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Hemorrhagic Cyst of the Kidney1
HEMORRHAGIC CYST OF THE KIDNEY 1
J. DELLINGER
BARNEY
From the Urological Service, Massachusetts General Hospital
After reviewing the literature of hemorrhagic cyst of the kidney, one is impressed by (a) its rarity, (b) its obscure and varied symptomatology, and (c) the divergent opinions as to its etiology. There is also no doubt that these cysts may present a difficult problem in differential diagnosis. Many theories have been advanced as to the etiology of hemorrhagic cysts. By many they are thought to begin as simple solitary cysts, the etiology of these being in themselves obscure, which later are the seat of hemorrhage of unknown cause. Considerable weight seems to attach to a congenital origin. It has also been suggested that these cysts are really bizarre forms of hematoma; while Judd and others are inclined to the view that they are of an aneurysmal nature. Certain experimental evidence would suggest the possibility that they may arise from embolic or thrombotic infarction. The factor of trauma, recognized or probable, seems to be an important element. Stirling reported a personal case, and collected 31 others from the literature. In 1932 Munger reviewed the 1,ubject with great care and with an eye more critical than that of Stirling. He accepts but 18 of those collected by Stirling, and adds a case of his own. It is also pointed out that Judd and Simon in 1927 thought that of the cases reported up to that time only 13 were sufficiently well described to be accepted as true hemorrhagic cyst. As Munger remarks, "if the contention for hemorrhagic cyst as a separate entity is worthy of consideration, then we must establish a uniformity of histologic picture in contradistinction to that of other types of renal cysts . .. ." After reviewing the literature it seems to me that either because of inadequate description, both gross and microscopic, or because there is actually no uniformity, it is impossible, in the present state of our knowledge, to say whether any given hemorrhagic cyst started as a simple serous cyst or whether it contaiI\ed blood or bloody fluid from the outset. If and when the etiology of the solitary renal cyst is well understood, and after enough histologic studies have been made of all 1 Read at the annual meeting of the American Urological Association, Boston, Mass., May 19, 1936.
602
HEMORRHAGIC CYST OF KIDNEY
603
the tissue removed, then I believe that we can make some sort of a classification. With these thoughts in mind I wish to add 2 cases to those already reported. If we accept Stirling's list of 32 and add Munger's case, my 2 cases will bring the total up to 35. If, on the other hand, we add my cases to Munger's list of 19, then we have a total of 21. In any event the condition is certainly rare. It may cause no symptoms whatever, as we know may be the case with simple cysts, because of slow growth, small size, slowly-developing hemorrhage and location in the kidney. The second case which I report was entirely free from symptoms referable to the kidney, for one or all of the reasons which I have enumerated. It may, on the other hand, cause the same symptoms as a simple cyst, plus, if hemorrhage is acute and profuse as in my first case, those of sudden loss of blood under pressure. I do not feel that it is possible, and certainly it is not easy, to make a diagnosis of hemorrhagic cyst unless the radiographic shadow shows more than the usual density, or unless the bleeding has been sudden and excessive.
Case 1. A man of 60 years, headmaster of a boys' school, was referred to me November 10, 1931. He had always enjoyed good health, and in his younger days was an athlete of considerable renown (the possibility of trauma is to be considered here). During the past few years he had had marked pyorrhoea with apical abscesses requiring the extraction or extensive :filling of several teeth (the factor of infection enters here). On various occasions he had been troubled with an acute bursitis over the acromion process of the left side. This bursitis would always improve after the extraction of a tooth. From a medical friend of the patient I obtained the information that he had had in the recent past one or two brief circulatory accidents, during which time there was momentary loss of consciousness. These episodes suggest possible aneurysmal, embolit or thrombotic origin. For some years, especially the last two or three, the patient had been excessively tired. On the whole, however, up to the present illness, the patient declared himself to be in very good health, with no change in weight, a good appetite, and normal bowel movements. In the afternoon of the day I saw him he had lain down in his study for a nap after luncheon. On arising from the couch, he felt a sudden, sharp and very severe pain in the right loin, which he ascribed to a muscular strain (here again the possibility of trauma is to be considered) . There was no nausea or vomiting or other symptoms. After a few moments the pain subsided to the extent that he was able to walk over to the next building to attend
604
J.
