IS ALBUMINURIA t R I CONTRA-INDICATION -*§■ e Tn e - OVARIOTOMY? By REYNOLD W. WILCOX, M. D., Clinical Assistant at the Post-Graduate School of Medicine, Phy- sician to the North Eastern Dispensary, Nezc York City. Reprinted from the St. Louis Medical and Surgical Journal, Nov., 188JL ST. LOUIS: MEDICAL JOURNAL PUBLISHING COMPANY. 2622 Washington Avenue. 1884. Is Albuminuria a Contra-indication to Ovariotomy ? By Reynold W. Wilcox, A. M., M. D., Clinical Assistant at the Post-Graduate School of Medicine, Physician to the North Eastern Dispensary, New York City. Although much has been written on ovarian tumors and the methods employed in their removal, attention has been called to the tumor itself, so that many interesting and important concomi- tant processes have only been incidentally alluded to or have escaped observation altogether. As the science of medicine in the future is to be influenced and in some instances, indeed, to be made up from the clinical records of to-day, the smallest contri- bution will add its share. While the immediate derangements resulting from the presence of an ovarian tumor have been the subject matter for much thought, some of the more remote though none the less important ones have failed to receive their due share of attention. Renal complications, doubtless, have their weight in turning the scale of life, but as one searches the literature, some scattered allusions to theii' gravity, suggestive but not precise, a few un- supported opinions, rarely a positive statement, are all that one meets. While statistics are industriously collected to show that this or that method of treating the pedicle is the safest, labora- tory study and clinical research are invoked in behalf of that or the other method of dressing, but one finds only a few vague statements in regard to the presence of albumen or of casts in the urine of a patient suffering from an ovarian tumor. Five cases is a number far too small from which to draw any wide sweeping conclusions, but when out of fifteen consecutive cases of ovarian disease which underwent the operation of ovariotomy, during three months, five have at some period, albumen in the urine, 4 these cases, few though they are, yet suffice for making a sugges- tion that some one hereafter, under increased opportunities, may draw a definite conclusion. At first, though albuminuria seems to be a serious symptom, it suggests a complication that would shortly render useless all our endeavors to restore the patient to health, yet of those five cases one only succumbed, and that too almost immediately after the operation. Practically it hardly bears upon the question, as it was a case of carcinoma. Enquiries addressed to distinguished ovariotoinists have not resulted in data sufficient for any conclusion. Only a few habitu- ally examine the urine of patients upon whom they propose to do this important operation, some have never found albumen, or, having found it, have made no notes as to what significance is to be attached to its presence. Given a case complicated by albu- minuria, one surgeon would operate, others still would hesitate, believing it a grave symptom; another declines to operate upon a patient whose urine containes albumen. Albuminuria, other than that arising from renal complications, hardly bears upon the subject under discussion. The chronic cys- titis, the reaction, the association of the various forms of bladder epithelium and leucocytes in sufficient number to account for the amount of albumen, the absence of casts, all limit the lesion. Of the discharges from the vagina, the leucorrheal easily diagnostica- ted from the epithelium and leucocytes, the catamenial from the blood corpuscles, furnishing suitable explanation for the albu- men, do not call for further investigation. An acute attack of cystitis may temporarily obscure the previously purely renal albuminuria, but repeated examinations will determine the actual nature of it. Chronic cystitis is per se by no means a contra- indication to the operation of ovariotomy 1; only so far as it is associated with renal symptoms does it have weight. It is albuminuria in connection with renal changes that is most pertinent to the question of the expediency of operating in cases of ovarian tumor. This association and the usual per- sistence of the albuminuria shows clearly that there exists more than the so-called physiological form.2 Of the three prominent theories of the causation of albuminuria that is so ably advocated by Lecorchb, 3 the anatomical theory, though possessing perhaps some of the truth, does not so well explain the symptoms in this connection as the remaining ones. In an excellent paper by Ellis,4 on the significance of albuminuria as a symptom, there 5 is an allusion to abdominal tumors as having a causative influ- ence on the production of that symptom. The thought then sug- gests itself: is albuminuria, even accompanied by casts, a great contra-indication to the operation of ovariotomy, for may not the renal lesion disappear after the removal of the cause ? In reference to the mechanical theory of albuminuria, Roberts5 remarks, that passive congestion accompanies pres- sure on the inferior vena cava, giving as an instance abdominal