- Email: [email protected]
Dermoid cyst of kidney
NEW SERIES VOL. VI,
No.
I
Cyst
Valentine-Dermoid
T
HERE are four interesting points in this case: (I) Iarge chunks of epitheIium were passed; (2) the patient had no urinary compIaint; (3) he had IeucopIakia in this diverticuIum, and (4) there was a cystoscopic resembIance to carcinoma. There had been onIy two cases of bIadder IeucopIakia containing diverticuIum reported up to the time when Dr. Bughee reported one and the writer reported this at the recent meeting of the American Association of Genito-Urinary Surgeons. The first operation the writer performed on returning from this meeting was another diverticuIum case which presented typica IeucopIakia both grossIy and microscopicaIIy. The patient had a very marked urinary infection and compIained of marked frequency of urination.
CYST OF KIDNEY* NEW
0
NLY a few cases of dermoid cyst of the kidney have been reported in the Iiterature and their pathoIogica1 study is scantiIy recorded. The most recent before
Section
of Genito-Urinary
93
LEUCOPLAKIA IN A BLADDER DIVERTICULUM
J. J, VALENTINE,
*Read
of surgery
two months after his Bergenhem operation, abIe to hoId his urine in the rectum for from two to six hours. For the first few months he had quite a bit of nocturna1 incontinence but graduaIIy gained compIete contro1. He caIIed on me Iast faI1 and at that time was quite abIe to hoId it for from four to six hours and had measured individua1 voidings that were as much as 350 C.C. His phthaIein output in two hours was 25 per cent. He has gone on now about seventeen years and is entireIy comfortabIe and abIe to work and mingIe with his friends.
the bIadder was sewed up and the right ureter implanted by the Coffey technique. A catheter was Ieft in the ureter. In comparison with the operation on the other side, with no catheter in the ureter, there was some fever (up to IO~‘F.) and pain in the corresponding kidney. In both instances a cigarette drain was pIaced at the site of the ureterosigmoida1 anastomosis. About six weeks after this Iast operation the patient was abIe to hold the recta1 contents for about four hours. When he went home on March 16, about two months after his last implantation, he was abIe to hoId his urine from four to six hours. We did a phthaIein test and obtained from the rectum 20 per cent in two hours. His bIood chemistry was normal. His perinea1 wound has not yet closed up. CASE II. The other patient was a case of ectopia vescicae. When the patient first came to the writer in the faI1 of Igr I, he was a boy of sixteen. Three attempts had been made to cIose the bIadder when he was about two years oId. It is not necessary to go into the details of the history; they have ah-eady been published. We catheterized the ureter and proved that there was no infection of either kidney; the phthalein output was 30 per cent in one hour. Operation was performed ApriI 6, IgI I, by the Bergenhem method, that is, both ureters were isolated extraperitoneaIIy from the promontory of the sacrum to the bIadder and cut away with a smaI1 ring of bIadder mucosa attached to each, without either uretera orifice being cut into. These were impIanted into his recta1 waI1 through independent smaI1 holes and were Ieft there without any s’uture. During convaIescence there were attacks of pain in the Ieft kidney, which cIearIy indicated some infection of that side. The patient went home from the hospita1
DERMOID
American JUMI
of Kidney
Surgery,
M.D.,
P.A.C.S.
YORK
contribution seems to be by of CoIumbus, Ohio in Ig 15. he quotes the famous case Paget’ of dermoid tumor of New York
Academy
of Medicine,
J. F. Baldwin In his articIe of Sir James the kidney in
March
21,
1928.
94
American
Journal
VaIentine-Dermoid
of Surgery
Cyst
JANUARY, 1929
in the cysts five times. An indefinite substance of varying coIor and consistency occurred within the cysts in 6 cases. ChoIesterin crystaIs were found in 4 cases; fat in 4 cases. Two of the cysts were subcapsuIar.
the sheep, as we11 as five compIete case reports in the human. In order to anaIyze these cases and to compare the interesting findings with the one now presented, they may best be tabuIated. _ DERMOID
of Kidney
CYSTS
OF
KIDNEY
Preoperative Diagnosis
Pain
Pathology and Contents, or cyst
ResuIt
_ Haeckel’sa reported Wedeman. -____---
by
20
2 yrs.
