THE RELATION OF CERTAIN URINARY CONDITIONS TO GYNECOLOGICAL SURGERY.1 Early in my career as an operator I lost three patients from suppression of urine following operation. This experience called my attention forcibly to the relation which exists between the condition of the urinary organs and the successful or dis- astrous results of operation, and led me to give the subject care- ful and systematic study. It is my purpose to record in this paper the observations which have been made and the conclu- sions which have been reached in a study of some live hundred cases at the Kensington Hospital for Women. It will be con- venient to cover the subject by a discussion of several propo- sitions, the discussion being rather from the standpoint of the practitioner than from that of the pathologist. 1. Albuminuria is a Frequent Condition among Gynecologi- cal Patients.-It is my custom to have the urine of every pa- tient admitted to the hospital examined chemically and micro- scopically. When convenient the urine of patients requiring grave operations is examined repeatedly, and this is always done when the first examination proves unsatisfactory. The " heat and acetic acid " and the " ring " (nitric acid) tests have been used to determine the presence of albumin, being considered the best for clinical purposes. It has been found that ten per cent of the patients admitted have albuminuria. 2. Albuminuria often is not significant of Serious Disease.- In general medicine it has been learned that albuminuria is by no means necessarily of serious import. Frequently it is of a transient character, due to acute conditions from which the 1 Read before the Section on Gynecology and Abdominal Surgery of the Pan-American Medical Congress. 2 noble: the relation of certain urinary patient entirely recovers. This is even more frequently the case among gynecological patients. The urine, of women, intended for a chemical examination should always be drawn by catheter. Unless this is done the presence of albumin in the urine may mean only that a certain amount of vaginal discharge, or perhaps of menstrual discharge, has become mixed with the urine. In private practice, when a catheter is not available, the woman should at least be given a vaginal douche and have the external genitals washed before passing urine intended for examination. In this way fairly accurate results may be obtained. Eliminating such external sources of contamination, albuminuria in women may be, and often is, due simply to bladder irritation or to cystitis. Should a careful examination of the urine show the absence of tube casts and the presence of some albumin, pus, and bladder epi- thelium, especially if the specific gravity is 1.018 or more, it would indicate that the albuminuria was from bladder and not from renal disease. Albuminuria from ureteral disease and from pyelitis is not so very easy to determine, and it is to be hoped that the use of the ureteral catheter in the study of this question may help to make it clear. Albuminuria from the above sources does not unfavorably in- fluence the prognosis of operations. Albuminuria of renal origin is not always significant of seri- ous disease. At times it is not accompanied by the presence of tube casts in the urine and is of an intermittent character; in such cases being due probably not so much to the renal disease as to some interference in the metabolism of the nitrogenous food products. Several such cases have been under my care ; and quite recently I performed ovariotomy upon one in which large quantities of albumin would be present on one day, and the next day it would be entirely absent. The urine was other- wise normal. The urinary condition was not at all influenced by the operation. Repeated examinations of the urine in this case showed the absence of tube casts, and I believe that the kidneys are perfectly sound. Another class of cases in which albuminuria of renal origin is not significant of danger is that in which it is produced by the presence of large tumors. Here the presence of the albumin is due to the pressure of the tumor upon the renal vessels. CONDITIONS TO GYNECOLOGICAL SURGERY. 3 3. The Presence of Tube Casts in the Urine is not always significant.-In the case of large tumors, even the presence of tube casts in the urine does not signify that the patient will not recover from operation. In many such cases the condition of the kidneys is directly due to the pressure of the tumor, and when this is removed such patients often get surprisingly well and their kidneys become practically normal. But all gynecological cases requiring operation and having tube casts in the urine require, in my judgment, the most care- ful consideration. Repeated examinations of the urine to de- termine not only the presence and quantity of albumin, casts, and sugar, but also its specific gravity, the total amount of the urine passed, and the amount of urea and other solids it contains, are of the greatest importance. Should such examinations show the existence of gross structural disease of the kidneys and indi- cate the early death of the patient from the kidney disease, it is more than questionable in such cases whether it is wise to operate. The existence of chronic interstitial nephritis (contracted kid- neys) is a contra-indication to any operation of gravity. In such cases at times albumin is absent or only occasionally present, and then in very small quantities. Tube casts may be absent, or at least the most careful examinations may fail to reveal them. If repeated examinations of the urine show the occasional