DELLINGER BARNEY
a meeting. During this meeting he remembered feeling suddenly dizzy and then became unconscious, but apparently for only a short time. He did not recall having any pain. He was removed at once to the school infirmary and put to bed. His temperature was 99°, pulse said to be rapid but of good quality, blood pressure not recorded. White blood count was reported to be 28,000. A urine examination was said to show a few blood and pus cells. During the interval between then and until I saw the patient, some 6 or 7 hours later, he said he had no actual pain but only a sense of discomfort in the right loin, where there was, however, marked tenderness. The patient was found to be lying quietly and comfortably on his right side. He looked rather pale, was conscious, rational, and had a pulse which was rapid but of good quality. He was transferred at once to another hospital. At the moment I was inclined to the diagnosis of renal colic, although the picture also suggested hemorrhage. A very complete study of the patient was made. Repeated blood pressure readings were all within normal limits (140/90), the white blood count about 18 hours after the onset of symptoms fell to 11,500. The blood smear was normal. Hemoglobin 70 to 80 per cent. Blood nitrogen 24 mgm. per 100 cc., blood sugar 81 mgm. per 100 cc. The urine continued to show a few red and white cells. There was a moderate degree of chronic bronchitis. Repeated abdominal examination during the next 2 or 3 days showed moderate tenderness and spasm in the right loin extending down into the right iliac fossa. This was in marked contrast to the extreme degree of tenderness found when the patient was first seen. At no time could any well-defined mass be made out, although there was always the suggestion of a soft, rounded, movable tumor like that of a hydronephrotic kidney. Rectal examination showed a smooth, elastic prostate of normal size. Cystoscopic examination on November 12, 2 days after the onset of symptoms, showed a normal bladder mucosa, prostate and ureters. Catheters passed easily the full distance to each kidney with a slow but normal flow from each, rather more profuse on the right side. Indigo-carmin given intravenously appeared on the left side in 5 minutes, on the right in about 6 minutes. Both urines were clear, each showing only a little microscopic blood, probably due to trauma of the catheters. Cultures of both kidney urines and of the bladder urine were sterile. A right retrograde pyelogram was made. The X-ray Department reported as follows: "The outline of the left kidney is indistinct; on the right the kidney shadow is not visible. The right flank is dull, and the psoas muscle not well shown. Low in the bony pelvis are several small, round shadows which are probably phleboliths. The bones of the spine and pelvis show no evidence of disease. After injection a markedly distorted shadow of the right kidney pelvis is seen. The course of the ureter is normal and it is not dilated. These findings were
605
HEMORRHAGIC CYST OF KIDNEY
confirmed by a subsequent intravenous pyelogram (fig. 1). The character of the deformity of the kidney pelvis on the right is that seen in large tumors of the kidney; the greater part of the pelvis is obliterated and the calices are elongated or obliterated." After some days of further observation and speculation I arrived at a diagnosis of either neoplasm or cyst of the kidney. The patient being extremely apprehensive of the possibility of a neoplasm, I finally told him that he probably had a cyst of the kidney into which there had been a hemorrhage. The patient subsequently told me that he was willing to put into writing the fact that I had made this preoperative diagnosis.
FIG.
1
FIG.
2
FIG. 1. Intravenous pyelogram of right kidney showing deformity of pelvis and suggesting neoplasm. FrG. 2. Right kidney bisected longitudinally just after removal. From above downward is seen the normal upper pole, the thin-walled serous cyst, and the thick-walled cyst filled with bloody fluid and fresh clot.
Operation was performed November 20 under gas-oxygen anesthesia. A transverse, intraperitoneal incision was made. The intestines were walled off with gauze. A dark, fluctuant, cystic mass, evidently in the lower pole of the kidney, presented itself. The overlying posterior peritoneum was incised, a line of cleavage found, and the kidney delivered without difficulty. The kidney was about half again as large as normal. The entire lower pole and the middle third of the organ was occupied by two cysts, the lower being the size of a small grapefruit. This cyst was of a dark, purplish color and was quite solid with blood clot and bloody fluid. The cyst above this, and situated on the posterior surface of the kidney, was about the size of an apple, thinwalled and filled with clear fluid. Still above this there was an area of what
606
J.
