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NEPHROCOLOPTOSIS 
 
LiGAMENTUM NepHROCOLICUM. (LoNGYEAR.) 
 
 Illustrating the location of the nephrocolic ligament, showing the right 
 
 cohc" H^ment"*^ ^-^h*^" '°-l°" ^""^ ?,"^"^ '^^ ^^^ peritoneum and t1.e nepA?o- 
 cohc ligament. The peritoneum has been drawn aside with a cord and 
 the nephrocolic ligament is shown isolated and drawn away from the ^t bv 
 tn^show Thl ^'"''''^f- ^°'°^- ./^^^ ^^^^^^ 1^^^ ^""^^ turned half around in order 
 unde^The cecum " nephrocolic ligament, the ileum being turned 
 
NEPHEOCOLOPTOSIS 
 
 A Descriptiox of the Nepheocolic Ligament and its 
 
 Action in the Causation of Nephroptosis, 
 
 With the Technic of the OpePiAtion of Nephrocolopexy, 
 
 in which the Nephrocolic Ligament is Utilized 
 
 TO Immobilize both Kidney and Bowel 
 
 BY 
 
 H. W. LONGYEAR, M. D., 
 
 professor of gvnkcologi' and abdominal surgery, detrf)it post- 
 graduate mkdicau school; clinical professor of gynecology, 
 detroit college of medicine; gynecologist to harper 
 hospital; consulting obstetrician to the woman's 
 hospital; ex-president of the American associa- 
 tion OF obstetricians and gynecologists. 
 
 WITH EIGHTY-EIGHT SPECIAL ILLUSTRATIONS AND 
 A COLORED FRONTISPIECE 
 
 ST. LOUIS 
 C. V. MOSBY COMPANY 
 
 1910 
 

 ■*'i 
 
 Copyright, 1910, by C, V. Mosby Company 
 
AFFECTIONATELY DEDICATED TO THE MEMOKY OF 
 
 MY FATHER, 
 JUDGE JOHN WESLEY LONGYEAR 
 
FOREWORD. 
 
 This monograpli presents my views of the subject 
 treated, and is not a compilation or a historic treatise, 
 mention being only incidentally made of other opinions 
 and theories. 
 
 I believe that in the nephrocolic ligament I have dis- 
 covered the principal positive etiologic factor in nephro- 
 ptosis. The belief that a nephroptosis, because of the 
 action of this ligament, must always be secondary to and 
 the result of a coloptosis (except when due to trauma), 
 and conseciuenth-' should not be considered separately 
 from, but of necessity with, the prolapsed colon, explains 
 my reason for both the form of the title of the book and 
 the etiologic basis on which the subject is treated. 
 
 My contention regarding this action of the nephrocolic 
 ligament gives araison (Petre for, and assists materially 
 in proving the truth of, the observation of Glenard, viz.: 
 "Enteroptosis without nephroptosis, but never nephro- 
 ptosis without enteroptosis." This fact being accepted, 
 the consideration of the subject of displaced kidney by 
 itself, ignoring its cause and unavoidable accompaniment 
 in the displaced colon, would be a serious pathologic 
 error and an omission of a full statement of fact, which 
 would tend to lead to the unsatisfactory therapeutic re- 
 sults that have usually attended the treatment of cases 
 of nephroptosis in the past. 
 
 The terms "splanchnoptosis" and ''enteroptosis," 
 while describing a condition which may exist in excep- 
 tional cases, give an erroneous idea of the pathology when 
 
6 FOEEWORD. 
 
 applied to all cases of nephroptosis, and tend to lead into 
 a maze of uncertainty and iridefiniteness regarding both 
 etiology and treatment. Gastroptosis may be present 
 with a nephroptosis, but not necessarily so, as is the case 
 with a coloptosis, and when so present is almost inevit- 
 ably a sequel to the nephrocoloptosis, and one of the later 
 developments of the pathology. The liver has no ana- 
 tomic connection to be influenced by a nephrocoloptosis, 
 and hepatoptosis may occur independently of any of the 
 other conditions. 
 
 To arrive at a working basis for treatment, it is true 
 that all of these conditions and their relations to each 
 other must be considered, but a concentration of thought 
 upon the heginning of the involvement of the pathology is 
 necessary to such an end. Still more misleading is it to 
 look into the pathology no farther than the loose kidney. 
 I believe that because of the commonly accepted and 
 erroneous idea of considering the displaced kidney by 
 itself, the full pathological situation is misunderstood, 
 as well as the true significance and value of the symptom- 
 atology. It is quite commonly asserted by a number of 
 authors that this little body, when movable, can, by the 
 pressure of its weight, cause a variety of serious dis- 
 orders, such as a kink in the colon by dragging it down, 
 uterine displacements by the right kidney falling upon 
 the organ, appendicitis by its weight interfering with 
 circulation, ovaritis, salpingitis, menorrhagia, metror- 
 rhagia, hematocele, cystitis, etc. When one considers 
 that the weight of the kidney is only from four to six 
 ounces, this all seems absurd; and when the fixation of it 
 by the old methods — even when anatomically successful 
 — so often not only has failed to relieve the numerous 
 manifestations attributed to it, but has augmented them, 
 it is no wonder that many physicians have become skep- 
 
rOEEWORD. / 
 
 tical on the whole subject, and advise their patients to 
 rather bear the ills they have than fly to those they 
 know not of. 
 
 Patients are often told that the displaced kidney is of 
 little importance, and that all that is necessary is for 
 them to ''get fat" and they "will be all right." That 
 is quite a safe prognosis, as these patients usually can not 
 get fat, but, on the contrary, continue to lose flesh, re- 
 gardless of dietetic regimen, tonics, etc. These are the 
 patients who may be temporarily benefited by the Weir- 
 Mitchell treatment of forced rest and feeding. They get 
 up feeling much improved, and consider themselves well, 
 but the erect position soon causes a return of the irrita- 
 tion of the digestive organs, and consequent interference 
 with nutrition. The fat fades away, and the old drag 
 of colon on kidney and duodenum again begins. The 
 rest treatment is not to be decried in these cases, but an 
 operation should precede it, after which the rest and 
 feeding will assist materially in making the cure per- 
 manent. 
 
 I was much in the uncertain frame of mind mentioned 
 when an accidental observation during an appendectomy 
 led to the discovery of the action of the tissue which I 
 call the nephrocolic ligament. After this the pathologic 
 landscape became clear, symptomatology meant some- 
 thing definite, and therapeutic indications became posi- 
 tive. 
 
 The operation referred to took place at the Solvay 
 Hospital, Delray, Mich., December 3, 1903. The patient, 
 a girl of 16 years of age, had complained more or less of 
 constant pain in the region of McBurney's point and in- 
 creasingly obstinate constipation for over a year. After 
 a thorough examination (no radiograph), in which every- 
 thing was negative, excepting a sensitive area in the sup- 
 
8 rOEEWORD. 
 
 posed location of the cecum and appendix, appendectomy 
 was decided on. Both kidneys were normally placed and 
 in no degree mobile. At the operation the cecum, with 
 the appendix deformed by adhesions to itself, was found 
 in the hottoni of the pelvic cavity. During the manipulation 
 it was noted that the right kidney could be pulled well 
 down into the abdomen by making traction on the cecum, 
 and, moreover, could be held in the prolapsed position by 
 .continuing the traction, so that it was impossible to re- 
 turn it to its normal position by counter-pressure with 
 the finger inside the abdomen. On removal of the trac- 
 tion, however, the kidney quickly slipped up to its normal 
 position. These observations led to investigations on 
 both the cadaver and the living subject, with the object 
 of ascertaining what connection there could be between 
 the gut and kidney that was strong enough to give such 
 a manifestation. The result was the isolation of the 
 tissue, which I call the nephrocolic ligament, as the only 
 union between the gut and kidney which was strong and 
 inelastic enough to cause the kidney to be so readily 
 pulled down. 
 
 This girl's constipation continued to increase, and one 
 year after the appendectomy, reasoning from my previous 
 observations, I concluded that the torpidity of the bowel 
 was due to the low position of the cecum, and made a 
 nephrocolopexy, solely to relieve the constipation. The 
 operation was a marked success, and has continued to be 
 so up to a very recent date (October 17, 1908). At this 
 operation the nephrocolic ligament was found to be long 
 and lax, which accounted for the kidney remaining in 
 place with such a marked coloptosis. 
 
 I believe that a more general use of the x-ray, a more 
 thorough palpation technic, and a due appreciation of 
 their symptomatology will result in a needed improve- 
 
FOREWORD. 9 
 
 ment in tlie early diagnosis of these cases and conse 
 qnently in the treatment of less of them for neurasthenia, 
 intestinal indigestion, chronic appendicitis, cholelithiasis, 
 cholecystitis, gastric dyspepsia, etc., and a practical thera- 
 peusis based on the existing pathology — the cause ^ and 
 not the effect — will then receive attention. 
 
 Early diagnosis of these cases should also insure the 
 proper treatment before the development of symptoms of 
 a serious nature, which occur occasionally in an explosive 
 manner, and at unexpected and inopportune times. Such 
 a case came under my observation recently: A young lady, 
 having a well-recognized nephrocoloptosis, had improved 
 for several months and gained some flesh imder the use 
 of an abdominal band. She became engaged to be mar- 
 ried, and a date was set and invitations issued for the 
 wedding. Three days before this was to occur, while 
 packing a trunk, she was taken with pain in the right 
 side, and a well-marked and very severe attack of Dietl's 
 crisis developed, which completely prostrated her and 
 contuied her to bed for several weeks, resulting in much 
 mental distress as well as bodily pain, and great incon- 
 venience and embarrassment of all parties concerned. 
 
 No one can foretell the stage of a nephroptosis in which 
 torsion of the pedicle may occur and such an attack be 
 precipitated. Without fixation by surgical means, any 
 case is liable at any time to the accident. The attacks 
 are not only severe and painful at the time, but, especially 
 when long continued, sequela of a serious nature are 
 liable to develop. 
 
 Diagnosis of this malady has not been taught to stu- 
 dents in any practical way in the past, and of recent years 
 teaching has been, at best, superficial. The use of pos- 
 ture, palpation, and the x-ray in abdominal diseases 
 should be as thoroughly taught clinically as is the phys- 
 
10 FOKEWORD. 
 
 ical diagnosis of diseases of the chest. Very few general 
 practitioners know how to examine for nephroptosis; 
 they do not recognize these cases, and wonder where 
 their fellow-practitioners find so many. I was asked re- 
 garding this question, during the reading of a paper be- 
 fore the Michigan State Medical Society, by a country 
 physician of large practice, who said he had seen but one 
 case in several years. Another doubted my diagnosis in 
 a case which he had sent me, but subsequently demon- 
 strated the fact of the displacement by following my 
 written directions for examination. 
 
 I recently operated on a case of extreme nephroptosis 
 in a woman, who had been suffering from severe neuras- 
 thenia and malnutrition, and who had spent the last year 
 in a fruitless search for health, trying sanitariums, osteo - 
 pathic and other kinds of treatment. She had been 
 examined by a number of reputable physicians, but only 
 one — a neurologist — told her she had a floating kidney, 
 and he barely mentioned it, remarking that it might 
 trouble her some time. She said she had had many elabo- 
 rate examinations of her chest, blood tests, tuberculin 
 tests, and urine and sputum analyses, but no one even 
 suspected the kidney and colon. She had been treated 
 by these physicians for neurasthenia and intestinal in- 
 digestion. 
 
 The foregoing is a common and, from my point of view, 
 a rather discreditable picture. The diagnostic ohsessive 
 apatliji that exists among the rank and file of the profes- 
 sion regarding the pathology in question is almost be 
 yond belief or explanation. I believe the tendency to 
 neglect this serious pathologic condition is simply a bit 
 of every-day human nature, arising from disinclination to 
 delve into that which is not definitely understood and for 
 which, if discovered, one is unable to apply a satisfactory 
 remedy. 
 
rOREWORD. 11 
 
 What it is hoped to accomplish by here recording my 
 observations and experience is to furnish a remedy for 
 this unsatisfactory state of affairs. If by the use of some 
 original theories, and others equally as good, an etiology 
 can be formulated that is not only simple to understand 
 and reasonable in theory, but which is also based on 
 sound mechanical principles, a comprehensive symptoma- 
 tology advanced, a method of diagnosis described that 
 every general practitioner can apply, and a plan of treat- 
 ment recommended that will give positive results in the 
 relief of symptoms, then my object will be attained and 
 the science of this important field of endeavor be ad- 
 vanced. 
 
 The prevalence of nephrocoloptosis is widespread and 
 not wholly confined to any class, nationality, age, or sex. 
 The floating kidney is found among the Bedouin women, 
 who live a nomadic life close to nature, where the de- 
 velopmental restraints of civilization and the corset play 
 no part, as well as among the women of the most civilized 
 countries, where dress and artificial ways of living are so 
 much in. evidence. The hard-working, muscular factory 
 girl and the delicate, pampered society belle suffer equal- 
 ly. Many cases of nephroptosis have been noted in 
 young children, and I have seen a well-marked case in a 
 girl of 8 years of age. 
 
 Women are much more subject to the displacement 
 than men, and yet many cases among men have been 
 noted by other observers. Suckling^ states that he has 
 found movable kidney present in about forty percent of 
 women and in six to seven percent of men suffering from 
 nervous disorders. 
 
 As my work has been almost entirely confined to the 
 gynecologic field, my observations relate largely to ex- 
 
 1 Movable Kidney, 1909. 
 
12 FOKEWORD. 
 
 perience in connection with the diseases of women. Of 
 the last two hundred examinations of women presenting 
 themselves with histories of some kind of abdominal or 
 pelvic disease, I have found floating kidneys present in 
 fifty-six— fifty-one right nephroptoses and five in which 
 both kidneys were down, but not one case of only a left 
 displacement. In four hundred cases preceding this se- 
 ries I found seventy-six floating kidneys — seventy-four on 
 the right side and two on both sides — but here, also, not 
 one only on the left side. In another series of four hun- 
 dred cases preceding the second series I reioort only 
 twenty-three cases — nineteen on the right side and four 
 on both sides. These three series show percentages of 
 28, 19, and 5.75 respectively. The larger percentage in 
 the more recent series doubtless represents the difference 
 in skill acquired in their diagnosis, as well, jjrobably, as 
 my increasing interest in looking for them. 
 
 A comprehensive understanding of the subject should 
 lead to more thorough diagnostic effort directed to the 
 kidney and colon than is usually displayed in the public 
 institutions conducted for the treatment of those suffer- 
 ing from nervous and mental disorders. I have been of 
 the opinion for a long time that our asylums and sani- 
 toriums have many chrouic invalids whose mental re- 
 cuperation could be assisted b}^ the discovery and treat- 
 ment of this condition. Many may also be saved from 
 complete mental breakdown by the early recognition of 
 the condition, as the long continued malnutrition, intes- 
 tinal irritation, toxemia, and neurasthenia caused by the 
 displacement are so frequently the chief factors in the 
 beginning. The young woman who has a sudden nervous 
 collapse, preceded for some time by indigestion, flatu- 
 lence, headaches, insomnia, progressive emaciation, and 
 anemia, may be sufl'ering from nephrocoloptosis, and not 
 
FOEEWORD. 13 
 
 be one of those common cases where the easy diagnosis of 
 ' ' just nerves ' ' is made. 
 
 Suckling refers to nephroptosis as a frequent and most 
 positive cause in mental and nervous disorders in the fol- 
 lowing words: *'A11 |)hases of mental disturbance are 
 met with in dropped kidney, but mental depression and 
 melancholia are the most frequent. The following con- 
 ditions are very common: loss of memory, suicidal tend- 
 encies, mental confusion, homicidal impulses, mental de- 
 pression, morbid fears, melancholia, emotional disturb- 
 ances. The frequency of suicide when dropped kidney 
 exists is remarkable." An operation for this condition 
 made by myself in an asylum had a most happy outcome 
 — the patient, a young woman of fine education and bril- 
 liant literary attainments, recovering and afterwards 
 inarrying. A photograph of her first baby — a fine, 
 healthy boy — was sent me four 3^ears after the operation. 
 
 I am under obligations to the following persons for 
 valuable assistance in the prej)aration of the material for 
 this book: Norman Saxon Chamberlin, the artist who 
 made all the drawings and also contributed many helpful 
 suggestions; Dr. C. B. Burr, who contributed the article 
 on "Psychiatric Nephroenteroptic Symptomatology," 
 and rendered valuable revisionary assistance; Dr. P. M. 
 Hickey, who contributed the article on the "Technic 
 of the Examination of the Gastro-intestinal Tract by 
 Means of the Rontgen Ray, ' ' made all of the radiographs, 
 and gave freely of time and energy in their preparation; 
 Dr. William E. Blodgett, who contributed the article on 
 "Orthoioedic Considerations of Abdominal Ptosis;" and 
 the publishers, who have been most generous and pains- 
 taking in practical co-operation. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 Anatomy akd Pathology. 
 
 PAGE 
 
 The nephrocolic ligament — Diagrammatic description of the rela- 
 tions of the kidneys with other organs and tissues involved in 
 nephrocoloptosis — The kidneys and their capsules — Importance 
 of the fatty capsule in the formation of the nephrocolic liga- 
 ment — Directions for the dissection necessary to demonstrate 
 the presence of the nephrocolic ligament — Gerota's capsule — 
 Large intestine — Duodenum — Common hile duet — Stomach . 21 
 
 CHAPTER II. 
 
 Etiology. 
 
 Hereditary weakness of restraining tissues the primary cause of 
 ptosis of internal organs — Contributing or secondary causes — 
 The union of colon with kidney by the nephrocolic ligament, 
 causing the kidney to be pulled oiit of place by the prolapsed 
 colon, the principal contributory etiologic factor — Combination 
 of conditions necessary to the displacement of the kidney — 
 Lack of restraining power of the hepatocolic ligament causes 
 the commencement of the chain of pathology which later in- 
 volves the kidney — Explanation of great predominance of right 
 nephroptosis is in the action of the nephrocolic ligament — Long, 
 loose nephrocolic ligament allows coloptosis without nephropto- 
 sis — Faulty body shape only one of the contributory causes . 48 
 
 CHAPTER III. ,^ 
 
 Symptomatology, 
 
 Symptoms complex and varied resulting in liability of erroneous 
 diagnoses — Intestinal manifestations usually the most predomi- 
 nant — Distended cecal end of the colon often causes symptoms 
 simulating appendicitis — Colonic angulations the cause of much 
 abdominal pain, and even stoppage — Constipation or diarrhea, 
 with mucous stools, very generally present — Toxemia frequently 
 caused by a colonic stasis — Nervous manifestations of all de- 
 grees of severity, commonly met with, often of a melancholic 
 character — "Nervous breakdown" in the young — Psychopathic 
 nephroenteroptic symptomatology, by C. B. Burr, M. D.— Dietl's 
 crisis causes symptoms simulating peritonitis — Jaundice and 
 "biliousness" caused by traction on the duodenum .... 53 
 
 15 
 
16 CONTENTS. 
 
 CHAPTER IV. 
 
 Diagnosis. 
 
 PAGE 
 
 Drudgery of painstaking examination can not be avoided — History 
 one of long standing-^Dyspepsia and neurasttienia — Facial ex- 
 pression in chronic cases — Chronic diarrhea, or alternating 
 diarrhea and constipation — Pain and tenderness at McBurney's 
 point — Diagnosis of coloptosis always certain in cases of neph- 
 roptosis — Physical examination essential in all cases — Posture 
 very important — Dorsal and lateral decubitus — Inflation of 
 stomach and bowel when radiograph is impracticable — Radio- 
 graph the most important aid to diagnosis — Technic of the ex- 
 amination of the gastro-intestinal tract by means of the Ront- 
 gen ray, by Preston M. Hickey, M. D. — Differential diagnosis 64 
 
 CHAPTER V. 
 
 Teeatment. 
 
 Treatment must be, to a large extent, mechanical — The complex 
 pathology must be recognized in the treatment — Prophylactic: 
 In the young; Orthopedic considerations, by Wm. E. Blodgett, 
 M. D.; Early attention to the colonic function; Supervision of 
 the family physician in cases of underdeveloped children of 
 importance — Medicinal: Directed principally to the colonic 
 function; Cathartics to be avoided; Oil and other "lubricants" 
 recommended; Physostigmin in Dietl's crisis — Topical: Heat 
 the most important agent — Mechanical: Kidney must be sup- 
 ported, indirectly, by supporting the colon; Bands, supports, 
 corsets, and trusses; Adhesive plaster band; Author's abdomi- 
 nal supporter — Operative: Result of stripping away fatty cap- 
 sule in the customary operation of nephropexy is increased 
 colonic ptosis; Author's operation of nephrocolopexy fixes both 
 kidney and bowel by utilizing the nephrocolic ligament; Tech- 
 nic of author's operation; Post-operative considerations . . 79 
 
 CHAPTER VI. 
 
 Reports of Cases. 
 
 Operation of nephrocolopexy in fifty-four cases — Details of diagno- 
 sis — Radiographs in many cases — Additional operations not 
 contraindicated — Tabulated resume, showing essential results^ — 
 Most remarkable in restoring the colonic function and normal 
 nutrition — No mortality — Convalescence comparatively painless 
 and comfortable — Nonoperative cases, illustrating various in- 
 teresting phases of obscure symptomatology and the great as- 
 sistance of the radiograph in diagnosis 130 
 
ILLUSTRATIONS. 
 
 Ligamentum Nephrocolicum — (Longyear) Frontispiece 
 
 PAGE 
 
 Figs. 1, 2. Diagrams illustrating the relation's of the kidney with the 
 
 other organs and tissues involved in nephrocoloptosis . . 23, 24 
 
 Fig. 3. Front view — Schematic drawing showing the normal location 
 
 of the organs involved in the pathology of nephrocoloptosis . . 26 
 
 Fig. 4. Front view — Schematic drawing showing the resultant chain 
 
 of pathology following prolapse of the colon at the hepatic flexure 27 
 
 Fig. 5. Back view — Schematic drawing showing the situation of the 
 nephrocolic ligament and the normal location of the organs in- 
 volved in the pathology of nephrocoloptosis 30 
 
 Fig. 6. Back view — Schematic drawing showing the etiologic im- 
 portance of the nephrocolic ligament and the resultant chain of 
 pathology following the prolapse of the colon at the hepatic flexure 31 
 
 Fig. 7. Location of the incision in the cadaver for the removal of the 
 attached kidney and colon in the demonstration of the presence 
 of the nephrocolic ligament 33 
 
 Fig. 8. Method of dissection for the removal of the attached kidney 
 and colon for the demonstration of the presence of the nephrocolic 
 ligament 34 
 
 Fig. 9. Posterior view of the right kidney, colon, and cecum, showing 
 
 the nephrocolic ligament 35 
 
 Fig. 10. Anterior (peritoneal) view — The nephrocolic ligament — 
 
 Right kidney, cecum, and colon 36 
 
 Fig. 11. Anterior (peritoneal) view — The nephrocolic ligament — 
 
 Right kidney, cecum, and colon 37 
 
 Fig. 12. Anterior (peritoneal) view — ^The nephrocolic ligament — ( 
 Left kidney — Attached portion of colon 38 
 
 Fig. 13. Transverse section showing the relations of Gerota's capsule 
 
 and the nephrocolic ligament 40 
 
 Fig. 14. Technic of physical examination for nephroptosis — Dorsal 
 
 decubitus — First position of examiner's hands 66 
 
 Fig. 15. Technic of physical examination for nephroptosis — Dorsal 
 
 decubitus — Second position of examiner's hands 67 
 
 Fig. 16. Technic of physical examination for nephroptosis- — Lateral 
 
 decubitus — First position of examiner's hands 68 
 
 Fig. 17. Technic of physical examination for nephroptosis — Lateral 
 
 decubitus — Second position of examiner's hands 69 
 
 Fig. 18. Technic of physical examination for nephroptosis — First po- 
 sition of examiner's hands in both positions of the patient . . 70 
 
 Fig. 19. Technic of physical examination for nephroptosis — Second 
 
 position of examiner's hands in both positions of the patient . . 71 
 
 17 
 
18 ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. 20. Faulty standing posture 82 
 
 Fig. 21. Favorable standing posture 82 
 
 Fig. 22. Faulty sitting posture 83 
 
 Fig. 23. Favorable sitting posture 83 
 
 Fig. 24. Author's abdominal supporter 95 
 
 Fig. 25. Position assumed while massaging the abdomen previous to 
 
 fastening the truss attachment of the author's abdominal suppoi'ter 96 
 Fig. 26. Front view — Proper adjustment of the author's abdominal 
 
 supporter 9'i^ 
 
 Fig. 27. Side view — Proper adjustment of the author's abdominal 
 
 supporter 98 
 
 Fig. 28. Back view — The result of cutting away the fatty capsule 
 
 from the kidney in the old operation of nephropexy .... 100 
 Fig. 29. Author's kidney elevator used in the operation of nephro- 
 
 colopexy 103 
 
 Fig. 30. Method of using the author's kidney elevator .... 105 
 Fig. 31. Instruments used by the author in the operation of nephro- 
 
 colopexy 1**'"' 
 
 Fig. 32. The operation of nephrocolopexy — ^Method of finding the 
 
 nephrocolic ligament after Gerota's capsule is entered . . . 108 
 
 Fig. 33. Skeleton reference to Fig. 32 109 
 
 Fig. 34. The operation of nephrocolopexy — Fasciculi of the nephro- 
 colic ligament drawn out 112 
 
 Fig. 35. Skeleton reference to Fig. 34 113 
 
 Fig. 36. The operation of nephrocolopexy — ^Method of gathering to- 
 gether the entire nephrocolic ligament by the use of the forceps- 
 hook 114 
 
 Fig. 37. Skeleton reference to Fig. 36 115 
 
 Fig. 38. The operation of nephrocolopexy — Method of forming a loop 
 
 of the nephrocolic ligament by opening the forceps-hook . . . 116 
 
 Fig. 39. Skeleton reference to Fig. 38 117 
 
 Fig. 40. Front view — The operation of nephrocolopexy — The scheme 
 
 of operation 118 
 
 Fig. 41. Skeleton reference to Fig. 40 119 
 
 Fig. 42. Front view — The operation of nephrocolopexy — Closure of 
 
 the transversalis fascia 120 
 
 Fig. 43. Skeleton reference to Fig. 42 121 
 
 Fig. 44. Front view — The operation of nephrocolopexy — Final closure 
 
 of the wound 122 
 
 Fig. 45. Skeleton reference to Fig. 44 123 
 
 Fig. 46. The operation of nephrocolopexy — Completed operation . . 124 
 
 Fig. 47. Skeleton reference to Fig. 46 125 
 
 Fig. 48. Position of kidney before and after fixation of the nephro- 
 colic ligament 126 
 
 Fig. 49. Method of applying post-operative abdominal pad in the op- 
 eration of nephrocolopexy 127 
 
ILLUSTEATIONS. 19 
 
 PAGE 
 
 Figs. 50 to 69. Radiographs of colonic and gastric displacements ac- 
 companying reports of operative cases 151-211 
 
 Figs. 70 to 86. Radiographs of colonic and gastric displacements ac- 
 companying reports of nonoperative cases 221-238 
 
 Fig. 87. Radiograph showing complete coloptosls following old opera- 
 tion of nephropexy 240 
 
 Fig. 88. Radiograph showing displaced colon raised by recumbent 
 
 position 241 
 
NEPHEOCOLOPTOSIS. 
 
 CHAPTER I. 
 ANATOMY AND PATHOLOGY. 
 
 In the presentation of the subject of the anatomy of 
 the parts involved in the pathology in question, no new 
 or previously unrecognized tissue is offered for considera- 
 tion, but, instead, the privilege is claimed of presenting 
 a new name and a newly discovered function for a previ- 
 ously recognized anatomical part, whose important office 
 had not been recognized until it was presented by the 
 author to the profession in an original observation re- 
 ported first in the transactions of the Michigan State 
 Medical Society, in June, 1905,^ and three months later 
 in a presidential address before the American Association 
 of Obstetricians and Gynecologists. - 
 
 Apart from the description of the nephrocolic ligament, 
 the anatomical descriptions in this book are drawn from 
 well-known sources. Only those parts which are pri- 
 marily concerned in the displaced colon and kidney, and 
 those which are secondarily affected as a result of the 
 displacement, will be considered. The prime object is 
 to direct attention to the essentials which have an im- 
 mediate mechanical bearing on the parts involved. 
 
 While the apparatus under consideration has that vital 
 force which is called "life" or "vitality," and which 
 
 iJournnl Michigan Stale Medical Society, vol. 5, No. 1, p. 41. 
 
 = "A Study of Floating- Kidney, witli Sug-g-estions Changing the Opera- 
 tive Technic of Nephropexy," Transactions American Association Obstetri- 
 cians and Gynecologists, 1906. 
 
 21 
 
22 N^EPHKOCOLOPTOSIS. 
 
 must be accounted an important factor in any study of 
 the various parts concerned in the displacements, this 
 condition is almost purely of a mechanical nature, and 
 may very properly, and it is thought with profit, be 
 treated largely from a mechanical standpoint. 
 
 The parts to be described are arranged diagrammatic- 
 ally for the purpose of iudicating the relations of the dis- 
 placed organs to each other, and, as far as possible, also 
 the continuity of the various structures with each other, 
 which continuity makes possible the ptoses and their 
 sequelae. It will be found that this arrangement also 
 simplifies the question of pathological sequence of in- 
 volvement of the various organs. 
 
 Relations of the Kidneys with Other Organs and Tissues. 
 
 The following two illustrations are diagrams showing 
 the relations of the kidneys with the other organs and 
 tissues involved in nephrocoloptosis. 
 
