[Reprinted from The Medical News Apr. 22, 1899.] 
CHRONIC NEPHRITIS AFFECTING A MOVA- 
BLE KID NE Y AS AN INDICATION 
FOR NEPHROPEXY. 
By GEORGE M. EDEBOHLS, M.D., 
OF NEWYORK; 
PROFESSOR OF DISEASES OF WOMEN IN THE NEWYORK POST- 
GRADUATE MEDICAL SCHOOL; GYNECOLOGIST 
TO ST. FRANCIS HOSPITAL. 
The voluminous literature of movable kidney is 
practically silent upon the subject matter indicated 
in the title of this paper. The few and scattered 
words devoted to the matter serve simply to give ex- 
pression to the sentiment that in the presence of 
chronic nephritis nephropexy for movable kidney is 
to be avoided in common with all other operations 
not called for as a vital indication. In quite an ex- 
tensive search of the literature I have been unable to 
find the record of a single case of nephropexy for 
movable kidney performed upon a patient suffering 
at the time of operation from either acute or chronic 
nephritis. 
While recently reviewing the clinical records of 
154 nephropexies performed by myself upon 118 pa- 
tients during the past nine years, with a view to ascer- 
taining the final results, I found that I had anchored 
the kidney or kidneys of six patients, who, at the 
time of operation and for a greater or less period 
preceding were known to have had chronic neph- 
ritis. In view of the paucity, or rather non-existence 
of similar records, I may be pardoned a little pro- 
lixity. I will premise by stating, and wish to 
emphasize the point, that in none of the five first cases was the nephropexy undertaken with any idea 
of favorably influencing the chronic nephritis known 
to exist; the indication for operation was given 
simply by the existence, in an aggravated degree, of 
the usual symptoms due to mobility of the kidney or 
kidneys. The effects of the nephropexy upon the 
chronic renal inflammation, whatever they might 
prove to be, were simply hazarded in view of the 
necessity of relieving the patient of a number of in- 
tolerable symptoms. The fortunate effects in three 
of these five cases influenced me to regard the 
chronic nephritis of the sixth as a new indication, 
additional to other well recognized and admitted 
existing indications, of nephropexy for movable kid- 
ney. I have recently seen two further cases of 
chronic nephritis associated with movable kidney, 
and have advised nephropexy in the hope of favor- 
ably influencing the kidney inflammation; both pa- 
tients are having operation under consideration. 
Case I.—Miss A. 8., eighteen years of age, came 
under my care in November, 1891, suffering from 
chronic metritis and anteflexion, for which curet- 
tage and amputation of the cervix were performed 
in December, 1891. Cysts of both ovaries subse- 
quently developed and grew to a considerable size 
during the first half of 1892. On June 28, 1892, I 
performed bilateral ovariotomy and ventral fixation 
of the uterus. Examination of urine preceding these 
operations showed diffuse chronic nephritis. Soon 
after the removal of the ovarian tumors the right 
kidney became movable, producing serious derange- 
ment of health, the chronic nephritis at the same 
time persisting. Right nephropexy was performed 
on November 29, 1892. At operation the structural 3 
changes in the right kidney due to chronic inflam- 
mation were plainly recognizable. Primary union. 
Two months after nephropexy the albumin and casts 
disappeared permanently from the urine. The left 
kidney subsequently became movable but, causing 
no symptoms, did not and does not to this day call 
for nephropexy. The patient has now been under 
constant observation for a period of more than six 
years, during all of which time she has enjoyed per- 
fect health. The right kidney remains securely 
anchored and the urine free from albumin and 
casts. 
Case ll.—Mrs. G. H., aged thirty-nine years, 
came under my care in March, 1893. The condi- 
tions recorded as found on examination were; Right 
kidney movable 12 cm,; left kidney movable 10 cm.; 
endometritis; salpingo oophoritis sinistra; nephritis 
diffusa chronica; hysteria. Bilateral nephropexy, 
March 10, 1893. My records do not contain any 
note of the appearance and feel of the kidneys at 
operation. The wilful and unmanageable patient 
repeatedly sat up in bed and removed the dressings 
during the first days following operation with result- 
ant infection of both wounds, necessitating healing 
by granulation. The nephritis still persisted on her 
discharge from hospital six weeks after operation. A 
year and a half after operation I learned from Dr. 
Ernest Palmer of Brooklyn that the right kidney was 
again movable, the left remaining firmly anchored. 
