The Surgical Treatment of 
Movable Kidney, with Re- 
port of Four Nephror- 
rhaphies. 
BT 
A. J. Mc€OSHv M. D. 
REPRINTED FROM 
£l)e Ntto ¥orft Jtletitcal .journal 
for March 15, 1S90. Reprinted from the New York Medical Journal 
for March 15, 1890. 
THE SURGICAL TREATMENT OF 
MOVABLE KIDNEY, 
WITH REPORT OF FOUR NEPHRORRHAPHIES.* 
By A. J. McCOSH, M. D. 
Fifteen years ago a movable kidney was regarded mere- 
ly as a surgical curiosity. The subject was scarcely men- 
tioned in our treatises on surgery. Even to-day it is not 
accorded the thought and observation which it merits.. 
Many physicians and surgeons still regard this abnormity 
as one of very infrequent occurrence. Men of large experi- 
ence acknowledge that they have never recognized a case 
of movable kidney, and they are apt to attribute the occa- 
sional diagnosis of this condition by some of their colleagues 
to a special enthusiasm. That the importance of the sub- 
ject is becoming more recognized is shown by the attention 
which it receives in medical journals and the increased space 
accorded to it in our text-books. This abnormity is cer- 
tainly one that ought not to be called rare, nor ought it to 
be denied that not uncommonly a movable or floating kid- 
ney causes considerable annoyance and in a few cases great 
suffering. I am convinced, however, that it is a condition 
which is frequently overlooked, and that symptoms for 
* Read before the New York Surgical Society, February 12, 1890, 2 
THE SURGICAL TREATMENT OF 
which it is responsible are often attributed to other causes. 
Unless specially sought for, it will rarely thrust it self on the 
examiner’s attention. When patients lie on the back the 
wandering kidney is apt to return to its normal position, 
and generally it is only when they roll over on the opposite 
side or assume the horizontal position that the dislocated 
organ makes itself felt. If the patient is aware of its pres- 
ence, some movement will be made or some position assumed 
which often will bring the misplaced kidney into contact 
with the hand that searches for it. Another reason for 
frequent failure to diagnosticate this condition is, that in 
the female the symptoms produced often resemble those 
caused by disease of the uterus or its appendages. The ex- 
aminer’s finger finds some abnormity in one of these or- 
gans, the mind is satisfied with this, and, instead of looking 
farther, decides that here will be found the cause of all the 
symptoms. Two cases in my own experience illustrate 
this. In one the ovaries and tubes had been removed, in 
another an anteflexion of the uterus had been remedied by 
divulsion and a stem pessary. Neither patient had been 
benefited by these operations. Each possessed a movable 
kidney. A complete cure was accomplished in the one case 
by a bandage, and in the other by a nephrorrhapby. 
In the post-mortem room it is only those who look for 
this condition that will discover it. After death the kidney 
falls back into its normal position, where it remains, unless 
manipulated for a distinct purpose by the pathologist. 
A distinction is generally adopted between movable and 
floating kidney. A “ floating kidney ” is covered by peri- 
tonaeum which forms a mesonephron, and it floats about in- 
side of the abdominal cavity. A “ movable kidney ” is 
situated, as it should be, behind the peritonaeum, and its 
movements take place between this structure and the mus- 
cular parietes behind. The kidney may be mobile inside MOVABLE KIDNEY. 
3 
the adipose capsule, which is distended into a large sac, or 
this capsule may remain adherent to the kidney and move 
with it. 
It will not be amiss to give a few7 figures as to the fre- 
quency of these abnormities. The greatest difference of 
opinion exists on this point. Lindner * states that one 
woman in every five or six possesses a wandering kidney. 
This is of course a very extreme view. Skorczewsky f ex- 
amined 1,422 patients with reference to this condition, and 
out of 1,030 females found a movable kidney in 32, and in 
392 males a similar condition in 3. In 3,652 autopsies 
made by Ebstein in the Charite in Berlin, a movable kid- 
ney was noted in five cases, or 1 in 732. In 5,500 autop- 
sies conducted by Rollet in Oppolzer’s clinic, 22 cases were 
noted. Doubtless the estimate from autopsy reports is too 
low, as no special examinations were made to ascertain if 
this abnormity existed. 
By far the greater number of cases occur in women ; 
thus, in 474 cases collected by C. Schutze, 405, or eighty-five 
per cent., were in females. The right kidney is more often 
affected than the left. Morris gives the proportion as 12 
to 1. Both kidneys are displaced in one out of every twenty 
cases (Landau). 
Floating or mo.vable kidney is a condition not dangerous 
to life, in the majority of cases not of grave importance, and 
which only very rarely demands surgical interference. In 
not a few cases, however, the result has been a life of suf- 
fering or of chronic invalidism. It is as much the province 
of the surgeon to rescue patients from these states as to in- 
terfere for the cure of more dangerous maladies. Although 
denied by some that this condition ever causes suffering suf- 
ficiently severe to warrant operative interference, yet it 
* Lindner, Wanderniere der Frauen, p. 2. 
f Morris, Diseases of the Kidney, p. 27. 4 
THE SURGICAL TREATMENT OF 
seems to me that every unprejudiced observer, especially lie 
who meets with many cases of abdominal troubles, must ac- 
knowledge that he has seen patients in whom the diagnosis 
was unmistakable and in whom palliative treatment had 
failed to effect a cure. Surgeons, however, are not by any 
means agreed as to the propriety of operation for the cure 
of a wandering kidney. At the last meeting of the British 
Medical Association, in the discussion on nephrorrhaphy this 
difference was clearly brought out. During the past year 
both in France and Germany the subject has been frequently 
discussed with the same result. 
Landau * and a few others maintain that a movable kid- 
ney is not a condition which ever demands surgical inter- 
ference. They maintain that nephrorrhaphy is not only 
unjustifiable, but contra-indicated ; that the movements of 
the kidney are compensatory and prevent obstruction of its 
blood-vessels and the ureter. 
At the other extreme is the view of Keppler,f who con- 
siders that a wandering kidney is a condition always at- 
tended by danger, and advises in nearly every case its ex- 
tirpation. 