 By referring to and comparing the two diagrams, a 
 glance is sufficient to impress the mind with the fact that 
 the right kidney, because of its adhesion to and intimate 
 relations with more important tissues than is the left, 
 must be of the greater relative importance in any con- 
 sideration of the displacement of the two organs. It is 
 especially interesting to note the relations of the right 
 kidney to the organs above it which become influenced by 
 the nephroptosis. The chain of descensus is thus seen 
 as beginning from below, with the hepatocolic ligament 
 relaxation (or absence); then, in succession, the right 
 end of the colon, then through the nephrocolic ligament, 
 the kidney (which degree of displacement may be influ- 
 enced by the adhesion to Gerota's capsule), duodenum 
 (by its adhesion to the fatty capsule, and held in angula- 
 tion by the mesocolon), stomach, common bile duct — the 
 
ANATOMY AND PATHOLOGY. 
 
 23 
 
 latter disturbing the function of the liver and pancreas. 
 On the other hand, the left kidney, being isolated, as it 
 were, above (the duodenal adhesion so slight as to be 
 
 
 
 Liver, pancreas j 
 
 
 
 
 Mesocolon 
 
 Ck)m. bile duct 
 
 
 
 1 Stomach | 
 
 
 
 
 1 1 
 
 
 
 Duodenum 
 
 
 Gerota's capsule 
 
 Nephrocolic ligament 
 
 Cecum, ascending and transverse colon 
 
 Hepatocolic ligament 
 
 Fig-. 1. Diagram showing- the right kidney; the fatty capsule sur- 
 rounding it, and passing downward to form the nephrocolic ligament; 
 Gerota's capsule to the outside of and attached to the fatty capsule, and 
 passing downward to form part of the nephrocolic ligament; the ascend- 
 ing colon connected with the kidney through the nephrocolic ligament; 
 the hepatocolic ligament attached to the colon. Above the kidney the 
 duodenum adherent to the fatty capsule; stomach connected with and 
 continuous with the duodenum; common bile duct connected with the 
 duodenum, and liver and pancreas with it; mesocolon, where duodenum 
 passes under it. 
 
 negligible), its displacement affects no other important 
 organs. The great complexity of symptoms arising from 
 a right nephroptosis, and the rarity of symptoms of a left 
 side displacement — which must be of a renal character 
 exclusively — are thus clearly indicated. 
 
24 
 
 NEPHROCOLOPTOSIS. 
 
 The kidney, being the center of disturbance, will be de- 
 scribed in detail first, and then the other organs accord- 
 ing to their etiologic importance in the displacement. 
 
 Gerota's capsule 
 
 Nephrocolic ligament 
 
 Transverse and descending colon 
 
 Phrenoeolic ligament 
 
 Fig. 2. Diagram showing- tlie left kidney; the fatty capsule surround- 
 ing it, and passing downward to form the nephrocolic ligament; Gerota's 
 capsule to the outside of and attached to tlie fatty capsule, and passing 
 downward to form part of the nephrocolic ligament; tlie colon connected 
 witli tlie kidney through the nephrocolic ligament; the phrenoeolic liga- 
 ment attached to the colon. 
 
 The Kidneys. 
 
 The kidneys are bean-shaped organs, situated on either 
 side of the spinal column. (Fig, 3, Nos. 4, 9.) They are 
 usually described as lying in the lumbar region, but are 
 really intersected by the horizontal and vertical planes 
 which separate the hypochondriac, lumbar, epigastric, 
 and umbilical regions from each other, and may therefore 
 be said to pertain to all three segments of the abdominal 
 space. They lie on the fascia of the quadratus lumborum 
 muscle and on the vertebral portion of the diaphragm, 
 and extend from about the third lumbar vertebra to the 
 eleventh rib, or even above. The left kidney is somewhat 
 higher than the right. They are usually of a flattened 
 
ANATOMY AND PATHOLOGY. 25 
 
 oval shape, with the long diameter nearly parallel to the 
 vertebral column; but the form is variable, and they may 
 be slender, the length being three times the breadth, and 
 the convex and concave borders almost concentrically 
 curved; or they may be short and broad, the vertical 
 diameter being only a little greater than the transverse. 
 The '^ horse-shoe" kidney is found quite frequently, and 
 other anomalous forms may be encountered. 
 
 Each kidney is about four inches in length, two inches 
 in breadth, and about one inch in thickness, the left being 
 somewhat longer and thinner than the right. The 
 weight of the organ in the adult varies from four to six 
 ounces, being somewhat heavier in the male than in the 
 female, and the left kidney slightly heavier than the 
 right. 
 
 The kidney is surrounded by two sheaths — an inner 
 fibrous layer called the true capsule, and an outer so- 
 called fatty sheath or capsule. As it is in the latter — the 
 fatty capsule — that our special interest lies, being the 
 tissue the framework of which forms the nephrocolic 
 ligament, it will be of interest to note the observations of 
 others on this particular structure. 
 
 Gray: An old edition of Gray refers to the fatty cap- 
 sule as a "considerable quantity of fat," by which the 
 kidneys are usually surrounded. 
 
 Kelly-Noble: "The fatty capsule is developed espe- 
 cially on the posterior aspect of the kidney, al:)out the con- 
 vex border and the lower pole; in front it is very thin. 
 • Beneath the inferior extremity of the kidney it forms 
 quite a pad or bolster for the organ, and is continuous 
 with the cellulo-fatty tissue of the false pelvis. The 
 fatty capsule itself is confined between the two layers of 
 what is known as the perinephric fascia, and throughout 
 its extent there are fibrous septa which pass from the 
 kidney to those layers. ' ' 
 
26 
 
 NEPHROCOLOPTOSIS. 
 
 Pig. 3. Front view. Showing- the normal location of the organs in- 
 volved in the pathology of nephrocoloptosis. 
 
 1. Gall-bladder. 
 
 2. Common bile duct. 
 
 3. Duodenum at the point of 
 attachment of the hepatoduodenal 
 ligament and where it passes under 
 the gastrocolic omentum. 
 
 4. Right kidney covered with 
 fatty capsule. 
 
 5. Hepatic flexure of the colon. 
 
 6. Right ureter. 
 
 7. Ileum. 
 S. Cecum. 
 
 9. Left kidney covered with 
 fattj- capsule. 
 
 10. Splenic flexure of colon. 
 
 11. Jejunum. 
 
 12. Left ureter. 
 
 13. Suspensory muscle (seen 
 through stomach) which supports 
 the duodenojejunal angle. 
 
ANATOMY AND PATHOLOGY. 
 
 27 
 
 l^-mMneRJirjJ- 
 
 Fig. 4. Front view. Showing- 
 lowing prolapse of the colon at the 
 
 1. Common bile duct. 
 
 2. Gall-bladder. 
 
 3. Angulation of duodenum at 
 the insertion of the hepatoduodenal 
 ligament and where it passes under 
 the gastrocolic omentum. 
 
 4. Angulation of duodenum at 
 point of insertion of suspensory 
 muscle, behind stomach. 
 
 5. Angulation of common bile 
 duct. 
 
 6. Acute angulation and re- 
 sultant dilatation at splenic flexure 
 of colon. 
 
 7. Jejunum. 
 
 8. Umbilical region. 
 
 the resultant chain of pathology fol- 
 hepatic flexure. 
 
 9. Right kidney displaced be- 
 low costal margin. 
 
 10. Angulation of duodenum 
 at its point of adhesion to the 
 fatty capsule. 
 
 11. Angulation of prolapsed 
 transverse colon at its lowest point. 
 
 12. Right ureter compressed 
 and kinked. 
 
 13. Ileum. 
 
 14. Cecum. 
 
 15. Appendix vermiformis sit- 
 uated low in pelvis. 
 
 16. Left kidney. 
 
 17. Nephrocolic ligament pass- 
 ing from right kidney to posterior 
 wall of descending colon. 
 
28 NEPHROCOLOPTOSIS. 
 
 Will. Billiiigton, M. B., M. S., Lond., F. R. C, S., in 
 ''Movable Kidney from a Surgical Standpoint:" "A 
 typical movable kidney, as seen dnring oxoeration, pre- 
 sents certain well-marked features. The true capsule is 
 thickened and has a mottled appearance, due to the pres- 
 ence of opaque, yellowish-white patches of varying size. 
 These patches indicate areas of greater thickness, and to 
 them are attached adhesions, often of great strength. 
 The perirenal fat is usually scanty, and its place is taken 
 by adhesions which surround the entire kidney. The ad- 
 hesions are sheet-like in appearance, with dense bands 
 leading to the opaque patches on the true capsule. They 
 extend between the true capsule and the fascial capsule 
 outside. . . . Sometimes the adhesions hetiveen the colon 
 and kidney are very dense and their separation is effected 
 with difficttlty .'' ^ (Italics by the author.) 
 
 C. A. L. Reed, of Cincinnati, in "A New Technique for 
 the Fixation of Floating Kidney, with Special Reference 
 to the Utilization of Long-year's Ligament:" . . . 
 ' ' But another thing that impressed me was the frequency 
 with which, in endeavoring to enucleate the kidney, I 
 found it bound down by apparently connective tissue, 
 striae extending downward from its lower extremity. I 
 took the trouble to see if these striae belonged there, but 
 found no reference to them, either in the anatomies or in 
 Glautenay and Gerota's valuable contribution on "Le 
 Fascia Perirenal." 
 
 Zuckerkandl was equally silent ? ' ' I accordingly looked 
 upon the structure as strictly adventitious, probably of 
 inflammatory origin; but, as it seemed to hold the kidney 
 in its displaced position, I divided it with scissors. This 
 left a good stump, which, situated as it was, seemed to be 
 a good thing to stitch into the upper angle of the wound, 
 where it served a good purpose in holding the kidney pre- 
 
ANATOMY AND PATHOLOGY. 29 
 
 cisely where it belonged. . . . The lower segment of 
 the ligament is best disposed of by fixation to the lower 
 margin of the wound. ' ' 
 
 Thus is seen the development of recognition of the fact 
 that the structure of the fatty capsule is something be- 
 sides fat and loose connective tissue. The last two 
 observers — surgeons of large experience — are emphatic 
 in their opinion regarding the strength of the tissue. 
 Both believed its volume and strength to be of inflamma- 
 tory origin, and thus abnormal and adventitious. Bil- 
 lington's observation that this condition is peculiar to 
 cases of nephroptosis coincides with that of the author, 
 and seems to cover a valuable point in the anatomic ex- 
 perience of some others, who, failing to find the ligament 
 as described, base their opinions on the examination of 
 subjects which have had no displacement of the kidney. 
 
 If Billington and Eeed had gone a little farther and 
 examined the attachment of this tissue, they would have 
 found the distal portion in the posterior wall of the colon, 
 and that the bowel formed the resistance which pre- 
 vented the easy delivery of the kidney, which was liber- 
 ated by cutting through the tissue, as reported by Reed. 
 This is as the author finds it, and would define the struc- 
 ture as follows: 
 
 The Fatty Capsule. 
 
 The fatty capsule is a sheath which envelops the whole 
 kidney, is situated upon and attached to the surface of the 
 fibrous capsule, and is composed of a network of fine 
 fasciculi, or tendonse, interspersed more or less with fat. 
 The fasciculi composing the network of the capsule coa- 
 lesce at the lower pole of the kidney, and, passing longi- 
 tudinally downward, form 
 
30 
 
 NEPHROCOLOPTOSIS. 
 
 Fig. 5. Back view. Sliowing tli 
 ment and the noi-mal location of tlie 
 nephrocoloptosis. 
 
 1. Gall-bladder. 
 
 2. Duodenojejunal angle at the 
 point of Insertion of the suspen- 
 sory muscle. 
 
 3. Right kidney covered with 
 fatty capsule, and duodenum ad- 
 herent to front surface of capsule. 
 
 4. Right ureter. 
 
 5. Jejunum. 
 
 e situation of the nephrocolic liga- 
 organs involved in the pathology of 
 
 6. Right nephrocolic ligament 
 inserted in posterior wall of colon 
 between peritoneal reflection. 
 
 7. Umbilical region. 
 
 8. Cecum. 
 
 9. Left kidney covered with 
 fatty capsule. 
 
 10. Left nephrocolic ligament. 
 
ANATOMY AND PATHOLOGY. 
 
 31 
 
 \ -^^;\ 
 
 Fig. 6. Back view. Sliowing I 
 colic ligament and the resultant c 
 lapse of the colon at the hepatic fle 
 
 1. G-all-bladder. 
 
 2. Common bile duct. 
 
 3. Kink, or angle, in the duo- 
 denum at the insertion of the hep- 
 atoduodenal ligament and where it 
 passes over the gastrocolic omen- 
 tum. 
 
 4. Angulation of colon at 
 splenic flexure caused by the pro- 
 lapse of the transverse colon. 
 
 5. Angulation of common bile 
 duct. 
 
 6. Right kidney covered with 
 fatty capsule. 
 
 7. Angulation of duodenum at 
 its point of adhesion to front sur- 
 face of fatty capsule. 
 
 le eLiologic importance of the nephro- 
 hain of pathology following the pro- 
 xure. 
 
 8. Right ureter compressed by 
 position of kidney. 
 
 9. Right nephrocolic ligament 
 making traction on kidney by pro- 
 lapse of colon (seen through 
 ileum). 
 
 : 10. Cecum. 
 
 11. Left kidney covered with 
 fatty capsule. 
 
 12. Angulation at duodenoje- 
 j junal junction at insertion of sus- 
 pensory muscle. 
 
 13. Left ureter. 
 
 14. Left nephrocolic ligament. 
 
 I 15. Prolapsed transverse colon 
 
 I and lines of attachment of meso- 
 , colon. 
 
32 NEPHROCOLOPTOSIS. 
 
 The Nephrocolic Ligament, 
 
 wMch, on the right side, is inserted into the posterior 
 wall of the ascending colon between its peritoneal attach- 
 ments, and on the opposite side in a similar manner into 
 the descending colon. (Fig. 5, Nos. 3, 6, 9, 10.) The 
 nephrocolic ligament is adherent, ventrally, to the peri- 
 toneum above its attachment to the bowel; its tissue co- 
 alesces with the attenuated wall of the anterior lamella of 
 Gerota's capsule, which adds considerably to its tensile 
 strength. The "ligament" is an irregularly shaped 
 aggregation of fasciculi, which have much resisting 
 power when bunched together, but it may be readily torn 
 apart and its continuity destroyed if carelessly and 
 roughly handled, or if traction is made upon it section- 
 ally with tearing or lacerating instruments. 
 
 To demonstrate the nephrocolic ligament in its integ- 
 rity, showing its relations and attachments, the following 
 directions for the dissection should be observed: 
 
 Lay open the entire upper abdominal cavity (Fig. 7) 
 to inspection by an incision, severing all of the tissues of 
 the abdominal wall superiorly and laterally, beginning at 
 Poupart's ligament below the crest of the ileum on one 
 side, passing upward close to the side as far as the costal 
 margin, then across to the opposite side and down to 
 Poupart's ligament. The flap thus made and turned 
 downward exposes the entire cavity, so that the ascend- 
 ing and descending colon, with the hepatic and splenic 
 flexures, may be readily reached, and their attachments to 
 the kidney demonstrated without mutilative dissection. 
 
 On the right side, tie and cut loose the ileum close to the 
 cecum, and the transverse colon near the hepatic flexure, 
 sever the peritoneal attachments of the ascending colon 
 and the peritoneum covering the kidney, so as to leave 
 
ANATOMY AND PATHOLOGY. 
 
 33 
 
 the bowel and kidney covered with the membrane. (Fig. 
 8.) Then pass the hand under both bowel and kidney, 
 and dissect them, held thus together and protected by the 
 hand, from the loose attachments to the back and the 
 tougher tissue composing Gerota's capsule. The remain- 
 
 Pig. 7. Showing- the location of the incision in tlie cadaver for the 
 removal of the attached kidney and colon in the demonstration of the 
 presence of tlie nephrocolic ligament. 
 
 ing attachment will be the blood vessels and ureter, 
 which may be severed with the scissors. Now, with the 
 specimen still in hand, turn it over, with the peritoneal 
 side downward, and on removing the hand, which covers 
 the back of the kidney and bowel, the connection of the 
 
34 
 
 NEPHROCOLOPTOSIS. 
 
 kidney to the colon by the nephrocolic ligament is readily 
 seen. (Fig. 9.) 
 
 To demonstrate the ligament still farther, turn the 
 
 
 Fig. 8. Showing- the method of dissection for the removal of tlie at- 
 tached kidney and colon for tlie demonstration of tlie presence of the 
 nephrocolic ligament. 
 
 specimen over, so that the peritoneal covering of the 
 kidney and bowel will be uppermost; strip back about a 
 half inch of the cut edge of the peritoneum from the 
 parietal side of the kidney and bowel, and the margin of 
 
ANATOMY AND PATHOLOGY. 
 
 35 
 
 Gerota's capsule will be uncovered and seen to pass 
 
 downward and merge with the ligament. (Figs. 10, 11.) 
 
 The left side is removed in like manner after severing 
 
 Peritoneum jg^K '^j»* 
 
 
 Hepatic flexure 
 of colon 
 
 Margin of 
 peritoneum 
 
 Ascending colon 
 
 Margin of peritoneum 
 
 Cecum 
 
 Fig-. 9. The Nephrocolic Iiigrament. Posterior view of the right kid- 
 ne5^ colon, and cecum, showing the nephrocolic ligament. 
 
 the colon above and below the kidney, and shows the 
 same formation of capsule and ligament. (Fig, 12.) 
 
 For the best demonstration a very thin subject should 
 be used, as the presence of much adipose tissue may 
 
36 
 
 NEPHROCOLOPTOSIS. 
 
 obscure tlie characteristic appearance of tlie ligament. 
 Like many other structures of the body, the nephrocolic 
 ligament will be found to vary much in size and tensile 
 strength in different individuals. Like the round liga- 
 ment of the uterus, whose constant presence in the in- 
 
 Fig- lu. The Nephrocolic Iiig-anient. Anterior (peritoneal) view. (Same 
 specimen as Fig. 9, turned over.) Rig-lit kidney, cecum, and ascending 
 colon, showing the anterior surface covered witli peritoneum, the edge of 
 which has been turned back between the kidney and bowel, showing the 
 nephrocolic ligament secured by the forceps-hook (open), as in the author's 
 operation of nephrocolopexy. 
 
 guinal canal was for many years a subject of contro- 
 versy, in a small percentage of cases it will be found 
 very fragile, but, also like the round ligament, it can 
 alwaj^s be utilized for practical surgical purposes if skill- 
 fully handled, whether large or small. 
 
 There is no doubt, however, that in well-marked cases 
 
ANATOMY AND PATHOLOGY. 
 
 37 
 
 of nephroptosis the fibrillfe composing this structure are 
 much more voluminous and have more tensile strength — 
 and can thus be practically utilized — than in cases having 
 no renal displacements. Whether this increase of tissue 
 over the average is cause or effect is not known. It may 
 be due to both — a congenital strength of the connection 
 
 Fig-. 11. The Nephrocolic Lig-ament. Anterior (peritoneal) view. 
 Rlg-ht kidney, cecum, and ascending- colon, sho-wing the anterior surface of 
 bo-wel and kidney covered with peritoneum, the edge of which (1) has been 
 stripped back from the underlying capsule of GeTota, showing its margin 
 (2) to pass downward, and, becoming attenuated, merge into the nephro- 
 colic ligament (3), which is seen secured with the forceps-hook (open), as 
 in the author's operation of nephrocolopexy. 
 
 between bowel and kidney allowing the kidney to be 
 pulled out of place, and afterwards the constant activity 
 of the connected parts, due to the great mobility, causing 
 increased development of the ligament connecting them. 
 The attachment to the bowel has been found invariably 
 present. In some cases the ligament is short, and binds 
 the bowel closely to the kidney, while in others it is long 
 
38 
 
 NEPHROCOLOPTOSIS. 
 
 and loose, allowing a good deal of play between the kid- 
 ney and bowel. The latter condition is believed to be 
 present in cases of coloptosis without nephroptosis. 
 
 The nephrocolic ligament and fatty capsule may, for 
 illustration, be compared to the cordage of a balloon — 
 the kidney the bag of gas, and the ascending colon and 
 cecum the car. 
 
 Fig-. 12. Tlie Neplirocolic Ligament. Anterior (peritoneal) view. The 
 left kidney and attached portion of the colon at the splenic flexure, show- 
 ing- the anterior surface covered with peritoneum, the edge of which (1) 
 has been stripped back from the underlying capsule of Gerota, showing its 
 margin (2) to pass downward, and, becoming attenuated, merge into the 
 nephrocolic ligament (3), which is seen secured with the foi'ceps-hook 
 (open), as in the author's operation of nephrocolopexy. 
 
 Gerota 's Capsule. 
 
 Gerota 's capsule, or the perirenal fascia, is a compara- 
 tively new anatomical discovery, no mention of it being 
 found in the older text books on anatomy. At the time 
 the author read his first paper mentioning Gerota 's cap- 
 sule, a demonstrator of anatomy in a prominent medical 
 college called on him and asked to be shown the au- 
 thority for it, stating he had never seen it in dissection, 
 and knew of no literature on the subject. At that time 
 the only reference at the author's command was in the 
 
ANATOMY AND PATHOLOGY. 39 
 
 article on the kidney in that admirable encyclopedia, 
 ''The Eeference Handbook of the Medical Sciences," 
 which was shown him. The drawing here presented 
 (Fig. 13) is an adaptation of one in the article referred 
 to, and shows clearly the mode of formation of the 
 capsule. 
 
 As the perirenal fascia has much to do with both the 
 etiology and therapeutics of nephroptosis, its character- 
 istics and relations should be studied carefully. As 
 described by Gerota, Zuckerkandl, Glautenay, and others, 
 it is composed of the subperitoneal fascia, which splits 
 into two lamellae when it reaches the line upon the lateral 
 aspect of the abdominal wall on either side of the body, 
 from which the parietal peritoneum is reflected, to 
 pass on to and over the ascending and descending colons 
 respectively. At this point the fascia divides into two 
 layers, one of which passes over the front and on the back 
 of the kidney of each side. The anterior layer (Fig. 13, 
 No. 6), after crossing the kidney in front, is continued 
 and joins its fellow of the opposite side, making a con- 
 tinuous membrane overlying the posterior part of the ab- 
 dominal wall. From the point at which it separates from 
 the anterior lamella, the other, or posterior, leaf of the 
 perirenal fascia passes behind the kidney and is con- 
 tinued across the psoas muscle, to be inserted on the 
 lateral aspect of the bodies of the vertebrae near their 
 anterior surface. (Fig. 13, No. 12.) 
 
 The two lamellae meet at the upper end of the kidney 
 and send fibers to the under surface of the diaphragm; 
 they also pass between the upper pole of the kidney and 
 the adrenal body, sending fibers to both, thus loosely at- 
 taching one to the other. The connection is not an inti- 
 mate one, and on this account the adrenal remains behind 
 when the kidney is removed, except when there has been 
 
40 
 
 NEPHROCOLOPTOSIS. 
 
 Fig. 13. Transvei'se section showing- the relations of Gei-ota's cap- 
 After Gerota, with supplemental no- 
 
 sule and tlie neplirocolic ligament, 
 tations.) 
 
 1. Psoas muscle. 
 
 Body of the sacrolumbalis 
 
 2. 
 muscle. 
 
 3. 
 cle. 
 
 Quadratus lumborum mus- 
 
 4. Peritoneum (dotted line). 
 
 5. Kidney. 
 
 6. Anterior lamella of Gerota's 
 capsule (becoming attenuated as it 
 passes downward and merges with 
 the nephrocolic ligament). 
 
 7. Colon. 
 
 8. Subperitoneal fascia. 
 
 9. Proper point of entrance to 
 Gerota's capsule in the operation of 
 nephrocolopexy (close to quadratus 
 lumborum muscle, and just below 
 the twelfth rib). 
 
 10. Improper point of entrance 
 in the operation of neplirocolopexy 
 (peritoneal cavity, and not Gerota's 
 capsule, will be entered). 
 
 11. Nephrocolic ligament. 
 
 12. Posterior lamella of Gero- 
 ta's capsule. 
 
ANATOMY AND PATHOLOGY. 41 
 
 a previous inflammatory process whicli has produced ad- 
 hesions, binding them together. In this way there is 
 formed a sac which incloses the kidney and its fatty en- 
 velope, and which is closed above and at its outer side, 
 but is more or less open below, and entirely so toward the 
 median line of the body — a very important anatomical 
 point in its relation to nephroptosis. 
 
 The trabeculaB forming the framework of the fatty 
 cupsule are more or less adherent to the inner surface of 
 the perirenal fascia, and, as they are likewise attached to 
 the outer surface of the fibrous capsule, the kidney's 
 motility is to a considerable extent dependent on this 
 peculiar distribution of tissue. This adhesion to Gerota's 
 capsule and its attachment to the back around the hilum 
 and blood vessels form the kidneys' only defense against 
 dislodgment. 
 
 Thus it is seen that the kidney is, first, surrounded by a 
 closely adhering membrane — the fibrous capsule — which 
 encases it firmly and moves with it; second, around this 
 is the fatty capsule, holding the kidney loosely in a net- 
 work of fasciculi, which allows the kidney some motion 
 within it, but yet moves with it, and may be pulled down- 
 ward by its lower attachment to the bowel ; and, third, we 
 have the capsule of Gerota surrounding the fatty capsule, 
 excepting at its inner side and below, where it becomes 
 attenuated and merges with the nephrocolic ligament at 
 its attachment to the ascending colon. (Figs. 11, 12.) 
 The kidney, in its excursions, must thus carry with it 
 both the fibrous capsule and the fatty capsule, but the 
 capsule of Gerota, being fixed, remains in place, and, be- 
 ing open at its inner aspect, allows the kidney to pass 
 out of its embrace in that direction. This formation of 
 Gerota's capsule, with resultant action of the loose kid- 
 ney, explains the cause of the discomfort experienced by 
 
42 NEPHROCOLOPTOSIS. 
 
 many patients suffering from nephroptosis when lying on 
 the left side. 
 
 The Large Intestine. 
 
 The large intestine (Fig. 3) is that part of the ali- 
 mentary canal which connects the small intestine, ending 
 at the ileocecal valve, with the anns, and is from five to 
 six feet in length. It is readily distinguished from the 
 small intestine by its sacculated contour and its longi- 
 tudinal muscular bands, as well as by the greater thick- 
 ness of its walls. Tn its normal position it is horse-shoe 
 shaped, with the curve uppermost, and extends from the 
 right iliac region upward to the under surface of the 
 liver, then across the abdomen — under the liver, stomach, 
 and spleen — to the left side, where it passes down and 
 over the brim of the pelvis to its outlet, the anus. It has 
 three flexures — viz. : the hepatic flexure, the splenic flex- 
 ure, and the sigmoid flexure — the first two signifying the 
 angles which the bowel forms in passing respectively 
 from ascending to transverse (at the liver) and from 
 transverse to descending (at the spleen), and the third, 
 situated in the pelvis, at the termination of the descend- 
 ing colon, so called because of its fancied resemblance to 
 the Greek letter sigma, ^ These flexures are all im- 
 portant anatomical points in the bowel, as they are so 
 frequently concerned in occlusions and constipation; but, 
 as the pathological conditions under consideration prac- 
 tically implicate no structure lower than the splenic flex- 
 ure and the beginning of the descending colon, only the 
 hepatic and splenic flexures need be especially consid- 
 ered in this connection. 
 
 The large intestine is supported in its position in the 
 abdomen centrally by its mesentery, laterally by its peri- 
 toneal attachments (occasionally partly by mesentery 
 
ANATOMY AND PATHOLOGY. 43 
 
 also), and to a considerable extent, in the opinion of the 
 author, by the nephrocolic ligament. The large intestine, 
 at the hepatic flexure, passes in front of the lower pole of 
 the right kidney, to which it is attached by the nephro- 
 colic ligament (which is situated between its peritoneal 
 attachments), and on the opposite side it is in about the 
 same relation with the left kidney at the splenic flexure, 
 being attached to it in like manner by the nephrocolic 
 ligament. The most important points of support de- 
 rived from the peritoneum consist of two folds of this 
 membrane, a fold situated at either end of the transverse 
 colon. They serve mainly to hold the gut suspended in 
 its upper position in the abdomen. These folds are 
 known as the hepatocolic and phrenocolic ligaments. 
 Gray says the hepatocolic ligament is not invariably 
 present. The hepatic and splenic flexures are apparently 
 formed by the upward pull of these two ligaments at the 
 respective ends of the transverse colon, and become very 
 important etiologic factors in connection with the sub- 
 ject of nephrocoloptosis. The bowel is further supported 
 on each side by the nephrocolic ligaments, which connect 
 the kidney on the right side to the posterior wall of the 
 ascending colon, and the kidney of the left side to the 
 posterior wall of the descending colon. 
 
 The diameter of the large intestine decreases from the 
 cecum, where it is about three inches, to the descending 
 co]on, where it is about one and one-half inches. The 
 divisions of the large intestine are the cecum, ascending- 
 colon, transverse colon, descending colon, sigmoid colon 
 or flexure, and rectum. The cecum is the blind sac which 
 forms the end of the bowel and receives the contents of 
 the ileum through the ileocecal valve. The ascending 
 colon is that portion which extends from the cecum to the 
 spenic flexure at the hepatocolic ligament. 
 
