MOVABLE KIDNEY. 
BY 
CHARLES P. NOBLE, H.D., 
SURGEON-IN-CHIEF, KENSINGTON HOSPITAL FOR WOMEN, 
PHILADELPHIA. 
REPRINTED FROM GAILLARD'S MEDICAL JOURNAL. MOVABLE KIDNEY.* 
BY CHARLES P. NOBLE, M.D., 
Surgeon-in-Chief, Kensington Hospital for Women 
Philadelphia. 
I desire to call the attention of the society to the subject of 
movable kidney, especially as met with in women. In order that my 
remarks may not exceed the brief limit prescribed by the society, I 
shall limit myself to my own investigations concerning this condition. 
It will be seen that in most respects my observations and conclusions 
are similar to those of other gynecologists, who have studied this 
subject. .,,11! 
Frequency.'—A movable and displaced kidney is a very common 
condition among women. I find that about one-fourth of my patients 
have a movable kidney. I do not affirm that this is true of the com- 
munity at large, but only of the class of patients that consult a gynecol- 
ogist. The right kidney is much more ferquently displaced than the 
left ; indeed, I have not seen the left kidney displaced independently 
of the right. In about every tenth case both kidneys are displaced, 
the right usually more than the left. 
Causation.—Various causes have been assigned for the occurrence 
of movable kidney, such as falls, pregnancy and tight lacing. My ex- 
perience leads me to believe that these causes are operative in only a 
limited number of the cases. With one exception all the patients having 
a movable kidney that I have seen have been thin, that is the supply of 
adipose tissue has been abnormally small. The single exception was a 
woman having a pendulous abdomen, with a resulting downward dis- 
placement of most of the abdominal viscera. I find movable kidney 
very frequent among the well-to-do and the poor, the married and the 
single, the fertile and the sterile, and the one point that they all have 
in common is that they are thin, or even emaciated. This experience 
leads me to believe that the lack or the loss of adipose tissue, is the 
underlying cause of movable kidney. Anatomical considerations also 
favor this view, as the kidney has no proper ligaments, but is held in 
place by the cellulo-adipose layer of tissue in which it is embedded. I 
have no doubt that tight lacing, laborious work, and multiple preg- 
nancies, leading to relaxation of the abdominal walls, are factors in the 
production of movable kidney in certain cases, but they are most apt to 
* Read before the State Medical Society of Pennsylvania. 2 
displace the kidney when it is poorly supported owing to the absence 
of a normal deposit of fat in the renal region. 
Symptoms.—The symptoms of movable kidney are both reflex 
and local. The reflex symptoms are sometimes general, but more 
usually abdominal. Many patients are extremely nervous, having 
the manifold symptoms which accompany an irritable condition of the 
nervous system. Others suffer from indigestion of varying degree, 
from the mildest type to the most extreme. Bloating from distention 
of the bowels with gas is a common symptom. This is frequently ac- 
companied by palpitation of the heart and by cardialgia. Neuralgic 
areas are met with in many patients, pain being referred most often to 
some point in the abdomen, and to the region of the heart. The local 
symptoms of movable kidney vary extremely in degree. The 
symptom most commonly complained of is a sense of dragging or 
weight, which is most annoying after prolonged standing or walking. 
In extreme cases the patient becomes aware of the presence of the 
movable kidney, and recognizes it as a tumor, which is painful and 
annoying. Severe: pain in the kidney itself is not a frequent symptom, 
but is met with in rare instances, being due probably to extreme con- 
gestion of the kidney from traction on the renal veins in some cases, 
and in others to obstruction of the ureter due to a twist or kink in this 
organ, giving rise to an acute hydro-nephrosis. Acute strangulation 
of the kidney had been reported, being due to obstruction of the renal 
veins by torsion of the kidney on its vessels. This condition is rare, 
and I have not met with it. Broadly speaking the reflex symptoms 
are less marked in cases having extreme displacement or mobility of 
the kidney. This is quite analogous to what is seen in the pelvis. 