tumor, an impediment to a slight degree giving merely a scanty dense urine depositing urates, with more marked hyperaemia we may have albumen, blood and even fibrinous casts. Further, if this congestion becomes persistent, we may have structural" chan- ges from the presence of blood corpuscles and fibrinous plugs in the delicate tubular structures; and the combined hypersemia must derange the nutrition of the glandular elements." On a following page 6 he seems to believe that this may subsequently result in the production of connective tissue and later, atrophy. The first stage of this process is identical with that produced in rabbits by Robinson7, subsequently confirmed by Frerichs8, on ligation of the renal vein. Further, Gros-Fillay 9 believes that the pressure exercised by the tumor upon the portal system or pelvic vessels, may even account for a generalized oedema. But this mechanical theory is not, as has been shown by Char- cot, 10 in accordance with the views of Runeberg 14, that lower- ing of the blood pressure favors the transudation of albumen, nor indeed with those of Litten,12 who, denying the influence of pres- sure, assigns to the slowing of the circulation an important influ- ence, such as would take place in the vaso-motor paralysis after a strychnia spasm. Of somewhat the same opinion is Jaccoud,1 3 although he assigns an impediment as well as a slowing to the circulation. The dyscratic theory as to the causation of albuminuria is certainly not new, Cotugta 14 assumed that nature by this mode removed pathological products. In recent literature, Charcot (loc. cit.) holding the principal cause to be the prolonged stay of the hardly oxygenized blood in the capillaries of the kidney, Gub- ler, 15 the hyperalbumenosis of the blood in comparison with the cellular elements and tqe demands made upon it, and at last Sem- mola 16 argues with force and eloquence that the pathological change is qualitative and not quantitative in its nature. Con- firmatory are the experiments of Stokois17, showing the differ- 6 ing results following the ingestion of egg and serum-albumen. It is not necessary here to recapitulate Semmola's arguments, but in the general malnutrition usually associated with large ovarian tumors, there seems to be no reason why the albumen having become incapable of performing its function, should not be elimi- nated and thus set up disease of the renal tissue. As yet, medical literature has not adopted the distinctions between the two classes of albumen, 18 that of the nephrites and that of the dyscrasias, proposed by Bouchard. As a conclusion, one may say that both mechanical and dyscrasic causes contribute to the initial stage of albuminuria, and that from these causes true anatomical lesion may be produced. z After the operation of ovariotomy the lesion may, still exis- ting, continue to render the urine albuminous and even casts may persist. Or the circulation taking place under changed mechani- cal conditions, albumen maybe found. Still, in those cases where albumen had not been remarked previous to the operation and it now appears, the cause may be the pyrexia. So also we may have from this cause, a slight catarrhal nephritis with epithelial and a few hyaline casts 19. The importance of the symptom of albuminuria is in point of view of the choice of the anaesthetic,-prognosis and the treat- ment. It has been for years a well established fact that the ad- ministration of an anaesthetic in diseased conditions of the kid- neys, notably of ether, has been followed by coma and death. The cases of Emmet, 20 Norris, 21 Hunt and Montgomery, 22 the renal lesion, verified post-mortem, are not suceptible of other ex- planation. The kidneys being active agents in the elimination of ether, can not perform their functions, the skin being inactive, coma and death result, so then the fact of the renal lesion being established, the safer anaesthetic, chloroform, is to be selected, that in subjecting the patient to a serious operation the surgeon may not knowingly diminish her chances for recovery. The prognosis of ovariotomy when complicated by renal dis- ease has been generally regarded as unfavorable, but as one looks over the literature he meets with but few decided statements, and those are at times in variance with the few records on this sub- ject which are accessible for study. Peasfte 23 although believ- ing an operation contra-indicated, a few pages later 24 seems to limit this contra-indication to acute renal disease. In an earlier opinion 25 he is even more decided in his prognosis, Wells 26 holds 7 substantially the same opinion; Vegas,27 Nonat 28 and Koeberl&,29 lay particular stress upon chronic renal disease and similar organic diseases profoundly affecting the system. Gros-Fillay 30 speaks much more emphatically against the operation, yet imme- diately follows with the statement that the presence of the tumor is sufficient to'account for the generalized cedema that one may meet. Emmet 31 speaks of the condition of the kidneys as " a most important matter in ovariotomy, for upon their even more than usual activity depends a favorable termination," again, " if ad- vanced organic disease exists, we must be prepared in all proba- bility for