WITH COMPLIMENTS OF THE AUTHOR. 
MOVABLE KIDNEY; 
ith a Report of Cases Treated by Nephrorrhaphy. 
BY 
GEORGE M. EDEBOHLS, A.M., M. D„ 
Professor of Diseases of Women at the New York Post Graduate Medical 
School and Hospital; Gynecologist to St. Francis Hospital, New York,  from the “American Journal of the Medical Sciences,” 
March and April, 1893. 
MOVABLE KIDNEY; WITH A REPORT OF CASES 
TREATED BY NEPHRORRHAPHY.1 
PROFESSOR OF DISEASES OF WOMEN AT THE NEW YORK POST GRADUATE MEDICAL SCHOOL AND 
HOSPITAL ; GYNECOLOGIST TO ST. FRANCIS HOSPITAL, NEW YORK. 
George M. Edebohes,"A.M., M.D., 
In the opinion of the writer there is scarcely a subject of more 
practical importance and interest to the gynecologist than that 
of movable kidney. This conviction has steadily grown upon 
him since his attention was first attracted to the subject, nearly 
four years ago, since which time he has had abundant oppor- 
tunity to note both the frequency of its occurrence in women 
and the important interdependent relations between movable 
kidney and diseases of the female sexual organs. 
Indeed, in view of the fact that the subject of movable kidney 
has been more or less fully treated of within the past dozen 
years by Hahn, Landau, Keppler, Pokrowsky, Lindner, von 
Fischer, Litten, Henderson, McCosh, Keen, Senator, Schmitt, 
and others, it is astonishing how little is known of it—or, at 
least, how little practical application is made of this knowledge 
by both general practitioner and gynecologist. The latter could 
have found in it a solution of many perplexing difficulties which 
beset him in daily practice. Why, for instance, a woman, the 
lesions of whose genital tract have been successfully repaired by 
the gynecologist’s art, and in whom no organic lesion can be 
discovered elsewhere, should, after operation, in spite of the 
gynecologist pronouncing her well, persist in asserting the con- 
trary and in clinging to most, if not all, of her former symptoms, 
would no longer be an enigma. The solution, in many instances, 
might be found in the vicinity of the renal regions. There, also, 
in not a few instances, can be found the explanation of symptoms 
usually interpreted as dependent upon disease of the female 
genital organs, when a most critical and painstaking examination 
1 Read before the Section on. Obstetrics and Gynecology, New York Academy of Medicine, 
October 27, 1892. of those organs fails to reveal the least evidence of disease. 
Instances illustrating both of the above assertions I have 
repeatedly encountered in my own practice, and a few of them 
may be found recorded in the histories of cases appended to the 
end of this article. 
The main explanation, to my mind, of the existing general 
apathy and indifference to a subject of such great practical 
importance, lies in the hitherto unsatisfactory therapeutics of 
the condition. A movable kidney is, in the vast majority of 
cases, one of the easiest things in the world to diagnosticate, 
provided only its possibility in a given case be borne in mind. 
But when it comes to treatment, bandages have proved inefficient; 
nephrectomy is a too radical and unjustifiable procedure; neph- 
rorrhaphy has hitherto proven more or less disappointing, owing, 
as the writer believes, to imperfections of technique; massage 
has been too little tried, and meets with too general incredulity. 
It is one of the main purposes ot this paper to furnish evidence 
that nephrorrhaphy, carefully performed after the method to be 
described later on, is capable in most, if not all, uncomplicated 
cases of movable kidney, of correcting the abnormality, and of 
relieving greatly or removing entirely the symptoms dependent 
thereon. 
Frequency.—The frequency of the condition has been 
variously estimated by different writers, depending probably 
upon the greater or less fidelity with which each patient present- 
ing is examined for the existence of the condition, as well as 
upon varying individual ability to recognize the minor degrees 
of the abnormality. While some authorities assert that movable 
kidney is of very rare occurrence, Ifindner, for instance, states 
that he found it in one out of every five or six women examined. 
My experience has satisfied me that Ifindner is very nearly, if not 
quite, right. I have taken the trouble to look over the histories 
of the last 500 women examined by me, and among them I find 
90 recorded as possessing, amongst other things, a movable 
kidney. I am confident that a similar experience awaits every 
gynecologist who will make it a matter of routine to examine 
every woman consulting him for the existence or otherwise of 
the condition. I should, however, not like to be understood as 
asserting that every movable kidney produces symptoms. On 
the contrary, I am convinced from personal observation that 
such is not the case, and that many owners of movable kidneys 
experience no noticeable discomfort from the condition. Just here 
lies the difficulty ; to determine exactly what symptoms, in a 
given case, are probably due to a movable kidney, in as much as 
the- lesion is so frequently associated with disturbances in the 
genital sphere and many symptoms are common to the two 
conditions. 
2 Further on I hope to show, however, that this differentiation 
may be made with reasonable accuracy in nearly all cases. 
Etiology.—The etiology of movable kidney is still greatly a 
matter of speculation and theory, and it will probably require 
considerable added experience, and perhaps experiment, to 
satisfactorily elucidate this part of the subject. Bartels is inclined 
to regard lacing as a causative factor in both men and women. 
I am led from my own observations to believe that the very 
opposite is the case, and that tight lacing is the most effective 
external agent we can apply to maintain a kidney in its normal 
position. Indeed, I am in the habit of prescribing a well-fitting 
and rather tight corset for women with movable kidneys, 
provided no contra-indication to the corset is found in the con- 
dition of the genital organs. In the few cases in which I have 
met movable kidneys in men, I have advised the wearing of a 
tight elastic abdominal supporter, the main compression being 
made about the waist. 
Laxity of the abdominal parietes, the result mainly of child- 
bearing, has been regarded by many as a causative agent of 
movable kidney. This hypothesis, however, will not bear close 
scrutiny. It loses its value when we consider that as many, if 
not more, movable kidneys are found in virgins and nulliparae 
as in multiparse. The statistics of Lindner show this, and my 
own experience bears him out. That, however, laxity of the 
abdominal walls bears a certain, though small, share in the 
etiology of the affection, I am not prepared to deny. 
The theory of a congenital anomaty or predisposition to the 
disease is one difficult to either prove or disprove. For the 
present it is a mere conjecture as far as concerns movable kidney: 
a floating kidney may depend upon a congenital mesonephron. 
The theory which upon critical and pidicial review of the cases 
under my observation seemed most satisfactorily to account for 
the development of the condition in a majority of instances, is 
that of absorption or atrophy of the peri-renal fat. It has been 
quite a common experience with me to note the beginning of 
symptoms due to movable kidney immediately after recovery 
from one of the wasting diseases, or on the occurrence of a 
noticeable loss of weight from any cause. My own clinical 
observation, therefore, would seem to indicate that loss of peri- 
renal fat is the chief etiological factor in the production of 
movable kidney, though I am inclined to believe that other 
causative agencies may play a part, less important and frequent 
though it be, in the development of the disorder. It is quite 
easy, for instance, to understand how excessive and prolonged 
vomiting might occasionally loosen a kidney, as in a case reported 
by Dr. C. O. Baker [N. V. Medical Record, May 14, 1892). The 
patient, himself a physician, first noticed the development of 
3 a movable tumor (kidney) in tbe right hypochondrium after 
a voyage in which he suffered much from incessant sea-sickness. 
Even in this case, however, rather clearly as the evidence points 
to vomiting as the cause, it may be questioned whether the 
movable kidney was not a result of the wasting of fat, including 
the peri-renal, due to the prolonged inanition. 
A movable kidney may rarely develop quite suddenly, as in 
the case just mentioned, or the condition may be of more or less 
rapid growth. While the majority of movable kidneys un- 
doubtedly require months, and even years, to develop, I have 
several times been in a position to observe, the development of 
a mobility of six to eight centimetres in a kidney, which from 
personal examination, I knew to be in its proper place two or 
three months previously. One or two such instances are narrated 
in the appended histories. 
For practical purposes a distinction should be made between 
movable and floating kidney, although the latter condition 
probably represents, in some instances at least, but the final 
stage of development of the former. A movable kidney, as I 
interpret it, is one movable within a pouch or hollow formed 
within its own fatty capsule ; while a floating kidney is one 
supplied with a mesonephron, the length of which determines 
the extent of its mobility. The floating kidney has normal 
relations with its fatty capsule, or at least that portion of the 
latter which it carries with it in its excursions. The movable 
kidney for reasons which will appear further on, produces more 
distressing symptoms than the floating kidney, although the 
latter has by far the greater range of mobility. The movable 
kidney is by far more frequent than the floating kidney. I have 
met at least fifty movable kidneys to every one floating kidney, 
and it is with the movable kidney alone that this paper has to deal. 
kitten makes a further distinction between movable and 
wandering kidneys on the one hand and a dislocated kidney on 
the other hand. By the latter term I presume he means a dis- 
placed kidney fixed in its abnormal situation. I have met the 
latter condition but twice, the right kidney in each instance 
being fixed alongside the spinal column some eight centimetres 
below its normal position, and being insusceptible of reduction. 
A characteristic of the movable kidney is the facility with which 
it can be brought back to its normal situation. 
kitten still further refines between a congenital wandering 
kidney (floating kidney ?) and an acquired movable kidney. As 
used by the Germans, the term Wanderniere (wandering kidney) 
embraces both movable and floating kidneys. For reasons 
already stated, however, I prefer to maintain the distinction 
between the two. 
The path of dislocation of a movable kidney varies. In a propor- 
4 tion of cases, estimated at 75 percent, by Idndner, it becomes dis- 
placed outward and then forward and inward along the course of the 
lower ribs until it reaches the region of the anterior superior iliac 
spine. In the remaining cases it moves directly inward and down- 
ward. Whatever may have been the original path of dislocation, the 
result, as far as the final position of the movable kidney is concern- 
ed, will be the same as soon as the organ has attained a range of 
mobility of ten to twelve centimetres. When this range of mobility 
has been attained, the kidney can be readily moved about any 
where within the segment of a circle whose centre is at the nor- 
mal situation of the kidney, whose radius measures ten to twelve 
centimetres, and whose arc extends from the vicinity of the anter- 
ior superior spine of the ilium to the under surface of the liver. 
