Intrapelvic Kidney mistaken for Diseased Uterine Appendages. Abdominal Nephrectomy; Recovery. BY PAUL F. MUNDE, M. D., PROFESSOR OF GYNECOLOGY AT THE NEW YORK POLY- CLINIC J GYNECOLOGIST TO MOUNT SINAI HOSPITAL. REPRINTED FROM Qtye Neto ¥orfc jfRebfcal Journal for July 21, 1888. Reprinted from the New York Medical Journal for July £1, 1888. INTRAPELVIC KIDNEY MISTAKEN FOR DISEASED UTERINE APPENDAGES. ABDOMINAL NEPHRECTOMY; RECOVERY. By PAUL F. MUNDS, M. D., PROFESSOR OF GYNAECOLOGY AT THE NEW YORK POLYCLINIC ; GYNAECOLOGIST TO MOUNT SINAI HOSPITAL. Movable or floating kidneys are so frequently met with nowadays and so easily recognized, as a rule, that no one thinks of recording isolated cases. Landau, in his monograph on " Die Wanderniere bei Frauen" (Berlin, 1881), gives a list of forty-five cases seen by himself; Lindner (" Frauenarzt," July, August, September, October, 1887) bases his article on twenty-four personal cases; and I myself remember having encountered at least a dozen. They occur by far more fre- quently in women, as a result, as was formerly supposed, of the relaxation of the adipose attachments of the kidney by repeated pregnancies, assisted by some sudden strain. Lan- dau's observations seem to confirm this setiological relation. But Lindner denies that parturition has any special predis- posing influence on a dislocation of the kidney, since he has seen movable kidneys in nulliparous women of every condition of life and of ages from sixteen to forty years. He believes that the predisposition to dislocation of the organ is based on a congenitally loose attachment, to which is added 2 INTRAPELVIC KIDNEY MISTAKEN FOR a general malnutrition ; the exciting cause, then, lies in a sud- den violent strain or a succession of moderate downward pro- pulsions of the movable abdominal viscera (tight lacing, con- stipation, carrying heavy weights, etc.). In the majority of cases where sudden pain is felt in a certain part of the ab- domen after some violent exertion, and examination reveals a floating kidney at that spot, Lindner believes that the kidney was movable long before, but suddenly became for- cibly dislocated. In all the cases of movable kidney which I have seen and which I have found reported in detail the mobility of the organ varied from a few inches below its normal site as far down as the superior pelvic strait. But few in- stances are recorded where the kidney descended below the iliac fossa, and none where it was contained complete- ly within the pelvic cavity. When the organ is found floating about the brim of the pelvis it may easily be mis- taken for a small, solid ovarian tumor or a pediculated fibroid of the uterus, both of which in shape may resemble a kidney; or, if on the left side, the spleen may be thought of. If the tumor is larger than the normal kidney, the diagnosis may be still more obscure. A careful bimanual examination of the pelvic organs, eventually even the intro- duction of the whole hand into the rectum under anaesthe- sia, and the discovery in this manner of the uterus and ovaries in their normal positions, will, of course, at once eliminate those organs from consideration ; and the absence of the kidney from its normal position, as shown by bimanual palpation and percussion of the lumbar region, will aid in settling the diagnosis. The examination of the urine is of no avail as a diagnostic sign for floating kidney, since only in renal tumors (chiefly malignant) does bloody urine indi- cate disease of that organ, whether displaced or not. When, however, there is no suspicion whatever of dis- DISEASED UTERINE APPENDAGES. 3 placement of the kidney ; when the urine is normal; When pain dating from a certain period is complained of in one side of the pelvis; when bimanual examination reveals a distinct, oblong, slightly movable, very tender, elastic body in the pelvic cavity where the pain is complained of; when the normal ovary on that side can not be felt and the uterus is found to be slightly limited in mobility but otherwise normal in size and position; and when, moreover, this ob- long, sensitive, and slightly movable body in the sensation it imparts to the examining fingers corresponds exactly to an enlarged and adherent ovary and tube, the result of peri- oophoritis-then, I say, the presumptive diagnosis is cer- tainly in favor of the latter condition, and a failure to sus- pect or diagnosticate the intrapelvic