a fatal termination of the ovariotomy." On looking over the many tables of ovarian disease and the large number of isolated cases, one rarely finds anything mentioned concerning the examination of the urine, or if the case was fatal, regarding the condition of the kidneys, thus Lyman 32 in his compilation of three hundred cases, makes no allusion to renal complications, in Guy's Hospital fatal cases,33 eighty-eight in number, the kidneys were apparently not carefully examinedin a single case. On the other hand, among Thomas' 34 forty-nine fatal cases in one hun- dred and ninety-nine ovariotomies, one case of uraemic convul- sions is recorded, of Kimballs'34 sixty-five deaths in tw'o hundred and sixty-seven operations, two cases are assigned to nephritis ard two to renal haemorrhage. Still further in confirmation of this clinical evidence is Ds/ran, quoted by Thornton, 33 that advanced granular disease of tne kidneys is common with large abdominal tumors. In regard to the treatment of these cases, in addition to exer- cising care in the choice of an anaesthetic, the main reliance is to be placed upon the maintenance of the functions of the skin and kidneys. The preliminary baths and inunctions for the week previous to the operation, some increased action of the bowels, and in the case of scanty and concentrated urine, Wells36 adminis- ters lithia or a mixture of citrate of potash and lithia. Thorn- ton, 37 in a case recently reported, directed digitalis, citrate of potash with a cold-water pack of the upper extremities. The first case was that of a single woman, twenty-seven years old, who awoke one morning with great pain and inability to pass water. There existed no assignable cause for these symptoms. From that date these symptoms persisted, accompanied by an increase in the size of the abdomen. Six months later she began to have great dysmenorrhcea, on locomotion, pain in side. No 8 general symptoms, but the urine contained albumen and renal casts. After three months observation, the urine having in the meantime become normal, the operation of ovariotomy was per- formed. Both ovaries being diseased, were removed, the left one being the seat of a moderately large tumor, (twenty pounds). The operation was the usual one and was uncomplicated. A rise of temperature to 101. 2° F. followed the operation, but the urine was of good color, fourteen ounces in amount. On the second day twenty ounces of urine were drawn, clear, acid, no albumen, urea increased, the sediment consisting of a slight cloud of mucus, holding in suspension some mucous but no renal casts. The urine on the third day was twenty-two ounces, acid, albumen five per cent, by volume, great increase of urea, the sediment consisting of mucous coagula, with leucocytes, hyaline and finely granular, with few blood casts. The temperature had not varied but little from the first days record, but fell now to about 99. 5° F. The fourth day, urine was nineteen ounces in amount, the albumen in the same quantity, hyaline, finely granular, few blood and epi- thelial casts. Began to take milk and limewater by the mouth. On the fifth day the patient passed twenty-eight ounces of acid urine, containing a smaller amount of albumen - two or three per cent.-of the specific gravity of 1026, in the sediment of which were a few hyaline, finely granular and blood casts. On this day the patient began to take citrate of lithia and the liquor of the acetate of ammonia. On the sixth day the urine became alka- line, of specific gravity 1021, twenty-three ounces, containing eight to ten per cent, of albumen, large amount of pus, bacteria, triple phosphates obscuring the renal casts. On the seventh day the temperature, which for the two preceeding days had ranged above 100° F., became 99. 2° F. The urine passed was forty ounces, alkaline, of specific gravity 1022, containing five per cent, of albumen, phosphates, spores, bacteria bladder, round, epithelium, pus and a few blood cells. The eighth day, urine was the same in microscopical characters, but contained only a trace of albumen, twenty-nine ounces. For the next three days the urine changed but little, the diuretic being given in diminished doses. On the twelfth day the temperature arose to 102. 2° on account of a mural abscess, the urine daily improving. At the end of the third week the urine was of normal color and odor, acid, two to three per cent, of albumen, some pus, little blood, few finely granular casts. At the end of the seventh week the urine 9 became and continued perfectly normal and a perfect result was attained. The second case presents almost the same features, save those of cystitis. A single woman, twenty four years old, had noticed a slowly increasing enlargement of the abdomen for sixteen months; had been tapped twice. On account of the continual presence of albumen and casts in the urine, chloroform was cho- sen as the anaesthetic. The ovarian tumor showed advanced degenerative changes and was complicated by extensive adhesions. The next day's urine contained much albumen, solidifying by the heat test, great increase of urea, large numbers of hyaline and finely granular casts, temperature somewhat over 101° F., much nausea and vomiting. The third day showed