The subject of movable kidney is of paramount importance to 
the gynecologist, because of its preponderating frequency in 
women as compared with men, and because its symptoms are so 
similar in many respects to those accompanying various lesions of 
the genital sphere. Perhaps, however, the comparative frequency 
of its occurrence in the sexes is not as great as usually supposed. 
Abdominal palpation is practised much more frequently upon the 
female than upon the male, and the gynecologist, with tactile sense 
sharpened by daily practice in bimanual examination, is much 
more likely to discover minor degrees of the lesion than is the gen- 
eral practitioner. And it is just these minor degrees that are the 
unrecognized cause of so much suffering and distress. 
My practice being exclusively gynecological, I am scarcely in a 
position to estimate from personal observation the frequency of the 
occurrence of movable kidney in the male. I have seen but two 
cases in men, both of them during the past year. Both were per- 
sonal friends, who, in speaking of their health, casually mentioned 
a combination of symptoms, such as is usually found associated 
with movable kidney. In both, upon examination, I found the 
right kidney movable to the extent of about ten centimetres. 
Movable kidney, in women at least, occurs in the right side in 
the overwhelming majority of cases. I have seen the condition but 
four times on the left side, in three of the patients the right kid- 
ney being movable at the same time and to a greater degree than 
the left. In the fourth patient (Case I.) the left kidney became 
movable six months after fixation, by nephrorrhaphy, of a mov- 
able right kidney. Why the right kidney should so much 
more frequently become movable than the left I can only surmise. 
Perhaps it is more exposed to displacing influences on account of 
its situation immediately beneath the liver, a heavy organ, subject 
to great fluctuations in size and weight. 
Symptoms.—As already stated, many of the symptoms of mov- 
able kidney are common also to many diseases of the sexual or- 
gans in women. The symptoms of the earlier and of the later 
5 stages of movable kidney differ considerably from eacb other, 
those of the earlier stages being by far the more distressing. The 
suffering, according to my observations, seems to be greater with 
a kidney movable from four to ten centimetres; after the latter 
limit of mobility has been exceeded the symptoms generally abate 
in intensity and some of them disappear altogether. Quite enough 
morbid manifestations, however, remain to make the patient more 
or less a chronic invalid. It is but just to state, however, that 
this observation of the greater severity of the symptoms in the 
earlier stages of movable kidney, as compared with the later, 
does not harmonize with the experience of Lindner and others, 
who claim that the greater the degree of mobility the more severe 
and numerous the symptoms. 
I will first describe what I consider to be the most prominent 
and characteristic combination of symptoms, as I have found it, 
in uncomplicated cases of movable right kidney, in which the mo- 
bility ranges from ten centimetres downward ; enumerating sub- 
sequently the other symptoms more or less frequently observed. 
The morbid phenomena due to a movable right kidney in its earlier 
stages are : digestive disturbances, chronic in character; general 
nervousness ; epigastric pain, usually located somewhat to the left of 
the median line, at or near the free border of the left costal cartilages; 
cardiac palpitation; inability to feel comfortable or to sleep when ly- 
ing on the left side. These symptoms, or as many of them as may 
be present in the particular case, are all more or less constant and 
chronic in character. When disease of the genital apparatus is 
associated with movable right kidney, the symptoms immediately 
become more manifold, and it requires close clinical study to 
differentiate between the manifestations belonging to the renal 
and the genital abnormality, especially as a movable kidney ex- 
ceptionally produces symptoms such as dysmenorrhoea and aty- 
pical uterine hemorrhages which generally point to lesions of the 
genital tract. I will, therefore, dwell somewhat upon the symp- 
toms above enumerated as usually accompanying movable kid- 
ney, before enumerating the other morbid manifestations more or 
less frequently observed. 
The digestive symptoms usually observed are, in their order of 
frequency: anorexia; gaseous eructations; epigastric pain and dis- 
tress, most severe from half an hour to three hours after meals; 
constipation ; occasional vomiting ; foul breath. Quite a number 
of patients suffering from movable kidney have been treated for 
years by the ablest practitioners for gastro-intestinal or intestinal 
catarrh before coming under my observation, and it is one of the 
most gratifying experiences to see how rapidly and completely 
these symptoms usually vanish after fixation of the movable 
kidney by a bandage or by nephrorrhaphy 
General nervousness, of greater or less degree, but always de- 
6 cided, is the next most frequent concomitant of movable kidney. 
There is nothing peculiar about this nervousness to distinguish it 
from that due to other causes. It disappears to a marked extent, 
though not as rapidly or completely as the digestive symptoms, 
after fixation of the kidney. 
The epigastric pain associated with movable kidney is quite 
constant in its location, being generally referred to a point some 
five to six centimetres to the left of the median line, at or near 
the free border of the left costal cartilages. The nature and 
source of this pain are not quite clear. It is not markedly in- 
creased by pressure, and in this respect differs from ordinary in- 
tercostal neuralgia. It appears to be independent of the digestive 
processes, occurring at any time, irrespective of the fullness or 
otherwise of the stomach. Dandau calls it a cardialgia, and, for 
reasons to be explained later, I am of the opinion that this term 
is probably correct, albeit the pain is somewhat lower than that 
of cardialgia from other causes. This pain also disappears 
promptly after the malposition of the kidney is rectified. 
Cardiac palpitation is one of the most annoying and persistent 
symptoms. In some patients it is almost constant, and occas- 
ionally they become so habituated to it that they are unaware 
that their heart is beating rapidly, although the examiner may 
find the pulse 120 or more. This symptom, like the general ner- 
vousness, yields more slowly than the other symptoms after fix- 
ation of the kidney. 
The last of the principle symptoms is inability to rest with 
comfort or to go to sleep lying on the left side. That this symp- 
tom is not by any means imaginary is attested by the frequency 
with which patients complain of it before they are informed that 
they have a movable kidney, and by its prompt and complete 
disappearance after fixation of the kidney. 
Among the other symptoms which, compared with the above, 
occur with comparative rarity in uncomplicated cases of movable 
kidney, I will merely mention the following: Vertigo; a dull back- 
ache; painful menstruation; increase of the menstrual flow; pain 
in region of displaced kidney ; mild urinary symptoms, such as 
intermittent hydronephrosis, moderate polyuria, slight frequency 
of micturition; icterus; anaemia due to interference with the di- 
gestive functions. It is unnecessary to dilate upon these symp- 
toms; they are quite secondary in importance to the five symp- 
toms above described. 
It is quite curious and interesting to observe the influence of 
menstruation and pregnancy upon the symptoms of movable kid- 
ney, these being always intensified during menstruation and 
during the early months of pregnancy, while they completely 
disappear during the latter half of utero-gestation. The explan- 
ation is probably this. During menstruation and the early months 
7 of pregnancy the increased collateral flow of blood to the ab- 
dominal organs produces hypersemia and increased weight of the 
displaced kidney, with intensification of the symptoms. During 
the latter half of pregnancy the uterine tumor pushes the kidney 
upward and supports it in its proper place in a better manner 
than can be done by any abdominal supporter. It has been an 
oft-repeated experience with me to have patients state that the 
only times at which they have felt well during many years past, 
ever since the beginning of their illness, was during the latter 
half of their pregnancies, whatever the number of the latter may 
have been. I have also noted in one case the appearance of 
symptoms of movable kidney immediately following the removal 
of a large ovarian cystoma. The cyst had, until removed, sus- 
tained the movable kidneys in their place, and thus kept the 
symptoms in abeyance. 
Authors are not as yet agreed upon the mode of causation of 
the symptoms due to movable kidney. The majority of those 
who have expressed themselves upon this subject are of opinion 
that obliteration of the lumen of the duodenum by the displaced 
kidney leads to retention of the contents of the stomach, and, as 
a result of this, secondarily to the production of the other symp- 
toms above narrated. They differ somewhat in their views as to 
how this duodenal obstruction is brought about. Idndner, for 
instance, believes that the descending kidney obliterates the lumen 
of the duodenum by traction, claiming to have substantiated this 
view by experiments on the cadaver. Bartels, on the contrary, 
holds that the middle or descending portion of the duodenum is 
closed by direct pressure upon it of the displaced kidney. 
With all due respect to these high authorities and those who 
agree with them, I am of opinion that mechanical occlusion of the 
duodenum is insufficient to account for the symptoms of movable 
kidney, even if the hypothesis of a mechanical occlusion of the 
duodenum occurring as £i sequence of movable kidney could be 
proven true, which, as far as I know, has not hitherto been the 
case. I think the explanation of the symptoms must be sought 
in other directions, and personally am inclined to look for it in 
disturbances of the abdominal sympathetic system, more especially 
of the solar plexus with its branches distributed to the abdom- 
inal and thoracic viscera. After reading the extract from Gray’s 
Anatomy, which I shall presently quote, it does not seem to me 
difficult to understand how a movable kidney, by pressure and 
traction, by stretching and irritation of various parts of the im- 
portant sympathetic centre called the solar plexus, and of its 
branches, is quite capable of producing all the various sensations 
and functional disturbances noted under the head of symptoms. 
While all cases, to my mind, become explicable by this theory, 
the hypothesis of duodenal obstruction fails entirely to explain 
8 wliy the same series of phenomena occurs when either the right 
or the left kidney, or both, become movable. It may be claimed, 
and with justice, that the left kidney is rarely, if ever, movable 
alone, and that in this case the movable right kidney produces 
the symptoms. But Case 1., narrated below, has the value of a 
crucial experiment in determining this question, and to me was 
proof positive that a movable left kidney, the right being secure- 
ly anchored in its place, is capable of producing exactly the same 
symptoms as a movable right kidney. Indeed, it was the obser- 
vation of the progress of this case that led me to abandon the 
view of .duodenal obstruction which I had previously held, and 
to seek another explanation of the causation of the symptoms of 
movable kidney. The following quotation is from Gray’s 
Anatomy. (The italics are mine.) 
“ The epigastric or solar plexus supplies all the viscera of the abdominal cavity. 
It consists of a dense network of nerves and ganglia, situated behind the stomach 
and in front of the aorta and crura of the diaphragm. It surrounds the coeliac 
axis and root of the superior mesenteric artery, extending downward as low as 
the pancreas and outward to the supra-renal capsules. This plexus, and the 
ganglia connected with it, receive the great splanchnic nerve of both sides, part 
of the lesser splanchnic nerves, and the termination of the right pneumogastric. 
It distributes filaments, which accompany, under the name of plexuses all the 
branches from the front of the abdominal aorta.” 