_-,-__-Walkers..
.
.1
II
r
~-----
’ None made
Pultaceous yeIIow stance. Hair -------
~Hematuria
Colic
-----
_---_.
1 I yr.
Floating w i t h pedicle
Irritable bladder
None
CoIic and pain in I. lumbar
kidney twisted
made
sub-
I Recovery __--
Subcapsular cyst. Large quantity reddish mealy material. Hair
Recovery
Three cysts; one fitled with fatty mnteria1 and fine hair
Recovery
--_--
--------
Schlegtenda! lung.’
& Made-
zz
M
_Boni’.
I
I
......
GoIdsmith”.
Yes
58
.
..
45
F
AI1 his life
----
------
10 yrs.
Cystic tumor fiIIed with smeary mass. Fat cells. Crystals of cholesterin
Ecchinococcus cyst of liver
None
__----
----
Not stated/
Not stated
Died
Five intercommunicsting cysts. Yellowish ~ Died ereen turbid Auid and hetritus. Skin structure, with sebaceous sweat glands. Hair foIIicIes and hair
Hydronephrosis. probably due to calculus
; I
Ossilird walls containing mass of cholesterin
I
a vnn10
-1
B Id
Author’s
Case.
.I-
/
Bardenheuerg
_._.
16
46
1
yrs.
~ None
P
14
_-
I
I .-----
~ No
Yes
F
-------
-I-
. . . . . .._. . . . . . . . . . . . . . . . t _-___ ___--_ None
j
Possible ovarian dermoid
Walls of bony plates. Cavities containing dir-. ferent colored
Probable caIcrlIus tical)
Subcapsular cyst. Thick light yetlow pasty sobFat globules and cholesterin ergs131s. No hair
1Recovery
No hair
._
It wiI1 be noted that a paIpabIe tumor occurred in a11 but the present -case, and that the tumor had been there for severa years. ProbabIy because these cases presented themseIves many years ago and because they were studied by other than uroIogists, no detaiIed uroIogica1 investigation was made either by cystoscopy or roentgenoIogy. The pathoIogica1 findings, whiIe not aIike in a11 the cases, bear some degree of uniformity. For exampIe, hair was found
Fat and hair
Yes
rena1 (c 0 r-
stance.
1Recovery i
Attention is caIIed to the fact that in no instance was it possibIe to make a correct preoperative diagnosis, as there seemed to be no definite characteristic cIinica1 symptoms nor has there been a sufficient number of cases studied from the uroIogica1 standpoint to submit additiona vaIuabIe data. CASE
REPORT
Mrs. M. O., aged forty-six, admitted to PoIycIinic Hospital June 23, 1927. Chief compIaints were frequency and burning urination, pus in urine for many years and pain in back.
NEW SERIES VOL. VI. No. I
VaIentine-Dermoid
Cyst
of Kidney
American
~~~~~~~ or
surgery 94
Her genera1 history was negative except for her uroIogica1 disturbances. For many years she had had marked frequency of urination
project into the urethra anterior to the sphincter. These bodies as we11 as the Iarger tumor were destroyed by fulguration with the eIectro-
FIG. I. Showing
FIG. 2. Pyelogram
shadow in Ieft ca!cu!us.
kidney
resembting
with considerabIe burning which occurred during and after the act. At times she had seen a Iittle bIood in her urine. She aIso stated that she had had a left-sided backache for several years. Genera1 examination negative as regards chest and abdomen. Because of her marked frequency and burning urination, our attention was first fixed on her bIadder and urethra. Voided urine was hazy, containing a moderate amount of pus, a few red bIood corpuscIes, and cuIture showed a gram-negative bacillus growth. Cystoscopy showed bladder congested, otherwise negative. Not finding sufficient pathoIogy
showing
shadow within kidney.
tome current. FoIIowing this there was very IittIe reaction. The patient remained in the hospital about forty-eight hours and was aIIowed to go home. She reported to the Clinic in two weeks and stated that her frequency of urination was materiaIIy reduced and that she feIt very much better. She had less burning than she had experienced in years. Her backache, however, was not in any way reIieved. A plain roentgenogram was taken and cystoscopy performed at this time to investigate her upper urinary tract. Both ureters were catheterized and specimens obtained. Examination of these specimens showed : Left
Gross appearance of urine.