The moderate and more reasonable view, that surgical 
interference is demanded only in exceptional cases, is the 
one held by the great majority of surgeons. Operation is 
not, however, justifiable until all other curative means—such 
as bandages, etc.—have been tried and failed. They agree 
as to the propriety of surgical interference, but differ as to 
the operation to be preferred. On the one hand, nephror- 
rhaphy is recommended; on the other, nephrectomy.- The 
greater weight of opinion is decidedly in favor of the former 
operation. By such men as Agnew, Guyon, Kiister, Keen, 
Kummel, Laugenbuch, Morris, Richardson, Schede, Terril- 
* Die Wanderniere der Frauen, Berlin, 1881. 
f Arch. f. kl. Chir., 1879, p. 520. MOVABLE KIDNEY. 
5 
Ion, Thornton, Weir, and indeed the majority of surgeons, 
nephrorrhapby is considered a comparatively safe and sat- 
isfactory operation. There are a considerable number of 
others, however, who assert that it is a useless procedure 
and never results in a cure. L. Tait is an example of this 
class. At the British Association he declared that he looked 
back with inexpressible regret on the three cases in which he 
had been persuaded to perform the useless and unjustifiable 
operation of nephrorrhapby “ with the result that not one 
of the patients has been benefited in the least, and one of 
them has died under such circumstances that I think the 
operation might fairly be blamed for it. I shall have noth- 
ing more to do with fixing kidneys.” * Lindner,f also, to 
a certain extent shares this view, and says that he would 
rather assume the risk of doing a nephrectomy than subject 
his patient to an operation which is not free from danger 
and where the result is so doubtful. Other surgeons of note 
advocate this same view. 
The operation of nephrorrhapby may often have failed 
to effect a cure. That such failure has resulted in a con- 
siderable number of cases is not denied. The operation 
has, however, effected a cure in many patients, and has 
ameliorated the sufferings of others. The operation is a 
comparatively safe one. The mortality is not over two per 
cent. Is the patient to be deprived of this chance for cure 
simply because certain surgeons are skeptical as to the 
beneficial results of suturing the kidney to the loin ? Or is 
the misplaced organ to be extirpated by an operation the 
mortality of which is twenty-five per cent. ? It seems to 
me that there should be only one answer to these questions, 
as there is ample proof that in very many cases nephror- 
rhaphy has been followed by most satisfactory results. The 
cases reported where permanent relief from suffering has 
* British Med. Assoc., August, 1889. 
f Loc. cit. 6 
THE SURGICAL TREATMENT OF 
resulted in patients who have been under many years’ ob- 
servation by careful observers are now too numerous to be 
attributed to enthusiasm on the part of surgeon or patient, 
or to any mental effect produced by operation. While the 
condition of some patients who suffer from a dislocated 
kidney is serious enough to warrant an attempt at cure by 
nephrorrhaphy, in how many is it sufficiently grave to war- 
rant the extirpation of that organ ? (In thirty-six nephrec- 
tomies, collected by Lindner,* for movable kidney, nine 
died from the effects of the operation, equal to twenty-five 
per cent.) I should consider that there is no warrant for this 
latter operation until every other means has been tried and 
failed, and then only in the most desperate cases. An at- 
tempt should certainly first be made to fasten the kidney by 
means of suture. Should this attempt fail, it will be a 
question whether nephrorrhaphy should not again be tried. 
Numerous cases have been reported where a second 
nephrorrhaphy has resulted in cure, and, where failure has 
twice occurred, a third trial has been successful in more 
than one patient. 
In the four cases where I have done nephrorrhaphy the 
diagnosis has been unmistakable, and every other means of 
relief for the three patients had been tried and failed. . 
Case I.—Miss E., twenty-eight years of age, a German 
teacher, since girlhood had suffered dragging pain in her right 
loin. When she was sixteen it was so decided that she was 
taken to Professor Bartels, of Kiel, who diagnosticated “ float- 
ing kidney,” and ordered a bandage. This gave little or no re- 
lief, and was soon cast aside. Four or five years later she was 
taken to Paris. On recommendation of various surgeons, four 
or five different bandages were tried. These were soon dis- 
carded as useless. The only one which for a time gave relief 
consisted of a round pad at the end of a spring, like a hernial 
* Loc. cit., p. 45. MOVABLE KIDNEY. 
7 
truss. This, also, was soon abandoned, as the kidney would 
escape beneath it and new distress was caused by its pressure. 
In 1882 I first saw the patient; she then complained of drag- 
ging, often cutting, pains in the right side of her abdomen ex- 
tending down into the pelvis. Sometimes the pain would con- 
tinue for weeks with but little intermission, and then for a time 
would almost entirely disappear. It was increased by bodily 
exertion and was more severe at her menstrual epochs. Oc- 
casionally the suffering was so great that she was obliged to re- 
main in bed for days. The pain at night would often be as 
severe as during the day. Her other symptoms consisted of 
digestive disturbances. She often suffered from nausea and 
vomiting. Attacks of colic were frequent and severe. Flatu- 
lency was always present, and obstinate constipation existed. 
The diagnosis of movable kidney was made. The patient, after 
trying her bandages, etc., passed out of my hands for the next 
two or three years. On her return she reported that she had 
consulted numerous physicians, most of whom made light of 
her diagnosis of floating kidney. Among other methods of 
treatment employed was divulsion of the uterus and insertion 
of a stem pessary, which she wore for several months, to cor- 
rect an anteflexion of the uterus. During this time all her 
symptoms had increased in severity, especially after a fall, 
which she had received a few months before. 
The patient, who is tall and very thin, was markedly anae- 
mic* No foetor ex ore (Lindner) was, or had been, percepti- 
ble. On physical examination, by a little manoeuvering on her 
part a hard, movable tumor was felt in the right side of her 
abdomen. This body could be grasped by the hand through 
the thin abdominal wall. It could be brought over to the 
median line and then down almost to Ponpart’s ligament. It 
was not sensitive to pressure. I examined the patient on many 
occasions, and in perhaps three times out of four could easily 
feel the tumor, while in the fourth instance every endeavor on 
the part of both would fail to dislodge it. The patient was 
anxious for operation, and entered the Presbyterian Hospital 
for nephrorrhaphy. 
On April 8,1888, the patient was etherized and placed on her 8 
THE SURGICAL TREATMENT OF 
left side and belly. A vertical incision at the outer edge of the 
erector spin® muscle was extended down to the circumrenal fat. 
