Physical Signs and Symptoms. In the great majority of cases the patient accidentally discovers the tumour without the attention having been directed to it by painful or other sensations. When, however, it has become known that one of the kidneys is movable, it is not uncommon to find symptoms develop which are referred to the condition of the kidney. When the movement of the kidney is slight there may be no subjective symptoms developed, and it may be only after death that the condition is revealed. If, however. the movement is considerable, a tumour, of characteristic renal form, may be discovered on careful palpation. The sensation communicated to the fingers by the kidney can scarcely be mistaken for that of any other kind of tumour, and it is said by some observers that pulsation of the renal artery may be felt; of the truth of this I have some doubt. The kidney forms an oblong, hard, and resisting mass, the lower extremity rounded, the surface very smooth; it is easily pushed in various directions, downwards, upwards, and laterally, and glides with great facility into the lumbar region. In most cases the abdomen is so flaccid that the organ can be easily grasped with the hand, and when it is manipulated a sickening and peculiar faint sensation, frequently accompanied by pain shooting down the thigh and lower part of the abdomen, is produced. On percussion over the renal region posteriorly, a tympanitic note may be elicited; but a dull note is not got, as might be expected, over the displaced kidney, but rather a muffled tympanitic one. This, of course, is due to the fact that anteriorly the kidney is usually, I might say always, covered by a layer of intestine. When the hand is applied to the postero-lumbar region a depression may be felt when the kidney is displaced, but when it is thrust back to its normal position the natural sense of resistance in the renal region is restored. The note heard on percussion over the renal region in cases of movable kidney shows how unreliable percussion is as a means of diagnosis as to the position of the organ, unless it is considerably enlarged. In Cases 2 and 3 displacement of the kidneys makes very little difference in the percussion note; by this means alone it would be impossible to tell when the kidney was in an abnormal position and when it was in its proper place. The sense of resistance on percussion, and the feeling communicated to the hand when it is applied to the region, give more trustworthy results. The respiratory movements may influence the position of the kidney, deep inspiration may force it down, and forced expiration cause it to ascend; while the posture of the body tends greatly to alter its situation. When the patient sits up it falls towards the pelvis, when she lies on her side it inclines towards the middle line or away from it as the case may be, and if she assumes the supine posture the organ passes back to its proper place. As already indicated, the subjective symptoms may be entirely absent, or so slight as not to attract the attention of the patient or her medical attendant, and they may be chiefly of a local character. In the majority of cases, however, the patient becoms conscious, often accidentally, of the presence of a movable tumour in the abdomen, and complains of a feeling of weight and uneasiness in one or both loins. The pain usually experienced is of a dull character, but may occur in severe paroxysms resembling nephritic colic, and when the kidney is manipulated or pressed upon, a sinking, sickening sensation is experienced. This sinking sensation, or as the patient calls it, a "fainting pain," is very characteristic. It is described by one of my patients (Case 2) as being very much the same in character as that produced when the testicle is pressed or slightly bruised. The pain is relieved by the recumbent posture, rest in bed, opiates, and warm applications, and is increased by long sitting, walking, or any kind of exertion, by constipation, and, in females, during pregnancy and the periods of menstruation. Symptoms of dyspepsia, loss of appetite, sickness, flatulence, colicky pain, vomiting, and diarrhoea, may be present, and the urine may be altered from time to time, both in quantity and composition, and the act of micturition accompanied by more or less pain. In Case 3 the patient suffers from symptoms which not only indicate a diseased condition of the kidneys, but also point to occasional torsion or flexion of the renal vessels of ureter. These symptoms usually appear suddenly when the kidney is displaced, and disappear in from 20 to 56 hours. They consist of suppression of urine, or great diminution in the quantity excreted, severe pain in the renal regions, sickness, nausea, and vomiting, followed by dimness of sight, severe and persistent headache, lethargy with occasional paroxysms of excitement, in other words they are the symptoms of uræmia. These subjective symptoms are associated with a rapid increase in the size of the movable tumour, and the first indication of recovery is a sudden flow of concentrated urine, followed by secretion of a large quantity of urine of low s. g. In Case 2 the urine was on several occasions suddenly suppressed without any evident cause, the tumour was not increased in