[Reprinted from The Medical News, March 21, 1891.] EXTIRPATION OF THE KIDNEY FOR AN ENOR- MOUS MYXO-SARCOMA IN A CHILD AGED THREE YEARS ANQ EIGHT MONTHS. by a. v. l. Brokaw, m.d., DEMONSTRATOR OF ANATOMY AND OPERATIVE SURGERY IN THE MISSOURI MEDICAL COLLEGE ; JUNIOR SURGEON TO st. John's hospital, etc. Among the rare occurrences in operative surgery is the successful treatment of malignant renal dis- eases in children. This is shown by the alarming mortality in these cases of 44.9 per cent, due to the operation. The removal of tumors from the kidney in children is an operation of recent date ; for it has only been a very short time since surgeons would not attempt operative interference. Fischer1 tabulated twenty-five such cases, with a mortality of 48 per cent. Czerney,2 Schede and Roberts have also con- tributed to the cases on record. The literature up to date, including a case lately reported by Dohrn (Kdnigsberg), contains twenty-nine cases, bearing the above gloomy figures of 44.9 per cent, mortality, In view of these facts the case to be presented, and especially the technique of the operation, will contain points of no little interest to the surgeon. The patient, a boy, aged three years and eight 1 Deutsche Zeitschrift fur Chirurgie, 1889, Bd xxix, 2 Arch, fur Kinderheilk., 1890. 2 BROKAW, months, came under my observation on November 14, 1890. According to the statements of the parents the child had been complaining since June, 1890, of pain and general discomfort in the right side of the abdomen. Just beneath the free mar- gins of the ribs there appeared a swelling or protru- sion which led an irregular physician in charge of the case to the diagnosis of "hypertrophy of the liver." Until two weeks before I was consulted the boy had been engaged in his childish pastimes, playing as usual and giving no evidence of the frightful process which was going on within. The unmistakable growth, which was now diag- nosed, appeared so extensive that I expressed an unfavorable view of operative interference. The tumor filled entirely the lumbar and half of the umbilical region, extending from one and a half inches above the anterior superior spine of the ilium to the free margin of the liver, and on the right side it extended nearly to the middle of the left rectus muscle. It gave a peculiar elastic, almost fluctuating, sensation when palpated ; so marked, in fact, that the idea of a cystic growth was entertained by a consultant. The thoracic viscera were normal and nothing of pathological import was revealed by a careful urinary analysis. In the face of these facts and the tender age of the child the case appeared, to say the least, formid- able ; so that taking into consideration the general circumstances of the case, and having in mind the great mortality from the operation, I expressed a reluctance to interfere. The father, however, in- sisted, and accordingly preparations were made for operating on the following day. EXTIRPATION OF THE KIDNEY. 3 Under chloroform I made an incision six inches in length, extending from the margins of the quad- ratics lumborum muscle to midway between the last rib and the crest of the ilium. A few strokes of the knife brought the tumor to view. It presented a peculiar grayish color, with large venous trunks radiating over its surface. An attempt was made to separate the tumor from the ascending colon without entering the peritoneal cavity; failing in this, however, an opening some five inches in length was torn in the peritoneum. Firm adhesions had formed in almost every direction around the tumor, which made the enucleation of the growth exceed- ingly difficult. In separating some of the adhesions the capsule of the tumor was ruptured, and with a sudden gush the larger portion of the soft jelly-like mass escaped into the abdomen. Time was an all- important factor, and without stopping to meet this accident I hastily separated the adhesions binding the growth to the hepatic flexure of the colon and liver. I quickly formed a pedicle of the blood- vessels and ureter, and then passed an aneurismal needle between the latter and the vessels, and tied off the kidney with a. modified Staffordshire knot. Having completed this, I introduced my hand into the* abdomen and removed all the soft material which had escaped into the cavity. The abdominal cavity was thoroughly flushed out with hot water and carefully searched for any remnants of the jelly- like mass. The rent in the peritoneum was closed with a continuous catgut suture, and the muscles and skin were approximated with silk sutures. A tampon of iodoform gauze was inserted into the deeper part of 4 EXTIRPATION OF THE KIDNEY. the wound, and a heavy dressing of bichloride gauze arid absorbent cotton was applied and retained in position with a broad bandage. The shock of the operation was severe and he did not rally completely for four or five hours. The amount of blood lost during the operation was of necessity considerable. Every effort was made to complete the work in the shortest space of time, the entire operation lasting but twenty-three minutes. Fortunately the wound healed by first intention, and the convalescence of the little patient was rapid. After removal of the gauze tampon on the third day no further provision for drainage was deemed necessary, and a permanent dressing was placed over the wound. This was not removed for two weeks. Three weeks only had passed after the operation, when the boy resumed play indoors, and in less than a month he was in a fair state of health and able to be out of doors. For a period of two months he was free from all symptoms of the original trouble; but within the past ten days he has manifested some peculiar gastric disturbances which I fear indicates a metastasis. As might be supposed, the child's condition before the operation was deplorable. But after the removal of the of- ending growth he improved in every respect. His appetite was excellent and his strength seemed fully restored. February yd. On the night of January 26th the child was taken quite ill and gradually sank, dying February 2d. A metastasis to the liver and stom- ach had taken place and the tumor almost equalled in size the original growth in the extirpated kidney.