This was found to be rather scanty. Through it the kidney 
could not be felt until pressure was made from in front by an 
assistant. The fatty capsule throughout its whole extent was 
torn through, and the posterior surface of the kidney was ex- 
posed. Its movements up and down on natural respiration 
were to the extent of an inch and a half; when the patient 
breathed more deeply their extent was two inches and a half. 
The slightest push when the assistant’s hand was removed from 
the abdomen thrust the kidney out of sight. It was so unsteady 
that considerable difficulty was experienced in passing the sut- 
ures. A tenaculum thrust through its capsule quickly tore out. 
When somewhat steadied by the assistant's hand, I succeeded 
in passing the sutures. They consisted of four strong catgut 
threads passed through the capsule and a superficial portion of 
the cortical substance for a distance of about three quarters of 
an inch. They were then passed through the fasci® and mus- 
cles of each side of the wound, hut not tied until its deeper 
layers had been united by sutures of catgut. The sutures which 
had penetrated the kidney were then tied, bringing the organ 
firmly against the sutured fasciae and muscles. The skin and 
cellular tissue were united, except in the lower fourth of the 
wound, which had been left entirely open, and at the bottom of 
which the lower end of the kidney could be seen. This was 
packed with iodoform gauze. 
The operation was followed by no unfavorable symptoms. 
The urine was unchanged. The upper part of the wound, 
which had been sutured, united by primary union. The lower 
fourth filled up rapidly with granulations. The patient was 
kept on her back for two weeks, and at the end of the third 
week sat up. At this time nothing remained of the wound but 
a short sinus. At the end of the fourth week she was allowed 
to move about, but was cautioned against violent efforts for 
some time. 
As soon as she left the hospital the patient felt that she was 
better. She experienced none of her old pains and suffered less 
from indigestion. The flatulency persisted for several months. MOVABLE KIDNEY. 
9 
At the end of a year neither she nor I could feel the kidney, and 
no movement or effort on her part could dislodge it. She had 
gained twelve pounds in weight, and considered herself cured. 
I have seen her within the last week (twenty-two months since 
operation); she affirms that she has no pain, suffers but little 
from indigestion, and that her constipation troubles her but 
little. She is enthusiastic over the result of the operation. 
Case II.—Mrs. S., thirty four years of age, mother of two 
children, was kindly referred to me for operation by Dr. J. 
Lombard. Bandages and medical treatment had been tried in 
vain. Symptoms much the same as in last case, except that 
vomiting was more frequent and persistent. Belly rather fat 
but not pendulous. No foetor ex ore. Bladder acted natu 
rally. Urine normal. Patient was a working woman and de- 
sired operation, as, by reason of suffering, she was incapacitated 
from earning her living. The right kidney could be distinctly 
felt, was very movable, and not sensitive to pressure. In June, 
1888, nephrorrhaphy was performed according to the same 
method as in Case I. An ample fatty capsule was found, and 
the kidney seemed to move inside this capsule, which apparently 
did not follow the kidney in its movements. Three sutures of 
catgut were used. After operation the patient had no untoward 
symptoms. At the end of a month the wound was healed and 
she was allowed to go out. I saw her again at the end of three 
months. Her pain had disappeared, and during the preceding 
two months she had never vomited, or even experienced nausea. 
The kidney could be indistinctly felt apparently in its normal 
position and firmly fixed. I have not seen the patient since, 
but at the end of six months from the date of operation she 
wrote saying she was a well woman. 
Case III.—Mrs. H., aged twenty-six, mother of three chil- 
dren, was kindly sent to me by Dr. T. G. Thomas. As a girl 
she occasionally suffered from attacks of severe pain in the right 
side of the belly. After marriage, attacks became more frequent 
and severe. During her first pregnancy her sufferings were much 
increased, and since the birth of her child had been gradually 
increasing in severity. The paroxysms were more violent, oc- 
curred more frequently, and continued longer. For two or three 10 
THE SURGICAL TREATMENT OF 
months she might be comparatively comfortable, and then for 
an equal period her sufferings would be intense. Violent ex- 
ertion would at once bring on an attack, and then for weeks she 
would be obliged to remain in bed, often for days under the in- 
fluence of morphine. The pain she describes as gnawing in 
character and at times resembling severe u cramp colic.” Dur- 
ing this time she had been troubled with indigestion manifest- 
ing itself in flatulency and colic, occasionally nausea and vomit- 
ing. Since her first labor the patient had noticed a movable 
lump under the false ribs on the right side. She felt ihis before 
attention was called to it by her physician. She is positive that 
during her attacks of pain this mass increased in size and was 
exceedingly sensitive to pressure, which produced a sickish 
feeling. After the paroxysm passed off her right side would 
for days be tender. Often at night the pain was as severe as 
during the day. She had consulted numerous physicians, some 
of whom made the diagnosis of floating kidney, others of tumor 
of the bowel. Various kinds of treatment, including bandages, 
had been tried without benefit. During the last two years she 
had lost twenty pounds in weight. For six months she had 
been practically an invalid, scarcely venturing to leave the 
house, as any unusual movement resulted in an access of her 
pain. She had become much discouraged, was tired of life, and 
feared that she might succumb to the opium habit. With the 
hope that some operation might cure her, she came to New 
York from her home in Virginia. An examination was first 
made with the patient standing. The abdominal walls were 
found to be exceedingly lax. A solid, freely movable tumor 
was at once felt on the right side of her abdomen just below 
the ribs. This body could be grasped through the rather thin 
abdominal walls, carried to the left till it rested on the bodies 
of the vertebrae behind the umbilicus, and then back to its 
original position. When the patient lay quietly on her back it 
disappeared, and could be felt with difficulty. As she rolled 
over on her left side it became dislodged, and could be carried 
well to the left of the spinal column. Without difficulty an 
artery could be traced leading from the aorta to this movable 
body, where it terminated in a depression which, without doubt, MOVABLE KIDNEY. 
11 
was the hilum of the kidney. These manipulations caused but 
little discomfort to the patient. The urine was normal. There 
had never been frequency of micturition. On examination a 
few days later, when complaining of considerable pain, the kid- 
ney was found sensitive to pressure, which produced a feeling 
of nausea. 