44 NEPHEOCOLOPTOSIS. 
 
 The cecum and ascending colon together form a most 
 important and interesting part of the large intestine, for 
 this portion, unlike the remainder of the gut, performs a 
 very important part of the process of digestion and ab- 
 sorption. It is here that the reverse peristalsis occurs, 
 producing the "churning" action of the bowel, which 
 makes it possible for this sac, with its only outlet upward, 
 to absorb the large quantity of fluid poured into it from 
 the small intestine through the ileocecal valve. This 
 part of the bowel is the most richly supplied with lym- 
 phatics, and is apparently designed to finish the process 
 of absorption, passing the residue — the waste and useless 
 matter — along into the remainder of the bowel, which 
 acts simply as a reservoir, holding it only until it can be 
 evacuated. 
 
 With this understanding of the office of the cecal end 
 of the colon, it can be readily seen that any interference 
 with the normal mechanics of its function would cause 
 serious derangement of the parts and consequent dis- 
 turbance of normal nutrition, to say nothing of discom- 
 fort, distress, and annoyance caused by the disturbed ac- 
 tion of the musculature of the parts incident to such in- 
 terference. 
 
 The transverse colon is that section of the bowel which 
 passes across the upper abdomen from the hepatic flexure 
 to the left side, ending at the splenic flexure. The de- 
 scending colon is that part which commences at the 
 splenic flexure and passes down close to the left parietes 
 to the sigmoid flexure at a level with the crest of the 
 ileum. The sigmoid flexure lies below this latter point 
 and terminates in the pelvis with the rectum and anus. 
 
 The combined form, position, attachments to the body, 
 and peculiar office of the colon result in its easy displace- 
 ment, which is attended with a greater consequent de- 
 
ANATOMY AND PATHOLOGY. 45 
 
 rangement of function than obtains in the displacement 
 of any other part of the alimentary canal. Its position 
 being semi-fixed, and its contents, beyond the hepatic 
 flexure, semi-solid, and not freely moved by peristalsis — 
 as is the case with the fluid contents of the small intes- 
 tine — any displacement which causes unusual angulation, 
 it can be readily seen, would result in defective elimina- 
 tion of its contents. Its fixed jposition, in connection with 
 the fact that it must be of a definite leng-th to fill a given 
 space, renders the question of its distention and elonga- 
 tion — which occurs as a result of long continued partial 
 occlusion by angulation, etc. — a matter of serious impor- 
 tance, and one to be duly considered in connection with 
 these anatomic conditions. 
 
 The Duodenum. 
 
 The duodenum (Figs. 3, 4, 5, 6) is that portion of the 
 small intestine which passes from the pyloric end of the 
 stomach to the jejunum. It is about ten inches in length 
 and about two inches, or less, in diameter, runs a tor- 
 tuous course, is covered only in part by the peritoneum, 
 and differs essentially in position from the remainder of 
 the small intestine, being almost completely fixed and 
 immovable. It is this immobility, coupled with the fact 
 of its adhesion to the fatty capsule of the right kidney, 
 which makes this portion of the small intestine an im- 
 portant factor in the somewhat complex pathology of 
 nephrocoloptosis. The gut, soon after it leaves the 
 stomach, passes under the transverse mesocolon, and is 
 within its embrace during the remainder of its nearly 
 circular course, passing through it and becoming intra- 
 peritoneal again at its junction with the jejunum. The 
 bowel is further held by the suspensory muscle, a deli- 
 
46 NEPHKOCOLOPTOSIS. 
 
 cate, flat, fibromuscular band, whicli starts from the left 
 crus of the diaphragm and runs downward to its inser- 
 tion on the duodenojejunal angle. (Fig. 5, No. 2.) 
 
 The common bile duct (Fig. 6, No. 2) empties into the 
 gut shortly after it becomes extra-peritoneal, and the 
 head of the pancreas lies within its concavity and is ad- 
 herent to it. It is thus readily seen what effect the trac- 
 tion of the descending and adherent kidney must have 
 on the duodenum, held, as it is, rigidly at two points — 
 the first near its origin at the stomach by its attachment 
 to the hepatoduodenal ligament and by the edge of the 
 transverse mesocolon where it passes under it, and the 
 second at the duodenojejunal angle by the suspensory 
 muscle. The result is angulation of the gut at these 
 points, as well as the causation of more or less distortion 
 of the conmion bile duct, with consequent disturbance of 
 the normal hepatic and pancreatic functions. (Figs. 4, 6.) 
 
 The stomach (Figs. 3, 4), when of normal size, should 
 not be in a position for any portion of it to be found be- 
 low the umbilicus, except, perhaps, in some instances of 
 acute overdistention. The organ is said to be in a state 
 of ptosis when the greater curvature is found to be at or 
 below the navel, whereas the stomach is not usually 
 really dropped, but is in a state of dilatation, and, be- 
 cause of its increased size, the dependent portion is found 
 in this abnormally low position. The cardiac end is still 
 held in its fixed position at the termination of the esoph- 
 agus, and the pyloric extremity is held solidly by the 
 fixed position of the duodenum, especially at the point 
 where this bowel passes across and under the transverse 
 mesocolon and at the point of attachment of the hepato- 
 duodenal ligament — about an inch from the pylorus. 
 This latter is the important anatomic point which is of 
 interest in connecting the stomach with the chain of 
 
ANATOMY AND PATHOLOGY. 47 
 
 pathology beginning with the relaxation of the hepato- 
 colic ligament, as it is the compression of the duodenum 
 at this point, before described, which causes gastric stasis 
 and consecpient dilatation, and the so-called gastroptosis. 
 The elongation of the gastrohepatic omentum, which may 
 be more or less relaxed as a consequence of the constitu- 
 tional condition of weakness of restraining tissues, grad- 
 ually eventuates as the unusual strain put upon it by the 
 increasing]}^ enlarging stomach continues. 
 
CHAPTEE II. 
 ETIOLOGY. 
 
 The perfect construction of a well-designed macMne re- 
 quires that it shall be so made as to perform its work 
 loroperly, and at the same time to continuously do its 
 work for a reasonable i^eriod without breaking down or 
 getting out of order. That these purj^oses may be ful- 
 filled, the first requisite that the designer insists on is that 
 the materials used shall be of the quality best adapted to 
 the uses of the various parts of the mechanism. An 
 imjDerfectly tempered spring, die, or cam results in im- 
 perfect working of the machine, if not in utter failure. 
 
 The human body may be compared to a well-designed 
 machine, but it must be constructed according to specific 
 requirements in order to enable it to perform its given 
 work in a perfect manner — the functions of the various 
 parts must be performed in harmony, and the purely me- 
 chanical parts must operate without friction or failure, 
 and not break or yield when subjected to the normal 
 strains of the working machine. While this human 
 machine has been well designed, its construction is not 
 alwaj^s in accordance with its requirements, and the re- 
 sults are, naturally, variable — one will succumb to the 
 first strain almost as soon as finished, some vital part in 
 such an instance having inherited the tissue too frail to 
 do its |)art in the work of life. Defective construction in 
 others may be manifested in functional disorders, leading 
 to incomplete metabolism, gout}^ diathesis, tubercular 
 tendencies, etc. ; or the lack of structural integrity may be 
 marked in the jDurely mechanical tissues — those which 
 
 48 
 
ETIOLOGY. 49 
 
 have to do with the binding together of different parts, 
 the sustaining tissues — aponeurosis, fascia, tendon, and 
 muscle. In this manner the tendency to hernia, uterine 
 displacements, lateral curvature of the spine, prolajpse of 
 the internal organs of the body, etc., may be transmitted 
 by heredity as well as a crooked nose, imperfect teeth, or 
 other impro23erly constructed anatomy. A man says he 
 has a hernia caused by a strain, whereas the strain was 
 but a contributing incident, while the real, the funda- 
 mental, cause of his rupture existed before he was born — 
 even at the inception of his existence, concealed in the 
 germinated ovum. It would appear, therefore, that the 
 causes of displacement of internal organs are both pas- 
 sive and active — the former being the primary, or funda- 
 mental, etiologic factor, and the latter the secondary, or 
 contributory, causes. Finely drawn theories and elabo- 
 rate arguments are not necessary to substantiate this po- 
 sition, as clinical evidence in its favor is abundant. The 
 author has one family of three generations under his care 
 in which nephrocoloptosis occurs in the grandmother, 
 mother, and two daughters. This is not a coincidence, 
 but the outcome of natural law. 
 
 On the other hand, it does not seem reasonable that the 
 small weight of the kidney alone is sufficient to cause its 
 displacement, even when loosely secured, and so we must 
 look to the secondary or contributing causes for the link 
 to complete the causative chain. To prove it when found, 
 it must be always present with the nephroptosis, and its 
 action must be positive — mechanically positive. In colo- 
 ptosis and in the action of the nephrocolic ligament these 
 conditions are fulfilled. This conclusion is substantiated 
 by the evidence of the author's radiographic investiga- 
 tions, which show coloptosis present in all of a large num- 
 ber of cases of nephroptosis examined. 
 
50 NEPHEOCOLOPTOSIS. 
 
 Tliat the kidney is infiiiericed by tlie bowel, aud uot the 
 bowel by the kidney, is proved by the fact, as stated, that 
 all the eases of iDrolajDsed kidney had also prolajDsed 
 bowel, while a number of radiographs showed lorolapsed 
 bowel with normalh' jDlaced kidnej^, which is an indorse- 
 ment of Glenard's theory. The presence and action of 
 the nephro colic ligament makes it the most important 
 factor in connection with the secondary or contributory 
 causes, as by it the prolapsing colon pulls the kidney out 
 of place. 
 
 The factors necessary for the occurrence of nephrocolo- 
 ptosis are four in number, viz.: (1) weak or absent hep- 
 atocolic ligament, (2) loose attachment of kidney at its 
 hilum and to Gerota's cajDSule, (3) strong and short neph- 
 rocolic ligament, and (4) prolapse of cecum and ascend- 
 ing colon. Without this combination the kidney will 
 not be displaced, except by trauma. If the kidney is 
 bound strongly to the back by the tissues around the 
 hilum and blood vessels, and to the perinephric fascia 
 (Gerota's capsule), as usuall}' found in post-mortem, it 
 should not be only impossible to dislodge it by traction, 
 but, with a strong nephrocolic ligament, this mechanical 
 arrangement should assist in preventing a coloptosis, and 
 this is the normal mechanical action of these parts. 
 
 Reference to the radiographs of cases will show that 
 the laxity of the peritoneal attachment of the colon at the 
 hepatic flexure is the key to the whole line of descensus. 
 When this gives way, the cecum and ascending colon 
 drop, and the drag on the kidney through the nephrocolic 
 ligament begins. Hence the conclusion is reached that 
 the right kidney does or does not descend according to 
 the laxity of its supports and the degree of traction ex- 
 erted on it by the dropping of the ascending colon and 
 cecum, which is permitted by a lax, or absent, hepato- 
 
ETIOLOGY. 51 
 
 colic ligament. Tlie cecum, consisting of a sac with its 
 outlet upward, necessitates the contents of the viscus to 
 be always forced in that direction, which recjuires the 
 application of tractile force in the opposite direction, and 
 through the nephrocolic ligament the kidney is pulled 
 downward. (Figs. 3, 4, 5, 6.) AVhen to this natural 
 downward traction of the bowel is added the weight of 
 a full torpid cecum, distended more or less with fecal 
 matter, the force applied to the downward movement 
 of the kidney will 1)e still greater. The violent efforts 
 of the bowel to unload itself when so distended, and 
 to forccrthe contents over the acute angle at the hepatic 
 flexure, formed by the descent of the gut on each side, 
 aid materially in the completion of this etiologic factor. 
 The action of the colon on the left side is in the opposite 
 direction, and its contents are there forced downward, 
 thus making no countertraction on the kidney of this 
 side through the nephrocolic ligament. The phrenocolic 
 ligament, which supports the bowel at the splenic flexure, 
 is also an important factor in the prevention of displace- 
 ment of the gut at this point, as — unlike the hepatocolic 
 ligament — it is always present, and uniformly strong and 
 dependable. In consequence of these favorable mechan- 
 ical conditions the left kidney is rarely dislodged. When 
 the right kidney is forced downward by the dropped as- 
 cending colon, it pulls with it the duodenum by reason of 
 the adhesion of this intestine to the side of the fatty cap- 
 sule, and this action, causing a kink or angle in the bowel 
 and often closure of the biliary and pancreatic ducts, ex- 
 plains the presence of digestive and biliary symptoms in 
 cases of prolapse of the right kidney. Prolapse of the left 
 kidney alone is exceedingly rare, and when it does occur 
 from any cause, except trauma, gives practically no 
 symptoms. As the author has never found a left dislo- 
 
52 NEPHROCOLOPTOSIS. 
 
 cation singly, and but eleven cases of floating kidney of 
 the left side in one hundred and fifty-three nephroptoses 
 of the right, there mnst be some good reason for the great 
 difference. The weak jDoint of construction in the hepato- 
 colic ligament, the presence of the nephrocolic ligament, 
 and the action of the ascending colon and cecum explain 
 this in the most satisfactory manner. As a purely me- 
 chanical proposition it can not be refuted if the presence 
 of the ligament is admitted. (Figs. 3, 4, 5, 6.) 
 
 Goloi^tosis without nephroptosis is due to the presence 
 of a long, loose, nephrocolic ligament, which allows the 
 bowel to descend without making traction on the kidney. 
 This has been found to be true in several operations for 
 the cure of constipation and colonic irritability in cases 
 of coloptosis without nephroptosis. 
 
 Much has been said of late regarding the body shape as 
 a cause of nephro]3tosis, and deductions have been made 
 based on elaborate measurements and mathematical cal- 
 culations, but this theory has been found to be of little 
 ]3ractical use from either an etiologic or diagnostic stand- 
 point. While a large number have the conformation of 
 body described, many do not fill the requirements at all, 
 so that the author has come to look upon the imperfectly 
 developed body in these cases as due to the same primary 
 cause as the ptoses which are so frequently found asso- 
 ciated with it — viz. : hereditary laxity of restraining tis- 
 sues. Therefore, the body shape should not be consid- 
 ered in any sense as a primar}^ cause, but simjjly as a 
 concomitant condition. It acts, no doubt, to a consider- 
 able extent as a secondary or predisposing cause, and in 
 the therapeusis should receive treatment as such. 
 
CHAPTEE III. 
 
 SYMPTOMATOLOGY. 
 
 The symptoms caused by the displaced colon and kid- 
 ney are so complex and their manifestations so varied 
 that the patient is liable to be treated for all manner of 
 ailments which do not exist, and frecpiently gives a his- 
 tory of having ''suffered with many physicians" — con- 
 sulting doctors of all kinds, and each finding good symp- 
 tomatic grounds for classifying the i^atient in his special- 
 ty. The gastro-enterologist now gets the most of them, 
 with the neurologist (or psychiatrist) a close second. 
 The surgeon has been making a rather unsuccessful bid 
 for them by his nephropexies, which failed so frecpiently 
 because his pathologic vision took him no farther than 
 the loose kidney. 
 
 An intelligent consideration of the true etiology makes 
 plain the understanding of the symptomatic manifesta- 
 tions which lead to correct diagnosis and prognosis, and 
 to practical and efficient treatment. Hence, to under- 
 stand the symptoms and know what they mean we must 
 know what causes them. The first s^miptoms indicative 
 of a nephrocoloptosis are usually not those referable to 
 the kidney, but to the stomach or colon. Because of the 
 traction on the duodenum, with resultant angulation of 
 the bowel and interference with the function of the bili- 
 ary and pancreatic ducts, gastric manifestations will be 
 the most likely to be the first in evidence, and a super- 
 ficial diagnosis made of "indigestion" and "biliousness." 
 The symptoms are those ordinarily ascribed to dyspepsia 
 —distress after eating (referred to the right epigastric 
 
 53 
 
54 NEPHEOCOLOPTOSIS. 
 
 region), eructation of gas, occasional nausea, etc. The 
 complexion becomes muddy, or a slight jaundice may 
 occur. 
 
 The resultant loss of flesh and a general appearance of 
 malnutrition soon show markedly the result of the de- 
 rangements of the digestive system. Concurrently with 
 the gastric manifestations, or possibly preceding them, 
 there will occur those referable to the colon, caused by its 
 angulations and resultant sacculations and stasis of gas 
 and fecal matter. The most immobile points of attach- 
 ment of the colon are at the hepatic and splenic flexures, 
 so that when the cecum and transverse colon become dis- 
 placed, and lie low in the abdomen and pelvis, these two 
 high attached portions of the bowel — being hung up, as it 
 were, like a rubber tulie over a peg — cause sharp angu- 
 lation in each upper h3q3ochondriac region, which partial 
 obstruction of the bowel at these points causes the prin- 
 cipal colonic symptomatology. Pain is usually com- 
 plained of at the points of flexion, and assumes at times 
 a severe colicky character, that on the left side often be- 
 ing the most marked and of a more severe character, 
 which is doubtless caused l)y the greater mechanical 
 obstruction being at that point, as a result of the sag 
 of the transverse colon toward this side, due to the re- 
 laxation of the hepatocolic ligament, thus bringing the 
 greatest weight of the bowel to hang on this support. 
 (Figs. 4, 6, and radiographs of cases.) 
 
 The difficulty experienced by the cecum in evacuating 
 its contents frequently causes severe pain, with spastic 
 contraction of the gut, which is sometimes so severe as to 
 simulate peritonitis, or appendiceal disease. During such 
 attacks the distended sensitive cecum can, as a rule, be 
 easily demonstrated by palpation, and, as its descensus 
 mav be so extensive as to cause it to lie in the bottom 
 
SYMPTOMATOLOGY. 55 
 
 of the pelvic cavity, the position of the fulhiess and sensi- 
 tiveness may be deceptive and lead to faulty diagnosis. 
 
 The toxemia resulting from stasis of the colonic con- 
 tents, and the constant activity of the colon in its efforts 
 to free itself of the overdistention by forcing its contents 
 over these angles, causes a condition of chronic irrita- 
 bility of all of the structural parts of the bowel, besides 
 toxic symptoms of more or less severity. The mucous 
 membrane is the first to suffer, then the musculature, and 
 lastly that portion of the sympathetic nervous system 
 supplying the gut. The indications will be: (1) colonic 
 catarrh, as shown by masses of mucus in the stools, obsti- 
 nate constipation, and frequently alternating diarrhea 
 and constipation; (2) frequent attacks of colic, often of 
 long duration and of severe character, causing sensitive- 
 ness of the colonic region for long periods of time; (3) 
 nervous manifestations of various kinds and degrees of 
 severity, among which the most common are sudden at- 
 tacks of headache or vertigo, hysteria in various forms, 
 tachycardia (very common, often occurring at night dur- 
 ing sleep, causing a sudden awakening with feeling of 
 impending danger), insomnia, loss of menior}^, and mental 
 irritability. In cases of long standing a condition of 
 neurasthenia often develops that may lead to the most 
 extensive serious disorders of the nervous system, even 
 to the derangement of the reasoning faculties. 
 
 A comprehensive and forceful opinion regarding the 
 disturbance of the nervous system related to conditions 
 under consideration is the following by G. B. Burr, M. D., 
 medical director of Oak Grove Hospital for Nervous and 
 Mental Diseases, Flint, Mich.: 
 
56 IsTEPHEOCOLOPTOSIS. 
 
 Psychopathic Nephroenteroptic Symptomatology. 
 
 The theory of autotoxis as a causative factor in the psychoses 
 and neuroses has furnished a working basis for the explanation 
 of certain departures from the normal in the cerebro-spinal 
 sphere of activity. That the theory has been overloaded, possi- 
 bly goes without saying. This is unfortunately true of every 
 illuminating theory, but many pursuing the treatment of nervous 
 and mental maladies are reasonably well assured that deductions 
 from the favorable action of eliminatives post hoc justify the fur- 
 ther propier hoc assumption of the causative relation of retained 
 toxins to nervous perturbation. 
 
 Constipation is a bane of mankind, and seems unavoidable 
 under present-day conditions of living and work. It is espe- 
 cially the bane of womankind, and is often developed at an early 
 period of life through inadequate or indecent toilet facilities in 
 the public schools. "AYe have taken your advice and built our 
 new school-house around the Avater-closet, " said an experienced 
 member of a Board of Education to the writer on one occasion. 
 
 Constipation is indubitably a factor in, if not the ultimate 
 cause of, a frightfully large proportion of mental cases. Its 
 correction and the relief of incidental malassimilation are ends 
 to which the experienced psychiatrist directs early effort. Real- 
 izing the importance of elimination, it is impossible to refrain 
 from a congratulatory expression to the author of this book for 
 his painstaking directions for the medical relief of intestinal 
 torpor. Symptomatically the nervous case is invariably im- 
 proved by skillful attention to abdominal conditions arising from 
 constipation. Is your mental patient restless — attend to the 
 bowels. Is he irritable — attend to the bowels. Acquaint your- 
 self with the condition of the teeth, the ears, the eyes, the chest 
 organs, the kidneys — but incidentally unload the bowels. Is he 
 sleepless — see that the bowels are active. Is he lacking appetite 
 — empty the bowels. In the experience of the writer the best 
 hypnotic is ofteii a dose of castor oil, and the best tonic a colon 
 tlushing. Elimination and again elimination — ton jours elimina- 
 tion should be the watchword in the treatment of morbid mental 
 states. 
 
 It is probable that fecal impaction of large amount is a more 
 frequent condition than is generally recognized. Experience in 
 
SYMPTOMATOLOGY. 57 
 
 many cases — one very recent — indicates that impaction may be 
 present in extreme degree Avithout obvions abdominal indications 
 pointing to colonic distention. Nurses may be deceived by the 
 appearance of regularity in patients' stools, Avhile emptying the 
 intestinal canal at higher levels than the sigmoid does not occur. 
 "When through Avell-directed effort this finally takes place, the 
 amount of fecal accunuilation may be astounding. 
 
 That perverted emotional states in relatively healthy individu- 
 als may be induced I^y temporary bowel inactivity needs no dem- 
 onstration to one ha])itually regular in this function. Prevented 
 from its performance, there are irritability, hebetude, lassitude, 
 malaise, vaso-motor perturbation; the person's mental output is 
 indifferent and his emotional responsiveness is unstable. Add 
 to the sensations thus induced the results of months or years of 
 habitual constipation, and it is not difficult to understand how 
 morbid habits of thinking may be augmented, if not engendered, 
 by chronic bowel torpor. 
 
 It follows logically that any structural impediment to peristal- 
 sis should, if possible, be relieved, and that if relieved the symp- 
 toms dependent upon it will improve. Mechanical difficulties 
 (obstructions) that surgery can reach should be relegated to the 
 hands of the operator. The writer has no interest in that con- 
 ception of surgery which constitutes it the be-all and end-all in 
 treatment. Patients subjected to ill-advised operation are ren- 
 dered worse instead of better. The efficient and helpful surgeon 
 to nervous and mental cases must needs repress the enthusiasm 
 for operating and intelligently apply common-sense principles in 
 their care and medication. Many cases recover after surgery 
 when the operation is but an episode. A morbid condition has 
 been relieved, a focus of irritation removed, and the patient is 
 afforded a benefaction comparable with that furnished by a 
 dentist who extracts an aching tooth. In addition, the nursing 
 attention, the prolonged quiet, the rest in bed, are all adjuvants 
 to his betterment. 
 
 Again, mental and nervous cases recover where obvious and 
 palpable lesions, as of the pelvic floor and uterus, are left un- 
 corrected. The writer has been amazed at the facility with 
 which theoretically pure surgical cases from time to time re- 
 cover without surgery; on the other hand, he has observed the 
 
58 NEPHROCOLOPTOSIS. 
 
 beneficent results of surgical attention again and again in mental 
 cases. Eectification of the position of a displaced kidney has 
 been contributory to the relief of morbid depression in a case 
 upon which Dr. Longyear operated and in which he and the 
 writer were jointly interested. 
 
 The pathological connection between kidney displacement and 
 morbid mentality has been heretofore difficult of establishment. 
 That the downward dislocation is due, according to the ingenious 
 observations of Dr. Longyear, to a dragging on the nephrocolic 
 ligament — the primary fault being one of displacement of ali- 
 mentary and emunctory organs, with consequent embarrassment 
 to their functionating — sheds a flood of light on the subject. 
 The question resolves itself into one of impaired nutrition and 
 autotoxis, and the sequence of events in their etiological bearing 
 upon morbid processes in the nervous system is made as plain 
 as a pikestaff. He who runs may read their significance. 
 
 The combination of the effects of the colonic disorder 
 with the malnutrition resulting from the interference 
 with the gastric and hepatic functions causes, in extreme 
 cases of long duration, a facial expression which is quite 
 as characteristic and tYi)ical of this condition as the well- 
 known facies ovarina is of ovarian tumor. The muddy, 
 colorless complexion, lusterless eyes, deep facial lines, ex- 
 pressing weariness and exhaustion, and lack of natural 
 roundness of outline, mark the face of the patient suffer- 
 ing W'ith nephrocolojotosis. 
 
 Constipation of a more or less persistent character, 
 either alone or alternating with diarrhea, and the move- 
 ments usually accompanied by colicky pain, is a very 
 characteristic manifestation. The author has found this 
 condition of the bowels to be present in 74 percent of the 
 last one hundred cases. 
 
 Severe colicky i)ain in the right inguinal or lumbar 
 region may be caused b}^ the spastic condition of the 
 cecum, due to fecal accumulation. This is of frequent 
 
SYMPTOMATOLOGY. 59 
 
 occurrence, owing not only to the obstructive angle at the 
 hei3atic flexure, but also to the backing up of the colonic 
 contents from the obstructive angle at the splenic flexure. 
 As the cecal contents are of a fluid character, and the 
 hepatic angulation always less acute than that on the left 
 side, serious obstructive symptoms at this point do not 
 occur. Symptoms of obstruction may occur, however, in 
 extreme cases of coloptosis by reason of fecal impaction 
 in the transverse colon. The explanation of this is seen 
 in those radiographs which show a large portion of the 
 transverse colon situated in such a manner as to lie 
 almost jDarallel with the descending part of the gut. This 
 necessitates the forcing of contents uj^ward and over the 
 acute angulation at the splenic flexure. Dilatation of the 
 cecum results from this back pressure, and causes much 
 of the symptomatology referable to thfijdg'liL_side of the 
 _gut. The author l)elieves that the majority of the symp- 
 toms which are usually attributed to the floating kidney 
 itself are more properly gastric, duodenal, or colonic. 
 
 Beyond Dietl 's crises and their secjuelge, the s}' mptom- 
 atic manifestations of the loose kidney itself are insignifi- 
 cant and not of a serious nature. A sensation of drag- 
 ging in the loin, or of a constriction just below the ribs, 
 and some tenderness on pressure constitute the indica- 
 tions which can be justly attributed to the loose kidney. 
 The severe pain often complained of in the right hypo- 
 chondrium is usually found, on critical examination, to 
 be located in the colon at the hepatic flexure; or the 
 duodenum may be the seat of irritation because of the 
 traction on it by the adherent kidney. 
 
 Dietl's crisis^ constitutes the most severe, acute, and 
 symptomatic indication of floating kidney. The attack 
 
 1 Dietl: "Wandernde Nieron und deren Einklemmung'," Wiener Medi- 
 zinisclie Woclienschrift. 1S64, vol. 14, pp. 36, 37, 3S. 
 
60 NEPHROCOLOPTOSIS. 
 
 commences suddenly, with severe jjain in tlie right side 
 at the site of the displaced organ, which becomes swollen 
 and tender. The bowels are tymjjanitic and sensitive to 
 touch, and the patient, with the knees drawn up and an 
 anxious and pinched expression, has the general ai3pear- 
 ance of one suffering from the onset of an attack of peri- 
 tonitis. Jaundice is sometimes observed, due doubtless 
 to the mechanical closure of the bile duct, either from 
 pressure of the swollen kidney or torsion of the duo- 
 denum. Nausea and vomiting are usually prominent 
 symptoms at the beginning of the attack. There is usu- 
 ally little or no rise of temperature, but, after the lapse 
 of from ten to twenty-four hours, fever may be in evi- 
 dence, even of a high degree, caused by intestinal toxemia 
 incident to extreme paresis of the bowel. In severe at- 
 tacks of long duration, acute nephritis, pyelitis, hydro- 
 nephrosis, or perinephritis may develo]3, when the usual 
 symptoms pertaining to these conditions will be manifest. 
 Micturition is frequent during the beginning of the at- 
 tack, and the urine may evidence ureteral irritation by 
 containing some blood and epithelium. Later, albumin, 
 casts, blood, and pus will indicate the involvement of the 
 kidney or its pelvis. 
 
 When jaundice is present, an erroneous diagnosis of 
 gallstone is liable to be made, and the swollen displaced 
 kidney may be mistaken for a distended, inflamed gall- 
 bladder. The tympanitic, sensitive abdomen, simulating 
 peritonitis, may also lead to error in diagnosis in the 
 direction of the appendix, ruptured gall-bladder, or pyo- 
 salpinx, and so cause the performance of unnecessary 
 and harmful surgery. 
 
 A case referred to the author recently by Dr. B. E. 
 Shurly occurred at Harper Hospital, and, as it presents 
 
SYMPTOMATOLOGY. 61 
 
 quite a typical illustration of an attack of Dietl's crisis, 
 it is herewith presented in detail. 
 
 Patient, female, unmarried, waitress, aged 40 ; admitted 
 January 5, 1909, giving the following history: Diseases 
 of childhood — measles, mumps, whooping-cough, and 
 scarlet fever; good recovery from all. When 20 years of 
 age had typhoid fever, from which she made good re- 
 covery, and which began with a '* bilious attack," at- 
 tended with great pain in the right side, similar to others 
 which she has had since. During the last three years 
 these have become more frequent. The seizure usually 
 commences with severe pain in the right hypochondrium 
 and epigastrium, occasionally vomiting at onset. Jaun- 
 dice is usuall}^ present and increases during the attacks, 
 sometimes markedly. Complexion naturally swarthy. 
 Attacks may last from two days to two weeks, one of 
 which, eight years ago, was extremely severe and lasted 
 for about eighteen days. Since then she has been taking- 
 olive oil and Carlsbad salts to regulate the bowels. Has 
 noticed that the attacks are more frequent when the 
 bowels are constipated, which is their usual condition, 
 requiring persistent efforts to move them. Between at- 
 tacks she feels fairly well, although frail and never very 
 strong. Never had any menstrual or urinary disorders. 
 