Prolapsus uteri of moderate extent is accompanied by marked reflex 
symptoms, whereas a complete procidentia gives rise only to the local 
annoyance of a foreign body between the thighs, which interferes with 
walking. The explanation probably is, that in extreme displacement 
the nerves become overstretched, and that the circulation has time to 
adjust itself to the changed conditions. 
In my experience, in probably half the cases, the mobility of the 
kidney does not give rise to symptoms, so that many cases of this con- 
dition will be overlooked unless routine examinations are made. 
Symptoms referable to the bladder and to the sexual organs, re- 
sulting from a movable kidney, are frequently present, but are by no 
means constant. In the nervous or neurotic cases, a so called irritable 
bladder is the symptom usually complained of. When the mobility of 
the kidney is more extreme, and the symptoms are more purely local, 
attacks of pain beginning in the kidney itself, and passing along the ureter to the bladder, are not infrequent. Variations in the amount 
of urine passed in the twenty-four hours, are at times due to a twisted 
ureter. 
Dysmenorrhea is frequently associated with a movable kidney. 
The sensation of dragging- or weight in the lower abdomen is, I am 
convinced, frequently attributed to pelvic disease, when it is due to a 
displaced kidney. 
Diagnosis.—The existence of a displaced kidney may be sus- 
pected when a thin woman complains of general nervous symptoms, 
palpitation of the heart, indigestion, bloating, neuralgic areas, a sen- 
sation of dragging in the lower abodmen when standing, the inability 
to sleep when lying upon one or the other side, and finally, when pain 
is complained of in the renal region. The diagnosis, however, can be 
established only by a physical exploration, and the discovery of the 
kidney in its abnormal location, together with the fact of its undue 
mobility. 
In order to establish a diagnosis of a displaced and movable 
kidney, its proper location must first be agreed upon, and also the de- 
gree of its mobility. 
The position of the kidneys is variously stated by automatical text 
books. Thus Gray states that the lower border of the kidney is near 
the crest of the ileum, the right being lower than the left. McClellan 
states that the lower border of the right kidney reaches to the third 
lumbar vertebrae, that of the left not so low. It must not be for- 
gotten that the results of the investigations upon the dead and the 
living may vary; at all events, I am not disposed to accept these state- 
ments as to the usual location of the kidneys. In three-fourths of the 
cases examined by myself the kidney could not be palpated; in other 
words, neither kidney extends below the margin of the ribs. We 
must not forget, however, that the angle between the last rib and the 
spinal column is an acute one, well filled in by thick muscles, and that 
the kidney might extend slightly below the border of the rib at its 
junction with the vertebrae, without being apparent upon a clinical 
examination. From my standpoint, however, as in three-fourths of 
the cases examined the kidney could not be felt, it must be accepted 
that its normal, or in other words its usual position, is above the lower 
border of the ribs. As the distance between the lower border of the ribs 
and the ileum varies extremely in different patients, an allowance should 
be made for this fact in determining whether or not a kidney is abnor- 
mally low. T have no doubt that it is normal for the kidney to extend 
below the border of the ribs in some of these cases. 
The kidney is normally a movable organ, which descends with 4 
each inspiration, and ascends with each expiration; therefore, we must 
have some standard to determine whether or not a given kidney is ab- 
normally movable. A kidney may be displaced but not movable. It 
may be fixed in its abnormal position by adhesions. Doubtless in 
some cases it is congenitally located in an abnormal position, and gives 
rise to no symptoms, having in this case only its normal mobility. I 
would suggest as a criterion to determine whether or not a kidney is 
abnormally movable, the fact that it fails to ascend during expiration. 
When kidneys are very movable and much displaced their position is 
but slightly influenced by respiration. 
For some years, in my practice, I searched in tvain for movable 
kidneys. During that time I followed the method of examining the 
patient when she was lying on her back. I understand now why I 
failed to find the movable kidneys. It was because that in this 
position they slipped up above the margin of the ribs. In my entire 
experience I have felt not more than half a dozen kidneys with the 
patient lying on her back. These were cases of extreme displacement 
of long standing. 
