HYDATID CYST OF THE PROSTATE.
The following case is presented not only because of its rarity, but because of the questions of diagnosis involved.
I have called it an " Hydatid Cyst of the Prostate" be cause I can come to no other conclusion in regard to its ana tomical situation. The following history is taken from the records of my service at Bellevue Hospital.
G. H., thirty-nine years of age, single, a laborer, born in Germany, living at 105 Bowery. Admitted to Bellevue Hospital October 13, 190o. Pulse and temperature normal.
Patient denies all venereal history. He says that he never had difficulty in making urine until the present acute attack. On Thursday, October II, first noticed that he was passing very little urine. On Friday morning he had considerable pain in the region of the bladder, but was still able to pass a little urine. By Friday afternoon, October 12, the pain was intense and the retention was complete. The last urine was passed Friday evening, October 12, just before dark, and the quantity was very little. The patient was admitted to Ward 4 on Saturday morning, October 13, at 12 A.M. He was in great pain ; his abdomen was immensely swollen, and the outline of the bladder could be made out above the um bilicus. He was catheterized by the House Surgeon at 12 A.M., and sixteen ounces of pale, clear urine were withdrawn. This operation was repeated at intervals of about two hours for the first twenty-four hours, more and more urine being taken each time. It was found that 162 ounces of urine had been secreted in the twenty-four hours. This was repeated until on the second day, namely, October 15, the bladder was gradually and finally emptied, and he voided spontaneously two ounces. It was the first that he had passed spontaneously since entering the hospital. The House Surgeon reported that, although the bladder was apparently empty, there was a large tumor in the hypogastrium, extending over into the patient's left inguinal region.
He was examined by Dr. Bangs at 3.30 in the afternoon of Saturday, the 15th. His urethra was irrigated with boric acid solution ; a soft catheter was then introduced and his bladder emptied, sixteen ounces of urine being withdrawn. It was ob served that the catheter entered to an unusual degree before reaching urine; and the length of the urethra, that is to say, the length measured on the catheter from the point at which the urine flowed to its fenestrum, was ten and a half inches. A searcher was then introduced, and when its beak reached the prostatic urethra, the instrument rotated to the patient's right through an arc of, say, fifty or sixty degrees, and some manceuvring was necessary before it would enter the bladder. Searching of the latter was negative, excepting that all movements of the instru ment were limited on the patient's left.
October 16. It is still necessary to catheterize the patient about every four hours, but once during the day he voids spon taneously six ounces of urine. The patient is kept absolutely quiet in bed, and is receiving seven and a half grains of urotropin three times a day.
October 17. Patient voided twelve ounces spontaneously in these twenty-four hours. The patient is again examined ; the bladder is completely emptied by the catheter, and then palpation shows a tumor occupying part of the hypogastrium, beginning three fingers' breadth to the left of the median line and extending thence into the left inguinal region for a distance of four and a half inches ; it extends upward in these same regions nearly to a line drawn horizontally through the umbilicus. With two fingers in the rectum, the prostate is felt to be normal on the patient's right, but the left lobe is round, much larger than the right, and its posterior and lateral margins cannot be defined from the mass in the pelvis with which it seems to be continuous. Bimanual pressure either elevates or depresses the whole tumor, according as the pressure is made against the left lobe of the prostate with the fingers in the rectum, or with the other hand over the hypogastrium. It is spherical in shape, and there is a distinct sensation of elasticity conveyed to the fingers, but no sensation of fluctuation, fremitus, or ballottement. It seems to be connected with the prostate.
Urinalysis by Dr. Goldhorn, pale, acid, 1012; urea, 1.5 per cent.; albumen, faintest possible trace ; no sugar ; sediment, very scanty ; shreds of mucus, embedded in which are many leuco cytes, small cells, and spermatozoa ; a few crystals of calcium oxalate. The patient has been gradually resuming spontaneous urination until, on October 23, one catheterization during the twenty-four hours shows residual urine in the bladder of five ounces. Patient seen in consultation by Professors B. Farquhar Curtis and A. A. Smith, who agreed that exploratory operation was necessary to determine seat and nature of tumor.
October 29. Residual urine one ounce and a half.
November 2. Patient was operated upon by Dr. Bangs, as sisted by Dr. B. Farquhar Curtis, and the enlargement of the left lobe of the prostate verified with the searcher by Dr. Curtis. The bladder was entirely emptied by the catheter. A vertical incision in the median line three inches in length ; the tumor was exposed and found to be continuous with the left lateral hemi sphere of the bladder. In order to examine it thoroughly, the incision was extended upward to the umbilicus and downward near the pubes. The hand could be passed around the tumor upon its upper aspect, and a few small and easily separated adhesions to the intestines were found ; its left lateral aspect was free for its upper third, below this it was firmly attached to the tissues of the pelvis. The large iliac vessels could be felt distinctly ad herent to its outer surface, curving around its spherical circum ference. The finger could not be introduced between the tumor and the rectum, nor between it and the bladder, nor between its anterior surface and the inner surface of the descending ramus of the pubic bone. The abdominal cavity was shut off with pads ; an aspirating needle was introduced in the tumor and twelve ounces of a clear, serous fluid were withdrawn. A trocar and can nula were then introduced and some eight ounces or more were evacuated, but some of the fluid was lost. The tumor contained possibly in all about twenty-five ounces of fluid.
