Society Reports.

NEW YORK ACADEMY OF MEDICINE.

SECTION ON OBSTETRICS AND GYNECOLOGY.

Stated Meeting, Held April 23, 1903.

L. J. LADINSKI, M.D., CHAIRMAN.

Nephropexy for Movable Horseshoe Kidney. Dr. ARNOLD STURMDORF reported this case. He said that, according to Henry Morris, horseshoe kidney occurred once in 1,650 cases, and the rather extensive literature on nephropexy that had accumulated since Hahn's first publication in 1881 did not contain a single reference to this anomaly. His patient was an Italian woman, who had been referred to him through the courtesy of Dr. A. Morani. She had been married eight years, was the mother of three children, and had never aborted. There was nothing in the previous history bearing upon the condition. She complained of a dragging sensation in the lower dorsal and upper lumbar spine with constant pain of varying intensity radiating from this area downward and forward toward the lower abdomen. The pain and dragging would subside when the patient assumed a recumbent posture, but she was never entirely free from discomfort in the back and right side of the abdomen. These symptoms had first appeared two years ago after an instrumental delivery, and since that time had gradual ly become more severe until they had finally incapacitated her for household duties. Several times during the past seven months she had experienced sudden exacerbations of the pain during which complete anuria had occurred, followed after a variable period by a copious polyuria with partial abatement of all the symptoms. The patient had lost both weight and strength. When examined on February 2, 1903, it was noted that she was a pale and slender woman, but without any apparent abnormality of the bodily functions, with the exception of the urinary fluctuations referred to. Palpation revealed a hard and smooth solid mass occupying the right side of the abdomen and seeming to fill the right loin. It could be freely moved up and down and slightly from side to side. Its lower pole was on a level with a line connecting the two anterior superior spinous processes. It extended anteriorly to a continuation of the parasternal line. The lower end of the mass was indefinitely rounded, and the upper end reached under the ribs and could not be palpated. The right margin was rounded and well defined; the left was irregular and depressed. It did not appear to have the shape of the kidney, and although distinctly movable in an upward direction, it could not be made to slip into position on bimanual pressure in the manner so characteristic of a floating kidney. Its post-peritoneal origin was demonstrated by colonic inflation. The right renal region showed a depression below the ribs posteriorly. The urine was normal. The left kidney was not palpable, and the rest of the examination was negative. On February 10 a dorsal oblique incision was made from the last rib to

the iliac crest.

The upper pole of the kidney presented in the depths of the wound, and was readily liberated, but the lower pole could not be isolated because of its projection inward beyond the reach of the finger. The peritoneum along the outer border of the kidney was then incised, and this exposed a perfectly characteristic, mobile horseshoe kidney. The kidney could not be delivered sufficiently to allow of the use of the author's capsular flap formation, and accordingly the Senn method of gauze packing was resorted to. This gave firm anchorage and complete relief to the patient, who had entirely recovered at the end of three weeks. The speaker remarked that this could not be properly classed as a floating horseshoe kidney, inasmuch as the right segment was movable to a marked degree independently of the left; it was more probably a congenitally displaced

horseshoe kidney, the right half of which had become detached in some manner

Hysterectomy for Subperitoneal and Submucous Fibroids. Dr. AUGUSTIN H. GOELET presented specimens from a case of this kind.

Hysterectomy for Chronic Metritis and Uncontrollable Hemorrhage. Dr. BROOKS H. WELLS reported this case.

