of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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of the female urethra was among the rarest of malignant mani-
festations. A careful search of the literature up to 1910 gave
the reports of but thirty-five cases, including his own, of primary
cancer of the female urethra. A careful search of the litera-
ture failed to reveal the report of a similar case of hematoma of
the broad ligament recurring with pregnancy. Regarding the
case of fibroid tumor of the ovarian ligament, the only reference
to the occurrence of fibroids of the ovarian ligament which
he had been able to find were the two cases reported by Doran
in 1896. In both of these cystic cavities existed.

discussion.

Dr. Reuben Peterson, of Ann Arbor, Michigan, said he had
had two cases of this rare affection, one of which he had previ-
ously reported. A woman was operated on by him four or five years
ago for a carcinoma of the meatus which had extended up into
the urethra about half an inch. He removed it so radically
that incontinence followed, with subsequent prolapse of the
bladder mucosa through the remainder of the urethra. The
woman complained of this, so he sewed up the opening and made
one from the bladder into the vagina. She still complained of
incontinence. He then did a colpocleisis, making an opening
into the rectum. He reported this case at a meeting of the
American Medical Association, but did so again now in order to

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946 TRANSACTIONS OF THE

give the subsequent history of the case. The woman had passed
her urine through the rectum ever since, and to-day she was as
well and contented as a woman could be in that condition. He
examined the urine two and a half years ago and at that time
she had not had ascending pyelonephritis. This was interesting
because it had been contended that where this communication
was established with the rectum, pyelonephritis would sooner
or later take place where the ureters were implanted into the
rectum.

The second case of primary carcinoma of the urethra happened
a short time ago, although it looked like a urethral caruncle.
Microscopic examination showed it to be primary carcinoma.
In this case he removed about one-third of the urethra, and there
had not been any recurrence of the condition for two years.

Dr. Clement Cleveland, New York, had had two cases of
primary cancer of the meatus, on one of which he did a radical
operation, but the disease returned. In the second case he
resorted to the use of the actual cautery. He believed this
treatment would afford permanent relief of such a condition
when surgery was of very little value.

With regard to the use of radium, he had seen such excellent
and positive results from its use in the hands of Dr. Abbe, of
New York, not only in cases of cancer of the vagina, the fascia,
the lip, gum, nose, and ear, that he thought its application to
cancer of the urethra would be of great value. He felt very posi-
tive that if radium was used in such cases we would see as good
results in cancer of the urethra as we wpuld in cases of cancer
of the lip, nose, or the ear.

Dr. J. Riddle Goffe, of New York, asked Dr. Peterson
whether he had used the cautery in the removal of these growths.

Dr. Peterson replied that he had not.

Dr. Goffe, in resuming, said he recalled one remarkable
case of malignant urethral caruncle or primary carcinoma of the
urethra a number of years ago. The woman gave a history of
having been operated on by Dr. William T. Lusk six years pre-
viously. Dr. Lusk told her at the time she had cancer that he
did not think it was wise to undertake its removal, but that he
would make a button-hole in the urethra to save it from irrita-
tion, and that this was the best he could do for her. This was
what the patient told him. For six years she was comparatively-
comfortable, in that she had control of the urine, but passed it
through the button-hole in the urethra. At the time she came
under the speaker's observation there was a cauliflower excres-
cence protruding from the meatus. This was of a bright cherry-
red color, exquisitely sensitive, and the source of constant pain.
With the cautery he removed all the urethra and the surrounding
tissue from the posterior angle of the urethra, taking away all
but one-fourth of the urethra at the neck of the bladder. She
made a comfortable recovery from this interference, but in less
than a year the disease returned with the greatest violence.



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AMERICAN GYNECOLOGICAL SOCIETY. 947

involving all the surrounding structures, becoming constitutional,
and she died with great suffering about a year after the proce-
dure he had instituted.