No information as to the presence or absence of 
nephritis. 
Case 111.—Mrs. M. M., aged twenty-eight years, 
was seen by me in consultation with her physician, 
Dr. R. G. Wiener, in May, 1893. She had a mov- 
able large right kidney, chronic interstitial nephritis, 
endometritis, and bilateral salpingo-oophoritis. The 
nephritis to Dr. Wiener’s personal knowledge was of 
several years’ standing. The symptoms due to the 4 
mobility of the right kidney were so urgent that both 
Dr. Wiener and his patient, the latter also with a 
full knowledge of her nephritis, desired nephropexy. 
The operation was performed at the home of the pa- 
tient, with the kind assistance of Dr. Wiener, on 
May ii, 1893. The kidney was found extensively 
diseased, its surface being nodular and the capsule 
irregularly thickened and very adherent as a result 
of inflammatory changes. On the posterior aspect 
of the kidney, near its lower pole, squarely in the 
center of that portion of the kidney we depended 
upon for adhesion to the lumbar incision, a cyst 
nearly four centimeters in diameterwas encountered. 
The contents of the cyst, a turbid serum, were evac- 
uated by incision through the kidney substance, the 
wound of the kidney being closed by running cat- 
gut suture. The kidney was then anchored in the 
usual way. 
The wound healed by primary union throughout. 
Dr. Wiener informs me that all the symptoms due to 
the movable kidney disappeared for a period of eight 
to ten months when the kidney again became as 
movable as ever with a return of all her former 
symptoms. The nephritis remains uninfluenced for 
better or for worse. 
Case IV.—Miss L. G., aged twenty-five years, 
was reierred to me by Dr. B. R. Morrow in January, 
1896. She presented movable right and left kid- 
neys causing symptoms, chronic appendicitis, bilat- 
eral oophoritis, and chronic nephritis, although the 
duration of the latter could not be ascertained. 
Bilateral nephropexy, January 11, 1896, on which 
occasion the left kidney was found to be the seat of 
chronic interstitial nephritis, the right kidney being 
healthy. Primary union of both wounds. A pain 
persisting after operation in the region of the left 
kidney disappeared after inversion of the vermiform 
appendix and breaking up of ovarian adhesions on 5 
May 31, 1898. Both albumin and casts permanently 
disappeared from the urine some four months after bi- 
lateral nephropexy. It is now two years since oper- 
ation and the patient remains well and free from 
nephritis. Both kidneys securely anchored. 
Case V.—Mrs. M. F., aged forty-two years, came 
under my care in April, 1897, with movable right 
kidney, chronic metritis, chronic pelviperitonitis, 
chronic appendicitis, and chronic interstitial neph- 
ritis. She had previously had several operations for 
pelvic abscess by various operators. The symptoms 
due to mobility of the right kidney were so dis- 
tressing as to lead me to advise nephropexy in spite 
of the fact that she was known to have had chronic 
nephritis for six years past and had been under treat- 
ment for that condition constantly during all that 
time. On April 1, 1897, at the home of the pa- 
tient, I performed curettage of the uterus, amputa- 
tion of the cervix, and right nephropexy, the kidney 
at operation being found the seat of chronic intersti- 
tial nephritis. Primary union, uneventful conva- 
lescence, and marked and progressive improvement 
of general health followed operation. 
Oft-repeated careful chemical and microscopical 
examinations of the urine were made before and af- 
ter operation by Professor H. T. Brooks, who, one 
year after operation, pronounced the nephritis as 
practically cured. During this year she received 
absolutely no treatment for the nephritis, so the 
gratifying result may fairly be ascribed solely to the 
operation. The patient remains well with well an- 
chored right kidney and with urine free from albu- 
min and casts at the present writing, nearly two 
years after operation. 
Case VI.—Miss S. 0., aged twenty years, came 
under observation in January, 1898, suffering from 
mobility of both kidneys, endometritis, and inter- 
stitial nephritis. The duration of the latter could 6 
not be ascertained. In view of the favorable results 
obtained in the cases already cited bilateral nephro- 
pexy was advised, both to relieve the symptoms due 
to mobility of the kidney, and with the hope of 
favorably influencing the nephritis. Both kidneys 
were anchored and the uterus curetted, January 10, 
1898. 