pre- sence of small quantities of albumin and of granular casts, and a low specific gravity, the surgeon should be on his guard. A w'oman having such kidneys will not survive a serious and pro- longed operation. She will die from shock or from suppression of the urine. I believe that the prognosis after operation is most favorable in women (the subjects of renal disease) having fairly large tu- mors, especially ovarian cysts. In this class of cases, in general, the operation is quick and easy, and no septic material is pre- sent. By the operation the pressure of the tumor is removed from the crippled kidneys, with the result that they secrete usu- ally more urine than normal kidneys. An illustrative case will be given. When kidney disease complicates a small tumor (or, in other words, when the kidney disease is not dependent on the presence of the tumor), the prognosis depends entirely upon the character and extent of the kidney disease. The factor of the removal of theintra-abdominal pressure does not come into play in such cases. 4 NOBLE : THE RELATION OF CERTAIN URINARY In cases of tubo-ovarian inflammation, especially of marked character in women whose health is entirely broken down, the prognosis is very bad when the renal disease is of a serious cha- racter. The reason why such cases do not do so well after operation as cases of large cysts is clear. The factor of the re- moval of the intra-abdominal pressure is absent here, and in addi- tion we have a long operation, involving considerable handling of the pelvic viscera and usually the escape of septic matter into the peritoneal cavity, necessitating irrigation and drainage. The long operation and the handling of the abdominal viscera promote shock, and such patients are apt to die from suppres- sion of urine. I speak from the experience of two deaths in this class of cases. Occasionally women will have suppression of urine after ope- ration even when no kidney disease exists. I have had one such case, in which the operation was very simple. 4. The Secretion of Urine is diminished, after Operation, for several Days.-This statement is a matter of universal observa- tion. I have had careful records kept of the amount of urine passed by patients after abdominal section in all my cases. These records are practically accurate. In the time at my dis- posal it was not possible to look through the entire list of cases, hence I have selected the last fifty consecutive celiotomies for tabulation. Dr. W. E. Parke, assistant in gynecology at the Kensington Hospital for Women, has kindly prepared this table for me. We find that the patients pass on an average ten ounces of urine the first day after abdominal section, fifteen ounces the second day, thirteen ounces the third day, fifteen ounces the fourth day, and nineteen the fifth day, after which time the amount gradually increases. There are certain sources of error in this table. The first day really includes only about eighteen hours, and is made up of that part of the day subse- quent to the hour of operation, and the following night. The other days are twenty-four hours each. On the third day, at times, the amount of urine is estimated, because upon that day the patient's bowels move. With the free purgation naturally the amount of urine secreted is less. The same source of error exists for the subsequent days. One patient died at the end of twenty-four hours-a slight source of error for the following days. The smallest amount of urine passed on the first day was three ounces, the largest amount thirty-three ounces. The smallest amount passed on the second day was six ounces, the largest amount twenty-nine and a half ounces. As illustrating what I have said with reference to the relation of the condition of the urine to operation, I will make brief reference to the following cases : Case 1 illustrates the fact that suppression of urine may fol- low celiotomy, even after simple operations, in women having sound kidneys. This patient had healthy kidneys, and the ope- ration consisted in removing the ovaries, the seat of chronic in- flammation ; yet on the third day she developed an acute ne- phritis, was extremely ill with uremic symptoms, but fortunately recovered. The history of Case 1 is appended. Case 2 illustrates the danger of death from suppression of urine, after even a simple celiotomy, in women suffering with well-marked chronic kidney disease. This woman had small, contracted kidneys and was a physical wreck at the time of ope- ration. The operation consisted in the quick removal of a small ovarian tumor and of a small parovarian tumor, the operation consuming only fifteen minutes. In this case the kidney dis- ease had antedated the presence of the tumor, and the vitality of the woman was so reduced that the shock from even so sim- ple an operation caused death from suppression of urine. Case 3 illustrates the favorable issue of operations for large ovarian cysts when albumin and casts are found in the urine as a result of the pressure of the tumor. This patient was a feeble and greatly emaciated woman, who consulted me when the ova- rian tumor was very large, quite nodulated, and very painful. The presence of albumin and granular casts in the urine, the nodular outline of the tumor, and the fact that it caused great pain (giving rise to a suspicion of malignancy) caused me to give a guarded prognosis as to the issue of the operation. The patient's conclusion was that, as I could not promise her posi- tively that she would recover from the operation, she would live as long as possible with the tumor and then have it out. She carried out this purpose literally, and it was not until her kid- neys were greatly crippled, and that she was suffering with paresis of the bowels and with orthopnea from the pressure of the growth, that she desired operation. The removal of the tu- mor was easily accomplished, and she made as good a recovery as any patient upon whom I have ever operated. Curiously, she passed very much more urine after her operation than is the CONDITIONS TO GYNECOLOGICAL SURGERY. 