DELLINGER BARNEY
looked like normal renal tissue. There was nothing to suggest malignant disease. Nephrectomy was carried out without difficulty, and the abdominal wound closed in the usual manner with drainage. Convalescence was rather stormy and prolonged, owing to two episodes involving the lung, thought to be infarcts and so diagnosed by x-ray. These eventually cleared up, although the patient was quite seriously ill on one or two occasions. Also there was a recurrence of the bursitis of the left acromion process. The abdominal wound healed by first intention. Now, 4 years later, the patient is in excellent condition locally and generally. As in many of the other cases recorded, the report of the pathologist is meagre. This may be due to the fact, at least in my cases, that it was preferred to save the specimen for exhibition purposes, rather than cut it to pieces for microscopic study. "The kidney me.asures 19 x 8 x 8 cm. and contains two large separate cysts, measuring 9 and S cm. in diameter respectively. The larger is situated at the lower pole. It has thin walls and is filled with purplish fluid (and blood clot, J. D. B.). The smaller one is on the posterior surface near the hilum, and also has thin walls. The renal parenchyma shows nothing noteworthy on gross examination. Microscopic examination of both cysts shmvs no evidence of tumor. The larger one contains blood clot. Diagnosis: Multiple cysts of kidney with hemorrhagic exudate in the larger one." As a matter of fact, as may be seen in figure 2, the wall of the hemorrhagic cyst is much thicker than that of the serous cyst, and is filled with solid but recent and not well organized blood clot. Case 2. A male, 76 years old, entered the hospital April 4, 1932 complaining of frequency of urination of several years duration, recently becoming more severe and accompanied by dribbling. There were no other urinary symptoms, nor any referable to the kidney. He had lost about 10 pounds in the past 4 years. There was no history of trauma or infectio°'. The outstanding feature of this patient was that he was found to have a moderately enlarged prostate, the posterior lobe hard and nodular with probable extension toward the seminal vesicle on the right. Abdominal examination showed no mass or tenderness; neither kidney was felt. X-ray showed no evidence of metastases. A preoperative diagnosis of cancer was made. After the usual preoperative preparation and study, a prostatic resection was done on April 11, under spinal anesthesia, and radium seeds implanted into the prostate. On April 17 (6 days later) the temperature suddenly rose to 104° but fell to 100° the following day. During the next week the temperature varied from 100° to 103°, reading 104° on the thirteenth day. There was marked abdominal distention. The patient rapidly declined and died on April 26, two weeks after operation. At autopsy the kidneys were found to weigh 400 grams. The capsule
607
HEMORRHAGIC CYST OF KIDNEY
stripped with difficulty, leaving a scarred and hemorrhagic surface. There was one large cortical cyst, measuring about 3 cm. in diameter in the lower pole of the right kidney. There were also two smaller cortical cysts about 2 or 3 cm. in diameter which invaded the calices and pelvis of the right kidney, but did not open into them. All of these cysts contained clear fluid. In the upper pole of the left kidney there was a purplish red, moderately firm mass, apparently a blood clot, 3 cm. in diameter, which was completely surrounded by a calcified capsule (figs. 3 and 4). The cortex of the kidneys averaged 4 mm. The striations were moderately distinct. Both pelves and calices showed moderate injection of the mucosa. Beyond the fact that the patient had carcinoma of the prostate and that
FIG. 3
FIG.
4
FIG. 3. Roentgenogram of the left kidney showing calcified wall surrounding the cyst at the upper pole. FIG. 4. Left kidney bisected longitudinally, showing the cyst of upper pole filled with clot and surrounded by a thick and calcified wall.
he died of bronchopneumonia and a partial collapse of the lung, nothing more need be stated for the purposes of this report. The pathologist's report on the left kidney follows: "In the upper pole of the left kidney, there is a purplish red, moderately firm, apparent blood clot 3 cm. in diameter, which is completely surrounded by a calcified capsule. Microscopic examination of the cyst lining and of the blood clot shows no evidence of malignancy." SUMMARY
Two cases of hemorrhagic cyst of the kidney are reported. The hemorrhage in case 1 was acute, and gave rise to a train of obscure
608
J.
DELLINGER BARNEY
subjective and objective symptoms. The etiology is unknown, but the possibility of infection or trauma is to be considered, and perhaps especially embolism or thrombosis. The presence of another cyst in the same kidney, thin-walled and filled with serous fluid, increases the probability that what ended as a hemorrhagic cyst might well have started as a serous cyst. In case 2 nothing is known of the antecedents of the case. The fact that the opposite kidney contained three serous cysts might allow one to follow the same train of thought as in case 1. On the other hand the calcified wall surrounding the blood clot would indicate an ancient process, with symptoms so insignificant that the patient did not notice them. In case 1 there were no symptoms, subjective or objective, previous to the onset of the hemorrhage. At this time the symptoms were very suggestive of renal colic, due perhaps to calculus. There was in addition the strong suggestion of a rather severe but obscure hemorrhage. The pain and tenderness can be accounted for by the sudden increase of tension within the cyst cavity. The character and location of the pain in this case, and the tenderness also, was not like that which one usually associates with renal pathology. I feel that even though it might be an unlikely diagnosis, one might well think of the possibility of an acute hemorrhagic cyst of the kidney in any case of obscure abdominal pain. In case 2 there were evidently no signs or symptoms during life which could be elicited by the history or physical examination. The calcified cyst wall is indicative of a long-standing process, and the hemorrhage into it was not extensive enough to have caused symptoms at the time it took place. These 2 cases illustrate the point that cysts of the kidney may, and in fact often do, exist for an indefinite and probably a long time without declaring themselves. The factors which bring about their recognition are pressure, pain, presence of a tumor, intracystic pressure, or acute hemorrhage. I agree with Munger that more intensive study should be given such cases if we are to know their life history. REFERENCES MUNGER: STIRLING:
Jour. Urol., 27: 73, 1932. Jour. Urol., 26: 213, 1931.
J. DELLINGER
BARNEY
From the Urological Service, Massachusetts General Hospital
After reviewing the literature of hemorrhagic cyst of the kidney, one is impressed by (a) its rarity, (b) its obscure and varied symptomatology, and (c) the divergent opinions as to its etiology. There is also no doubt that these cysts may present a difficult problem in differential diagnosis. Many theories have been advanced as to the etiology of hemorrhagic cysts. By many they are thought to begin as simple solitary cysts, the etiology of these being in themselves obscure, which later are the seat of hemorrhage of unknown cause. Considerable weight seems to attach to a congenital origin. It has also been suggested that these cysts are really bizarre forms of hematoma; while Judd and others are inclined to the view that they are of an aneurysmal nature. Certain experimental evidence would suggest the possibility that they may arise from embolic or thrombotic infarction. The factor of trauma, recognized or probable, seems to be an important element. Stirling reported a personal case, and collected 31 others from the literature. In 1932 Munger reviewed the 1,ubject with great care and with an eye more critical than that of Stirling. He accepts but 18 of those collected by Stirling, and adds a case of his own. It is also pointed out that Judd and Simon in 1927 thought that of the cases reported up to that time only 13 were sufficiently well described to be accepted as true hemorrhagic cyst. As Munger remarks, "if the contention for hemorrhagic cyst as a separate entity is worthy of consideration, then we must establish a uniformity of histologic picture in contradistinction to that of other types of renal cysts . .. ." After reviewing the literature it seems to me that either because of inadequate description, both gross and microscopic, or because there is actually no uniformity, it is impossible, in the present state of our knowledge, to say whether any given hemorrhagic cyst started as a simple serous cyst or whether it contaiI\ed blood or bloody fluid from the outset. If and when the etiology of the solitary renal cyst is well understood, and after enough histologic studies have been made of all 1 Read at the annual meeting of the American Urological Association, Boston, Mass., May 19, 1936.
