TKe Diagnosis ar\d Treatment of 
“Floating Kiduey.” 
HY R. HARVEY REED, M. })., (UNIV. OF PENNA.) COLUMBUS, OHIO. 
Professor of Theory and Practice of Surgery and Clinical Surgery, Ohio Medical Uni 
versify ; Consulting Surgeon B. & O. and Big Four Railways, 
Surgeon Protestant Hospital, etc. 
A paper read by special invitation before the Sixth Annual M eting of the Shelby County 
Medical Society, at Sbelbyville, In 1. 
REPRINT FROM 
COLUMBUS MEDICAL JOURNAL. 
April, 1894. The Diagnosis ar\d Treatment of 
“Floating Kidney.” 
BY R. HARVEY REEI), M. D., (UNIV. OF PENNA.) COLUMBUS, OHIO. 
Professor of Theory and Practice of Surgery and Clinical Surgery, Ohio Medical Uni- 
versity ; Consulting Surgeon B. & O. and Big Four Railways, 
Surgeon Protestant Hospital, etc. 
A paper read by special invitation before the Sixth Anuual Meeting of the Shelby County 
Medical Society, at Sbelbyville, Iud. 
The frequency of floating kidney, associated with its various 
complications, together with the errors in diagnosis, certainly 
warrants our taking up this subject and considering it fora few 
moments before this Association. The experience of the writer, 
both as a general practitioner and consultant, has led him to be- 
lieve that a floating kidney is more likely to be misunderstood 
and taken for something else than perhaps any other one disease 
of the abdominal cavity. I have seen floating kidney treated for 
lumbago, also for sciatic rheumatism ; in another case I saw an 
able practitioner tap it for ascites, and still another where it was 
mistaken for an enlarged ovary. On the other hand, I have 
seen an enlarged and pendant gall bladder filled with gall stones 
mistaken for a movable kidney and the mistake was not discov- 
ered until revealed by an operation. With these few examples 
under my own observation and occurring in the experience of able 
practitioners, it is quite evident that the diagnosis of a floating 
kidney is not always an easy task. In fact, it has been my ex;-  2 
perience that the early diagnosis of floating kidney is seldom 
made, unless the patient is so fortunate as to fall in the hands of 
an experienced diagnostician. As a rule you are called upon 
by some practitioner who has treated the patient for months or 
even years without success, until one or both have become dis- 
satisfied and seek relief, either through counsel or a change in 
physicians. 
By this time you may have had torsion of the renal vessels 
and nerves and consequently find the patient suffering from 
lumbar pain, sciatica, or both. On the other hand the patient 
may be perfectly free from pain, except with more or less fre- 
quent paroxysms during which it may be likened to that of a 
case of renal colic. Not unfrequently the patient, especially if 
the abdominal walls are thin, will observe a tumor in the peri- 
toneal cavity, which excites attention, although when first dis- 
covered it may not cause any special pain. It is not uncommon 
to find that hydro-, or even pyo-nephrosis may have set in ; if the 
latter, it is not unusual to find it associated with secondary in- 
fection in the form of tuberculosis. 
The clinical facts have forced us to the conclusion that the 
symptoms of floating kidney vary in accordance with the condi- 
tions which may be associated with it, and which are largely 
modified by the changes and complications which, as a rule, 
sooner or later accompany this malady. 
It may be considered presumptuous on my part to even at- 
tempt a definite diagnosis of floating kidney, when such a 
noted authority as Agnew, in his Surgery, and even Pepper, in 
the American Text Book of Medicine, fail to give it, saying 
nothing of its omission in the American Text Book of Surgery; 
and yet our little cycle of experience has led us to the belief 
that it fills a position which is sufficiently important in the diag- 
nosis and treatment of abdominal diseases to justify us in con- 
tributing our mite to the study of this disease. 
I now imagine I hear some of my collaborators ask : What 
difference does it make? If you are satisfied there is a tumor 
in the abdominal cavity, make an excision and find out what it 
is. It will be time enough then to remove it if you can, or re- 
lieve it if you can not do any better, or let it alone if you must. 
While we are ready to accede this point to those who are 
experienced and practical operators, yet the point I wish to make 
is, that in the majority of cases movable kidney presents itself 
to the average practitioner who is not experienced in abdominal 
surgery or the diagnosis of abdominal tumors, who dares not 3 
open the abdominal cavity and look at its contents in order that 
he may make a diagnosis, but who must resort to text books for 
his information, and when, as I have already said, these text 
books fail to give him this instruction, it is our duty, although 
our experience may be limited, to give him what assistance we 
can to make an early diagnosis in this class of diseases. 
On making an early diagnosis, I believe, hangs the success- 
ful treatment of floating kidney. A failure to make an early 
diagnosis simply means that your patient will take nine chances 
out of ten of contracting complications which are liable to be so 
grave as to require nephrotomy or even nephrectomy to relieve 
them. It is in these neglected cases of floating kidney that you 
find long-continued severe neuralgias, due to torsion and sub-acute 
neuritis. It is in these that you find hydronephrosis, due to 
stenosis of the ureter, which, however, may last for weeks, and 
even months, without serious destruction to the substance of 
the kidney, as has been demonstrated by the author of this 
paper by repeated experimental research, but which, sooner or 
later, unless relieved, is nearly certain to be followed with either 
cystic degeneration or pyonephrosis tuberculous, or all, either 
one of which, if allowed to continue for any length of time, not 
only endangers the patient’s life, but will require a nephrectomy, 
or to say the least, a nephrotomy, to relieve. 
Diagnosis.—In making a diagnosis of a movable kidney, 
we should first consider the predisposition. This is largely gov- 
erned by sex. Women who have borne children, and especially 
if they belong to the laboring class, are particularly prone to this 
disease; poorly nourished females contribute their share, whilst 
age and occupation are important factors. In reference to sex, 
floating kidney occurs much more frequently in females than in 
males, although I have seen several ca ;es in males, and one case 
in a young man who was unusually strong and muscular. 
Notwithstanding our text books inform us that floating kid- 
ney usually occurs between the ages of 25 and 40, I have seen 
it occur in a young man under 18, and have found it in women 
who were past 70. 
Occupation unquestionably has a great deal to do with caus- 
ing floating kidney. The young man I have just referred to was a 
member of a base ball club and addicted to violent exercise 
which finally resulted in producing a floating kidney. 
Again, washer-women, who expose themselves to heavy 
strains, are frequently found suffering from this malady, whilst 
puny females, who lie around the house “studying how to do 4 
nothing,” not infrequently become victims of this disease, often 
by suddenly changing their habits during the presence of a 
friend, by jumping out of a buggy or over a fence. The same 
holds true of poorly nourished females who may be suffering 
from some constitutional disease or marasmus, which may reduce 
them to such an extent that the least exertion will force the 
kidney out of its place. 
Pressure on the kidney during pregnancy has a tendency 
to cause displacement, and is not unusually followed by a float- 
ing kidney. 
It is quite evident in attempting to arrive at a correct 
diagnosis, that it is of the greatest importance that we carefully 
study all the predispositions which may lead to the production 
of a floating kidney, and if possible ferret out the causes which 
may have been factors in producing it. Having accomplished 
this, which is comparatively easy, as compared with the differ- 
ential diagnosis, we are then ready to undertake to distinguish 
it from other abdominal maladies, which, I am sure, we are will- 
ing to admit is not always such an easy task. 
If the functions of the kidney have been interfered with by 
the displacement, the use of the ureteral catheter will be of 
great service in making a correct differential diagnosis, especially 
if the congestion has been so great as to produce hematuria. 
Where this occurs the use of the ureteral catheter will very 
greatly assist us in arriving at the correct diagnosis. 
In making the differential diagnosis between an enlarged 
and elongated gall bladder and a floating kidney, we must re- 
member that traction upon the tumor, in the case of the gall 
bladder, will reveal that it is attached to the liver, instead of the 
lumbar region, whilst traction upon the kidney will demonstrate 
that it is attached to the lumbar region instead of the liver. As 
a rule, the difference in texture, where the abdominal walls are 
not too thick, will enable you to diagnosticate between them ; 
yet, when the gall bladder has very thick walls and is very much 
distended with semi-liquid bile, and where the kidney is some- 
what flabby, it becomes very difficult to differentiate between the 
two by touch ; but as a rule, with the history and the predispo- 
sition to guide you, this feature of the diagnosis can be decided. 
Of course, if it happens to be the left kidney that is affected 
(which is very unusual), the complications of diagnosis are at 
once relieved. 