5 6 NOBLE : THE RELATION OF CERTAIN URINARY rule, the first day passing twenty-nine and a half ounces; the second day thirteen ounces which was measured, and very much more with bowel movements; the third day twenty-five and a half ounces, etc. The condition of the urine constantly im- proved, and at the present time, six months after operation, it is perfectly normal. Cases 4 and 5 illustrate the grave prognosis as to operations done for well-marked inflammatory conditions of the uterine appendages in women having serious chronic renal disease. Case 4 had small, contracted kidneys and was the subject of both gonorrhea and syphilis (tertiary). Her general health was fairly good. The operation consisted in the quick enucleation of dis- eased uterine appendages from a pelvis absolutely filled up with exudate. The duration of the operation was thirty-five min- utes. She went to bed in good condition, did well for two days, then developed uremic symptoms and died on the fifth day. Case 5 was perhaps the worst subject (from the standpoint of renal disease) for a serious operation in my experience. She had been an invalid for several years, had albuminuria due to large white kidneys, and was so debilitated at the time of the opera- tion that she had been confined to her bed for some weeks. This was one of my early operations, and I might here add that I should not operate at the present time upon such a patient for tubo-ovarian inflammatory conditions. The operation was ex- tremely difficult and lasted forty minutes. Upon the left side, in addition to the diseased tube, a small, intraligamentous ova- rian cyst, the size of an orange, was removed. When the tumor was enucleated from the broad ligament the ureter came up with it. This was separated and dropped back. It was ob- served to be very much thickened, and the supposition was that the woman had a surgical kidney, which proved to be the case. Suppression of urine followed the operation, and she died on the third day. Case 6 illustrates the fact that albuminuria, and even casts, in the urine, when due to acute inflammatory conditions of the pelvis (and personally I believe that cystitis and nephritis are often induced by suppuration connected with the uterine ap- pendages), are not a bar to a successful result after operations done for the removal of the diseased uterine appendages. Miss P., aged 19 years, contracted gonorrhea in December, 1892. She had a sharp attack of pelvic peritonitis in that month, a 7 CONDITIONS TO GYNECOLOGICAL SURGERY. second one in January, and a third one in March. In April and May she bled very freely from the womb, and when I saw her in consultation I found the bed elevated to prevent syncope. Examination showed a large, fixed mass to the right of the womb and a hard, doughy mass extending behind the womb and to the left of the pelvis. The history of the case and the physical conditions present suggested a diagnosis of ruptured extra-uterine pregnancy. It was recognized, however, that the conditions might be due to tubo-ovarian inflammatory disease. This patient's urine contained a large amount of albumin and some hyaline casts, but its specific gravity was 1.032. Opera- tion showed a suppurating right ovarian tumor and double pyo- salpinx. She made an uninterrupted recovery, passing sixteen ounces of urine the first day, fifteen ounces the second, sixteen the third, eighteen the fourth, etc. The condition of the urine is now normal. In conclusion I would emphasize especially the following points: 1. The importance of the systematic examination of the urine of gynecological patients, especially of those requiring celiotomy. 2. That the presence of albumin and of casts in the urine need not affect the issue of the operation. 3. That serious and prolonged celiotomies involving much handling of the abdominal viscera, in women having chronic Bright's disease (especially the small, contracted kidney), usually terminate fatally. 4. That the prognosis is best when the presence of albumin and casts in the urine is due to the pressure of an ovarian cyst which can be quickly removed. The histories of the following cases have been prepared by Dr. II. E. Applebach, assistant surgeon to the Kensington Hospital for Women : Case I.-Mrs. V., set. 30, Ilpara; one miscarriage ; menstru- ation regular; leucorrhea marked. History.-Health has been wrecked through child-bearing. Has had very grave vomiting each time when pregnant, and puerperal sepsis after each labor. Is extremely prostrated. Examination shows tender ovaries. Operation.-Abdominal section, January 29th, 1892. Re- moval of both uterine appendages. Duration, half an hour. No drainage. 8 noble: the relation of certain urinary Course.-Interrupted by acute nephritis on third day. Amount of urine passed : first day, thirteen ounces; second day, twelve and a half ounces; third day, sixteen ounces; fourth day, thirteen and a half ounces; fifth day, three-quarters of an ounce. She made a good recovery. Urine.-Examination prior to operation negative. The urine became normal within a month and has remained so. Case II.-Mrs. W., get. 40, Xllpara; five miscarriages; irre- gular ; leucorrhea very marked ; appetite poor; bowels costive ; urine 0. History.-Health has been bad eight years. Backaches; pain in abdomen, head; hemorrhoids. Bleeding from uterus quite marked on three occasions at intervals of six weeks. Repeated fainting attacks. Examination.-Masses in both ovarian regions. Operation.-Abdominal section, September 4th, 1890. Re- moval of uterine appendages. Ovarian cyst on right side, par- ovarian on left side. Duration, fifteen minutes. Drainage. Course.-Uremia set in on third day, resulting in death. Amount of urine passed: first day, twelve and a half ounces; second day, three and a half ounces during night (no report for day); third day, died. Urine.-Examination of urine proved negative before ope- ration. Autopsy.-Small, contracted kidneys. No peritonitis. Case III.-Mrs. A., get. 50, Opara ; no miscarriage; meno- pause at usual time; no leucorrhea; appetite poor ; bowels cos- tive ; urine scant, with albumin. History.-Has been unwell for past four years with distress- ing symptoms of stomach indigestion, etc. Enlargement of ab- domen noticed during past fourteen months, quite rapid the last six months. Marked loss of strength, and emaciation. Examination.-Large right ovarian cyst. Operation.-Abdominal section, February 4th, 1893. Remo- val of right appendage and tumor. Irrigation and drainage. Duration, forty-five minutes. Course.-Uninterrupted. Urine.-Repeated examination of the urine for two months prior to operation showed marked quantities of albumin, with few casts (hyaline) at different times, not uniformly present. The quantity averaged twenty ounces for twenty-four hours. Quantity of albumin not materially affected by treatment. On CONDITIONS TO GYNECOLOGICAL SURGERY. 9 day before operation amount of urine voided and by catheter was thirteen ounces; first day, twenty-nine and a half ounces; second day, thirteen ounces during night (frequent bowel move- ments prevented measuring of urine during day); third day, twenty-five and a half ounces; fourth day, twenty-five and a half ounces ; fifth day, twenty-eight ounces. The quantity of urine steadily increased after operation, with diminution of al- bumin. At the end of four weeks, quantity of urine norma], slight trace of albumin. Two examinations since discharge of patient show negative results. Case IV.-Mrs. M., set. 34, Opara ; no miscarriage ; menstru- ation too frequent (painful before period); cramps ; leucorrhea irregular. History.-Has abdominal distress, headache, backache. Had six or eight attacks of pelvic peritonitis. Had two attacks of gonorrhea from husband. Examination.-Tubo-ovarian masses on both sides. Operation.-Abdominal section, May 7th, 1890. Anesthetic, ether. Removal of uterine appendages; adhesion very dense ; enucleation difficult. Duration, thirty-five minutes. Irrigation and glass drainage. Course.-Gradual uremic intoxication, resulting-in death. Urine.-Examination of urine negative prior to operation. After operation, quantity of urine voided ranged from eight to eighteen ounces. Autopsy.-Small, contracted kidneys. No peritonitis. Case V.-Mrs. R., set. 29, Ipara; no miscarriage; menstrua- tion regular during first week, free, not much pain ; leucorrhea marked ; appetite poor ; bowels costive ; bladder irritable. History.-Has been an invalid for several years, marked pains in the head and womb alternating. Had inflammation of the bowels and ovaries for a year after her labor. Examination.-Uterus retroverted. Tubo-ovarian masses on both sides, especially on right side. Operation.-Abdominal section, March 7th, 1890. Removal of uterine appendages; adhesion very dense. Right ureter was attached to intraligamentous tumor, very much thickened ; was freed and dropped. Duration of operation, forty minutes. Irrigation and glass drainage. Anesthetic, chloroform. Course.-Suppression of urine followed operation after twen- ty-four hours ; on second day quantity by catheter and voiding, ten ounces ; on third day, one ounce by catheter; death third day. 10 NOBLE RELATION OF URINARY CONDITIONS TO GYNEC. SURGERY. Autopsy.-Right ureter and pelvis of right kidney dilated; large white kidneys. No peritonitis. Case VI.-Miss P., set. 19, Opara; menstruation regular un- til the past two months, metrorrhagia since ; very severe pain with last two periods; leucorrhea ; history of a well-marked at- tack of vaginitis in December, 1892. History.-She was a healthy girl until December, 1892, since which time she has had three severe attacks of peritonitis, and is at the present time confined to bed from pelvic soreness and from the effects of severe uterine hemorrhages. Examination.-Vagina relaxed. Womb enlarged, pushed for- ward, and fixed. External os quite patulous. A large, fixed mass can be felt upon the right side of the pelvis, which is palp- able above the superior strait. A doughy mass, continuous with the first, can be traced across the pelvis behind the womb. Urine.-Examination before operation showed albumin mark- ed ; hyaline casts; specific gravity 1.032. Operation.-Abdominal section, May 7th, 1892. Removal of uterine appendages and tumor of right ovary. Adhesions were universal, but friable. Time of operation, fifty minutes. Irri- gation and glass drainage. Course.-Marked shock when put to bed ; pulse 160. She rapidly improved and made an uninterrupted recovery. The amount of urine passed : first day, ten ounces ; second day, sixteen ounces; third day, fifteen ounces ; fourth day, sixteen ounces; fifth day, eighteen ounces. Three weeks after opera tion the urine is normal.