 Her present illness commenced ten clays before ad- 
 mission to the hospital, with severe j)ain in right hypo- 
 chondrium, chills, nausea and vomiting, slight headache, 
 jaundice, and rise of temperature. Says this is the first 
 attack, commencing with chills. Condition on entering 
 hospital: jaundice, not intense, but eyes somewhat yel- 
 low; lips and skin dry; temperature, 100° F.; pulse, 84; 
 respiration, 24. Pain severe in epigastrium and right 
 hypochondrium; nauseated, but not vomiting. Abdomen 
 much distended, tympanitic and tender to touch, espe- 
 
62 NEPHEOCOLOPTOSIS. 
 
 cially over the whole of the right side. Percussion 
 showed flatness in right hypochondrium and resonance 
 over other parts of abdomen. The sensitiveness and dis- 
 tention rendered j)alpation of the swollen kidney impos- 
 sible, and its contour could be judged only by percussion, 
 which indicated a mass more than double the size of the 
 kidney. 
 
 Urine by catheter: acid, slightly turbid, dark brown; 
 specific gravity, 1,020; albumin present (small quantity), 
 bile, few granular casts, and blood cells. 
 
 A diagnosis of Dietl's crisis, caused by torsion of the 
 pedicle of a floating' kidney, was made, and the following- 
 treatment ordered: physostigmin sulphat. gr. 1/100, 
 hypodermically every four hours; a high enema com- 
 posed of glycerine f)j, epsom salts fg, and water gvj, to be 
 used once daily; a low enema, to be retained, of normal 
 saline solution oviij, given every two hours; hot camphor 
 stupes over the abdomen; heroin gr. 1/10, hypodermic- 
 ally, when necessary for pain; fluid diet (no milk). 
 
 After five days of this treatment, with some modifica- 
 tions, the tympanitic distention had disappeared and the 
 nausea ceased. A large sensitive mass — the kidney — 
 could then be easily palpated in the right loin and extend- 
 ing well forward into the abdomen. This gradually di- 
 minished in size to nearly the normal kidney in ten 
 days more. 
 
 An examination of this case later showed a freely mov- 
 able kidney, and a radiograph taken at the same time 
 (Fig. 83) showed the cecum in the pelvis and much of the 
 transverse colon with it. 
 
 This case, while typical of Dietl's crisis, is an extreme 
 one, and is cited as such; the usual attack, however, is not 
 so severe, and is often apparently of less diagnostic sig- 
 nificance. Frequently the attacks will last but a few 
 
SYMPTOMATOLOGY. 63 
 
 hours; and consist mostly of pain located in the right epi- 
 gastric region. Such attacks are often diagnosticated as 
 gastric neuralgia, or gallstone colic. These short seiz- 
 ures are doubtless caused by a slight torsion of the 
 jjedicle, of short duration, with consequent dragging and 
 kinking of the duodenum and common bile duct. 
 
 A floating kidney, even of the most extreme character, 
 may exist for years without the occurrence of this acci- 
 dent, but as a ptosis of any degree is always subject to 
 it, and as it is known to occur in cases thought to be of a 
 mild degree, prognosis in all cases should be guarded and 
 treatment guided by this fact. 
 
CHAPTER IV. 
 DIAGNOSIS. 
 
 Successful therapeusis — the ultimate aim of medical 
 science — must be founded on correct diagnosis. The 
 drudgery of painstaking examination can not be avoided 
 by the clinician, as his ultimate success in treatment de- 
 pends upon the accuracy of his findings. To prescribe 
 for a patient for intestinal dyspepsia and neurasthenia 
 without making a physical examination is neither scien- 
 tific nor honest, and yet the slipshod method of snap 
 diagnosis is too frequently i3racticed in the class of cases 
 under consideration. 
 
 Snap diagnosis often appears wonderful and impress- 
 ive when witnessed by the inexperienced, but such 
 methodless practice should have no place in the exercise 
 of knowledge pertaining to any branch of the medical art, 
 and least of all to that of diseases of the abdomen, where 
 error may lead to dire disaster. Symptoms of a mild 
 character, meaningless to the tyro, may be of great diag- 
 nostic value to the experienced clinician, as he has 
 learned — that which every good diagnostician must 
 know — the value of symptoms. This knowledge enables 
 him to translate these ofttimes seemingly meaningless 
 signs into the language of disease. 
 
 I know of no class of cases in the field of pathology that 
 will yield a more fruitful reward for correctness in diag- 
 nosis, to both the patient and physician, than these en- 
 teroptics, whose manifold complainings are apt to be mis- 
 taken for hypochondriasis and the imaginings of the 
 chronic dyspeptic. The histories of these cases are ex- 
 
 64 
 
DIAGNOSIS. 65 
 
 ceedingly valuable as diagnostic indices, and should be 
 taken with care, as it is the analysis of the history, in 
 connection with existing symptoms, which points to the 
 probable diagnosis, and determines the necessity of fur- 
 ther investigation by means of physical examination. 
 
 Such a history is usually one of long-standing dys- 
 pepsia, with constipation- — or alternating constipation 
 and diarrhea — gradual loss of flesh, nervous exhaustion 
 and irritability, muddy comjolexion, and a drawn, weary 
 expression of countenance, frequent attacks of griping 
 pains in the lower abdomen, often located in the region 
 of McBurney's point; mucus in the stools, and often pain 
 in the left upper abdomen in the region of the splenic 
 flexure of the colon. Occasionally a patient will tell of 
 attacks of terrible pain in the right side, attended with 
 swelling around the kidney, fever, jaundice, etc., which 
 are recognized as attacks of Dietl's crisis. Few patients 
 will give all of these manifestations pointing positively 
 to the kidney and colon, and many will exhibit but few. 
 It is especially in such indefinite and obscure cases that 
 the physical examination and the x-ray will give the posi- 
 tive results that make the diagnosis clear. All cases hav- 
 ing abdominal symptoms should be examined physically, 
 and this is especially true of the obscure cases. 
 
 The physical diagnosis of nephrocoloptosis is a simpler 
 proposition than that of coloptosis alone, because of the 
 easily palpated kidney, and the fact that the colon is al- 
 ways prolapsed when the kidney is displaced makes the 
 coloptosis a foregone conclusion when the nephroptosis 
 is ascertained. 
 
 To palpate the kidney, posture is of the greatest im- 
 portance. The subject must be in such a position that 
 the muscles of the abdomen, the loin, and the thoracic 
 region will be relaxed. The position of standing with 
 
66 
 
 NEPHR0C0L0PT0SI8. 
 
 forward bending of the body, with arms resting on some 
 support, is found unsatisfactory because of discomfort 
 to the patient, if a woman, and inability to control the 
 muscular movements when in this position. The dorsal 
 and lateral postures, which the author uses exclusively, 
 have none of these objections, and serve the purpose ad- 
 mirably. 
 
 Fig-. 14. Sliowing- technic of physical exauiiiuiUon for nepliroptosis. 
 Dorsal decubitus. First position of examiner's hands. 
 
 First place the patient on the back, with a small pillow 
 under the head, the thighs flexed and heels close to the 
 buttocks. Expose the abdomen and the lower thoracic 
 region. (Figs. 14, 18.) Standing on the left side of the 
 patient, place the tips of the fingers of the right hand in 
 the triangular space in front of the right quadratus lum- 
 borum muscle, and just below the twelfth rib, and the 
 tips of the fingers of the left hand in front, just below the 
 
DIAGNOSIS. 
 
 67 
 
 costal margin of the same side. Direct the patient to 
 take a deep inspiration, allowing the fingers to gently 
 follow the movement of the parietes. When inspiration 
 is full, have the patient expire the air completely from 
 the lungs, and as this is being done press — at first gently, 
 then deeply — with the fingers of both hands, approximat- 
 ing them toward each other. At the end of expiration re- 
 
 Fig. 15. Showing technic of physical exumiiiation for nephroptosis. 
 Dorsal decubitus. Second position of examiner's hands. 
 
 place the fingers of the left hand with the thumb of the 
 right, continuing deep compression, and palpate below for 
 the kidney with the left hand. (Figs. 15, 19.) This will 
 usually dislodge a floating kidney of any degree of dis- 
 placement so that it can be felt, either wholly below the 
 costal margin or partially below. In some cases, how- 
 ever, failure results, owing to absence of muscular relax- 
 ation or limited action of the diaphragm. In others. 
 
68 
 
 NEPHROCOLOPTOSIS. 
 
 Gerota's capsule may prevent a downward displacement, 
 while permitting free mobility of the kidney toward the 
 median line. 
 
 If the foregoing form of examination is negative, the 
 lateral position mnst be tried. Turn the patient on the 
 left side, with the right hip showing a little more than a 
 quarter turn; flex both thighs slightly, the right one the 
 
 Fig. 16. Showing' teclmic of physical examination for nepliroptosis. 
 Lateral decubitus. First position of examiner's Irands. 
 
 most; proceed in the examination technic as described for 
 the dorsal position. (Figs. 16, 17, 18, 19.) This will 
 never fail to bring the loose kidney to the palpating 
 
 fingers. 
 
 The important detail in any examination is to bring 
 about as complete muscular relaxation as possible. In 
 investigation of the left side the examiner may find it 
 convenient to stand to the right of the patient, but as one 
 
DIAGNOSIS. 
 
 69 
 
 becomes expert this cliange of position is not necessary. 
 Sucli an examination may be made without exposure. 
 
 Generally, the best method to determine the position 
 of the stomach is by the use of the radiograph, but when 
 this can not be emjoloyed it may be quite readily ascer- 
 tained by percussion and palpation after inflation with 
 carbonic acid gas, liberated through the action of tar- 
 
 Fig. 17. Showing- teclinic of physical examination for neplaroptosis. 
 Lateral deculjitus. Second position of examiner's liands. 
 
 taric acid upon bicarbonate of soda. In the diagnosis of 
 the displaced colon the inflation of the gut will not be 
 wholly satisfactory. First, there is the inconvenience of 
 using air or gas by way of the anus, and, when success- 
 fully emj^loyed to distend the viscus, such distention 
 tends to straighten out and shorten the gut, and to give 
 a false impression of the position of the bowel when pal- 
 pated and percussed. Furthermore, the acute angle at 
 
70 
 
 NEPHEOCOLOPTOSIS. 
 
 the splenic flexure, when the bowel is prolapsed, favors 
 obstruction of the lumen of the bowel and prevents the 
 easy passage of air beyond the ascending colon. In the 
 absence of other and better methods, however, this may 
 be resorted to, care being taken not to distend the bowel 
 to its utmost capacity. The inflation of the bowel is best 
 accomplished with the patient in the dorsal position, and 
 
 Fig. IS. Showing techuic of physical examination for neplii'optosis. 
 First position of examiner's liands in botli positions of the patient. 
 
 by means of air furnished by an ordinary Davidson 
 syringe. Slow distention is preferable. Percussion and 
 pal]jation, made both before and after inflation, will de- 
 termine the position of the bowel. 
 
 The most accurate and satisfactory way of demon- 
 strating the location of both the colon and stomach is by 
 the use of the x-ray. The radiographs obtained have the 
 advantage of showing the viscera in their ordinarj^ state 
 
DIAGNOSIS. 
 
 71 
 
 of distention and repose, so that a true idea may be had 
 of the existing condition. Photographic prints may also 
 be made for recording cases and for demonstration. 
 
 Directions for Preparing the Patient for a Radiograph. 
 
 One ounce of subnitrate of bismuth in a pint of milk, 
 koumiss, or gum acacia solution is given from fourteen 
 
 Fig-. Ill, Sliuwiiig Lechuic ui [j1i> .sical examination for nephroptosis. 
 Second position of examiner's hands in both positions of the patient. The 
 kidney is held in ptosis by deep pressure of the thumb under the costal 
 margin and palpated by the tips of the fingers of the left hand. 
 
 to eighteen hours before the colon is to be rayed. Im- 
 mediately after the ingestion of the mixture a radiograph 
 is taken of the stomach, and again at the expiration of 
 the longer time as the bismuth reaches the bowel. The 
 time necessary for the bismuth to reach the colon is 
 somewhat v^ariable, depending largely on the condition 
 of activity of the intestine. If diarrhea be present, or if 
 
72 NEPHROCOLOPTOSIS. 
 
 a cathartic has been previously given, the bismuth will 
 find its way much more rapidly than if the alimentary 
 tract has been undisturbed. On the other hand, if given 
 to a patient whose bowels have not acted for several 
 days, the bismuth will fail to reach beyond the cecum. 
 
 For a radiograph of the descending colon, sigmoid, and 
 rectum the bismuth emulsion must be introduced by the 
 anus, as the splenic flexure usually resists the passage of 
 it beyond the transverse colon when given by the mouth 
 — unless a longer time is observed, and then it will have 
 passed beyond the cecum and no shadow of this part of 
 the bowel will be in evidence. 
 
 The standing position should always be used when the 
 apparatus will permit, as the displaced organs are then 
 in their most abnormal position of ptosis. 
 
 The following specific directions for making the radio- 
 graphic negative are kindly furnished by P. M. Hickey, 
 M. D., editor of the American Quarterly of Bontgenologi/, 
 who has done all of the radiographic work in connection 
 with the investigation of this subject: 
 
 Technic of the Examination of the Gastro-Intestinal 
 Tract by Means of the Rontgen Ray. 
 
 In considering the use of the Rontgen ray as an aid in the diag- 
 nosis of malpositions of the abdominal organs, particularly the 
 stomach and intestines, we must recollect, first of all, that the 
 plate which is obtained is a record of density of the part. When 
 we examine, for example, the chest, we have the density of the 
 heart forming a decided contrast to the density which is present 
 in the lungs, so that in this way we obtain very marked contrast. 
 When, however, Ave pass the Rontgen ray through the tissues and 
 organs below the diaphragm, we find that the resulting plate, on 
 account of the similar density of these parts, shows only a slight 
 difference in its shading. Accordiiigly, then, we must introduce 
 into the stomach and intestines some material which will have a 
 
DIAGNOSIS. 73 
 
 much greater weight than these soft parts. A number of dif- 
 ferent elements and chemicals have been used for this purpose, 
 but the substance which has seemed most suitable has been either 
 the isubnitrate of bismuth or the subcarbonate of bismuth. 
 
 For the purpose of outlining the stomach, one ounce of sub- 
 carbonate of bismuth can be administered either in watery solu- 
 tion or, preferably, in a thick solution. Kefir or koumiss holds 
 it in suspension for a long time. For the purpose of affording 
 a landmark upon the plate, a metallic object, as a small coin, 
 may be placed over the umbilicus and held in position by adhe- 
 sive plaster; but, if the abdominal wall is pendulous, as in obese 
 persons, the metallic marker can be attached to the tip of the 
 xiphoid cartilage. The plate can now be taken either with the 
 patient recumbent, Avith the abdomen resting upon the plate, or, 
 if we wish to know the amount of gastroptosis which is present, 
 we can make the plate with the patient in a standing position. 
 
 For the technic of making the plate it is necessary to employ 
 an x-ray apparatus that is sufficiently powerful to allow the ex- 
 posure to be made in a few seconds, while the patient holds his 
 breath. If the patient is allowed to breathe during the time 
 while the plate is being made, a blurring of the outlines occurs, 
 due to the communicated respiratory movements. If the exami- 
 nation is successful, we have the size, shape, and position of the 
 stomach graphically outlined. The use of this method of ex- 
 amination has quite revolutionized the ideas of the medical pro- 
 fession in regard to the average shape and position of the stom- 
 ach. From a large series of plates that have been made by 
 numerous observers in various parts of the world it has been 
 learned that the ordinary anatomical illustrations are entirely 
 at fault. 
 
 Owing to the rapid movement of the bismuth through the 
 small intestine, it has been impossible, so far, to obtain satisfac- 
 tory representations of the small intestine, except in cases of 
 marked stenosis of this part of the gut. "When, however, the 
 bismuth has passed on into the large intestine, we find that, owing 
 to the slowness of its passage through that part of the alimentary 
 tract, we can obtain an accurate idea of the position and angula- 
 tions of the large gut. 
 
 The length of time that it is necessary to allow to elapse be- 
 
74 NEPHROCOLOPTOSIS. 
 
 tween the taking of the plate of a stomach and the plate of the 
 large intestine will be found to vary in different individuals. 
 If peristalsis is rapid and the contents of the intestine are passed 
 along quickly, twelve to fifteen hours will be found sufficient. 
 If, however, the peristalsis is slow, it will be found advantageous 
 to wait from eighteen to twenty-four hours. The time of ex- 
 posure necessary to obtain a plate of the large intestine will be 
 found to be slightly longer than to obtain a plate of the stomach, 
 as the amount of abdominal tissue necessary for the rays to trav- 
 erse is somewhat greater. In this plate it will be found, also, 
 that distinctness and clearness of outline will be enhanced by 
 having the patient hold his breath during the time that the x-ray 
 tube is acting. 
 
 The plates which we obtain of the large intestine show the 
 anatomical construction of this part of the bowel, the position 
 in the lower part of the abdomen or in the pelvis, and show 
 clearly the degree of angulation of the hepatic and splenic flex- 
 ures. 
 
 Some criticism has been offered on this method of examina- 
 tion, due to the fact that a few cases of unpleasant symptoms 
 have been reported from the use of these large doses of bismuth. 
 The following precautions are advisable : large doses of bismuth 
 should never be administered to children; subcarbonate of bis- 
 muth should ah^ays be employed in preference to the subnitrate, 
 as no cases of unpleasant symptoms have ever been recorded 
 where one ounce of subcarbonate has been given. Where larger 
 doses of the subnitrate have been given, say two and three 
 ounces, symptoms of nitrite poisoning have been observed. It 
 is always best, after the examination, to have the patient take a 
 quickly acting cathartic to clear the bismuth from the intestinal 
 tract. 
 
 As a substitute for bismuth, various forms of iron have been 
 proposed, but have not come into general use. The latest sug- 
 gestion is that zirconium oxide be employed, which has the great 
 advantage of being nontoxic and of making a more contrasty 
 plate. It is, of course, necessary in writing a prescription for 
 the bismuth that the C. P. bismuth, free from arsenic, should be 
 insisted upon. 
 
 For the examination of the plate it is advisable that after the 
 
DIAGNOSIS. 75 
 
 plate has been washed and dried it should be viewed in an illumi- 
 nating box, with the observer in a darkened room. The contrast 
 of an underexposed plate, such as is sometimes obtained of indi- 
 viduals with thick abdominal walls, can be increased by viewing 
 the plate at some dista7ice, employing, if necessary, an opera 
 glass to make the plate seem nearer to the eye. When one first 
 examines these plates he is often struck by a lack of detail, which 
 is due to the fact that he is unaccustomed to observe what to an 
 experienced eye would be important points. The more one sees 
 of these plates and the more he studies them carefully, the more 
 information will he gather from them. 
 
 For the successful employment of this new aid in diagnosis, 
 the rontgenologist should be in possession of a powerful modern 
 equipment. The ordinary type of static machine, which can be 
 successfully used for examination of the thinner parts of the 
 body, does not furnish enough current to permit of the examina- 
 tion being made while the patient is holding his breath. Some 
 of the newer types of static machine are, however, more efficient 
 and may be used for this work. 
 
 If the induction coil is used, it should be capable of energizing 
 a high vacuum x-ray tube. Some of the newer types of trans- 
 formers, which do not necessitate the use of an interrupter (as 
 does the induction coil), deliver a tremendous amount of elec- 
 trical energy, which can be transformed in the tube and produce 
 a plate in a few seconds. Given, however, a powerful generating 
 apparatus, the next necessary part of the equipment is a suitable 
 tube. This should be of the size and construction to permit of 
 its receiving and transforming, for a few seconds at least, a very 
 large quantity of current. 
 
 In making exposures through the thicker parts of the body, 
 as the abdomen, it is necessary that the vacuum of this tube 
 should be high, in order that the penetration may be sufficient. 
 It is obvious that if we use a tube of slight penetration, such as 
 would be useful in the examination of the hand or elbow, that 
 we will not be able to pass the rays through the body, and the 
 resulting plate will be a comparative blank. This matter of the 
 selection of a tube of high penetration is the most important part 
 of the Rontgen teehnic. 
 
 The size of plate employed is usually 14x17 inches. The en- 
 
76 NEPHROCOLOPTOSIS. 
 
 velope in which it is contained can be ruled with diagonal cross 
 lines, so that the center of the plate is indicated. The junction 
 of these cross lines should be against the umbilicus. The position 
 of the tube is of importance. In order to avoid distortion, the 
 central rays, or those which are perpendicular to the long axis 
 of the tube, should pass through the center of the plate ; in other 
 words, the center of the tube should be opposite the center of 
 the plate, and the plane of the plate and the plane of the tube 
 should be parallel. If the center of the tube is placed higher, 
 for example, so that it is opposite the heart, it is evident that the 
 very oblique rays which will strike the lower part of the pelvis 
 will produce a great deal of distortion. 
 
 In the development of the plate a contrasty developer, such as 
 hydrochiuon solution, with a large amount of carbonate of potash 
 and an excess of bromide of potash, will be of value. The tem- 
 perature of the developer is also of importance, as, if the solution 
 is warm, the resulting plate will be lacking in contrast. The 
 purpose of the whole Rontgen technic is to produce a plate that 
 will be free from distortion and full of contrast. 
 
 Differential Diagnosis. 
 
 The diseases having a somewhat similar symptoma- 
 tology to that pertaining to nephroptosis, nephrocolo- 
 ptosis, or coloptosis, should be carefully considered and 
 the differentiation made in formulating the diagnosis. 
 
 The most important pathological condition, and the 
 one most likely to be confused with the renal and colonic 
 displacements under consideration, is appendicitis. It is 
 the most important by reason of the relative frequency 
 of its occurrence, and also because of the fact that the 
 increasing familiarity with its manifestations leads to 
 eager and often unwarranted, incomplete, and erroneous 
 diagnostic conclusions. Pain and sensitiveness alone, at 
 the McBurney point, are too often made the basis of such 
 diagnosis. A cecum and ascending colon, chronically 
 distended by reason of angulation of the large intestine 
 
DIAGNOSIS. 77 
 
 anywhere in its course, will cause symptoms simulating 
 subacute appendiceal disease; and an acute distention, 
 witli rapid dilatation of the cecal end of the gut, will give 
 several local manifestations of such a nature as to re- 
 quire careful differentiation. The temperature and pulse 
 record, if normal, in the acute cases, is valuable evidence 
 against the diagnosis of apiDendicitis, but, if a febrile 
 condition be present, further investigation is required, as 
 intestinal toxemia, resulting from the colonic stasis, may 
 be its cause. Absence of the "board-like feel" of that 
 side of the abdomen is valuable in contraindicating ap- 
 j)endiceal disease, but in the j)resence of great sensitive- 
 ness the differentiation may be difficult and uncertain. 
 If a radiograph is practicable, the diagnosis may be 
 cleared immediately. The radiograph may show a dis- 
 tended cecum, with its distal end lying low in the pelvis, 
 indicating the j)resence of the appendix far from the 
 sensitive area around McBurney's poiat. This would 
 indicate the cecum and ascending colon as the location of 
 the manifested disease, and not the apjoendix. A very 
 good illustration apropos of this is seen in the report of 
 case 52. A patient suffering from the acute symptoms 
 of Dietl's crisis of a severe type may be considered as 
 having appendicitis, perirenal al3scess, or peritonitis. 
 The history of the attack and the location of the sensitive 
 area, showing, by jDalpation, continuity of structure be- 
 tween the anterior surface of the swelling and the space 
 in the loin just below the twelfth rib, point to the en- 
 larged kidney characteristic of Dietl's crisis. 
 
 A tumor of the right lobe of the liver may simulate a 
 floating kidney, and, if movable, may prove difficult of 
 differentiation without resort to exploratory abdominal 
 section. If a malignant tumor, the history of progressive 
 growth and constant pain, with attendant cachexia. 
 
78 NEPHROCOLOPTOSIS. 
 
 would warrant an exploratory section. Such a case pre- 
 sented these conditions to the author. Abdominal sec- 
 tion here revealed a neoplasm springing from the under 
 surface of the right lobe of the liver, the free lower mar- 
 gin of which could be felt before operation, passing over 
 the tumor and distinct from it. 
 
 A hard fecal mass, resembling a tumor, situated near 
 the hepatic flexure of the colon, may be mistaken for a 
 floating kidney. The free administration of petrolatum 
 oil and the use of high enemata containing glycerine and 
 epsom salts will usually clear the diagnosis within two or 
 three days. 
 
 A distended gall-bladder may simulate a floating kid- 
 ney. Its fixed position at a distance from the loin, and 
 inability to elevate it into the renal fossa by manip- 
 ulation, should render the diagnosis fairly certain and 
 determine exploratory section. 
 
 A uterine myoma having a long, thin pedicle may be 
 mistaken for a kidney. In such an instance the free 
 mobility of the tumor downward compared with its lim- 
 ited mobility upward, and the fact that traction is felt to 
 be exerted on the uterus when it is pushed forcibly up- 
 ward, should differentiate it from the kidney. 
 
 In severe cachexia, which is often present in cases of 
 extensive renal and colonic displacement, and frequent 
 attacks of pain in the epigastric region, caused by trac- 
 tion on the duodenum by the dropped kidney, may deter- 
 mine a diagnosis of duodenal ulcer. Radiographic ex- 
 aminations should result in correcting the error. 
 
CHAPTER V. 
 TREATMENT. 
 
 In the selection of the therapeutic measures adapted 
 to the i^athologic condition in question, the fact should 
 not be lost sight of that the symptoms which bring the 
 patient to the physician 's office are the result of a 
 mechanical disarrangement of certain organs, and that 
 consequently any treatment ajoplied for the relief of the 
 condition must of necessity be of such a nature as to 
 cause their rearrangement, or rigliting. Treatment other 
 than this is palliative, and not curative. And yet, for 
 the purpose of relieving symptoms caused by long con- 
 tinuation of the displacements, such sym]3tomatic treat- 
 ment is often necessary and of great value, not only in 
 bringing comfort to the patient and in the preparation 
 for curative treatment, but also as a valuable adjunct to 
 be used with the more radical therapeutics. While rare 
 cases do occur which are completely and immediately 
 cured by operation alone (see case 37), they are by 
 far the exception to the rule, as treatment by other 
 methods — sometimes before, but usually after, operation 
 — is necessary to achieve the best results in the shortest 
 possible time. While the author believes that by surgi- 
 cal treatment the only short route to success is attained, 
 and that very few cases — possibly of recent occurrence, 
 before colonic dilatation has occurred — can recover with- 
 out it, yet it must never be depended upon alone, to the 
 exclusion of other therapeutic measures. 
 
 A prominent surgeon recently remarked to the author 
 after the operation of nephrocolopexy and after-treat- 
 
 79 
 
80 NEPHEOCOLOPTOSIS. 
 
 inent liacl been described to liim: "I don't like your 
 operation because you liave to put on an abdominal band 
 afterward. When I operate I want the operation to 
 cure and without farther treatment. I don't want to see 
 the patients afterward." He was assured that it was 
 largely that mental attitude of the surgeon that had con- 
 tinued the use of the old unsatisfactory operation of 
 nephropexy, but a change of the visual standpoint must 
 now be made. If these patients are to be cured, the com- 
 plexity of the pathology must be recognized and all the 
 indications met. These are not ''Gordian knot" cases, 
 to be cured by one sweep of the knife, and the sooner that 
 idea is understood the better, both for the patient's wel- 
 fare and for the advancement of the medical art. 
 
 The successful operation merely places the patient in 
 position for nature to undo the damage done to mucosa, 
 muscle, and nerve by the displacements. The repair, the 
 regeneration of tired and worn nerves, the renewal of 
 muscular tone, and the restitution of long disordered 
 functions demand all the assistance possible until natural 
 conditions are assured. 
 
 Treatment may be considered under five heads, viz.: 
 Prophylactic, Medicinal, Topical, Mechanical, Surgical. 
 
 Prophylactic Treatment. 
 
 The consideration of the primary cause of the ptosis 
 is of paramount importance in the selection of the meas- 
 ures best adapted to the prevention of the displacements 
 of the colon and kidney. 
 
 The child showing a tendency to weakness of liga- 
 ments and muscular tissues should receive the most care- 
 ful attention duriug the whole of the developmental 
 period. Every effort should be made to gradually 
 strengthen the developing tissues of the entire body in 
 
TEEATMENT. 81 
 
 such manner as to cause symmetrical growth of the mus- 
 cular and bony parts, and toughness of the restraming 
 tissues. Most children of delicate physique, with heredi- 
 tary tendencies toward displacements, lateral curvature 
 of the spine, stoop shoulders, prominent shoulder blades, 
 hernia, and other muscular or ligamentous insufficiency 
 may be made to develop into healthy men and women. 
 Well-poised, graceful bodies will result, chronic invalid- 
 ism will be obviated, and the misery to themselves and 
 others from ill health and awkward deformity escaped. 
 
