A Case of Hysterectomy for the Relief of Pyelitis from Obstruction
Boston Medical and Surgical Journal
Hospital; Clinical Instructor in Genito-Urinary Surgery in Har var d University. Before proceeding to the consideration of the case I have to report, I wish to allude briefly to the postmortem examination of another case, which I saw during the last days of life, and which illustrated very well the condition to which my patient might have expected to come, had she not been relieved by operation. In August, 1886, 1 saw a lady of over seventy, who had, for years, carried a fibroid tumor of the
... oid tumor of the uterus of moderate size. Many years before, she had suffered much from it, but it had finally become quiescent, and had gradually hardened and settled down into the pelvis. She had been troubled for u long time with frequency of micturition, and about a year and a half before I saw her, after a fall, she had an acute attack of pelvic inflammation, with an aggravation of urinary symptoms. The urine, at this time, became loaded with pus, and during the year before her death, she on several occasions passed small bits of phosphatic material. The pain in the bladder gradually increased in severity, urination became extremely frequent, with almost constant tenesmus, and she finally died in a ura^inic condition, with suppression of urine. For the notes of the autopsy, 1 am indebted to Dr. H. C. Ernst, who made the examination. He found that the fibroid, which sprang from the anterior uterine wall, and weighed four-and-a-half pounds, was almost completely calcified, and was so matted down into the pelvis by inflammatory adhesions, that it was with great difficulty that it could be dissected .out, with the bladder and rectum adherent to it. The bladder was very much contracted, and the walls thinned, evidently by pressure. It contained but a few drops of thick, ammoniacal urine. The urethra was normal, but the ureters, in their passage over the brim of the pelvis, had been pressed upon by the uterine tumor, so that above this point they were much dilated, having the calibre, on both sides, of a very large lead pencil. Their walls were much thickened and congested, and a little pus was found in each. The kidneys were large and soft, very dark-red in color, with their capsules extremely adherent. The pelves were much dilated, and full of masses of phosphatic material. The secreting substance of the kidneys was diminished in amount, of a dull red color, with well-marked Malpighian corpuscles. The proportions between the medulla and cortex were very little altered. We had here, then, an obstruction of the ureters by the pressure of a uterine fibroid, leading to chronic pyelitis, and finally, to pyelo-nephritis and death. In this case, the symptoms of obstruction to the ureters came on late in the history of the fibroid, and were possibly due to the settling of the tumor into the pelvis, and to the strong adhesions which it contracted in that position. 1 Read before the Association of Genito-Urinary Surgeons, at its meeting, May 17 and 18, 1887. In the case which I have now to report, pyelitis occurred as an early symptom, while the removal of the tumor was yet possible. Christine McL., aged twenty-five, a pale and thin young woman, was referred to me by Dr. J. E. Garland, of Gloucester, in December, 1886. She had a tumor, about the size of a child's head, occupying the lower median part of the abdomen, and projecting deep into the pelvis in Douglas's pouch.. The os uteri was to be felt anteriorly, high up, and the body could be indistinctly made out behind the pubes. Above this,a little to the right of the umbilicus, was a second tumor, about as large as a small orange, somewhat movable, but seemingly attached by pedicle to the larger growth below. In neither of these tumors could any fluctuation be detected, but over the whole anterior surface of the larger one, was a layer of fluid, which the passage of a catheter showed to be in the bladder, which was flattened and pressed up against the abdominal wall. The patient discovered the existence of a tumor about two years before, since which time its growth had been slow, but steady. At first there had not been much pain, but within the last six months she had had intermittent attacks of abdominal and pelvic pain, which were brought on usually by exertion, and incapacitated her from work. Micturition had lately been much increased in frequency, often coming with intervals of but half-anhour. The urine was alkaline, with a specific gravity of 1012. It contained considerable sediment, which consisted of pus, a little blood, bladder and vaginal epithelial cells, and triple phosphate crystals. The diagnosis was of either a fibroid, or an extremely tense, thick-walled cyst, wedged behind the uterus. The smaller tumor above was thought to be an accessory cyst or fibroid. The condition of the urine, and the character of the micturition, was ascribed to cystitis from pressure. At my advice, she entered the Massachusetts General Hospital. Owing to absence from the city, I did not see her again for two weeks, when, on my return, I found her in bed in a febrile condition, with evening exacerbations of temperature. She was suffering from pretty severe abdominal pain, and there was considerable tenderness, especially about the small tumor. It seeming probable that suppuration was starting in connection with one or other of the tumors, the patient was etherized, and the abdomen was opened. It was found that the large growth was a fibroid, starting from the posterior uterine wall, and firmly fixed in the pelvis, from which it could not be dislodged by any ordinary force. The smaller one was a little ovarian cyst, which, in consequence, apparently, of the pressure of the fibroid on its pedicle, was in a sloughing condition. This cyst was removed, and, in view of the feeble, feverish state of the patient, it was thought best, in the absence of special indications, to leave the fibroid. The other ovary was sought, but was fixed so deeply in the pelvis, behind the uterine tumor, that it could not be removed. The fever now disappeared, and the patient recovered quickly from this operation. During her stay in bed, with the aid of bladder irrigation, the urine lost its alkalinity, and the frequency of micturition came down to about what is normal. Before she was able to be up, however, she began to have pain through the left side of the back, and in the lower part of the abdomen on that side.