but had been first observed two and a half years since. Most of the time the pain was dull in character, extended down from the region of the liver into the pelvis, and was also noticed in the region of the navel. Occasionally she felt an acute pain in the side.

An

Upon examination I found the right kidney prolapsed into a little beyond the 2d degree, and very tender. Upon pressure it would recede, but would become prolapsed again, even while the patient was in the recumbent position. There was a great deal of tenderness over the region of the appendix. She had had no acute attack of appendicitis, but undoubtedly there was inflammation in and around the appendix. examination showed the urine negative. An operation was performed May 7, 1902, and performed as described in Case 1. An Alexander's operation was performed at the same time for a badly retroflexed uterus. The fatty capsule was found firmly adherent to the fibrous capsule at the lower end. This case is of so recent date that we are unable to say what the outcome will be. The patient has had no complications since the operation, but is still in the hospital.

CASE 4.—Mrs. S, aged 35, has three children, complains of a heavy, dragging, dull pain in the right side below the 12th rib. Occasionally she has severe pain with nausea and vomiting. These attacks are similar to the Dietel's crisis and resemble a renal colic. They are evidently due to the sudden twisting of the pedicle, causing a kinking of the renal vessels and a drawing on the renal nerves. Assuming a recumbent position, for a short time after these attacks, gives the patient relief. The extreme soreness of the kidney gradually disappears. Upon examination the right kidney is found prolapsed at times, a little below the 2d degree. Pads, corsets and bandages are all inadequate for the relief of these attacks. This patient has not yet been operated upon.

CASE 5-Mrs. T——, aged 45, married, no children, had an attack of gastro-enteritis one year ago, but has had more or less trouble with her stomach for a number of years. She is distressed after eating, and has occasional attacks of vomiting upon rising from a recumbent position. The pain in her right side has been

getting worse. She is jaundiced, sometimes more than others. According to Reid, this is probably due to the kidney drawing upon the hepaticoduodenal ligament, or, as happened in two of Wolff's cases, it might be due to the pressure on the bile-ducts. The attacks of vomiting come on suddenly, and the pain is quite severe afterward. The gastro-intestinal tract is now in good condition, and her attacks of vomiting are independent of any trouble in the stomach or intestines. She has lately had swelling of the limbs. Examination reveals the right kidney prolapsed to the 2d degree. Pads and bandages relieve her somewhat. Upon a careful analysis of her case, I find no other reason to account for the jaundice, attacks of vomiting and pain, and perhaps the swelling of the lower extremities than the prolapsed kidney. Pressure upon the kidney in this case, as in all other cases reported, caused a great deal of pain.

The conclusions that I wish to offer are as follows:
A certain percentage of prolapsed kidneys cause

discomfort.

2.

toms.

Prolapsed kidney often produces reflex symp

3. Prolapsed kidney is often associated with various complications or dependent conditions.

4. Symptoms depending upon prolapsed kidney are frequently attributed to other sources.

5. The degree of prolapse does not always determine the proportionate amount of discomfort.

6. When the symptoms present have been traced conclusively to a prolapsed kidney, and when the suffering cannot be relieved by pads or bandages, an operation should be advised.

7. The operation should be one which will anchor ́ the kidney most securely in the position most comfortable to the patient.

8. The operation, properly performed, gives most satisfactory relief.

BIBLIOGRAPHY

Edebohls.-Australasian Edition of Annals 'IoA
XXXV., No. 2, March, 1902.

Edebohls.-Medical Record, May 4, 1901, p. 690, Vol. 59, No. 18.
Beyea.-Pennsylvania Medical Journal, May, 1902.
Habershom.-Edinburgh Medical Journal, May, 1900.

Morris.-Medical Record, Feb. 23, 1901, p. 284, Vol. 59, No. 8.

Goelet.-American Medicine, Dec. 28, 1901, Vol. 2, No. 26. Davis Byron.-Journal American Medical Association, May 10, 1902, Vol. 37, No. 19, p. 1208.

Harris.-Journal American Medical Association, June 1, 1901, Vol. 36, p. 1527.

Marcy, Alex. J.-Journal American Medical Association, Feb. 9, 1902, Vol. 36, No. 6.

Abt.-Journal American Medical Association, April 27, 1901, Vol. 36, No. 17.

Kelley.-British Medical Journal, Feb. 1, 1902, No. 2144.
MacLaren.-St. Paul Medical Journal, June, 1901.

Goelet.-Medical Record, June 1, 1901, Vol. 59, No. 22.

DISCUSSION

Dr. J. E. Moore: I want to make a few remarks upon the doctor's excellent paper. It is a paper of interest to both medical men and surgeons, because we are confronted with floating kidneys every day. Every man who looks for them will find them. The practical question arises as to when operation is indicated, and this the doctor has well answered. I have generally advised against operation in these cases until the symptoms were very positive as indicating operation, and it seems to me we can reduce them almost to a general axiom, and say that when floating kidney is giving rise to symptoms, whether mental or physical, we should operate. I would especially emphasize the mental. I have women come to me suffering with kidney disease simply, and they are suffering only in mind, and I have sent them away telling them so. I have had a woman come back and insist that she was suffering terribly when I was satisfied that the suffering was in her head, and I finally anchored the kidney and cured the mental condition. So I believe the mental anxiety caused by a kidney bumping around in the abdomen is an indication for operation.