602
HEMORRHAGIC CYST OF KIDNEY
603
the tissue removed, then I believe that we can make some sort of a classification. With these thoughts in mind I wish to add 2 cases to those already reported. If we accept Stirling's list of 32 and add Munger's case, my 2 cases will bring the total up to 35. If, on the other hand, we add my cases to Munger's list of 19, then we have a total of 21. In any event the condition is certainly rare. It may cause no symptoms whatever, as we know may be the case with simple cysts, because of slow growth, small size, slowly-developing hemorrhage and location in the kidney. The second case which I report was entirely free from symptoms referable to the kidney, for one or all of the reasons which I have enumerated. It may, on the other hand, cause the same symptoms as a simple cyst, plus, if hemorrhage is acute and profuse as in my first case, those of sudden loss of blood under pressure. I do not feel that it is possible, and certainly it is not easy, to make a diagnosis of hemorrhagic cyst unless the radiographic shadow shows more than the usual density, or unless the bleeding has been sudden and excessive.
Case 1. A man of 60 years, headmaster of a boys' school, was referred to me November 10, 1931. He had always enjoyed good health, and in his younger days was an athlete of considerable renown (the possibility of trauma is to be considered here). During the past few years he had had marked pyorrhoea with apical abscesses requiring the extraction or extensive :filling of several teeth (the factor of infection enters here). On various occasions he had been troubled with an acute bursitis over the acromion process of the left side. This bursitis would always improve after the extraction of a tooth. From a medical friend of the patient I obtained the information that he had had in the recent past one or two brief circulatory accidents, during which time there was momentary loss of consciousness. These episodes suggest possible aneurysmal, embolit or thrombotic origin. For some years, especially the last two or three, the patient had been excessively tired. On the whole, however, up to the present illness, the patient declared himself to be in very good health, with no change in weight, a good appetite, and normal bowel movements. In the afternoon of the day I saw him he had lain down in his study for a nap after luncheon. On arising from the couch, he felt a sudden, sharp and very severe pain in the right loin, which he ascribed to a muscular strain (here again the possibility of trauma is to be considered) . There was no nausea or vomiting or other symptoms. After a few moments the pain subsided to the extent that he was able to walk over to the next building to attend
604
J.
DELLINGER BARNEY
a meeting. During this meeting he remembered feeling suddenly dizzy and then became unconscious, but apparently for only a short time. He did not recall having any pain. He was removed at once to the school infirmary and put to bed. His temperature was 99°, pulse said to be rapid but of good quality, blood pressure not recorded. White blood count was reported to be 28,000. A urine examination was said to show a few blood and pus cells. During the interval between then and until I saw the patient, some 6 or 7 hours later, he said he had no actual pain but only a sense of discomfort in the right loin, where there was, however, marked tenderness. The patient was found to be lying quietly and comfortably on his right side. He looked rather pale, was conscious, rational, and had a pulse which was rapid but of good quality. He was transferred at once to another hospital. At the moment I was inclined to the diagnosis of renal colic, although the picture also suggested hemorrhage. A very complete study of the patient was made. Repeated blood pressure readings were all within normal limits (140/90), the white blood count about 18 hours after the onset of symptoms fell to 11,500. The blood smear was normal. Hemoglobin 70 to 80 per cent. Blood nitrogen 24 mgm. per 100 cc., blood sugar 81 mgm. per 100 cc. The urine continued to show a few red and white cells. There was a moderate degree of chronic bronchitis. Repeated abdominal examination during the next 2 or 3 days showed moderate tenderness and spasm in the right loin extending down into the right iliac fossa. This was in marked contrast to the extreme degree of tenderness found when the patient was first seen. At no time could any well-defined mass be made out, although there was always the suggestion of a soft, rounded, movable tumor like that of a hydronephrotic kidney. Rectal examination showed a smooth, elastic prostate of normal size. Cystoscopic examination on November 12, 2 days after the onset of symptoms, showed a normal bladder mucosa, prostate and ureters. Catheters passed easily the full distance to each kidney with a slow but normal flow from each, rather more profuse on the right side. Indigo-carmin given intravenously appeared on the left side in 5 minutes, on the right in about 6 minutes. Both urines were clear, each showing only a little microscopic blood, probably due to trauma of the catheters. Cultures of both kidney urines and of the bladder urine were sterile. A right retrograde pyelogram was made. The X-ray Department reported as follows: "The outline of the left kidney is indistinct; on the right the kidney shadow is not visible. The right flank is dull, and the psoas muscle not well shown. Low in the bony pelvis are several small, round shadows which are probably phleboliths. The bones of the spine and pelvis show no evidence of disease. After injection a markedly distorted shadow of the right kidney pelvis is seen. The course of the ureter is normal and it is not dilated. These findings were
605
HEMORRHAGIC CYST OF KIDNEY
confirmed by a subsequent intravenous pyelogram (fig. 1). The character of the deformity of the kidney pelvis on the right is that seen in large tumors of the kidney; the greater part of the pelvis is obliterated and the calices are elongated or obliterated." After some days of further observation and speculation I arrived at a diagnosis of either neoplasm or cyst of the kidney. The patient being extremely apprehensive of the possibility of a neoplasm, I finally told him that he probably had a cyst of the kidney into which there had been a hemorrhage. The patient subsequently told me that he was willing to put into writing the fact that I had made this preoperative diagnosis.