This part of the subject would be incomplete without an allus- 
ion to the so-called “strangulated movable kidney” as described 
by Tandau and later by Idndner, a typical illustration of which 
condition I have seen in but two instances. The symptoms then 
become acute ; pain in the right side, vomiting, great restlessness, 
possibly a little febrile movement occur; the urine is diminished in 
quantity. This condition lasts from two to four days, when, with 
increased secretion of urine, the symptoms rapidly disappear. 
Tandau thinks an obstruction of the renal vein by torsion ac- 
counts for the strangulation, while Ihndner regards the symp- 
toms as due to temporary obstruction of the ureter, by torsion or 
kinking, thus producing hydronephrosis. 
Diagnosis.—A movable kidney is, in my opinion, the easiest 
of all intra-abdominal conditions to diagnosticate. The diagnosis 
is made by the discovery of a movable tumor, of the size, shape, 
and consistence of the kidney, in the right hypochondriac or 
lumbar regions, or in the iliac fossa; in fact, by feeling a movable 
kidney in any other but its normal position. The recognition of 
a movable kidney is an easy matter, especially for the expert gy- 
necologist whose tactile sense is educated by daily practice. With 
the patient in the dorsal position, and the thighs flexed to relax 
the abdominal parietes, the examiner sits at her right iside, oppo- 
site the loins, and with his left hand passed under the small of her 
back, presses deeply into the renal region to either crowd the 
kidney out of its place, or to keep it from slipping unrecog- 
9 nized into its normal position while the examination is being 
made. The fingers of the right hand palpating the front and 
side of the abdomen usually recognize the displaced organ with- 
out difficulty. When it is detected it should be caught between 
the fingers of both hands and gently pressed until it escapes alter- 
nately upward and downward from between the compressing fin- 
gers. The contour of the upper and lower poles and the entire 
characteristic kidney shape of the tumor are thus recognized 
without the possibility of mistake. The majority of movable 
kidneys when thus moderately pressed and handled are not sensi- 
tive to pressure ; in a minority of cases the patient complains of 
slight, quite bearable pain. ffandau has found that pressure 
upon a movable kidney causes cardialgia. I have never elicited 
this symptom, but have often produced a slight nausea on com- 
pression of the displaced organ. Perhaps the difference in the 
sensations of the patient may be due to varying degrees of press- 
ure employed. The displaced kidney is almost uniformly of about 
normal size ; in but five or six instances have I found it enlarged. 
Should there be difficulty in palpating the kidney in the dorsal 
position, the left lateral decubitus (Sims’ position), as recom- 
mended by kindlier, may be tried. I have myself never resorted 
to it. When I have failed, with the patient in the dorsal position, 
to dislodge a suspected movable kidney from its normal situation 
by pressure of the left hand applied to the back, I have always 
succeeded by directing the patient to sit upon the edge of a chair 
with the body inclined forward and the hands resting upon the 
knees. In this position I have never experienced difficulty in 
reaching a diagnosis. By employing this position, or the left 
lateral decubitus, the necessity of repeated examinations in 
doubtful cases, insisted upon by many authors, can be avoided. 
Very rarely, indeed, should there be difficulty in distinguishing 
a movable kidney from other tumors of the abdomen, and refer- 
ence to this part of the subject would scarcely be necessary were 
it not that errors have been made by the ablest diagnosticians. 
Thus in the case of Dr. Angus Mac , already alluded to as re- 
ported by Dr. Baker, the patient acquired a movable tumor in 
the right hypochondrium as a result of prolonged vomiting from 
sea-sickness. Several clinicians of the highest reputation exam- 
ined the tumor, and at least two of them pronounced it a mov- 
able kidney. The patient finally consulted Dawson Tait, who, 
ignoring previous opinions, made a diagnosis of distended gall- 
bladder and performed abdominal section. At the operation (pre- 
sumably performed in the dorsal position), Tait found the gall- 
bladder and adjacent structures healthy and the ‘ ‘ kidney in situ. ’ ’ 
He afterward said that the tumor was an hysterical tumor. Neph- 
rorrhaphy was subsequently performed by Dr. Baker and the 
patient relieved of his long suffering. 
10 It will thus be seen that a movable kidney may be mistaken 
for a distended gall-bladder. Attention to the shape and outlines 
of the tumor and to the range and direction of mobility should 
enable us to avoid this error. 
The so-called ‘ ‘ phantom or hysterical tumor ’ ’ should never 
be mistaken for a movable kidney. If the hysterical tumor be 
due to intestinal distention, percusssion will enable us to differen- 
tiate. If, as I believe is more frequently the case, the phantom 
tumor represents a localized spasmodic contraction of the abdom- 
inal muscles—most frequently of the recti—the expert fingers of 
the gynecologist should have no difficulty in detecting the con- 
dition. In very exceptional cases examination in narcosis would 
remove all doubt. I have myself never met with a case in which 
it was necessary. 
A movable right kidney should never be mistaken for carcinoma 
of the stomach or adjacent viscera, although the symptoms in 
many cases of movable kidney are similar in many respects to 
those of malignant disease of the abdominal viscera. A right 
kidney dislocated downward and fixed in its abnormal position— 
a rare condition, fortunately—may offer difficulties of diagnosis. 
The error of confounding the symptoms of a movable kidney 
and those of a chronic intestinal catarrh can only occur from 
failure to make a sufficiently painstaking examination, and is 
inexcusable at the present day. 
Prognosis.—A kidney once movable never again becomes 
firmly fastened in its normal position, except by operative inter- 
ference. Its mobility, however, may be diminished by increased 
deposit of fat around the organ accompanying general improve- 
ment in nutrition. The intensity of the symptoms, whatever the 
latter be, remains about the same until the kidney attains a range 
of mobility of ten to twelve centimetres. After this range has 
been attained, and during the further increase in mobility, the 
symptoms are somewhat mitigated. The patient, however, as 
already stated, remains more or less a chronic invalid. A mova- 
ble kidney may, however, become fixed in an abnormal position— 
rarely, I believe, by peritoneal adhesions, but rather by an in- 
duration or mild sclerosis of the fatty tissues surrounding it. A 
floating kidney, on the other hand, being contained in a fold of 
the peritoneum, may become fixed by agglutination of its peri- 
toneal coat to neighboring peritoneal surfaces. When this occurs 
the symptoms are likely to become very distressing. 
Treatment.—The dorsal decubitus will markedly mitigate 
or entirely remove, while it is maintained, the symptoms of 
movable kidney. It will, however, not lead to fixation of the 
kidney, no matter how long maintained, and the symptoms are 
certain to be reproduced on assuming the erect posture. 
I know of one case greatly benefited, though not cured, by the Weir Mitchell treatment of absolute rest in bed, forced feed- 
ing, massage, and electricity. The increased deposit of fat 
around the kidney probably explains the beneficial results, and 
the method may be tried in patients who can afford it, and who 
elect it after the alternatives have been fairly presented to them. 
Tasting relief can scarcely be expected, unless the obesity pro- 
duced can be maintained or even increased. This amelioration 
of symptoms is, as already remarked, occasionally observed to 
follow improved nutrition without any special medication. 
Eisenberg (Wiener med. Presse, 1391, No. 36) has reported 
successful results in the treatment of movable kidney by massage 
after Brandt’s method. Further experience in this direction is 
needed before we can arrive at definite conclusions. 
Abdominal supporters or bandages are relied upon by the ma- 
jority of those who recognize in movable kidney a pathological 
condition requiring treatment. In our resources against the con- 
dition it ranks second to nephrorrhaphy ; but in my opinion it is 
a poor second. It .will always appeal strongly to minds with 
anti-surgical bias, and I confess that until I saw my way clear to 
a more efficient and perfected nephrorrhaphy, with more uniform 
and lasting results than existing reports supplied, I preferred to 
relieve my patients as best I could with bandages. Even after I 
had gained some confidence in my ability to fix a movable kid- 
ney by nephrorrhaphy, I still advised the trial of a bandage to 
obtain relief before resorting to operative measures. Faithfully 
as I tried bandages, however, I must own that I accomplished 
little good with them. This might a priori be expected, as a 
movable kidney in the readiest manner escapes from beneath even 
the compressing hand, probably the most perfect pad as yet de- 
vised. Inability to obtain desirable results from the use of the 
bandage, and the almost absolute certainty of relief by neph- 
rorrhaphy in cases selected after careful study as indicating fixa- 
tion of the kidney, have led me latterly to urge nephrorrhaphy 
as the first resort to patients with movable kidneys producing de- 
cided symptoms. 
A bandage, to be effective in retaining a movable kidney, must 
support all the abdominal viscera and, through them, the dis- 
placed organ. The special compress or pad so generally used be- 
neath the bandage over the front of the renal region is a delusion 
and a snare, the kidney escaping from beneath it will the great- 
est facility. It is scarcely consistent for one avowing a disbelief 
in the efficacy of bandages to follow such an avowal by an ex- 
pression of predilection for certain forms of bandages. What- 
ever little good, however, I have accomplished in this direction 
has been by a simple bandage of elastic webbing entirely encirc- 
ling the whole abdomen and making as much compression as the 
patient can comfortably bear. A well-fitting, rather tight corset 
12 answers still better in males, and in women in whom no contra- 
indication to the wearing of a corset exists on the part of the 
sexual organs—a condition obtaining only in a ‘minority of the 
cases I have seen. 
Nephrectomy, or removal of the movable kidney, I mention 
only to condemn. It has no justification in this condition, while 
nephrorrhaphy, a much less dangerous and less mutilating opera- 
tion, can be made to yield results almost, if not quite, as good 
and positive. 
Lindner, in 1887, collected 36 nephrectomies for wandering 
kidney, with 9 deaths, a mortality of 25 per cent. Of these 36 
kidneys, 9 were removed by the lumbar incision without a death, 
whereas 25 were extripated by coeliotomy with 9 deaths. In 2 
cases the method of operation is not stated. This appalling 
mortality, I am inclined to believe, would be lessened by the 
addition of more recent cases. 
Lindner also collected 29 nephrorrhaphies with 1 death. Adding 
thereto my own 12 cases with 1 death, makes 41 cases with 2 
deaths, a mortality of less than 5 per cent. This mortality rate 
would also, no doubt, be lessened by the addition of all published 
cases, of which I can recall quite a number, without remember- 
ing having read of an additional death. (vide Note, page 28.) 