Where the gall bladder is involved, it is not unusual to 
have it associated with jaundice and all its accompanying symp- 
toms and complications. On the other hand, we would not ex- 5 
pect, except in anomalous cases, to find jaundice occurring in the 
case of a floating kidney. In many cases digital examination 
will enable you to distinguish the kidney in its natural position 
on the well side, and its notable absence on the other side. At 
the same time it is often an easy matter to replace the floating 
kidney, which, on pressure, will readily slip from under your 
finger, and either ascend under the margin of the liver, or de- 
scend even to the brim of the pelvis ; or it may in some cases be 
pushed over to the median line and assume a position on the 
abdominal aorta, so that the pulsations of the latter may be dis- 
tinctly felt underneath the displaced kidney, which may be out- 
lined very distinctly by the aid of these pulsations. Under these 
circumstances pressure will frequently shut off the circulation 
to such an extent that the femoral artery cannot be distin- 
guished. It would be difficult to accomplish this with a dis- 
tended gall bladder. In fact, I have never succeeded in doing 
so in cases of this class that have come under my observation. 
As a rule a displaced kidney is much more sensitive than 
an enlarged and elongated gall bladder, and whilst the shape 
may not always enable us to form a correct diagnosis, yet the 
difference in the outline of the tumor is such that we are guided 
with considerable accuracy in the directihn of a correct differen- 
tial diagnosis. 
The elongation of the right lobe of the liver may complicate 
the differential diagnosis in this class of cases. 
It is only a few days since I was consulted in a case of this 
kind, in which a lady came to me from the northern part of 
Ohio with the history of having suffered from a floating kidney 
for the last seven years. In addition to that, she had a very 
elongated and “ hour-glass ” shaped right lobe of the liver. The 
rest of the liver was apparently normal, but on careful digital 
examination we were enabled to shoot the kidney up under the 
elongated lobe of the liver and down below it and by pressing 
the liver outward and upward we could readily distinguish the 
kidney, which was also elongated, besides being flattened, 
evidently the result of pressure from the liver. As a rule, the 
patient who has a floating kidney is relieved when in the prone 
position, but in this case the pain was increased, owing to the 
fact that the prone position caused the liver to press upon the 
kidney and thus increased the pain, and no doubt was largely 
the cause of the displacement. This patient was admitted to 
the Protestant hospital and, assisted by Dr. Baldwin, I made 
the radical operation, when this condition was demonstrated and the movable kidney sutured fast to the muscles of the back, and 
the patient is now making a rapid recovery. In this case, how- 
ever, I am inclined to believe we can hardly expect to secure 
permanent relief, for the reason that the liver will continue to 
make pressure on the kidney, which may sooner or later have to 
be removed. 
The differential diagnosis between a movable kidney and 
the spleen is much more readily accomplished. The location of 
the spleen being on the left side, is less frequently called into 
question, owing to the fact that the left kidney is less frequently 
displaced. But when it is displaced, it is seldom that the spleen 
assumes a shape that in any respect corresponds to that of the 
kidney, and very seldom drops down as low in the abdominal 
cavity. Again, the kidney may be pushed up under the pendent 
portion of the spleen, which will enable you to readily feel both 
organs at one time. If, however, the spleen extends down over 
the kidney, it will be readily distinguished from it by a digital 
examination, and the kidney will be felt underneath that portion 
of the spleen which extends in front of it. 
The increased mobility of a floating kidney, as compared 
with that of the spleen, is a ready guide in making a differential 
diagnosis; so much so, that we can scarcely imagine how it is 
possible under ordinary circumstances to misconstrue what we 
are almost warranted in calling positive symptoms pointing to a 
correct differential diagnosis. 
Cancer of the pylorus might possibly be mistaken for a 
movable kidney, especially when the mesentery is very long 
and where the cancer assumes the shape and size of a kidney 
and drops down below the normal position of the kidney, as I 
have seen it in several cases. Only a few days ago, assisted by 
Dr. Means, I operated a case of this kind, which had been ad- 
mitted to the Protestant hospital, of Coltunbus, in which the can- 
cerous mass was so movable that it could be pushed beyond the 
median line on the left side and down as far as the kidney on 
the right side, and could, on the other hand, be pushed up under 
the margin of the liver or over the large curvature of the stomach. 
But on careful examination it was found entirely distinct from 
the kidney which remained stationary, no matter what position 
the tumor was placed in, saying nothing of the gastric disturb- 
ances enabling us to make a clear differential diagnosis. On 
making a laparotomy it was clearly demonstrated that our diag- 
nosis was correct. A gastro-enterostomy was made with the 
Senn bone plates and the patient, although 60 years of age, made 
a rapid recovery without a bad symptom. In these cases 7 
you always have the history of the stomach disturbances, which 
do not exist, as a rule, in displaced kidney. You have no inter- 
ference with the urinary secretions, no lumbar pains, no tender- 
ness on pressure of the kidney, whilst you have, as a rule, 
tenderness on pressure over the cancerous mass. 
