CONTRIBUTION TO THE SURGERY OF RENAL CYST.
True cystic degeneration of the kidneys in adults is a rare disease. It occurs mostly between the ages of thirty and sixty, and predominates in the male.
Whether it is of congenital origin or not is still open to discussion. While Koenig, Fuerbringer, Rosenstein, Birch Hirsch feld, and Marchand are in favor of the congenital theory, Ebstein and Virchow doubt it ; the latter only admit ting that a partial foetal degeneration may last for many years. Leichtenstern, Arnold, and Landau speak of pyelopapillitis or nephropapillitis as a cause, while Lejars assumes a peculiar proliferation of the epithelium of the uriniferous tubules fol lowed by colloid metamorphosis.
In cystic degeneration the kidney becomes considerably enlarged, the greater portion of its substance being converted in a system of cystic cavities, the size of which varies from that of a microscopical speck to that of a large walnut. In nearly all cases both kidneys are more or less affected.
The disease may last for decades without causing any symptoms at all. One of its most deplorable characteristics is that the clinical symptoms generally do not manifest them selves unless the degenerated organ has become greatly en larged. It is only then that traces of albumen are temporarily found in the urine, so that the suspicion of a renal lesion is raised.
In differentiating, it must be considered that a malignant tumor would not exist for so long a period without causing marked symptoms, among which cachexia would be most prominent. In pyonephrosis, cystitic or pyelitic symptoms, or tuberculosis, etc., would be found. But hydronephrosis, echinococcus, and cystoma could easily be mistaken for cystic degeneration. It is true that in the latter fluctuation may be detected, while in the others a more solid and nodular tumor may be palpated, but in most instances such differentiation will be unreliable.
Microscopical examination is likelier to clear the diag nosis. In the puncture-fluid from cysts containing dark brown fluid, Hoehne found a number of brown, round bodies, varying from the size of a lentil to that of a five-cent piece. The centre was structureless. They also presented one to five concentric rings, and had a radiating striation from the centre to the periphery. According to Hoehne, these peculiar rosette-like bodies, if found in the puncture-fluid from a supposed renal growth, strongly suggest the enlargement being due to cystic degeneration of the kidney.
Cystic kidney may well be suspected in the case of pres ence of a renal tumor, when sudden urwmia or anuria occurs in an individual who heretofore had not shown any signs of renal disturbance. The suspicion becomes a certainty if a renal tumor is found on both sides.
The great difficulty in suggesting proper therapeutic means hinges on the question to what extent the other kidney may be diseased. If found normal, extirpation of the renal tumor would be the simplest therapy. To ascertain the state of the other kidney, an incision should be made to permit of inspection as well as of palpation. But how treacherous even then our assumptions may be will be evident from the fol lowing history : Miss S., fifty-five years of age, was admitted to St. Mark's Hospital October 27, 1899. Her family history revealed that two sisters had succumbed to cystic degeneration of both kidneys. The older sister (single) died when fifty-four years of age, from ummia, no operation having been performed ; the autopsy show ing the presence of two enormous cystic kidneys. In the other sister, who was married and had two children, a renal tumor was detected when she reached the age of forty. She died ten days after a large cystic kidney was removed. The husband reported to me that on the autopsy degeneration of the other kidney was also found.
Miss S. had always been in excellent health until one year ago, when she began to suffer from slight digestive disturbances. Six months ago, Dr. Alexander Koch, of Brooklyn, detected a hard movable tumor of the size of a man's fist in the left hypo chondrium. The specific gravity of the urine, in which traces of albumen were found once in a while, was very low. There was also slight hypertrophy of the left ventricle.
During the last two months the digestive disturbances became aggravated. At the same time the growth increased its size and caused pain, the patient beginning to emaciate at the same time. Examination, October 27, showed the left abdominal side occupied by a solid nodular and movable mass, which reached from the spina posterior superior of the os ilii to the costal arch. It was hard in its centre and gave the impression of fluctuation at its periphery. Examination of the acid and pale urine showed the presence of a moderate amount of albumen and of granulated cylinders. The specific gravity was 1009.
In view of the family history, the diagnosis of multilocular renal cyst was obvious ; otherwise the possibility of hydronephro sis would probably have been considered.
Tuffier quotes fourteen cases in which renal cyst was taken for ovarian tumor ; but in this instance the seat of the growth, especially its attachment to the lumbar region, would have excluded the probability of the ovarian origin of the tumor. Clinical experience showing that in cystic degeneration both kidneys are nearly always simultaneously involved, I selected the transperitoneal route for operation, opening the abdomen by a vertical incision alongside the outer margin of the rectus muscle. After having ascertained that the tumor was really of a renal character, I examined the right kidney, which appeared but slightly enlarged and gave evidence of the presence of cysts at its lower pole only. So I removed the degenerated organ, which had pushed the diaphragm up as far as to the lower border of the fourth rib, in its entirety. It represented a conglomera tion of cysts, measured twenty-eight centimetres in length, and weighed nearly three pounds. (See illustration.) On the outer surface I could count more than a hundred cysts which varied in size from a small speck to three inches in diameter. They had penetrated cortex as well as medulla, and were filled with a thin, white-yellowish fluid, which contained uric and hippuric acid and oxalate of lime and cystin. The wound was closed, excepting a small space left for an iodoform wick.
The immediate reaction after the operation was insignifi cant. The amount of urine passed during the following twenty four hours was seventeen ounces. There were traces of albumen.
Eight days after nephrectomy the urine became scant, and the albumen as well as the renal cells increased. Urwmia set in, to which the patient succumbed eleven days after the operation. The autopsy revealed that the right kidney had increased its size considerably since the time of operation. The lower pole was also penetrated by cysts of various sizes in the same manner as the extirpated one ; so I can only assume that, on account of the additional load of elimination, fatal interstitial nephritis set in.
It is generally accepted that in cystic degeneration nephrectomy is indicated, provided that the other kidney is but little affected. But this experience shows that even a fairly normal condition of the other kidney does by no means war rant a favorable course.
I had intended to expose the right kidney by a lumbar incision as soon as the abdominal wound was healed, and by puncturing the cysts at the surface I had hoped for their per manent destruction. It has become very doubtful to me whether it will ever be justifiable to remove a cystic kidney even when the other appears to be normal. The case described suggested very strongly to me that in cases of cystic degenera tion, puncture, followed by the injection of a drop of a satu rated solution of iodoform in ether, should be tried in small cysts, while in large ones their peripheral walls should be ex cised. Very large cysts may even be totally exsected, the wound of the renal parenchyma then being united by sutures of formalin catgut. This can be done by the lumbar route, while the transperitoneal may be resorted to only in obscure cases or when the tumor is of large size.