EXTIRPATION OF A RETRO-RENAL SARCOMA BY ABDOMINAL SECTION. BY JAMES R. CHADWICK, M. D. Reprinted from the Boston Medical and Surgical Journal of October 30,1884. CAMBRIDGE: Printed at tl)« Hiuerside fflreea. 1884. EXTIRPATION OF A RETRO-RENAL SARCOMA BY ABDOMINAL SECTION.1 BY JAMES R. CHADWICK, M. D., BOSTON. Mrs. A. M. E., aged fifty-two, a widow, had had two children and five miscarriages. For twenty years she had occasionally had functional urinary disturb- ances. Since the birth of the last child, ten years ago, she had been in fair health except that for a year she had been having night sweats, chills, and been losing flesh and strength. In January, 1884, she had a very severe backache, attributed to cold, which was finally relieved by Dr. C. E. Stedman, who recognized no special cause until the fullness of her abdomen led him to the discovery of a tumor in the region of the left kidney early in April. Early in May I was called by him in consultation, when the left side of the abdomen was found to be filled by a rounded, slightly nodular growth, which ex- tended from the lumbar region to the median line laterally, and from the ribs down to the anterior supe- rior spine of the ilium. Dr. Stedman and I (as did Dr. . HG. Lyman, and Dr. J. C. Guptill, of North- borough, subsequently) concurred in the diagnosis of enlarged kidney, probably malignant, which was appar- ently confirmed by a report from Dr. E. G. Cutler, that a specimen of the blood was " apparently not leucocythemic," and by the following result of an anal- ysis of the urine by Prof. E. S. Wood : " Albumen, very slight trace. Considerable pus, some of which is in clumps ; little blood; small round cells; an occasional small granular cast; no excess of bladder or vaginal epithelium." Dr. Wood appended these remarks, of which the accuracy was remarkably verified subse- quently : - "There is certainly some trouble high up in the 1 Read before the Obstetrical Society of Boston, June 14, 1884. 2 Extirpation of a Retro-Renal Sarcoma. urinary passages, but I cannot tell its exact nature. The absence of any excess of bladder or vaginal epi- thelium shows that the pus does not come from those membranes, and the absence of any large number of casts shows that it probably does not come from the kidney itself. The only other place is the pelvis of the kidney, and your tumor may be a dilated pelvis or a morbid growth somewhat affecting the mucous membrane of the pelvis of the kidney. But I cannot make a posi- tive diagnosis. All that I can say is that the urine is not inconsistent with such a theory, and that there is probably some chronic inflammation of the pelvic mucous membrane." On learning the desperate character of the growth the patient imperatively demanded the small chance of recovery held out to her through extirpation of the dis- eased kidney. On May 27th she accordingly entered my private hospital for operation. In studying the literature of the subject, especially the recent papers by Drs. Harris1 and Homans,2 1 was impressed by the idea, as I now think unduly, that one of the chief immediate dangers of the operation is de- ficient .secretion of urine, for quite a number of the deaths, reported by these writers in their tables, were apparently attributed to " anuria " or " uraemia." In order to diminish the danger to my patient from this source I sought to stimulate her kidneys to secrete double the normal amount, and to reduce the amount of urea by restricting her diet to food containing buf a small amount of nitrogen. By discontinuing the daily small amount of morphine (half a grain) upon which she had become dependent, by administering half a drachm of acetate of potash three times a day, I so far succeeded in my purpose as to increase the daily amount of urine passed from one pint to four pints, al- though it again decreased to two pints on the day be- 1 American Journal Med. Science, N. S-, vol. Ixxxiv. pp. 109- 118, July, 1882. 2 Boston Medical and Surgical Journal, vol. ex., pp. 73-77, January 24,1884. Extirpation of a Retro-Renal Sarcoma. 