bulk, nor indeed was it necessarily out of position at the time the symptoms appeared ; the urine was not altered in composition, nor were the subjective symptoms aggravated. Hydronephrosis is often connected with movable kidney, but whether it is to be regarded as a cause or as an effect is somewhat difficult to determine. It may be both. When the kidney is moving freely about, the ureter is liable to be twisted and flexed so that the passage of urine into the bladder is retarded or entirely prevented. When such an accident occurs the urine accumulates behind the constriction, and leads to a gradual distension of the ureter and dilatation of the pelvis of the kidney, just in the same way as when hydronephrosis results from pressure of the pregnant or retroflexed uterus. Or again, it can be easily supposed that, in a case of hydronephrosis, the kidney is more liable to become displaced than when the organ is healthy, partly by reason of its increased weight, and partly as a result of the loosening of its connections and of the peritoneum owing to its enlargement. a mistake in diagnosis is not likely. A collection of fæces in the colon may, at first sight, appear to resemble movable kidney. The conditions most apt to be confused with, and most difficult yet necessary to discriminate from movable kidney, are small pedunculated tumours of the mesentery or omentum. Smoothness of surface, the ease with which the tumour slips into the lumbar region, the peculiar sickening pain on pressure, the shape and size, the detection of the hilus, the absence of the kidney from its normal position, and the fact that the tumour does not increase in size, indicate the existence of a movable kidney rather than a swelling caused by some form of new growth. TREATMENT. In some persons the inconvenience experienced from displacement of the kidney is not considerable, and very little treatment is required; indeed, in many instances, the symptoms produced are so slight that the condition has been discovered by the patient quite accidentally, and independently of them. In others, disagreeable impressions may only be felt while the patient is moving about or engaged in active employments; when in bed she may enjoy immunity from pain and other symptoms. There are cases, however, where the functions of the neighbour severe pain is produced so that life may even be endangered. So far as the physical condition is concerned, the evident indication is to endeavour to replace the organ in its normal position and keep it there. With the patient in the recumbent posture, the kidney should be replaced by manipulation and gentle pressure. This is usually very easily accomplished; the difficulty is to keep it in position without exerting undue pressure on it, or upon the neighbouring parts. Various methods have been proposed-tight bandages or belts round the abdomen, with a pad over the kidney to give the pressure more pointed effect, elastic bandages applied in a similar way, and trusses, have all been employed for the purpose of fixing the kidney by external support. DIAGNOSIS. Movable kidney is one of those conditions which one is very apt to overlook simply because it is rarely met with in practice, and although generally recognised as a possible accident, yet the contingency is not taken into consideration in diagnosing the case. In stout individuals, a class in whom movable kidney is not at all frequent, the conditioning organs are greatly interfered with, and may be difficult to detect by physical examination, but in the great majority of cases the presence of a movable tumour can be easily made out. We have already described the signs, and it is almost entirely upon a proper apprehension of them that the diagnosis rests. The diseased conditions with which movable kidney is most apt to be confounded are enlargement of gall bladder, small ovarian tumours, tumours of mesentery, and tumours of the omentum. An enlarged gall bladder may sometimes be mistaken for a movable kidney. The points in the physical diagnosis which would distinguish an enlarged gall bladder from a movable kidney are: The position which it occupies, the fact of the lower part of the tumour being more freely movable than the upper, of the lower end being more rounded, and less resistant on pressure, and the pres- The method of employing pressure which I ence of an occasional sense of fluctuation; if | have found most useful, and most easily applied in addition to these there be evidences of obstruction to the gall ducts, such as jaundice, absence of bile in the stools, &c., then the probability is in favour of the former condition. Small ovarian tumours, such as fibro-myomata, located either on the surface or in the substance of the ovary, might lead to some difficulty in diagnosis. The size and form of the mobile body, if possible tracing the tumour to its attachment, and the tendency to increase in size or remain stationary, will help to clear up the case. When the ovarian tumour is large, by the patient, is to have a well-fitting abdominal elastic bandage, extending from the line of Poupart's ligament to the level of the sixth or seventh rib. The bandage should be made to fit the body accurately and firmly, but without exerting undue pressure at any point. It may be