tumor as a displaced, if not exactly floating, kidney may well be excused. Such a case is the one I now wish to report. So far as I have been able to ascertain from a careful search through literature, the case is unique as regards both the peculiar position of the kidney and the operative treatment: * S. P., twenty-one years of age, married, the mother of two children, the last fourteen months old, was admitted to my service in Mount Sinai Hospital on Tuesday, May 22, 1888, com- plaining of severe pain in the left ovarian region which, she stated, had come on after an accident (falling of her baby upon her) three weeks previously. On being questioned, she said that she had had a chill and fever at that time and been con- fined to her bed for some days. Menstruation normal; urine amber, acid, 1-020 specific gravity, negative. Bilateral exami- nation of her pelvic organs without anaesthesia (which was un- necessary, as the abdominal walls were lax and thorough palpa- tion was practicable) showed the uterus in normal position, its * The case most similar to it which I have been able to discover is that of Polk (" N. Y. Med. Journal," 1882), where the left kidney was attached to the ovary and was removed by an incision parallel to Pou- part's ligament. The kidney had not, therefore, descended to the pel- vic floor. Its mal-position was supposed to be congenital. 4 INTRAPELVIC KIDNEY MISTAKEN FOR lateral mobility slightly impaired, the right ovary not recogniz- able ; in the left side of the pelvic cavity, apparently touching the bottom of Douglas's pouch, there was an irregular ovoid, exquisitely sensitive tumor of about the size of a flattened orange, which was slightly movable in every direction, and which presented the characteristic feel of an enlarged ovary and tube bound together by adhesions. No attempt was made to push this body out of the pelvis, since no doubt was entertained of its nature. The diagnosis was verified by several other gen- tlemen who happened to be present. As I was about to leave town for several weeks, and as the patient complained of a great deal of pain, I suggested to her to have the offending organs removed at once, to which pro- posal she readily assented. Accordingly, on May 25th, in the presence of Dr. John A. Wyeth and one of the gentlemen attending the New York Polyclinic, and assisted by the house surgeon, Dr. Howard Lilienthal, and the other members of the surgical house staff, I opened the abdomen in the usual manner. My first step was to feel for the right ovary and tube, which I found normal. I then passed my fingers down to the tumor, which was quite difficult to reach, as it lay on the floor of the pelvis; at first it seemed to be completely adherent, and I could find no place to begin enucleation. I remember saying to Dr. Wyeth that it felt just as though it were entirely covered by peritonaeum. Still no suspicion occurred to me that the tumor might really be extraperitoneal, since my fingers failed to encounter the left ovary, and I had frequently met with ap- parently quite similarly adherent ovaries and tubes. Suddenly the adhesions seemed to give way about the center of the tumor, my fingers slipped into a small furrow, and the enucleation of the mass w'as rapidly accomplished. Finding some difficulty in lifting the slippery tumor through the incision, I grasped it with flat forceps, which tore out, and quite a flow of dark blood took place. During these manipulations I remarked that I had never before had to handle so peculiarly feeling a mass in that locality. Finally I succeeded in drawing the tumor out of the incision, and a glance revealed its character. It was the left kidney in a high state of venous engorgement. DISEASED UTERINE APPENDAGES. 5 I need not describe my surprise and almost, I may say, con- sternation. If the capsule had been intact, I should have at once returned the organ to its bed ; but I had peeled the cap- sule as smoothly from the kidney as it could be done on the dissecting table. There was nothing to be done but to remove the organ. Still I employed the precaution to feel for the right kidney, which I thought I felt in its normal position. I at first laid an elastic ligature around the pedicle to stop the profuse venous oozing from the forceps bruise; and then I transfixed and tied off the pedicle with silk, using the Staffordshire knot, cut off the pedicle without searing it, and, having