MOVABLE KIDNEY.

ERNEST L. BELL, PLYMOUTH.

A movable kidney is one which changes position behind the peritoneum. Since Landau of Berlin in 1879 first called attention to this abnormal condition the questions of etiology, diagnosis and treatment have been of the keenest interest to all men engaged in surgical work.

Various degrees of mobility have been noted and classified by different observers, but there seem to be but two of any practical advantage-movable kidneys which develop definite symptoms, requiring treatment, and those which, though movable, produce no symptoms. There seems to be no definite connection between the degree of departure of the kidney from the normal position in the loin and the symptoms developed. A large degree of mobility producing at times no disturbance whatever, while a slight displacement may excite the most violent symptoms.

The kidney is supported in its position by a constant balance between the intra-abdominal pressure and the tension of the abdominal muscles, supplementing various suspensory devices. It therefore follows that any lax condition of the abdominal walls or elongation of the suspensory ligaments must predispose the kidney involved to dislocation. Moreover, the recess or trough in which the kidney lies varies in shape and depth. In the male it is deep and funnel shaped; in the female shallow and more cylindrical. May not this help to explain the fact that eighty-five per cent. of cases of movable kidney occur in

women? Again, the right kidney, with the liver superimposed, is slightly lower than the left, and is in intimate relation in its lower third with the posterior and extraperitoneal portion of the ascending colon. Through this contact with the colon a decided downward pull comes on the right kidney from the forced peristalsis of the loaded bowel during its constant effort to overcome the force of gravity in passing upward its fecal contents.

It is, therefore, more than coincidence that causes displacement of the right kidney to be fifteen times more frequent than that of the left.

We find movable kidneys more often in women of thirty to forty years of age; who have done hard physical work and have had many children. There are certain physical characteristics which play a very important part in predisposing to displacement of the kidney; namely, any physical abnormality which may tend to flatten and make shallow the normal paravertebral fossa. This explains the fact that palpable kidneys are found almost always in longwaisted, slender-bodied women.

Moreover the transient hyperæmia which occurs during menstruation loosens the kidneys' fascial attachments and may be a predisposing cause. Tight lacing cannot be an important contributing factor, as Samoan and Egyptian women who have never known corsets present a large percentage of palpable kidneys.

Harris presents his conclusions as follows:

1. The essential cause of movable kidney lies in a particular body shape.

2. The chief characteristics of the body form are a marked contraction of the lower end of the middle zone of the body with a diminution of the capacity of this portion of the body cavity.

3. The diminution of capacity depresses the kidney so that the constricted outlet of the zone comes above the center of the organ and all acts, such as coughing, strain

ing, lifting, flexions of the body, etc., which tend to adduct the lower ribs, press on the upper pole of the kidney and carry it still further downward.

4. It is the long-continued repetition, in a suitable body form, of these influences, which collectively may be called internal trauma, that gradually produces a movable kidney.

External trauma, violent muscular effort in a constrained position or during labor, are apt to result in a displacement of the kidneys.

Mrs. H., housewife, thirty-five, gives a history of administration by midwife at last confinement, four years before, of considerable ergot to stimulate her pains which were weak and ineffective. Pains became extremely forcible, so strong as to alarm her attendant. During one of the most violent efforts she felt something "tear in her side." Soon after getting up from her confinement she consulted her physician who found a movable kidney. She had a high fixation done by lumbar route but displaced her kidney again during a miscarriage sixteen months after fixation.

The symptoms produced by a movable kidney vary a great deal. Your trainman may tell you that he cannot ride his train unless standing up, a sitting position while the train is in motion producing great pain in his back. His pain may, however, simulate gall bladder trouble, or even an acute appendicitis, indeed he may have the disease as a complication, caused by compression of the mesenteric vessels by the movable kidney. Edebohls states that sixty per cent. of movable kidney cases have more or less trouble with the appendix. I am inclined to believe that his estimate is very conservative.

Your maid of all work may be unable to complete her accustomed duties on account of severe colic, intense pain in her side or an intractable cystitis. In short the pain of a movable kidney, which may be colicky, burning or drag

ging, constant or intermittent, may be referred to almost any of the viscera. Patients suffering from a displaced kidney are usually subject to peculiar attacks-cramp-like seizures-called Dietl's crises. Such an attack is marked by sudden pain, increasing in severity, nausea, perhaps vomiting. There may be chills with small pulse, collapse or a high temperature. The kidney is extremely sensitive, and if examined early in the attack may appear as a rounded tumor larger than normal. The abdominal tenderness and distension may be so excessive as to simulate peritonitis. The urine is always diminished in quantity. Hæmaglobinuria, albuminuria and oxaluria are common. Both hyaline and granular casts are not unusual, the urine at times presenting a perfect picture of acute nephritis. Pus is found at times; this as well as the other urinary abnormalities depending upon the degree and permanence of the interference with the blood supply. The attack passes off as suddenly as it began,-sometimes after a few hours, more often only after days,-its termination usually marked by a copious discharge of urine. This, however, is not what has been often called an hysterical urine, but the discharge of an hydronephrosis caused by a kinking, and consequent obstruction of, the ureter and renal vessels. The gradual increasing curvature and obstruction of the ureter has a marked effect upon the secreting force of the kidney, diminishing the secretion as the obstruction progresses until in extreme cases atrophy or cystic degeneration of the kidney may result. (Hall Journ. Obstet. & Gy. '04.)

It is very probable that many of the so-called hematogenous kidneys those kidneys infected with the colon bacillus, may have been originally movable kidneys. It is an established fact that the colon bacillus does enter the kidney through the renal artery and the conditions present in both intestinal and urinary tract in these cases of displaced kidneys are much more likely to promote rather than inhibit

such an infection. In fact, I believe that the investigations of Dr. Brewer (Boston) tend to prove that this does take place.

Our case histories show ".conclusively that the attacks are by no means all of them hysterical and that we are dealing with an acute disturbance which can be easily mistaken for a beginning appendix or for an acute inflammatory attack of the gall-bladder." (W. M. Conant, Plea for Fixation of Kidney.) Icterus may be a prominent symptom in these cases, caused by direct tension upon the duodenum or obstruction of the gall-ducts by pressure of the displaced kidney. This occasionally results in a cholecystitis which after a time may become chronic and the development of calculi very probable. I had the pleasure of seeing just such a case some time ago come to operation. In this instance the train of symptoms extending over some five years showed a gradual development from what was unquestionably a simple movable kidney, through slight recurrent attacks of jaundice, gradually increasing in frequency and severity until the removal from the gall-bladder of a number of good sized stones terminated the trouble. The position of the kidney at the time of operation, together with the testimony of the well trained observers who had seen the patient early in her trouble, seemed to prove conclusively that the displaced kidney had been. the most potent factor in the production of the gall-bladder mischief.

Tinkham (Journal A. M. A. July '07) reports two cases of unmistakable gall-bladder trouble relieved by fixation of displaced kidneys which were pressing on the bile-ducts.

Most sufferers from displaced kidney are subject to digestive troubles, depression of spirits, neurasthenia, or hysterical attacks. In fact it is difficult at times to decide whether the movable kidney is a cause or a coincidence.

The abnormally located kidney is usually easily recognized by bimanual palpation. In thin subjects it is easily