PARANEPHRIC CYSTS. 
BT 
ROBERT ABBE, M. D. 
EBPRIMTED KKOV 
Neto JTorfe fttcfifcal Sonata I 
for August 9, 1890. Reprinted from the New York Medical Journal 
for August 9, 1890. 
PARANEPHRIC CYSTS,* 
By ROBERT ABBE, M. D. 
The variety of cystic tumors one may encounter in the 
abdominal cavity is not great.. 
Ovarian, parovarian, salpingeal, in the female, and hy- 
datid, pancreatic, distended gall-bladder, and hydronephrotic 
cysts and pus collections, which are common to both sexes, 
are about all which one will find. Exceptionally one may 
meet a cystic tumor that will have an entirely different 
clinical history and require different treatment. There may 
be variations of the above, as the cyst of an extra-uterine 
pregnancy, or one of the class under consideration which 
heretofore may have been ranked with hydronephrosis of 
the common type. It is proper that they should be differ- 
entiated, clinically and anatomically, and it is with a view 
to giving a suitable rank to this class that I present the 
history of two striking cases that were extremely puzzling 
to me until laparotomy cleared up the nature of both : 
Case I. Large Paranephric Cyst; Exploratory Laparoto- 
my ; Lncision and Lumbar Drainage; Gholesterin in the Fluid ; 
Recovery.—A lady of forty-eight years, referred to me from Dr. 
Pellet, of Hamburg, N. J., was in fair condition when first seen by 
me on August 12, 1889. She gave no history of special illness ex- 
* Read before the New York Surgical Society, April 23, 1890. 2 
PARANEPHRIC CYSTS. 
cept an attack of inflammation of the kidneys lasting two weeks, 
seventeen years ago. Since that time the functional activity of 
the kidney has been normal and, as far as she has been aware, 
nothing unusual has occurred in the appearance of her urine. 
She had excellent digestion and health. No members of her 
family ever had tumors of any description. She had seven 
children in the past twelve years without unusual event. Four 
years ago she first noticed a swelling of her left side, not hard, 
and extending from the left loin toward the groin, about as long 
and as broad as her hand. It was painless and did not seem to 
grow for two years or more. Her health not being affected, she 
paid little heed to its presence, though she says she at first con- 
sulted Dr. T. G. Thomas, who said it was connected, he thought, 
with her kidney. As it enlarged it filled the left iliac fossa, en- 
croached on the median line, passed the level of the umbilicus, 
and grew upward to the ribs. During the past few weeks it 
has grown much more rapidly, and there has been a dull aching 
in the back. 
Her general health has not deteriorated. 
On examination, a large tumor was found to fill the left half 
of the abdomen, extending across to the opposite iliac fossa. It 
seemed like a large cyst, constricted somewhat vertically, the 
median portion dome-shaped, with the navel at the summit. 
The tumor filled the left iliac fossa and extended well across 
into the right. It rose into the left lumbar and hypochondriac 
region and raised the costal cartilages. A sulcus marked its sur- 
face obliquely to the left of the median line, and in this portion 
was resonance, as of an adherent intestine lying more or less ver- 
tically. Elsewhere the tumor was entirely dull on percussion. 
Auscultation was negative. 
Vaginal examination reveals a large patulous cervix, the 
uterus pushed backward and to tiie right, and movable inde- 
pendently of the tumor. The latter fills the anterior portion of 
the pelvis and gives a sense of resistance like a thin-walled cyst. 
The general appearance was of an ovarian cystoma of large size 
composed mainly of two principal cysts. The most unaccount- 
able feature was the oblique intestine confined to its surface. 
This was suspected to be adherent. On account of her history PARANEPHRIC CYSTS. 
3 
that Dr. Thomas had thought it renal in the early stage, the 
urine was carefully observed. It was of rather low specific 
gravity, 1*010; acid ; no albumin, and contained a few pus cells 
and epithelium—not enough to give the slightest suspicion of 
renal trouble. 