satisfied my- self that no vessels required separate ligatures, dropped it back and laid the folds of peritonaeum over it. I then looked for the left ovary and at first could not feel it. At last I detected a small, fiat body, bound down by adhesions to the posterior leaf of the broad ligament, and so covered as to be almost indistin- guishable. The patient thus had been through an attack of peri- oophoritis, as her history led us to surmise, and the limited mo- bility of the uterus was thereby explained. I decided to leave the left ovary, as I was afraid the manipulation and traction re- quired to detach it and ligate the pedicle might do some injury to the stump of the kidney. The abdominal cavity was then carefully cleansed of coagula by sponging and flushing with warm Thiersch's solution, and the wound closed with silkworm-gut sutures. The operation had lasted about forty minutes, consid- erable time having been devoted to a careful toilet of the peri- toneal cavity. The patient came well out of the anaesthesia, which was by chloroform. Directions were given to draw the urine and measure its amount each time, also to examine it chemically and microscopically daily. The condition of the patient for the first three days was that of depression or shock; the morale was bad; the pulse was small and high, usually 120, temperature 100° F.+ , and respira- tion 28. There was some vomiting and she was nourished per rectum, chiefly with Rudisch's sarco-peptones. Immediately after the operation she was catheterized and 2| ounces of urine were removed. Six hours later, 6 ounces were withdrawn. On the 6 INTRAPELVIC KIDNEY MISTAKEN FOR second day, at intervals of six hours, 4, 5, and 4| ounces, re- spectively, were withdrawn; five hours later, 4 ounces of urine were passed voluntarily-in all, ounces in the twenty- four hours. Urine acid, 1'026 specific gravity; reddish de- posit ; albumin, 3 per cent.; a few pus cells, abundant urates, no casts. Treatment, caffeine, brandy, seltzer-water, and milk. May 27th.-Temperature 99° to 100'8°, pulse 122 to 128, respiration 20 to 24. Passed 18 ounces of urine voluntarily. Kumyss, sarco-peptones, brandy and eggs in enemata. 28th.-Passed 24| ounces of urine; one stool. 29th.-Twenty-five ounces and a half of urine. 30th.-Nineteen ounces and a half. 31st.-Nineteen ounces. Chicken-soup and crackers; pulse 96, temperature 99° to 100'8°, respiration 22. The temperature and pulse gradually became entirely nor- mal ; the amount of urine voided increased to 31| ounces on June 4th; bowels regular. Urine practically normal; no casts. June 5th.- Stitches removed and patient moved from the private laparotomy-room into the general ward. Further re- covery uninterrupted. 15th.-No pain and gaining flesh ; out of bed. The weight of the kidney after five weeks' preservation in 50-per-cent. alco- hol is 3 ounces 5 drachms. A microscopical examination showed nothing abnormal. July 6th.-A vaginal and bimanual examination revealed nothing abnormal. Patient discharged well. The case after the third day passed under the care of my friend, Dr. B. Scharlau, who kindly acted as my substitute during my two weeks' ab- sence from the city, and to his efficient supervision and the unremitting attention of Dr. Lilienthal I think the rally from the deep shock must be largely attributed. Whether the left kidney actually slipped down into the pelvis at the time the patient complained of the severe pain in the left side, three weeks before admission, or whether it had gradually descended and for some reason only began to DISEASED UTERINE APPENDAGES. 7 be troublesome at the time mentioned, it is impossible to say. Indeed, the history and the condition of the left broad ligament and ovary render it more than probable that the pain complained of three weeks before, attended by a chill and fever, was due to a localized pelvic peritonitis, and that the presence of the kidney in the pelvis was an entirely acci- dental complication. At first sight it would seem certain that the descent of the kidney must have taken place after the birth of the second child, fourteen months ago, since it is hardly probable that so delicate an organ as the kidney could have endured without speedy reaction the injury in- evitably inflicted on it in its abnormal position by the child's head in its passage through the pelvic canal. An acute nephritis would more than probably have rapidly