The doctor's operation is a new one; it is a practical one and involves only a limited amount of laceration of the organ. I have secured best results from the more conservative operation of Dr. Deaver of Philadelphia. Get down and separate the kidney from its fatty capsule, and bring it up into the wound; slip a strip of iodoform gauze under either end of the kidney; then have the loose ends on the outside, and swing the kidney in them; and finally bring up the ends of the gauze, and tie them so you have the kidney swung in the gauze. After six or eight days the dressing can be removed, the gauze slipped out, and you get very excellent results.

Dr. W. E. Rochford: I have had the pleasure of seeing Dr. Benjamin do the operation described. Theoretically it looks like a good operation, but I feel a little as Dr. Moore, that it is a rather severe one. It seems to me there is danger in handling the kidney so much. Lifting the kidney into the outer world, and denuding a large surface of its capsule, cannot be performed without a good deal of trauma. I would expect to have this operation followed by some pretty severe symptoms. Personally I have operated upon only one case, and in this one the results, after six or seven months, are fairly satisfactory. I did practically the Senn operation, putting in two sutures, and packing with iodoform gauze. This is an operation which any one can do who is at all skilled in surgical work. We need more light

on the subject, for few of us have performed many operations of this character.

If I remember correctly Dr. Abbott told me a little while ago that at the last meeting of the Mississippi Valley Medical Association the consensus of opinions of the surgeons who discussed the subject there was that the operation is one to be performed only in severe cases; and that generally the results are unsatisfactory.

There is one point that Dr. Benjamin mentioned which deserves emphasis; it is that there is danger of anchoring the kidney too high.

Dr. J. L. Rothrock: The question of when to operate for this condition is one which must be settled by the surgeon in individual cases. About one of every four slender women have some degree of movability of the right kidney, yet clinical experience shows that only when the condition has existed for some time and has become pronounced does it give rise to serious symptoms.

I have never been willing to operate in the absence of pronounced symptoms, and think it best, if on casual examination of a patient I find a movable kidney, to say nothing to the patient about it, if I find on careful inquiry that it has given rise to no symptoms. Many of these patients are highly neurotic, and wnere symptoms from the movable kidney are not especially pronounced I have seen excellent results from the rest cure. In the presence of pronounced symptoms, manifested by pain in the side or back with the presence of a palpable tumor falling to the level of the umbilicus, gastric disturbances or Dietel's crises, with lateral curvature of the spine, occasioned by the patient's effort to assume the most comfortable position, it becomes imperative to operate.

The operation which I have employed consists in exposing the kidney by the usual incision, removing the fatty capsule, and incising the true capsule for at least two-thirds its length. Three silk sutures are then passed through the folded edge of the capsule on either side of the incision, and through the fascia of the quadratus lumborum, bringing the kidney into close contact with the muscle. The sutures are placed one near the upper pole of the kidney, one about the middle, and one near the lower pole. In this way the kidney will be firmly held in place, and rotation will be impossible. The wound is then closed without drainage. In six cases on which I have performed this operation the results have been entirely satisfactory.

Dr. A. E. Benjamin (Essayist): I think the operation of Dr. Moore is a very good one; however, we are not sure how long the kidney will remain in place on account of the cicatricial tissue which is apt to stretch. In the operation I have described the flaps hold the kidney in position, and we have, in addition, the cicatricial tissue. We do know that sometimes in nephritis removing the capsule of the kidney in part does some good. It did in the case mentioned. I can hardly attribute the results obtained in the one case to the fact that she remained in bed for a certain time. The amount of urine was increased, and the amount of albumen was decreased. Removing the capsule in

part, and establishing a different circulation for the kidney, is theoretically good. We shall have to wait a time, however, to see whether this operation produces the desired results. The handling of the kidney is very little. You can pull upon it, and hardly produce any injury. The kidney is worked out of the wound, which procedure does no harm. You could not fasten a kidney very well without producing some traumatism, yet by this method we do not irritate the cortex of the kidney, we simply separate the fibrous capsule, and there is little hemorrhage and much less traumatism in this way than there is by the introduction of a suture. There is not much danger in this operation. I have not heard of any cases where bad symptoms appeared afterwards. There is occasionally a little blood in the urine when the kidney is injured, but I have not had any blood in the urine where I have not injured the cortex.

I think Dr. Rothrock said that each case had to be settled according to the indications present. Neurasthenics are bad cases, and I would not promise good results always. I am askoi if the kidney will remain in place. I never guarantee a cure. I tell the patients they have to take the chances. Where symptoms point directly to prolapsed kidney an operation is indicated.

The character of the operation often determines the success, and results are what count. Dr. Rothrock did not mention whether he left the suture in place. Silk is taken care of very nicely where there is a chance of its being passed out afterwards, but whether or not it causes any trouble in these cases, I am not sure. I think chromicized catgut lasts long enough to be of the benefit we wish it to be. I have never had suppuration in any of these cases.

REPORT OF TWO CASES OF ECTOPIC PREGNANCY, WITH DISCUSSION OF THE DIAGNOSIS AND THE TIME TO OPERATE

GEORGE E. BARTON, M. D.

Minneapolis

I was called on April 23, 1901, about 6 p. m., to see Mrs. R-, a little English woman 34 years old. She was suffering intensely with pain in the abdomen, but did not show any marked anemic appearance, and as I had never seen the patient before, I did not know but what the pallor shown was due to the shock produced by the pain. I found considerable difficulty in getting a history of the case, but finally secured the following: