THE RELATIONS OF URINARY 
CONDITIONS TO GYN/ECO- 
LOGICAL SURGERY. 
BY 
CHARLES P. NOBLE, M.D. 
REPRINT FROM 
American Medico-Surgical Bulletin, 
October, 1893. TO CONTRIBUTORS. 
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New York city. Editor American Medico-Surgical Bulletin. THE RELATION OF URINARY CONDITIONS TO 
GYNAECOLOGICAL SURGERY.* 
IT gives me great pleasure to be with you 
this evening, to listen to the paper by 
Dr. Kelly, and to participate in its dis- 
cussion. The subject is one in which 
I have been interested for a long time. 
Early in my career as an operator, I had 
three deaths from suppression of urine fol- 
lowing operation, which fact impressed 
upon me the important relation between the 
condition of the kidneys and the successful 
issue of operations. I shall discuss the 
points made by Dr. Kelly seriatim, and 
from the standpoint of the practitioner, 
rather than that of the pathologist. 
i. That albumin is often observed in the 
urine of gynecological patients. 
It is my custom to have the urine of 
every patient examined several times prior 
to operation,-if possible to have it ex- 
amined at intervals of several days. The 
results of this work amply bear out Dr. 
Kelly's statement that albumin is often 
observed in the urine of gynaecological pa- 
tients. In my experience, about xo% of 
such patients have albuminuria. 
CHARLES P. NOBLE, M.D. 
* Read before the Obstetric and Gynaecological Section of the 
N. Y. Academy of Medicine. 2. That its presence is often not significant. 
I agree entirely with the reader of the 
paper upon this point, also. In general 
medicine we have learned that albuminuria 
is by no means necessarily of serious im- 
port. Frequently, it is of transient charac- 
ter due to acute conditions, from which the 
patient entirely recovers. This is more 
often true among gynaecological patients. 
Unless the urine be drawn by catheter, the 
presence of albumin in the urine may only 
mean that a certain amount of vaginal dis- 
charge, or perhaps menstrual discharge, 
has become mixed with the urine. Hence, 
the rule must be followed that the urine of 
female patients, intended for examination, 
should be drawn by the catheter. When 
this is not feasible, the patient should be 
directed to give herself a vaginal douche, 
and to wash the external genitals before 
passing her urine. In this way fairly ac- 
curate results can be obtained. 
Eliminating such external sources of con- 
tamination, albumin in the urine of women 
may be due simply to bladder irritation, or 
to cystitis. A careful microscopical ex- 
amination showing the presence of pus and 
bladder epithelium, together with its normal 
specific gravity, would show that the albu- 
min was due to bladder trouble, and not to 
renal disease. Albuminuria due to ureteral 
disease (including pyelitis) is not so easy to 
determine,-unless, indeed, the study of 
2 such cases by means of the ureteral cathe- 
ter (which subject has been brought to the 
attention of the American practitioner 
largely through the labors of Dr. Kelly) 
shall make this question clear. Albuminuria 
of renal origin is not always significant. At 
times, it is not accompanied by the presence 
of tube casts in the urine, and is of an inter- 
mittent character ; in such cases being due 
probably not so much to renal disease as to 
some interference in the metabolism of the 
nitrogenous food-products. I have had 
several such cases, and have recently done 
a coeliotomy upon one, in which large 
quantities of albumin were presentone day, 
and the following day the urine would be 
absolutely normal. The urinary condition 
was not at all influenced by the operation. 
Repeated examinations in this case showed 
the absence of tube casts, and I believe 
that the kidneys are perfectly sound. One 
class of cases in which the albuminuria of 
renal origin is not significant is that in 
which it is due to the presence of large 
tumors. Here the presence of albumin is 
due to the pressure of the tumor. 
3. That tube casts are not always significant. 
Here, also, my experience tallies with 
that of Dr. Kelly, provided great stress is 
laid upon the word "always." In cases of 
large tumors, even the presence of casts in 
the urine does not signify that the patient 
will not recover from the operation. In 
3 many such cases, the condition of the 
kidneys is directly due to the presence of 
the tumor, and when this is removed such 
patients often get surprisingly well and the 
kidneys become practically normal. But 
such cases require the most careful con- 
sideration, in my judgment. Repeated 
examinations of the urine to determine, not 
only the presence of albumin, casts, and 
sugar, but also the specific gravity of the 
urine, and the amount of urea and other 
solids it contains, are of the greatest im- 
portance. Should such examinations show 
the existence of gross structural disease in 
the kidneys, and indicate the early death of 
the patient from the kidney disease, it may 
be questionable in such cases whether it is 
wise or justifiable to operate. The presence 
of " chronic contracted kidneys" is apt to 
get the surgeon into serious trouble. In 
such cases, not infrequently albumen is 
absent, or only occasionally present, and 
then in very small quantities. Tube 
casts may be absent, or, at least, the most 
careful examinations will at times fail to 
reveal them. If repeated examinations of 
the urine show occasional presence of 
small quantities of albumin and of granu- 
lar casts, and a low specific gravity, the 
surgeon should be on his guard. A woman 
having such kidneys will not stand a serious 
and prolonged operation. She will die 
from shock or from suppression of urine. 
