Page images
PDF
EPUB

but it is extremely uncommon for tuberculous inflammation here to lead to this sacculated condition. In this case, this sac might have led to various errors of diagnosis. It might have been mistaken for pelvic abscess, ovarian cyst, etc. In a former communication on the subject (Med. News, Jan. 3d, 1885), the writer shows that in nearly all cases of uterine tuberculosis, infection took place from the peritoneal cavity. This is evident from the tuberculosis of the Fallopian tubes, which almost always accompanied the uterine affection. In this case the Fallopian tubes were not affected. It seems probable to the writer that, the rectum being affected and containing large masses of bacilli, the affection of the uterus might have resulted from the entry of these organisms through the extensive recto-vaginal fistula into the vagina, and thence into the uterus. Cohnheim was the first to

speak of the possibility of the tuberculous virus being transmitted by coition, and a tuberculosis of the genitalia so produced, and several cases have lately been reported in which it seemed possible that such was the case. In the case under consideration, there was every opportunity given for the entry of bacilli into the vagina. The diphtheritic patches in the vagina were most probably caused by contact with the infectious necrotic material from the fistula. A similar condition is sometimes found in carcinoma of the uterus, where the discharge is of a highly acrid and putrid character.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF NEW YORK.

REPORTED BY THE SECRETARY, DR. H. C. COE.

Stated Meeting, January 5th, 1886.

The President, DR. PAUL F. MUNDÉ, in the Chair.

EPITHELIOMA OF THE BLADDER.

THE PRESIDENT exhibited the specimen, which he had removed from a woman 42 years of age, who entered Mt. Sinai Hospital a month before, complaining of painful micturition and hematuria. She said that two years before, Professor Taufer, of Pesth, had removed from her a tumor of the left ovary, the operation being a difficult one. From the length of the abdominal cicatrix it was evi

dent that the tumor had been a large, and possibly a solid, one. Dr. Scharlau had seen the patient previous to her entrance. On making an examination, the President found a diffuse thickness all over the anterior vaginal wall. On passing a sound into the bladder, that viscus did not seem to be very large, but it evidently contained some foreign growth; the withdrawal of the instrument was followed by a gush of blood. A few days later, the urethra was dilated (by the gradual method), the index finger was introduced, and a soft, sessile tumor as large as an orange was felt occupying the base of the bladder. It broke down easily under the touch, and felt like an epithelioma. There was some thickening of the tissue around the bladder, but no distinct evidence that the disease had extended beyond the organ. Six or eight ounces of blood escaped from the urethra after the examination; the bladder was irrigated with a solution of hot vinegar, followed by one of boracic acid (one to one thousand). In order to avoid hemorrhage, it was decided to attempt the removal of the growth per urethram, instead of by vaginal cystotomy. The patient's temperature had been elevated ever since she entered the hospital; it never fell below 101° F., and was accompanied by a dry, furred tongue. On the day appointed for the operation, the thermometer registered 104°. The woman refused to have the operation then, but consented a week later. The urethra was dilated, and a mass of soft, friable material removed by means of the finger and Simon's curette, the bladder being subsequently washed out with a hot solution of vinegar and water (one part to three), followed by one of boracic acid. The President stated that the patient had been perfectly comfortable since the operation, the dysuria had disappeared, and there was no return of the septic symptoms. Portions of the growth were examined microscopically by Dr. Heitzmann, who pronounced it to be an epithelioma. The President said in conclusion that epithelioma of the bladder was a somewhat rare disease. According to Winckel's statistics, out of thirty-seven cases, thirtythree occurred in women, that is, it was eight times as common as in the male sex.

DR. BYRNE asked what advantage was gained by operating in such a case. Was it not better to let the patient alone, since the disease was sure to return in every instance?

DR. H. M. SIMS thought that, if the patient's life was prolonged and rendered more comfortable, the operation was justifiable.

DR. NOEGGERATH believed that the presence of decided septic symptoms constituted a sufficient reason for an operation. The operation was performed, he inferred, in order to eliminate the cause of the sepsis.

DR. MURRAY asked if Winckel's statistics referred to primary or secondary cancer.