FIG.
1
FIG.
2
FIG. 1. Intravenous pyelogram of right kidney showing deformity of pelvis and suggesting neoplasm. FrG. 2. Right kidney bisected longitudinally just after removal. From above downward is seen the normal upper pole, the thin-walled serous cyst, and the thick-walled cyst filled with bloody fluid and fresh clot.
Operation was performed November 20 under gas-oxygen anesthesia. A transverse, intraperitoneal incision was made. The intestines were walled off with gauze. A dark, fluctuant, cystic mass, evidently in the lower pole of the kidney, presented itself. The overlying posterior peritoneum was incised, a line of cleavage found, and the kidney delivered without difficulty. The kidney was about half again as large as normal. The entire lower pole and the middle third of the organ was occupied by two cysts, the lower being the size of a small grapefruit. This cyst was of a dark, purplish color and was quite solid with blood clot and bloody fluid. The cyst above this, and situated on the posterior surface of the kidney, was about the size of an apple, thinwalled and filled with clear fluid. Still above this there was an area of what
606
J.
DELLINGER BARNEY
looked like normal renal tissue. There was nothing to suggest malignant disease. Nephrectomy was carried out without difficulty, and the abdominal wound closed in the usual manner with drainage. Convalescence was rather stormy and prolonged, owing to two episodes involving the lung, thought to be infarcts and so diagnosed by x-ray. These eventually cleared up, although the patient was quite seriously ill on one or two occasions. Also there was a recurrence of the bursitis of the left acromion process. The abdominal wound healed by first intention. Now, 4 years later, the patient is in excellent condition locally and generally. As in many of the other cases recorded, the report of the pathologist is meagre. This may be due to the fact, at least in my cases, that it was preferred to save the specimen for exhibition purposes, rather than cut it to pieces for microscopic study. "The kidney me.asures 19 x 8 x 8 cm. and contains two large separate cysts, measuring 9 and S cm. in diameter respectively. The larger is situated at the lower pole. It has thin walls and is filled with purplish fluid (and blood clot, J. D. B.). The smaller one is on the posterior surface near the hilum, and also has thin walls. The renal parenchyma shows nothing noteworthy on gross examination. Microscopic examination of both cysts shmvs no evidence of tumor. The larger one contains blood clot. Diagnosis: Multiple cysts of kidney with hemorrhagic exudate in the larger one." As a matter of fact, as may be seen in figure 2, the wall of the hemorrhagic cyst is much thicker than that of the serous cyst, and is filled with solid but recent and not well organized blood clot. Case 2. A male, 76 years old, entered the hospital April 4, 1932 complaining of frequency of urination of several years duration, recently becoming more severe and accompanied by dribbling. There were no other urinary symptoms, nor any referable to the kidney. He had lost about 10 pounds in the past 4 years. There was no history of trauma or infectio°'. The outstanding feature of this patient was that he was found to have a moderately enlarged prostate, the posterior lobe hard and nodular with probable extension toward the seminal vesicle on the right. Abdominal examination showed no mass or tenderness; neither kidney was felt. X-ray showed no evidence of metastases. A preoperative diagnosis of cancer was made. After the usual preoperative preparation and study, a prostatic resection was done on April 11, under spinal anesthesia, and radium seeds implanted into the prostate. On April 17 (6 days later) the temperature suddenly rose to 104° but fell to 100° the following day. During the next week the temperature varied from 100° to 103°, reading 104° on the thirteenth day. There was marked abdominal distention. The patient rapidly declined and died on April 26, two weeks after operation. At autopsy the kidneys were found to weigh 400 grams. The capsule