4 I will draw attention presently to certain 
practical divisions of cases having kidney 
disease. I believe that the prognosis after 
operation is most favorable in women 
having fairly large tumors, especially 
ovarian-cysts. Here, in general, the ope- 
ration may be conducted quickly and 
easily, and no septic material is present. 
When the pressure of the tumor is removed, 
this aids the crippled kidneys, and the re- 
sult usually is that they secrete as much, 
or even more, urine than normal kidneys. 
An illustrative case will be given. 
When the cysts are small,-or, in other 
words, when the kidney disease has no 
relation to the tumors,-the prognosis de- 
pends entirely upon the amount and 
character of the kidney disease. The fac- 
tor of the removal of intra-abdominal pres- 
sure will not come into play in this class of 
cases. 
In cases of tubo-ovarian inflammation, 
especially of marked character, in women 
whose health is entirely broken-down, the 
prognosis is very bad, when the renal 
disease is of a serious character. (Of 
course, the mere presence of albumin in 
the urine, due to bladder trouble, would 
not influence the prognosis.) The reasons 
why such cases do not do so well as cases 
of large cysts is clear. The factor of the 
removal of mtra-abdominal pressure is 
absent here, and, in addition, we have a 
5 long operation, involving considerable 
handling of the pelvic viscera, and usually 
the escape of septic matter into the peri- 
toneal cavity, necessitating irrigation and 
drainage. The long operation and the 
handling of the abdominal viscera promote 
shock, and such patients are apt to die from 
suppression of urine. I speak from an ex- 
perience of two deaths. 
Occasionally, women will have suppres- 
sion of the urine after operation, even 
when no kidney disease exists. I have had 
one such case, in which the operation was 
very simple. 
4. The secretion of urine is diminished 
after operation for several days. 
This statement is a matter of universal 
observation. I have had records kept of 
the amount of urine passed by patients 
after abdominal section in all my cases. 
These records are practically accurate. In 
the time at my disposal, it was not possible 
to look through the entire list of cases, 
hence, I have selected the last fifty con- 
secutive coeliotomies for tabulation. Dr, 
W. E. Parke, assistant in gynaecology 
at the Kensington Hospital for Women, has 
kindly prepared this table for me. We 
find that the patients pass, on an average, 
ten ounces of urine the first day after ab- 
dominal section ; fifteen ounces, the second 
day ; thirteen ounces, the third day ; fifteen 
ounces, the fourth day; and nineteen 
6 ounces, the fifth day ; after which time the 
amount gradually increases. There are 
certain sources of error in this table. The 
first cay really includes only about eighteen 
hours, and is made up of that part of the 
day of the operation subsequent to the hour 
of operation, and the following night. The 
other days are twenty-four hours each. On 
the third day, at times, the amount of 
urine is estimated, because upon that day 
the patient's bowels move. With the free 
purgation, which is usually secured on that 
day, naturally the amount of urine secreted 
is less. The same slight source of error 
exists for the subsequent days. One pa- 
tient died at the end of twenty-four hours. 
The smallest amount of urine passed on the 
first day was three ounces,-the largest 
amount thirty-three ounces. The smallest 
amount passed on the second day was six 
ounces,-the largest amount twenty-nine 
and a half ounces. 
As illustrating what I have said with re- 
ference to the relation of the condition of 
the urine to operation, I will make bnet 
reference to the following cases : 
Case i illustrates the fact that suppres- 
sion of urine may follow coeliotomy, even 
after simple operations in women having 
sound kidneys. This patient had healthy 
kidneys, and the operation consisted in re- 
moving the ovaries, the seat of chronic in- 
flammation ; yet, on the third day, she 
7 developed an acute nephritis, was extremely 
ill with uraemic symptoms, but fortunately 
recovered. 
Case 2 illustrates the danger of death 
from suppression of urine, after even a 
simple cceliotomy, in women suffering with 
well-marked chronic kidney disease. This 
woman had small contracted kidneys, and 
was a physical wreck at the time of opera- 
tion. The operation consisted in the rapid 
removal of a small ovarian tumor, and of 
a small par-ovarian tumor,--the operation 
consuming only fifteen minutes. In this 
case, the kidney disease had antedated the 
presence of the tumor, and the vitality of 
the woman was so reduced that the shock 
from even so simple an operation caused 
death from suppression of urine. 