THE PRESIDENT replied that of the thirty-seven cases only seven were examples of primary cancer, three being in men and four in

women.

DR. NOEGGERATH thought that the operation might have been

made a more radical one, since the disease had not extended beyond the viscus. It might have been possible to remove a portion of the base of the bladder together with the tumor.

THE PRESIDENT answered Dr. Byrne's objection regarding the justifiability of the operation by stating that the septic symptoms were such that it was clearly necessary to remove the cause. These symptoms were relieved by the operation, the painful micturition was alleviated, and the patient was rendered much more comfortable than before. Indeed, all bladder symptoms were now absent. The results of the operation were certainly as good as those obtained in the operative treatment of cancer in other parts of the body. The infiltration felt on the left side of the bladder was such that it did not seem desirable to attempt the radical measure suggested by Dr. Noeggerath. It would have been necessary in this case to excise the entire base of the bladder.

A SPECIMEN OF SUPPOSED TUBAL PREGNANCY.

DR. HUNTER exhibited the specimen, and mentioned the following facts in connection with it: The patient from whom it was removed was a multipara, 30 years of age, who had entered the Woman's Hospital several weeks before, in an emaciated condition, suffering from severe abdominal pain. On examination, an obscure rounded mass was felt behind and to one side of the uterus. The patient's temperature ranged from 100.5° to 102° F. While waiting for an improvement in her condition, she had an attack of acute peritonitis, so that Dr. Hunter determined to operate at once. Previous to making the incision, he passed a sound into the uterus, which entered so far that he suspected that the wall of the organ had been perforated. There was a profuse hemorrhage on opening the abdomen. A mass as large as an orange was found adherent to the right horn of the uterus. As it was impossible to remove this mass, and an attempt to separate it led to alarming hemorrhage, it was decided to remove as much of the uterus as possible. A rubber cord was passed around the organ, and the body was removed with the tumor.

The patient was in a very bad condition at the time of the operation, and died thirty-six hours after, never having rallied. An examination of the specimen showed that the mass attached to the uterus was a collapsed cyst which was probably a tubal pregnancy that had ruptured. The tube was examined by Dr. Coe, and was found to be dilated, and its interior being covered by a thick spongy growth, easily detachable, which showed under the microscope chorionic villi. The sac contained a large blood-clot, but no fetus could be found; it had probably escaped into the abdominal cavity. The posterior wall of the horn of the uterus adjacent to the mass was much thinned, and the sound had passed through it at this point. Dr. Hunter remarked that the history of the patient, as obtained from her physician, gave no clue to her condition; there was simply pain and extreme emaciation. The sac had probably ruptured before the operation, and given rise to peritonitis.

A SPECIMEN OF SMALL OVARIAN CYST WITH PYO-SALPINX.

DR. HUNTER showed at the same time this specimen, which he had removed three days before from a patient who entered St. Elizabeth's Hospital, giving a history of severe pain before and during her periods, with a scanty flow. The diagnosis of ovarian and tubal disease was made, and an operation was advised. On opening the abdomen, the left ovary was found to be cystic, and the corresponding tube enlarged and filled with pus. They were firmly adherent to both the intestines and omentum, so that they were removed with great difficulty. The operation was a long one, and the hemorrhage from torn adhesions was profuse, so that the patient became extremely weak, and it appeared doubtful if she would leave the table alive. The pedicle was so short and broad that it could not be tied, so it was secured by a pair of longhandled compression-forceps, which were allowed to protrude from the lower angle of the wound, together with a glass drainagetube. The patient rallied after the operation, and had done perfectly well, her temperature remaining below 100° F.

DR. MURRAY, in discussing the first case, referred to one in which a woman who was suffering from pelvic cellulitis was suddenly attacked with severe abdominal pain and symptoms of internal hemorrhage. Her abdomen was opened promptly, and it was found that the sac of an extrauterine pregnancy (of three months), which was situated behind the uterus, had ruptured. On account of the unusual situation of the sac, the diagnosis had been obscure.