On November 19,1889, the patient was etherized and placed 
on the belly with the lower extremities hanging over the 
edge of the table. A vertical incision was carried down till 
the perinephric fat was exposed. This appeared normal in 
quantity. Before the lumbar fascia had been opened the fat 
was seen moving up and down an inch or more with the respir- 
atory movements. The finger pushed against this adipose cap- 
sule felt no kidney and met with no resistance till it felt the 
hand of an assistant pressing upon the front of the abdomen. 
At the upper and external part of the wound under the twelfth 
rib, on deep palpation, a solid body was felt which slipped out 
of reach as soon as the finger came into contact with it. The 
house surgeon, Dr. Sharpe, by manipulations through the ab- 
dominal wall, brought this body against the fat at the bottom of 
the wound. The adipose capsule was then torn throughout its 
whole extent, and the kidney, held in place by the assistant’s 
hand, came into view. It appeared to be of normal size, color, 
and consistency. When pressure was relaxed it moved freely 
up and down with the respiratory movements, the tunica adi- 
posa sharing to a great extent in its movements. When the as- 
sistant removed his hand the kidney slipped out of sight and 
reach. It was easily forced back into the wound, and its pedi- 
cle was so long and flexible that it could easily have been pushed 
entirely outside the wound. It was united to the lumbar mus- 
cles by seveu catgut sutures passing directly under the capsule 
for a distance of about half an inch, and necessarily through a 
superficial portion of the cortical substance. Three of these in- 
serted on the border at the inner side of the wound and three 
on the opposite border were united to the edges of the divided 
muscles and fasciae. One catgut suture, passing under the cap- 
sule for about an inch and through the muscles on each side 
of the wound, was not tied until the different layers, with the 12 
THE SURGICAL TREATMENT OF 
exception of the skin, had been united. This closure was ef- 
fected only in the upper fourth of the wound, the greater part 
being left open and packed with gauze down to the kidney, 
which lay at the bottom. No bad symptoms followed. The 
wound rapidly filled with granulations. The patieDt was kept 
on her back for seventeen days and then allowed to turn on the 
side. At that time the kidney could be indistinctly felt on deep 
palpation, and appeared to be anchored somewhat external to 
its proper position. 
On the twenty-first day the patient remarked that she could 
feel the kidney below her ribs, and that it was movable. She 
was not mistaken, for the obstreperous organ, or the lower end of 
it, was distinctly felt just below the last rib. It was movable 
to a limited extent only, much less than it had been before 
operation. Fearing that in the future the result would be un- 
satisfactory, if it was not already so, 1 advised a second oper- 
ation, to which she consented. 
Case IV.—On December 10, 1889, the patient (same as Case 
III) was etherized and the old wound reopened. Considerable 
cicatricial tissue was present where in the former operation the 
fatty capsule had been found. On tearing through this, no kidney 
was seen or felt. While before this organ was easily forced 
into the bottom of the wound, this was now a difficult matter. 
Adhesions evidently bound it at the external edge of the wound, 
for its tendency was to slip outward and forward, and consid- 
erable force was needed to hold it in such a position that it 
could be fastened to each edge of the incision. It was very evi- 
dent that it had formed some new adhesions of considerable 
firmness. Three silk sutures were passed through the substance 
of the kidney for, perhaps, three quarters of an inch at a depth 
of about half an inch. They were then brought out through 
the fascite and muscles on each side of the incision, and, after 
these latter had been united, were tied over them. The skin 
was then sutured, a drainage-tube at the lower end of the 
wound passing down to the kidney. The patient made a good 
recovery. She was kept on her back for two weeks, and at the 
end of the third week was allowed to sit up. She was sent 
home wearing a bandage, with a pad pressing against the region MOVABLE KIDNEY. 
13 
of the kidney. The result was apparently satisfactory. The 
kidney could be felt somewhat external to its normal position, 
but it was firmly fixed, and could not be moved either by the 
patient or myself. Within the last few days I have heard from 
the patient (two months after operation), and she is entirely free 
from pain. 
The results attained in these four cases are certainly en- 
couraging. One patient, at the end of two years, is com- 
pletely cured. In another, at the end of six months, the 
result was in every way satisfactory. In the third patient 
the first operation was apparently a failure ; what the final 
result of the second operation will be can not yet be de- 
cided, but, at the end of two months, the outlook is favor- 
able. 
Before discussing the technique of the operation, a 
word as to the best form of bandage. In the majority of 
patients the one that gives the greatest comfort consists of 
a well-fitting abdominal bandage made, in part at least, of 
some elastic material. At the point where the kidney es- 
capes under the ribs is fastened a pad, in size, shape, and 
consistency made to suit each individual case. 
More elaborate forms of apparatus arc used, but, in the 
end, are generally discarded to be replaced by this simpler 
bandage just mentioned. As a rule, it is not necessary to 
wear any support at night. 
Since the operation of nephrorrhaphy * was first intro- 
duced by Hahn in 1880, a number of different methods 
have been employed for fixation of the kidney. Practically, 
all procedures are alike in one point—that they fasten the 
kidney to the lumbar muscles by means of sutures. They 
are unlike in the material of which the suture is composed 
and the tissues through which it passes. Experience alone 
* Nephropexie (Le Dentu). 14 
THE SURGICAL TREATMENT OF 
will determine which method is followed by the best re- 
sults. The incision down to the adipose capsule is made 
as in other operations on the kidney. It may be cither 
vertical or oblique, between the last rib and the crest of the 
ilium, external to the erector spina; and quadratus lumborum 
muscles. The later steps of the operation differ to some 
extent according to the operator. These different plans may 
be divided into the following four classes: 
1. The adipose capsule, opened or unopened, is united 
by sutures to the edges of the incision. 
2. After freely opening the adipose capsule, the sutures 
are passed through the fibrous or true capsule of the kidney. 
3. After free exposure of the kidney, the sutures are 
passed directly through its parenchyma. 
4. A certain portion of the capsule proper is stripped 
off the kidney, and the sutures passing through its paren- 
chyma bring the raw surface thus made directly in contact 
with the cut tissues in the loin. The sutures enter and 
emerge through the capsule just outside of the raw margin, 
and are then passed through the tissues on each side of the 
incision, which is closely united. 
The first method is the one originally employed by 
Ilahn.* Experience has shown that it has been less effi- 
cient than some of the more recent methods. This was the 
initiatory and somewhat experimental stage of nephror- 
rhaphy. As the operation has developed, the advance has 
always been in one direction—viz., that the sutures be 
passed in such a manner that they will take a deeper and 
firmer hold of the kidney. 