Dr. Frederick J. Taussig, of St. Louis, Missouri, reported a
case of carcinoma of the urethra that occurred in the practice
of Dr. Dorsett and himself. The patient was kept under
observation for a long time. He saw her in 1900, and at that
time there was a urethral caruncle, chronic urethritis, a retro-
verted uterus, and a relaxed pelvic floor. He operated on her
for the retroversion and the relaxation of the pelvic floor, but did
nothing further to the urethra. Three years later the patient
returned with a history of bloody discharge for three weeks.
She had been examined two months previously by an experienced
man, although nothing had been detected so far as the urethra
was concerned. When he examined her he found an infiltrating
cancer involving the lower part of the urethra. Operation con-
sisted of removing the entire urethra to the point of its entrance
in the bladder, putting a purse-string suture around the opening
which was left in the bladder so as to strengthen the muscular
tissue there, and then, as a further precaution, removing the
external inguinal glands on both sides, although there was no
glandular enlargement at the time. The patient made a good
recovery from the operation. There was slight partial incon-
tinence. The patient was kept under observation* for nine
months, and then small nodules were noticed in the inguinal
region and also about the internal iliac vessels, the triangle
between the external and internal iliac vessels. A second
operation was done, removing the affected glands, although
difficulty was experienced in removing the disease about the
iliac vessels on account of adhesions. A year and a half after
the primary operation the patient returned with a recurrence in
both the inguinal regions and higher up about the aorta. She
was kept at the skin cancer hospital two or three months under
trypsin treatment, which at that time seemed to offer a possible
excuse for its use, but with no benefit. The patient died, and
at the autopsy there was absolutely no recurrence at the primary
site. The tissues about the urethra and bladder were free from
carcinoma, and the glandular involvement was not merely con-
fined to the lymphatics, but the disease involved the liver and
spleen.

Dr. Seth C. Gordon, of Portland, Maine, reported the case
of a woman, seventy years of age, who had a growth for nearly
a year about the urethra, and at the time she came under his
care she had been treated by caustics for six or eight months.
The growth was as large as a walnut and bled on the slightest
touch. He removed the tumor with three-quarters of an inch
of the urethra, bringing the remainder down and attaching it.
This operation was done four years ago, since which time there
had been no return of the disease. Microscopic examination
revealed the tumor to be a carcinoma.



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948 TRANSACTIONS OF THE

Dr. Hiram N. Vineberg, of New York, recalled a case of
primary carcinoma of the urethra that came under his obser-
vation some years ago, the disease involving the anterior third •
of the urethra. He did a thorough operation, went close to the
vesical sphincter, and as the result of this there was a slight
incontinence. Prior to the operation this woman had no
symptom of pain or of hemorrhage. Microscopic examination
proved the growth to be a carcinoma. He did a plastic some
time afterward and found, in trying to build up an artificial
urethra and in bringing the stump of the urethra forward, the
operation was only partially successful. The woman could
retain her urine while in bed for an hour or so. She was kept
under observation three years, and during that time there was no
recurrence. He had not heard from her since. At that time
he reviewed the literature and collected eleven cases of primary
carcinoma of the urethra.

Dr. Henry T. Bypord, of Chicago, said he had had one such
case, and called attention to the fact that this disease was not
so rare in the urethra as one would judge from the number of
cases reported by the essayist.

Dr. Francis H. Davenport, of Boston, said he saw a woman
who had been under the care of a female practitioner. This
practitioner had tried the injection of serum for carcinoma of the
urethra, and with some comfort to the patient, but the disease
was not arrested. When the speaker saw her nearly one-quarter
of the urethra was involved, so that it seemed absolutely im-
possible to remove everything radically. Radium was tried
for several months, but not as thoroughly as the surgeon would
like to have tried it, owing to the fact that it could not be applied
in the urethra itself on account of severe pain, but only externally
from the vaginal side. Finally the growth became so large that
there was retention of urine and a suprapubic fistula had to be
made which relieved her of the immediate symptoms; but within
three months after that she died from exhaustion.

Dr. I. S. Stone, of Washington, D. C, said that next to the
report of individual cases, it was essential to know something as
to how wide the excision should extend, and how far the malig-
nant process extended when one began to operate on these cases
of early manifestations of carcinoma of the urethra. All of the
cases of cancer in this region in his experience had ultimately
resulted fatally.

