CLINICAL REPORTS.

VESICO - URETERO - PYELO - NEPHRITIS.

By Frederick Shimonek, M.D., Milwaukee.

C. W. Age 35; married; fireman by occupation.

*

Previous Condition.-General health good; no history of venereal disease. When ten years of age some inflammatory process developed in his penis, which finally led to the formation of an urinary fistula through the corpus spongiosum urethrae, about half an inch from the normal meatus; the normal meatus urinarius became obliterated.

The fistula was of such a diminutive size that during those twenty-five years he labored under a great disadvantage in voiding his urine. It required a considerable effort on the part of the accessory muscles to empty the bladder, so that residual urine was always present in large quantity. Micturition was very frequent, day and night, gradually increasing in frequency and difficulty; the quantity of urine also increased to over one hundred ounces.

Status Praesens.-Great constitutional disturbance; temperature, 104°; pulse, 90, regular and strong; anorexia: insomnia, tongue heavily coated; bowels constipated; frequent and very painful micturition. Complains of excessive pain in the right lumbar region; favors the right side when in the erect position by bending his body to that side so as to relieve the pressure upon the kidney; pain is of a steady, throbbing character; very large amount of pus and some blood in the urine. Sp. Gr. 1020; pus casts, no sugar. The presence of albumin is due to the pus and has no other significance. Examination revealed the right kidney palpable and extremely tender to touch, so that it was impossible to feel the outline very distinctly; but it appeared to be greatly enlarged.

Diagnosis.--The urethral obstruction was regarded as a predisposing cause, leading gradually to infection of the bladder, ureter, pelvis of the kidney and finally the kidney itself.

Treatment. First: Enlarging the unnatural meatus by slitting it open to adequate proportion.

Second: Nephrostomy, i. e., the establishment of thorough drainage of the kidney through the loin, in contra-distinction to nephrotomy -meaning the incision followed by immediate closure of the kidney. The loin incision was commenced at the point of meeting of the quadratus lumborum and the twelfth rib, and carried obliquely downward and forward about six inches toward the crest of the ilium; it was gradually deepened until the false capsule was reached, which was then torn through with the fingers. The kidney was carefully isolated, little by little, gently and gradually lifted from its bed into the lumbar wound and through the wound delivered to the lumbar surface. An incision was carried along its convexity from one pole to the other and down into its pelvis, which was then explored with the finger. The ureter was explored with a No. 4 English soft bougie, passed *Reported at the Milwaukee Medical Society, May 12, 1903.

through the incision and pelvis and found to be perfectly patent, thereby demonstrating that the future of the kidney was good and that a permanent lumbar urinary fistula would not exist.

Third: Silk-worm-gut sutures were passed through each edge of the kidney incision, the kidney gently replaced, and sutures passed through the edge of the muscles of the lumbar cut and lightly tied. It was feared that they might not hold on account of the excessive softness of the kidney tissue, but since it was very easily approximated to the abdominal wall, they were perfectly efficient. A large amount of very dark blood flowed from the kidney wound, which, however, was very easily controlled by gauze packing. The external wound was partly closed by silk-worm-gut sutures at each pole, so that the center corre sponded directly with the incision in the kidney, thus facilitating the repacking.

Pathology. The kidney was very large, soft, almost black, some adhesions were shown in shreds on the surface of its true capsule. No pus could be seen, but a hard nodule, which seemed to the touch as if it might be a stone, was found in the upper pole; this was simply an exudate, where in all probability an abscess would have developed in the near future. On closer inspection here and there small white lines could be seen in the parenchyma of the kidney; they were taken to be pus in the tubuli uriniferi.

Urine discharged freely through the lumbar incision; temperature and pulse slowly became normal, tongue clean and appetite good; pain in the right loin diminished until it completely vanished in the course of some weeks after convalescence: nutrition became painless and easy. The large quantity of urine voided before the operation persisted for several weeks. The large quantity of water the patient drank and the urinary irritation very probably explain the enormous excretion the high sp. gr. shows it not to have been merely a transudation, but due to an increase of the excretory function of both kidneys. This certainly was a most happy circumstance, for had it been the reverse, as is frequently found in such intense infection of the urinary organs, the addition of uremia to the infection must have been fatal.