The second method was next adopted. At one time or 
another it has been employed by almost every surgeon who 
has done many nephrorrhaphies, and while many of its re- 
* Ctrlbl. f. Chir., 1881, p. 449. MOVABLE KIDNEY. 
15 
suits have been admirable, still a number of failures have re- 
sulted. Until recently it was the method generally em- 
ployed, but it is now being somewhat superseded by pro- 
cedures which promise better results. An ample experience 
has established the fact that the kidney is in no way injured 
by the passage through its capsule of sutures. The occa- 
sional failures have apparently been due to tearing out of 
the sutures. Although generally passing through a super- 
ficial portion of the cortical substance as well as through the 
somewhat fragile tissue of the capsule, sufficient resistance 
is not offered by these structures to withstand the efforts of 
the kidney to free itself. The sutures will not accomplish 
their object unless they retain the kidney in place until it 
is firmly secured by adhesions. Even during the operation 
these stitches have torn out. Yet they ought to retain their 
hold for two weeks or longer, and this seems almost too 
much to demand from a tissue not tougher than the capsule 
of the kidney. When relapses occur, as they frequently do, 
a short time after operation, it seems reasonable to conclude 
that the sutures have cut their way out. 
The third method, probably the one most generally 
adopted at the present day, was introduced for the purpose 
of avoiding this accident. The sutures are passed through 
a considerable portion of the substance of the kidney, and 
at such a depth that they completely control its movements. 
Inserted in this way, they do not appear to tear out unless 
tied too tightly. It has been thought that perhaps the pres- 
ence of numerous threads in the midst of the secreting sub- 
stance of the kidney might result in permanent damage to 
its structure. From their experiments on animals, Tuffier * 
and Yanneufville f have concluded that this need not be 
feared. 
* Etudes exp6rimentales sur la chirurgie du rein, Paris, 1889. 
f De la ndphrorrhaphie, Thesis, Paris, 1888. THE SURGICAL TREATMENT OF 
16 
Experience also has shown that these sutures have no 
injurious effect. In a few cases after operation albumin has 
appeared in the urine, but has never persisted. Thus far 
the results have been most encouraging. In twenty-nine 
cases operated on according to this method, twenty 
cures, five improvements, and four failures resulted. (In 
twenty-two cases where the capsule alone was sutured the 
result in nine was cure, in seven improvement, and in six 
failure.) * 
The fourth method is a comparatively recent one. Suf- 
ficient cases have not been reported, nor has long enough 
time elapsed, to allow of any decision as to the superiority 
of this procedure. Jordan Lloyd f operated according to 
this method in 1886. TuffierJ and Guyonw advocate it. 
The former found that, in animals where the kidney de- 
prived of its capsule was brought into contact with the cut 
muscles in the loin, the union resulting was far firmer than 
when the unbroken capsule was brought into apposition with 
the same structures. Several operations, followed apparent- 
ly by good results, have been done according to this plan by 
Guyon, Tuffier, and others. 
Although all operations may be classified according to 
one or other of these methods, there are many points of dif- 
ference as far as the details are concerned. 
First, as regards the treatment of the wound. This may 
be left entirely open to fill up with granulation tissue or may 
be closely united by one or more rows of suture. It is 
thought by many that the adhesions between the kidney 
and the loin will be firmer if the wound be allowed to unite 
by secondary intention. From a close examination of the 
* See tabulated cases. 
+ The Practitioner, September, 1887. 
J Revue de chir., p. 932 ; Arch. gen. de m6d., 1889, p. 562. 
# Bull, de l’acad. de m6d., Paris, Feb. 26, 1889. MOVABLE KIDNEY. 
17 
histories of cases reported, it appears to me that equally good 
results are obtained when the wound is closed by sutures as 
when the open plan is adopted. 
Second, as regards the sutures. Various materials have 
been used—catgut, silk, kangaroo tendon, silkworm gut, and 
silver wire. This is a very important point in the operation, 
and more experience is needed to determine which ma- 
terial is the best. While at first sutures were mainly of cat- 
gut, this is being more and more replaced by a thread that 
will prove more durable. For the past year or so operators 
of the largest experience have generally employed either silk 
or some strong animal ligature, such as kangaroo tendon. 
With this latter substance Morris, Gould, Gardner, etc., have 
obtained excellent results. If it can be shown that it is a 
harmless procedure to leave several threads of an unabsorb- 
able material within the kidney, then the choice of suture 
will be in direct proportion to its durability. Tuffier and 
others have proved that in animals at least this may be done 
with impunity. Personally, I should prefer silk to kanga- 
roo tendon. It is more reliable and more easily rendered 
aseptic. It may be that silkworm gut will be an admirable 
material. It has been successfully employed by Guermon- 
prez. 
Third, as regards the structures to which the kidney sut- 
ures are fastened. They may be attached to the edges of 
the divided fascia} and muscles which may or may not be 
united. They may be brought out through the entire thick- 
ness of each lip of the wound and be tied externally after 
the various layers of the incision have been united. In either 
case they can be taken out after the kidney is considered 
firmly fastened. It is generally believed to be better, how- 
ever, not to remove them. 
A number of operators, principally of the Italian school 
(Cecherelli, Bassini, De Paoli), also Duret, consider it wiser 18 
THE SURGICAL TREATMENT OF 
to fasten the upper end of the kidney at a higher point than 
can be obtained by suture to the ordinary incision. To accom- 
plish this, they have resected, in whole or in part, the twelfth 
rib, and sometimes the eleventh as well. To the periosteum 
of these ribs the sutures are united. Unless in exceptional 
cases, this appears to be a rather unnecessary procedure. It 
must certainly add somewhat to the dangers of the oper- 
ation. This manoeuvre was to some extent responsible for 
one of the deaths reported (Case XVII). The sutures have 
in a few cases been attached to the periosteum without re- 
moval of any portion of the bone. 
By most operators the adipose capsule is sutured to the 
edges of the wound. Bryant,* Dunning,f and others lay 
stress on the importance of this step. If the fatty capsule 
be adherent to the kidney, a firm anchorage may by this 
means be secured ; but if the kidney, as often happens, 
moves inside this capsule, then certainly the adhesion of this 
latter structure can not be of much service. 