3 fore the operation. By a diet of milk and gruels I assumed that the excretion of urea was reduced to one half the normal amount, as has been demonstrated to result from such a diet. In other respects the woman's condition was fairly good, though she was much reduced in strength and flesh. Tuesday, June 3, 1884. Operation at eleven a. m., assisted by Drs. C. E. Stedman, J. W. Farlow, and C. M. Green, in presence of Drs. B. Cushing, J. E. Kelley, R. T. Edes, and C. P. Putnam. Ether administered by Dr. F. H. Lombard. An incision about nine inches long was made in the median line of the abdomen, this location being selected because the tumor was manifestly too large for extraction through a lumbar incision, because for the same reason it was thought that an incision in the linea semilunaris would give a less easy access to the renal vessels, which it was my wish to ligate before I raised the kidney from its bed. The left rectus muscle was so rigid that it was found necessary to make a transverse incision, two inches long, through it at the level of the navel in order to expose the tumor. The stomach was found overlying the upper part of the tumor and was pushed upwards. The transverse colon crossed the tumor at its middle, its mesentery investing the lower portion of the tumor and containing many large vessels. The peritonaeum investing the portion of the tumor about the colon was devoid of large vessels, and was consequently selected as the place for incision through which to enucleate the tumor. While incising this peritoneal layer every fine bleeding point was tied with silk sutures. The tumor was seen to be about the size and shape of an ostrich egg. Its lower rounded end was entirely invested with peritonaeum, which was slowly peeled off with the fin- gers, every vessel which ran into the tumor being tied on both sides before being cut. The ureter, which passed to the right of the tumor and was not involved in it, was carefully avoided. The kidney rested upon the upper end of the tumor on its inner side, having been lifted from its bed by the tumor ; it was closely Extirpation of a Retro-Renal Sarcoma. Extirpation of a Retro-Renal Sarcoma. bound to the tumor by adhesions, which were sepa- rated with but one slight laceration of the renal tis- sues, the oozing of blood from which was checked by the benzine cautery. At this point the pulse failed and respiration ceased, although not more than six to eight ounces of blood had been lost. Subcutaneous and rec- tal injections of brandy together with artificial respira- tion slowly revived the patient. The only remaining attachment of the tumor was to the subrenal cellular tissue; this, which could hardly be called a pedicle, was transfixed with a curved needle and tied in two halves. The tumor was now lifted out of the abdo- men. The kidney, which was uninjured, except for the small lesion alluded to, and unimplicated in the growth, was put back in its proper site. All blood- clots were carefully wiped from out the peritoneal cavity, which subsequently remained dry. The two in- cisions were rapidly closed with silk sutures and the abdomen covered with borated cotton. The carbolic spray was not used, but otherwise the full antiseptic method was pursued. The room had been thoroughly disinfected on the day before the operation by burning sulphur in it. The tumor was sent to Dr. W. F. Whitney, curator of the Warren Museum, who reported as follows: " The weight 650 grammes ; it is an oval shape, being of the dimensions of 16 X 8 X 5| centimetres. The structure shows it to be a large round-cell sarcoma, but its origin and finer histology will have to be made out after hardening." The operation was completed at one p. m. The curves of the pulse and temperature exhibit the changes 6 Extirpation of a Retro-Renal Sarcoma. in her condition for the thirty-two days subsequent to the operation. There was much pain and vomiting during the first week, and a tendency to collapse, which was met by morphine, stimulants, beef juice, cham- pagne, coffee, quinine, etc., chiefly by the rectum. The bowels were moved by an enema on the eighth day. After the eighth day the food was given entirely by the mouth. On the thirteenth day a small abscess near the anus was lanced and some pus evacuated. From this incision a constantly increasing amount of pus escaped until her death, besides numerous large sloughs of the rectum and cellular tissue, constituting a large rectal fistula and pelvic abscess. The abdom- inal wound healed chiefly by first intention. The silk sutures were removed on sixth to ninth day. After the twentieth day a tumor began to form in the left hypochondriac region, from which six ounces of pus were drawn off by the aspirator on the twenty-ninth day. A second insertion of the aspirator obtained only fresh blood, presumably from the substance of the kidney. The tumor did not entirely disappear, but remained quiescent. The attempt was made on the fortieth day to make a permanent opening in the lumbar region at the point of the previous aspira- tion. No pus could be reached, but only blood smell- ing plainly of urine. The urine, for two days af- ter, contained blood, and subsequently pus, until her death, which occurred from exhaustion at the end of the tenth week, owing to lack of recuperative power, and to the drain of the faecal fistula, which never showed any disposition to heal. An autopsy was ac- cidentally lost. Before closing I must say a word about the secre- tion of urine and its character. The following table shows the amount passed in successive periods of twenty-four hours terminating at nine A. m. : - Day before the operation . . . 