 To accomplish this properly requires intelligent direc- 
 tion and patient teaching on the part of the doctor, and 
 persistent application on the part of the patient and at- 
 tendants for a considerable time. Gymnastic exercises 
 are of the greatest benefit, and will accomplish the most 
 satisfactory results in these cases, but the exercises must 
 be carefully chosen with reference to the tendencies of 
 these patients, and they must be so applied and their in- 
 crease so graduated that the frail tissues which are to be 
 worked on shall be raised in tone and endurance slowly, 
 steadily, and surely, without depleting by overwork or 
 crippling by undue strain. The author has seen such 
 careful gymnastic training, carried out under the super- 
 vision of a competent orthopedist, accomplish really 
 wonderful results in the stimulation and development of 
 these weak tissues. 
 
 Breathing exercises should be conducted in ways to 
 develop the intercostal muscles and diaphragm, and 
 cause broadening and increase of capacity of the lower 
 part of the thoracic cavity. Moderate work with light 
 dumb-bells, exercises to develop the abdominal muscles, 
 correct posture in standing and sitting — all of these in- 
 telligently and persistently followed are of the utmost 
 value. 
 
82 
 
 NEPHEOCOLOPTOSIS. 
 
 The author has been so much impressed with the value 
 of well-directed orthopedic treatment in these cases of 
 imperfect development, that there is here presented a 
 
 Fig. 20. Faulty standing pos- 
 ture. Chin forward; chest sunk- 
 en; shoulders forward-drooped; 
 lumbar lordosis decreased; abdo- 
 men prominent; knees slightly 
 flexed; feet everted and pronated. 
 The appearance of exaggeration is 
 because persons in ordinary life 
 are clothed, and involuntarily as- 
 sume under observation an im- 
 proved attitude; faulty attitude is, 
 therefore, commonly not seen at 
 its worst. 
 
 Fig. 21. Favorable standing 
 posture. Chin retracted; chest the 
 most prominent part; shoulders 
 flat behind; abdomen flat; but- 
 tocks prominent; knees fully ex- 
 tended; feet straight forward. 
 
 supplemental and detailed article from the viewpoint of 
 the orthopedist by William E. Blodgett, M. D., member 
 American Orthopedic Association: 
 
 Orthopedic Considerations of Abdominal Ptosis. 
 
 Faulty posture may be a factor in causing or aggravating dis- 
 placement of abdominal viscera, and, correspondingly, favorable 
 
TREATMENT. 
 
 83 
 
 posture is important in prophylaxis and treatment of visceral 
 ptosis. 
 
 Faulty and favorable posture in standing and sitting are illus- 
 trated by Figs. 20, 21, 22, 23, from photographs of a normal, well- 
 developed child, 11 years old. This model is young enough to be 
 
 Fig-. 22. Faulty sitting- pos- 
 ture. Cliin for-ward and upward; 
 spine belo-w necli makes one long- 
 curve, convex back-ward; slioul- 
 ders forward-drooped; abdomen 
 prominent. 
 
 Fig. 23. Favorable sitting 
 posture. Chin retracted; chest 
 prominent; spine and abdomen 
 flat. 
 
 free from clothing deformity, artificial poses, and nervous con- 
 straint, and old enough to suggest the adult figure. 
 
 There are three chief ways in which faulty posture tends to 
 cause abdominal ptosis : ( 1 ) by reduction of the lordosis, or for- 
 ward convexity of the lumbar spine, with the attached soft parts, 
 which, when normally curved, makes a projecting shelf in the 
 lower half of the abdomen ; ( 2 ) by relaxing the recti abdominis 
 muscles; (3) by the general weakness, of which faulty posture 
 is a cause and a result. Faulty posture tends to reduce mental 
 
84 NEPHEOCOLOPTOSIS. 
 
 and moral vigor, and the resultant psychical depression reacts 
 unfavorably on the physical health. 
 
 Faulty posture may cause also structural round shoulders — 
 i. e., shoulders which can not be placed in normal position — sacro- 
 iliac joint strain (a very common cause of lumbago, coccygo- 
 dynia, and sciatica), and pronated painful feet. Presence of 
 any of these conditions assists in the diagnosis of habitually 
 faulty posture. 
 
 Treatment is chiefly by education and exercise in favorable 
 posture. The patient is first taught to assume the favorable pos- 
 ture upon command, and then to execute simple movements with- 
 out departure from this favorable posture — movements such as 
 breathing and symmetrical movements of the arms. A long mir- 
 ror in front of the patient is helpful. Next, the patient is taught 
 to execute more complicated movements of the whole body, always 
 starting from and returning to the exactly favorable posture. 
 In some cases the chief need is re-education and new co-ordina- 
 tion of the muscles to secure and hold favorable posture ; in oth- 
 ers the muscles and ligaments need strengthening as well. In 
 the latter cases, gradually increased weight-lifting and dumb-bell 
 exercises are indicated ; but in all these exercises exactly correct 
 posture is to be kept in mind and overexhaustion avoided. Spe- 
 cial exercises for strengthening the recti abdominis can be under- 
 taken, such as powerfully retracting the abdomen, and raising the 
 trunk from dorsal decubitus to the sitting posture. 
 
 When pain interferes with normal posture of any of the parts, 
 temporary artificial support may be needed, notably shoulder 
 supports, sacro-iliac joint supports (a tight belt about the pelvis, 
 just below the anterior superior spines), abdominal supports, 
 spinal jackets, and arch supports for the soles. Such supports 
 should be made to fit the individual patients and their special 
 needs; the object of them is to relieve pain, or assist in main- 
 tenance of favorable posture, without interference with normal 
 function, until natural support has become sui^cient and new co- 
 ordinations established. Passive resistance of the shoulders or 
 feet to being placed in favorable posture, or the presence of any 
 interfering deformity or disability, may require surgery. 
 
 In addition to this education and exercise in favorable posture, 
 clothing, outside air (especially at night), cold bathing, regular 
 
TEEATMENT. 85 
 
 and complete defecation, and general personal hygiene are to be 
 considered. If the clothing can not be suspended from the hips, 
 as in young girls, the supporting shoulder straps should pass 
 close to the neck and not over the more easily depressed tips of 
 the shoulders ; the corset, if worn, should be very loose in its up- 
 per half and properly shaped ; the stockings should be supported 
 by straps from slightly in front of the sides of the corset and not 
 from the front ; the shoes should have fairly straight inner bor- 
 ders, and broad, not excessively high, heels. These matters of 
 clothing and invigorating personal hygiene are all together an 
 important help in the establishment of favorable posture. 
 
 To prevent and assist in the care of abdominal ptosis, educa- 
 tion and exercise in favorable posture must be painstaking, exact, 
 and long continued. 
 
 Attention should be paid to the diet, and each patient's 
 digestive abilities and peculiarities studied, so that the 
 greatest benefit may be acquired from nutrition, and also 
 that intestinal toxemias do not poison this fountainhead 
 of supply. 
 
 It is of great importance that these patients be taught 
 natural methods of regulating the bowels, and the too 
 free use of cathartic medicines should be prohibited. 
 Eegular habits of going to stool should be advised. The 
 patient should go and make the effort to defecate at a 
 certain hour each day, preferably after breakfast, even 
 if there be no desire to have a movement. Long habit of 
 neglect of regularity of the function induces an obtuse- 
 ness of the nerves of the rectum, which allows distention 
 and often impaction of the viscus, without the patient 
 being aware of the condition by an}^ sensation of a desire 
 for defecation. The daily systematic effort to unload 
 the rectum will usually overcome this habitual torpor, 
 and gradually the natural sense of rectal fullness will re- 
 turn; the patient will know by the sensation when the 
 bowel needs emptying, and be uncomfortable until it is 
 
86 NEPHROCOLOPTOSIS. 
 
 accomplished, as is the case in the normal condition. 
 The patient should be instructed to exercise the anal and 
 rectal muscles, while attempting defecation, by alter- 
 nately raising and lowering the anus by muscular action. 
 The expulsive effort by the abdominal muscles should 
 accompany the relaxation, and, if the patient sits with 
 the knees high and thighs flexed against the abdomen, 
 the expulsive force will be augmented, and be more 
 natural than if sitting in the usual manner, with the 
 thighs at right angles to the body, or even somewhat 
 dependent. Abdominal massage may be used to advan- 
 tage. 
 
 The knowledge that colonic stasis, with the consequent 
 fecal accumulation and increasing weight as the bowel 
 expands, acts mechanically upon the hepatocolic liga- 
 ment,, and induces the beginning of the ptosis that gradu- 
 ally extends and causes the complex pathology under 
 consideration, should make this question of constipation 
 — especially among the young — a very important one 
 from a prophylactic standpoint. The family physician 
 may use his influence here to advantage in the prevention 
 of much future suffering. But, be the patient young or 
 old, the advice can not be too strongly emphasized. 
 
 If the kidney of a child is displaced in any degree, an 
 abdominal band should be worn until the formation of 
 a good intra-abdominal pad of fat shall make its use 
 unnecessary. In those cases which have a predisposition 
 to ptosis, or in which it has previously been present, the 
 rapid loss of flesh, from wasting disease or other causes, 
 removes the omental fat — the intra-abdominal pad — 
 which acts as a support to the colon. The bowel, unsup- 
 ported, is then liable to drop, as the weak hepatocolic 
 ligament gives way to the unaccustomed strain. Such 
 cases should be under careful supervision, and all tend- 
 
TREATMENT. 87 
 
 encies to colonic distention discovered and overcome. 
 The same caution is to be observed after childbirth. A 
 snugly fitting abdominal band worn until the abdominal 
 muscles regain their tone is a valuable prophylactic in 
 all post-partum cases. Corsets which contract the lower 
 thoracic zone should be avoided, and breathing exercises 
 used to expand this portion of the anatomy. 
 
 Increase of body fat is only of mechanical use, as it 
 applies to tlie support of the colon intra-abdominal ly, 
 and for this purpose it should be encouraged in every 
 way. Enforced rest and feeding are of value in many 
 cases for this purpose. 
 
 Medical Treatment. 
 
 While the number of drugs which can be used with 
 direct benefit to the displaced colon and kidney is limited, 
 yet the conditions are such that, in addition to them, in- 
 direct medication is often of value, and many cases are 
 very materially benefited by the use of other remedies 
 for the correction of disordered systemic conditions 
 which may appear not to be directly associated with or 
 caused by the ptosis. The uric acid diathesis, digestive 
 disorders, inefficient metabolism, and nervous disorders 
 are pathologic conditions which are very common to 
 these cases, and require appropriate treatment. 
 
 Cathartics should be avoided as much as possible, as 
 the colonic irritability is likely to be greatly increased by 
 their use. The use of eliminatives which act by increas- 
 ing peristalsis, for the purpose of accelerating defeca- 
 tion, may be compared to the principle illustrated by the 
 application of an increase of power to the machine whose 
 bearings require oil — apparent immediate efficiency re- 
 sults, attained, however, at the expense of future useful- 
 
«» NEPHROCOLOPTOSIS. 
 
 ness of the apparatus. The action of the bowels must be 
 regulated by remedies which smooth out, as it were, and 
 soothe the sharp angles of the bowel, and at the same 
 time cause the material to be soft and easily moved for- 
 ward by the natural peristalsis. Nature endeavors to do 
 this by throwing out much mucus, which is so frequently 
 seen in the stools of these patients. 
 
 Lubricants, then, rather than cathartics, must be the 
 rule, and, when used intelligently — frequently by enema 
 as well as by the stomach — the results are usually of the 
 most gratifying nature. For this purpose the author has 
 found nothing else which serves the purpose as satisfac- 
 torily in most cases as the so-called ''petrolatum oil," or 
 liquid vaseline. The properly prepared oil should be 
 tasteless, nearly clear — not amber colored — and should 
 be thick and heavy in consistency. The thin oil, which 
 is used largely as a medium in spray medication, is not 
 suitable for this purpose. The preparation is, chem- 
 ically, paraffin, and not a fat, as its name would signify, 
 and consequently does not saponify with alkalies, or be- 
 come digested or altered in passing through the alimen- 
 tary tract. It is this quality which causes it to act in a 
 mechanical way only, passing through the stomach and 
 small intestines unchanged, and then into the colon, 
 where, b}^ mixing with the fecal matter and coating the 
 mucous meml)rane, the effectiveness of peristalsis is aug- 
 mented; the contents of the bowel pass over the angula- 
 tions with a minimum amount of effort and irritation, to 
 the consequent comfort of the patient. The dose is usu- 
 ally one tablespoonful taken clear twice daily on an 
 empty stomach. The author usually directs one dose to 
 be taken late in the afternoon, about an hour before the 
 evening meal, and the other at bedtime. The effect of 
 this oil is usuallv sufficient to cause the contents of the 
 
TREATMENT. 89 
 
 bowel to pass into the descending colon, and in some 
 cases to result in regular and satisfactory defecation; but 
 the long habit of irregularity is often not so easily over- 
 come, and, unless further assisted, the torpid descending- 
 colon and the rectum do not act. Therefore, it is the rule 
 of the author to direct the patient, while taking the oil, 
 to use an enema of normal salt solution, to overflow, 
 every evening if no satisfactory defecation has been had 
 during the day. After a time the enema becomes un- 
 necessary, and as the action of the bowel becomes regular 
 the dose of the oil is gradually reduced and discontinued. 
 Difficulty is often experienced in holding those patients 
 rigidly to the performance of this formulary who have 
 long been addicted to the use of cathartic medicines. 
 Any relapse occurring after the use of the oil has been 
 once discontinued is liable to be followed by repetition of 
 the old habit of pill dosing, with consequent results of 
 colonic irritability. To prevent this, patients who are 
 not to be under frequent supervision, especially after 
 operative treatment, should be warned against the per- 
 niciousness of such action. 
 
 In cases of extreme torpidity, especially those in which 
 the fecal matter fails to reach the rectum, causing the 
 evening enema to be unsatisfactory in results — or, as in 
 rare cases, painful — the use by enema of four ounces of 
 warm olive oil at bedtime, the patient holding it until 
 morning, will usually act very kindly in the induction of 
 the desired morning stool, possibly assisted by the 
 enema. Some patients find it necessary, in order to re- 
 tain the oil taken thus by rectum, to assume the Sims, 
 or knee-chest, position for a few minutes after its infec- 
 tion. Cases having dilatation of the sigmoid are much 
 benefited by the oil enema. 
 
 The author has found a few cases much improved by 
 
90 NEPHEOCOLOPTOSIS. 
 
 the administration of olive oil in gelatin capsules — three 
 to five capsules of thirty minims each after each meal. 
 The oil given with the gelatin in this manner seems to be 
 more efficacious than when given alone; its nutritive 
 value is certainly enhanced, as the stomach bears it bet- 
 ter by this method. The gelatin doubtless acts some- 
 what as a demulcent, besides subdividing the oil and 
 rendering it more digestible. iVs an aid to any method 
 of increasing the fatty tissue of the patient it is of much 
 value. In some instances a laxative becomes necessary, 
 and in such cases castor oil, given in the same manner 
 in gelatin capsules, small doses after meals for a day or 
 two, will be sufficiently effective and comparatively free 
 from irritative action. 
 
 The taking of two tablespoonfuls of wheat bran in a 
 glass of hot water immediately on awakening in the 
 morning, and some little time before breakfast, acts well 
 as a demulcent, and also mildly as a food laxative. 
 Small doses of bromide of sodium and chloral given in 
 chloroform water will be found useful, symptomatically, 
 in soothing the colic caused by the spastic contraction of 
 the bowel, and may be given in preference to the opiates, 
 which dry the mucous membranes and increase torpidity 
 and stasis. 
 
 In cases having uric acid diathesis the spastic con- 
 dition is frequently much improved by using the appro- 
 priate treatment for this condition. 
 
 Intestinal antiseptics are useful in combating the 
 toxemia which the sluggish condition of the colon fre- 
 quently induces. For this purpose the author has used, 
 with good results, the sulphocarbolates of zinc, calcium, 
 and soda, carbolic acid, menthol, eucalyptol, salol, sali- 
 cylic acid and the salicylates, powdered charcoal, aspirin, 
 etc. 
 
TREATMENT. 91 
 
 Physostigmin sulphate, gr. 1/100, given liypoder- 
 mically every three to six hours, has been found to be a 
 dependable remedy for controlling the intestinal paresis 
 which is often such an alarming symptom in Dietl's 
 crisis. 
 
 Topical Treatment. 
 
 Heat, which may be applied in various ways, is the 
 principal and most reliable remedy of this class. Hot 
 fomentations, applied alone or in combination with 
 spirits of camphor, are useful in alla3dng the colonic irri- 
 tability and relieving the general abdominal soreness and 
 pain. The severe colicky pains caused by the spastic 
 condition of the bowel may be treated with gratifying- 
 results by these applications. 
 
 In severe attacks it is sometimes necessary to keep the 
 patient in bed, and apply the heat almost constantly for 
 several days at a time before the pain and soreness are 
 overcome. 
 
 Dry heat is the most useful when the application is to 
 be long continued. The hot water bag, or hot plates, 
 may be used for this purpose, or the electric pad may be 
 employed. The latter is convenient for the continuous 
 application, as it is capable of developing any tempera- 
 ture desired. It can be left on indefinitely, and requires 
 no changing and reheating as does the bag or fomenta- 
 tion. 
 
 The camphor stupe is especially useful in the tympan- 
 itic condition of Dietl's crisis. 
 
 Mechanical Treatment. 
 
 Any treatment by mechanical means should be di- 
 rected with a view to replacing the dropped organs, and 
 
92 NEPHEOCOLOPTOSIS. 
 
 to do this understandingiy the imderlying etiologic fac- 
 tors must be borue in mind. 
 
 The knowledge of the part played by the nephrocolic 
 ligament and Gerota's capsule in x)tosis of the kidney 
 exiolains the cause of failure of the old method of placing 
 a pad directly under the kidney. The same knowledge 
 points to a mechanical treatment that will be the most 
 efficient. The proj^osition is simple and purely mechan- 
 ical in its nature. Eemove from the kidney the down- 
 ward strain of the nephrocolic ligament, press the intes- 
 tines against it from the direction of the median line, so 
 that it can not easily slip out of Gerota's capsule, at its 
 only oj)en side, toward the median line. The kidney will 
 then remain in its normal position, the weight of the 
 bowel, and not that of the kidney, being the aggressive 
 factor. 
 
 This means that a suitable apparatus should be worn 
 by the patient to cause the cecum and transverse colon 
 to be held up out of the iDelvic cavity and lower abdomen. 
 This may be accomplished by the use of bands, trusses, 
 or corsets, which must be adapted to individual peculiar- 
 ities and requirements. A very thin woman, with re- 
 tracted abdomen, broad pelvis, and projecting iliac 
 crests, presents far different requirements from one with 
 fat, protruding abdomen and narrow pelvis. The name 
 or make of an apparatus is of value only as signifying 
 a type, a shape, or a principle, and becomes useful only 
 when it is made to meet the requirements of the in- 
 dividual patient. Perfunctory band and corset fitting 
 by the average artisan is liable to be productive of much 
 harm, and tends to bring the use of valuable therapeutic 
 methods into disrepute. The fitting of apparatus of this 
 kind is an art, and should be done by those skilled in such 
 work, and with a definite knowledge of the objects to be 
 
TEEATMENT. 93 
 
 attained by their use. Moreover, when the litting is de- 
 clared right, the patient should be directed to report to 
 the physician for inspection. It is only by such pains- 
 taking attention to details and individual requirements 
 that satisfactory results are achieved. The first requisite 
 for any appliance to be used for this purpose — such as 
 pads, trusses, corsets, bands, etc. — is that all j)ressure 
 exerted by them should be aioplied to the lower abdomen, 
 in the space bounded above by the navel, below by the 
 pubes, and laterally by the iliac crests and Poupart's 
 ligaments. With i^ressure supporting the abdomen over 
 this area, and the avoidance of all constricting bands, 
 corsets, or other clothing which contract and lessen the 
 capacity of the abdominal cavity above the navel, or at 
 the lower thoracic zone, the fundamental principles gov- 
 erning the use of mechanical supports for the bowel and 
 kidney will be met. 
 
 The practical application of these principles in the 
 form of some mechanical contrivance seems to be largely 
 a matter of individual experience, as there are in the 
 market many varieties of trusses, bands, and corsets, the 
 respective inventors of which extol their individual 
 merits. A corset specially adapted to support the ab- 
 domen is, no doubt, practical, and can be made to fulfill 
 the requirements, but the greatest, and a very potent, 
 objection to the use of the corset is the difficulty of con- 
 trolling its continuous proper application. There is too 
 much variation in adjustment, which the patient may 
 control at will, often causing the desire for a good figure 
 on the part of the patient to frustrate the therapeutics of 
 the doctor. The corset is also more difficult to adjust in 
 such a way as to give the requisite abdominal support in 
 cases having prominent hips and retracted abdomen, and, 
 as these patients are nearly all undernourished and thin 
 
94 NEPHROCOLOPTOSIS. 
 
 in the beginning of treatment, preference is decidedly in 
 favor of the band or truss, to be used until the patient 
 gains sufficiently in flesh, when a corset possessing the 
 proper requirements may be substituted. For patients 
 whose iliac bones are not prominent, and those of little 
 or no flatness of the abdomen, the author uses a silk 
 elastic band having steel stays and leather re-enforce- 
 ment, and with a thick hair-filled pad placed beneath, so 
 as to make pressure on about half of the lower abdominal 
 space. The band is held downward by two perineal 
 straps made of heavy tape, covered with soft rubber 
 tubing, the fastening being behind by an adjustable knot 
 and forward by a ball-and-socket glove fastener. The 
 band is laced behind to fit, when the ends should be about 
 an inch and a half apart, to allow for tightening when 
 the elasticity decreases. It should be just wide enough 
 in front to fill the space between the navel and pubis, 
 which varies in different individuals from five to seven 
 inches, and behind about two and a half inches less. 
 After it is once fitted, the patient slips it on and off over 
 the thighs, morning and night, without farther attention 
 to the lacing, which may be left in adjustment until the 
 elasticity decreases, or the form of the patient changes, 
 demanding the alteration. 
 
 The majority of patients, however, require a sujDport 
 so constructed as to exert more pressure on the lower 
 abdominal space, and especially one which will be made 
 efficient in this respect in the class of patients before 
 mentioned^ — those of meager habit, flat abdomen, and 
 prominent hips. Such a band the author has in the form 
 of a combination of the elastic band and truss. (Fig. 24.) 
 The shape of the band proper is exactly the same as the 
 elastic band. It is made of strong linen, with elastic 
 webbing only over the hips, laces together behind, and 
 
TREATMENT. 
 
 95 
 
 is fitted the same as the elastic band. The truss attach- 
 ment is made by the use of a strip of flat spring brass, 
 which is made to exert any amount of pressure desired 
 on the center of a hair-filled pad placed beneath the band. 
 This spring is adjusted to the figure of the patient by first 
 making a pattern of soft sheet lead, and then bending the 
 spring to conform to it. After the spring is fashioned, 
 to fit, the center is bent inward more or less, according to 
 the amount of pressure desired in each case. By this 
 device the thinnest of patients, with prominent hips and 
 
 Fig. 24. Author's abdominal supporter. 
 
 flat abdomen, can be fitted perfectly, and without the 
 discomfort of making a too tightly constricting band. 
 Each end of the spring is turned back around the hip and 
 ends in a buckle, by which a strap of webbing passing 
 behind connects the two and tightens the spring. The 
 device is light in weight, thin, and not cumbersome in 
 any way, so that it can be worn without disarranging or 
 interfering with ordinary clothing. The adjustment of 
 the band should be such that its grip will be around the 
 circumference of the pelvis, and in no case allowed to 
 ride upward around the waist. The perineal cords, when 
 
96 
 
 NEPHEOCOLOPTOSIS. 
 
 properly adjusted, should prevent this, and the patient 
 should be instructed to see that the upper margin of the 
 band is on a level with the navel. The patient should 
 always wear the band when not in the recumbent po- 
 sition. It may be slipped on and off without unlacing 
 in the same manner as with the elastic band, except for 
 the fastening and releasing of the truss. In the daily 
 
 Fig-. 25. Sliowing position assumed while massaging the abdomen 
 previous to fastening tlie truss attacliment of the author's abdominal sup- 
 porter. 
 
 application of the band, after it is pulled up over the 
 thighs and adjusted to its proper position around the 
 hips, the patient should, before buckling the truss fast, 
 assume the dorsal position, with the hips raised rather 
 high — a modified Trendelenburg — on cushions if neces- 
 sary, and while in this position massage the abdomen 
 deeply from the pubis upward with the ends of the fin- 
 gers of both hands under the pad. (Fig. 25.) This 
 
TREATMENT. 
 
 97 
 
 should be done for several minutes for the purpose of 
 freeing the lower abdomen, as much as possible, of the 
 prolapsed bowel. The truss is then fastened by the 
 buckles while still assuming this position. The author 
 has found this band to be an ideal support for the cases 
 in question, and makes use of it in many cases which 
 are being prepared for operation, and in all cases, for 
 
 Fig. 26. Front view. Proper adjustment of the author's abdominal 
 supporter. 
 
 varying periods of time, after operation. AVhile this 
 supporter is the most satisfactory in filling all the re- 
 quirements of all others with which he has had experi- 
 ence, he uses it only as a valuable assistant in the cure of 
 these patients — the operation about to be described being- 
 essential to permanent recovery. 
 
 Figs. 26 and 27 show the proper position of supporter 
 when adjusted. Note the width in front is from navel to 
 
98 
 
 NEPHROCOLOPTOSIS. 
 
 pubis, and on the sides a little less, so as not to ride up 
 above the liips and around the waist. The truss is so 
 placed on the sides between the iliac crests and the groin 
 that it will remain stationary during ordinary move- 
 ments of the body, and will not interfere with the flexion 
 of the thigh. 
 
 Fig-. 27. 
 supporter. 
 
 Side view. Proper adjustment of the autlior's abdominal 
 
 For temporary use, a pad may be held in place by ad- 
 hesive straps, which should pass around the pelvis, and 
 be applied in such a manner as to till the requirements of 
 the band before mentioned. The iliac crests should be 
 protected from pressure hj thin pads of gauze or cotton. 
 Ten days is almost the limit of time that such a support 
 can be worn, as the plaster causes a good deal of irrita- 
 
TREATMENT. 99 
 
 tion of the skin if left much longer. This is a useful 
 method of support, applied immediately after the opera- 
 tion of nephrocolopexy, and is applied in all cases until 
 the band can be worn. 
 
 Operative Treatment. 
 
 Any surgical treatment of nephroptosis which ignores 
 the accompanying and causative coloptosis must fail as a 
 therapeutic procedure. A moment's glance at the ana- 
 tomic relations of the parts involved is all that is neces- 
 sary to confirm this observation. Strip the fatty capsule 
 from the kidney, fasten the kidney to the muscles of the 
 loin or other tissues in that region, and what happens? 
 (Fig. 28.) The floating kidney may be cured, anatom- 
 ically speaking, but the patient is not, ais nearly all the 
 symptoms, but especially the digestive and nervous symp- 
 toms, not only continue as before, but become even more 
 aggravated. This is due to the connection of duodenum 
 and ascending colon by the fatty capsule, the framework 
 of which forms the nephrocolic ligament. The result of 
 freeing the fatty capsule from the kidney is to increase 
 the mobility of the ascending colon and cecum, so that 
 the traction exerted by the large intestine on the duo- 
 denum not only continues in force, but is augmented. 
 All symptoms would then be aggravated, excepting pos- 
 sibly those which may have been due to Dietl's crisis. 
 
 The principal cause of the frequent failure of the usual 
 operation of nephropexy is thus explained. 
 
 As the first step toward nephroptosis is made by the 
 relaxation of the hepatocolic ligament and the conse- 
 quent increased mobility and dropping of the ascending 
 colon and cecum, so must the first step toward a surgical 
 cure be either the restitution of this support or the crea- 
 
100 
 
 NEPHROCOLOPTOSIS. 
 
 tion of a substitute for it, which shall do its work in the 
 prevention of the downward drag of the colon on kidney 
 and duodenum. It seems, therefore, that the prime fac- 
 
 Pig-. 2S. Back view. Showing- the result of cutting- away the fatty 
 capsule from the kidney in the old operation of nephropexy. Increased 
 descent of cecum and traction on duodenum ensues. (In confirmation of 
 this theory see Figs. S7, 88.) 
 
 tor in the surgical therapeutics is fixation of the colon, 
 and that fixation of the kidney is of secondary impor- 
 tance. 
 
 Before becoming convinced of this principle, and be- 
 
TKEATMENT. 101 
 
 fore realizing the surgical importance of the nephrocolic 
 ligament, the author made several operations in which it 
 was attempted to make fixation of the bowel by fastening 
 the peritoneum at the hepatic flexure into the wound in 
 the loin. It was this work which led to the practical 
 investigation of the nephrocolic ligament in the living 
 subject, and when the author became convinced that it 
 had sufficient tensile strength, when the fasciculi were 
 bunched together, to support the bowel, he abandoned 
 the peritoneal route and developed the simpler and safer 
 method — the extra-peritoneal operation — which he now 
 uses to his great satisfaction. 
 
 In a series of fifty-six operations the author has 
 found only two cases in which the tissue of the ligament 
 was so distributed that its utilization was difficult and un- 
 satisfactory. In these cases the network of fasciculi, in- 
 stead of enveloping the whole kidney and passing down 
 together around the lower pole of the organ, as usually 
 found, were placed on the front side of the kidney and 
 were spread out and closely adherent to the peritoneum, 
 between the kidney and colon, which caused the difficulty 
 in isolating them. 
 