Dr. Joseph Brettauer, of New York, said that he had
repeatedly had cases sent to him which were diagnosed as car-
cinoma of the urethra, but which turned out to be urethral
caruncle by microscopic examination, so that at times it was very
difficult to decide whether the growth was malignant or not.
As a rule, the younger the patient, the more malignant the
growth.

Dr. Edward L. Duer, of Philadelphia, said that not long ago
he did an extensive operation for a carcinomatous growth of the



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AMERICAN GYNECOLOGICAL SOCIETY. 949

urethra which extended well into the end of the vagina. It was
very large. It was difficult to operate without enlarging the open-
ing nearly into the rectum. He removed the growth, sewed up the
parts, and the wound healed. The condition returned in a short
time after the operation, and the x-ray was applied to the exter-
nal parts, but in the course of a few months the disease returned,
then radium was tried. He commenced with a weak prepara-
tion of radium, which seemed to have had little or no influence
on the disease. He then increased the strength of it a hundred
per cent., and after the use of radium the patient improved and
had continued to improve. Previous to this treatment the
patient had been confined to bed for nearly a year. When she
was carried to the country she could not walk. She was now
living in Germantown, was able to ride in her carriage, and to go
shopping, and seemingly was perfectly well so far as could be
determined by the last examination.

Dr. Manton, in closing, said the only point he desired to make
was as to whether all the cases reported were really instances of
primary carcinoma of the urethra. There were a great many
cases of periurethral carcinoma which were mistaken for ure-
thral malignancy, and no doubt some of them belong to this
class.

BILATERAL TUBAL PREGNANCY.

Dr. Palmer Findley, of Omaha, Nebraska, reviewed the
literature on the simultaneous development of a fetus in either
tube. He found twenty-eight cases reported as examples of
bilateral tubal pregnancy, but only eight were unquestioned as
being of simultaneous development. Of the twenty cases of
doubtful identity, the clinical diagnosis was not supported by
the macroscopic and microscopic findings of fetal structure in
the two tubes.

To these eight cases the author added a ninth in which there
was a probable simultaneous development of both fetuses in
either tube, with rupture of the right tube, and the escape of the
ovum through the fimbriated end of the left tube. The escape
of the two ova was probably simultaneous. The pelvis was full
of blood, and there was a general peritonitis. Decidual tissue
and choronic villi were found in both tubes, but neither fetus was
discernible. Both ovaries were cystic and adherent. In the
right ovary there was a fresh corpus luteum. An abdominal
section was performed with the removal of both tubes and the
escaped blood. The abdomen was drained. Death ensued
from general peritonitis.

A successful reimplantation of a pelvic kidney in the

FEMALE, WITH REMARKS ON THE SURGICAL TREATMENT
OF KIDNEY MISPLACEMENTS IN THE TRUE PELVIS.

Dr. Dougal Bissel, of New York, gave a detailed statement
of the case of a Mrs. C, aged forty-one, married seventeen years.



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950 TRANSACTIONS OF THE

He gave the history of the case prior to operation, especially the
record of a delivery by premature labor, the pelvis being
obstructed by a tumor afterward found to be a misplaced
kidney, described the method of surgical replacement through a
median abdominal incision; also spoke of freeing the retroperit-
oneal pelvic kidney and forming a bed for it in the lumbar
region, attaching it to the lumbar fascia and muscles by two
sling sutures.