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Large Polycystic Kidney; Operation.-Dr. WELLS also showed a large polycystic kidney, removed by operation in June, 1902, from a young woman sent to him by Dr. Hetzel of Southport, Conn. She complained of general malaise, a dragging sensation, and a constant dull pain, increasing in severity. These symptoms represented the pressure effects of a slowly growing oval tumor occupying the right side of the abdomen and extending from under the ribs to two inches below the umbilicus. It was rounded, nodular, slightly movable, and sensitive. The kidney on the left side was apparently normal, as was also the urine. The patient's general condition was good. A diagnosis of tumor of the kidney, probably cystic, was made, and on June 10 the usual incision along the outer edge of the quadratus lumborum muscle was made in an attempt to remove the tumor. The tumor was enucleated and removed, and the wound was closed without drainage. The patient made a quick recovery, there being very little shock and no fever or urinary disturbance. The speaker said that he had waited ten months before reporting this case, because surgeons, as a rule, advised against removal of a large polycystic kidney on the ground that the disease was usually bilateral, and even if a fatal anuria did not rapidly supervene, the other kidney was liable rapidly to develop the same cystic condition. He believed, however, that in the rare instances, like the one just reported, in which there was good reason to believe that the disease was unilateral, and the tumor was causing distress, surgical intervention was justifiable, and that life was likely to be prolonged by the removal of the diseased kidney. At the present time his patient appeared to be perfectly well, and she had been completely relieved of her former symptoms.

Surgical Kidney, Probably Tuberculous.-Dr. WELLS also presented this specimen, which had been removed from a man of twenty-three. Six years ago he had suffered from gonorrhoea, and had been treated for it for one year. In April, 1901, he had been treated by a physician for gleet and stricture, sounds being passed frequently into the bladder. During this period he suffered repeatedly from what he called chills and fever, as well as from pain and stiffness in the right lumbar region. He then applied to Dr. Beyea of New Rochelle, who found fluctuation over the quadratus lumborum muscle on that side, and evacuated pus. The incision closed after three weeks, but the patient continuing to fail, he was referred to Dr. Wells in July. His appearance at that time was decidedly septic, and the urine contained blood, numerous granular and epithelial casts and a large quantity of albumin. There was no tenderness or tumor over the region of the right kidney, gall-bladder, or appendix, but there was pouting red area an inch above the ilium and about an inch and a half from the median line on the right side. Under ether this was incised, and the fistulous tract followed down to the kidney, resulting in the evacuation of about ten ounces of creamy pus. The wound was packed and drained. Convalescence was slow, and the wound did not heal completely for three months. The kidney felt rather hard to the touch, but because of the existing local and general conditions, it was not incised. The patient's general condition and the urine improved slowly after this operation, but last January the patient began again to complain of dull pain in the right loin and of general malaise, and there was a discharge of a few drops of watery pus from the upper angle of the old wound. An x-ray photograph of the right loin showed a faint opacity over the area of the kidney. On February 18 the kidney was removed through the usual loin incision, and the wound

was closed, except for a small cigarette drain. The patient made a rapid convalescence and improved in color and strength, and the urine became normal except for an occasional pus cell. On incision of the kidney the parenchyma was found to have entirely disappeared, the capsule being fi'led with a mass of inspissated pus resembling mortar. Abdominal Hysterectomy for Myofibromatous Uteri.-Dr. H. J. BOLDT presented a number of specimens. The first specimen was one of pan-hysterectomy. The cervix was very short and one fibroid was of the intraligamentous variety. The patient, a nulliparous woman of thirty-two, had suffered several years from pressure symptoms in the left lower abdomen, associated with lancinating pains radiating down the entire lower extremity. At times there was oedema of the leg. There was menorrhagia but no metrorrhagia. The opeation presented the difficulties usually met with in this class of tumors, but recovery was uninterrupted.

The second case was one of supravaginal amputation, dɔne in a virgin of thirty-six, who had suffered from numerous attacks of metrorrhagia, and had had menorrhagia for a number of years. At times there were present intense bearing down pain in the abdomen and severe backache. The large submucous tumor had a broad and inseparable base with the uterus proper, so that it formed a part of that organ.

Because of the anæmic condition of the patient, 1500 c.c. of saline solution were injected into the median basilic vein before the operation was commenced, a procedure always to be recommended where there was extreme anæmia. Recovery was uneventful.