 The first idea of the author, in utilizing the ligament, 
 was to cut it through midway between the kidney and 
 bowel, suture the intestinal portion into the lower angle 
 of the wound and that attached to the kidney into the 
 upper angle, but he ultimately adopted the present 
 method of making a loop of the ligament and slinging up 
 both bowel and kidney by suturing the tough tissue of 
 Gerota's capsule under it and re-enforcing this by fasten- 
 ing the transversalis fascia to and under the ligament by 
 a silver wire suture. This is the best possible way of 
 securing the fixation, because its permanency does not 
 depend on the adhesion of the ligament alone to adjacent 
 
102 NEPHROCOLOPTOSIS. 
 
 tissues. The imion of heterogeneous tissues, especially 
 when containing fat, is a doubtful process at best, and 
 needs the assistance of all possible favoring conditions, 
 which would not be the case if the ends were simply 
 sutured fast and no other safeguard made against fail- 
 ure. Eeed, of Cincinnati, utilizes the nephrocolic liga- 
 ment in this manner, but he safeguards the suturing by 
 also fixing the kidney in the usual way. 
 
 Author's Operation of Nephrocolopexy, 
 
 Preparatory treatment. — In cases which are recover- 
 ing from Dietl's crisis or extreme colonic irritability, the 
 patient should be put to bed and treated by the methods 
 already described for these conditions, the operation be- 
 ing made only after the complete subsidence of all acute 
 manifestations and the entire disappearance of all in- 
 flammatory perirenal exudate. Special care should be 
 exercised in examinations of the urine, as all evidence of 
 acute nephritis, which frequentl}^ persists for some time 
 after Dietl's crisis, must be absent. The alimentary tract 
 should be completely emptied the day previous to opera- 
 tion, preferably by a saline cathartic. For this purpose 
 the author usually uses Seidlitz powders, giving a double 
 powder every two hours, beginning before breakfast, and 
 continuing their use until five or six satisfactory stools 
 have resulted. By commencing the use of the cathartic 
 thus early in the day the evacuation is complete before 
 night, giving the bowels time to become quiescent before 
 the time of operation the next morning — which is impor- 
 tant. The diet during the day should be light — soft. 
 
 The field of operation is sterilized in the evening, and a 
 pad wet with sublimate solution applied with a binder. 
 The morning of the operation the patient receives a 
 
TREATMENT. 103 
 
 simple enema, and immediately before going to the oper- 
 ating room a hypodermic of strychnia sulphate gr. 1/40.- 
 
 Anesthetic. — Nitrous oxide gas, followed by sulphuric 
 ether, unless otherwise indicated. Gastric lavage with 
 normal salt solution is used at the conclusion of the 
 operation. 
 
 Severe post-operative vomiting, which must always be 
 a menace to the success of a recently fixed kidney, is 
 practically a thing of the past in cases in which this rou- 
 tine is followed. 
 
 Fig. 29. Author's kidney elevator used in tlie operation of neplirocolo- 
 pexy. 
 
 Before the adoption of the use of the author's kidney 
 elevator, much time was usually consumed in placing the 
 patient in a satisfactory position, owing to the unstable 
 condition of the body of the patient caused by the use of 
 the inflated rubber bag. 
 
 The author's kidney elevator (Fig. 29) is composed of 
 two i^arts: (1) a round-top dome of nickel-plated spun 
 brass, having an open base and a round opening cut in 
 the top, and (2) an ordinary rubber ice cap. To prepare 
 the appliance for use, the rubber portion of the ice cap 
 is pushed through the hole in the top of the dome from 
 within, filled al)out lialf full of warm water, and the stop- 
 per screwed on. The flange onto which the stopper is 
 screwed, being larger than the hole in the dome, holds 
 
104 NEPHROCOLOPTOSIS. 
 
 the water cusliion well in place on the top of the elevator. 
 By the use of this simple device, which may be used on 
 any kind of a table, the patient may be placed in position 
 without loss of time by raising the hips high, with the 
 patient lying face downward, and sliding the elevator 
 under, with the water cushion uppermost. (Fig. 30.) As 
 the weight of the patient is let down on the cushion, it 
 being placed centrally under the abdomen, the abdominal 
 contents are pushed upward and the kidney held in po- 
 sition. A pad or sand bag placed against each thigh 
 holds the patient in exactly the position desired, which is 
 usually with the side to be operated on slightly the 
 higher. 
 
 Before making the incision, the reposition of the kid- 
 ney should be assured by examination, as a very loose 
 kidney in a broad subject having a relaxed abdominal 
 wall may not be pushed into place by the elevator, and 
 may need manual direction into the fossa. 
 
 Instruments used in the operation of nephrocolopexy. 
 — (Fig. 31.) Scalpel, 1; scissors, 1; narrow retractors, 
 2; hemostatic forceps, 1; short Kocher forceps, 2; long 
 Kocher forceps (made with loose lock to avoid crushing 
 tissues), 1; tissue forceps, 2; curved ligature carrier, 1; 
 bayonet-pointed side curved handled needle, 1; full- 
 curved large Hagadorn needle, 1; author's nephrocolic 
 ligament forceps-hook, 1; shot crusher, 1; suture ma- 
 terial. No. 1 twenty-day catgut throughout, excepting for 
 the stay suture in the transversalis fascia, where No. 26 
 silver wire is used, the twisted ends protected by a per- 
 forated silver shot. 
 
 The seat of operation, having been previously steril- 
 ized, is simply washed with alcohol. The incision, about 
 
TREATMENT. 
 
 105 
 
 J 
 
106 
 
 NEPHROCOLOPTOSIS. 
 
 Fig-. 31. Instruments used by the author in the operation of nephro- 
 
 colopexy. 
 
 1. Curved handled needle, with 
 bayonet point and eye close to it. 
 
 2. Author's forceps-hook for 
 securing: and forming a loop of the 
 nephrocolic ligament. 
 
 3. No. 26 silver wire and per- 
 forated silver shot for buried mat- 
 tress suture of transversalis fascia 
 (shown as applied). 
 
 4. Bistoury. 
 
 5. Shot crusher. 
 
 6. Long Kocher forceps (with 
 loosely fitting teeth) for finding the 
 nephrocolic ligament. 
 
 7. Ligature carrier for passing 
 ligatures under the loop of liga- 
 ment. 
 
 8. Short Kocher forceps for 
 isolating margins of transversalis 
 fascia. 
 
 9. Fine-toothed tissue forceps 
 for isolating margins of Gerota's 
 capsule. 
 
 10. Hemostatic forceps. 
 
 11. Hagadorn needle. 
 
 12. Retractors. 
 
 13. Scissors. 
 
TREATMENT. 107 
 
 two and a half inches in length, is begun just over the 
 lower margin of the twelfth rib, and at the outer margin 
 of the quadratus lumborum muscle- — which point is a 
 little over two inches from the vertebral spine — and car- 
 ried a little diagonally outward toward the iliac crest. 
 Skin, fat, and superficial fascia are severed, when blunt 
 dissection is used through the latissimus dorsi muscle to 
 the transversalis fascia, which is grasped by two Kocher 
 forceps and incised between; or the fascia may be entered 
 also by blunt dissection by thrusting through and open- 
 ing the hemostatic forceps. The subperitoneal (not 
 perirenal) fat appears. Eetractors are inserted and the 
 fat pushed downward with the finger, when Gerota's 
 capsule (perirenal fascia) is seen at the upper angle of 
 the wound, near the twelfth rib, as a pinkish-colored 
 membrane, somewhat resembling peritoneum. This is 
 grasped with the two fine-toothed tissue forceps and in- 
 cised between, when the perirenal fat appears. If in- 
 cision has been made through the transversalis fascia too 
 far downward, and not near the twelfth rib, the peri- 
 toneum (Fig. 13, No. 10), and not Gerota's capsule, will 
 be opened at this stage of the operation. The index fin- 
 ger is inserted through the opening in Gerota's capsule 
 (Figs. 32, 33), and the lower pole of the kidney located — 
 and it is important that the lower end of the kidney be 
 made out definitely, as the nephrocolic ligament, if 
 grasped and fixed at the side of the kidney, is secured in 
 but a small part and will have little supporting strength. 
 With the end of the finger against the lower pole of the 
 kidney, acting as a guide, the long Kocher forceps are 
 thrust deep in beside the finger and about an inch below 
 the kidney, opened wide, transversely to the axis of the 
 kidney, and the tissue below the finger grasped by gently 
 closing the forceps. Traction indicates to the finger the 
 
108 
 
 N"EPHROCOLOPTOSIS. 
 
 p, ft 
 
 o a 
 
 <1 bX) 
 
 . O 
 
TREATMENT. 
 
 109 
 
110 NEPHEOCOLOPTOSIS. 
 
 success or failure to locate the ligament. If properly 
 held by the instrument, the kidney may be pulled up 
 forcibly against the finger by it, and the fasciculi of the 
 ligament may be felt to pass from the forceps to the 
 kidney. Several attempts may be made, in some cases, 
 before the ligament is satisfactorily secured, but it is 
 usually found at once. Occasionally the kidney lies low, 
 or in such a position that the examining finger can not 
 reach the lower pole, in which case two force]DS may be 
 used, and the kidney brought up by a "climbing" 
 process, so that the ligament below the pole may be 
 reached. When secured, the kidney is pulled up to the 
 wound. (Figs. 34, 35.) This spreads out the fasciculi 
 of the ligament in a fan-shaped manner, as the inner side 
 of it is adherent to the peritoneum between the kidney 
 and bowel. To gather together these separated fasciculi 
 into one mass of parallel fibers is the next step, which is 
 accomplished by means of the forceps-hook. (Figs. 36, 
 37.) While the assistant holds the ligament gently taut 
 with the long Kocher forceps, the closed hook is passed, 
 with the finger as a guide, into Gerota's capsule anterior 
 to the ligament and about an inch below the kidney, and 
 pushed gently backward slightly beyond the lower pole 
 of the kidney, the end being held upward, so that the 
 hook lies parallel with the kidnej^ After it is placed in 
 this manner, the end is turned toward the back of the 
 patient, so as to cross the back of the ligament with the 
 hook, and then drawn upward toward the wound. The 
 finger, being removed at the same time from the anterior 
 side of the ligament and placed on its posterior side — still 
 within Gerota's capsule — guides the end of the hook up 
 out of the capsule and forces it through the tissues cling- 
 ing to it. Examination is then made, and if a good mass 
 of tissue has been secured, which pulls strongly on the 
 
TREATMENT. Ill 
 
 kidney and holds it firmly np to the wound, the hook is 
 opened about an inch, which strijjs some of the ligament 
 from the i^eritoneum and forms a loop through which 
 the fascia and capsule are to be sutured. (Figs. 38, 39.) 
 After opening the forcej)s once, they are allowed to close, 
 and are opened only when necessary in passing ligatures 
 under and drawing the edges of the capsule through. 
 Some tough tissue is usually brought up on the tip of the 
 hook, which is the part of Gerota's capsule that passes 
 down with the ligament to its insertion in the bowel, and 
 should be included with the ligament, as it materially 
 strengthens it. (Fig. 11.) 
 
 The next step is the suturing of the overlapped mar- 
 gins of Gerota's capsule under the loop of ligament. 
 (Figs. 40, 41.) For this purpose a mattress stitch of cat- 
 gut is used on each side, the first being passed twice 
 through the free margin of the capsule on the abdominal 
 side, the long ends brought through the loop of ligament 
 under the hook with the curved ligature carrier, passed 
 under the capsule on the vertebral side, and with the 
 handled needle the separate ends passed through the cap- 
 sule and tied about half an inch from the margin. A 
 similar ligature is then made fast to the margin of the 
 capsule on the vertebral side, the ends threaded through 
 the eyes in the end of the hook and the hook withdrawn, 
 bringing the catgut through under the ligament with it, 
 when it is passed through the outside of the capsule on 
 the abdominal side, about half an inch from the margin 
 of the loop of ligament, and tied under the edge of the 
 flap. The loop of ligament is still held by the long 
 Kocher forceps, which are not removed till the suturing 
 around the ligament is finished. 
 
 The opening in Gerota's capsule at each end of the 
 projecting tissue of the ligament is closed with ligatures, 
 
112 
 
 NEPHEOCOLOPTOSIS. 
 
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TREATMENT. 
 
 113 
 
114 
 
 NEPHEOCOLOPTOSIS. 
 
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TREATMENT. 
 
 115 
 
116 
 
 NEPHROCOLOPTOSIS. 
 
 
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 5" 
 
TREATMENT. 
 
 117 
 
118 
 
 NEPHEOCOLOPTOSIS. 
 
 after which the silver wire mattress suture is passed with 
 the handled needle through the transversalis fascia from 
 side to side, broadly, under the loop of ligament and fas- 
 
 Fig. 40. Front view. Autlioi''s operation of neplirocolopexy, sliowing 
 Gerota's capsule overlapped and sutured under the loop of the nephrocolic 
 lig-ament, and the silver wire mattress suture passed through the trans- 
 versalis fascia and under the loop of ligament. 
 
 tened, thus bringing the margins of the fascia under and 
 firmly against the tissue of the ligament. (Figs. 42, 43.) 
 The wire is made fast by twisting the ends, and a small 
 perforated silver shot run over the ends down to the 
 
TREATMENT. 
 
 119 
 
 shoulder and crushed with the shot-crushing forceps. 
 The ends of the wire are cut flush with the shot, which 
 leaves the suture in a condition free from any possibility 
 of causing- irritation to the tissues. No post-operative 
 trouble is had with this buried suture made with this 
 size of wire, protected by the silver shot. Farther clos- 
 
 Latissimus dorsi 
 muscle 
 
 Subperitoneal fat 
 
 Fig-. 41. Skeleton reference to Fig. 40. 
 
 ure of the transversalis fascia is made with interrupted 
 catgut sutures. 
 
 The long Kocher forceps are removed from the liga- 
 ment, which is now covered over by the closure of the 
 muscle and superficial fascia by interrupted sutures, 
 care being taken here — as, in fact, during the entire 
 operation — to leave no dead spaces or bleeding points. 
 The operation is finished by closure of the skin incision 
 
120 
 
 NEPHROCOLOPTOSIS. 
 
 (Figs. 44, 45) with a subcutaneous suture of catgut, which 
 is entirely buried. If the skin margins are not exactly 
 coapted, they are brought together by narrow strips of 
 aseptic adhesive plaster. The scheme of the completed 
 
 Fig- 42 Front view. Author's operation of nephrocolopexy, showing 
 the transversalis fascia closed and the method of using the silver wire 
 mattress suture. 
 
 operation is seen in Figs. 46, 47, and the result of the op- 
 eration on the displaced kidney and compressed ureter is 
 illustrated in Fig. 48. 
 
 The wound is dressed by dusting with aristol, covered 
 
TREATMENT. 
 
 121 
 
 with a small gauze pad, which is held and surrounded 
 by adhesive plaster, and loosely with a large pad of 
 cotton, reaching entirely across the width of the back, 
 the latter being held by adhesive plaster and a loosely 
 applied binder. The patient is then turned on the back, 
 
 Nephrocolic lig-ament 
 
 Shotted 
 
 silver wire suture 
 
 Retractor 
 
 Latissimus dorsi 
 muscle 
 
 Interrupted sutures 
 of transversalis fascia 
 
 Fig. 43. Skeleton reference to Fig. 42. 
 
 and the large abdominal pad applied. (Fig. 49.) (See 
 Mechanical Treatment.) This pad should be thickest in 
 the middle, and of sufficient size to fill the abdominal 
 space below the navel, and yet not extend beyond so as 
 to cause pressure on ileum or pubis. It must be worn 
 constantly during convalescence, and held securely at all 
 times by the adhesive plaster and a binder in addition. 
 In cases of severe post-operative vomiting this pad is a 
 
122 
 
 NEPHROCOLOPTOSIS. 
 
 valuable safeguard against the threatened tearing away 
 of the newly sutured tissues by the violent muscular 
 activity incident to the einesis; it acts further as a con- 
 stant support to bowel and kidney during the healing 
 
 Fig. 44. Front view. Author's operation of neplirocolopexy, sliowing 
 muscle and superficial fascia closed over loop of lig-ament with inter- 
 rupted sutures and the continuous., subcutaneous, buried suture placed 
 and ready to draw tight and tie. 
 
 process, thus removing much of the strain on the sutured 
 parts. 
 
 After-treatment. — The patient remains quietly in bed 
 for from seventeen to twenty days, this length of time 
 
TREATMENT. 
 
 123 
 
 being considered necessary to insure the firm union of 
 the mixed tissues involved. The position for right neph- 
 rocolopexy may be dorsal or right lateral, but lying on 
 the left side is strictly prohibited during convalescence. 
 
 'v^ 
 
 Interrupted sutures.^ 
 of superficial ^^^ 
 
 aponeurosis and muscle . i 
 
 Skin-., 
 Fat 
 
 Pig-. 45. Skeleton reference to Fig. 44. 
 
 In the bilateral operation the dorsal position only should 
 be allowed. 
 
 The diet is of a fluid character (not including milk) 
 for three days, then light soft diet for seven days, and 
 mixed diet afterward. The bowels are moved by a low 
 
124 
 
 NEPHROCOLOPTOSIS. 
 
 Fig. 46. Author's operation of neplirocolopexy, sliowing completed 
 operation and metliod by which both bowel and kidney are supported by 
 fixation of the neplirocolic ligament by the use of Gerota's capsule and 
 the transversalis lascia. 
 
TREATMENT. 
 
 125 
 
 Superficial aponeurosis. 
 
 Skin 
 
 12 th rib-.] 
 
 Overlapped margins of 
 Qerota's capsule 
 
 Nephrocolic ligament 
 
 Interrupted sutures 
 of transversalis fascia 
 
 Shotted silver wire -- 
 suture through 
 
 transversalis fascia-fj 
 
 Continuous 
 subcutaneous suture 
 
 Interrupted sutures 
 of superficial 
 aponeurosis and 
 latissimusdorst 
 muscle -*'-^-.. 
 
 True perirenal fat 
 
 -Right kidney 
 
 -Ileum 
 
 Fig. 4 7. Skeleton reference to Fij 
 
 46. 
 
126 
 
 NEPHROCOLOPTOSIS. 
 
 glycerine enema (glycerine gj, water gv) on the third 
 day, or before if tympanites be tronblesome. A low 
 enema of normal saline solution is nsed, to overflow, on 
 the evening of each day thereafter when a satisfactory 
 movement has not been had during the day. The admin- 
 istration of petrolatum oil (gss), afternoon and bedtime, 
 is begun on the fourth day and continued until the bowels 
 
 Fig-. 48. A, position of pi'olapsed kidney, showing- compression of thft 
 ureter. B, position of tlie l^idney -n'hen replaced by flxatioii of tlie 
 neplirocolic lig-ament. 
 
 become regulated without the use of the enema, when it 
 may be gradually discontinued, as indicated. It is some- 
 times necessary to continue the use of the oil for some 
 time after convalescence, or to use it from time to time 
 as the colonic function demands. 
 
TREATMENT. 
 
 12< 
 
 A mild saline laxative is often necessary on the second 
 or third day to clear up the after-effects of the anesthetic, 
 when Husband's magnesia (oij), well stirred in a glass 
 of water, will be found useful and easy in its action. 
 The glycerine enema is frequently needed to start the 
 movement, and may be given if the bowels do not act 
 within six or seven hours. 
 
 Fig'. 49. Showing- method of applying post-operative abdominal pad 
 in the operation of nephrocolopexy. The pad is held in place by adhesive 
 plaster and the binder laid on ready to apply. 
 
 The wound is dressed on the fourth or fifth day by re- 
 moving dressings, washing with alcohol, and reapplying 
 the same as before if the condition of the wound is good. 
 On the tenth day the dressings are all removed, except 
 the large pad, which is allowed to remain as a protection 
 to the wound from injury. 
 
 The majority of these patients — either from the effects 
 of the long-continued toxemia to which they have been 
 subjected, or from constitutional causes — exhibit a tend- 
 
128 NEPHEOCOLOPTOSIS. 
 
 ency to the formation of uric acid and oxalate of lime in 
 the urine, and demand treatment accordingly during con- 
 valescence. For this purpose nothing has been found 
 that equals in effectiveness the use of acid, nitro-mur. 
 dilut. Mv in half a glass of water every three hours. 
 
 For several weeks after the operation some patients 
 complain of discomfort in the region of the ascending 
 colon, caused, no doubt, by the unusual strain on the 
 nephrocolic ligament. This subsides in due time, and no 
 harm ever eventuates from. it. 
 
 Getting up and about should be slow and exercise 
 taken gradually, but special care need be observed only 
 against any accident or overdoing that would cause sud- 
 den or severe strain. 
 
 The abdominal truss-band, or supporter, is put on when 
 the patient gets up, and is worn thereafter, when not in 
 bed, until the accumulation of an intra-abdominal pad of 
 fat may make its further use unnecessary. For a month 
 after getting up the patient is directed to wear at night a 
 large abdominal pad, applied with a binder. 
 
 The patient should be under observation for several 
 months after operation, as the old bad habits of bowel, 
 nerve, and muscle frequently persist to a certain extent, 
 the symptoms not all disappearing at once. In fact, the 
 betterment comes gradually, and the patient must be told 
 that this will be so, and that some period of time must 
 elapse before great betterment can be expected. 
 
 In cases previously attended by severe neurasthenia, 
 great tenderness of the abdomen, gastric irritation, etc., 
 much benefit has been derived by some patients from a 
 course of post-operative sanitarium treatment, in which 
 artificial rest and feeding, freedom from care, abdominal 
 fomentations, and other h3^drotherapy seemed to be the 
 principal restorative agents. In fact, the conditions pre- 
 
TEEATMENT. 129 
 
 senting in most of these patients demand, for their best 
 welfare, the utmost that they can obtain from the sur- 
 geon, gastro-enterologist, neurologist, psychiatrist, and 
 hygienist. When this principle is generally acted on, 
 and these specialists act in harmony — each doing his 
 very important share, and giving to the patient the best 
 in his field — then will the greatest gain be made in their 
 treatment and enteroptic cases will cease to be a re- 
 proach to medicine. 
 
CHAPTER VI. 
 REPORTS OF CASES. 
 
 The following reports of eases on which I performed 
 my operation of nephrocolopexy have been compiled 
 from the records as concisely as possible consistent with 
 their intelligent presentation, the aim being to teach by 
 them the princijjles already laid down in the text and 
 drawings, and to emphasize the im]3ortant points of 
 pathology, diagnosis, and treatment, as well as to record 
 results. 
 
 To accomplish this has necessitated the omission of 
 much of the record of detail treatment, which, while 
 often of much interest to the student in showing the 
 process by which the patient passes from one form of 
 treatment to another, and at last to the surgeon who 
 effects the cure, the epitomizing is demanded for brevity 
 and clearness. 
 
 Every case has been reported, where possible, up to 
 date of publication, and effort has been made, by corre- 
 spondence with patients and their physicians, to obtain 
 the histories of cases since operation, and especially to 
 learn the permanency of results. 
 
 The first of the series of operative cases in which my 
 present technic of nephrocolopexy is followed is one of 
 the most interesting and instructive of the entire number, 
 as the trials and vicissitudes of the enteroptic suffering 
 from the results of erroneous diagnoses and treatment are 
 most graphically illustrated, and, as it teaches so much 
 that may be useful in the study of the obscure diagnostic 
 points in these cases, it is presented rather fully. 
 
 130 
 
REPORTS OF CASES. 131 
 
 Case 1. 
 
 Female; aged 26; small figure; thin habit; one child 
 1 year old. First consulted me in 1900, complaining 
 of abdominal pain, especially in the right lower quadrant. 
 Tenderness at McBnrney's point and an enlarged right 
 ovary led to an abdominal section and the removal of a 
 nearly normal appendix and a cystic ovary on October 
 1, 1900, at the Woman's Hospital. Recovery was un- 
 eventful, and the patient went to her home in the in- 
 terior of the state. Reports from her continued to be 
 unsatisfactory, and she returned to me in May, 1901, com- 
 plaining of headache, constipation, insomnia, backache, 
 occasional sharp pains in the right side of the abdomen 
 (as before operation), dyspepsia, and loss of flesh and 
 strength. 
 
 At this time an easily palpable floating kidney on the 
 right side was found, and also a retroversion of the 
 uterus of second degree was diagnosticated. An ab- 
 dominal band, with a pad placed under the loose kidney, 
 was applied, and the uterus replaced and a Thomas 
 Hodge pessary inserted. The kidney pad and band 
 proved a failure (as this one-time-much-recommended 
 appliance always has done, and always will do, as the 
 idea of its use is based on erroneous principles, as before 
 described in this book). The pessary behaved better, 
 and afforded some comfort by changing it from time to 
 time, the size necessary for sustaining the uterus in its 
 normal position gradually increasing. 
 
 After five years more of semi-invalidism, resulting, as I 
 now know, principally from the nephrocoloptosis, she 
 again came to me through the courtesy of Dr. I'lorence 
 Huson, at which time the displacements of both kidney 
 and uterus were found much more extreme and the symp- 
 
132 NEPHROCOLOPTOSIS. 
 
 toms correspondingly aggravated. Previous to this time, 
 especially for tKe last two years, she had consulted a 
 number of physicians and experienced a variety of treat- 
 ment, including two periods of three months each of 
 forced rest and feeding. The latter benefited her great- 
 ly, but the improvement ceased in both instances as soon 
 as she began to get about, and soon afterward she was as 
 bad as ever. Previous to consulting Dr. Huson, a repu- 
 table surgeon proposed to remove the remaining ovary 
 and make a ventrofixation of the uterus. 
 
 At this time I first saw her with Dr. Huson in Decem- 
 ber, 1905, at the Woman's Hospital, where a period of 
 three weeks of rest treatment, with hot fomentations, 
 etc., was necessary to prepare her for operation because 
 of the abdominal tenderness and other evidences of ex- 
 treme colonic irritability. 
 
 On January 8, 1906, assisted by Dr. Huson, the 
 operations of nephrocolopexy, Alexander's operation, and 
 trachelorrhaphy were performed. This was the first 
 case in which I utilized the tissue of Gerota's capsule as 
 I do now to assist in fixing the nephrocolic ligament. 
 
 Eecovery was uneventful, and the patient was dis- 
 charged in about four weeks after the operation. Dr. 
 Huson reports, November 17, 1909: ''Patient very well 
 since operation in 1906, and has demanded treatment 
 since only for some s^nnptoms of gastric indigestion. 
 Gave birth to a child one year ago at the Woman's Hos- 
 pital. Uterus and kidney both in normal position. Has 
 had no return of the old pain in the right side since the 
 operation, and the bowels move regularly." 
 
 The relief of the pain in the region of McBurney's point 
 was no doubt due to the immobilization of the cecum and 
 ascending colon, giving the gut a fixed point, b^^ which its 
 muscular activities were facilitated and made efficient 
 
REPOKTS OF CASES. 133 
 
 in results. This result following the nephrocolopexy so 
 positively, and no benefit in this respect having been 
 obtained from the previous operation of appendectomy 
 and oophorectomy, justifies the conclusion. It also leads 
 to the opinion that the appendectomy was unnecessary — 
 as my observation leads me to believe is true in similar 
 cases occurring constantly — and that a riper experience 
 with the enteroptic by all concerned in her treatment 
 would have saved this patient much distress, health, time, 
 and monej^. 
 
 The following two cases are of especial interest be- 
 cause of their family history respecting the condition of 
 prolapse. 
 
 Case 2. 
 
 Female; aged 26; single; good figure; student. Sister, 
 mother, and grandmother had floating kidney. Con- 
 sulted me May 22, 1905, for a nearly constant, dull pain 
 in the right side of the abdomen, which she had had for 
 over a year; fatigue caused by walking; alternating con- 
 stipation and diarrhea; mucus in stools; loss of flesh; 
 dysmenorrhea. Examination in the dorsal position 
 showed the right kidney down entirely below the costal 
 margin. Applied elastic abdominal band, with large 
 pad below umbilicus. 
 
 June 8, 1905. Reports that she can walk with much 
 less fatigue since wearing the band, and feels much bet- 
 ter in every way, excepting for the alternating constipa- 
 tion and diarrhea, which shows but little improvement. 
 Intestinal antiseptics prescribed December 20, 1905. The 
 bowel symptoms continuing, and the pain in the side re- 
 turn ing at times, operation was advised. 
 
 January 13, 1906. Operation at Harper Hospital. 
 Nephrocolopexy; dilatation of os uteri. Recovery un- 
 eventful. 
 
134 NEPHROCOLOPTOSIS. 
 
 November 26, 1906. Reports that the result of the 
 operation has been of the best; bowels regular; strength 
 and endurance good; walked miles every day during her 
 summer outing without fatigue or ill effect; gamed ten 
 pounds in weight ; kidney not palpable. 
 
 November 10, 1909. Is in good health, the kidney in 
 normal position, and bowels regular. While away from 
 the city, two years ago, had an attack of appendicitis 
 and was successfully operated on by another surgeon. 
 
 Case 3. 
 
 Traumatic post-operative displacement of kidney, leav- 
 ing" bowel fixation intact, does not prevent symptomatic 
 recovery. 
 
 Female; aged 27; married; mother of one child 5 
 months old, which is not at the breast. Sister, mother, 
 and grandmother had floating kidney. (Sister of case 2.) 
 
 Diagnosis of right nephroptosis made by me a year be- 
 fore marriage, and an abdominal elastic band, with pad 
 below umbilicus, prescribed. Patient sent to me by Dr. 
 B. R. Shurly, January 26, 1906. Was wearing the ab- 
 dominal belt, as she felt uncomfortable without it. Com- 
 plains of nervousness; depression; pain in the right side 
 of abdomen; general weakness and exhaustion on slight 
 exertion; backache; flatulence; constipation of bowels, 
 requiring constant use of laxatives; hemorrhoids, which 
 bleed frequently; leucorrhea. 
 
