REPRINT FROM “THE CANADIAN PRACTITIONER,” TORONTO, 
MARCH, 1887. 
Congenital Cyst of Left Loin 
Operation; Recovery, 
WILLIAM M.D,, 
Professor of Gynaecology, McGill University ; Gynaecologist to the 
Montreal General Hospital. CONGENITAL CYST OF LEFT LOIN. 
OPERATION: RECOVERY. 
S. M., aged 28, unmarried, was sent to me 
from Ottawa, on the 14th Dec., 1886, by my 
friend Dr. H. Beaumont Small, with the fol- 
lowing history:—She had always had a large 
abdomen : her mother asserts that this was the 
case from infancy, but until a week previous to 
my first seeing her, her health had been perfect 
and she had always been fit for her duties as a 
domestic servant. The abdominal enlargement 
had been so marked, increasing of late, that she 
had often been suspected to be pregnant. Of 
this there was not the slightest evidence in the 
abdomen or genitals. Six months ago she 
came from England, and had been constantly 
at work in Ottawa as a chambermaid, till about 
the Bth of December, when she was suddenly 
seized with severe abdominal pain, rapidly in- 
creasing enlargement, chills and fever, perspira- 
tions, vomiting and loss of appetite. These 
symptoms had lasted for a week. When she 
appeared in my office she looked pale and thin, 
appeared to be very ill, and complained of lan- 
cinating pain in the left hypochondriac and 
lumbar regions; temp. 101|°, pulse 100; the 2 
the tongue furred and dry. On examining the 
abdomen, it was found to be distended on the 
left side from the margins of the lower ribs 
down to near the pubic bone, by a tense, elastic 
and very sensitive tumor which extended some 
distance to the right of the median line. It 
clearly extended backwards to the loin, where 
the elastic fluctuation could be distinctly felt 
when the tumor was manipulated. Dalness 
on percussion existed in an area corresponding 
to the most prominent portion of the tumor, and 
also in the loin and most of the lateral areas, 
but resonant bowel note was most distinct in 
some portions. 
Hymen ruptured; uterus retroflexed with 
a tender mass beneath it, felt through the pos- 
terior cul de sac of the vagina. No part of 
the elastic abdominal tumor could be felt by 
vaginal examination. Urine healthy, no blad- 
der symptoms now or at any previous time. 
Menstruation always regular. The last period, 
two weeks ago ; had ceased previous to the ad- 
vent of the present symptoms. On the evening 
of the 15th the temperature rose to 101°; 
but on the following evening it was only 100°. 
The diagnosis being obscure, and the condition 
grave and demanding prompt action, I decided 
to do an exploratory abdominal operation, and 
deal as might seem best with whatever might 
be found. 
Operation on the 17th of December, Dr. Jas. 
Bell assisting; Drs, Roddick and Ross also 
being present. Median incision of inches 3 
from umbilicus downwards. On getting through 
the peritoneum, and raising the non-adherent 
omentum, the transverse and descending colon 
and meso-colon were found projected forwards 
by what was now clearly seen to be a retro- 
peritoneal collection of fluid. It was, how- 
ever, at once obvious that it could not be 
advantageously dealt with through the median 
incision, which was at once closed. To make 
sure of the nature of the contents, a fine aspira- 
tor needle was now passed into the tumor from 
the loin behind. A dark brown fluid contain- 
ing numerous iridescent crystals at once ap- 
peared. 
I next made an incision inches long over 
the most prominent part of the enlargement, on 
a level with, and three inches to the left of, the 
umbilicus. On exposing the tumor, a long 
curved trocar was plunged into it, and 70 
ounces of fluid withdrawn. The trocar opening 
was enlarged sufficiently to admit the finger. 
Its edges were stitched to the edges of the ab- 
dominal wound, and a glass drainage-tube in- 
serted to the bottom of the cyst. The fluid, on 
standing, deposited a thick greyish-white sedi- 
ment, which the microscope shewed to be pus, 
with cholestearine crystals. The subsequent 
course of the case was toward recovery, abso- 
lutely without interruption. All pain and 
fever disappeared from the moment of the opera- 
tion. The cavity rapidly shrank and secreted 
only a little thin purulent fluid, which was re- 
moved through the tube by a Lawson Tait’s 4 
sucker. The glass tube was replaced in a few 
days by one of rubber, which was gradually 
shortened as the cavity contracted, and was 
still kept in the opening when the patient was 
discharged from hospital on the 14th January, 
1887, twenty-eight days after the date of opera- 
tion. The history and clinical characters of the 
dense thick-walled cyst and its contents leave, I 
think, no room for doubt that it was congenital; 
while the sudden onset of the acute symptoms 
can be explained only by the advent of 
inflammation and suppuration. Such cysts are, 
without doubt, very rare. The point of origin 
of the cyst was clearly in the neighborhood of 
the kidney; but there were no evidences of in- 
volvement of that organ. There was no history 
of any injury which might have explained the 
sudden onset of the acute symptoms. The in- 
terior of the cyst, as felt with the finger, was 
uniformly smooth. 
The treatment, so far as the site of election 
for opening and drainage of the cyst is con- 
cerned, is doubtless open to criticism, inasmuch 
as it involved opening the peritoneal cavity. 
The opening could have been made by the loin 
without involving that cavity. lam convinced, 
however, that the objectors will be found 
among surgeons with little experience in abdo- 
minal surgery, and who are still imbued with 
the traditional dread, now so fast disappearing, 
of wounding the peritoneum. As I write, 
February 7th, the patient is quite well, and a 
week ago took a situation as housemaid.