fol- lowed the confinement. For this reason I at first rejected the otherwise plausible idea that the malposition was con- genital. But a curious fact has led me to reconsider this decision-namely, after the woman's recovery, one of her children, a boy of three years, was brought into the hospital with cholera infantum, and died, and at the post-mortem his left kidney was found displaced to the brim of the pelvis, although not so low as that of his mother. The hereditary tendency to floating kidney, therefore, seems not improba- ble. But we are not so much concerned here with the questions when and how the kidney got into the pelvic cav- ity as with the uncommon and unexpected fact of its being there without exciting the least suspicion as to its true char- acter. The question, therefore, is one of diagnosis, or how to enable us to distinguish between a retroperitoneal tumor (as in this case, the displaced kidney) and an intraperitoneal mass, the general feel and outline of both being similar to that peculiar to an ovary and tube enlarged and adherent to- gether and to the neighboring tissues, the result of local ad- 8 INTRAPELVIC KIDNEY MISTAKEN FOR hesive inflammation. I am not aware that any of the usual diagnostic methods employed in these cases will enable us to make an absolutely correct diagnosis, except, perhaps, the introduction of the whole hand into the rectum under anaesthesia, combined with palpation with the other hand through the abdominal walls. But this measure is not de- void of danger either by overdistension of the rectum or rupture of pelvic adhesions, and is not likely to be em- ployed unless the extraperitoneal situation of the tumor is suspected and a knowledge of its real character is indispens- able. Simple bimanual palpation will usually (but not always) permit us to decide whether the ovaries and tubes are nor- mal (that is, if they can be felt); and, if the normal append ages can not be recognized, the probability always is that the mass felt to one side or the other, or on both sides, of the uterus is the more or less diseased appendages, What the exact nature of their pathological condition is-whether the tube contains serum, blood, or pus, or the ovary is poly- cystic or a haematoma-can not be determined until the ab- domen is opened. Lindner * reports a case of Lawson Tait's f where a right movable kidney was mistaken for an ovarian or tubal tumor, the error only being discovered at the laparotomy. An additional source of error lies in the fact that women suffering from movable kidney complain of sacralgia, bear- ing-down pelvic pain, reflex gastric, cephalic, and other dis- turbances, usually supposed to indicate pelvic disease, but all disappearing after replacement or removal of the kidney. If now the appendages are diseased, especially atrophied, and the broad ligament is contracted by more or less recent peritonitis, so that the ovary can not be distinguished by * L. c. f " Birmingham Med. Review," 1885, DISEASED UTERINE APPENDAGES. 9 palpation, as in my case, I do not see how a correct differ- ential diagnosis of the intrapelvic tumor can be made. In this respect the only lesson to be learned from my case is that the possibility of the kidney's descending into the pelvis should always be borne in mind in diagnosticat- ing and operating on intrapelvic tumors which present out- ward characteristics similar to the kidney. Lindner* has collected thirty-six cases of removal of the displaced kidney, with a mortality of nine, or about 25 per cent. All the deaths occurred after the abdominal (intra- peritoneal) operation; the lumbar incisions were all followed by recovery. In such a case as mine, of course Hahn's method f of cutting down over the normal site of the kid- ney, pressing it back into place, and attaching it there by sutures passed through the circumrenal fat and the edges of the incision (nephrorrhaphy), would be impracticable, since I do not believe that the kidney could have been pushed out of the pelvis and back to the lumbar region. * L. c. f A very complete article, with a list of cases of nephrorrhaphy, by Maurice Richardson, of Boston, has recently appeared in the " Boston Medical and Surgical Journal." > Jgk REASONS WHY PMms siionlfl Subscribe ~r0R~ The NewYork Medical Journal, Edited by FRANK P. FOSTER, M.D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. 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