The cyst presented at once in the incision, but differed en- 
tirely in appearance from an ovarian cyst. It was invested by an 
independent loose peritoneal covering, with large vessels travers- 
ing it laterally. The presenting adherent intestine was evidently 
the descending colon raised from its normal bed. The hand, 
being introduced into the abdomen, was passed over the face of 
the tumor downward to ascertain its base of origin. It dipped 
well down into the pelvis, then up behind it freely to the ilio- 
lumbar region. Laterally it passed over the smooth surface 
into a sulcus in the left loin, where the peritonaeum reflected on 
to the tumor at the site of the normal colon, which, however, 
had been raised faraway from its site. On the median side the 
hand passed around the cyst and returned beneath it to the 
region of the left kidney. Above, it passed freely over the top, 
and, reaching the diaphragm, slipped down behind the cyst again 
to the kidney region. 
On August 14,1889,1 made exploratory median laparotomy. 
It was evident then, from all sides, that the tumor originated 
about the left kidney, and that it had best be opened posteriorly. 
At the same time, to avoid opening the peritoneal cavity pos- 
teriorly, it would be necessary to keep well behind the reflec- 
tion of lumbar parietal peritonaeum. Therefore, while protect- 
ing the anterior wound with hot compresses, yet maintaining 
my hand within to define the peritoneal limits, I made a free 
lumbar incision as if for colotomy. Rapid evacuation of the con- 
tents took place and the cyst collapsed so completely that it was 
difficult to detect its remaining thin walls by the hand in the 
abdomen. The colon descended nearly to its normal site. 
The most noticeable feature observed was the spread-out 
kidney. It was not distended, but flattened out against the loin, 
a crater-like rim being felt on its surface, marking the bed from 
which the cyst sprung. This was an unmistakable feeling, and 
was recognized by manipulation through the lumbar as well as 4 
PARANEPHRIC CYSTS. 
the abdominal wound, but best from in front. Some time was 
taken to discover if possible any connection between the cyst 
and the pelvis of the kidney, but no sense of distended calyces 
or funnel-shaped pelvis was present; and it was completely 
evident that the cyst was independent of the renal pelvis. The 
anterior wound was closed, and large drainage-tubes introduced 
through the lumbar wound into the cyst. 
The fluid evacuated was as remarkable as the cyst. It meas- 
ured between ten and twelve pints, was of a pinkish milky 
color, thin, turbid, and glistening with myriads of cholesterin PARANEPHRIC CYSTS. 
5 
crystals, which, on standing, deposited to the amount of one 
fifth the bulk of fluid. The latter was of specific gravity 1-030 ; 
contained a large quantity of albumin ; microscopically, choles- 
terin, red blood-cells, a large number, and a trifling number of 
pus cells; large multinuclear cells, granular round cells, irregu- 
lar granular masses, and free fat. The patient made a speedy 
and uninterrupted convalescence. The urine was watched for 
possible appearance of crystals of cholesterin, which certainly 
had not appeared before operation. On the day following op- 
eration a trace of albumin, a few casts, and a few cholesterin 
crystals were found, but never afterward. These may readily 
be explained by the manipulation and probing during the opera- 
tion, which may easily have lacerated some part of the delicate 
sac. No urine ever appeared at the lumbar wound. 
Under irrigation and drainage the cyst closed, so that in four 
weeks it would hold hut four ounces on distension. In six 
weeks she was discharged cured, a slight sinus remaining which 
healed soon after her return home. Since that date, more than 
six months, the patient has remained perfectly well; has gained 
thirty pounds in weight, and is actively employed at home. 
The second, case presented itself three months later. 
Case ll.—The patient was a young lawyer, aged twenty- 
three years, of good physique. About the Ist of September he 
was taken with acute pain in the right hypochondrium, nearly 
in the region of the gall-bladder, and simultaneously noticed a 
large swelling at the site of the present tumor. When he was 
seven years old, and again at fifteen, he remembers to have had 
similar attacks. He had no fever with this attack and the pain 
gradually subsided. 
He came under the care of Dr. Kinnicntt and Dr. Draper, 
with whom I saw him on October 3, 1889. 
He seemed to be in good health, excepting that he had a tu- 
mor in his side that gave him a little pain. 
His normal pulse was 55. Temperature varied from 98° to 
99° during two weeks’ observation before operation. 
Examination showed a globular tumor of the abdomen in 
tbe right hypochondriac region, the apex of which lay between 6 
PARANEPHRIC CYSTS. 
the point of the tenth rib and the nave). Palpation showed it 
to be of very even surface, but more prominent near the point 
of the tenth rib. It sloped equally in all directions. The loin 
was also filled by it, so that pressure there raised the summit, but 
there was no lumbar prominence as there was in front. The liver 
boundary was raised three quarters of an inch upward. The tu- 
mor descended to the level of the navel and extended across the 
median line. This was discovered rather by palpation than per- 
cussion. The colon was pushed downward. There had been PARANEPHRIC CYSTS. 
no jaundice. Tlie urine was normal. Palpation in different 
attitudes revealed a lateral movement of the mass of two inches. 