607
HEMORRHAGIC CYST OF KIDNEY
stripped with difficulty, leaving a scarred and hemorrhagic surface. There was one large cortical cyst, measuring about 3 cm. in diameter in the lower pole of the right kidney. There were also two smaller cortical cysts about 2 or 3 cm. in diameter which invaded the calices and pelvis of the right kidney, but did not open into them. All of these cysts contained clear fluid. In the upper pole of the left kidney there was a purplish red, moderately firm mass, apparently a blood clot, 3 cm. in diameter, which was completely surrounded by a calcified capsule (figs. 3 and 4). The cortex of the kidneys averaged 4 mm. The striations were moderately distinct. Both pelves and calices showed moderate injection of the mucosa. Beyond the fact that the patient had carcinoma of the prostate and that
FIG. 3
FIG.
4
FIG. 3. Roentgenogram of the left kidney showing calcified wall surrounding the cyst at the upper pole. FIG. 4. Left kidney bisected longitudinally, showing the cyst of upper pole filled with clot and surrounded by a thick and calcified wall.
he died of bronchopneumonia and a partial collapse of the lung, nothing more need be stated for the purposes of this report. The pathologist's report on the left kidney follows: "In the upper pole of the left kidney, there is a purplish red, moderately firm, apparent blood clot 3 cm. in diameter, which is completely surrounded by a calcified capsule. Microscopic examination of the cyst lining and of the blood clot shows no evidence of malignancy." SUMMARY
Two cases of hemorrhagic cyst of the kidney are reported. The hemorrhage in case 1 was acute, and gave rise to a train of obscure
608
J.
DELLINGER BARNEY
subjective and objective symptoms. The etiology is unknown, but the possibility of infection or trauma is to be considered, and perhaps especially embolism or thrombosis. The presence of another cyst in the same kidney, thin-walled and filled with serous fluid, increases the probability that what ended as a hemorrhagic cyst might well have started as a serous cyst. In case 2 nothing is known of the antecedents of the case. The fact that the opposite kidney contained three serous cysts might allow one to follow the same train of thought as in case 1. On the other hand the calcified wall surrounding the blood clot would indicate an ancient process, with symptoms so insignificant that the patient did not notice them. In case 1 there were no symptoms, subjective or objective, previous to the onset of the hemorrhage. At this time the symptoms were very suggestive of renal colic, due perhaps to calculus. There was in addition the strong suggestion of a rather severe but obscure hemorrhage. The pain and tenderness can be accounted for by the sudden increase of tension within the cyst cavity. The character and location of the pain in this case, and the tenderness also, was not like that which one usually associates with renal pathology. I feel that even though it might be an unlikely diagnosis, one might well think of the possibility of an acute hemorrhagic cyst of the kidney in any case of obscure abdominal pain. In case 2 there were evidently no signs or symptoms during life which could be elicited by the history or physical examination. The calcified cyst wall is indicative of a long-standing process, and the hemorrhage into it was not extensive enough to have caused symptoms at the time it took place. These 2 cases illustrate the point that cysts of the kidney may, and in fact often do, exist for an indefinite and probably a long time without declaring themselves. The factors which bring about their recognition are pressure, pain, presence of a tumor, intracystic pressure, or acute hemorrhage. I agree with Munger that more intensive study should be given such cases if we are to know their life history. REFERENCES MUNGER: STIRLING:
Jour. Urol., 27: 73, 1932. Jour. Urol., 26: 213, 1931.