Small Spindle-cell Sarcoma of the Ovary and Liver.The interesting feature here was that the enormous liver filled the abdomen so complet ly, and at one part was directly attached to the ovarian tumor, so that, on pal pation, the tumor was thought to be entirely of ovarian origin, there being no space between the neoplasms. The tumor that filled the pelvis palpably contained fluid, whereas the abdominal part of the tumor was unquestionably solid, and the nodular condition of the solid tumor, associated with ascites and cachexia, led to the diagnosis of sarcoma of the ovary. It was thought that the liver was crowded up under the diaphragm. The specimens showed clearly that a differential diagnosis was impossible. The true condition did not become apparent until the hand was placed at the summit of the tumor to dislodge it, when it was found that the liver formed the tumor. The sarcoma of the ovary was removed because of hemorrhage from adhesions to the liver. Dr. H. T. Brooks, as the result of his examination, believed the ovarian sai coma to be the primary tumor.

Tubal Abortion; Profuse Intraperitoneal Hemorrhage, No Formation of a Hematocele.-The patient had given birth to her last child nineteen months ago, and had been nursing the infant up to two months ago. Her menstruation had been regular for several months until the last period, when she went eight days overtime. For two weeks she had irregular spotting. On April 20 she had intense pain of a cramp-like character in the right iliac region, radiating over the entire lower abdomen. The physicians called in made a probable diagnosis of perityphlitis, or of appendicitis. At that time she began to bleed more profusely, but it was thought to be the regular menstrual flow. Examination the following day revealed a thickening of the right Fallopian tube near the abdominal extremity to about four times its normal dimensions, and a swelling sensitive to the slightest touch. There was an indefinite fulness in the cul-de-sac, as though fluid was present in it. There was no evidence of a formed hæmatocele. Appendicitis was excluded absolutely. The diagnosis of progressing tubal abortion was made, and in view of the fact that there was no apparent tendency of the blood to coagulate, operation was advised. The abdomen was found very full of blood at the time of operation, and the patient was almost pulseless, so that an intravenous infusion of 1,800 c.c.

was given. Bleeding from the fimbria was still present. A large quantity of saline solution was left in the abdomen. Convalescence was now progressing satisfactorily.

Ovarian Cystoma; Three Twists of the Pedicle from Left to Right. The patient had been aware of the presence of an ovarian tumor for about eighteen months, but had been informed by her physician that medicine would cure her. Two days before she was seen by Dr. Boldt she felt the pain, which had been present about two weeks in the lower abdomen increase, greatly in intensity, so that even ice-bags and opiates gave no relief. Examination showed diffuse peritonitis at the time when seen. The diagnosis of a right ovarian tumor with twisted pedicle was readily made, and, in view of the peritonitis, she was at once removed and operated upon. The tumor was found to be gangrenous; many adhesions were present, and a considerable quantity of bloodstained ascites. The right Fallopian tube was greatly distended with blood, and blood was oozing from the fimbriated extremity at the time. An acute appendicitis was associated with the condition, probably as a result of an extension of the inflammation. Recovery was progressing satisfactorily.

Cancer of the Uterus; Vaginal Hysterectomy; Recovery. The patient, forty-two years old, had been bleeding irregularly for two months. Examination showed that a malignant neoplasm involved the entire cervix. Although she had consulted her family physician about the bleeding, no examination had been made, ergot and hydrastis seemingly having been relied upon to control the bleeding. Although gynecologists had often insisted that, in all instances of atypical bleeding, one must suspect malignant disease, and a positive exclusion of such change must be made before internal remedies were used to control the bleeding, this teaching did not seem to have found a general foothold.