It occurred to me that by examining the patient standing the diag- 
nosis could mqre easily be made, and experience has shown that this 
was one thing lacking in my previous investigations. The exam- 
ination should bo conducted as follows: The patient’s clothing 
should be loosened, all bands about the waist unfastened, and the 
skirts supported by a nurse or assistant, so that the patient will not be 
embarrassed with the fear that her clothing will fall off. She should 
then stand before a table or desk of convenient height, about thirty 
inches, with the examiner seated upon her right The patient then 
bends forward from the hips, and supports some of her weight by rest- 
ing her hands upon the table. She is directed to respire regularly, 
care being taken to relax herself thoroughly during expiration. The 
examiner’s left hand is placed against the lumbar region posteriorly, 
and his rirdit hand in a corresponding position in front of the kidney. 
Bv a conjoint manipulation the region between the two hands can be 
carefully palpated, and if present the kidney is easily recognized. The 
points to be looked for are the shape and size of the kidney, and the 
fact that it can be readily displaced upwards beneath the margin of 
the ribs, and that it will return to its former location so soon as the 
examiner’s hands no longer support it. When the kidney is com- 
pressed, as a general rule the patients complain of tenderness or pain 
of a peculiar character, and often make the statement that the pain 
causes them to feel faint or somewhat nauseated. 
The kidney must be differentiated from pelvic tumors, from tumors 5 
of the bowel, from the displaced liver, and from the distended gall- 
bladder. Pelvic tumors can be excluded as a rule, because their range 
of mobility is downward rather than upward. The contour of the 
tumor is also of service in differentiation. The displaced liver is much 
more bulky, and asi a rule, the thin lower border of the liver can easily 
be distinguished from the rounded border of the kidney. The dis- 
tended gall-bladder is to be distinguished by its small range of mobility, 
and usually by the history pointing to liver disease. Tumors of the bowel, 
usually malignant in character, might be mistaken for the movable 
kidney, but this is not likely, as by the time such tumors have grown 
sufficiently in size to be recognized by palpation, the history as a rule 
points definitely to the character of the disease. In all such cases, if 
the patient be fat the supposition is against the existence of a movable 
kidney. 
Treatment.—The subject of movable kidney is comparatively so 
new, that up to the present time I have been extremely careful of my 
advice in such cases. I have taken every opportunity to watch the 
progress of the cases, and have directed treatment to the condition 
itself onlv when the sufferings of the patient absolutely demanded it. 
In a large percentage of the cases passing through my hands, I believe 
in nearly half of them, the symptoms complained of have been com- 
paratively trifling, and symptomatic treatment has been sufficient to 
make the patients comfortable. That is, I have treated these patients 
just as I would had they presented the same symptoms with the kidney 
in its normal position. In these cases the good results have been due 
to improving the general health of the patient. As the patient’s gen- 
eral health improved, the various nervous disturbances disappeared. 
In the other half of the cases, and I think the larger half, though exact 
notes of all the cases have not been kept, symptomatic treatment has 
failed absolutely in giving relief. 
Believing that the normal support of the kidney is the peri-renal 
fat, it has seemed to me a rational plan of treatment to use such meas- 
ures as will increase the body weight. I have made use of the rest 
cure, strictly carried out, in five cases of movable kidney, and of a 
modified rest cure in a number of other cases. The results obtained 
have not been satisfactory. The nervous symptoms disappeared for a 
time during and after the rest cure, but in every case they have returned 
to a greater or less extent. The results have been equally disap- 
pointing as to the improvement in the position or mobility of the 
kidney. In the future I shall recommend the rest cure only for 
patients having a very moderate displacement of the kidney, for ex- 
ample not exceeding two or at the most three inches; being guided also somewhat by the probable duration of the displacement. It seems 
rational that this method of treatment should be curative in the milder 
cases, because while the patient remains on her back, the kidneys keep 
their normal position. If now the body weight be markedly increased 
by the increase of adipose tissue, it seems rational that a cure should 
be effected. 1 } | ! j : 
I am convinced from the experience I have had, that the rest cure 
will be a source of disappointment if used with the idea of curing the 
more severe cases. In such cases it will improve the general health, 
but will not markedly influence the local condition. 
