouble of any kind. But I found that although the curette freed the growths from the walls of the urethra, it did not remove them from the canal ; they were left behind when the curette was drawn out. Here I found the cotton tampons of great service; for the growths which had been previously detached by the curette, and were lying loose in the urethral canal, adhered to the cot- ton and were easily drawn out. (One medium-sized absorbent cotton tampon on the end of an ordinary wire tampon-holder is better for the purpose than two small ones.) I worked in this way over the whole diseased area, going from before backwards, using first a curette and then a tampon, and clearing up about an inch of surface at a time. That is to say, I curetted about an inch of mucous membrane, removed the curette, and passing in a tampon, extracted the growths; then curetted another inch, and extracted with a fresh tampon, and continued this until I had reached the termination of the growths, a point about four and one-half inches from the meatus. When I had finished, the endoscope showed the mucous membrane to be highly congested, bleeding moderately, with here and there a growth left hang- ing. I did not try to remove these, but left them, trusting that they would come away in urination ; or 7 if they did not, to remove them at a future date. As it proved they did come away with the stream of urine. It is important to keep the penis well-stretched out while the curette is being used, for if this is not done a loose fold of mucous membrane can easily get caught between the edge of the endoscope and the curette, and a wound of the urethra follow. This curetting was done very gently, and in the fol- lowing way : An endoscope was inserted, and (after removing the obturator) was slowly withdrawn until some of the growths were in the field. The curette was then passed in through the endoscope to this point, and held there. The endoscope was partially drawn out leaving the curette among the vegetations. Then, after stretching the penis well out, and com- pressing it over the endoscope with one hand, with the other the curette was drawn lightly over all sides of the urethra for a short distance. I did not attempt to look through the endoscope while doing this. The mirror was used only in seeing that the curette was placed accurately. To remove each growth or collec- tion of growths separately, by means of a mirror, would be extremely tedious and difficult, and is wholly unnecessary. The operation was done with cocaine. T found about two drachms of a four per cent, solution suffi- cient to prevent pain ; giving it in divided injections (that is from time to time, as necessary), with a deep urethral syringe. Antisepsis was, of course, carefully attended to, and at the end a thorough irrigation was given with 1 to 5000 corrosive solution. Bleeding, of which 1 had been afraid, proved trifling and caused no trouble. The subsequent history was wholly satisfactory. I did not see the patient for a week, when he reported that there had been some oozing of blood for about 8 twelve hours after the operation. The penis was sore for several days, and micturition painful, which was not surprising; but there had been no retention of urine or other accident, and h'e had kept about his business without inconvenience. A sharp urethritis started up the day following operation, and was still active; but a few injections of permanganate of potash quickly checked the discharge. Two weeks later (three weeks after operation) I made an examination, and found the urethra wholly cleared up. It was slightly congested in places, but there were no growths and no discharge. The patient spoke particularly of a change in the character of the stream, which was much larger and came more freely than at any time since he could remember. It is now seven and a half months since I operated, and he reports that he has been completely free from his former trouble, - coitus being no longer followed by a urethritis. I have not been able to get another look through the endoscope; but, from the fact that for over seven months the symptoms of urethral irritation have com- pletely disappeared (and that, too, for the first time in eight years), I think it can be safely said that the growths have not recurred, and the case can be fairly regarded as a cure. To sum up briefly : The symptoms are those of chronic irritation of the urethra. But an accurate diagnosis cannot be made by the symptoms alone. An endoscope must be used and the urethra thoroughly inspected. The prognosis is good ; and, for treatment, the writer would recommend, as being both rapid and effective, the removal of the growths through an en- doscope with a curette and cotton tampons, in the manner described above. If after-treatment is neces- sary, injections of permanganate of potash for several 9 weeks. If this is not sufficient, then sounds or topical applications of nitrate of silver. There has been very little written on the subject, especially as regards treatment, which is certainly an important point. The symptoms are a constant source of annoyance and discomfort, which can be quickly relieved by a safe and simple operative meas- ure. Works on surgery, both general and genito- urinary, have little to say about it, and what they do say consists mainly in stating the fact that papillomata or condylomata sometimes occur within the urethra. Directions for removing them are either not given at all, or are not made sufficiently explicit. Oberliinder's admirable article, previously spoken of, is the only one which I have found giving a careful and accurate de- scription of the entire subject. Dr. J. T. Bowen has very kindly made sections of some of the pieces which were scraped out, and the accompanying draw- ing which he has made shows the microscopic appearance of a single tuft (Fig. 2). I think papilloma- tous urethritis must be an uncommon condi- tion ; but it may be found by a more gen- eral use of the endo- scope in cases of chronic inflammation of the urethra especially where of long-standing, that in some of these the symptoms are in reality due to the presence of papillomatous growths. Fig. 2. THE BOSTON Medical and Surgical Journal. A First-class Weekly Medical Newspaper. This Journal has now been published for more than sixty years as a weekly Journal under its present title. Such a record makes superfluous the elaborate prospec- tus and profuse advertisments as to enormous circulation, etc., etc., required by younger aspirants for professional and public confidence. It is, however, no less incumbent upon this Journal than upon others to assure its patrons from time to time, as the occasion arises, of its desire, its ability, and its determin- meet all the requirements of the most active medi- cal journalism of the day, without sacrificing any of that enviable reputation which is an inheritance from the past. It is under the editorial management of Dr. George B. Shattuck assisted by a large staff of competent coadjutors. Communications from all quarters of the country are ac- ceptable. Liberal arrangements are made for reprints of original articles, and for such illustrations as serve to in- crease their value or interest. The word " Boston " is retained in the title, as it was in the original name, but every occurenceof professional im- portance whether within or without the borders of New England, will receive prompt and impartial notice. The circulation is large and steadily increasing; the sub- scription-list covering almost every nook and corner of the United States and Canada, and extending to foieign coun- tries. All communications for the Editor, and all books for review, should be addressed to the Editor. Subscriptionsand advertisements received bv the under- signed, to whom remittances bv mail should be sent by money-order, draft, or registered letter. Terms $5.00 a year, or $2.50 a half year, in advance. DAMRELL & UPHAM, Publishers, BOSTON.