C.E. Corlette
1920 The Lancet  
Hydatid disease has not lost its interest for us in Australia. It still kills people. It still furnishes problems of many kinds. And we are still finding new matter for study, from which we can reach forward to some new knowledge, and by which we can test the value of current views. The case here recorded, I think, represents an instance of this. H. H., male, aged 65, from the Coonamble district, New South Wales, was admitted to the Sydney Hospital on Nov. 2nd, 1918, complaining of pain in the
more » ... ight thigh and hip and a swelling of the same thigh, said to have existed for eight years. Eighteen years ago he had had pneumonia, but, with this exception, had apparently enjoyed ordinary health up to nine years ago, when a horse fell on the limb. It was said not to have been broken, but he had been lame eversince. Three years later he was run over by a cart, when the limb became very swollen. The swelling was incised at the time and had never entirely disappeared. The patient had walked with a stick for several years, and for the last five years had been subject to attacks of stabbing pain in the thigh and buttock. Twelve months ago he noticed the appearance of a small swelling in the groin, and three months later a larger swelling appeared below the inguinal ligament. P7.esemt condition (Nov. 2nd).-Lies with right leg everted, and is unable to rotate it inwards. The right lower limb is 15 cm. shorter than the left. There is a large, uneven tumour, smooth in contour, most prominent above and internally, and projecting there about 2 or 3 cm. It extends downwards from the inguinalligament in the femoral region to near the junction of the middle and lower third of the thigh. It is not tender on pressure, elastic, but not fluctuating. In the inguinal region is a further large swelling, which is soft and elastic to touch and gives an impulse ('?) on coughing. The swelling fills up the inguinal canal and is reduced in I size by pressure. Over the most prominent parts of the swelling the skin has a dusky red, congested appearance. Behind, a large, tense, elastic tumour can be felt below the gluteal fold. The muscle of the thigh is considerably wasted, and the upper portion of the thigh is disproportionately large as compared with the lower part. On palpation of the abdomen a large elastic mass can be felt outside the lateral border of the rectus, extending up from the inguinal ligament to the right costal margin. It is not tender except to a slight degree in the angle between the twelfth rib and the sacro-spinal muscle. The area of the mass is dull to percussion, and it is continuous with the liver dullness above. The arteries are thickened, the heart sounds distant, and the second aortic sound accentuated. The only note about the respiratory system is that the patient suffers from a cough. A radiographic examination was made, and the plate showed fracture of the right femur at its upper extremity, with appearance suggesting a new growth. There was great enlargement of the bone. The shadow of the ilium was faint and ill-defined and showed irregular defects of calcification. Op<'a:o?;. On Nov. 6th, under ansesthesia, a small incision was made over the upper of the two tumours in the region of the groin. Immediately a large quantity of a soft, mushy material, of granular consistency, and somewhat resembling boiled milk-sago, flowed out of the opening. A close naked-eye examination showed that it consisted of enormous numbers of minute hydatid cysts mixed with apparently granular material. (These granules 1 This is an abridgement of an article which appears in full in the Australian Medical Journal. were found later on to be more minute hydatid cysts, of microscopic dimensions.) The material, therefore. consisted of a pultaceous mass of closely packed hydatids. A finger was then inserted and a large cavity was discovered containing several sacculations, dividing it up into loculi. Somewhere on its mesial wall a small opening was found, at first not large enough to admit the finger. This opened out into another large sacculated cavity. extending downwards into the femoral region, and dipping deeply into the adductor side of the thigh. but subcutaneous in its anterior portion. Both these cavities contained also numerous small pieces of friable calcified deposit, one or two pieces being as large as the terminal phalanx of a finger. These pieces were obviously not bone. From beside the first cavity a small, separate sac, about as large as a walnut, was dissected out entire, and found to contain the same material as the cavities first opened. There was no trace of any mother-cyst. The cavities were washed out with saline solution, and the wound closed without drainage. -The wound looked well and matters went on all right for a week, but it gaped again, unhealed, when the sutures were removed. Immediately enormous quantities of the same soft, sago-like material began to pour out. The tense, elastic tumour behind disappeared and its site became soft and lax. The edges of the wound showed some redness, the temperature rose somewhat, though not very high. On the tenth day a few blood clots began to exude from the opening, and continued to escape till the patient died, on the twelfth day. The apparent haemorrhage was not very large. The sagolike discharge continued to the last. Post.mortem Exaiiiination. The cavity opened up at the operation was found to intercommunicate with other larger and smaller loculi around the upper part of the femur, and these again with other cavities passingup behind the iliac bone and through erosion-holes and also via the obturator foramen into the pelvis and thence upwards. The swelling which had been noticed behind the hip, below the gluteal fold, belonged to a very large cavity extending up over the dorsum ilii. It was found at the post-mortem examination that this contained, together with the material which has been described, a large quantity of blood-clot. It seemed that the chief bleeding had occurred in this cavity, and that it might be explained by rupture of a large vein on relaxation of the hydrostatic pressure as the hydatid material drained away. The large mass noted on the right side of the abdomen was found to have been produced by an enormous ramifying cavity reaching from within the pelvis up along the general course of the psoas as high as the liver, but not invading this organ or the kidney. The cavity was mesial in relation to the kidney and partially covered it. Bone lesions.-As for the bone, the right side of the pelvis was eroded everywhere, and its skeletal structure was reduced to a fretwork, or network, of thin bone. The acetabular cup had vanished, and with it had vanished the head of the femur. (Fig. 1.) Through the perforation extended a large branch connecting the upper cavity with the cavity in the femur. The neck of the femur was tunnelled by this, so that only the cortical part survived. The tunnel opened into a large gap at the top of the shaft of the femur, the trochanteric part of the bone being very widely expanded around it. The cavity here became continuous with the loculi around the femur and the dorsal surface of the ilium. The congeries of intercommunicating cavities from above the kidney down into the upper part of the thigh, notwithstanding all the drainage that had been going on, still contained several pints, perhaps several quaits, of the characteristic, creamy-white, mushy agglomeration of tiny hydatids that had oozed out at the operation. But they were not all so small. There were larger cysts, though few in number, measuring up to 2 cm. in diameter. In addition to the system of intercommunicating cavities on the right side. other separately encapsuled accumulations of the same material were discovered at
doi:10.1016/s0140-6736(00)62639-9 fatcat:nz22ml26qve7valcind2odmp7i