Nephrorrhaphy.—The main object of this communication is 
to advocate the performance of nephrorrhaphy, or fixation of the 
kidney by suture, in all cases of movable kidney where the 
patient’s life is endangered by the persistence of the condition, 
or in which the sufferings are of such an aggravated character 
as to make life a burden. It is understood, of course, that a 
careful diagnosis must precede the operation. Such diagnosis 
must not be confined to the mere detection of a movable kidney, 
but must include a complete canvass of the patient’s physical con- 
dition, all the organs, but especially the generative, being 
thoroughly interrogated for evidence of disease. Only after such 
thorough investigation can it be decided whether the symptoms, 
or the majority of them, depend upon movable kidney, and 
whether is likely to afford relief. In many cases 
it will be found that operations upon the genital organs are 
indicated in addition to nephrorrhaphy. Whenever possible, 
all the various operations necessary in a particular case should 
be performed at the same sitting. 
I will now describe the operation of nephrorrhaphy as I have 
practised it ; 
The patient is placed upon the table in the left lateral (Sims’) 
position. Two small, firm pillows or cushions are so placed 
upon the table as to press into the left lateral and anterior regions 
of the abdomen, crowding the viscera upward to the site of opera- 
tion and putting the latter well upon the stretch by separating, as 
13 far as possible, the right twelfth rib from the crest of the right 
ilium. The same antiseptic and aseptic precautions are observed 
as at a coeliotomy. The incision, made along the outer edge of 
the erector spinae muscle, should in all cases extend the entire 
distance between the lower edge of the twelfth rib and the crest 
of the ilium. It should be made more or less oblique, according 
to the lesser or greater distance between these points. The 
superficial fat, the tendon of the latissimus dorsi, and the con- 
joined tendon of the internal oblique and transversalis are succes- 
sively divided along the whole length of the cutaneous incision 
until the peri-renal fat is reached. The outer fibres of the quad- 
ratus lumborum occasionally overlap the line of incision, and 
are then cut through along their length. The fatty capsule is 
penetrated by a small incision until the kidney with its capsula 
propria is detected at the bottom of the wound. Palpation of 
the kidney, with one or two fingers, through the wound of the 
fatty capsule, will enable us to get our bearings and determine 
the extent to which the length of the incision in the fatty capsule 
should be increased in both the upward and downward directions. 
The fatty capsule is incised along the whole length of the con- 
vexity of the kidney, after which it is drawn out of the wound as 
far as it will go, and the redundancy of the fat sac is cut off on 
either side at a level with the bottom of the wound. In doing 
this care must be exercised not to open the peritoneum at the 
lower pole of the kidney. The trimmed edges of the fatty cap- 
sules are secured with a small pair of T-shaped forceps for guid- 
ance in the subsequent suturing. The delicate part of the work 
now begins. The capsula propria of the kidney is incised along 
the whole length of the convexily of the organ in themessial line. 
To do this successfully the kidney must be moved up and down 
so as to expose successively, at the bottom of the wound, the 
low7er and upper halves of the organ. A pair of tenaculum 
forceps or two are of material aid in this and the subsequent parts 
of the operation. They must, however, be used with exceeding 
gentleness, as the kidney substance is exasperatingly friable, and 
they readily tear out. During this and subsequent steps of the 
operation it is of paramount importance that the kidney be pressed 
well into the bottom of the wound, so as to be readily accessible. 
If the two cushions spoken of at the beginning have been well 
placed under the left loin, nothing further is generally necessary, 
the kidney being w7ell sustained in place, merely moving rhyth- 
mically upward and downward with respiration. If the cushions 
are not properly placed, or prove insufficient, the hand of an as- 
sistant pressing upon the abdomen so as to crowd the kidney 
into the wound must be made to take their place or to supplement 
them. After the capsula propria has been incised it is stripped 
off from the kidney substance on either side, until about pnq 
14 and a quarter centimetres of the kidney substance are exposed on 
either side along the whole length of the incision through 
the capsule, thus making raw a surface ten to twelve centimetres 
long by two and a half centimetres wide for union with the deep 
parts of the lumbar incision. It is just here where nephrorr- 
haphy performed by stitching the fatty capsule alone, or by 
stitching the kidney without opening its capsula propria, failed, 
both the fatty capsule and the capsule proper being tissues in 
no way adapted to firm cicatricial union with contiguous parts. 
The stripped off capsula propria is not removed, but is doubled 
backward upon the still adherent portion like the lapel of a coat. 
Thus far the steps of the operation have been identical in all 
my cases. In the method of suturing, however, I have made 
slight variations. At first I sewed with silkworm-gut, embracing 
on either side, in each suture, skin, superficial fat, the tendons of 
the abdominal muscles, the cut and trimmed edges of the peri- 
renal fatty capsule, the reflected as well as the still adherent cap- 
sula propria. The loop of the suture penetrated the kidney sub- 
stance to the depth of one to one and a half centimetres. Five 
or six such sutures were usually passed and tied upon the skin 
after a rubber drain had first been passed to the bottom of the 
wound and caused to lie along the raw kidney substance its whole 
length, with an end emerging at either angle of the wound. In 
my later cases I attached the kidney to the deeper and firmer 
tissues of the abdominal walls, the muscles and aponeuroses, by 
buried sutures of kangaroo tendon or silkworm-gut, passing a drain 
composed of ten or twelve silkworm strands along the raw kid- 
ney surface, instead of the rubber drain. The purpose of the 
drain is two-fold ; first, to remove all secretions, which might in- 
terfere with primary union, from the depths of the wound, and 
secondly, to favor firm cicatricial union by mild irritation of the 
raw kidney substance and the contiguous deep tissues of the ab- 
dominal wound. In tying the deep buried sutures, whether of 
silkworm-gut or of kangaroo tendon, care must be exercised not 
to draw them too tightly, as they readily cut through the friable 
kidney substance. The skin and superficial fat are closed over 
the deep buried sutures by a running suture of catgut. Union 
by first intention has been the rule. The dressings are changed 
for the first and last time on the eighth day, when the drain is 
removed. The patient is kept upon the back for three weeks, 
and then allowed to sit up and go about as she pleases. 
Although the stitches are passed deeply through the kidney 
substance, I have only in one case, a double nephrorrhaphy at 
one sitting, observed hsematuria or albuminuria after operation, 
though other writers mention these as of occasional occurrence. 
Since the experiments of Tuffier have demonstrated that des- 
troyed or ablated kidney tissue is readily and speedily replaced, 
15 under ordinary circumstances, by a liberal regeneration of new 
kidney structure, we need no longer take into account the slight 
traumatism inflicted by the passage of needles and sutures. 
The mortality of the operation should be practically nil. Of 
my twelve cases I lost one in which the peritoneum was accident- 
ally opened, and a diphtheritic infection of that membrane oc- 
curred. The details are narrated in the history of the case as 
recorded below. 
Of the eleven cases which recovered, one, a double nephrorr- 
haphy performed at one sitting, is as yet too recent to speak of 
final results. A second patient has not as yet left her bed. Of 
the other nine, in not one has the sutured kidney, to my know- 
ledge, become movable, the first patient having been operated 
upon February 8, 1890, and the last, four months ago. Both ana- 
tomical and therapeutical results are all that could be desired. 
None of my patients have worn a supporter of any kind since 
operation. 
I have in the above endeavored to state facts and formulate 
views based upon my own experience and observations, as well 
as upon the work of those authors who have preceded me in 
writing upon the subject of movable kidney. I have avoided 
lengthy quotations from and frequent references to the writings 
of others, not from want of appreciation of their work, but from a 
desire not to extend unduly the limits of this paper. 
I append the histories of all the cases of movable kidney, 
twelve in number, in which I have performed nephrorrhaphy. 
Case I. Movable right kidney; endometritis and hypertrophic 
elongation of cervix ; nephrorrhaphy, with relief of symptoms and 
permanent fixation of right kidney; subsequently movable left 
kidney, for a time, with return of symptoms ; final cure.—R. K., 
twenty-two years, single, seamstress, was admitted to hospital 
January 23, 1890. Menstruation began at thirteen, and with the 
exception of one year of amenorrhoea, has been regular, though 
scanty, ever since. Three years ago had a severe and prolonged 
attack of malarial fever. Since then she has suffered continuously 
with extreme nervousness, hysterical manifestations, almost con- 
stant cardiac palpitation, pyrosis, dyspepsia, constipation, oc- 
casional pains in back, and more or less dysmenorrhoea. 
Examination : Tubes and ovaries normal in size and position, 
not tender on pressure. Uterus normal in position ; corpus 
normal in size, cervix markedly elongated. Endometritis. Right 
kidney normal in size, freely movable between its normal position 
and a point just within the anterior superior spine of the ilium. 
Reft kidney in normal position. 
Nephrorrhaphy, February 8, 1890, after the method described 
in the body of the paper, the uppermost kidney suture passing 
through the eleventh intercostal space and embracing the twelfth 
rib. Uneventful recovery. Patient discharged March 7, 1890. 
One year later the patient gave the following account of her- 
self : Following the operation the nervousness, cardiac palpitation, 
16 and stomach symptoms disappeared almost entirely. The dys- 
menorrhoea and occasional backache, however, persisted, although 
in less severe degree. For six months she regarded herself as 
substantially well, when all the old symptoms, one by one, re- 
turned. A slight cough developed in addition. 
Examination showed persistence of the endometritis and a 
slight swelling of the left tube. Right kidney immovably fixed 
behind the scar of lumbar incision. Reft kidney movable to the 
extent of seven to eight centimetres in a downward direction. 
Signs of incipient phthisis at apices of both lungs. Patient re- 
quested operative fixation of the second kidney, but in view of 
her poor family history (three sisters dead of pulmonary con- 
sumption), the condition of her lungs, and a suspicion of develop- 
ing tubal tuberculosis, I advised waiting. 
The patient is, nearly two years and nine months after oper- 
ation, the picture of perfect health. Immediately following the 
last report, a year and a half ago, she improved in health and got 
married. The symptoms due to the movable left kidney slowly 
but completely disappeared as she grew stouter. She has had 
absolutely nothing to complain of for a year past, and is now two 
months pregnant. The right kidney, as several of you have veri- 
fied by examination, is immovably fixed to the scar of the lumbar 
incision. The lower edge of the left kidney can be barely palpated, 
its previous mobility having almost entirely disappeared, due no 
doubt to increased deposit of peri-renal fat. 