made of one piece, or, what I consider much better, of strips of elastic bandage sewn together, and united in the middle line in front by means of steel slips similar to those used to fix stays. The patient should have her bowels well opened every morning, and then, before getting up for the day, should slip over the lower extremities, and upwards around the abdomen, a tight-fitting jersey, applying over the region of the kidney a hair pad, and then buckling over it the broad elastic bandage. With this treatment two of my cases (2 and *4) are almost free from pain, and are able to take a considerable amount of exercise. To patients suffering from this affection, all forms of exercise involving active or sudden movements of the body, such as running, dancing, jumping, or travelling over rough roads, must be strictly forbidden, and even long continued standing or much walking should be avoided. The following remarks by Dr. Roberts are of value : "If there be anæmia, or other disorder of the general health, the removal of this by appropriate remedies is of course to be attempted. Restoration of the tone of the abdominal muscles, which, in most cases, are relaxed and flaccid, is probably the most effective means of reducing to a minimum the inconveniences which attend on mobility of the kidney. To this end, ferruginous and other tonics, and shower baths, with avoidance of fatiguing exercise, seem to be the means best adapted. A curious case is recorded by Dr. Hare, in which the mobility of the kidneys was markedly diminished after two pregnancies; the steady pressure of the gravid uterus having apparently acted as a mechanical support to the dislodged organs. "The regulation of the bowels is a point to be carefully attended to. Accumulation of fæcal matter in the large intestines invariably aggravates the inconveniences of movable kidneys. Tight lacing and all violent modes of exercise (equitation, dancing) should of course be strictly forbidden. but temporary. The surgeon is, therefore, sometimes required to consider the question of operative interference. When severe symptoms are not ameliorated by other means, or if the patient has comparative comfort only when strict attention is paid to certain conditions, the irksomeness of which renders life miserable and useless, then the urgent demands of the patient make it necessary that something should be done to cure the disease or palliate suffering. Some authorities regard operative interference as unjustifiable, whether the operation consists of removing the organ by abdominal section, or by an extra-peritoneal incision in the lumbar region, or of the milder course of transfixing and stitching the kidney to the abdominal wall. When the patient is able to move about, or sit up in comparative comfort, with the assistance of an elastic bandage, then an operation should not be thought of. But it is otherwise when little or no relief is derived from milder modes of treatment. When severe pain is experienced, extending to the lower part of the abdomen, and felt also in the course of the crural nerves, in the loins, thighs, and genitals, increased by any exertion, or even by movements in bed, sometimes amounting to paroxysms resembling nephritic colic, and occasionally accompanied by fainting, sickness, and persistent vomiting, then I do not see why the only chance of relief should be denied to the unfortunate sufferer. I. Nephrectomy. Keppler claims that a movable kidney is a continual menace to the life of the patient, and that the danger should be removed by the excision of the organ as soon as detected. Landau, on the other hand, believes that it seldom threatens life, and regards nephrectomy as unjustifiable. Of late years, great advances have been made in regard to operations on the kidney, but still the mortality from nephrectomies is very high. Of the 16 cases of movable kidney, recorded in the table by Dr. Harris, of Philadelphia, ten recovered and the remainder died, and of these latter one suffered from sarcomatous disease, another from encephaloid cancer, and a third from fatty degeneration of the kidney. So that, in only three can the kidneys be described as healthy. That is to say, out of 13 cases where a healthy kidney was excised three died, thus giving a mortality of 23%. In the other diseased conditions calling for the operation, the mortality was almost exactly 50%, and in not a few of them both kidneys were found diseased. The high mortality in such cases can be easily understood. For many "When the symptoms of so-called strangulation of the kidney occur-violent pains, sickness, frequent micturition, enlargement and excessive tenderness of the tumour-complete repose, in the recumbent posture, should be prescribed during the attack; hot poultices, or even leeches, should be applied over the seat of pain, and morphia administered internally." Operative Treatment. There are instances where the patient cannot bear any form of mechanical appliance to her abdomen, pressure seems, in fact, to increase rather than alleviate the symptoms, and even when the bandage is permissible, it cannot be expected to do more than temporarily fix the kidney. The organ is fixed so long as the pressure is applied, and is thereby prevented from coming in contact