........................
Urea. ........... ......................... BIood .......................................... Epithelium. .................................. Leucocytes, .................... ............ CuIture ................. Indigo-carmine.,
....
.......................
.....................................
in the bladder, urethroscopy was performed and a small cystic tumor was seen in the midIine on the upper margin of the bladder neck. AIso several smaI1 cystic bodies were seen to
.
Clear (later bloody probab!y trauma) 0.4 per cent s-10 per &Id Rare ce!! About z per fie!d Sterile 1 min. m good conccntratlon
Right CIear 0.9 per cent IO-IS per field Occasional I -2 per fie!d SteriIe . . 4 mm. m good concentration
BIood chemistry, normaI. Despite the Iack of pathoIogy in urine, the roentgenographic findings, with and without pyeIograms, made us conclude that we were
96
American Journal of Surgery
VaIentine-Dermoid
deaIing with a cortica1 stone in her Ieft kidney, and expIoration was advised. Operation. A Ieft curved, oblique, Iumbar
FIG. 3. Schematic drawing showing subcapsular tion of cyst and its reIation to caIcies.
Cyst
of Kidney
JANUARY, rg.29
with iodoform gauze, the end of which was used as a drain extending from the upper angIe of the wound, and the kidney was dropped
IocaFIG. 4. Dermoid cyst after its enucIeation from kidney.
incision was made, exposing a normal sized kidney. Before freeing kidney to bring it up into the wound, carefu1 paIpation was made for the caIcuIus but it was not feIt. The kidney was then freed and brought up into fuI1 view in the wound. Inspection showed the true capsuIe of the kidney to be separated from the kidney itself by fIuid under the capsuIe. SeveraI bubbIes couId be seen under the capsuIe and made to move by making pressure on the kidney. At about the juncture of the upper and middIe portions of the kidney, in the centra1 Iine aIong the cortex, couId be seen a yeIIowish mass, pIainIy visibIe through the true capsuIe and not attached to it. The true capsuIe was nicked and about 2 drams of Ruid escaped. The true capsuIe was separated for the entire Iength of the kidney and was readiIy peeIed away, exposing the growth just mentioned. This growth, as one Iooked down on it, appeared Iarger than the diameter of a twentyfive cent piece, and Iooked something Iike an oId tubercuIous (firm, cheesy) deposit. It seemed to be covered by its own capsuIe, and it was easiIy separated from the adjacent cortex of the kidney. It was not attached to the true cortex in any portion except at its very base where it seemed adherent. When enucIeated from its bed the point of attachment bIed freeIy. This point of bIeeding was cIamped and Iigated. The bed of this growth now seemingIy was a gap in the kidney, Iined with true kidney cortex. The capsuIe was then sutured with pIain catgut and the cavity from which the growth was removed was packed
back into its natura1 bed. The wound was cIosed in the usua1 layer fashion. Postoperative recovery was uneventfu1 and the patient Ieft the hospita1 twenty-six days Iater. PathoIogicaI Report. The specimen was composed of a cystic structure removed from the kidney. It was circumscribed, ovoid in shape, and measured 335 X 23% X I cm. It contained a thick, Iight yeIIow, pasty material. Microscopica examination of this materia1 showed numerous fat gIobuIes and a few choIesterin crystaIs. The waI1 varied from I to 3 mm. in thickness and the inner surface was roughened. There was apparentIy no Iining. Microscopica examination of sections taken from different areas of this waI1 showed that it was composed chieffy of dense strands of hyaIine connective tissue. On the inner surface there was a Ioose areoIar structure in which there were many blood vesseIs, some of which had rather thin waIIs but others had very much thickened waIIs. It was aIso infiItrated with numerous inffammatory ceIIs. There was observed. Diagnosis was no Iining epitheIium dermoid cyst of the kidney. Postoperative history. Patient has been seen frequentIy since the operation, and she states that she has compIeteIy recovered from her urinary frequency as we11 as from her backache. The mariIy
case in question is interesting pribecause of the earIy and accidenta
NEW SERGES VOL. VI, No.