an increase of albu- men, if possible, lower temperature (100° F.), but the same num- ber of casts. On the two following days the urine remained as before in quantity, twenty ounces, albumen much diminishing with a fewer number of casts. The urine, pulse and temperature steadily improved until the eleventh day, when a mural abscess appeared which caused a temporary rise of pulse and tempera- ture. The urine became again scanty,albuminous, but contained few casts, and much pus. At the end of a month the general symptoms were alleviated but there still remained some albumen with a few large granular casts. At the expiration of six weeks the patient was cured, as far as the tumor and the results of the operation were concerned. The urine contained no casts and but a small amount of albumen, which could nearly all be accounted for by the mucus present. > The third, case, that of a married woman, forty-seven years old, presented herself for the operation of ovariotomy. She had noticed an enlargement of the abdomen for five years. The ex- amination of the urine was negative as regards casts, although not decisively so, as no diuretic bad been given, specific gravity 1010, amount below the normal. There was found an indistinct aortic systolic murmur. Both ovaries were removed, the operation being uncomplicated. The urine was carefully examined daily for casts but none were found, although albumen was present. The tem- perature remained about 100° F. with a good pulse, on the fifth day urine was fifteen ounces in amount, alkaline, the sediment consisting of phosphates, mucus, bacteria and pus, but in quantity insufficient to account for the albumen. This continued for two •days, when the quantity and quality of the urine were improved 10 by washing out the bladder every six hours. The urine became norma], the albumen gradually disappearing until the recovery was pronounced complete at the end of five weeks. The fourth case believed her tumor to have existed four years. It had given her no inconvenience except from the extra weight. The examination of the urine was entirely negative. The tumor was a large one, fifty-five pounds. The second day's urine con- tained a moderate amount of albumen, with large and fine gran- ular casts, thirty-seven ounces in amount. Temperature 101°. F. and pulse 98 to 108. On the fifth day, the albumen gradually diminishing in amount, the casts being fewer in number, twenty- two ounces were passed. The patient's general condition im- proved rapidily. On the eighth day no casts could be detected,, but the urine was loaded with urates, the temperature and pulse remaining nearly constant. The urine became normal in every respect on the fourteenth day. In four weeks she was pronounced completely cured. Although both ovaries were removed she con- tinued to menstruate regularly for one year after the operation. The fifth case was one of carcinoma, in a married woman thirty-six years old, in poor general condition, duration of illness unknown. The urine contained a small amount of albumen, one tenth of one per cent., with many large and finely granular- casts as well as a few small granular ones. General symptoms of ovarian disease well marked. The operation was complicated by extensive adhesions and although chloroform was given as the anaesthetic, the respiration was shallow. There was much haem- orrhage and the operation was finished as speedily as possible. Death resulted shortly after the operation. The tumor was a cysto-carcinoma of the ovary of over twenty pounds weight, nearly one half being solid. These cases were treated on the same general plan, a mild cathartic and vaseline inunctions during the few-days previous to the operation, which was performed with the usual antiseptic precautions, afterwards nourishment, per rectum, of beef juice, to which was added a moderate amount of quinine and opium,, hypodermatic injections of morphine and stimulants as might be necessary. Liquid diet towards the end of the first week, the rise of temperature above 101° F. was controlled by the external application of dry cold to the abdomen and head. To recapitulate these cases briefly ; in the first on the second day the concentration of the urine rendered the detection of casts 11 somewhat difficult, although if albumen existed it must have been in small quantities, but on the next day the urine presented the same characteristics as before the operation with the addition of blood casts which may have been due to the exacerbation of the renal complication by the increased temperature. The attack of cystitis, which may have been in part caused by catheterization, obscured the casts, then followed normal urine with the restora- tion to health. The second case presents almost a typical case of rapidly improving renal symptoms. Here there could be no error, the symptoms aside from the results of urinary examination being confirmatory. The pus persisting after the final disappearance of the casts and accounting for the albumen present, can he ex- plained by local causes. In the third case, no casts were detected, but the accentuation of the heart sounds would lead us to infer that a more careful examination would have detected them. The quantity of the albumen