with, or dragging upon, other parts within the ab-years it has been a recognised fact that anidomen, and in this way the pain and uneasi- mals can live, without their health being imness are, for the time being, relieved. To paired, after one kidney has been excised, so some the relief is but partial, and to all it is long as the remaining organ is healthy. It has also been satisfactorily shown that a man can afford to loose one half of his urine-secreting tissue. When one kidney is excised, as a rule, the urine is immediately diminished in amount by a half; but if the other kidney be healthy, its secreting power is greatly increased, so that, within a few days, a normal quantity of urine is excreted. When the operation is called for in cases of pyelitis, hydronephrosis, or local injury strictly limited to one side, it should be performed; but in cases of malignant disease, and tuberculosis of the kidney, where the probability is that both organs are involved, then the operation of excision is a very questionable procedure. In cases of movable kidney, where the organs are the seat of organic disease, unless the diseased conditions be strictly limited to the movable kidney, the operation seems unjustifiable, on the ground of the very high mortality; and where the case is one of uncomplicated movable kidney, then extirpation should not be thought of till nephroraphy has been tried and failed. It is not right to excise an organ so necessary to life as the kidney, before making an endeavour to save it by a less heroic operation. II. Nephroraphy. When I saw my first case of movable kidney, in 1880, with Dr. Yair, I proposed not to excise the kidney but to stitch it to the abdominal wall. At that time I did not feel justified in urging her to have the operation performed, as I still entertained some hope of relief being derived from external appliances, and, besides, the operation of nephroraphy had then never been performed to my knowledge. Stitching the kidney, by means of sutures, to the abdominal wall, seemed in itself a less dangerous operation than excision, and the future prospects more favourable. Dr. E. Hahn published, in the Centralblatt für Chirurgie for July 23, 1881, his first two cases-"In one case there was a strong suspicion that in one kidney, and possibly not the floating one, there was a calculus, while in the other, both kidneys were movable." His first operation was performed, in April, 1881, upon a woman, æt. 38, unipara, who suffered from severe pain, associated with movable displacement of the right kidney, and with a suspicion of a renal calculus on the right side. In the second case, the patient suffered from similar symptoms, and both kidneys were found to be movable, the right, however, more so than the left. The first case was quite successful, the second partially so. The operation consisted of cutting down upon, but not opening, the capsule of the kidney, by an incision made along the edge of the sacrolumbalis muscle, from the lowermost rib to the crest of the ilium. The adipose capsule was drawn into the wound and stitched to the muscle and fascia by six or eight catgut sutures. In one of his cases the kidney became movable after the operation, so that Dr. Hahn now recommends more secure fixation by opening the capsule and stitching it to the more superficial tissues at a point corresponding to the lowest limit of the area of mobility, so as to avoid straining the adhesions when the patient stands upright. In cases where the kidney is not movable within the adipose capsule, but simply floats about behind the peritoneum, an operation such as Hahn has performed may be sufficient, but when the adipose capsule has become separated, and forms a sac in which the kidney moves freely, something more is required. In my first case I found that on opening the adipose capsule the kidney was easily pushed backwards and forwards within it. I therefore found it not only necessary to stitch the edges of the open capsule to the wound in the abdominal walls, but also, in order to secure the kidney, to pass two sutures through the cortex, and fasten them externally by means of buttons. The details of the operation will be found in the appendix, Case I. The objects in such an operation appear to be (1) to reduce the size of the cavity in which the kidney moves, (2) to fix the kidney and the walls of the sac to the abdominal parietes, and (3) to form adhesions between the kidney and the capsule surrounding it. When the adipose capsule is very loose, and the kidney moves freely within it, a portion of the capsule should be removed before stitching its edges to the wound in the parieties; by doing this the cavity is reduced in size, and the chances of future mobility are thereby lessened. The divided capsule should be stitched firmly either to the deep or to the superficial edges of the wound in the loin by not less than eight chromic catgut sutures, and two strong sutures of the same material should be passed through the abdominal walls, then through the cortex of the kidney, and out again through the muscles, fascia, and skin, on the other side of the incision. The sutures passed into the kidney become destroyed more rapidly than elsewhere; the living renal tissue seems to have an unusual power of