In an endeavor to collect all the cases of nephrorrhaphy 
which have been reported, I have succeeded in finding a 
record of one hundred and seventeen such operations. A 
detailed account, however, is given of only eighty-seven 
patients. The excellent pamphlet by Lindner and the re- 
cent able article by Frank have been of much service to 
me in this work. Many of the reports have been made at 
the expiration of a few weeks from the time of operation, 
and, as a patient ought not to be considered as permanently 
cured until a year at least has elapsed, it is impossible to 
draw any definite conclusions as to the relative proportion 
of successes and failures. 
Out of fifty-six nephrorrhaphies collected by Frank,\ 
* Med. Record, Jan. 12, 1889. 
+ Western Med. Reporter, October, 1888. 
| Loc. tit. MOVABLE KIDNEY. 
19 
twenty-one patients had been under observation for a year 
or more. The result in eleven of these was permanent cure, 
in four decided improvement, and in six failure. Out of 
eleven cases where the sutures passed through the paren- 
chyma of the kidney, nine were cured. Morris* claims 
seven successes out of ten cases. In the one hundred and 
seventeen cases recorded below, three deaths have occurred. 
One of these, however, can not be attributed to the oper- 
ation, as an ileus, supposed to be due to a floating kidney, 
existed before operation, and was unrelieved. The fatal 
result in another patient (Case XVII) can only in part be 
attributed to the nephrorrhaphy; a pleurisy followed, due 
to attachment of sutures to the twelfth rib, but it was com- 
plicated by a fatty heart and atheromatous arteries. In 
the third case septicaemia resulted from passage of a suture 
through an old embolic infarction in the kidney. 
Of the eightv-seven detailed cases, thirty-two patients 
had been under observation for one year or longer. In fif- 
teen of these radical cure resulted, in four decided improve- 
ment, and in thirteen failure. As has been stated, it is not 
just to compare these figures with the total number of 
cases, for in a large proportion the permanent result is un- 
known. 
Relapses generally occur within the first few weeks after 
operation, and therefore it is reasonable to suppose that the 
majority of patients who are well at the end, say, of three 
months will be permanently cured. A comparison of the 
results at this period ought to be of some value. There are 
sixty-two patients whose condition at the expiration of three 
months is stated. In thirty-two a cure had been effected, 
in fourteen decided improvement had resulted, and in thir- 
teen no benefit had been derived from the operation. In 
* Brit. Med. Assoc., August, 1889.  SURGICAL TREATMENT OF MOVABLE KIDNEY. 
20 
twenty-nine of these cases the sutures had been passed 
through the parenchyma of the kidney, with the result that 
twenty were cured, five improved, and four unimproved. 
In twenty-two of the same cases the capsule alone was sut- 
ured, and the result was nine cured, seven improved, and 
six unimproved. No. 
Operator. 
Reference. 
Sex 
ai.dage 
1 
Side. 
Sutures passed through. 
Result. 
Remarks. 
1 
Kiister. 
Yerhandl. deut. Chir. Cong., 1882. 
Adipose capsule 
R. 
At end several months marked 
Kiister. 
(opened). 
improvement; kidney fixed. 
2 
Lindner. Wanderniere der Frauen. 
F., 27. 
R. 
Parenchyma (1 silk); 
R. 
At end several years permanent 
Kiister. 
Ibid. 
capsule (7 catgut). 
cure. 
3 
F., 35. 
R. & 
Parenchyma (silk and 
R. 
Symptoms persisted, although 
Kiister. 
Ibid. 
L. 
catgut); both kidneys. 
kidneys firmly fixed. 
4 
F., 52. 
R. 
Parenchyma (4 silk and 
R. 
Cure at end of several years. 
2 catgut). 
5 
Kiister. 
Ibid. 
F., 34. 
R. 
Parenchv. (silk & catgut). 
R. 
Failure; relapse in six months. 
6 
Kiister. 
Ibid. 
F., 26. 
R. 
Parenchyma. 
R. 
Failure. 
7 
Esmarch. 
Yerhandl. deut. Chir. Cong., 1882. 
F. 
R. 
R. 
At end of few months, decided 
improvement. 
8 
Delhaes. 
F. 
R. 
Parenchyma. 
R. 
Decided improvement. 
9 
Bassini. 
Ann. univ. di med. e chir., Milano, 
F., 27. 
R. 
Parenchyma and fast- 
R. 
Cure at end of few months. 
1882; Lindner, lor. cit. , 
ened to 12th rib. 
10 
Newman. 
Glasgow Med. Jour., 1883, p. 831. 
F., 40. 
R. 
Parenchym-. 
R. 
Cure at end of three months. 
11 
Weir. 
N. Y. Med. Jour., Feb., 1883. 
F., 33. 
R. 
Capsule (2 catgut). 
R. 
12 
Weir. 
Personal communication. 
“ Tuffier’s method.” 
Parenchyma. 
R. 
R. 
13 
Swennson. 
Frank, in D. med. Wochensch., 
F., 21. 
.... 
R. 
Complete cure at end of two 
14 
Agnew. 
1889, p. 173. 
years. 
Med. News, Jan. 29, 1887. 
M., 32. 
R. 
Capsule (animal suture). 
R. 
Failure; in 6 mo. nephrectomv. 
15 
J. Greig Smith. 
Lancet, 1884, ii, 10. 
F., 39. 
R. 
Kidney scarified ; no sut. 
R. 
Cure; short observation. 
16 
Gardner. 
Austral. Med. Jour., 1885. 
F., 45. 
.... 
Parenchyma (2 kangaroo 
R. 
Cure at end of 3 months. 
17 
Cecherelli. 
tendon). 
Hivista clin., Bologna, 1883, p. 
F., 28. 
Capsule to 12th rib. 
D. 
In 45 hrs.; pleural cavity filled 
290; Lindner, loc. cit. 
with fluid; atherom. arter- 
ies ; fatty heart. 
18 
I)e Paoli. 
Gaz. clin. Torino, 1885 ; Lindner, 
F., 30. 
R. 
Capsule (12th rib resect- 
R. 
Result satisfactory at end of 
loc. cit. 
ed) and to periost., 11th 
7 weeks. 
and 12th ribs. 
19 
Ghinozzi. 
Raccoglitore med., 1886: Lindner. 
M.. 20. 
L. 