I have done nephrorrhaphv in but six cases, in two of these doing 
a double nephrorrhaphv. This experience is too small to be of 
special value, so that I shall merely say that the results obtained have so 
far been very satisfactory. In the past I have hesitated to advise 
nephrorrhaphv, first because I did not know from experience how 
much or how little could be done by non-surgical means, and second 
the reports from other surgeons as to the results obtained by nephrorr- 
hapliv were conflicting. From a study of my own cases, and what I 
have seen in the practice of others, I believe that nephrorrhaphv is a 
simple and safe operation in the hands of a surgeon of experience, and 
that the results obtained by it are satisfactory, the symptoms due to the 
movable kidney are relieved, and the kidney remains permanently fixed 
in its new position. My own cases are so recent that they must be 
left out of consideration in deciding whether or not the kidney remains 
permanently fixed by the operation. This opinion is based upon a 
study of the recent literature. The percentage of cases in which the 
kidney again becomes displaced is quite small. In the future I shall 
advise nephrorrhaphv whenever the displacement is marked, and the 
symptoms sufficient to interfere with the patient’s enjoyment of life, or 
the performance of her usual duties. The indication, of course, is 
more marked when the symptoms complained of are localized in the 
kidney itself, especially when the displacement leads to attacks of renal 
colic, or to hvdro-nephrosis. In such cases destructive lesions of the 
kidney are apt to follow if the displacement is not corrected. Calculus, 
pyelitis, hydro-nephrosis and abscess of the kidney, not infrequently re-1 
suit from displacement of the kidney. 
Conclusions.—Movable kidney is a very common condition among 
women. I find it in one-fourth of my own patients. Both kidneys 
are movable in about one-tenth of the cases. 
The underlying cause of movable kidney is a deficiency of adipose 
tissue, especially in the peri-renal region. Tight lacing, multiple preg- 
nancies and falls, occasionally act as contributing causes. 7 
The symptoms of movable kidney are both reflex and local. The 
reflex symptoms are those at times of neurasthenia, irrespective of its 
cause. In other cases, nervous dyspepsia, palpitation of the heart, 
distention of the abdomen with gas, and neuralgic areas, are the 
symptoms complained of. Patients usually are unable to lie upon the 
side opposite to the movable kidney. The local symptoms are a sense 
of weight or bearing down, soreness in the kidney region, attacks of 
pain similar to renal colic, and in rare instances symptoms of strangula- 
tion due to torsion of the vessels of the kidney. 
Movable kidney may be suspected when its rational symptoms are 
present, but the diagnosis must be made by a physical exploration. 
This should be made with the patient in a standing position. The 
diagnosis can be made with the patient lying on her back only in long 
standing cases, where the displacement is extreme, as usually in the 
position the kidney slips up under the margin of the ribs. In many 
cases movable kidney gives rise to no symptoms, and therefore does 
not require treatment. The rest cure promises to be efficient in cases 
of slight degree, as the kidney returns to its normal position while the 
patient is lying on her back, and the increase in fat, which the rest cure 
usually brings about, should effect a cure. The rest cure used in cases 
of long standing, with extreme displacement of the kidney, will im- 
prove the general condition of the patient, but will not improve the 
local trouble. Nephrorrhaphy is a simple and safe operation, which 
should be done in the cases having well marked displacement, that is 
three inches and upward. The more marxed the local symptoms, the 
more necessary is the operation. The reported cases indicate that the 
results are permanent. 
The object of this paper is to emphasize the great frequency of 
this condition, and the ease with which it can be diagnosticated. Also, 
to urge upon those who have not done so, the necessity for studying 
its relation with the various reflex and nervous symptoms met with !n 
thin women. 
1637 N. Broad street.