Urotropin in 45 gr. doses daily to asepticize the urine, also considcrable quantities of sodic phosphate to increase its acidity and to drain. through the intestinal tube, were given, I think, with benefit.

The bladder was irrigated daily with a weak solution of salicylic acid, followed by permanganate of potassium.

The loin fistula closed in six weeks, and the patient returned to work several weeks later, fully restored to health.

REPORT OF TWO LAPAROTOMIES FOR THE REMOVAL OF
UTERINE TUMORS. *

By Arthur J. Puls, M.D., Milwaukee.

CASE I.

Mrs. Y, aged 35, mother of two children, nine and seven years, respectively, became aware of a gradual enlargement of her abdomen. *Presented at the Milwaukee Medical Society, May 12, 1903.

She is of short build, very stout, anemic, and weighs 180 pounds. Suspecting that the enlargement was not due to a natural increase of fat tissue, she submitted to an examination by her house physician, who diagnosticated an ovarian cyst in the abdominal cavity. A few days later the patient came to me for an examination, and I found a large, solid tumor, having the size of a fifth month pregnancy, extending high up in the abdominal cavity above the umbilical region, and freely movable. On placing the patient in the dorsal position the tumor presented itself plainly by its upper sharp contour; on palpation, on account of the resistance given by the tumor, I excluded pregnancy and felt assured that the mass was a monodular uterine fibroid. On bimanual examination it was evident that the tumor was within the uterine walls, since the entire growth moved freely with the cervix uteri. Both uterine appendages could not be outlined, hence an ovarian cyst was out of the question. The patient later consulted two other colleagues, who confirmed my diagnosis, and both advised an immediate operation.

In her history the patient repeatedly stated that she never felt better in her life, but concealed from me and her house physician the fact that several months previous to the first examination she had been troubled with swelling of the feet and ankles. At the time of my examination the heart was normal and the urine free from albumen. The presence of the tumor gave her no pain at any time, nor did it cause profuse menstrual flow or irregularity of the monthly periods; she was not troubled with leucorrhea. On looking over the specimen you will notice that the uterine cavity is twice its normal size and the uterine body likewise elongated. The tumor itself is situated in the posterior uterine wall and does not protrude into the cavity nor does the uterine mucous membrane show signs of atrophy at any one place. This condition offers sufficient explanation for the absence of both menorrhagia and uterine colic-oftentimes present in interstitial myomata.

Operation April 16, 1903. On opening the peritoneal cavity I was surprised at the thickness of the peritoneum, and still more so at the cystic degeneration of both ovaries, since these changes had taken place without causing distress or discomfort to the patient.

The operation itself was a difficult one owing to the shortness of the broad ligaments, and more so on account of the thick abdominal walls. However, the tumor was removed without much loss of blood and with no apparent shock to the patient. Convalescence was interrupted on the tenth day by an attack of pleurisy on the right side, which had subsided considerably on the sixteenth day. The temperature did not at any time exceed 102° and the pulse 110°. She never had a chill, and aside from pain in the chest the patient felt no discomfort. She was allowed to sit up on the twelfth day, and from then on daily, an hour at a time, and previous to this was propped up to prevent hypostasis of the lungs.

The dressing was removed on the sixth day and the wound found closed per priman with the exception of 5 c.m. at the upper end, in the

neighborhood of the umbilicus; this part was added to the wound in order to allow the extraction of the tumor.

While sitting in the chair Sunday morning at nine o'clock, May third, the sixteenth day after the operation, the patient, apparently in the best of spirits, desired to get up and lie down on the bed. During the attempt to get out of the chair alone she fell back suddenly and without uttering a cry stopped breathing. Efforts of resuscitation were of no avail.