The tumor was then brought up into the wound, widely laid open, and many collapsed secondary cysts found in it and re moved. About twenty of these appeared to be complete. Others were in fragments, which made it impossible to estimate the total number of the secondary cysts. Four or five" pearls" were found. The inner lining of the sac was rubbed dry and all the cysts cleared away. It was found to be impossible to remove the sac, there fore the edges of its opening were stitched with silk to the ab dominal wall in the lower fifth of the incision ; two drainage tubes were inserted in the sac, and the abdominal wound closed. Microscopic examination showed the presence of hooklets and many secondary cysts in the fluid evacuated from the tumor.
November 4. Wound clean. Slight amount of thin fluid from the drainage tube.
November 8. The patient has been dressed daily ; primary union of the abdominal wound. Cavity of the sac washed daily with i to 5000 bichloride. Discharge from the interior diminish ing daily.
The cavity rapidly diminished in size, leaving a narrow sinus, which finally entirely closed about the 1st of January, Isom, say, in about eight weeks.
In my opinion, the case is one of prostatic origin for the following reasons : ( ) The length of the urethra, viz., ten and one-half inches, in a young man of thirty-nine years of age in whom were no evidences of an inflammatory process.
(2) The obstruction to urination was at the neck of the bladder and in the situation of the left lobe of the prostate, the latter being found to be asymmetrically enlarged.
(3) The notable rotation towards the right of the beak of the searcher as it came in contact with the left lobe of the patient's prostate, and the left lateral deflection of the handle of the instrument to enable its distal end to curve around (so to speak) the obstruction.
(4) The situation of the tumor as determined by digital examination by the rectum, as verifed by two other observers; but this is admittedly inconclusive.
(5) The findings at the time of the operation. A careful search of the literature within our reach has been made for me by Dr. Goldhorn, and it is interesting to note how few cases of this seat of hydatid cysts are on record. Out of twenty-three cases of hydatids of the pelvis tabulated by M. Nicaise (Bulletin de la Societe de Chirurgie, in 1884), there are but seven which have any close relation to the pros tate, and the diagnosis is so doubtful that Henry Thompson does not hesitate to say, "It is doubtful if hydatid cysts have ever been met with in the prostate." tle is inclined to think "that all cases of hydatid of the prostate are cases of hydatids between the bladder and the rectum, the prostate gland having been more or less absorbed by pressure from an external cyst, so that the latter came at length to occupy the seat of this organ." Notwithstanding this ingenious argument of Sir Henry Thompson, with which he attempts to throw doubt upon the situation of the tumor, there are three cases which we have been able to find which seem to me to correspond with mine and fortify me in the diagnosis which I feel warranted in making. There may be others, but I have not been able to find them.
It may be interesting to quote these somewhat in extenso in order to compare them with the case which I have just presented to you. (Extract from Transactions of the Medico Chirurgical Society, Vol. xxix, p. 253, Anno 1846, George Lowdell, Esq.) Whether the hydatid cyst was formed in the prostate itself or external to the organ, destroying it by pressure alone, is stated to be a matter of doubt. Appearances led Mr. Lowdell to the former view. Mr. Lowdell expressed this belief, but added that he "should be scarcely warranted in maintaining that opinion without question," because hydatid disease of the prostate was not on record, and that there were other tumors in the omentum. Just what the latter fact had to do with the development of doubt in his own mind, I do not see.
M. Tillaux reported to the Societe de Chirurgie in 1883 the following case : Man aged forty-three, a waiter, who entered hospital Sep tember 23, 1882, and was discharged November 3. For a year past patient has had to get up frequently at night to micturate; constipation and diarrhcea have alternated for about two years ; hence these symptoms preceded the bladder symptoms for about a year. The patient cannot work on account of pain in his back at the level of the sacrum, and he defecates only with great diffi culty. He entered the hospital on account of retention of urine. Examined by M. Tillaux on September 29, a rectal examination showing a voluminous prostate, entirely smooth, the two lobes blended, and no median furrow can be made out ; consistency elastic ; fluid seems to be present. Two fingers could not be in troduced so as to be able to induce fluctuation. A little pain upon pressure. The tumor seems to be equally voluminous anteriorly. The hips of the patient were elevated by means of a bolster, and an effort is made to introduce a metallic catheter, but he can only reach with the point of the instrument the internal orifice of the urethra, and barely a few drops of urine are ob tained. Although the bladder is full of urine, no kind of cathe ter will enter, and M. Tillaux gave up all efforts at catheteriza tion.
