Donald Macgregor
1865 The Lancet  
590 cut down on the pelvic tumour through the perineum. In doing so, the incision was at first guided by the introduction of a catheter into the urethra, and, having opened this canal, ' , incisions were made, guided by the index-finger of the left i hand, backwards towards the tense tumour, which was felt deeply seated. This was then punctured with the trocar and canula, and its contents were at once recognised as being hydatid. Knowing that a free outlet would be required for the escape of
more » ... or the escape of such a quantity as the cyst evidently contained, I at once laid open the perineum backwards into the rectum, thus leaving one deep wound bounded by the urethra at its upper border, the posterior surface of the bowel at its posterior, and the cyst at its base. With a bistoury I then made a free incision into the hydatid cyst, and, by means of my finger, forceps, and spoon, evacuated upwards of three quarts of hydatid cysts. Some were firm and globular; many were broken; whilst others had evidently been dead for some time. The cavity occupied by the cyst was then well washed out. My attention was next directed to the condition of the bladder, which could be distinctly felt through the abdominal walls as a large cyst in the left iliac fossa; and it was remarked that the large abdominal tumour had disappeared, and that the intestines had probably floated over its site, as indicated by resonance. From the perineal wound, however, the bladder could not be detected. Some little time was expended in an attempt to introduce a catheter through the urethra, but without success, and consequently other means had to be employed. With the assistance of Mr. Haslop, who placed his hands firmly upon the bladder over the abdomen, the distended viscus was pressed somewhat downwards, and with a firm upward simultaneous pressure of the hand, with the finger introduced through the perineal wound, the distended bladder could be clearly felt, having been pushed completely out of its natural situation into the left iliac fossa. The prostate gland could not be clearly made out. The bladder was then punctured with the trocar and canula, and upwards of a quart of darkcoloured urine drawn off. An elastic catheter was then passed through the canula into the bladder, to avoid the chance of the latter becoming displaced, and both were fastened in. The patient expressed himself as being at once relieved. Warm brandy-and-water had been freely given during this tedious operation, for chloroform was refused; and before we left the house the patient appeared to be very comfortable. Directions were left that he should be well supported by good food and stimulants, and that the hydatid-cyst cavity should be washed out twice daily, a weak solution of the hyposulphite of soda being employed. It must be added that this patient went on well for three days, when his powers bpgan to fail, and on the seventh day he died. After death it was found that he had diseased kidneys. Remarks.-The first point which strikes the attention on reading the history of this case is the peculiar character of the first two attacks of retention of urine: both came on after a more prolonged urinary retention than the patient usually allowed; in both skilled surgeons failed to afford relief by means of the catheter; and in either instance the bladder resumed its functions and the urethra its patency without assistance. The stream of urine before each attack, and after, was of a normal nature, and it is to be remembered that after the second the urethra was carefully examined and declared to be sound. Under such circumstances, it was somewhat difficult to explain the cause of the retention, although, from the subsequent history of the case, it is now tolerably clear that it was produced by the presence of the hydatid cyst. But in what way could such a retention be brought about? I would venture to suggest the following explanation as the most probable. It is tolerably clear that the hydatid cyst had pushed the bladder well up into the left iliac fossa, elevating the whole viscus and prostate from the pelvis, and thus stretching the urethra, and displacing it completely to the left side. It is also clear that for many years the bladder had never been, as a rule, well filled, and for many months it had never held more than an ounce of urine. Under such circumstances it seems probable that in the expansion of the bladder, so placed against the bone in the iliac fossa, the urethra would be bent sideways at an angle towards the centre, and thus a retention would be produced. The natural relief also seems capable of a somewhat similar explanation ; for let the distended bladder become still further distended, the pressure upon it from the cyst would be comparatively greater, and, as a result, the bladder would be pressed still further upwards, and the urethra I i again made straight by stretching ; the natural channel would thus be again reopened, and relief secured. Respecting the present seizure, it is to be noticed that it had been induced by the same cause as had brought on the two former-compulsory retention,-and that the passage of a, catheter into the bladder was likewise impossible. It was accompanied neither with any great constitutional disturbance, nor with much local distress, although it was tolerably clear that both the retention of urine and constipation were produced by the same cause, mechanical obstruction. The peculiar aspect of the abdominal tumour, its prominent projection on one side, and its unequal enlargement, were points of striking. interest, and appeared to indicate the presence of something more than an enlarged bladder ; although a distended bladder is not always symmetrical, and the history of the case went to prove that there had been a gradual encroachment of a pelvic tumour upon the organ. This opinion was also strengthened by the statement of the patient, which was extracted from him during his treatment, that he had never passed more than two tablespoonfuls of urine at one time for a great many months, and had often felt as though the lower part of the bowel was paralysed. In the treatment of the case there is nothing worthy of special comment; it was suggested by the necessities of the occasion. The diagnosis of a pelvic and abdominal tumour having been made, it was deemed the wisest course to open it through the perineum; for the true position of the bladder was most uncertain, although the passage of a catheter down the urethra appeared to indicate that the bladder had been pushed up into the leftiliacfossa; there was, however, no certainty in that conclusion, and even if such a fact could have been made out, it is questionable whether another form of practice would have been preferable. There was not much difficulty in finding the cyst through the perineum, nor any in emptying it when once opened, a free outlet having been made for the escape of its contents-a point of practice which appeared to be a necessity. The difficulty in finding the bladder through the perineal wound was very great, but, when this was surmounted, the propriety of puncturing it could not have been doubted. The immediate relief to the patient was very marked. Finsbury-square, Nov. 1865. A SUCCESSFUL excision of the hip-joint has been so rarely, if ever, accomplished in Scotland, that I trust the following case may not be uninteresting to the numerous readers of THE LANCET. I shall first give a rough outline of the history of the case from the commencement of the disease up to the time of operation, then describe the operation itself and the after-treatment. James M-, aged seventeen, in humble circumstances and of strumous habit, two years ago suffered from a pain in his left hip, which he likened to "rheumatic pain." " He thought lightly of this till, in the course of a month, the pain increased so much that he was unable to walk to his work, and he sought admission to the Royal Infirmary. After a week's rest in bed he felt so thoroughly recovered that he was dismissed to resume his work. In a fortnight afterwards, however, pain in the hip returned with increased severity. He was obliged to leave off work again, and seek parochial relief, and was accordingly admitted to this hospital. In spite of rest, the long splint, good diet, and cod-liver oil, suppuration took place. The matter pointed on the outer aspect of the hip, opposite the root of the great trochanter. Free vent was given to the pus, and poultices were applied, with a continuance of rest, to the affected joint, the limbs being now tied to a pillow placed longitudinally between them. The discharge having gone on for many months, while the patient was supported on wine, porter, and good diet, it gradually dried up, the skin cicatrized, and the patient began to improve. The case went on well for a considerable time, whilst the limb was kept at rest with a view to anchylosis. Reason-
doi:10.1016/s0140-6736(02)50325-1 fatcat:7o5jzp5bojdxrc354jczkqylp4