Various opinions had been expressed in reference to the diagnosis, but I do not think a definite conclusion was arrived at until I acci dentally discovered hooklets in the freces. This gave the clue to the case. The other symptoms were due to the great pressure exercised within the pelvis. Both kidneys were hydronephrotic, the ureters largely dilated, and the intestines distended and impacted with forces. By degrees this state of abdominal and pelvic infarction became com plete, and it was difficult to know what was best to be done for the patient. A laparotomy appeared out of the question, and to open and drain the cyst by a direct incision through the abdominal wall did not in the matter of subsequent drainage commend itself to me.
Mr. Durham was good enough to see the case with me and Mr. Rand. After a very careful consideration from all points of view we came to the conclusion that it would be best to open the cyst from the perineum between the bladder and rectum, and thus to empty and drain the cavity. This was accordingly done, and I made my perineal incision just as if I was performing a lateral lithotomy but without opening the urethra. The position of the latter was indicated to me by a flexible bougie passed into the bladder. I then made my way between the prostate and the rectum until the cyst was reached. This was freely opened by incision, when a large mass of hydatids suf ficient to overfill a quart vessel was evacuated, the process of extru sion being assisted by abdominal pressure and the use of a lithotomy scoop. There was very little hemorrhage. A large gum-elastic drainage-tube was introduced and secured.
A number of daughter cysts were subsequently passed and free drainage and irrigations were maintained. The hydronephrotic con dition gradually subsided, and in the course of a short time the dis tended abdominal viscera had gradually returned toward their nor mal dimensions. The patient was able to go home at the end of three weeks from the private hospital where the operation was performed. The perineal wound still continued to drain, and the only symptoms the patient had to overcome were those directly clue to the morphine habit which by reason of his previous sufferings he had acquired. The distention of the abdomen, partly by the hyclatids and partly by the enlargement proceeding from the intestines and the hydro nephrotic ureters and kidneys, rendered the case a remarkable one.
In the treatment of hydronephrosis it must not be forgotten that in some this condition is due to the impaction of the ureter by a calculus or even by a plug of necrotic renal tissue. This would not be unlikely in a case where the local signs had been preceded by the history of renal colic, or by the escape of renal calculi by Under such circumstances a trial should be made to facilitate the extrusion of the obstruction from the ureter, as by the use of manipu lation and shampooing of the loin. Two instances at least of this
nature are reported, one by Sir William Broadbent (referred to by Morris) and the other by Sir William Roberts, where the loin tumors subsided under such efforts.
It is remarkable how little it sometimes takes to induce a calculus to move downward, and where a ureter is more or less permanently dilated, as in the case of persons who frequently pass calculi, the explanation is obvious. Reference has been made by me to the fact" that the injection of water into the bladder so as to distend it has occasionally proved of assistance in favoring the release of a calculus clown the ureter. This process has also been found of service in expediting the discharge of tuberculous debris from the kidney. It would probably also be useful in those exceptional cases, such as the one recorded by Dr. Rattray and Mr. Greig Smith," where sloughs of renal tissue made their escape by the urethra. Again it is of ad vantage in suppurative pyelitis, by assisting the escape of matter downward. It has been noted that after its adoption high tempera tures from the retention of pus have ceased. Here causes are enu merated sufficient to start or maintain a hydronephrosis.
Reference has already been made to the difficulty that exists in determining between a large hydronephrosis and an ovarian cyst. A somewhat similar difficulty may also occur in the case of ascites and hydatid cysts. A dilated kidney can generally be recognized by the colon being in front of the swelling, and by the absence of resonance in the lumbar region. Further, much direct information relative to an ovarian cyst may be obtained by a vaginal examination. Ascites often coexists with advanced hydronephrosis, but the changes in the level of the fluid arising out of altered positions of the body usually enable us to recognize this dropsical condition. Hydatids may be suspected by the presence of a characteristic fremitus as well as by vesicles in the urine.
Taking the instance of a single hydronephrosis which continues to fill and cause pain or inconvenience, in spite of the repetition of as piration, what further steps can be taken? The more radical meas ures of nephrotomy, or opening the kidney from the loin and drain ing until the sac either consolidates or is reduced to the condition of an innocuous sinus, or the still more complete measure of nephrectomy or removal of the kidney, have both been recommended and practised. I am in favor of the former and would prefer its adoption, unless the necessary exploration through the loin that this entails leads to the discovery of a kidney which is completely disorganized. In the latter case a prolonged suppuration would certainly overtax the strength and endurance of the patient, and nephrectomy is indicated. These two operations will be described later on.