There was no history of renal colic, with its characteristic 
pain. 
On first examination, my conclusion was that we had to deal 
with a greatly distended gall bladder. The following points 
were a fair guide to this decision : 1. There was an absence of 
history of renal symptoms. 2. The tumor was evidently a fluid 
one. 3. The position was considerably higher in the abdomen 
than the tumor of hydronephrosis. 4. The rotund fullness was 
most pointed at the apex of the tenth rib and enlarging thence 
toward the navel. 5. The history of this attack of acute pain, 
with two preceding ones in former years, was like that of gall- 
stone impaction. During the two weeks following the patient 
had no pain; walked about and drove out. 
Further examination showed a slight increase in growth 
across the median line, with less fullness between the navel and 
the tenth rib. While admitting the possibility of this tumor 
springing from the kidneys after the fashion of the paranephric 
cysts, the case previously narrated being fresh in my memory, 
I was yet more inclined to regard it as occupying the site of the 
gall-bladder when distended. It may have had a little more 
latitude of motion than a gall-bladder of similar size, and pos- 
sibly could be said to be more full in the lumbar region than 
that. 
The patient was eating and sleeping well. Urine was nor- 
mal in specific gravity and reaction ; had no albumin, or sugar, 
or abnormal elements on microscopical examination. The pres- 
ence of the tumor, however, was a menace to him, and there- 
fore, after consultation with Dr. Draper, Dr. Kinnicutt, and Dr. 
Bull, I operated under ether on October 22, 1889. Incision 
vertical, as for cholecystotomy. On opening the abdominal 
cavity, the presenting surface of the tumor was at a glance, as in 
the former case, seen to be covered by the posterior peritoneal 
wall of the abdominal cavity, indicated by the appearance of 
the large vessels traversing it laterally, and by the relatively 
loose attachment of peritonaeum to the tumor. The fingers, 
passed into the cavity, found the liver free, but pushed upward, 8 
PARANEPHRIC CYSTS. 
and the gall-bladder normal. Passing backward, the possibility 
of hydatid cyst springing from the liver was excluded. The 
slope of the tumor in all directions was backward toward the 
loin. It was free from adhesions on every side. 
While conducting these explorations somewhat vigorously, 
the peritoneal layer investing the tumor was seen to grow rap- 
idly oedernatous and puft’ up so as to fill the incision. Growing 
rapidly thinner, it burst open in the wound as I attempted to 
secure it with forceps, and gave exit to a rapid flow of watery, 
colorless, limpid fluid, sufficient of which was caught for exami- 
nation. The presenting rent was secured in the wound, and 
the fluid kept out of the peritoneal cavity. The rent was en- 
larged, and the flow seen to come from the loose-meshed retro- 
peritoneal tissue. The tumor so rapidly disappeared and its 
remnant sank hack into the loin so quickly that it was difficult 
to identify any distinct cyst wall among the cellular tissue, and 
it was deemed unwise to strip up the peritonaaum for further 
exploration. The evacuation being completed, an estimate was 
made that two pints of fluid had escaped. 
A digital examination of the site of the tumor was made. 
The rent in the peritonaeum was two inches above the colon at 
its hepatic flexure. The liver was entirely uninvolved. The 
finger passed backward to the aorta and renal vessels, thence 
downward around the colon and over it to the kidney, whose 
entire surface was palpated. The lower end was round, 
smooth, and normal. The rest of its surface was not quite as 
even as natural, and was spread out into four flattened lobula- 
tions. The collapsed tumor sac and adjacent colon fell hack so 
as to cover this area, and no trace of other abnormal condition 
could be discovered. The posterior rent was therefore stitched 
to the abdominal incision and the latter closed, except for 
drainage of the retroperitoneal space, through which the fluid 
had escaped. My original intention had been to drain poste- 
riorly if I found such a renal cyst, but the bursting of the sac 
required anterior drainage. 
The cyst fluid was of very low specific gravity—DOGS. It 
contained a trace of albumin; no urine salts; no bile salts; no 
hydatid elements; some chlorides. During evacuation hydatid PARANEPHRIC CYSTS. 