Case 11. Movable right kidney; retroversion of uterus ; lacera- 
tion of cervix uteri ; trachelorrhaphy and shortening of round liga- 
ments followed by but slight relief; nephrorrhaphy followed by im- 
mediate a7id complete disappearance of symptoms.—Mrs. A. Reß., 
thirty-seven years, married, mother of five children. Rast con- 
finement three years ago ; no miscarriages. Menstruation regu- 
lar, with rare exceptions, the flow lasting seven days. Family 
history indifferent. For two or three years past has been troubled 
with general nervousness, and a moderate degree of cardiac pal- 
pitation and gastric dyspepsia. During the past four months pains 
in the left epigastrium, in tenth intercostal space posteriorly, and 
in left inguinal regions have been the prominent symptoms. 
Anorexia ; bowels regular. 
Examination, in narcosis, May 15, 1890. Ovaries and tubes 
normal in size. Uterus retroverted in second degree. Corpus 
uteri normal in size. Cervix slightly thickened and enlarged, 
lacerated for 2.5 centimetres to left. Ectropion of cervical muc- 
osa. Vagina and vulva normal. 
Right kidney normal in size, displaced downward and forward 
to pelvic brim. From this position it can be freely moved across 
the bodies of the lumbar vertebrae to the left of the spine, thence 
upward on the left side, and again across the spine to its normal 
position. Reft kidney in normal position. 
May 19, 1890. Trachelorrhaphy and shortening of round lig- 
aments, the left ligament being shortened nine, and the right ten 
centimetres. Primary union of all wounds. 
These operations were followed by but slight relief of symp- 
toms, the majority of which were construed as due to the movable 
right kidney. 
Nephrorrhaphy, June 12, 1890, after the method described. The peritoneum was accidentally opened near the lower pole of 
the kidney, the rent being immediately closed by running catgut 
suture. Uneventful and afebrile recovery. Patient discharged 
four weeks after operation. 
Two months later the patient presented herself with the state- 
ment that since the nephrorrhaphy she had been perfectly well 
for the first time in many years, all her disagreeable symptoms 
having disappeared. The right kidney was found securely an- 
chored to the cicatrix of the lumbar incision. Uterus in normal 
anteversion. In spite of persistent efforts to trace the patient I 
have been unable to learn anything of her since. 
Cask 111. Mobility of both kidneys ; endometritis and catarrhal 
salpingitis; emphysema pulmonum ; nephrorrhaphy for fixatio7i of 
right kidney; complicated recovery; permanent fixation of right kid- 
ney a7idpartial relief of sympto77is; subseque7it i7icrease of adipose 
tissue, resulti7ig in better support of left kidney, and a co77iplete cure. 
—M. A., thirty-four years, single, religious. Family history poor, 
her father, a brother, and a sister having died of pulmonary phth- 
isis. Menstruation regular, the flow lasting five to six days. 
With the exception of symptoms due to pulmonary emphysema 
patient was well up to four years ago. At that time she began to 
notice a frequent swelling of the abdomen, and to be troubled with 
general nervous symptoms and gastric indigestion. The nervous- 
ness and dyspepsia gradually became intensified, pains in both 
inguinal regions were superadded, and the periods became pain- 
ful. Ueucorrhoea, constipation, and occasional scalding on mic- 
turition. 
Examination, April 25, 1891. Uterus normal in size and 
position. Endometritis corporis et cervicis. Bilateral catarrhal 
salpingitis, the tubes being slightly thickened and exquisitely 
sensitive on pressure. Ovaries normal. 
Right kidney normal in size and freely movable in the arc of 
a circle having its centre at the normal position of the kidney, 
and a radius of ten centimetres. Left kidney movable to extent 
of five centimetres in a downward direction. 
Nephrorrhaphy, April 29, 1891. Chloroform employed in pre- 
ference to ether on account of the tendency to bronchitis. Oper- 
ation as described. Convalescence complicated and retarded by 
an acute catarrhal pneumonia, involving the lower half of right 
lung, and lasting 10 days ; by an acute endocarditis of a week’s 
duration, and by the formation of a peri-renal abscess, which 
kept discharging until six weeks after operation, when it defin- 
itely healed. Patient discharged June 25th, nine weeks after 
operation. 
Permanent relief of the majority, though not of all the symp- 
toms followed the operation. A year following the operation the 
right kidney remained firmly anchored in its new position ; the 
mobility of the left kidney, the endometritis, and the salpingitis 
remained unchanged. Curettement and fixation of left kidney 
advised. Patient feels so comparatively well, however, that fur- 
ther operative interference is declined. 
Patient last seen a few days ago, a year and a half after oper- 
ation. Her weight had increased from 105 pounds at time of 
operation to 145 pounds. The great increase of fat has resulted 
in better support and decidedly lessened mobility of the left 
18 kidney. Right kidney firmly anchored to lumbar .scar. With 
the exception of a slight leucorrhoea patient considers herself in 
the best of health, and has absolutely nothing to complain of. 
Case IV. Movable right kidney; nephrorrhaphy ; death from 
acute septic (diphtheritic) peritonitis thirty-six hours after operation. 
—A. 8., thirty-four years, single. Referred to me by Dr. A. 
Strong. Family history indifferent. Menstruation regularly 
every three weeks, the flow lasting three days. Has suffered 
much and constantly during the past four or five years with dys- 
peptic symptoms, of which severe pain in the epigastrium, most 
intense about one hour after meals, was most bitterly complained 
of. Occasional attacks of nausea, vertigo, vomiting, and con- 
stant anorexia the other main symptoms. 
Examination, April 28, 1891. Genitalia normal in every re- 
spect. Right kidney movable to extent of twelve centimetres 
forward and downward. Reft kidney in its proper place. 
Nephrorrhaphy, April 30, 1891. Usual incision—more oblique 
than ordinarily, on account of limited space between ribs and 
crest of ilium. Peritoneum accidentally opened near lower pole 
of kidney. Some time was spent in examining the peritoneal 
rent to make sure that no viscus was wounded. After satisfying 
myself that such was the case, the peritoneum was closed by a 
running catgut suture, and the operation completed in the cus- 
tomary manner. Six hours after operation the patient developed 
symptoms of acute peritonitis, to which affection she succumbed 
thirty-six hours after operation. 
Autopsy, twelve hours after death. Peritoneum everywhere 
intensely injected and its lustre lost to a great degree. No ad- 
hesions. The injection was most intense in the vicinity of the 
right kidney, where also a thick reddish fluid to the amount of 
seventy-five grammes had collected. The peritoneal wound 
made at operation involves the parietal peritoneum onljq no viscus 
being injured. Kidney sutures were examined and found not to 
have cut through the kidney substance, which they traversed at 
a depth of a little over one centimetre from the surface of the 
organ. 
On the morning of operation I awoke with a pain in the throat 
which I disregarded, not being subject to throat affections. The 
operation was performed at 9 a.m. Immediately after the oper- 
ation I noticed that the pain in the throat had increased and that 
I was slightly feverish. A colleague examined my throat and 
pronounced me suffering from diphtheria, a diagnosis which 
further developments confirmed. I believe that while I was bend- 
ing over and examining the opened peritoneum the latter be- 
came infected from the expired air from my throat. The foudroy- 
ant character of the peritonitis, unusual even in the most septic 
forms, would tend to bear out the supposition. Unfortunately, 
no bacteriological investigation of the peritoneal contents was 
made. 
Case. V. Movable right kidney; endometritis ; bilateral catarrhal 
salpingitis ; curettement, followed by partial relief; nephrorrhaphy 
seven months later, followed by complete cure.—A. H., thirty-three 
years, single, cloakmaker. Father died of pulmonary consump- 
tion. Periods regular every four weeks, lasting five to nine 
19  Eeucorrhoea for the past twenty, and severe dysmenorr- 
hoea for the past fifteen years. Had a fall eighteen months ago, 
and a constant pain since over public region, aggravated on stand- 
ing or walking. Urination frequent, but without pain or scalding. 
Following an attack of typhoid fever and pneumorrhagia six 
years ago, the following symptoms developed in addition to those 
above enumerated. It may be added that before the attack of 
typhoid fever the patient was quite stout, but has never since re- 
gained her original weight. She has become moderately nerv- 
ous, appetite has failed, pain in left half of epigastrium after eating; 
flatulence, constipation and cardiac palpitation have developed. 
Examination, September 3, 1891. Uterus in normal position, 
slightly and uniformly enlarged. Eeft ovary and tube normal in 
size, prolapsed into Douglas’ sac. Right ovary and tube normal 
in size, fastened in normal position by adhesions. Both tubes 
tender on pressure. Endometritis ; double catarrhal salpingitis. 
Kidneys not examined. 
September 14, 1891. Curettement followed by swabbing of 
uterus with equal parts of carbolic acid and glycerine and gauze 
drainage. 
March 28, 1892. Patient reports that the dysmenorrhoea and 
the leucorrhoea, from which she had suffered so long and severe- 
ly; had entirely disappeared since the curettement, the menstrual 
flow lasting only half as long as formerly and being entirely 
painless. The nervousness, dyspeptic symptoms, epigastric 
pains, and cardiac palpitation persisted as formerly. 
Examination shows quite normal condition of uterus and ap- 
pendages. Tubes no longer sensitive on pressure. 
Right kidney movable some eight centimetres in a downward 
direction, a condition entirely overlooked at previous examinations. 
Nephrorrhaphy, April 8, 1892, in usual manner, except that 
kidney was fastened by buried sutures of kangaroo tendon. 
Primary union ; uneventful convalescence. 
July 24. Pain in left side has entirely disappeared. Appetite 
and digestion are steadily improving. Patient considers herself 
perfectly well. Right kidney remains firmly anchored in its new 
position. 
October 27. Every one of her old symptoms has entirely dis- 
appeared. Right kidney, on examination to-day, found securely 
anchored to the scar of the lumbar incision. 
Cask VI. Movable right kidney ; laceration of cervix uteri; neph- 
rorrhaphy, curettement, and trachelorrhaphy, at same sitting ; cure. 