appeared to be the same, when cystitis supervened, there was an excess not accounted for by the amount of pus present. Here also the albumen disappeared on recovery. The examination of the urine in the fourth case was negative, but the appearance of albumen with such a large number of large and finely granular casts, throws doubt upon the accuracy of the observation. The removal of such a large tumor, disturb- ing the established circulation, the weakness of the pulse, would not be satisfactory explanations of this phenomenal change in the character of the urine. Neither could it be assigned as a pyrexial albuminuria. This case also illustrates the gradual dis- appearance of the albumen and casts, the symptom of concentra- ted urine being the last to disappear. The last case is recited here for the sake of completeness, as the death was so soon after the completion of the operation and due to the general exhausted condition of the patient, that its testimony is no more against the operation of ovariotomy on a patient whose urine is albuminous, than would the death of a patient similarly exhausted, without renal complications, be an argument against ovariotomy. Here the condition was well recognized and chloroform was administered, unfortunately no post-mortem could be obtained. The results as obtained in these cases are by no means in ac- cordance with the views of different authorities cited in another 12 portion of this paper. The number of observations is too small to serve for more than an indication, but when one considers the different methods of origin of the albuminuria and that even casts can be accouhted for by the same explanations, it appears reasonable that the cause being removed, the renal symptoms may disappear, that it should not be cited as a contra-indication to the operation of ovariotomy any more than dyspnoea caused by thetumoi' as an argument for allowing the disease to progress to a fatal termination. In conclusion, then, it seems, a simple albuminuria should certainly not be considered as a contra-indication, since it may be caused by the presence of the tumor. Given even a paren- chymatous nephritis, this may be and probably is increased by the tumor and the surgeon should not on this ground deny the patient her only chance for life. In the light of what few statistics we have, and of the great number of cases, many of which must be complicated by renal disease that undergo the operation suc- cessfully, we have no reason to regard albuminuria as a weighty contra-indication. New York City, October, 1884. 1. Gallez, Hist, des Kystes de 1'ovaire, Brux. 1873, p 564 quoting LR- gois, Gaz. des hop. 1868, p. 538. 2. Cf. 'Leube, Virchow's Archiv. Bd. 72. Hft, 2. S. 145, et seq and Ger- hardt, Deutsches Archiv. f. Klin. Med. Bd. 5, S. 212. 3. Traite des maladies des reins. 4. Bost. Med. and Surg. Jour., Apr. 1880. 5. Urinary and Renal Diseases, Lond. 1876, p. 345. 6. Op. cit., p. 348. 7. Medico-Chir. Trans. 1843, p. 51. 8. Die Bright'sche Krankheit, 1851. 9. Traitmentdes Kystes de 1'ovaire, Paris, 1874, p. 86. 10. Lemons sur 1'albumenuria, Revue de medicine, 1881. 11. Arch. f. Heilkunde, 1877. xviii, S. I. fl. andDeutches Arch. f. Klin. Med. 1880, Hft. 3 u. 4, p. 221. 12. Centralbl. f. die med. wissensch. 1880, no. 9. S. 165. 13. Nouvean Diet, de Med. et Chir. prat., Paris, 1884, p. 522. 14. Dominici Cotunuii de Ischiade nervosa, Viennae, 1770. p. 28. 15. Diet. Encyc. les sciences m£d. 1865. 16. Gaz. d. Hop. Paris, 1867 p. 492, et L' Union m6d, June 1883, p. 1006. 17. Centralbl. f. d. med. wissensch, 1864, II. S. 596-8. 18. Le Gendre, L'Union m6d, Juillet. 1883, p. 25. 19. Wagner, Man. of general Pathology, Am. Ed. X. Y. 1879, p. 644 and Gerhardt, Deutsche^rchiv f. Klin. Med. 1868. Bd. V. S. 2. 2 u. Wie- ner Med. Presse, XV. Janrg. 1871. 1. 13 20. Prin. and Prac. of Gynaecology, Phila. 1880, p. 745. 21. Med. and Surg« Reporter, Phila. 1882, Vol. 46, p. 470. 22. Quoted by Tufbull in above report. 23. Ovarian Tumors, N. Y. 1872, p. 360. 24. Op. cit. p. 387. 25. Trans. N. Y. Acad, of Medicine, N. Y. 1865, p. 30. 26. Ovarian and Uterine Tumors, London, 1882, pp. 264 et seq. 27. L'Ovariotomie, Paris, 1869, p. 94. 28. Maladies de 1'uterus, Paris 1869 1.1, p. 866. 29. De 1'ovariotomie, Paris, 1865. 30. Op. cit. p. 86. 31. Op. cit. p. 829. 32. Mass. Med. Soc. Prize Essay. Boston, 1856. 33. Bryant, On Ovariotomy, Lond, 1867. 34. Bigelow, Am. Jour. Obstet, Vol. XV. Nos. 2 and 3,1882. 35. Med. Times and Gazette, London, 1882, P. I. p. 211. 36. Op. cit. p. 418. 37. Loc. cit. p. 211. Note.-For the urinary examinations and notes of the cases cited above, the writer is indebted to Dr. H. C. Coe. -*HTHE e SAINT t LOUISA- Medical & Surgical Journal. EsEahlishEd 1843. 96 Pages a Month, $3,00 Per Annum, in Advance, Editorial Department. LEGRAND ATWOOD, M. D., Editor. FRANK M. RUMBOLD, M. D., Publisher and Proprietor. Associate Editors : H. CHRISTOPHER, A. M., M. D., St. Joseph, Mo. WM. A. BYRD, M. D, Quincy, 111. A. E. PRINCE, M. D., Jacksonville, III Departments. Original Articles ; Translations from the French and German Journals, by Dr. S. Pollak of St. Louis. Department of Dermatology and Syphilis By A. II. 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