I
Dickinson-BiIateraI
discovery of the cyst in the course of ordinary routine uroIogica1 examination. The cyst, casting a roentgenographic shadow which was interpreted as being a caIcuIus, was sufficient reason for operative interference for the reIief of pain. It is likewise of interest to have Iearned that the cyst was subcapsuIar, causing an exudate to distend the true capsuIe of the kidney, producing nephraIgia. After remova of the cyst the pain ceased. J. R. Losee, who studied this specimen, refers us to Ewing’s10 work wherein is recorded : “ EpidermaI rests derived from the WoIffIan duct are probabIy the source of certain dermoids of the kidney. They contain no derma1 gIands.” Rokitansky’l says there is often no epitheIium in the Iarger cysts and their inner Iayer is striate bIastema externaIIy spreading into fibers in the direction of the Iong axis of the ova1 nucIei it contains. Losee states that regardIess of the fact that no squamous epitheIia1 Iining was observed in this cyst, he believes the diagnosis can be made from its contents.
Snapping Hip
BILATERAL
SNAPPING
HIP
surgery 97
It is understood that these cysts arise from remnants of the mesonephros, which structure is supposed to degenerate in the Iatter stage of the deveIopment of the embryo. If part of this does not degenerate there is some form of cystic structure remaining. The epitheIia, Iining these mesonephric tubuIes, are not very we11differentiated at that earIy period, therefore one can conceive that it wouId be possibIe to have any one of these various types of epitheIia. REFERENCES I.
2.
3. 4.
;: 7. 8. 9. IO. II.
BALDWIN, J. F. Surg., Gynec. CY Obstet., 20: IgIg. PAGET, SIR J. Surgical PathoIogy. London, Longmans, 1853. WEDEMAN, E. Ein FaII yen Dermoid der Niere. Jena, B. Engau, 1902. GOLDSMITH. Tr. Soutb. Surg. ti Gynec. Ass., 21: 95, 1908. WALKER. Tr. Am. Surg. Ass., 15: 591, 1897. SCHLEGTENDAL and MADEISJNG. Arch. j. k&n. Cbir., 36: 304, 1887. BONI. Osp. magg., I: 386, 1906. WYSS. Lancet, Lond., I : 561, 1906. BARDENHEUER.Ibid. EWING, J. NeopIastic Diseases. PhiIa., W. B. Saunders Co., 1922. ROKITANSKY. SurgicaI PathoIogy. London, Longmans, I 853.
CASE REPORTS BY DR. ARTHUR ALBANY,
Americnn .rournal of
N.
M. DICKINSON*
Y.
cause pain and discomfort. When pain and discomfort do resuIt, the condition becomes pathoIogica1. CommonIy onIy one hip is affected. A
L
NAPPING of the hip may not be an unusua1 condition in Iarge orthopedic S centers, but to the genera1 surgeon it ETIOLOGY is a very uncommon and often trying There are many factors which have been condition. References to it in the Iiterature of this country are rather meager as considered as causes in producing snapping contrasted with the quite frequent cases of the hip. A few of these are infIamed bursae, malformations of the hip joint, a reported in foreign Iiterature. A certain amount of snapping of the hip tic or spasm of the muscIes, either vohmtary or invoIuntary, and muscuIar reIaxmay be aImost physioIogica1 in chiIdren ation, especiaIIy of the gIuteus maximus, and aIso in aduIts with reIaxed periarticuwith or without actua1 tears in the muscle. Iar structures. In some instances it becomes Before the causa1 factors are weighed, it a practiced trick to be demonstrated at is we11to consider the anatomy of the parts. wiI1 for the astonishment of companions. As a ruIe this type of snapping hip does not The hip joint is essentiaIIy a baI1 and socket * Submitted for publication, June 25, 1928.