 Examination showed the right kidney entirely below 
 the costal margin, dorsal position, without inspiratory 
 efl^ort. Some tenderness at McBurney's point was ap- 
 parently caused by a distended cecum, which could be 
 easily palpated through the abdominal walls, which were 
 thin. Pelvic examination showed rupture of perineum 
 
EEPORTS OF CASES. 135 
 
 of second degree and a hemorrhoidal mass which nearly 
 encircled the anus. 
 
 February 15, 1906. Operation at Harper Hospital. 
 Nephrocolopexy; perineorrhaphy by the split flap, buried 
 suture method; Whitehead operation on the anus. Re- 
 covery ideal, excepting slight superficial stitch abscess. 
 Petrolatum oil prescribed. Abdominal band to be worn 
 until twenty pounds of flesh is gained. 
 
 April 4, 1906. Condition good; gaining flesh, and feels 
 well. 
 
 April 14, 1906. Met with an accident, having a severe 
 fall, after which severe pain was felt in the region of the 
 kidney, which was found to be palpable and sensitive to 
 touch. About half of the organ felt below the costal 
 margin. Patient was kejot quiet in bed most of the time 
 for two weeks, when the tenderness had gone and only 
 the lower pole of the kidney could be felt on deep in- 
 spiration. 
 
 January 15, 1907. Kidney not loose enough to be en- 
 tirely palpable, but lower pole easily felt on deep in- 
 spiration. Bowels regular by use of the oil only. 
 
 February 1, 1909. Is very well; bowels regular with- 
 out medication and kidney gives no trouble. Has gained 
 fifteen pounds. The loosening of the kidney by the acci- 
 dent was probably due to the fact that it tore its way 
 through the fatty capsule, thus becoming partially dis- 
 placed only, and leaving the bowel fixation intact; the 
 latter condition doubtless caused the marked subsequent 
 improvement of the patient, and is evidence of the cor- 
 rectness of my theory regarding the role played by the 
 displaced bowel in these cases. Does not wear the ab- 
 dominal supporter. 
 
 February 2, 1910. Gained twenty-one pounds since 
 operation; bowels regular without aid of any kind; per- 
 
136 NEPHROCOLOPTOSIS. 
 
 fectly well, excepting for the presence of pain and sore- 
 ness in the right side, which is of recent occurrence and 
 followed an attack of acute bronchitis. Examination in 
 the dorsal position was negative, but in the left lateral 
 position half of the right kidney could be palpated and 
 was sensitive to touch. Otherwise abdomen not sensi- 
 tive. Abdominal supporter to be worn until relieved of 
 pain and sensitiveness. 
 
 Case 4. 
 
 Severe infection resulting from improper surroundings 
 causes failure of operation. 
 
 Female; aged 34; single; a teacher and convent resi- 
 dent. Had suffered for years with pain in the region of 
 the right kidney, apparently a mild Dietl's crisis; ab- 
 dominal pain; constipation; gradual loss of flesh. 
 
 March 10, 1906. Examination showed the right kidney 
 entirely below the costal margin with patient in the 
 dorsal position and without deep inspiration. 
 
 March 12, 1906. Operation of nephrocolopexy at the 
 convent, assisted by Dr. Cadieux, the convent physician. 
 The surroundings were not ideal for surgical work, and 
 every aseptic precaution possible was taken, but without 
 avail, as a very violent septic condition supervened and 
 the wound suppurated freely, necessitating opening and 
 drainage. I believe, even with this suppuration, the fix- 
 ation would have been successful if the silver wire had 
 been used to support the transversal is fascia, as it would 
 have kept the parts in position until the cessation of the 
 infective process would have allowed the healing to take 
 place. But the buried catgut was depended on exclu- 
 sively, and of course the natural result happened — the 
 sutures gave way, allowing the parts to slip back to their 
 
EEPORTS OF CASES. 
 
 137 
 
 old positions of prolapse, and a failure had to be re- 
 corded. I wished to reoperate, but the opportunity has 
 not thus far presented. 
 
 Case 5. 
 
 Female; aged 28; single. Patient of Dr. G. E. Potter, 
 who had made the diagnosis of floating kidney and asked 
 me to operate. 
 
 March 10, 1906. Examination showed the right kid- 
 ney about two-thirds below the costal margin with the 
 patient in the left lateral position and during deep in- 
 spiration. 
 
 March 13, 1906. Operation at Harper Hospital, as- 
 sisted by Dr. Potter. Recovery without incident. 
 
 November 15, 1908. Dr. Potter reports the kidney in 
 normal position; slight increase in weight; less nervous; 
 less pain. 
 
 Case 6. 
 
 Female; aged 29. In the clinic of Dr. Repp at St. 
 Mary's Hospital. 
 
 March 17, 1906. Operation at St. Mary's Hospital, as- 
 sisted by Dr. Repp. Recovery good. 
 
 April 1, 1908. Dr. Repp reports the operation a suc- 
 cess, both anatomically and symptomatically. 
 
 Case 7. 
 
 Type of common class of cases, often diagnosed as 
 nervous exhaustion and intestinal dyspepsia, cured by 
 operation after years of ''tinkering." 
 
 Female; aged 31; mother of one child 7 years old. 
 Cervix was lacerated at the time of the birth of the 
 child, and this was repaired by another surgeon, four 
 months before coming to me. 
 
138 NEPHKOCOLOPTOSIS. 
 
 Patient sent to me by Dr. David Ingiis, December 3, 
 1903, to whom she had gone for relief of symptoms of an 
 obscure nervous character. Complains of attacks of 
 pain of a bearing-down character, which commence in 
 the back, pass around in front and down into the vagina 
 and vulva, causing great nervousness and frequent mic- 
 turition. Bowels very constipated. Has lost flesh grad- 
 ually, about fifteen pounds during the last two years. 
 Heart normal; urine normal. 
 
 Abdominal examination showed the right kidney one- 
 half below the costal margin while in the dorsal position. 
 Besides the slight nephroptosis, the cervix uteri was 
 found to be cystic, and the cervical canal very narrow 
 and tortuous (result of careless surgery in its repair). 
 Treatment was instituted for the latter condition, and 
 the position of the kidney ignored, as a ^'movable" kid- 
 ney was not supposed to give symptoms, and the accom- 
 panying coloptosis not recognized. Only slight relief 
 followed the treatment, and the patient passed from my 
 care until January 2, 1906, when she returned, present- 
 ing the following history of symptoms and conditions: 
 menstruation irregular during the last year, and none 
 for nearly two months; diarrhea more or less for a year, 
 with much mucus in stools; frequent attacks of pain 
 in abdomen, especially in the right side; frequent mictu- 
 rition. 
 
 Abdominal examination showed the right kidne}'^ en- 
 tirely below the costal margin, and in the left lateral 
 position it could be palpated in the region of the navel. 
 The cervix was no longer cystic, but the os was closed 
 completely. The true significance of the nephroptosis 
 was now recognized, and a diagnosis of ''nephrocolo- 
 ptosis" made, with recommendations for immediate 
 operation. 
 
EEPOETS or CASES. 139 
 
 June 2, 1906. Operation at Harper Hospital. Nephro- 
 colopexy; incision; dilatation of the os uteri. Kecovery 
 without incident. My abdominal band applied, and dis- 
 charged from hospital June 25, 1906. 
 
 July 11, 1906. Eeported feeling much better; frequent 
 micturition ceased. Lower pole of kidney felt below 
 costal margin, but could not bring it lower by effort. Os 
 admits sound easily. 
 
 October 15, 1906. Kidney symptoms disappeared; 
 bowels regular and no diarrhea; no return of abdominal 
 pain or frequent micturition. 
 
 March 25, 1909. Reports she has gained fifteen pounds 
 since operation; bowels are regular; feels well, excepting 
 for occasional dyspeptic symptoms; kidney in normal 
 position. 
 
 Case 8. 
 
 Malnutrition and intractable constipation cured by 
 operation. 
 
 Female; aged 54; mother of ten children, youngest 11 
 years old. Still menstruating, though irregularly and 
 scantily. Patient of Dr. F. L. Newmann, sent to me May 
 22, 1906. Complains of weakness, loss of flesh, and nerv- 
 ousness, and says her bowels are so constipated that she 
 has an action but once or twice a week. 
 
 Examination showed a variety of pathology, including 
 a right nephroptosis — kidney passing freely into the ab- 
 domen on deep inspiration while in the left lateral po- 
 sition; large varicosities of left labium majus, thigh, and 
 leg; ruptured perineum of second degree; lateral lacera- 
 tion of cervix uteri, with cysts and erosion. Recom- 
 mended operation on all the diseased conditions. 
 
 June 6, 1906. Operation at Harper Hospital. Nephro- 
 colopexy; perineorrhaphy; trachelorrhaphy; curettage; 
 
140 NEPHEOCOLOPTOSIS. 
 
 dissection and ablation of the varicosities of vulva, thigh, 
 and leg". Eecovery was slow, owing to imperfect healing 
 of the incisions on the thigh and leg; otherwise incisions 
 healed by first intention. Nutrition had been bad for so 
 long that her strength returned slowly. Petrolatum oil, 
 half an ounce afternoon and bedtime, was prescribed 
 after the third day, to be continued until bowels became 
 regular. My abdominal band, with large pad, was ap- 
 plied before she left the hos^Dital, which was on July 4, 
 1906. 
 
 October 29, 1906. Eeports feeling better in every way, 
 has more endurance, and bowels are regular. Examina- 
 tion shows kidney in good position; though the lower 
 pole can be palpated on deep inspiration, it can not be 
 forced further down and returns to its normal position. 
 
 July 1, 1909. Reports bowels regular; has gained ten 
 pounds. Kidney can be felt half below costal margin 
 on deep inspiration, but causes no further trouble and is 
 not sensitive to touch. Has discarded the abdominal 
 band. 
 
 Case 9. 
 
 Severe constipation cured, nervous breakdown ar- 
 rested, and normal nutrition induced by operation. 
 
 Female; aged 27; single; stenographer. Patient of Dr. 
 E. S. Sherrill. 
 
 Examination June 6, 1906. Had severe anemia three 
 years ago, and dates present illness from that time. Is 
 very nervous and debilitated. Has lost flesh gradually 
 for the last two years, and for the last six months has 
 had, almost constantly, a dull pain in the back of the 
 head and neck, slight nausea, but no vomiting; a feeling 
 of fullness and throbbing across the abdomen; bowels 
 
EEPORTS OF CASES. 141 
 
 very constipated, requiring daily attention; menstruation 
 very painful and too frequent. 
 
 Abdominal examination showed the right kidney en- 
 tirely below the costal margin while in the dorsal po- 
 sition without effort; was easily replaced manually, and 
 quite sensitive to touch. Vaginal examination negative, 
 excepting showing endometritis. Operation advised. 
 
 July 6, 1906. Operation at Harper Hospital. Nephro- 
 colopexy; dilatation; curettage. Recovery without inci- 
 dent. 
 
 July 23. Discharged from hospital, wearing abdomi- 
 nal band and taking petrolatum oil. 
 
 September 24, 1906. Reports first menstruation pain- 
 less, and second somewhat painful and scanty. Bowels 
 perfectly regular since operation. Has had some pains 
 in cecal region, apparently due to distention with gas (a 
 common symptom for several weeks after this operation, 
 which passes away when the bowel regains its tone). 
 Examination showed the lower pole of the kidney pal- 
 pable, but it could not be brought farther below the 
 costal margin. 
 
 November 21, 1906. Feels very well; menstruation 
 painless; bowels continue regular; has gained ten and 
 one-half pounds since the operation. Has taken off band, 
 and since doing so notices some return of the pain in the 
 cecum. Advised reapplication of the band. 
 
 December 28, 1909. Dr. Sherrill reports the patient 
 in good condition in every way; weighs one hundred and 
 twenty-two pounds (a gain of about twelve jDounds since 
 operation) ; has no symptoms, as before operation, con- 
 nected with the kidney, which retains its normal po- 
 sition; bowels slightly constipated. 
 
142 NEPHEOCOLOPTOSIS. 
 
 Case 10. 
 
 A case for the neurologist. 
 
 Female; aged 29; married three years; never pregnant. 
 Patient of Dr. Jones, of Pittsford, Mich. 
 
 September 15, 1906. Examined at St. Mary's Hospital. 
 Was wearing an adhesive plaster abdominal band, which 
 patient said had been applied two weeks before by a 
 gastro-enterologist for floating kidney. The band had 
 not benefited her, and was causing a good deal of irrita- 
 tion of the skin, as is usual with adhesive plaster when 
 left on longer than a week or ten days. Has had daily 
 attacks of severe nausea and emesis, attended with great 
 nervous disturbance, for over a year, and dates the begin- 
 niQg of the symptoms from an attack of acute nephritis, 
 from which she completely recovered. Six months ago 
 had the uterus and adnexa removed by a surgeon in the 
 interior of the state, but with no benefit. 
 
 Abdominal examination showed right nephroptosis of 
 moderate degree in left lateral position, and a sensitive 
 area in the epigastrium. Urine normal. Operation was 
 advised, although the neurotic element in the case made 
 the outcome problematic, and the husband was so in- 
 formed, with the understanding that an exploratory ab- 
 dominal section should be made to determine the con- 
 dition of the pylorus and gall-bladder. 
 
 September 19, 1906. Operation of nephrocolopexy and 
 ex23loratory abdominal section (negative result) at St. 
 Mary's Hospital before the class of the Detroit Post- 
 Graduate Medical School. Recovery was uneventful, and' 
 for the following two weeks the pain, nausea, and other 
 symptoms were decidedly better. After this time they 
 began to gradually recur, nausea occurring very early in 
 
EEPOETS OF CASES. 143 
 
 the morning; these attacks gradually increased in sever- 
 ity after leaving the hospital. 
 
 May 24, 1907. Patient reported in person. The kid- 
 ney was in normal position, and the bowels regular, but 
 all other symptoms were much worse, and, as the neu- 
 rotic element now seemed to be most decidedly the domi- 
 nant factor, I sent her to my friend. Dr. David Inglis, 
 who reports that he treated the patient from June 11, 
 1907, to September 9, 1907; that treatment at first was 
 based on the supposition that a uric acid diathesis was 
 the causative factor in the pathology, but later concluded 
 the attacks were purely hysteric in origin, and advised 
 certain disciplinary measures. An abstract from a let- 
 ter written by 'her husband in December, 1907, gives a 
 very encouraging report of the results of the last advised 
 form of treatment. 
 
 Case 11. 
 
 The following is the case on which the original obser- 
 vation was made that led to the discovery of the nephro- 
 colic ligament. It is also my first case of operation for 
 the relief of symptoms caused by coloptosis alone, with- 
 out nephroptosis. Obstinate constipation completely 
 cured. 
 
 Female, aged 16; single. Patient of Dr. Hugh Gary, 
 of Delray, Mich. 
 
 December 10, 1903. Saw patient in consultation with 
 Dr. Gary, when she complained of a pain, often of a grij)- 
 ing character, in the right side of the abdomen, which 
 she had had for about a year. During this time she had 
 gradually lost flesh, and the bowels had become more 
 and more constipated. Menstrual history normal. Ex- 
 amination was negative, excepting for a marked tender- 
 ness on pressure at McBumey's point. The kidneys 
 
144 NEPHEOCOLOPTOSIS. 
 
 were carefully examined for ptosis, with negative results. 
 The sensitive area at McBnrney's iDoint and the history 
 of the pain in the same region led to the diagnosis of 
 aiDj)endiceal disease of some kind — probably adhesions — 
 and appendectomy was advised. 
 
 December 17, 1903. The operation of appendectomy 
 was made at Solvay Hospital, when the organ was found 
 bound by adhesions to the cecum in sharp angulation. 
 As the cecum was found in the bottom of the pelvis — 
 and, as a matter of course, the appendix with it — I 
 marveled at the time at the pain and tenderness at Mc- 
 Burney 's point previously experienced by the patient. I 
 know now that the |)ain was not in the appendix at all, 
 but was in the cecum and ascending colon, and was due 
 to the coloptosis. It was during this operation that I 
 discovered that the right kidney could be pulled down 
 by making traction on the cecum, as described on pages 
 9, 10. The patient made a good recovery, and was dis- 
 charged from the hospital with expectation of complete 
 relief. But this result did not occur, as the pain not only 
 continued the same, but the constipation became so bad 
 as to cause almost an intestinal obstruction at times, re- 
 quiring more and more evacuants, and, when these failed, 
 larger and larger enemas to cause the discharge of the 
 fecal contents of the colon. This condition was some- 
 what relieved by the use of an abdominal supporter, but 
 the constipation continued as bad as ever, so that, with 
 my later acquired knowledge of the action of the pro- 
 lapsed colon and the utility of the newly discovered 
 nephrocolic ligament, I advised the operation of nephro- 
 colopexy for the sole purpose of relieving the torpidity 
 of the bowel. At this time the patient complained of 
 frequent sick headaches, had become very thin, her com- 
 plexion was sallow, skin rough and pimply, and expres- 
 
REPORTS OF CASES. 145 
 
 sion apathetic, besides complaining of severe dysmenor- 
 rliea for six months. 
 
 September 28, 1906. At the Solvay Hospital, Delray, 
 I performed the operation of nephrocolopexy and dilated 
 the cervix uteri, and removed a small mucous polyp from 
 the endometrium. Recovery was ideal in every way. 
 
 October 7, 1907. Reports bowels perfectly regular 
 without medication, and have been so since the operation 
 of over a year ago. Has gained fifteen pounds. 
 
 October 17, 1908. Bowels regular. Feels well, except- 
 ing for occasional pain in the cecum, apparently due to 
 gas. 
 
 Case 12. 
 
 Case of "chronic diarrhea" — a neurasthenic invalid 
 — cured by nephrocolopexy. A gain of twenty-two 
 pounds in weight. 
 
 Female; aged 42; married; no children. Patient of 
 Dr. R. W. Alton, of Portland, Mich. 
 
 For several years had suffered with neurasthenia; 
 daily abdominal pains; alternating constijoation and 
 diarrhea, with much mucus in stools; flatulence; occa- 
 sional attacks of pain and tenderness in the right side of 
 the abdomen; during the last two years lost a great deal 
 in weight and became very nervous, and is in conse- 
 quence a chronic invalid; exceedingl}^ thin; weighs nine- 
 ty-four pounds. 
 
 October 4, 190G. Examination in the dorsal decubitus 
 showed the right kidney entirely prolapsed without 
 bringing it down b}^ the inspiratory effort. It was easily 
 replaced manually, and remained in normal position 
 while the patient was recumbent, but immediately 
 dropped out of jDlace on assuming the erect position. 
 
 October 5, 1906. Operation of nephrocolopexy at 
 
146 NEPHEOCOLOPTOSIS. 
 
 Harper Hospital. Eecovery ideal. Patient in iDed two 
 weeks. Abdominal supporter applied and petrolatum 
 oil prescribed. Discharged October 30, 1906. 
 
 December 7, 1909. Dr. Alton, in answer to my request 
 for a report on this case, sends me a long letter from tlie 
 jDatient, dated Idaho Falls, Idaho, December 1, 1909, 
 from which I make the following quotations: ^'Yes, I 
 am sure the kidney is in place. I still have to use enemas 
 occasionally, but the bowels are so much better than be- 
 fore the operation that I am sure they will get entirely 
 well. When we left for the West I weighed one hundred 
 and four pounds (a gain of ten pounds), and I now 
 weigh over one hundred and sixteen pounds (total gain 
 of twenty-two pounds), and am in horror of growing old 
 and fat! My general health is certainly much better, 
 and you can judge about my endurance when I tell you 
 I am doing all the hard work for a family of six, and on 
 a ranch at that, and I get nervous only when I get over- 
 tired. I am so much better than before my operation 
 that I hardly know myself." 
 
 Case 13. 
 
 Perfect anatomic result of operation. Case having 
 persistent uric acid diathesis and severe neurasthenia. 
 
 Female; aged 32; married; mother of three children, 
 the youngest 2 years old. Patient of Dr. F. W. Mann, of 
 Detroit, Mich. Her history was exceedingly stormy and 
 eventful from a pathologic and operative standpoint, and 
 presented a doubtful proposition for the further exploita- 
 tion of surgery. She had had about a dozen operations, 
 including four for tubercular glands, two for repair of 
 lacerations incident to parturition, several for hemor- 
 rhoids, and one for post-partum infection. 
 
REPORTS OF CASES. 147 
 
 August 30, 1906. Gave the following history in ad- 
 dition to the alcove: lost a good deal of weight during 
 the last year; very nervous and despondent; nearly con- 
 stant i^ain in )3ack of hips and right side of abdomen, the 
 latter tender to touch; frequent attacks of severe pain, 
 attended with nausea and retching, without vomiting, 
 requiring hypodermics of morphia to relieve; bowels 
 very constipated, requiring constant attention; menstrua- 
 tion too frequent, is frequently clotted and often lasts ten 
 to fourteen days. Was in bed six weeks a year ago for 
 neurasthenia. 
 
 External examination showed general abdominal ten- 
 derness, which was especially acute on the right side in 
 the region of McBurney's point; the right kidney was en- 
 tirely below the costal margin without effort; freely 
 movable and easily replaced, although sensitive to touch. 
 
 Pelvic examination showed a laceration of the cervix 
 uteri on the right side; uterus and cervix large and 
 hyperplastic; adnexa normal and organs in normal po- 
 sition. 
 
 Urine, specitic gravity, 1.028; acid reaction; highly col- 
 ored; slightly turbid. No albumin or sugar. Micro- 
 scopic examination showed a few leucocytes, squamous 
 epithelium, and large crystals of uric acid. 
 
 A diagnosis was made of nephrocoloptosis, laceration 
 of cervix, and endometritis, and operation advised. The 
 character of the attacks of pain in the region of the 
 pylorus and gall ducts, as I had not seen the patient in 
 one, were something of a problem, but, as the tenderness 
 was in the kidney and not in the region indicated, I 
 concluded the attacks were probably due to some form of 
 Dietl's crisis, or were produced by a sharp kink in the 
 common bile duct arising from the traction of the kidney 
 on the duodenum. (Figs. 4, 6.) 
 
148 , NEPHROCOLOPTOSIS. 
 
 October 18, 1906. Operation at Harper Hospital. Neph- 
 rocolopexy; trachelorrhaphy; curettage. The wounds 
 healed perfectly. Patient was kept in bed eighteen 
 days, and made an unexpectedly smooth recovery while 
 in bed, but convalescence, after being up a few days, be- 
 gan to be stormy, and continued so for about six weeks, 
 the symptoms being of a nervous and dietetic character, 
 and apparently due to faulty metabolism. The urine 
 during this time was usually of low specific gravity, con- 
 taining free urates and occasionally uric acid crystals. 
 An occasional attack of the old epigastric pain was 
 averted each time by a hypodermic of hyoscin liydro- 
 bromate gr, 1/200, as were also other attacks of a purely 
 hysteric character. She was discharged from the hos- 
 pital November 10, 1906, but did not leave her room at 
 home until December 30, 1906. After this time a muscu- 
 lar rheumatism of the right side and shoulder developed, 
 which was successfully treated at a sanitarium. 
 
 April 29, 1907. Patient reported in person. Gained 
 some in flesh, digestion improved, bowels regular (takes 
 the oil) ; has had but two slight attacks of the epigastric 
 pain in four months. The kidney was in normal position, 
 only the lower pole being palpable on deep inspiration in 
 left lateral position. 
 
 Have not been able to see this patient since the last 
 date, as she lives at a distance. She writes that she has 
 not gained much in flesh, and that her nervous symptoms 
 are still in evidence. 
 
 The case is apparently one which demands constant 
 supervision of diet and general habits of life to combat 
 the effects of the uric acid diathesis, which seems to be 
 the basic element m the present pathology. 
 
EEPOETS OF CASES. 149 
 
 Case 14. 
 
 Perfect anatomic and symptomatic results of operation. 
 Apparent wounding of cortex of kidney, resulting in pro- 
 fuse leakage. Perfect recovery. 
 
 Female; aged 40; married; one child 8 years old. Ab- 
 dominal section and bilateral salpingo-oophorectomy for 
 hydrosalpinx and cystic ovaries by me in 1900. 
 
 September 10, 1906. Has had abdominal pains of a 
 griping character for over a year, mostly in right side; 
 lost weight steadily for two years; bowels very consti- 
 pated, and movements often attended with abdominal 
 pains; is nervous and sleeps badly; menstruates regu- 
 larly and normally; has some leucorrhea. 
 
 Examination in the dorsal decubitus showed general 
 abdominal tenderness, and right kidney entirely below 
 the costal margin and freely movable. Vaginal exami- 
 nation showed a cystic cervix and hyperplastic uterus. 
 Applied abdominal band, and prescribed petrolatum oil 
 —one tablespoonful afternoon and bedtime, and warm 
 olive oil — three ounces by rectum at bedtime; scarified 
 cervix. 
 
 October 8, 1906. No improvement. Advised fixing 
 the colon and kidney, and curetting the uterus. 
 
 October 20, 1906. Operation at Harper Hospital. 
 Nephroeolopexy; curettage. Buried sutures used of 
 twenty-day catgut only. The external continuous suture 
 of silkwormgut was removed on the sixth day (October 
 26), when union was good and wound appeared normal, 
 and a normal recovery indicated, with no pain or rise of 
 temperature. 
 
 October 31. Pain in the scar, which was found to be 
 distended and bulging, and, on incision, quite a quantity 
 of thin, clear, odorless fluid spurted out. A drainage 
 
150 NEPHROCOLOPTOSIS. 
 
 tube was inserted, and this clear fluid dripiDed constantly 
 from it to the extent of from thirty to forty ounces daily. 
 A specimen was sent to the Detroit Clinical Laboratory 
 on November 3, and the following report made: ''This 
 fluid is almost colorless, with a slight yellow tinge, is 
 cloudy, neutral in reaction, and has a specific gravity of 
 1,003. The fluid gives a test with sodium hypobromate 
 for urea, the urameter showing 0.3 percent. Micro- 
 scopically numerous leucocytes are seen. "While it can 
 not be positively stated that the fluid consists only of 
 urine, the evidence points to the presence of urine in it." 
 
 At the time this fluid first appeared, the patient 's tem- 
 perature was 100.5°, but subsided to normal shortly after 
 the evacuation, and remained so during her further con- 
 valescence. The wound closed closely around the rub- 
 ber drainage tube, allowing of little leakage, so that the 
 daily quantity was readily collected and measured, which 
 amounted to from thirty to forty ounces. This decreased 
 gradually until January 14, 1907, when she left the hos- 
 pital in good condition, with the wound closed and re- 
 tracted. 
 
 January 25. The scar was found slightly bulging, and 
 was incised, letting out about an ounce of clear, odorless 
 fluid. After this the scar remained closed and retracted, 
 and gave no further trouble. During the time of the 
 discharge of the fluid, and since its cessation, the kidney 
 gave no symptoms. 
 
 March 21, 1909. Patient reports that she is enjoying 
 good health; that the bowels are regular, requiring occa- 
 sionally- — for a week or so at a time — the use of the 
 petrolatum oil; the abdominal pains have disappeared; 
 she has gained twenty pounds in weight. Kidney is in 
 normal 'position. 
 
EEPOETS OF CASES. 
 
 151 
 
 Case 15. 
 
 Case having Dietl's crisis; obstinate constipation and 
 malnutrition cured by operation. 
 
 Female; aged 42; single; saleswoman. Patient of Dr. 
 R. E. Loueks. 
 
 March 23, 1907. Saw her in consultation. Has had 
 griping pains in abdomen for several years; lost weight 
 steadily for three years; bowels very constipated, re- 
 quiring much medication, and movements filled with 
 
 Fig. 50. Case 1.5. 
 
 mucus; had attack of severe pain and swelling in right 
 side of abdomen and loin three weeks before, which con- 
 fined her in bed for two weeks; menstruation normal. 
 
 Examination showed a very tender and somewhat en- 
 larged right kidney, entirely below the costal margin; 
 also much sensitiveness over entire right side of ab- 
 domen. 
 
 Vaginal examination showed normal introitus; small 
 cervix pointing forward; fundus fixed in retroversion of 
 third degree; two small nodules anteriorly and to right 
 
152 NEPHROCOLOPTOSIS. 
 
 on fundus, all fixed and immovable, and very sensitive; 
 heart normal; urine normal. 
 
 April 1, 1907. A radiograpli (Fig. 50) showed the 
 cecum lying in the bottom of the pelvis, with its lower 
 end in the region of the bladder and uterus, the first half 
 of the transverse colon lying across the pelvis nearly in 
 juxtaposition with it, and the second half in a vertical 
 position, lying close to the left parietes, and apparently 
 directly in front of the descending colon. This position 
 of the second section of the transverse colon would neces- 
 sitate the formation of a very acute angle at its junction 
 with the descending colon at the splenic flexure — similar 
 to a rubber tube hung over a peg — and at a glance 
 showed the difficulty the bowel must labor under in forc- 
 ing material from the transverse colon over this angle 
 into the descending colon. The suggestiveness of this 
 point revealed by this, my first successful radiograph of 
 the colon, was immecliateh" apparent as an index to much 
 of the sjTuptomatology in not only this case, but in others 
 of a similar nature. 
 
 The acute irritation of the kidney having subsided, 
 operation was advised on both the kidney and the pelvic 
 organs. 
 
 April 3, 1907. Operation at Harper Hospital. Nephro- 
 colopexy; abdominal section, with enucleation of two 
 walnut-size fibroids from the uterus; breaking up ad- 
 hesions; appendectomy, the organ being adherent to the 
 parietal peritoneum in front of the bladder; Alexander's 
 operation by the blunt hook method. (Kellogg.) 
 
 Recovery good and afebrile; in bed sixteen days; had 
 pleuritic pains in right side, lasting three days, during 
 the middle of convalescence. Abdominal supporter ap- 
 plied and petrolatum oil prescribed on discharge from 
 the hospital. 
 