32 fluid ounces. First day after the operation . . . 7| fluid ounces. Second day after the operation . . 9 fluid ounces. Third day after the operation . . 56 fluid ounces. Fourth day after the operation . . 40 fluid ounces. Extirpation of a Retro-Renal Sarcoma. 7 Fifth day after the operation . . 33 J fluid ounces. Sixth day after the operation . . 40 fluid ounces. Seventh day after the operation . 56 fluid ounces. Eighth day after the operation . . 45 fluid ounces. Analyses of the urine, made by Prof. E. S. Wood : - Day before the operation. "Specific gravity 1008. Very slight trace of albumen. Considerable pus, some of which is in clumps. Little blood. An occasional small granular cast. No excess of vaginal or vesical epithelium. Total amount of urea = 12.9'8 grammes. Total amount of phosphoric acid = 0.88 grammes. Total amount of chlorine = 2.535 grammes." First day after the operation. " Specific gravity 1027|. A trace of albumen. Numerous granular, brown granular, and fibrinous casts. Very little pus and blood. Renal and pelvic epithelium." Fourth day after the operation. " Specific gravity 1028. Very slight trace of albumen. Brown granular and fibrinous casts. Large brown renal epithelium, and very little blood. Better than the urine of the first day." Seventeenth day after the operation. " Specific gravity 1016|. Very slight trace of albumen. Very little blood. An occasional blood corpuscle. An occasional hyaline cast and patch of pelvic epithelium. Slight excess of renal epithelium. There is very great im- provement so far as the renal hyperaemia is concerned. There is a little pyelitis which, probably, will not last long." This record shows that the immediate effect of the operation was to produce an acute hypertemia of one or both kidneys and some pyelitis; that during the forty-eight hours immediately following the operation the amount of urine was greatly reduced, but after that fluctuated within normal limits. That the de- creased excretion of urine was not due to the conges- tion of the kidney is evident from the fact that the amount of urine became and remained normal after the second day, although the hyperaemia persisted, with but gradual abatement, for three weeks and over. 8 Extirpation of a Retro-Renal Sarcoma. I have searched the daily bulletin of this case to ex- plain the diminution and increase of the renal excre- tion. Scarcely any liquid was taken by the mouth un- til after she had a dejection, on the seventh day. During that week she had frequent small enemata of concentrated beef juice, brandy, etc., the total volume of liquid absorbed into the system being small. She had, during the week, from half a grain to a grain of morphine subcutaneously each day. There was no special vomiting attributable to the ether, but frequent regurgitation of fluid throughout the week. The only possible clew which my record shows is derivable from the pulse and temperature curves. On these it will be noticed that the temperature was depressed for the first three days (which includes the day of the operation) ; that the pulse, though subject to fluctua- tions, ranged lower than on the subsequent days. For the week of observation before the operation the pulse had never been lower than 110, or the temperature than 100° F. These facts seem to me entitled to great significance in connection with the fluctuations in the amount of urine, and impel me to the belief that the marked deficiency in the amount of urine passed during the forty-eight hours following the operation is in this case attributable to the depressed state of the patient's system, that is, shock, and not to the fact of the interference with the kidney and the hyperaemia shown to exist. Applying the same reasoning to the cases of death after extirpation of one kidney, attrib- uted directly or by implication to " anuria " or " urae- mia," I feel justified in entertaining a doubt as to the correctness of the assertions. I have hitherto kept no exact measurement of the urinary excretion after severe abdominal operations, but recall distinctly sev- eral cases in which the volume of urine passed in the first few days was very small. I do not believe that a dangerous urin- ary secretion should be regarded as one of the perils of nephrectomy.