Prolapse of the Inverted Lower Portion of 
the Right Ureter through the Urethra 
in a Child Two Weeks Old. 
BY 
AUGUSTUS CAILLE, M. D., 
Visiting Physician to the German Hospital and to the German Dispensary 
{Department of Children's Diseases'), New York. 
FROM 
THF: AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
May, 1888. Extracted from the 
American Journal of the Medical Sciences for May, 1888. 
PROLAPSE OF THE INVERTED LOWER PORTION OF THE 
RIGHT URETER THROUGH THE URETHRA IN A 
CHILD TWO WEEKS OLD. 
Augustus Caille, M.D., 
VISITING PHYSICIAN TO THE GERMAN HOSPITAL AND TO THE GERMAN DISPENSARY 
(DEPARTMENT OF children's DISEASES), NEW YORK. 
The following interesting case came under my observation in the 
surgical department of the German Dispensary of the City of New York, 
in the service of Dr. Ernst Schottky, who courteously invited my par- 
ticipation in the observation and treatment of the same, and ultimately 
submitted its publication to me. 
Baby S., female, two weeks old, nursed by mother. Family history 
good. The mother states that her child had had diarrhoea since birth, 
on an average eight to ten evacuations daily, sometimes accompanied 
by tenesmus, but without a trace of blood. The passage of urine was 
not accompanied by any symptoms to attract attention. The child was 
often restless, and slept but little; the home remedies, to check the 
diarrhoea, administered by the mother proved ineffectual. 
On November 6, 1886, the infant appeared extremely restless and 
refused to take the breast. Toward evening a severe prolonged fit of 
crying left it exhausted and pale in its mother's lap. 
The next inspection of the child's genitals for diapering revealed the 
presence of a tumor or swelling protruding from the vulva, and in this 
condition it was presented at the Dispensary the following day. 
A preliminary examination revealed a soft, bluish-red tumor, pyri- 
form in shape, the size of a walnut, protruding from the vulva. 
Palpation of the protruding part gave the impression of a smoothly 
lined sac. Careful digital examination per rectum elicited nothing ab- 
normal. Traction on the swelling in an upward direction showed a 
very distinct introitus vagina. The hymen was absent and the vaginal 
canal large enough to admit of the introduction of the oiled index finger 
and palpation of the jwrtio vaginalis uteri. 
The tumor was located midway between the symphysis pubis and the 
introitus vaginae, and could be pressed well into the vagina, thus disap- 
pearing from sight, but remaining perfectly distinct to the touch and 
irreducible by pressure, the possibility of a diagnosis of prolapse of the 
anterior vaginal wall being thereby excluded. The urethral orifice was 
not in view, while its site was occupied by an annular tumefaction from 
the centre of which the pedicle of the tumor seemed to take its origin. 2 
CAILLE, PROLAPSE OF URETER. 
This condition, in view of several published cases of prolapse or in- 
version of the bladder, naturally led to the assumption that the case in 
question was of such a nature, viz., prolapse of the whole or a part of 
the bladder through the urethra. A close inspection of the tumor was 
made and a lateral opening in its right side was found, which admitted 
the passage of a probe. (See illustration.) 
Immediate reduction of the prolapse was decided upon. After thor- 
oughly disinfecting the genital region, the child was chloroformed and 
we succeeded without much difficulty in reducing the prolapsed part by 
means of a curved silver catheter, whereupon the enormously dilated 
urethral orifice came into view. The bladder was now washed with a 
disinfecting solution of potassium permanganate and the vagina packed 
with iodoform gauze to prevent a possible relapse, and the child was 
sent home with a warning to the mother to guard against overfeeding. 
Showing the anatomical relation of the parts. 
R. K. Right kidney. L. K. Left kidney. R. U. Right ureter (double). L. U. Left ureter. B. Bladder 
Ua. Urethra. P. Prolapsed right ureter. I. S. Inflammatory swelling (tumor). Ue. Urine. 
Nov. 8. The mother reports extreme restlessness of the child with no 
improvement in the character and frequency of stools, they being thin, 
yellow, and containing considerable mucus. The child also vomited 
after each nursing, which was probably due to the anaesthetic (chloro- 
form). 
The urine was reported to be clear and was passed in jets spouting in 
an anterior and posterior direction, the function of the sphincter vesicae 
being evidently unimpaired. Facies indicative of slight collapse. Ab- CAILLE, PROLAPSE OF URETER. 
3 
domen gave evidence of tympanites and tenderness on pressure. Tem- 
perature in rectum 102° F. (peritonitis). 
Inspection revealed the prolapsed part again protruding in its original 
form, its surface being darker and spotted with a grayish exudation. 