Adipose capsule fastened 
R. 
loc. cit. 
to 12th rib. 
weeks. 
20 
Lauenstein. 
D. Chir. Cong., 1882. 
.... 
R. 
At end of several months no 
improvement; kidney firm. 
21 
Lauenstein. 
D. med. Wochensch., 1887, p. 26. 
F., 42. 
R. 
Parenchyma (5 catgut). 
R. 
Complete cure at end of 9 
months; kidney firm. 
22 
Kiimmel. 
Arztl. Yerein zu Hamburg, 1887 ; 
Capsule. 
R. 
Improvement at end of 6 mos.; 
23 
Kiimmel. 
Lindner, loc. cit. 
Ibid. 
Parenchyma. 
R. 
kidney still movable. 
Improvement slight at end of 
24 
Kiimmel. 
18 months; kidnev firm. 
Ibid. 
F., 60. 
R. 
Parenchy. tore out; cap- 
R. 
Failure; nephrectomy at end 
sule strip’d off & sutur’d. 
of few months. 
25 
Kiimmel. 
Ibid. 
Parenchyma. 
R. 
R. 
Complete cure at end 18 mos. 
Cure at end of few months. 
Improvement; not cure. 
Result good at end of few wks. 
At end of 3 months result sat- 
26 
Sehede. 
Ibid. 
F. 
27 
Schede. 
Ibid. 
F. 
R. 
28 
Sehede. 
Ibid. 
F. 
R. 
29 
Hahn (Schiiler).* 
Centralbl. f. Chir., 1881, No. 29 ; 
F., 38. 
R. 
Adipose capsule. 
R. 
Lindner, loc. cit. 
isfaetory. 
30 
Hahn (Woyack).f 
Ibid., Frank, loc. cit. 
F., 28. 
R. 
Adipose capsule. 
R. 
31 
Hahn (Woyack). 
Frank, loc. cit. 
Same 
L. 
Capsule. 
R. 
pat. as 
No. 30. 
82 
Hahn (Woyack). 
Ibid. 
2d op. 
R. 
Capsule. 
R. 
Improvement; hernia of kid- 
on No. 
30. 
F. 
ney followed. 
33 
Schiiler. 
Ibid. 
Capsule. 
R. 
Compl. cure at end several vrs. 
34 
35 
Ehlert. 
Bolke. 
Ibid. 
Ibid. 
F., 35. 
F„ 32. 
• • • 
Capsule. 
Capsule. 
R. 
R. 
Complete cure at end of 7 yrs. 
Cure complete at end of 9 mos. 
36 
Graefe. 
Ibid. 
L. 
Capsule. 
R. 
Cure complete at end of 4-j- 
years; kidney fixed. 
37 
Dunning. 
WTest. Med. Reporter, 1888, Oct. 
F., 44. 
R. 
Adipose capsule. 
R. 
Cure at end of 2 years; kidney 
slightly movable. 
38 
Dunning. 
Ibid. 
F., 54. 
R. 
Adipose capsule. 
R. 
Failure; nephrectomy at end 
39 
Dunning. 
Ibid. 
of 1 year. 
F. 
R. 
Adipose capsule. 
R. 
Cure at end of 2 years ; kidney 
firmlv fastened. 
40 
Kazmierowski. 
Frank, loc. cit. 
F., 32. 
R. 
Capsule. 
R. 
Failure; relapse at end of 6 
months. 
41 
Kazmierowski. 
Ibid. 
F. 
R. 
42 
Ludwig. 
Ibid. 
F., 51. 
R. 
Capsule. 
R. 
Failure; no improvement. 
43 
W abnitz. 
Ibid. 
F., 46. 
R. 
Capsule. 
R. 
Complete cure at end 20 mos. 
44 
Kloski. 
Ibid. 
F., 23. 
R. 
Capsule. 
R. 
Improvement at end of 15 mos. 
45 
Griinberg. 
Ibid. 
F., 28. 
R. 
Capsule. 
R. 
Great improvement; kidney 
> 
fixed at end of 13 months. 
46 
Ilenckel. 
Ibid. 
F., 36. 
R. 
Parenchyma. 
R. 
Cure at end of 2 months. 
47 
In clinic of Maylander. 
Ibid. 
F., 35. 
R. 
Capsule. 
R. 
Complete cure at end 3 years. 
48 
In Oberlinhaus, 
Ibid. 
F., 30. 
R. 
Capsule. 
D. 
At end 48 h., cause unknown ; 
Nowawess. 
op. done for symptoms of il- 
eus, which were unrelieved 
49 
Berger. 
Ibid. 
F., 40. 
R. 
Capsule. 
R. 
Improvement; kidney fixed. 
50 -1 
W egner. 
Ibid. 
F., 29. 
R. 
Parenchyma. 
R. 
Failure; kidr.ev fixed. 
51 
Krause. 
Frank, loc. cit. 
F., 31. 
R. 
R. 
Improvem’t slight; intermittent 
hydronephrosis persisted. 
• 
* Attributed by Frank to Schiiler. 
f Cases 30, 31, and 32 are attributed by Frank to Wroyack. 
CASES OF NEPHRORRHAPHY. No. 
Operator. 
Reference. 
Sex 
and age. 
Side 
Sutures passed through. 
Result. 
Remarks. 
52 
Morris. 
Ann. of Surg., 1887, p. 289. 
F., 41. 
R. 
Cortical substance (1 
R. 
Cure, and kidney firm at end 
F., 56. 
heavy catgut). 
of 8 months. 
53 
Morris. 
Ibid. 
Parenchyma (2 silk sut- 
R. 
Result fairly good at end of 6 
ures removed 12th day ; 
months. 
capsule (2 catgut). 
54 
Braun. 
Lindner, loc. rit. 
F., 27. 
R. 
Cortical substance (1 silk); 
R. 
Complete cure at end of 1 year. 
adipose capsule (7). 
55 
Braun. 
Ibid. 
F., 35. 
R. 
Result good at end of 5 weeks. 
Symptoms persisted; kidney 
56 
Schwerdtfeger. 
Inaug. Dissert., Greifswald, 1886; 
F. 
R. 
Capsule. 
R. 
Frank, loc. cit.. 
firmly fastened; patient had 
locomotor ataxia. 
57 
Von Tischendorf. 
Centralbl. Chir., 1887. 
F., 32. 
R. 