No.
I
Cyst
Valentine-Dermoid
T
HERE are four interesting points in this case: (I) Iarge chunks of epitheIium were passed; (2) the patient had no urinary compIaint; (3) he had IeucopIakia in this diverticuIum, and (4) there was a cystoscopic resembIance to carcinoma. There had been onIy two cases of bIadder IeucopIakia containing diverticuIum reported up to the time when Dr. Bughee reported one and the writer reported this at the recent meeting of the American Association of Genito-Urinary Surgeons. The first operation the writer performed on returning from this meeting was another diverticuIum case which presented typica IeucopIakia both grossIy and microscopicaIIy. The patient had a very marked urinary infection and compIained of marked frequency of urination.
CYST OF KIDNEY* NEW
0
NLY a few cases of dermoid cyst of the kidney have been reported in the Iiterature and their pathoIogica1 study is scantiIy recorded. The most recent before
Section
of Genito-Urinary
93
LEUCOPLAKIA IN A BLADDER DIVERTICULUM
J. J, VALENTINE,
*Read
of surgery
two months after his Bergenhem operation, abIe to hoId his urine in the rectum for from two to six hours. For the first few months he had quite a bit of nocturna1 incontinence but graduaIIy gained compIete contro1. He caIIed on me Iast faI1 and at that time was quite abIe to hoId it for from four to six hours and had measured individua1 voidings that were as much as 350 C.C. His phthaIein output in two hours was 25 per cent. He has gone on now about seventeen years and is entireIy comfortabIe and abIe to work and mingIe with his friends.
the bIadder was sewed up and the right ureter implanted by the Coffey technique. A catheter was Ieft in the ureter. In comparison with the operation on the other side, with no catheter in the ureter, there was some fever (up to IO~‘F.) and pain in the corresponding kidney. In both instances a cigarette drain was pIaced at the site of the ureterosigmoida1 anastomosis. About six weeks after this Iast operation the patient was abIe to hold the recta1 contents for about four hours. When he went home on March 16, about two months after his last implantation, he was abIe to hoId his urine from four to six hours. We did a phthaIein test and obtained from the rectum 20 per cent in two hours. His bIood chemistry was normal. His perinea1 wound has not yet closed up. CASE II. The other patient was a case of ectopia vescicae. When the patient first came to the writer in the faI1 of Igr I, he was a boy of sixteen. Three attempts had been made to cIose the bIadder when he was about two years oId. It is not necessary to go into the details of the history; they have ah-eady been published. We catheterized the ureter and proved that there was no infection of either kidney; the phthalein output was 30 per cent in one hour. Operation was performed ApriI 6, IgI I, by the Bergenhem method, that is, both ureters were isolated extraperitoneaIIy from the promontory of the sacrum to the bIadder and cut away with a smaI1 ring of bIadder mucosa attached to each, without either uretera orifice being cut into. These were impIanted into his recta1 waI1 through independent smaI1 holes and were Ieft there without any s’uture. During convaIescence there were attacks of pain in the Ieft kidney, which cIearIy indicated some infection of that side. The patient went home from the hospita1
DERMOID
American JUMI
of Kidney
Surgery,
M.D.,
P.A.C.S.
YORK
contribution seems to be by of CoIumbus, Ohio in Ig 15. he quotes the famous case Paget’ of dermoid tumor of New York
Academy
of Medicine,
J. F. Baldwin In his articIe of Sir James the kidney in
March
21,
1928.
94
American
Journal
VaIentine-Dermoid
of Surgery
Cyst
JANUARY, 1929
in the cysts five times. An indefinite substance of varying coIor and consistency occurred within the cysts in 6 cases. ChoIesterin crystaIs were found in 4 cases; fat in 4 cases. Two of the cysts were subcapsuIar.
the sheep, as we11 as five compIete case reports in the human. In order to anaIyze these cases and to compare the interesting findings with the one now presented, they may best be tabuIated. _ DERMOID
of Kidney
CYSTS
OF
KIDNEY
Preoperative Diagnosis
Pain
Pathology and Contents, or cyst
ResuIt
_ Haeckel’sa reported Wedeman. -____---
by
20
2 yrs.
_-,-__-Walkers..
.
.1
II
r
~-----
’ None made
Pultaceous yeIIow stance. Hair -------
~Hematuria
Colic
-----
_---_.
1 I yr.
Floating w i t h pedicle
Irritable bladder
None
CoIic and pain in I. lumbar
kidney twisted
made
sub-
I Recovery __--
Subcapsular cyst. Large quantity reddish mealy material. Hair
Recovery
Three cysts; one fitled with fatty mnteria1 and fine hair
Recovery
--_--
--------
Schlegtenda! lung.’
& Made-
zz
M
_Boni’.
I
I
......
GoIdsmith”.
Yes
58
.
..
45
F
AI1 his life
----
------
10 yrs.
Cystic tumor fiIIed with smeary mass. Fat cells. Crystals of cholesterin
Ecchinococcus cyst of liver
None
__----
----
Not stated/
Not stated
Died
Five intercommunicsting cysts. Yellowish ~ Died ereen turbid Auid and hetritus. Skin structure, with sebaceous sweat glands. Hair foIIicIes and hair
Hydronephrosis. probably due to calculus
; I
Ossilird walls containing mass of cholesterin
I
a vnn10
-1
B Id
Author’s
Case.
.I-
/
Bardenheuerg
_._.
16
46
1
yrs.
~ None
P
14
_-
I
I .-----
~ No
Yes
F
-------
-I-
. . . . . .._. . . . . . . . . . . . . . . . t _-___ ___--_ None
j
Possible ovarian dermoid
Walls of bony plates. Cavities containing dir-. ferent colored
Probable caIcrlIus tical)
Subcapsular cyst. Thick light yetlow pasty sobFat globules and cholesterin ergs131s. No hair
1Recovery
No hair
._
It wiI1 be noted that a paIpabIe tumor occurred in a11 but the present -case, and that the tumor had been there for severa years. ProbabIy because these cases presented themseIves many years ago and because they were studied by other than uroIogists, no detaiIed uroIogica1 investigation was made either by cystoscopy or roentgenoIogy. The pathoIogica1 findings, whiIe not aIike in a11 the cases, bear some degree of uniformity. For exampIe, hair was found
Fat and hair
Yes
rena1 (c 0 r-
stance.
1Recovery i
Attention is caIIed to the fact that in no instance was it possibIe to make a correct preoperative diagnosis, as there seemed to be no definite characteristic cIinica1 symptoms nor has there been a sufficient number of cases studied from the uroIogica1 standpoint to submit additiona vaIuabIe data. CASE
REPORT
Mrs. M. O., aged forty-six, admitted to PoIycIinic Hospital June 23, 1927. Chief compIaints were frequency and burning urination, pus in urine for many years and pain in back.
NEW SERIES VOL. VI. No. I
VaIentine-Dermoid
Cyst
of Kidney
American
~~~~~~~ or
surgery 94
Her genera1 history was negative except for her uroIogica1 disturbances. For many years she had had marked frequency of urination
project into the urethra anterior to the sphincter. These bodies as we11 as the Iarger tumor were destroyed by fulguration with the eIectro-
FIG. I. Showing
FIG. 2. Pyelogram
shadow in Ieft ca!cu!us.
kidney
resembting
with considerabIe burning which occurred during and after the act. At times she had seen a Iittle bIood in her urine. She aIso stated that she had had a left-sided backache for several years. Genera1 examination negative as regards chest and abdomen. Because of her marked frequency and burning urination, our attention was first fixed on her bIadder and urethra. Voided urine was hazy, containing a moderate amount of pus, a few red bIood corpuscIes, and cuIture showed a gram-negative bacillus growth. Cystoscopy showed bladder congested, otherwise negative. Not finding sufficient pathoIogy
showing
shadow within kidney.
tome current. FoIIowing this there was very IittIe reaction. The patient remained in the hospital about forty-eight hours and was aIIowed to go home. She reported to the Clinic in two weeks and stated that her frequency of urination was materiaIIy reduced and that she feIt very much better. She had less burning than she had experienced in years. Her backache, however, was not in any way reIieved. A plain roentgenogram was taken and cystoscopy performed at this time to investigate her upper urinary tract. Both ureters were catheterized and specimens obtained. Examination of these specimens showed : Left
Gross appearance of urine.
........................
Urea. ........... ......................... BIood .......................................... Epithelium. .................................. Leucocytes, .................... ............ CuIture ................. Indigo-carmine.,
....
.......................
.....................................
in the bladder, urethroscopy was performed and a small cystic tumor was seen in the midIine on the upper margin of the bladder neck. AIso several smaI1 cystic bodies were seen to
.
Clear (later bloody probab!y trauma) 0.4 per cent s-10 per &Id Rare ce!! About z per fie!d Sterile 1 min. m good conccntratlon
Right CIear 0.9 per cent IO-IS per field Occasional I -2 per fie!d SteriIe . . 4 mm. m good concentration
BIood chemistry, normaI. Despite the Iack of pathoIogy in urine, the roentgenographic findings, with and without pyeIograms, made us conclude that we were
96
American Journal of Surgery
VaIentine-Dermoid
deaIing with a cortica1 stone in her Ieft kidney, and expIoration was advised. Operation. A Ieft curved, oblique, Iumbar
FIG. 3. Schematic drawing showing subcapsular tion of cyst and its reIation to caIcies.
Cyst
of Kidney
JANUARY, rg.29
with iodoform gauze, the end of which was used as a drain extending from the upper angIe of the wound, and the kidney was dropped
IocaFIG. 4. Dermoid cyst after its enucIeation from kidney.
incision was made, exposing a normal sized kidney. Before freeing kidney to bring it up into the wound, carefu1 paIpation was made for the caIcuIus but it was not feIt. The kidney was then freed and brought up into fuI1 view in the wound. Inspection showed the true capsuIe of the kidney to be separated from the kidney itself by fIuid under the capsuIe. SeveraI bubbIes couId be seen under the capsuIe and made to move by making pressure on the kidney. At about the juncture of the upper and middIe portions of the kidney, in the centra1 Iine aIong the cortex, couId be seen a yeIIowish mass, pIainIy visibIe through the true capsuIe and not attached to it. The true capsuIe was nicked and about 2 drams of Ruid escaped. The true capsuIe was separated for the entire Iength of the kidney and was readiIy peeIed away, exposing the growth just mentioned. This growth, as one Iooked down on it, appeared Iarger than the diameter of a twentyfive cent piece, and Iooked something Iike an oId tubercuIous (firm, cheesy) deposit. It seemed to be covered by its own capsuIe, and it was easiIy separated from the adjacent cortex of the kidney. It was not attached to the true cortex in any portion except at its very base where it seemed adherent. When enucIeated from its bed the point of attachment bIed freeIy. This point of bIeeding was cIamped and Iigated. The bed of this growth now seemingIy was a gap in the kidney, Iined with true kidney cortex. The capsuIe was then sutured with pIain catgut and the cavity from which the growth was removed was packed
back into its natura1 bed. The wound was cIosed in the usua1 layer fashion. Postoperative recovery was uneventfu1 and the patient Ieft the hospita1 twenty-six days Iater. PathoIogicaI Report. The specimen was composed of a cystic structure removed from the kidney. It was circumscribed, ovoid in shape, and measured 335 X 23% X I cm. It contained a thick, Iight yeIIow, pasty material. Microscopica examination of this materia1 showed numerous fat gIobuIes and a few choIesterin crystaIs. The waI1 varied from I to 3 mm. in thickness and the inner surface was roughened. There was apparentIy no Iining. Microscopica examination of sections taken from different areas of this waI1 showed that it was composed chieffy of dense strands of hyaIine connective tissue. On the inner surface there was a Ioose areoIar structure in which there were many blood vesseIs, some of which had rather thin waIIs but others had very much thickened waIIs. It was aIso infiItrated with numerous inffammatory ceIIs. There was observed. Diagnosis was no Iining epitheIium dermoid cyst of the kidney. Postoperative history. Patient has been seen frequentIy since the operation, and she states that she has compIeteIy recovered from her urinary frequency as we11 as from her backache. The mariIy
case in question is interesting pribecause of the earIy and accidenta
NEW SERGES VOL. VI, No.
I
Dickinson-BiIateraI
discovery of the cyst in the course of ordinary routine uroIogica1 examination. The cyst, casting a roentgenographic shadow which was interpreted as being a caIcuIus, was sufficient reason for operative interference for the reIief of pain. It is likewise of interest to have Iearned that the cyst was subcapsuIar, causing an exudate to distend the true capsuIe of the kidney, producing nephraIgia. After remova of the cyst the pain ceased. J. R. Losee, who studied this specimen, refers us to Ewing’s10 work wherein is recorded : “ EpidermaI rests derived from the WoIffIan duct are probabIy the source of certain dermoids of the kidney. They contain no derma1 gIands.” Rokitansky’l says there is often no epitheIium in the Iarger cysts and their inner Iayer is striate bIastema externaIIy spreading into fibers in the direction of the Iong axis of the ova1 nucIei it contains. Losee states that regardIess of the fact that no squamous epitheIia1 Iining was observed in this cyst, he believes the diagnosis can be made from its contents.
Snapping Hip
BILATERAL
SNAPPING
HIP
surgery 97
It is understood that these cysts arise from remnants of the mesonephros, which structure is supposed to degenerate in the Iatter stage of the deveIopment of the embryo. If part of this does not degenerate there is some form of cystic structure remaining. The epitheIia, Iining these mesonephric tubuIes, are not very we11differentiated at that earIy period, therefore one can conceive that it wouId be possibIe to have any one of these various types of epitheIia. REFERENCES I.
2.
3. 4.
;: 7. 8. 9. IO. II.
BALDWIN, J. F. Surg., Gynec. CY Obstet., 20: IgIg. PAGET, SIR J. Surgical PathoIogy. London, Longmans, 1853. WEDEMAN, E. Ein FaII yen Dermoid der Niere. Jena, B. Engau, 1902. GOLDSMITH. Tr. Soutb. Surg. ti Gynec. Ass., 21: 95, 1908. WALKER. Tr. Am. Surg. Ass., 15: 591, 1897. SCHLEGTENDAL and MADEISJNG. Arch. j. k&n. Cbir., 36: 304, 1887. BONI. Osp. magg., I: 386, 1906. WYSS. Lancet, Lond., I : 561, 1906. BARDENHEUER.Ibid. EWING, J. NeopIastic Diseases. PhiIa., W. B. Saunders Co., 1922. ROKITANSKY. SurgicaI PathoIogy. London, Longmans, I 853.
CASE REPORTS BY DR. ARTHUR ALBANY,
Americnn .rournal of
N.
M. DICKINSON*
Y.
cause pain and discomfort. When pain and discomfort do resuIt, the condition becomes pathoIogica1. CommonIy onIy one hip is affected. A
L
NAPPING of the hip may not be an unusua1 condition in Iarge orthopedic S centers, but to the genera1 surgeon it ETIOLOGY is a very uncommon and often trying There are many factors which have been condition. References to it in the Iiterature of this country are rather meager as considered as causes in producing snapping contrasted with the quite frequent cases of the hip. A few of these are infIamed bursae, malformations of the hip joint, a reported in foreign Iiterature. A certain amount of snapping of the hip tic or spasm of the muscIes, either vohmtary or invoIuntary, and muscuIar reIaxmay be aImost physioIogica1 in chiIdren ation, especiaIIy of the gIuteus maximus, and aIso in aduIts with reIaxed periarticuwith or without actua1 tears in the muscle. Iar structures. In some instances it becomes Before the causa1 factors are weighed, it a practiced trick to be demonstrated at is we11to consider the anatomy of the parts. wiI1 for the astonishment of companions. As a ruIe this type of snapping hip does not The hip joint is essentiaIIy a baI1 and socket * Submitted for publication, June 25, 1928.