9 
daughter cysts were watched for hut not seen. The diagnosis, 
therefore, must remain of thin-walled cyst of the surface of the 
kidney, growing so as to distort the organ by surface pressure. 
After operation, free drainage of limpid fluid continued for 
thirty-six hours, when it rapidly lessened, and his convalescence 
was uninterrupted. His temperature fell to normal in four or 
five days. On the fourth day he had considerable albumin ap- 
pear in his urine, with casts. All disappeared during the four 
days succeeding, and he was discharged cured during the fourth 
week. 
He has since been carefully examined by Dr. Draper, nearly 
six months after operation, and he remains free from all signs 
of trouble. 
There seems in the cases given to be evidence that in 
both we had renal cysts not of the usual type of hydrone- 
phrosis. The pelves of the kidneys were not the seat of 
distension, and excepting that, through scratching, a few 
cholesterin crystals entered the urinary channel a few hours 
after operation, there was no contamination of the urine 
by the cyst contents. 
The retention cysts of the renal cortex resulting from 
fibrous change in granular kidney are usually multiple and 
rarely attain much size. They are bilateral also. Congeni- 
tal cysts are very rare and due to cystic degeneration of 
rudimentary tubes. The kidney substance is not left in 
bulk as in the cases narrated, but attenuated or wanting, 
and the victims of this deformity are apt to have other de- 
formities and die in infancy. Simple cysts and paranephric 
cysts, however, are of a class by themselves that directly 
concern the surgeon by their rarity and importance. 
The pathology of their origin is not easily ascertained, 
as they have usually so attenuated the capsule of the gland 
and compressed the neighboring cortex as to make it im- 
possible to say whether they sprang from the meshes of the 
cellular layer beneath the capsule, or from the Malpighian 10 
PARANEPHRIC CYSTS. 
corpuscles, or from their investing cellular layer, or from 
lymphatic channels. The contents of the cyst give no clew 
to its origin ; they are as various as in cysts elsewhere, 
varying from clear aqueous contents of very low specific 
gravity and containing a trace of albumin and salt through 
every grade of colloid and straw-colored serum. Usually 
clear, they may have such ingredients as cholestcrin, which 
results from the degeneration of any fatty or cellular sub- 
stance, or, as seems most probable, of blood. They never 
have urinous elements in solution. 
This uncertainty as to origin entitles such tumors as 
have been described to the name of paranephric cysts, 
resting upon the kidney, there being no evidence that they 
arise within the cortex. The recorded cases are not very 
numerous. They have been known to grow to larger pro- 
portions than the first one I have mentioned, and to have 
been mistaken for ovarian tumors. This seems extremely 
easy to do if one regards the shape and fluctuation of the 
tumor and the appearance of the patient. If an early his- 
tory of growth in the ilio-hypochondriac region can be 
elicited, or if the physical examination reveals a course of 
the intestine over its surface, such as the colon took in one 
case under consideration, it would give a strong point toward 
differential diagnosis. In my second case the relation of 
the colon was also of interest, it being pushed down and in 
front of the tumor. This is perhaps one of the best points 
for diagnosis that the colon is usually in front of a renal 
tumor. Yet, as Morris says, an exceptionally large renal 
tumor will push the colon aside, and, on the other hand, a 
portion of intestine will occasionally though rarely fasten 
itself in front of an ovarian cyst. 
As regards the second case, which resembled a dis- 
tended gall-bladder, I may say on reviewing it that the 
tumor, while not less prominent than a gall-bladder cyst, PARANEPHRIC CYSTS. 
11 
was perhaps less pyriform, more movable laterally, and some- 
what more easily raised by lumbar pressure than even a 
large gall-bladder would have been. Its position was too 
high for the usual hydronephrosis. 
The successful treatment of all serous cysts by incision 
and drainage makes it probable that no other treatment 
would have been more successful or less dangerous in these 
cases. The first case of large cyst shows that a lumbar in- 
cision without guidance from within would have probably 
penetrated the peritoneal sac before entering the cyst, on 
account of the persistent reflection of the peritonaeum close 
to the kidney, in spite of the fact that the colon had been 
raised to the surface of the cyst. Exploratory aspiration 
also would have allowed the muddy cholesterin fluid to 
empty somewhat into the peritonaeum if puncture had been 
made anywhere but close to the kidney. REASONS WHY 
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