On April lo, in the presence of Drs. Cleveland, Goflfe, and others,
he opened the patient's abdomen through the median abdominal
incision. The pelvic body was found retroperitoneal, in part
immediately behind and to the right of the lower segment of the
uterus. The uterus was temporarily stitched anteriorly for
better vision and manipulation. The patient was then placed
in an extreme Trendelenburg position so as to make the intes-
tines gravitate out of the pelvis toward the diaphragm, where
they were maintained by the aid of gauze pads throughout the
operation. The posterior peritoneal surface of Douglas' culdesac
was incised, and the pelvic body was separated from the loose
connective tissue immediately surrounding it and delivered into
the peritoneal cavity. The body proved to be the right kidney
as supposed, normal in size and appearance, with its hilum
directed a little upward and toward the median line. Freed
from its cellular tissue it could be elevated to the sacral prom-
ontory. Two bands of tissue connecting the lower pole of the
kidney with the pelvis prevented further elevation. These bands
proved to be supernumerary arteries, arising from the region
of the internal iliac artery or one of its branches. They were
of considerable size, about one- twelfth of an inch in diameter,
and about two inches in length. When these arteries were
severed, the kidney could be raised approximately to its normal
position. In fact, the renal artery and vein were found much
elongated and could be traced upward in the direction of their
normal site. The original incision in the peritoneum was then
extended several inches above the ileopectineal line, and to
the right or outer side of the cecum and ascending colon. The
cellular structure immediately beneath this incision was torn
up until the fascia of the lumbar region was exposed. The
kidney was then prepared for replacement in the following
manner: Its fibrous capsule was incised longitudinally along
the middle of the convex border and separated from the kidney
structure about one-half inch on each side. Two chromic catgut
sutures (No. 2) were passed, one around each pole, which when
attached to the fascia and muscles of the back, formed a sling to
support the kidney and insure its maintenance of position and
contact with the fixed structures until union of the opposed sur-
faces should take place.

To prevent the possibility of these sutures' slipping from either
pole they were made to penetrate the fibrous capsule at several
points as they encircled the organ; that is, both upper and lower



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AMERICAN GYNECOLOGICAL SOCIETY. 951

sutures were made to penetrate first the liberated portion of the
fibrous capsule, one above and one below, one-half inch or more
from the middle of the convex border of the kidney; then they
were passed through the tissues, one above and one below the
pelvis of the ureter as it enters the hylum of the kidney, then they
were passed through the freed portion of the fibrous capsule on
the other side at points opposite their entrance. In penetrating
the tissues above and below the pelvis of the ureter, it was well
to use the head of the needle rather than the point, so as to
avoid [injury to the branches of the renal artery which were
commonly found in the vicinity of the upper pole.

The ends of each suture were temporarily tied together, in
order that they might the more easily be found in the second step
of the operation, and the kidney placed with its convex surface
to the lumbar fascia, and the peritoneum sutured over it. The
abdominal wound was then closed and the patient placed on
her abdomen. The usual lumbar incision was made, which ex-
posed the kidney and the knotted ends of the catgut. These
ends were untied, threaded upon needles, and passed through
the fascia and muscle at the upper angle of the wound. The
incision was closed by the layer method, both plain and chromic
catgut being used, the chromic guts forming the slings tied last.
The patient made an uneventful recovery. The urine, which
immediately before the operation was normal, after the operation
showed a trace of albumin and granular casts.

On January 29, 1910, the patient presented herself for ex-
amination before Drs. Cleveland, GoflFe, and himself. The
pelvic contents were found normal and the right kidney where
it was placed. The distressing symptoms of exhaustion and
backache which had been more or less present for seven
years had practically disappeared.

DISCUSSION.

Dr. Clement Cleveland, of New York, was present during
the operation on this woman, and the operation as described
was correct. As to the method of procedure, he felt at the time
Cesarean section should have been performed, but the woman
and her husband were opposed to it and it was decided to deliver
the child through the normal channel, but he believed there
would have been less risk to the mother by Cesarean section.

Dr. a. Lapthorn Smith, of Montreal, said that in view of the
great safety of Cesarean section and the great danger of pre-
mature labor and accouchement forc€ generally and the danger
of injuring the kidney in such a case as the one reported, he
would strongly favor Cesarean section and fixation of the kidney
afterward.