—Mrs. E- 8., twenty-three years, married, mother of three child- 
ren, the last born eighteen months ago. Symptoms date from 
December, 1891. Pain in left half of epigastrium, worse after 
eating ; anorexia ; emaciation ; nervousness, and especially rest- 
lessness at night; headaches ; dysmenorrhoea. 
Examination, April 23, 1892. Uterus normal in size and posi- 
tion. Adnexa on both sides normal. Cervix uteri slightly lac- 
erated. 
Right kidney movable to the extent of ten centimetres in a 
downward direction. Deft kidney in a normal position. 
Nephrorrhaphy, curettement, and trachelorrhaphy, at same 
sitting, April 26th. Kidney fastened by buried kangaroo 
sutures. Primary union of all wounds. 
20 Relief of all symptoms began within two weeks after operation 
and persisted when patient was last seen, three months later. 
Kidney remains fixed in its new position. 
October 27. Patient examined, and right kidney found secure- 
ly fastened to lumbar scar. All her symptoms had vanished as 
if by magic on the day of operation and have remained away 
since. 
Case) VII. Movable right kidney; retroversion of uterus; endom- 
etritis; double catarrhal salpingitis; curettement, shortening of round 
ligaments, and nephrorrhaphy, at same sitting; cure.—A. 8., 
twenty-five years, single, trained nurse, suffered from acute 
arsenical poisoning in 1887, from typhoid fever and yellow fever 
in 1888, from influenza and pneumonia in 1891. Menstruation 
was regular until three years ago; it has since gradually become 
less frequent until now it occurs about once in four months and 
is very scant. Four years ago, as a result of severe strain at 
lifting, the uterus prolapsed completely outside of the body, 
necessitating reduction under ether. 
For past four years she has had chronic dyspepsia, pains of a 
neuralgic character in various parts of abdomen, headache, ex- 
treme nervousness, and pronounced hysteria, with almost con- 
stant cardiac palpitation. During the past year leucorrhoea, a 
pressure pain over pubis, and occasional tumefaction of abdomen 
have been added to the above symptoms. 
Examination, May 8, 1892. Adnexa uteri normal in size, 
sensitive on pressure. Uterus undersized; retroverted in first 
degree. 
Right kidney of normal size, movable for ten to twelve centi- 
metres in a downward and forward direction. Reft kidney can- 
not be palpated. 
Curettement, shortening of round ligaments, and nephrorn 
haphy, at one sitting, May 10, 1892. 
All operative wounds healed by primary union. Ten weeks 
after operation patient reports as follows: With the exception of 
weakness (and well-marked anaemia) she now considers herself 
perfectly well. The dyspeptic symptoms disappeared two weeks 
and the leucorrhoea three weeks after operation. Neither has re- 
turned. The hysteria and nervousness yielded more slowly but 
are now almost entirely gone. She was practically a new 
woman. On examination the uterus is found in normal antever- 
sion and the right kidney securely moored in its normal position. 
Efforts made within the past two weeks to trace the patient 
have proved unsuccessful. 
Case; VIII. Movable right kidney; enaometritis; salpingitis 
catarrhalis; curettement and nephrorrhaphy; cure.—J. H., eighteen 
years, single; began to menstruate at eleven, and ever since has 
suffered from severe dysmenorrhoea, the flow occurring every 
four weeks and lasting three to fourteen days. She was other- 
wise well until thirteen years of age, when she had a severe at- 
tack of diphtheria. Following this, the following symptoms de- 
veloped one by one: Marked emaciation, pains in left inguinal 
and left epigastric regions, leucorrhoea, anorexia, dyspepsia, 
periodical tumefaction of abdomen, marked nervousness, head- 
aches, cardiac palpitation, inability to sleep upon the left side, 
21 constipation. For the past five years she has been under the 
care of many physicians, traveling to Europe a number of times 
in hopes of finding relief. For the above history I am indebted 
to her family physician, Dr. George C. Stiebeling, who brought 
the patient to me for examination, May 13, 1892. 
Exaggerated anteversion of uterus. Catarrhal salpingitis of 
left side with slight thickening of tube. Right appendages nor- 
mal. Endometritis. 
Right kidney moderately enlarged and movable ten to twelve 
centimetres downward and forward to just behind umbilicus. 
Eeft kidney cannot be palpated. Spleen decidedly enlarged. 
May 17, 1892. Currettement followed by nephrorrhaphy. 
Uneventful convalescence, the wound healing by primary 
union. 
Ten weeks after operation patient reports as follows: The first 
period following operation was the only painless one of her life. 
The second was as painful as usual; the third again painless. 
Every symptom she formerly complained of, with the exception 
of the nervousness, disappeared as if by magic during the first 
two weeks after operation, not to appear again. The nervous- 
ness had diminished so greatly as to be no longer uncomfortable. 
The mental condition has changed from one of melancholy to 
cheerfulness and happiness. 
Right kidney remains where it was anchored at operation. 
Pelvic organs apparently normal. 
October 26. The patient remains perfectly well, every symp- 
tom, including the nervousness, having entirely and permanently 
disappeared. Right kidney remains securely anchored in its nor- 
mal position. 
Case IX. Movable right kidney ; laceration of cervix uteri; en- 
dometritis ; curettement, amputation of cervix, and nephrorrhaphy, 
at one sitting.—Mrs. E. M., forty-three years, married, mother of 
three children, the youngest being eight years old. Menstrua- 
tion began at eighteen years, and was regular up to eighteen 
months ago. At that time an amenorrhoea of three months was 
followed by the passage of clots (miscarriage ?) and free bleeding 
lasting some six weeks. As a result she became very thin and 
anaemic, and from this period dates her symptoms. These are: 
occasional leucorrhoea and scalding on micturition, pain after 
eating, gaseous eructations, transitory pains in left epigastrium, 
nervousness, and irritability. These symptoms have gradually 
increased in intensity. She was placed under my care by her 
family physician, Dr. A. Rupp. 
Examination, June 11, 1892. Ovaries normal in size. Both 
tubes slightly sensitive to pressure, but not enlarged. Uterus in 
normal position ; corpus of normal size ; cervix slightly hypertro- 
phied and lacerated for 2.5 cm. to left. Eversion and erosion of 
cervical mucosa. Endometritis. Right kidney movable in a 
downward and forward direction, until its lower pole reaches the 
median line at a point eight centimetres below the umbilicus. 
Thence it can be swept around in a circle across the spine to the 
left and back to its normal position on the right side. Kidney 
not enlarged. 
June 14, 1892. Curettement, amputation of cervix, and neph- 
rorrhaphy at same sitting. Primary union of all wounds. 
22 Patient discharged July 6th, feeling well, and with right kid- 
ney in good position. 
October 22. Patient presents herself to-day with the state- 
ment that all her symptoms have disappeared, and that she con- 
siders herself perfectly well. On examination the right kidney 
is found securely anchored to the scar of the lumbar incision. 
Cass X. Movable right kidney ; descensus et retroversio uteri, 
both in first degree ; e7idometritis ; laceratioyi of cervix uteri and of 
perineum; curette7nent, amputation of cervix, and perineorrhaphy 
at one sitting, followed by scarcely a7iy relief; subsequently ventrofix- 
atio7i of uterus and nephrorrhaphy, followed by speedy disappeara7ice 
of symptoms.—Mrs. S. K., thirty-eight years, married, mother of 
three children, the youngest being six years of age. Sent by Dr. 
E. J. Messemer. Menstruates regularly for five days every four 
weeks. Ever since birth of first child, nine years ago, she has 
been troubled with the following ills : Beucorrhoea, backache; 
pains in all parts of body, fugitive in character (spinal irritation); 
dizziness, nervousness, anorexia, dyspeptic symptoms, cardiac 
palpitation. 
Examination, May 10, 1892. Appendages normal on both 
sides. Uterus prolapsed and retroverted, both in first degree. 
Corpus normal in size. Cervix lacerated bilaterally, thickened 
and elongated. Moderate cystocele and rectocele. Perineum 
and lower end of vaginal tube lacerated in first degree. Right 
kidney movable ten centimetres in a downward direction. Reft 
kidney in normal position. 
May 13, 1892. Curettement, amputation of cervix, and perine- 
orrhaphy. Primary and firm union. Patient discharged June 9, 
1892. 
In spite of the successful result of the plastic operations, 
patient experienced only moderate relief,' the chief annoying 
symptoms persisting. Among these were various pains, an un- 
easy feeling in the right lumbar region, great nervousness, dys- 
peptic symptoms, and a full feeling in vagina. 
Examination June 26. Slight cystocele persists ; rectocele has 
disappeared. Uterus still low in pelvis and retroverted in first 
degree. Kidneys as at first examination. 
June 28. Nephrorrhaphy and ventrofixation of uterus at same 
sitting. The nephrorrhaphy in this case proved unusually diffi- 
cult, the patient being short and stout, and the distance between 
the last rib and crest of ilium measuring but four centimetres. 
An unusually oblique incision was employed, and the operation 
successfully completed under great disadvantages. 
The nephrorrhaphy and the coeliotomy wounds healed by first 
intention. Convalescence was complicated and prolonged by an 
acute catarrhal pneumonia which developed a week after opera- 
tion, and ran a course of one week, and by a phlegmasia alba 
dolens of right leg (thrombosis of right femoral vein), begin- 
ning two weeks after operation and keeping the patient in bed 
until July 27th. Discharged August 6th, with both uterus and 
kidney held well in place. Nearly every one of her former 
symptoms disappeared before she left hospital. 
October 27. Every symptom of which the patient formerly 
complained has disappeared and remained away. The right leg 
still a little swollen. The sutured kidney remained securely 
anchored in its normal position. 
23 Cask XI. Mobility of both kidneys following removal of a large 
ovarian cystoma ; double nephrorrhaphy at one sitting.—M. 8., forty 
years, single, domestic, was referred to me by Dr. Carl Edel. On 
June 17, 1892, I removed from patient a large, many-chambered 
ovarian cyst filling the abdomen. Twisting of the pedicle had 
occurred, the cyst had become strangulated, and all its chambers 
were filled with blood, fluid aud clotted. Patient made an un- 
eventful recovery from the ovariotomy, and was discharged four 
weeks after operation. Dyspeptic symptoms and general nerv- 
ousness, which had existed for some time prior to the development 
of the ovarian tumor, but had disappeared with the increase of 
the abdominal enlargement, now reappeared with increased 
severity. On examination before leaving hospital both kidneys 
were found to be freely movable ; the right down to the anterior 
superior spine of the ilium, the left from 8 to 10 centimetres in a 
downward direction. 