It is stated that the patient has in the right lateral region of the thorax a cicatrix of a cold abscess ; the diagnostic inference is therefore made that the liquid in the prostate might be a cold abscess.
On the 9th of October an incision into the rectal face of the prostate was made with a bistoury, which was guided by the finger ; a clear liquid, resembling urine mixed with blood, ran out. M. Tillaux put his finger into the sac to a depth of six or seven centimetres; the sac seemed to be divided into chambers.
On the loth the patient passed clear urine, but with diffi culty; and this A.M. the bladder was distended with urine. He had pains in the abdomen, some fever, and, briefly, symptoms of peritonitis.
October 12. Urination free. Patient passed per rectum a membrane resembling a hydatid.
October 13. More hydatid membranes per rectum. October 16. Urinates freely.
October 17. Rectal digital examination shows the prostate to be still somewhat voluminous. The incision can be felt, and it has not yet closed.
On the 3d of November the patient left the hospital for his home.
A discussion ensued which shows the difference of opin ion existing in regard to these cases. Tillaux says that this is a very rare case; that Le Dentu tried to show that hydatid cysts of the prostate do not exist, but he claimed that no doubt exists in this case. M. Marche thinks it advisable to be cer tain that the cyst was not in the cellular tissue between the rectum and the bladder. M. Lannelongue thinks the cyst might have been in the muscular tissue of the rectum, and thus have given rise to the phenomena reported. M. Perrier agreed with these two gentlemen ; quotes Davaigne (Traite des Ento zoaires), who describes some cysts of the true pelvis which have given rise to similar phenomena ; M. Tillaux insists that his cyst was located in the prostate, and, moreover, that it was in the glandular tissue of the organ.
Another case was that of M. Millet, reported by M. Ni caise to the Societe de Chirurgie in 1884.
M. Millet was called to see a patient on July 16, 1882, who had retention of urine ; patient was aged fifty-nine ; he had had difficulty in urination for an indefinite period. The existence of a voluminous tumor occupying the region of the prostate was established. Attempts were made to catheterize the patient with different catheters, and, finally, a soft rubber one entered the bladder. There was recognized in the right iliac fossa a globular, hard, and regular tumor. Rectal examination shows that the pelvis is filled by a tumor occupying the right side, and that it pushes the rectum backward and towards the left. This mass is of a resisting nature, and conveyed to Dr. Millet the idea that it was a cyst. The patient has been experiencing difficulty in defecation for a long time. Dr. Millet sent the patient to Dr. Nicaise. The latter found upon rectal examination, at the site of the prostatic region, a voluminous tumor, regular in its out lines, tense, movable, and covered by the rectal mucous mem brane. He hesitates as to the diagnosis, but believes it to be a cyst.
The patient received instructions as to the use of a catheter, etc., but six months later Dr. Millet was again called to him to relieve a retention of urine of twelve hours' standing. It was found impossible to introduce a catheter ; the bladder was there fore punctured and more than a quart of urine withdrawn. Rec tal examination shows the presence of the tumor previously noted. As the patient lives at a distance, another attempt is made to pass a metal catheter ; suddenly M. Millet feels the tip of the instrument press upon a stretched membrane ; a rent is produced, and at the same moment a pint of liquid, clear as water, gushes through the catheter ; not a drop of urine follows. The quan tity of fluid amounts to about 700 cubic centimetres, and it con tains a little albumen. The patient now urinates without diffi culty. After a few days the patient's urine became foul-smelling, and he had marked dysuria. Small membranes of a milky-white color were passed by the urethra. These continued for some days, until February 20, when on that day he had violent colic, followed by diarrhcea (the patient had eight to ten stools per diem), and he passed from the rectum membranous debris and little white vesicles. From the onset of this diarrhcea, namely, the 2 st of February, the urine had been normal ; the diarrhcea ceased in a few days, and the patient made a rapid recovery.
In neither of these cases is there any record of the care ful steps which are necessary to establish a diagnosis of a lesion of the prostate. In my own with the exception of cystoscopy, a careful and methodical diagnosis was made.
A few words may be added as to the patient's present condition. A digital examination of his prostate by the rectum shows that a small and normal prostate can be defined, but a sausage-like mass can be felt extending from the posterior edge of the left side of the prostate backward and upward as far as the finger can reach. Although the posterior margin of the left lobe of the prostate is well defined, a little deeper pressure will determine that it is blended with the lower ex tremity of the mass. Furthermore, when a searcher is in troduced into the bladder, its beak is still rotated to the patient's right on reaching the level of the prostate.