Severe crying and straining on the part of the little patient necessi- 
tated repetition of the narcosis (chloroform), causing considerable delay, 
and after removal of the vaginal tampon and application of iodoform to 
the prolapsed part, a second reduction was successfully managed. The 
vagina was again firmly packed to the introitus, and the parts anointed 
with iodoform vaseline. A cold compress was ordered to the abdomen. 
As nourishment barley-water, whiskey in water, occasionally the breast. 
Medication: bismuth and opium. 
9th. During the past twenty-four hours the child had rested quietly. 
Tympanites was less marked. Temperature 1012 ° F. Expression and 
general appearance better. No recurrence of prolapse. Urine clear 
and passed at regular intervals. One thin evacuation. Vaseline and 
iodoform reapplied, and the parent advised to continue the treatment of 
the day previous. 
lOf/i. The infant had two normal evacuations, took the breast readily, 
but passed cloudy and bad smelling urine, and appeared restless after 
each application of the cold compress. Temperature 10120 F. Tym- 
panites moderate, expression again denoting collapse. The prolapse 
was again visible and appeared discolored. Chloroform was again ad- 
ministered, the stage of relaxation setting in more rapidly than before, 
narcosis was deeper and lasted longer. The tampon was removed, and 
the vagina and bladder irrigated with potassium permanganate solution, 
fresh tampons were introduced, and continuance of previous treatment 
advised. Instead of the cold compress, warm, moist bandages were 
ordered over the abdomen. 
11th. Diarrhoea had again set in, amounting to seven greenish evacu- 
ations, with much tenesmus and restlessness. Urine no longer offensive, 
and general condition satisfactory. No prolapse visible. During exami- 
nation patient had a thin, yellow passage. The bladder was irrigated 
as usual, the fluid returning clear. Rigorous dietary restrictions, which 
had been left unobserved by the mother, were again insisted upon, and 
frequent doses of bismuth and opium advised, also local treatment by 
means of enemata of lukewarm water. 
12i/i. Diarrhoea same as on previous day. The orders as to strict diet 
had been again neglected. Prolapse not visible. Removal of tampons, 
irrigation of vagina and bladder, and reintroduction of fresh tampons 
were possible without narcosis. The mother's statement that the urine 
came clear and free from smell was corroborated by the spontaneous 
passage of urine during the above manipulations, but previous to this 
the urine washed out by the irrigation liquid appeared dirty and had 
an ammoniacal odor. Strict diet, nitrate of silver, opium, gum arabic, 
and whiskey were ordered for the next twenty-four hours. 
IB^A. Inspection revealing a recurrence of prolapse, the parts were 
now subjected to another careful examination, as a result of which we 
were enabled to come to the positive conclusion that it was not simply 
a vesical prolapse in toto we had to deal with, but presumably a prolapse 
of a part or diverticulum of the bladder, for the following reasons: 
(1) Careful manipulation resulted in the successful passage of a 4 
CAILLE PROLAPSE OF URETER. 
catheter between the tumor and the annular tumefaction surrounding 
its base (representing the urethral orifice) into the bladder beyond. 
(^2) It was also observed that straining efforts on the part of the child 
forced urine through the same passage from within outward. 
(3) Rotation and forward movement of the probe around the neck or 
pedicle of the tumor further enabled us to locate a right lateral insertion 
into the base of the bladder. 
IRA. The surface of the sac showed a slough in the immediate neigh- 
borhood of the opening before recognized, through which a probe when 
introduced descended to the same depth as when passed into the bladder 
proper. Furthermore, the opening revealed the existence of a small, 
hard tumor, about the size of a pea, within the'cavity of the prolapsed 
sac. The nature of this tumor we were unable to determine. Believing 
the prolapsed part to be a diverticulum, and having found it to be irre- 
ducible, we agreed to remove it. 
Bladder, diverticulum, and vagina were again irrigated with potassium 
permanganate solution. In the meantime tannic acid had been adminis- 
tered internally to check the diarrhoea, and as a result the child now had 
one or two normal evacuations daily. The temperature alternated, being 
at times normal, subnormal, or elevated, but never exceeding 102° F. 
The child urinated well, did not vomit, nursed fairly, but slept insuffi- 
ciently, and had become much emaciated. 
Two days previous to the operation the opening in the prolapsed sac 
was noticed to afford exit to a purulent, offensive discharge. A flow of 
urine was never seen to take place from the prolapsed portion. 
The sac was cut away on the twelfth day after presentation at the 
dispensary, under chloroform, which the child bore very badly. The 
diverticulum was put upon the stretch, thoroughly ligated, and as much 
as possible removed by scissors. The child died in twelve hours. 