Case 3 illustrates the favorable issue of 
operations for large ovarian-cysts, when 
albumin and casts are found in the urine as 
a result of the pressure of the tumor. This 
patient was a feeble and greatly emaciated 
woman, who consulted me when the 
ovarian tumor was very large, quite no- 
dulated, and very painful. The presence of 
albumin and granular casts in the urine, 
the nodular outline of the tumor, and the 
the fact that it caused great pain (giving 
rise to a suspicion of malignancy) caused 
me to give a guarded prognosis as to the 
issue of the operation. The patient's con- 
clusion was that, as I could not promise 
8 her positively that she would recover from 
an operation, she would live as long 
with the tumor as possible, and then have 
it out. She carried out this purpose liter- 
ally, and it was not until her kidneys were 
greatly crippled, and that she was suffering 
with paresis of the bowels, and with or- 
thopnea from the pressure of the growth, 
that she desired operation. The removal 
of the tumor was easily accomplished, and 
she made as good a recovery as any patient 
upon whom I have ever operated. Curi- 
ously, she passed very much more urine 
after her operation than is the rule ; the first 
day, passing 29^ ounces; the second day, 13 
ounces, which were measured, and very 
much more with bowel movements ; the 
third day, 25^ ounces, etc. The condition 
of the urine constantly improved, and at 
the present time (three months after opera- 
tion) it is perfectly normal. 
Cases 4 and 5 illustrate the grave prognosis 
as to operations done for well-marked in- 
flammatory conditions of the uterine ap- 
pendages in women having serious chronic 
kidney disease. Case 4 had small con- 
tracted kidneys, and was the subject of 
both gonorrhoea and syphilis (tertiary). 
Her general health was fairly good. The 
operation consisted of the rapid enucleation 
of diseased uterine appendages from a pel- 
vis absolutely filled up with exudate. The 
duration of the operation was thirty-five 
9 minutes. She went to bed in good condi- 
tion, did well for two days, then developed 
uraemic symptoms, and died on the fifth 
day. 
Case 5 was, perhaps, the worst subject 
for a serious operation in my experience. 
She had been an invalid for several years, 
had albuminuria, due to large white kid- 
neys, and was so debilitated at the time of 
operation that she had been confined to her 
bed for some weeks. This was one of my 
early operations, and I might here add that 
1 should not operate at the present time 
upon such a patient for tubo-ovarian in- 
flammatory conditions. The operation 
was extremely difficult and lasted forty 
minutes. Upon the left side, on addition 
to the diseased tube, a small intra-ligament- 
ous ovarian-cyst (the size of an orange) 
was removed. When the tumor was enu- 
cleated from the broad ligament, the ureter 
came up with it. The ureter was separated, 
and dropped back. It was observed to be 
very much thickened, and the supposition 
was that the woman had a surgical kidney, 
which proved to be the case. Suppression 
of urine followed the operation, and she 
died on the third day. 
Case 6 illustrates the fact that albuminu- 
ria, and even casts in the urine, when due 
to acute inflammatory conditions of the 
pelvis (and, personally, I believe that cys- 
titis and nephritis are often induced by 
10 suppuration connected with the uterine ap- 
pendages), are not a bar to successful re- 
sult after operations done for the removal 
of the diseased uterine appendages. Miss 
P., aged nineteen, contracted gonorrhoea in 
December, 1892. She had a sharp attack 
of pelvic peritonitis in that month, and a 
second one in January, and a third one in 
March. In April and May, she bled very 
freely from the womb, and, when I saw 
her in consultation, I found the bed elevated 
to prevent syncope. 
Examination showed a large, fixed mass to 
the right of the womb, and a hard, doughy 
mass extending behind the womb, and to 
the left side of the pelvis. The history of 
the case, and the physical conditions pres- 
ent suggested a diagnosis of ruptured 
extra-uterine pregnancy. It was recognized, 
however, that the conditions might be due 
to tubo-ovarian inflammatory disease. 
This patient's urine contained a large 
amount of albumin and hyaline casts, but 
its specific gravity was 1,032. Operation 
showed a suppurating right ovarian tumor 
and double pyosalpinx. She made an un- 
interrupted recovery; passing 16 ounces of 
urine the first day ; 15, the second ; 16, the 
third ; 18, the fourth, etc. The condition of 
the urine is now normal. 
In conclusion, I would emphasize espe- 
cially the following points : 
1) The importance of the systematic ex- 
11 amination of the urine of gynaecological 
patients, especially of those requiring coelio- 
tomy. 
2) That the presence of albumin and of 
casts in the urine need not affect the issue 
of the operation. 
3) That serious and prolonged coelio- 
tomies, involving much handling of the ab- 
dominal viscera, in women having chronic 
Bright's disease (especially the small con- 
tracted kidney), usually terminate fatally. 
4) That the prognosis is best when the 
presence of albumin and casts in the urine 
is due to the pressure of a large ovarian 
cyst which can be rapidly removed. 
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