Surgical Kidney; Nephrectomy.—The patient had been seen for the first time thirteen months ago, at which time a diagnosis of pyelitis had been recorded. She had not been seen again until a few days ago, when she entered the hospital for operation, the pain in the right loin having become constant. The kidney was large and, as a result of inflammatory changes all around it, was exposed with great difficulty. Two stones were felt in the organ, and an attempt was made to save the organ, but while endeavoring to dislodge the kidney one abscess was tom into, and the structure somewhat mutilated. It was then thought best to remove it. Several abscess cavities were found in the kidney, and four stones were imbedded in the pelvis. The ureter was thickened considerably, but was not much dilated. Convalescence was progressing satisfactorily.

Abdominal Hystero-salpingo-oophorectomy. The patient had had a ventral suspension done by Dr. Boldt about six months previously, and the appendix, which was the seat of catarrhal inflammation, had been removed at the time. Several cysts in the ovaries were treated with a Paquelin cautery. An abdominal-wall abscess followed. and a sinus, which went into the pelvis, had been present since the operation. At times there had been metrorrhagia. To cure the sinus, the old abdominal scar was incised four weeks ago, and the sinus thoroughly curetted The adnexa at that time were seemingly in good condition A week later an examination showed the right adnexa to be the seat of an abscess, probably ovarian, and the left showed evidence of inflammation. The sinus itself proved to be incurable. In view of the existing tuboovarian inflammation, which on the right side was suppurative, the operation as done was determined upon request of the patient. The vaginal operation was not sidered safe because of the dense intestinal adhesions supposed to be present, and the abdominal section proved the wisdom of the course pursued. The intestinal adhesions were very extensive, and so firm that in places it

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was necessary to divide them with scissors. It was likely that the suppurative process was tuberculous, but the examination had not yet been completed. The woman was doing well.

Possible Malignant Disease of the Colon and Stomach.Dr. L. J. LADINSKI exhibited the specimen removed from the patient presented by him to the section at the last meeting. It consisted of a portion of the colon and a portion of the anterior wall of the stomach and of the abdominal wall. So far as the microscopical examination had gone the results were not decisive as to the presence of malignant disease. On making the abdominal incision the indefinite tumor was found to consist of a matting together of the anterior wall of the stomach, the transverse colon, the greater omentum, and the abdominal wall. The incision of the abdominal wall entered the colon. This diseased portion of the colon was removed, and the tumor was separated from the abdominal wall. A button was inserted. The entire stomach appeared to be involved quite deeply. The colon had not healed thoroughly, and if the disease were not malignant he expected to do a lateral anastomosis.

Dr. BOLDT, referring to the uterus presented by Dr. Wells, said that the appearance was such as to indicate to him that there had been originally a septic infection.

Dr. STURMDORF said that the use of the curette in these cases of persistent uterine hemorrhage was going out of vogue because experience had shown that the curette often gave only temporary relief. Recent studies indicated that the hemorrhage was due to a degeneration of the musculature of the uterus, and that the uterine muscle was in constant action, not only in pregnancy, but at other times. These facts threw light on cases of what had in the past been considered to be inexplicable hemorrhage. The curette should be limited to the cases in which a cause for the hemorrhage could be distinctly found, as, for example, the presence of a fungous endometritis.

He had been deeply interested in the kidney presented by Dr. Wells. He understood that the infection was an ascending one from the passage of sounds, yet from the appearance of the specimen he was disposed to think that it was a tuberculous kidney. The deposits present were not those from the urine, but rather those found in connection with tuberculosis of the lungs.

Dr. WELLS replied that the pathologist, Dr. Jeffries, had reported that there were no tubercle bacilli present and that the material was gritty and crystalline.