absorption. The chromic catgut which I used was kindly given to me by Dr. William Macewen, and he informed me that it would probably last for a month or six weeks in the tissues. This I quite believe would be the case in any other tissue but the kidney; but the sutures in my case separated on the 14th day, and on examination I found that the portions which passed through skin, fascia, muscle, and even granulation tissue, were firm and strong, whereas the parts which had been in contact with the renal tissues were tent. By changing the position of the body, softened, and partly absorbed. It is therefore necessary to use a strong suture, and one that has been kept for a long time in chromic acid, for operations where the the kidney is involved in the stitch. With the object of forming a firm union between the parts it is well to allow any blood which may escape after the adipose capsule has been opened to remain in the latter, and to fill up any space that may be left between it and the kidney. I did this in my case, and have had no reason to regret it. When the case is kept aseptic, the blood clot readily becomes organised into connective tissue, and so forms a bond of union between the adipose capsule, the kidney and the granulation tissue uniting the two edges of the wound. The deep edges of the wound should be kept wide apart by a large drainage tube, so as to allow a considerable mass of granulation tissue to form between these surfaces and the convex surface of the kidney. Up to the present time the operation of nephroraphy has been very successful, no deaths having occurred as a consequence of it, and in some of the cases the suffering of the patient has been completely relieved; in others the symptoms have been modified considerably. The following table includes the cases of the operation which I have been able to collect up to the present time: FLOATING KIDNEY is always a congenital condition, and the existence of a meso-nephron is not uncommonly associated with other malpositions of the peritoneum, or of other abdominal organs. The following by Mr. Durham illustrates this: "Upon opening the abdomen of J. C., æt. 34, it was at once noticed that the left kidney was situated lower down and nearer the middle line than usual; the descending colon was also nearer the middle line, and formed no sigmoid flexure in the left iliac fossa, but passed across the last lumbar vertebra, and entered the pelvis on the right side of the sacrum. Upon slightly pressing the kidney, it slipped at once into its normal situation, and upon further examination it was found to be movable to a most remarkable ex or by gentle manipulation, the kidney was caused to pass, according to circumstances, quite up under cover of the ribs, across to the front and slightly to the right side of the bodies of the vertebræ, or down into the iliac fossa. This mobility appeared to depend principally upon the unusual disposition of the peritoneum, which was associated with the misplacement of the colon. Instead of passing over the anterior surface of the kidney, and then forming the descending mesocolon, the peritoneum from the side of the spinal column only just touched the lower part of the inner border of the kidney, and then, having been reflected over the descending colon, touched the lower part of the outer border of the kidney, as it passed on to line the side of the abdominal cavity; and again, the 'lesser sac of the peritoneum' extended behind the spleen, and as low down as the upper border of the kidney. Thus, the kidney, instead of being fixed in its position by a single layer of peritoneum over its anterior surface, was placed, as it were, in the middle of three diverging layers, none of which could afford much support. 44 Before any of the viscera were injured or removed, the trunk of the subject was exhibited to the Society, and careful diagrams were made of the disposition of the viscera, and of the various positions which the kidney could be made to assume by mere motion of the body. "Upon dissection, it was found that there was little or no fat in the lumbar region, and that the kidney was consequently only surrounded by very loose cellular tissue. To this circumstance, doubtless, must be attributed, in great part, the remarkably prominent appearance of the kidney when the abdomen was laid open. The renal artery was somewhat longer and thinner than usual. The kidney itself was rather small, but of perfectly healthy structure. No other anatomical peculiarities than those already described were met with. No history of the recognition of the mobility of the kidney during life could be obtained." It would, indeed, be difficult to explain how a meso-nephron, properly so-called, could be formed otherwise than congenitally, unless by supposing that the displaced kidney has pushed before it a fold of peritoneum, the surfaces of which have become adherent around it, and united to each other along the line of the renal vessels. That such a condition might arise as a result of localized peritonitis seems possible; there are, however, no cases recorded where there is any evidence of this having taken place. When inflammation has occurred in cases of movable kidney, it has in most instances led to an adhesion of the layers of the |