Cortical subst. and around 
R. 
Complete cure ; kidney fixed at 
12th rib; laparotomy 
end of 4 months. 
for cholecvstotomv. 
58 
Wilcox. 
Ann. Surg., 1888, p. 192. 
F., 24. 
Adipose capsule. 
R. 
Improvement great at end of 
4 months; kidney firm. 
59 
Stonham. 
Lancet, 1888, ii, p. 109. 
F., 34. 
R. 
Parenchyma (1 silk); 
R. 
Perfect cure at end of 9 mos. 
capsule (2 silk). 
60 
Richardson. 
Boston Med. and Surg. Jour., 1888, 
F., 36. 
R. 
Capsule (4 silk). 
R. 
Cure at end of 8 mos.; kidney 
June 14. 
fastened 2 in. lower than nor- 
mal position. 
61 
Duret. 
Bull. acad. de Belgique, 1888, p. 
F„ 33. 
R. 
Capsule and cortex of kid- 
R. 
Perfect result at end of 5 mos. 
440. 
ney and to periost. of 11th 
and 12th ribs, which had 
been resected. 
62 
Duret. 
Ibid. 
F., 39. 
Same method as Case 64. 
R. 
Decided improvem’t at end of 4 
m.; kidney slightly movable. 
G3 
Turgard. 
Bull. m6d. du Nord, Lille, 1887, 
F. 
R. 
Adipose capsule. 
R. 
Failure. 
p. 344. 
64 
Gilmore. 
Bull. med. du Nord, Lille, 1887, 
p. 344 (in report of commission). 
Capsule. 
R. 
Failure; followed by nephrec- 
tomy. 
65 
Lloyd. 
Practitioner, 1887, Sept. 
Parenchyma; capsule 
peeled off and sutured. 
R. 
Cure at end of several months. 
66 
Hager. 
Berl. klin. Wochenschr., 1889, 
p. 33. 
F„ 22. 
L. 
R. 
Sympt. continued ; probably due 
to calculi; r’t kidney had been 
67 
Parenchyma (silk). 
Warfoinge. 
Schmidt’s Jahrbuch, 1885, pp. 
108, 205. 
R. 
R. 
extirpated because movable. 
Result satisfactory at end of 
few months. 
68 
Gould. 
Lancet, 1888, ii, p. 674. 
F., 28. 
R. 
Cortical substance, 2 
R. 
Perfect cure at end of 2£ mos. 
kangaroo tendons. 
69 
Gould. 
Ibid. 
R. 
Failure; at end of 3 mos. re- 
lapse. 
removed in few days. 
70 
Gould. 
Ibid. 
Same 
Parenchyma, kangaroo 
R. 
Result satisfactory at end of few 
2d operation. 
pat. as 
No. 65. 
tendon. 
months. 
71 
Terrillon. 
Ann. malad. organ, genito-urin., 
M„ 57. 
R. 
Adipose capsule, as kid- 
R. 
Perfect cure at end of 5 mos. 
vii, p. 469. 
ney could not be forced 
into wound. 
72 
Terrillon. 
Ibid. 
F„ 42. 
L. 
Capsule and cortical sub- 
R. 
Marked improvement at end of 
stance. 
2 months. 
73 
Guermonprez. 
Report by Terrillon, Bull, de l'acad. 
F., 37. 
Parenchyma (silkworm 
R. 
m6d., 1889. 
gut)- 
74 
Keen. 
Med. News, 1889, p. 431. 
F., 35. 
R. 
Capsule (silk). 
R. 
Great improvement end of 6 m. 
75 
Rosenberger. 
Report by Wagner in Schmidt’s 
F., 22. 
R. 
Capsule sutured to peri- 
R. 
Result satisfactory; short ob- 
Jahrbuch, 1889. 
tonaeum (7 silk). 
servation. 
76 
Langenbuch. 
Deut. medic. Wochensch., 1889, 
F., 19. 
R. 
Parenchyma (4 sutures). 
R. 
p. 325. 
77 
Langenbuch. 
Deut. med. Wochensch., 1889, 
F., 43. 
R. 
Parenchyma. 
D. 
On 3d day, septicaemia; suture 
p. 325. 
passed through old embolic 
infarction in kidney. 
78 
Guvon. 
Bull, de l’acad. de m£d., Paris, 
F., 54. 
R. 
Parenchyma and around 
R. 
Complete cure at end of 9 mos. 
1889, p. 239. 
12th rib (4 catgut). 
79 
Guyon. 
Ibid. 
F., 20. 
R. 
Parenchyma (catgut). 
R. 
Complete cure at end few mos. 
80 
Mears. 
Ann. Surg., 1889, p. 241. 
F., 29. 
R. 
Cholecvstotomv at same 
R. 
Cure; short observation. 
operation. 
81 
Dodd. 
Drummond in Lancet, Jan. 11,1890. 
Med. Record, Jan. 12, 1889. 
M., 38. 
R. 
R. 
Cure. 
82 
Brvant. 
M., 28. 
R. 
Adipose capsule. 
R. 
Cure; short observation. 
83 
Hume. 
Report b\ Drummond, Lancet, 
Jan. 11, 1890. 
F., 31. 
R. 
R. 
Cure at end of 4 months. 
84- 
K lister. 
No details given except all 
R. 
Majority of cases were satisfac- 
tory. 
97 
cussion on Frank’s paper. 
— 
98- 
Morris. 
Discussion in Brit. Med. Assoc., 
Details not given ex- 
cept all 
R. 
Results satisfactory. 
105 
Aug., 1889. 
105- 
Tait. 
Ibid. 
Details not given except 
R. 
Results not satisfactory. 
108 
109- 
113 
114 
Bruce Clark. 
Ibid. 
Details not given except 
R. 
Results satisfactory. 
McCosli. 
F., 28. 
R. 
Capsule. 
Capsule. 
Capsule. 
Parenchyma. 
R. 
Complete cure at end 22 mos. 
Cure at end of 6 months. 
115 
McCosh. 
F., 34. 
R. 
R. 
116 
McCosli. 
F., 26. 
R. 
R. 
Partial failure. 
117 
McCosh. 
R. 
At end of 2 months results sat- 
2d operation. 
pat. as 
No 116 
isfactory. 
CASES OF NEPIIRORRHAPHY—(Concluded). REASONS WHY 
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