Secondary or Repeated Laparotomy. Dr. HENRY C. COE was the author of this paper. He said that secondary operations were doubtless less frequent than in the early days of imperfect aseptic technique, but there was still much room for improvement, as shown by the fact that a number of patients still required a secondary laparotomy before being restored to health. Exudates, fistulæ, newly-developed neoplasms, ectopic gestation were common conditions for which a secondary laparotomy was demanded. One experimenter had made the statement that adhesions followed whenever the abdominal cavity was opened, but clinical experience was opposed to this view. Nevertheless adhesions did occur in spite of the most painstaking efforts to prevent them. Secondary pus foci might be an evidence of imperfect technique, unwise conservatism, or secondary infection. It was a common experience with the abdominal surgeon to see an apparently insignificant cystoma of the ovary, left undisturbed at the first operation, grow to such an extent as to require subsequent removal. Personal experience led him to consider it necessary to remove both ovaries in cases in which only one appeared to be the seat of papilloma. The abdominal route was preferred by him for conservative work. He had invariably endeavored to preserve the function of menstruation whenever the ovary could be safely retained, but he was beginning to doubt the wisdom of the surgeon's allowing himself to be hampered by promises to preserve portions of these organs.

He was strongly averse to resection of the tubes and ovaries in pus cases. The most promising cases often proved ultimately to be the most disappointing. In at least a dozen cases he had been obliged to remove the uterus for profuse hemorrhage which did not yield to curettement, and serial sections of these uteri appeared to indicate that the cause was situated outside of this organ, Not a few of the secondary laparotomies at the present day were performed upon patients in whom at first so-called conservative surgery had been practised. There was a strong argument in favor of removing the appendix whenever it became necessary to open the abdomen for other conditions. Dysmenorrhoea, menorrhagia, and gastrointestinal disturbances might be so severe as to require surgical relief, but pain was usually the cause which made the patient seek a second laparotomy. The pain might be general or localized, and might be entirely out of proportion to the lesion. Limitation of the peristaltic movement of the bowel was often responsible for this severe pain. Why this pain should exist in some apparently insignificant adhesions and be absent when the coils of intestine were extensively matted together was difficult to say, although no doubt the neurotic element played an important part. Hemorrhages so profuse as to eventually sap the vitality of the patient frequently called for the removal of the uterus. He had met with this phenomena in connection with atrophied ovaries and where no satisfactory explanation could be given. Attention had been called to the effect of traction on the stomach in causing obstinate vomiting of other gastrointestinal disturbance.

In order to draw a correct inference as to the nature of the lesion calling for a secondary laparotomy one should have an exact history of the case, including a good description of the former operation; yet this very essential element in the diagnosis was very frequently entirely lacking among hospital patients. The presence of intestinal lesions might be inferred from a history of more or less constant colicky pains in the lower part of the abdomen. Examination under anæsthesia was advisable in doubtful cases, especially neurotic subjects. When the probable cause of the trouble was more or less extensive adhesions, one should be careful not to promise relief, for the result was always extremely problematical. While all agreed that pus sacs were best treated through the vagina, he still felt that firm adhesions above the pelvis could hardly be satisfactorily treated except by the abdominal route.

Gynecological Surgery and True Surgery.-Dr. EGBFRT H. GRANDIN opened the discussion. He said that he was beginning to reopen the abdominal cavity for the simple reason that some years ago he either had not done enough or had attempted to save too much; in other words, because he had practised what he believed was wrongly called "conservative surgery." The pus cases were the ones most frequently coming for secondary operation. The avoidance of injury to the parietal peritoneum at the time of the first abdominal section through the use of sharp retractors he would pass by, although admitting that it was a frequent source of adhesions and of subsequent pain. The same might be said about the use of silk and non-absorbable suture material. One of the chief causes of secondary operation was the fact that we did not yet know how to repair the damage done in the pelvis by an exceedingly difficult salpingo-oophorectomy with the leaving behind of a raw surface. It was not the surgeon's fault that such raw surfaces were left, but one should strive to improve the technique. He did not think that the leaving of saline solution in the abdominal cavity would be of much service. It was possible that Cargile membrane, recommended by Dr. Robert T. Morris, might prove useful, although he had not yet tried it. One excellent plan was the use of gauze to keep the intestines up in place until retained by plastic exudate. When, because of pelvic peritonitis, it became necessary