At operation the right kidney was found perfectly 
healthy. The left kidney on the other hand was 
large, irregular in shape, hard from increase of con- 
nective tissue, and with firmly adherent capsule 
proper; in short it presented the changes character- 
istic of chronic interstitial nephritis. Primary union 
of both wounds, uneventful convalescence, and rapid 
disappearance of every former symptom. Frequent 
examinations of the urine were made by Professor 
H. T. Brooks and by Dr. A. Strong, who kindly as- 
sumed the treatment of patient after operation. Al- 
bumin and casts disappeared permanently from the 
urine one month after operation. One year after 
operation patient perfectly well, both kidneys se- 
curely anchored and urine free from albumin and 
casts. 
The fact that stands out strikingly in the above 
record of clinical experience is the disappearance of 
all symptoms and signs of chronic nephritis in four 
out of six patients after and, in all human probabil- 
ity, as a consequence of nephropexy. For, be it re- 
called, none of the patients subsequently to nephro- 
pexy received any treatment whatsoever directed to 
the nephritis. In one patient with extensive inter- 
stitial and cystic changes in the anchored kidney 
the latter became detached eight to ten months after 
operation and the nephritis persists. The redetach- 
ment of the kidney in this case was probably due to 
the advanced cystic degeneration. One patient 
finally has been lost track of after bilateral nephro- 7 
pexy and nothing is known respecting the continuance 
of her nephritis except that it still persisted six weeks 
after operation. 
An important clinical fact indicated by the four 
successful cases is that chronic nephritis is probably 
unilateral much oftener than is usually suspected. 
In two of the four cases all the symptoms and signs 
of chronic nephritis disappeared after fixation of a 
movable right kidney proved at operation to be the 
seat of chronic interstitial changes. The left kidney 
in these cases must have been healthy, otherwise the 
urine would have continued to furnish albumin and 
casts even after convalescence of the right kidney. 
In each of the other two patients upon whom bi- 
lateral nephropexy was performed the nephritis was 
found unilateral, affecting the right kidney in one 
and the left in the other. In all of these four cases 
the chronic nephritis was unilateral, i.e., it affected 
only one organ, a fact pregnant with hope and com- 
fort to sufferers from chronic nephritis. 
Judging from the evidence afforded by frequent 
examinations of the urine the chronic nephritis in 
each of the four cases disappeared in two months, 
four months, one year, and one month respectively 
after nephropexy. The fact of the disappearance of 
chronic nephritis without further treatment after 
nephropexy amounts to almost proof positive that 
the displacement of the kidney was the original 
cause of the nephritis. My own not inconsiderable 
experience with movable kidney has furnished 
numerous examples of congestion of the kidney, as 
evidenced by traces of albumin and hyalin casts in 
the urine accompanying this condition. This con- 
gestion of the kidney, due to displacement with 
consequent distortion and greater or less obstruction 
of the renal vessels, and especially of the renal vein, 
is as good as uniformly relieved by a successful 
nephropexy. If displacement of the kidney gives 8 
rise to congestion why may not he latter condition 
occasionally progress to inflammation? And if 
nephropexy of a movable kidney will do away with 
renal congestion why may not the beneficial effects 
of the operation, occasionally at least, assert them- 
selves even when the circulatory disturbances have 
already progressed so far and been so long main- 
tained as to result in the changes characteristic of 
chronic nephritis ? 
That a well-anchored kidney is in a better position 
and condition to maintain or regain its organic in- 
tegrity, as the case may be, than a movable kidney, 
is patent from the evidence already adduced. An 
added proof is afforded by the investigations of 
Wolff into the subsequent histories of fourteen cases 
of nephropexy performed by E. Rose, and corrobo- 
rated by my own observations upon a much larger 
number of patients upon whom I have performed 
nephropexy, unilateral or bilateral. In not one of 
Rose’s cases and in none of my own, except the 
cases of chronic nephritis existing at operation de- 
tailed in this paper, could any evidences of renal 
changes as evidenced by the presence of albumin or 
casts in the urine be found at the last examination, 
made from six months to fourteen years after operation. 
The various experiences and observations recorded 
in this paper, will, if corroborated in larger num- 
bers, necessitate a modification of current opinions 
on the etiology of chronic nephritis. Mobility of 
the kidney will probably be found as playing a very 
important part in the causation of chronic nephritis. 
Just as probably the therapy of chronic nephritis, in 
so far as the latter be found to be dependent upon 
and connected with movable kidney, will become 
surgical. My own favorable experience warrants me 
for the present in regarding chronic nephritis affect- 
ing a movable kidney as an important indication for 
nephropexy. 59 West 49th Street,