Post-mortem Appearances.-Abdominal cavity: Stomach and intes- 
tines much inflated, but empty and not congested. Their removal exposed 
to view a bluish, fluctuating mass about the size of a hen's egg, representing 
the right kidney, also a mass similar in appearance but smaller, represent- 
ing the left kidney. Both ureters dilated. The right ureter was double, 
with double insertion into the hilus, both branches converging in their 
downward course, and terminating by a single opening in the bladder. 
The bladder was found empty, no hemorrhage having taken place. 
The point of insertion of the amputated sac was plainly visible and cor- 
responded to the site of the opening of the right ureter in the normal 
state. It appears, from the description, that the probe introduced into 
the supposed diverticulum must have entered the dilated right ureter. 
The right kidney had undergone cystic degeneration, and contained 
sero-purulent fluid. 
The prolapsed sac, which had been removed by operation, was continuous 
with the mucous lining of the right ureter, and was, in fact, a prolapse of 
the inverted lower third of the right ureter into the bladder and through the 
urethra. 
The whole urino-genital apparatus was removed for preservation and 
subsequent microscopic examination. 
At the time of the autopsy the microscopic appearance of the kidneys 
suggested sarcomatous degeneration. The tabulated appearance was 
noticeable in both kidneys, but more so in the left one. On section of CAILLE, PROLAPSE OF URETER. 
5 
the right kidney several cavities filled with pus were detected, the largest 
being the size of a cherry, the smallest the size of a pea. 
A section of the left kidney showed no abscesses, but marked thicken- 
ing of the cortical substance with pale red nodules interspersed, which, 
to the touch, proved to be harder than the surrounding portions. Pelvis 
of kidney wider than normal, otherwise unchanged. 
Sections for microscopic examination were made from the prolapsed 
mucosa of the right ureter and from the cortical and pyramidal parts of 
both kidneys. 
Right kidney: Inflammatory changes were most marked in the neigh- 
borhood of the abscesses, gradually fading toward portions little attacked. 
The epithelia of well-preserved lobules exhibited coarse granulation. In 
the intensely invaded portion only the tufts could be made out. When 
tufts and capsules were visible, the space between them was partly or 
completely filled with inflammatory corpuscles. A breaking down of 
capillary loops and interstitial tissue was well marked in numerous places. 
In some places remnants of both convoluted and straight tubules were 
recognizable by their epithelia, which were comparatively little altered. 
In many places, however, the epithelia appeared so broken that the 
whole tissue looked uniformly crowded with inflammatory corpuscles, 
and but faint traces of former tubular epithelia could be made out. In 
the pyramidal portion of the kidney only slight inflammatory changes 
were present. • 
Left kidney: In the left kidney the nodules above mentioned were 
the main objects of microscopical research, owing to the suspicion upon 
examination with the naked eye that possibly these nodules were of a 
sarcomatous nature. A careful analysis of their minute structure dis- 
proved this assumption. In fact, the nodules were of the same nature 
as the diffused infiltration of the right kidney, viz., interstitial nephritis 
tending toward suppuration, which had not yet taken place. The latter 
changes were most conspicuous in the epithelia of the narrow and loop- 
tubules, whose calibre appeared to be lost to a great extent. The inter- 
stitial connective tissue was infiltrated to a varying extent, and the 
capillary bloodvessels therein appeared rather compressed or destroyed. 
The general appearance was that of infiltration immediately preceding 
suppuration. The prolapsed part of the ureter showed at the site of the 
sloughed small tumor nothing but marked inflammatory infiltration of 
the mucosa and submucous connective tissue. 
In summing up, we may positively state that the pathological con- 
dition in both kidneys was strictly inflammatory. 
Remarks.-From a careful review of the foregoing account of this 
unique case it would appear that, owing to the formation of a warty or 
papillomatous small growth in the right ureter near its vesical insertion, 
a partial or complete occlusion of the ureter took place, in consequence 
of which the small tumor was pressed into the bladder, and finally 
through the urethra, carrying with it or dragging along the inverted 
lower third of the ureter, which presented in the form of the sac. The 
sac was supposed to be a diverticulum of the bladder, owing to the fact 
that at no time was it possible to insert a probe into the opening in this 
sac to a greater depth than when inserted at the side of the sac into the 6 
CAILLE, PROLAPSE OF URETER. 
bladder proper, and at no time was a discharge of urine noticed to take 
place from this sac. 
The inflammatory changes in the right, and those also in the left 
kidney, were probably due to infection taking place through the exposed 
and sloughed membrane. An explanation for the persistent diarrhoea 
is of minor importance, and is therefore not attempted. 
As far as our reading goes, a similar case has never been reported. THE MONTHLY PUBLICATION OF 
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