Dr. J. Wesley Bovee, of Washington, D. C, said the case
reported by Dr. Bissell was very interesting. He was interested
in this manner of dealing with the kidney because his thesis for



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952 TRANSACTIONS OF THE

admission into the Society was with reference to this class of
work. At the time he performed an operation on a dog of dis-
placing the kidney downward to facilitate or to make possible
the splicing of a portion of the ureter which had been lost by
accident during operation, and which had since been done on
the human being successfully. Now, Dr. Bissell had planned
this operation and had done it successfully in displacing the
kidney in the opposite direction. The case was unique, inas-
much as there was not a report of anything like it on record.
He agreed with the essayist in the belief that this was an acquired
displacement, although he did not quite understand why we
should have aberrant vessels given off from the internal iliac
to the kidney. His impression was that aberrant vessels to the
kidney were not given off so low down, but the fact that there
was a long ureter would be abundant evidence that this was an
acquired displacement downward of the kidney. He was in-
terested in the method of suturing this kidney up in the lumbar
region. He did not know whether this method of placing sutures
which passed around the poles of the kidney near the ureter
or near the pelvis of the kidney might not do injury by cutting
into the tissue of the kidney itself, as it seemed to him there
might be danger there, for the reason that in case of considerable
vomiting after operation the kidney might be forced markedly
against these sutures. However, as he had never seen the
sutures placed in the kidney in that way, he hoped the essayist
would tell the members what he thought of the future of the
operation.

Dr. J. Riddle Goffe, of New York, said he could bear
personal testimony to the fact that the report as given was ex-
actly in accordance with the facts. The case was extremely
interesting to him, and he was fortunate enough to see it.

Dr. Reuben Peterson, of Ann Arbor, Michigan, said there
were some points from an obstetric standpoint which might
be brought out. Unquestionably for a condition like this,
with a tumor or kidney or prolapsed spleen or an ovarian
tumor in that position. Cesarean section would be the safer
operation in attempting to lift up the tumor at the brim of the
pelvis; but he questioned whether Dr. Smith's reason for Cesarean
section would be the correct one. He did not remember how
long it took the essayist to do this operation, but he should
judge from the description given that it took a considerable time,
and it was questionable whether one would want to add that to a
Cesarean section. In his experience Cesarean section was a
short operation up to a certain point. The child and the pla-
centa could be removed easily within a minute, but the com-
pleted operation, even in a normal case, took from twenty min-
utes to half an hour, even though a man might be a rapid operator.
The question arises in similar cases to this, with a tumor in the
pelvis, whether it would be good surgery to do the other operation
at the same time on account of the length of time it takes.



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AMERICAN GYNECOLOGICAL SOCIETY. 953

Dr. Hiram N. Vineberg, of New York, stated that experience
had shown that the dystocic kidney was usually a single one, and
in most of the cases in which it was the only kidney the patient
had it had been found very much out of its normal position.
He asked Dr. Bissell if that was true in his case and what pre-
cautions were taken to prevent removing the kidney and in de-
termining whether a second kidney was present. He thought the
statistics showed that in about one to three thousand five hundred
or four thousand cases there was only one kidney present.

Dr. Edward Reynolds, of Boston, said it had been assumed
throughout the discussion that this was an acquired malposition
of the kidney. If, on the contrary, it was a partial malposition
of the kidney, the field open for us in future cases was much
larger. Embryologically, the kidney was developed near the
posterior end of the sacrum. Subsequently it might rise forward
retroperitoneally precisely as the ovary and testicle migrated
posteriorly during development. The primitive kidneys were
nourished by vessels springing oflF opposite each body. A few
of them coalesced to make a permanent kidney, and the body so
formed subsequently migrated forward. It did not seem to him
that the length of the ureter was sufficient evidence that the dis-
placement was acquired in the case reported by Dr. Bissell. He
thought time would show that the failure of this kidney to
migrate was due to the persistence of the posterior vessels which
should have been absorbed, and everyone who had dealt with
a ureter throughout its length retroperitoneally knew that the
moment it was freed from the peritoneum it became a tube
which was capable of easy elongation, and what appeared short
became long. The most interesting point in the whole paper
was the question of whether Dr. Bissell had not given us a
means of complete or, at any rate, moderate replacement of
congenitally displaced kidneys.

The speaker's experience with Cesarean section had made him
feel that it was not one of the few operations in which rapid
completion of the operation was essential to success. He would
be sorry to do Cesarean section and go on to a lengthy operation
at this time. He had been obliged to remove the kidney with



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 97 of 109)