DR. NOEGGERATH stated that it was sometimes possible to make the diagnosis of extrauterine pregnancy by scraping the interior of the uterus, and examining the scrapings for the large decidual cells which were so characteristic. If these were found, one could be sure of the existence of extrauterine pregnancy.

DR. GRANDIN did not believe that a positive diagnosis of ectopic pregnancy could be made before the fourth month. After that time, the presence of spasmodic pains in the abdomen, and the absence of rhythmical contractions of the uterus would justify the physician in passing a sound, and settling the diagnosis. When the sac lay behind the uterus, it was always possible to examine per rectum. The only tumor liable to be mistaken for a retrouterine sac was a small ovarian cyst. An ectopic gestation was recognized more easily, the speaker thought, when it lay behind the uterus than when it was on one side of the organ.

The PRESIDENT thought that the absence of pulsations in a retrouterine cyst would favor the idea that it was a small ovarian cyst. In regard to the second case reported by Dr. Hunter, the President thought that it opened up the subject of early ovariotomy, upon which he asked for a general expression of opinion.

DR. SIMS believed that the earlier an ovarian tumor could be diagnosticated, and an operation performed, the better were the chances of the patient's recovery. He thought that the success of British ovariotomists was due largely to the fact that they operated early.

DR. HUNTER thought that the removal of the cyst in his case

would have been much easier if it had been accomplished before peritonitis occurred.

DR. NOEGGERATH maintained that patients could often be cured by tapping cysts, when they were small, with a hypodermic needle. He had tapped several cysts in this way per vaginam, and never had any septic trouble save in one case. When the patient could not be placed under the care of a skilled operator, it was often better to resort to simpler treatment first.

The PRESIDENT asked for particulars as to Dr. Noeggerath's method of tapping small ovarian cysts.

DR. NOEGGERATH replied that, if a cyst was situated in Douglas' pouch, he tapped it through the posterior fornix; if it lay above or in front of the uterus, it was better to aspirate it through the abdominal wall.

DR. HUNTER asked if tapping was not frequently as dangerous as a radical operation.

DR. NOEGGERATH replied that it was, if the operation was not perfectly aseptic.

DR. HUNTER said that he had seen very serious results follow aspiration for diagnostic purposes.

DR. NOEGGERATH explained that he alluded to complete, and not partial, evacuation of cysts. In small cysts, the fluid was generally clear, and of a serous, non-irritating character.

DR. HUNTER asked if it was not somewhat unusual to meet with cysts which could be completely emptied by the needle.

DR. NOEGGERATH did not think so.

The PRESIDENT recalled a case in which he had ruptured a small cyst while making a vaginal examination, no evil results following the accident. In another instance, he tapped a small cyst per vaginam, and a violent attack of peritonitis resulted. He thought that if a cyst was adherent, it was perfectly safe to evacuate it in this way; but if it was movable, the operation of tapping was dangerous, and it was preferable to open the cyst freely, and to drain it. He did not wish to have it placed on record that the Fellows of the Society advocated the early removal of diminutire cysts which gave rise to no symptoms whatever.

DR. HUNTER believed that it was good surgery to remove an ovarian cyst as soon as it was clearly recognized as such.

DR. NOEGGERATH agreed with the last speaker, provided that the operation was performed by a skilful hand.

DR. GRANDIN did not see what could be gained in these cases by waiting until the cyst increased in size. He asked if Dr. Noeggerath advocated tapping through the abdominal wall.

DR. NOEGGERATH said that he did, provided that the cyst could be felt distinctly through the wall.

THE PRESIDENT did not favor aspiration until after the patient was on the operating table, or the cyst had been exposed during ovariotomy. He said that cystic ovaries were frequently discovered during vaginal examinations, but these often gave rise to no symptoms, and did not increase in size for years, or give the slightest trouble. He was disposed to take a somewhat conservative view of the subject.

DR. HUNTER asked Dr. Noeggerath if he approved of aspirating a cyst which caused no symptoms.

DR. NOEGGERATH replied in the negative. He agreed with the President in believing that many cysts remained almost stationary. In one case he watched a cyst for sixteen years; it was originally

« PreviousContinue »