An autopsy of the body was refused by the family, and I therefore signed "embolism" as the probable cause of the exitus, on the death certificate.

Osler in dealing with the subject of acute pleurisy (Principles and Practice of Medicine, 4th edition, page 671) says, "When one pleura is full and the heart is greatly dislocated, the condition, although in a majority of cases producing remarkably little disturbance, is not without risk. Sudden death may occur, and its possibility under these circumstances should always be considered. I have seen two instances one in right and the other in left-sided effusion-both due, apparently, to syncope following slight exertion, such as getting out of bed. In neither case, however, was the amount of fluid excessive. Weil, who has studied carefully this accident, concludes as follows: (1) That it may be due to thrombosis or embolism of the heart or pulmonary artery, edema of the opposite lung, or degeneration of the heart muscle; (2) such alleged causes as mechanical impediment to the circulation, owing to dislocation of the heart or twisting of the great vessels, require further investigation. Death may occur without any premonitory symptoms."

CASE II.

Mrs. H., aged 33, married 14 years, sterile, was operated on May 16, 1896, and an ovarian cyst having the size of a fetal head was removed, together with the adjacent right tube. The left uterine appendage was found adherent to the pelvic floor, and was freed and brought into view in order to correct the anatomic changes, and if possible to re-establish its functions.

The fimbriated ends of the tube were separated by blunt dissection, and the patency of the lumen of the tube established by introducing a probe down into the uterine cavity. The fimbria were spread over and sutured to the surface of the ovary and then both tube and ovary were replaced into the pelvic cavity.

The uterus was found normal in size and position, likewise the vermiform appendix.

The patient made an uneventful recovery and left the hospital in apparently good health, although she claims never to have been free from pains during the menstrual period which returned at regular intervals up to the present time.

Bimanual examination May 4, 1903, reveals the following conditions: The uterus is increased in size to that of an orange, nodulated and irregular in shape, freely movable and inclined to adopt the retroverted position. Within Douglas's pouch is found a mass firmly fixed

to the posterior uterine surface which corresponds in its outline to that of the left appendage.

Celiotomy performed May 12, 1903, disclosed a number of intestinal adhesions which were dissected from their attachments; the first from the bladder, the second from the anterior abdominal wall and another from the pelvic floor in the neighborhood of the appendix; the irregular and enlarged mass, which I had erroneously taken for a large uterine body at the previous examination, was found to consist of a pedunculated myoma arising from the posterior surface of the atrophied uterus. The left appendage was found fixed to the pelvic floor within the cul-de-sac and was easily separated from its adhesions.

Hysteromyomectomy and removal of the remaining appendage seemed to me to be indicated and was performed after Kelly's method.

An examination of the specimen shows another myoma, having the size of a bean, within the uterine walls anterior to the internal os. The uterine canal measures only 4 c.m. and the entire uterus 5 c.m. The tube is not enlarged and is still in the same condition as when it was sutured at the first operation. The ovary has undergone cystic degeneration and shows very little healthy tissue. A peculiar looking fibrous growth about 3 mm. in length presented itself on the anterior wall of the sigmoid flexure, and was also enucleated.

Dr. Theodore Hartwig, of Cedarburg, died Sept. 21st, 1903, aged 83 years. Dr. Hartwig had practiced at Cedarburg over fift years.

the father of Dr. Max Hartwig, of Port Washington.

He was

Dr. F. E. Darling has received the appointment of Registrar of Vital Statistics at Milwaukee, succeeding Dr. W. H. Bennett, who resigned recently to resume private practice at Oregon, Wis.

Dr. Henry B. Hitz, of Milwaukee, has been elected Professor of Rhinology and Laryngology at the Wisconsin College of Physicians and Surgeons.

The Wisconsin College of Physicians and Surgeons has purchased a lot adjoining the present property of the institution at the southeast corner of Fourth and Reservoir avenue. It is the intention to erect a building for the dental department of the college.