Double nephrorrhaphy, October 11, 1892, the left kidney being 
first sutured. I found it very difficult to operate on the left kid- 
ney, the organ showing a tendency to hide behind the ribs. It 
required one hour to sew the left kidney, and a further half-hour 
to fixate the right. 
Patient has made a perfectly uneventful recovery. On the 
third day a slight transient albuminuria was noticed, which dis- 
appeared in a few hours, not to return. This is the only one of 
my cases in which albuminuria was noted after nephrorrhaphy. 
November 10, 1892. Patient left her bed three weeks after 
operation. Both kidneys are securely anchored in the loins, and 
the patient’s symptoms have vanished. 
I record the case more especially because double nephrorrha- 
phies are as yet comparative rarities. 
In Dindner’s collection of twenty-nine nephrorrhaphies, the 
double operation figures but twice ; Hahu, in 1881, operated at 
two sittings, four months apart, upon the right and left kidneys 
of the same patient, and Kuster performed a double nephrorr- 
haphy at one sitting in 1883. 
Cask XII. Movable right kidney; retroversion of uterus; cirr- 
hosis of left ovary; double uterus; mitral insufficiency; nephrorr- 
haphy, curettement, unilateral salpingo-oophorectomy and ventrofix- 
ation of uterus at one sitting; recovery.—K. H., twenty-three 
years, single, domestic, has been ill for nearly two years with a 
variety of symptoms, evidently due to a number of pathological 
conditions. The chief complaints noted are cough aud dyspnoea 
on exertion, cardiac palpitation, cardialgia, frequent vomiting 
spells, nausea, gaseous eructations and distress after meals, con- 
stipation, pain in back, leucorrhoea and coccygodynia. 
Examination, October 15, 1892. Uterus somewhat large, re- 
troverted in second degree. Tubes and ovaries on both sides 
normal in size, non-sensitive on pressure. Deft ovary very hard 
(cirrhosis). Right kidney normal in size, movable seven to eight 
centimetres in a downward direction. Rude systolic bruit over 
left ventricle and apex of heart. Spleen moderately enlarged. 
Enngs normal. 
Operative interference dissuaded from on account of the multi- 
plicity of lesions conjoined with organic cardiac disease. The 
possibility of death on the table was presented to the patient. 
24 She, however, insisted on operation, stating that she preferred 
risking her life in trying to get well to living further in the same 
misery. 
On October 25, 1892, under ether ansethesia, I performed 
nephrorrhaphy, curettement, salpingo-oophorectomy (the left 
tube and calcareous left ovary being removed), and ventrofixa- 
tion of the uterus, at one sitting. At the curettement it was 
noticed that the curette could be passed into two different 
cavities within the uterus, with a partition between them. On 
opening the abdomen the corpus uteri was found to be double 
(with a single cervix). The two halves were fused along the 
median line, each corpus having but one tube and ovary. The 
larger, right half of the uterus was ventrofixated in the usual 
way. 
November 10. Patient has thus far made an uneventful re- 
covery, is out of danger, and is feeling well. 
Resume.—The subject of movable kidney is of paramount im- 
portance and interest to every practitioner of the healing art, but 
especially so to the gynecologist. 
Movable kidney is of much greater frequency in the human 
female than is generally supposed. Of a series of five hundred 
women examined by the author, ninety were found the pos- 
sessors, amongst other things, of movable kidneys. 
The affection appears to be comparatively rare among men. 
In the overwhelming majority of cases the right kidney alone 
is movable. 
Not every movable kidney produces symptoms. 
The symptoms of movable kidney frequently both coexist with 
and simulate those of various diseases of the female sexual 
organs. The discriminating diagnosis may offer difficulties. 
Atrophy or absorption of the peri-renal fat is the chief etiolog- 
ical factor in the production of movable kidney. Other causes 
assigned by various authors are ; tight lacing, laxity of abdom- 
inal walls, congenital predisposition, and severe straining. 
A distinction should be maintained between movable and float- 
ing kidney. 
A movable kidney is one movable within a pouch or hollow 
formed within its own fatty capsule. A floating kidney has 
normal relations with that portion of its fatty capsule which it 
carries with it in its excursions, and is supplied with a mesone- 
phron, the length of which determines the degree of mobility. 
This paper deals only with the movable kidney. 
The symptoms are likely to be more distressing in the earlier 
than in the final stages of movable kidney. 
The most characteristic combination of symptoms of uncom- 
plicated movable kidney is the following : Digestive disturbances, 
chronic in character ; epigastric pain, usually located somewhat 
to the left of the median line ; general nervousness ; cardiac pal- pitation ; inability to feel comfortable, or to sleep, when lying- 
on the left side. 
The other symptoms associated with movable kidney occur 
less frequently and are of secondary significance. 
The symptoms of movable kidney are accentuated during 
menstruation and the early months of pregnancy. They dis- 
appear during the latter half of pregnancy and during the exist- 
ence of large intra-abdominal growths. 
The symptoms of movable kidney are due to pressure and 
traction upon, stretching, and irritation of various parts of the 
solar plexus of the sympathetic and of its branches. The 
of obliteration of the lumen of the duodenum, by pressure or 
traction, is insufficient to account for the symptoms. 
A movable kidney is the easiest of all intra-abdominal condi- 
tions to diagnosticate. The diagnosis is made by palpation of 
the displaced organ. 
A kidney once movable never becomes firmly fastened in its 
normal position except by operative interference. 
The symptoms due to movable kidney may be ameliorated by 
the dorsal decubitus, the Weir Mitchell treatment, massage, 
electricity, and abdominal supporters. All of these measures 
are, however, in the large majority of cases disappointing, and 
the benefit obtained, if any, is likely to prove only transient. 
Nephrectomy, or extirpation of the movable kidney, is too 
radical and dangerous a resource as compared with nephrorr- 
haphy. 
Nephrorrhaphy properly performed upon properly selected 
cases can, as demonstrated by appended histories, be depended 
upon to afford relief, with a good prospect of the permanency of 
the latter. 
Addendum.—From the date of reading this paper (October 27, 
1892) to the date of revision of proof (March 10, 1893) I have 
performed ten further nephrorrhaphies for movable kidney. All 
of these made good and perfectly smooth recoveries, although in 
all of them but three, one or more additional operations were 
performed upon the genital organs at the same sitting. This 
makes my personal statistics twenty-two nephrorrhaphies with 
one death, {vide Note, page 28.) 
For buried sutures to fasten the kidney to muscle and 
aponeuroses, I now use silkworm gut exclusively, having aban- 
doned kangaroo tendon for reasons which this is not the proper 
place to enter upon. 
I have had occasion since reading the paper to see again most 
of the eleven cases whose histories I have recorded above. In 
all of these, as well as in the ten patients since operated upon, 
the fastened kidneys remain securely anchored in their new posi- 
26 tlon. In fact, Ido not know of a single case in which I have 
performed nephrorrhaphy in which the fastened kidney again 
became movable. 
For the sake of completeness I append an outline of the ten 
additional cases operated upon. Their histories are but a dupli- 
cation of the twelve reported in full above, and to record them at 
length would be weary to the reader. 
Case XIII. M. K., aged thirty-five years, married. Endom- 
etritis ; laceration of cervix and perineum ; adherent retro- 
ver ted uterus ; cystoma of right ovary ; movable right kidney ; 
insufficiency of mitral valve. 
May 17, 1892. At one sitting ; Curettage of uterus ; amputa- 
tion of cervix; ovariotomy ; liberation and ventrofixation of 
uterus. 
Recovery and partial disappearance of symptoms. 
November 8, 1892. Nephrorrhaphy and perineorrhaphy at 
one sitting. 
Recovery and complete cure. 
Case XIV. S. S., aged twenty-seven years, married. Hsema- 
toma of left ovary ; movable right kidney ; hystero-epilepsy. 
February 16, 1892. Unilateral salpingo-oophorectomy, fol- 
lowed by disappearance of the epilepsy ; the hysteria and symp- 
toms due to the movable kidney persisting. 
November 18, 1892. Nephrorrhaphy. Recovery, followed by 
disappearance of nearly all symptoms during the next two 
months. 
Case XV. A. 8., aged nineteen years, single. Anteflexion 
of uterus ; fungous endometritis ; catarrhal salpingitis ; movable 
right kidney. 
September 12, 1891. Amputation of cervix uteri, with no re- 
lief of any kind. 
December 22, 1891 Curettage and iodoform gauze drainage 
of uterus. Some relief followed this treatment. 
During the spring of 1892 rapidly growing cystomata developed, 
under observation, in both ovaries. 
June 28, 1892. Double ovariotomy and ventrofixation of 
uterus. Uneventful recovery, but persistence of the symptoms 
due to the movable right kidney. 
December 2, 1892. Nephrorrhaphy. Recovery and complete 
cure. 
Case XVI. A. u., aged twenty-five years, single. Emphy- 
sema pulmonum ; bronchitis chronica ; endometritis ; movable 
right kidney. 
December 2, 1892. Curettage of uterus and nephrorrhaphy. 
Recovery. Disappearance within two months of all symptoms 
except those due to pulmonary emphysema, and general nervous- 
ness, which latter has, however, considerably improved. 
Case XVII. M. W., aged twenty-three years, married. En- 
dometritis ; catarrhal salpingitis ; movable right kidney ; pul- 
monary phthisis. 
27 January 6, 1893. Curettage of uterus and nephrorrhaphy. 
Recovery and partial disappearance of symptoms. When last 
seen, two months after operation, was suffering from morbus 
maculosus Werlhoffi. 
Case XVIII. A. O’C., aged twenty years, single. Endome- 
tritis ; movable right kidney ; menstrual epilepsy. 
January 6, 1893. Curettage of uterus and neplirorrhaphy. 
Recovery. Patient left hospital feeling well, but has not re- 
ported since. 
Case XIX. K. O’R., aged thirty-one years, single. Movable 
right kidney ; endometritis. 
January 27, 1893. Curettage of uterus and neplirorrhaphy. 
Reft hospital improved, February 20, and has not been heard 
from since. 
Case XX. M. 8., aged eighteen years, single. Movable 
right kidney ; endometritis. 
February 10, 1893. Curettage of uterus and neplirorrhaphy. 