The principal points which might lead us astray in a case 
of this kind are the size, shape and location of the tumor, 
together with its mobility. 
Omental tumors, which are quite frequent, might possibly 
be taken for a movable kidney, but as a rule they are seldom 
painful except as they produce mechanical pressure, and like- 
wise they seldom interfere with the functions of the kidnev, 
unless it is by mechanical pressure on the ureters producing 
hydronephrosis. This, however, seldom occurs. Where an 
omental tumor is movable, it is readily distinguished from the 
kidney by digital examination and palpation, as the latter will 
be found in its normal position, whilst the other may be moved 
around through the different parts of the abdominal cavity sel- 
dom, if ever, invaded by the kidney. 
A small ovarian tumor, with a long pedicle, might possibly 
be mistaken for a movable kidney. Comparison between the 
two would, however, on the one hand enable us to raise the kid- 
ney far above a point which would be at all probable in the case 
of an ovarian tumor, whilst the latter would be found to be 
anchored in the pelvic region, instead of in the lumbar, as in the 
case of the former. A vaginal examination would aid in deter- 
mining the presence of an ovarian tumor, whilst in the case of 
a floating kidney it would be quite out of the question to force 
it down to a point where it could be touched with the fiager in 
the vagina. 
We must also remember that a movable kidney, in the early 
stages, is extra-peritoneal, while an ovarian tumor is practically 
intra-peritoueal, the latter usually having a broad pedicle, which, 
as we have already said, is anchored in the pelvis, whilst the 
former has a long, narrow meso-nephron anchored near the 
median line of the lumbar regions. 
Treatment.—We have little confidence in the palliative 
treatment of a floating kidney, as we believe it is the exception 
that such treatment results in any permanent relief. Experience 
has taught that efforts at securing relief by palliative treatment 
are worse than useless. Blisters, liniments, bandages and com- 
presses we look upon, and especially the latter, as actually in- 
jurious, and only submit the patient to additional torture with 
little or no prospects of permanent relief, and are almost certain 8 
to be followed sooner or later by organic disease necessitating 
nephrotomy and often nephrectomy. 
It is our firm belief that the only safe and successful treat- 
ment of a movable kidney is a radical operation by which the 
kidney is replaced and firmly anchored by a number of sutures, 
which should not only pass through the capsule, but should in- 
clude a portion of the parenchyma as well as the fascia and 
muscles underneath. 
For accuracy and rapidity of the radical operation for a 
movable kidney, we would suggest the use of a suture of either 
chromatized catgut or silk worm gut, each end of which should 
be armed with a long, slim needle, varying from six to eight 
inches in length, according to the patient, the points of which 
should be triangular. When used, it should be passed through 
the capsule and the parenchyma of the kidney and directly 
through the muscles of the back, making its exit through the 
skin. The second needle should also be passed through the 
kidney, from one-half inch to an inch distant from the former, 
and directly through the muscles of the back, making its exit 
through the skin, the same as its mate. If you desire to let the 
suture remain, an incision should be made through the skin and 
the suture tied and the skin stitched over it. If, on the other 
hand, you desire to remove the suture subsequently, all that is 
necessary is to tie your sutures on the skin and allow them to 
remain until you are ready to remove them. This procedure 
will very greatly simplify the operation, which will require a 
much smaller opening than where you use a curved needle and 
attempt to fasten by suturing the kidney and its capsule to the 
fascia and muscles of the back in the ordinary manner. With 
the use of the long needle the sutures can be put in very quickly 
and as many as are necessary to hold the kidney to place, tying 
them on the patient’s back, and closing the abdominal incision. 
All this can be done in a very few minutes, and I believe it to 
be equally as efficient and much easier performed than the old 
method generally in use. 
If the patient submits to this line of treatment in the early 
stages of this malady, before serious complications arise, there 
is little or no doubt of permanent recovery, and with practically 
little danger in the operation. On the other hand, where the 
radical treatment is not resorted to, there is always danger of 
serious organic disease of the kidney, which may sooner or later 
prove fatal; or if not, the patient becomes a nervous, suffering, 
miserable creature, of little benefit to herself or those around her. 
150 E. Broad St.