Horse-shoe kidney. Recovery ; still in hospital. 
Case XXI. A. M., aged twenty-three years, single. Movable 
right kidney ; pneumo-phthisis. 
February 14, 1893. Neplirorrhaphy. Recovery; still in hos- 
pital. 
Case XXII. G. C., aged thirty-one years, single. Movable 
right kidney ; endometritis ; left salpingo-oophoritis ; fissures of 
anus. 
February 14, 1893. Curettage of uterus, neplirorrhaphy, and 
dilatation of sphincter ani. Patient still under treatment. 
Note.—Up to the date of publication of this reprint, July 26th, 
1893, the author has performed nephrorrhaphy upon thirty-five 
patients in all, with but one death (Case IV., page 19). Eight of 
these were bilateral nephrorrhaphies, forty-three kidneys being 
sewn fast in thirty-five women. In seven of the eight double 
nephrorrhaphies both kidneys were operated upon at the same 
sitting ; in the eighth the operations were performed at two sit- 
tings, four and a half months apart. 
The statement made on page 27 : “ I do not know of a single 
case in wrhich I have performed nephrorrhaphy in which the fast- 
ened kidney again became movable ” still holds good. 
28 (Reprinted from the Transactions of the NEW YORK OBSTETRICAL SOCIETY, 
Meeting of April 18th, 1893.) 
Dr. G. M. Bdebohls presented two patients upon whom he had 
performed. 
BILATERAL NEPHRORRHAPHY 
fastening a movable right and a movable left kidney at the same 
sitting. 
The first patient was one whose case (Case XI) he had already 
published in detail in his recent paper on Movable Kidney (Am- 
erican Journal of the Medical Sciences, March and April, iBpj.) 
He presented her this evening for the purpose of demonstrating 
the permanent fixation of both kidneys in their new positions. 
The second patient was a widow of thirty-nine, who had never 
conceived and who had for more than ten years past suffered 
from the usual symptoms associated with movable kidney. Dur- 
ing all that time she had received much and varied treatment, 
chiefly directed to the genital organs, without any relief, the mo- 
bility of her kidneys passing undetected until she came under the 
care of Dr. Edebohls. 
Her most annoying symptoms were apparently connected with 
the bladder, consisting of frequent attacks of painful micturition, 
with sudden interruptions of the flow, and occasional complete 
suppression of urine, generally lasting from twelve to fifteen 
hours. The bladder although tender on pressure, gave no other 
evidence of disease on careful examination. The suppression of 
urine was interpreted as the result of kinking or torsion of the 
ureters due to the mobility of the kidneys. The patient had 
found out for herself that the only way to relieve it was to as- 
sume the recumbent position, when a free flow of urine soon fol- 
lowed. During a week of observation preceding operation her 
urine was examined daily and was invariably found to contain 
albumen. No casts, however, were discovered. 
The right kidney was movable about twelve, and the left some 
ten centimetres, in a downward direction, so that the hands, one 
pressing from the hypochondrium backwards and the other from 
the lumbar region forwards, could easily be made to meet above 
the upper pole of either kidney, between that organ and the free 
border of the ribs. The kidneys were thus palpable in their en- 
tirety and were found normal in shape and size. 
Double nephrorrhaphy was performed on March 10, 1893, both 
kidneys being operated upon at the same sitting. 
The albuminuria persisted for ten days following operation, 
and then disappeared, not again to return. The wilfulness of the 
patient, sitting up in bed repeatedly during the first six days 
after operation, interfered to a slight extent with wound healing, 
but did not nullify the result as far as anchorage of the kidneys 
29 was concerned, both of which are to-night firmly moored to the 
lumbar scars. 
The symptoms, nervous, gastro-intestinal, genital, vesical and 
urinary, which have existed for so many years have, nearly all of 
them, entirely disappeared since operation, and the delighted 
patient considers herself perfectly well. 
Dr. Edebohls reported a third case of 
BILATERAL NEPHRORRHAPHY 
performed upon the patient, a girl of twenty-six, whom he had 
presented to the Society at its last meeting, and in whom, as the 
members who examined her will recall, the right kidney was dis- 
placed some fifteen and the left some thirteen centimetres down- 
ward, both organs being excessively movable. 
The case was of interest because the patient, an otherwise 
healthy country girl, with no nonsense or hysteria about her, 
presented an array of symptoms, such as dysmenorrhoea, pains in 
left ovarian region, general pelvic distress and intolerable bearing 
down sensations which most gynecologists would look upon as 
probably indicating disease in the genital sphere. Yet on careful 
examination the genital organs were found absolutely normal, 
and all her symptoms were interpreted as due to the movable 
kidneys. 
Double nephrorrhaphy was made on April 7th, both kidneys 
being sutured at the same sitting. Recovery had been unevent- 
ful ; it was yet too early, however, to speak of therapeutic re- 
sults. 
Dr. Edebohes next showed a patient, a girl of twenty, upon 
whom he had operated for 
movable right kidney and endometritis associated with 
MENSTRUAL EPILEPSY, 
on Jan. 6th, 1893, performing curettage of the uterus and neph- 
rorrhaphy at the same sitting, and whose case he had outlined in 
the paper above alluded to (Case XVIII). 
For two years previous to coming under his care she had suf- 
fered from dysmenorrhoea and hystero-epilepsy during the whole 
of each menstrual period, the flow occurring every four weeks 
and lasting five days. Since the operation she had had three 
periods. In none of them did the hystero-epilepsy recur and in 
but one did she experience dysmenorrhoea. 
The curious feature of the case was that the left kidney, which 
at the time of operation was in its normal situation, was now dis- 
placed far downwards, at least fifteen centimetres, towards the 
pelvis, while the right kidney remained securely anchored where 
Dr. Edebohls had fixed it. The patient had, for some reason not 
30 perfectly clear to him, grown very thin since operation, and ab- 
sorption of the peri-renal fat no doubt explained the excessive and 
rapidly acquired mobility of the left kidney. 
He had been able to relieve many patients with minor degrees 
of movable kidney by ordering a well-fitting and tight corset, the 
pressure of which crowded the displaced organs into place. This 
was not a case, however, that could be relieved in that way, the 
kidney being below the waist line of the corset, the tightening of 
which would therefore crowd the organ further downward rather 
than upward to its normal situation. 
Dr. Bdebohls also presented a patient, a married woman of 
twenty, with 
mobility op both kidneys, endometritis and catarrhal 
SALPINGITIS 
on whom he proposed first to perform a double nephrorrhaphy, 
as he considered most, if not all, of her symptoms due to the 
movable kidneys, and to follow the operation, if necessary, by 
treatment directed to the uterus and tubes. 
He showed the patient mainly for the purpose of demonstrating 
what enlarged experience had taught him was the best method 
of examining for movable kidney. This was to examine with the 
patient standing, the examiner sitting at her right side. After 
the right kidney had been palpated, the examiner, without chang- 
ing his or the patient’s position, reached around her in front and 
behind and felt for the left kidney. Since adopting this method 
of examination he had found more movable left kidneys than 
formerly. 
Both in this patient and in the one presented at the last meet- 
ing, neither kidney could be felt with the patient lying on the 
back. Yet on assuming the erect attitude, the four kidneys fell 
out of their places to various distances ranging from eight to 
twenty centimetres. 
Dr. Edebohls next presented a recent device of his: 
AN AIR CUSHION TO FACILITATE NEPHRORRHAPHY. 
In his paper, already alluded to, on “Movable Kidney,” he 
had advised the performance of nephrorrhaphy with the patient 
in Sims’ position. Further experience with the operation had 
taught him a preferable position, especially so when both kidneys 
were to be operated upon at the same sitting. He had already 
insisted upon the fact that the one thing which made the opera- 
tion easy or difficult was the proper or improper position of the 
cushions placed between the table and the patient’s abdomen 
with a view to crowding the viscera, and on top of them the 
kidney, towards the site of operation in the lumbar region. The 
proper placing of these cushions and their maintenance in posi- tion was not always an easy matter, and frequently the operation 
had to be interrupted to readjust them. 
He had overcome all these difficulties by operating with the 
patient lying flat upon the abdomen and anterior surface of the 
chest upon the table. After the lumbar region had been pre- 
pared for operation by washing, the patient was lifted sufficiently 
to allow the cylindrical air cushion shown to be placed trans- 
versely across the table beneath her abdomen. The air pressure 
crowded the abdominal viscera towards the lumbar regions, carry- 
ing the wandering kidney or kidneys back to their normal situation. 
The air cushion was a perfect cylinder of rubber, twelve inches 
long by eight inches in diameter, and inflated by a foot-ball valve 
and key, the valve being secured in the centre of one head of the 
cylinder. Any manufacturer of rubber goods could make one, or 
J. Reynders & Co., 303 Fourth Ave., N. Y., would supply them. 
The maintenance of anesthesia was easy in the position des- 
cribed, the face being turned to one side and the elevation of the 
abdomen upon the cushion freeing the chest from pressure by 
the table. In performing the operation on the Edebohls table 
the anterior surface of the thighs rested upon the table, while the 
legs and feet were suspended by means of the Edebohls leghold- 
ers. In using a longer table the entire lower extremities lie 
upon the table. The position spould prove a good one also for 
other operations upon the kidney, as well as for sacral proctect- 
omy or hysterectomy, and in his next case of either of the latter 
he proposed to give it a trial. 
The use of this cushion has also enabled Dr. Edebohls to im- 
prove upon the technique of the operation itself. Instead of 
passing the sutures through the kidney in the depths of the 
wound, he now took the kidney to be operated upon out through 
the lumber incision, and thus having free access to the entire 
organ he was able to inspect and palpate it thoroughly and to do 
much more accurate work, splitting and reflecting the capsula 
propria to the exact extent required, and in the exact situation 
desired. He then passed his sutures, to the number of five gen- 
erally, through the kidney, after which the kidney was replaced 
in the body and the ends of the kidney sutures passed on each 
side through the muscles and fascia. Previous to tying them he 
had the cushion taken away, so as to remove the tension upon the 
lips of the lumbar incision and permit of the easy approximation 
of the (Jeep portions of the wound, so that cutting of the buried 
sutures through the kidney substance by reason of too great 
tension was avoided. He was perfectly satisfied both with the 
technique and the results of nephrorrhaphy as he now practiced it. 
198 Second Avenue, New York, N. Y 
32