EEPOKTS OF CASES. 153 
 
 September 24, 1907. Gained ten pounds and looks 
 well; bowels still need tlie oil, and occasionally the even- 
 ing enema; some soreness in the kidney, the lower pole 
 of which can be palpated below the costal margin on deep 
 inspiration. Olive oil per rectnm prescribed. 
 
 From this time on for a year gained constantly in flesh 
 and looked well, bnt complained more or less of soreness 
 in the region of the cecum and kidney, and a pulling sen- 
 sation in the round ligament fixations. 
 
 May 3, 1909. Kidney in good condition, gives no 
 trouble in any way, and is free from sensitiveness. 
 Bowels in better condition, but require the use of the 
 petrolatum oil, and the olive oil per rectum occasionally. 
 Had pneumonia six months ago, and since recovery from 
 that has gained flesh and is now back to normal weight. 
 
 Case 16. 
 
 A case of nephroptosis, with unrecognized coloptosis, 
 of long standing. 
 
 Female; aged 41; married; mother of one child, now 
 25 years old. Patient of Dr. Sidney I. Small, of Saginaw, 
 Mich. Saw her first April 23, 1903, when she gave the 
 following history: menstruation normal; bowels very 
 constipated for years, and lately movements attended 
 with abdominal pain and much mucus seen in the stools; 
 pain in back and hips for six months, and for years has 
 had pain at times in the left side of the upper abdomen; 
 fatigues easily and can walk but little; riding ''jars," 
 and causes abdominal pain and headache. Had opera- 
 tion for lacerations incident to parturition seventeen 
 years ago, and had an attack of "inflammation of the 
 bowels" a year afterward. Has had no return of the in- 
 flammatory trouble since. Pulse and temperature normal. 
 
154 NEPHROCOLOPTOSIS. 
 
 Abdominal examination in the dorsal decubitus showed 
 the right kidney entirely below the costal margin with- 
 out effort, and a fullness and sensitiveness over the en- 
 tire left side. Pelvic examination showed a normal 
 perineum; large cystic cervix, lacerated on the right side; 
 uterus normal. 
 
 Diagnosis showed floating kidney, lacerated cystic 
 cervix, and colonic catarrh (the fact that coloptosis is 
 always present with nephroptosis not then known to me). 
 A silk elastic abdominal band, with pad, below the navel 
 was applied, flushing of the colon with normal salt solu- 
 tion prescribed, and the cervix scarified. This treatment 
 was continued until June 24, 1903, when the operation 
 of trachelorrhaphy and curettage was done at the 
 patient's residence. Recovery from this was slow, 
 though the cervix healed well and there were no local 
 symptoms. Patient's nutrition continued inadequate; 
 she lost weight gradually, and became nervous and de- 
 spondent; the bowel symptoms continued as before. 
 Various kinds of treatment, by myself and others, were 
 used, with no satisfactory results until April 2, 1907, 
 when I was called to see her in consultation with Dr. 
 F. E. McClure, who had treated her for some weeks with- 
 out benefit. I found her confined to bed and suffering 
 with the old colonic symptoms intensified, and also from 
 severe attacks of pain in the pelvis and back. She was 
 in a state of extreme neurasthenia, could take little nour- 
 ishment because of gastric irritability, and had frequent 
 attacks of tachycardia. 
 
 Examination showed the nephroptosis as before, but a 
 change had taken place in the pelvic organs, the fundus 
 uteri being nodular and a cystic tumor present on each 
 side of it. 
 
 After trying some other forms of treatment, a further 
 
EEPORTS OF CASES. 155 
 
 consultation was held, Dr. C. G. Jennings at this time 
 assisting in the disposition of the trying case. Notwith- 
 standing her enfeebled condition, operation was decided 
 on, and the family so advised. 
 
 April 16, 1907. Operation at Harper Hospital, as- 
 sisted by Dr. McClnre. Nephrocolopexy; abdominal sec- 
 tion; myomectomy of one small fibroid; double sal]3ingo- 
 oophorectomy (hydrosalpinx and cystic ovaries) ; appen- 
 dectomy. Both wounds healed perfectly and there were 
 no unusual temperature conditions, but the convalescence 
 was stormy in the extreme because of the persistent 
 atony of the bowels and the enfeebled condition of the 
 patient. These conditions were, however, successfully 
 met and the patient was out of danger in ten days after 
 the operation. In bed three weeks. Owing to s5"mptoms 
 of a nervous character, due largely to the menopause, 
 precipitated to some extent by the operation, the con- 
 valescence, after leaving the hospital, was slow. 
 
 June 10, 1907. Has gained ten pounds; bowels regular 
 by the use of the oil; passages contain no more mucus; 
 still has some colonic pain, which is steadily diminishing ; 
 appetite and digestion about normal. Examination 
 shows kidney in normal position. 
 
 July 2, 1908. Has gained eighteen pounds; bowels 
 regular by occasional use of the oil; no more mucus; only 
 occasional abdominal pain. 
 
 Case 17. 
 
 Nephrocoloptosis, complicated by infective chole- 
 lithiasis. 
 
 Female; aged 56; widow; three children, the youngest 
 22 years old. Patient of Dr. E. E. Loucks. 
 
 May 12, 1907. Saw her in consultation, when she gave 
 
156 NEPHKOCOLOPTOSIS. 
 
 a history of numerous attacks of gallstone colic, consti- 
 pation, loss of flesh, and neurasthenia. Menopause 
 passed for several years. Suffering with pain in the epi- 
 gastrium and right side, close under the costal margin. 
 
 Examination showed great sensitiveness and fullness 
 in the region of the gall-bladder and between Mc- 
 Burney's point and the costal margin, and without 
 effort a loose right kidney completely below the costal 
 margin. Heart normal, 100; temperature 100.5°. A diag- 
 nosis of biliary calculus in the cystic duct and nephro- 
 coloptosis was made, and operation advised. Examina- 
 tion of the urine on the following day showed it to be 
 normal. 
 
 May 14, 1907. Operation at Harper Hospital. Neph- 
 rocolopexy; cholecystotomy ; removal of stones; drain- 
 age. Drainage tube removed on tenth day. Recovery 
 without incident. In bed sixteen days. Abdominal band 
 applied and petrolatum oil prescribed, and patient dis- 
 charged June 8, 1907. 
 
 December 7, 1909. Dr. Loucks reports no pain in the 
 region of the kidney, which is in normal position; nutri- 
 tion very much improved, as shown by a large increase in 
 weight — about twenty pounds. 
 
 Case 18. 
 
 Colonic symptoms completely cured by operation. 
 
 Female (colored); aged 26; married; no children; clin- 
 ical patient. Had complete hysterectomy in 1905. 
 
 May 14, 1907. Gave the following history: has had 
 pains in the abdomen, of a griping character, for over a 
 year; has lost flesh considerably, but does not know how 
 much; bowels very constipated, and takes all sorts of 
 medicines to act on them; sleeps badly, and is so weak 
 
EEPOETS OF CASES. 157 
 
 that she is unable to do work. Examination in dorsal 
 decubitus showed the right kidney only slightly (lower 
 half) below the costal margin, but on putting her in the 
 left lateral position, with deep inspiration, the whole 
 kidney could be palpated in the region of the navel. 
 
 May 17, 1907. Radiograph showed the cecum and first 
 half of the transverse colon in the pelvis. 
 
 May 18, 1907. Operation at Harper Hospital. Right 
 nephrocolopexy. The wound healed perfectly, and re- 
 covery was normal and afebrile until the eleventh day, 
 when pain in the left groin was comj^lained of and a mild 
 phlebitis developed, which subsided in ten days without 
 leaving any untoward result. Because of that the pa- 
 tient was kept in bed for twenty-five days. 
 
 June 24, 1907. Discharged, wearing an elastic abdomi- 
 nal band and taking the petrolatum oil. 
 
 June 12, 1908. Patient reported at the office. Bowels 
 regular; no more al)dominal pain. Examination showed 
 kidney .in normal position. Has gained eight pounds. 
 
 Case 19. 
 
 Neurasthenia and malnutrition. Gain of twenty-six 
 pounds after operation. 
 
 Female; aged 41; single; seamstress. Patient of Dr. 
 R. E. Loucks. 
 
 May 17, 1907. Seeks relief for backache; monorrhagia; 
 leucorrhea; pain in the right side of abdomen; neuras- 
 thenia; loss of flesh; dyspepsia. Menstruation is irregu- 
 lar, and often is of ten days' duration. All symptoms 
 of three years' standing, and commenced with an attack 
 of nervous prostration, lasting several months. Weighs 
 one hundred and fourteen pounds; looks thin and anemic, 
 and badly nourished. 
 
158 NEPHEOCOLOPTOSIS. 
 
 Abdominal examination in the dorsal decubitus showed 
 the right kidney entirely below the costal margin, 
 brought down by deep inspiratory act, and readily re- 
 placed manually. 
 
 Pelvic examination showed a retroverted uterus of 
 second degree, which was apparently deviated backward 
 by a walnut-sized myoma situated anteriorly just above 
 the bladder. 
 
 Diagnosis made of nephrocoloptosis, uterine subserous 
 myoma, and granular endometritis. Operation recom- 
 mended. 
 
 May 20, 1907. Operation at Harper Hospital. Right 
 nephrocolopexy; curettage; abdominal section; myomec- 
 tomy. Recovery without incident. Left the hospital 
 wearing the abdominal band, but not taking the petro- 
 latum oil, as the bowels were regular. 
 
 October 8, 1907. Gained twelve pounds; no backache 
 or pain in abdomen and side; has menstruated but once 
 in the three months, and that very little. Examination 
 in left lateral position shows lower pole of kidney pal- 
 pable below costal margin, but can be brought no further 
 down. 
 
 October 2, 1908. A¥eighs one hundred and forty 
 pounds, has good endurance and nerve tone, and feels 
 well. 
 
 July 27, 1909. Says she has had no pain in side, ab- 
 domen, or back since operation. Weighs one hundred 
 and thirty-five pounds. Examination in dorsal decubitus 
 shows kidney in normal position; left lateral decubitus 
 allows palpation of lower pole below costal margin. 
 
 Case 20. 
 A case in which probable mutilative surgery could 
 have been avoided if the surgeon had had a knowledge 
 
EEPOKTS OP CASES. 159 
 
 of colonic pathology. Completely cured by nephro- 
 colopexy. 
 
 Female; aged 28; single; teacher. Had left ovary re- 
 moved in 1900 to cure a pain in the left side of the ab- 
 domen, and two years after had the appendix and right 
 ovary removed for pain in the right side of the abdomen. 
 Both operations by other surgeons. 
 
 December 15, 1904. Seeks relief for the same ab- 
 dominal pain as she had previous to the operations two 
 and four years ago. Still menstruates, though irregu- 
 larly and painfully; has backache and headache con- 
 stantly; is steadily losing weight and strength; is consti- 
 pated; sleeps badly; says she has had to give up her 
 position as teacher because of increasing exhaustion and 
 nervousness. Temperature and pulse normal. Urine 
 normal, excepting for amorphous urates. 
 
 Abdominal examination in the dorsal position showed 
 a very sensitive area at and around McBurney's point, 
 but no descent of the kidneys. The left lateral position 
 was therefore tried, with the result of bringing the right 
 kidney down and imprisoning it below the costal margin 
 with the hands. The left kidney could not be palpated 
 in either position. 
 
 Vaginal examination showed a small, movable uterus 
 in second degree of retroversion — otherwise negative. 
 Urine, pale color; specific gravity, 1,012; acid; no albu- 
 min or sugar; slightly turbid with urates. 
 
 A diagnosis of nephrocoloptosis was made, and a silk 
 elastic abdominal band, with abdominal pad, applied. 
 Various forms of internal medication, electrical treat- 
 ment, massage, etc., were used by myself and several 
 other physicians during the following two and a half 
 years, but without benefit, the patient constantly losing 
 
160 NEPHROCOLOPTOSIS. 
 
 flesh and sliowing continnally worse conditions of the 
 nutritive functions. 
 
 May 29, 1907. Patient returned to me, complaining of 
 attacks of severe pain in the region of the right kidney, 
 lasting about a week at a time; irregular, painful, and 
 often very free and clotted menstruation; leucorrhea; 
 constipation. Operation advised. 
 
 May 29, 1907. Operation at Grace Hospital. Nephro- 
 coloi^exy; dilatation; curettage of uterus. Eecovery 
 without incident. Abdominal supporter, with the truss 
 attachment, applied and petrolatum oil prescribed on 
 discharge from the hospital. 
 
 Gradual improvement ensued for the first six months, 
 with only some nervous symptoms, and the patient was 
 lost sight of until July 14, 1909, when she reported in 
 person. Had gained fifteen pounds since ojDeration; 
 bowels regular without medication; nervous system and 
 general endurance about normal. Had not worn the ab- 
 dominal supporter for several months, and, as she had 
 occasionally a "bearing down" in the abdomen when 
 fatigued, a new supporter was advised. Kidney in 
 normal position. 
 
 Case 21. 
 
 Nephrocoloptosis and hematocystic ovaries. Anatomic 
 and symptomatic recovery. 
 
 Female; aged 31; single. Patient of Dr. D. H. Burley, 
 of Almont, Mich. 
 
 June 7, 1907. Seeks relief for monorrhagia, pain in 
 lower abdomen and thighs, constipation, frequent and 
 painful micturition, leucorrhea, indigestion, occasional 
 attacks of griping pain in abdomen. Says she sleeps well 
 if lying on the right side, but badly on the left side owing 
 to palpitation of the heart while in the latter position 
 
EEPORTS OF CASES. 161 
 
 (common symptom in right neplirocoloptosis). Heart 
 normal, 80; temperature, 98°. Urine, acid; contained 
 nothing abnormal, excepting amorphous urates. 
 
 Examination in dorsal decubitus showed a flat ab- 
 domen, with thin walls. Abdominal sensitiveness gen- 
 eral; right kidney entirely below costal margin. Pelvic 
 examination showed a retroverted uterus, loosely fixed 
 by adhesions; two large, apparently cystic, ovaries, the 
 right being adherent to the uterus and cul-de-sac. Diag- 
 nosis of neplirocoloptosis, cystic ovaries, adhesions, uter- 
 ine retroversion, and endometritis. Operation advised. 
 
 June 21, 1907. Operation at Harper Hospital. Neph- 
 rocolopexy, curettage, abdominal section; bilateral oopho- 
 rectomy; breaking up adhesions. Both ovaries large and 
 polyhematocystic. Recovery without incident. Abdomi- 
 nal band applied and petrolatum oil prescribed, and 
 patient discharged July 18, 1907. 
 
 September 21, 1907. Bowels regular; still uses the 
 petrolatum oil, but requires no enema. Has some back- 
 ache, apparentl}^ caused by low position and some retro- 
 version of the uterus. Says she can now sleep on the 
 left side without discomfort, and micturition is normal. 
 Examination showed kidney in normal position. 
 
 July 11, 1908. Patient's condition good, and has 
 gained considerably in weight. Has had extract, ovarii 
 for "hot flushes" and some remedies for indigestion, but 
 otherwise has needed no treatment. Still wears the ab- 
 dominal band and takes the oil occasionally. 
 
 Case 22. 
 
 Perfect restoration of floating kidney by nephro- 
 colopexy. 
 
 Female; aged 36; married; mother of* one child 6 
 months old. Not nursing the child. 
 
162 NEPHKOCOLOPTOSIS. 
 
 January 18, 1907. Seeks relief for pain and ''bearing 
 down" in rectum and vagina, and pain in the right side 
 of the abdomen. Has had the pain in right side of ab- 
 domen for several years, but dates the pelvic symptoms 
 from the birth of the child, which was instrumental, and 
 from which slow recovery was made. Has not menstru- 
 ated since, and is very anemic and debilitated. 
 
 Examination in dorsal decubitus was negative, but in 
 the left lateral position the right kidney dropped entire- 
 ly below the costal margin and could be palpated at the 
 navel. 
 
 Pelvic examination showed a ruptured perineum of 
 the third degree and a badly lacerated cervix — poste- 
 riorly and right laterally. Operation advised. 
 
 June 24, 1907. Operation at Woman's Hospital. 
 Nephrocolopexy, trachelorrhaphy; perineorrhaphy. The 
 perineal tissue was very scanty, cicatricial, and retracted; 
 the parts were coapted with some difficulty by the split- 
 flap, buried suture method. The wounds healed per- 
 fectly, excepting that of the perineum, which suppurated 
 slightly, but it eventually closed so as to give a fairly 
 good result and a very good sphincter ani. 
 
 Owing to her debility, convalescence was slow, and she 
 was discharged from the hospital August 4, 1907, wear- 
 ing the abdominal band, but not using the oil, as the 
 bowels were regular. 
 
 October 4, 1907. Kidney in perfect position. Says 
 that she has no more pain in that side. 
 
 September 1, 1908. Pregnant seven months. 
 
 May 4, 1909. At confinement, four months ago, had 
 retained placenta and resultant sapremia, requiring 
 curettage. Examination showed a cystocele. Kidney in 
 normal position. 
 
REPORTS OF CASES. 163 
 
 Case 23. 
 
 Case illustrating the common occurrence of the mis- 
 take of making the operation of appendectomy for symp- 
 toms produced by nephroptosis. 
 
 Female; aged 23; single; teacher. Patient of Dr. 
 ^^ernier. 
 
 June 21, 1907. Seeks relief for pain and distention in 
 right side of abdomen; sensation of faintness caused by 
 the erect position; constipation; backache; distress in 
 stomach after eating; leucorrhea; menstruation, seven 
 days' duration, painful for three days. These symptoms 
 commenced about eighteen months ago and have gradu- 
 ally increased in severit}". Had operation of appendec- 
 tomy one year ago for relief of the pain in the side, but 
 without beneficial result. Heart normal, 82; tempera- 
 ture, 98°. Urine normal. 
 
 Abdominal examination in dorsal decubitus showed 
 right kidney entirely below costal margin without in- 
 spiratory effort. Kidney painful to touch, and patient 
 referred to it as the locality of her usual pain in that side. 
 Some tenderness in left epigastrium. 
 
 Vaginal examination showed normal introitus, small 
 cervix bathed in mucus, erosion of os, fundus retroverted 
 to third degree (easily replaced). 
 
 Diagnosis of nephrocoloptosis, retroversion of uterus, 
 and endometritis. Operation advised. 
 
 June 24, 1907. Operation at Grace Hospital. Nephro- 
 colopexy; curettage; Alexander's operation by the blunt 
 hook method. Recovery without incident. In bed four- 
 teen days. Wearing abdominal band when discharged, 
 but not taking the oil, as the bowels were regular. 
 
 September 24, 1907. Can stand better; bowels regular, 
 but has been taking the oil occasionally, as there has 
 
164 NEPHROCOLOPTOSIS. 
 
 been some constipation at times. Backache mucli better. 
 Kidney well in place, but lower pole can be palpated 
 when in left lateral position. 
 
 October 5, 1907. Kidney in normal position. Patient 
 died of pneumonia during the following winter. 
 
 Case 24. 
 
 Complete cure of nephritic and colonic symptoms, and 
 restoration of the kidney by operation. 
 
 Female; aged 30; married; never pregnant. Patient 
 of Dr. David Inglis. 
 
 June 10, 1907. Seeks relief for constipation; backache; 
 loss of strength and weight; nervous irritability; profuse 
 leucorrhea. Has had the leucorrhea for two years, and 
 the other symptoms for about a year, gradually increas- 
 ing. 
 
 Abdominal examination in the dorsal position was 
 negative, excepting for a sensitive area at McBurney's 
 point, but in the left lateral position the right kidney 
 dropped down into the abdomen and could be palpated at 
 the navel. 
 
 Vaginal examination showed nothing farther than 
 erosion around the os uteri. 
 
 Diagnosis of nephrocoloptosis and endometritis. Oper- 
 ation advised. 
 
 July 5, 1907. Operation at Plarper Hospital. Nephro- 
 colopexy, curettage. Ideal recovery. In bed eighteen 
 days. Abdominal band applied and petrolatum oil pre- 
 scribed on discharge from hospital. 
 
 September 24, 1908. Bowels regular, gained five 
 pounds, nervous symptoms greatly relieved.' Says everj'-- 
 thing Init the leucorrhea is very much improved. 
 
 February 20, 1909. Has gained eighteen pounds and 
 
EEPORTS OF CASES. 165 
 
 is very well, with normal endurance and very little of 
 the old nervousness. Still troubled with the leucorrhea. 
 Kidney not palpable in any position. 
 
 Case 25. 
 
 Disordered nutritive functions and nervous system 
 completely restored by operation. 
 
 Female; aged 30; single; bookkeeper. 
 
 September 18, 1907. Seeks relief for pain in back of 
 head and neck, which she has had for two years; loss of 
 flesh and strength; pain in left side of abdomen. Bowels 
 regular. Torso narrow. 
 
 Abdominal examination in dorsal position showed 
 right kidney entirely below costal margin without in- 
 spiratory eitort, and tenderness over McBurney's point. 
 
 Pelvic examination showed introitus normal, cervix 
 small, OS eroded, fundus uteri in third degree retro- 
 version (easily replaced). Heart normal, 82; tempera- 
 ture normal. Urine normal. Weight, one hundred and 
 twenty-eight pounds. 
 
 Diagnosis of nephrocoloptosis, retroversion of uterus, 
 and endometritis. Operation advised. 
 
 September 20, 1907. Operation at Harper Hospital. 
 Nephrocolopexy; curettage; Alexander's operation by 
 the blunt hook method. Recovery ideal. Abdominal 
 supporter applied. 
 
 November 4, 1907. Kidney and uterus in normal po- 
 sition. Bowels a little constipated. Still some pain in 
 back of neck. Petrolatum oil prescribed. 
 
 April 22, 1909. Has gained fifteen pounds since opera- 
 tion, and now weighs one hundred and forty-three 
 pounds. Says she feels well, and never knew what it 
 was to feel so before. Examination showed kiclnev in 
 
166 NEPHEOCOLOPTOSIS. 
 
 normal position, with lower pole barely palpable in left 
 lateral position. Has pain only in back of head and 
 neck when over-fatigued. Bowels regular. 
 
 Case 26. 
 
 Rapid gain of weight after operation. 
 
 Female; aged 41; married; mother of four children, 
 the youngest 9 years of age. 
 
 September 25, 1907. Seeks relief for neurasthenia; 
 malnutrition and loss of jflesh; insomnia; constipation; 
 catarrh of the colon, as shown by much mucus in stools; 
 pain of both griping and constant character in the right 
 side of the abdomen, and frequent attacks of pain and 
 tenderness located on the right side, close under the 
 costal margin. Had an attack of acute intestinal tox- 
 emia five years before, since which time these symptoms, 
 which had always been in evidence for several years, be- 
 came very much worse. 
 
 Abdominal examination in the dorsal position showed 
 marked sensitiveness on both sides of the abdomen on 
 .deep pressure; right kidney entirely below the costal 
 margin on deep inspirator}^ effort; left side negative. 
 
 Vaginal examination negative. Urine normal. Weight, 
 one hundred and ten pounds. 
 
 Diagnosis of nephrocoloptosis and operation advised. 
 
 September 20, 1907. Operation at Harper Hospital. 
 Nephrocolopexy. Convalescence was not smooth, as a 
 mild infection of the wound was introduced by the with- 
 drawal of the continuous silkwormgut stitch. Fearing an 
 insecure union, the patient was kept in bed for four 
 weeks, when, the wound being completely healed, she was 
 allowed to get up. During the time in bed the abdominal 
 band was especially cared for and the large pad kept 
 
EEPORTS OF CASES. 167 
 
 bound tightly down under the navel, so as to give the 
 kidney every possible support through the upward pres- 
 sure of the abdominal contents. On assuming the erect 
 position, the usual abdominal supporter was applied and 
 the routine of petrolatum oil and evening enema pre- 
 scribed. The convalescence to normal after discharge 
 from the hospital was slow, as the neurasthenia persisted 
 to a marked degree for some weeks. 
 
 November 30, 1907. Nutrition improving, as shown 
 by five pounds increase in weight. Bowels regular by 
 the daily use of the oil and an occasional enema. Neu- 
 rasthenia improving slowly. Still has some abdominal 
 pain, but less of it, and none at all in the region of the 
 kidney, which is in perfect position. 
 
 September 20, 1908. Has gained twenty pounds, has 
 good color, and looks in perfect health. Bowels regular 
 by the use of one daily dose of the oil. Pain occasion- 
 ally, evidently caused by distention of the cecum. Sleeps 
 much better. Kidney in normal position. 
 
 April 30, 1909. Has gained thirty-five pounds, and 
 now weighs one hundred and forty-five pounds. Is prac- 
 tically well, excepting for endurance, which comes slow- 
 ly. The kidney retains its normal position when ex- 
 amined in either position. 
 
 Case 27. 
 
 A perfect result, notwithstanding infection of wound. 
 No doubt the silver wire stay suture in the transversalis 
 fascia prevented failure. 
 
 Female; aged 57; ]narried; mother of five children, the 
 youngest 14 years old. Patient of Dr. C. G. Jennings. 
 
 July 10, 1907. Seeks relief for irregular and profuse 
 menstruation; debility; extreme neurasthenia, approach- 
 
168 NEPHROCOLOPTOSIS. 
 
 ing melancliolia ; backache; insomnia; gradual loss of 
 weight during last two years. Says bowels are regular. 
 Had typhoid fever four years before. Heart and tem- 
 perature normal; urine normal. 
 
 Abdominal examination in the dorsal position showed 
 the right kidney entirely below the costal margin; other- 
 wise negative. 
 
 Vaginal examination showed everything normal, ex- 
 cepting a large hyperplastic uterus in the third degree of 
 retroversion, which was readily replaced with the patient 
 in the knee-chest position. 
 
 An Albert Smith pessary was placed, an abdominal 
 supporter ordered, and tonic prescribed. 
 
 October 5, 1907. As various forms of treatment up to 
 this time had proved unsatisfactory, operation was 
 advised. 
 
 October 12, 1909. Operation at Woman's Hospital. 
 Nephrocolopexy; curettage; Alexander's operation by 
 the blunt hook method. 
 
 As stitch abscesses occurred in all the wounds, the pa- 
 tient was kept quiet in bed for four weeks, using great 
 care to keep the abdominal pad well bound in place to 
 keep the kidney supported. 
 
 December 27, 1907. Kidney and uterus in perfect po- 
 sition. 
 
 January 31, 1908. Kidney and uterus in perfect po- 
 sition. Has gained twenty-five pounds; nervous system 
 is very much improved, and bowels regular. 
 
 Case 28. 
 
 Female; aged 47; married; mother of one child 20 years 
 
 old. Patient of Dr. Sarah Conner, of Port Huron, Mich. 
 
 December 30, 1907. Seeks relief for nervous exhaus- 
 
EEPORTS OF CASES. 169 
 
 tion of a severe type; attacks of nausea and vertigo; con- 
 stipation; constant pain in the right side of the abdomen, 
 which is more acute at times just below the ribs; pain 
 lately in the back of head; palpitation of the heart; con- 
 fusion of ideas. Had total hysterectomy by another sur- 
 geon twelve years ago for these same abdominal pains 
 and menorrhagia. Heart normal, 106; temperature nor- 
 mal. . Urine normal. 
 
 Abdominal examination in dorsal position showed no 
 abdominal tenderness. On deep inspiratory effort the 
 right kidney dropped deep into the abdomen. Operation 
 advised. 
 
 December 31, 1907. Operation at Harper Hospital. 
 Nephrocolopexy. Eecovery without incident. In bed 
 sixteen days. Abdominal supporter applied and petro- 
 latum oil prescribed on discharge from the hospital. 
 Have not seen this patient since she left the hospital. 
 Her husband reported, May 6, 1908, that some of the 
 most distressing symptoms had left her, but some others 
 of a new character had appeared. 
 
 Case 29. 
 
 Ideal result in a case of long standing*. 
 
 Female; aged 31; married; mother of three chil- 
 dren, the youngest 7 months old, which was taken from 
 the breast three weeks ago. Patient of Dr. B. H. Jenne, 
 of Clio, Mich. 
 
 April 15, 1908. Seeks relief for pain in the right side 
 just below the ribs, which she has had for fifteen years; 
 cramps in the l)owels for five years; frequent nausea and 
 vomiting of bile; very intractable constipation for three 
 years; gradual loss of flesh. Looks weak and debilitated. 
 Had whooping-cough seven months ago and then had a 
 
170 NEPHROCOLOPTOSIS. 
 
 great deal of pain in the right side. Heart normal, 112; 
 temperature normal. Urine, specific gravity, 1,026; acid; 
 no albumin; heavy with urates. 
 
 Abdominal examination in. the dorsal position showed 
 some sensitiveness at McBurney's point, but more under 
 the costal margin on the right side, when inspiratory 
 effort brought down the right kidney entirely below the 
 ribs, and with (and apparently attached to the front of 
 it) an irregular rough-feeling mass that nearly covered 
 it, and yet could be moved somewhat separately. 
 
 Vaginal examination showed a ruptured perineum of 
 second degree; cervix normal; normal sized uterus in 
 third degree of retroversion (easily replaced in knee 
 chest position). 
 
 Sent to Harper Hospital and a blood examination 
 made, which was negative, after which operation was 
 advised, as farther examination of the mass on the dis- 
 placed kidney led to the belief that it was probably the 
 remains of an exudate caused by an attack of Dietl's 
 crisis, which may have occurred at the time the patient 
 had the whooping-cough. 
 
 April 17, 1908. Operation. Nephrocolopexy; perine- 
 orrhaphy (split flap, buried suture of No. 1 twenty-day 
 cutgut); Alexander's operation by the blunt hook 
 (buried suture) method. At the operation the kidney 
 was thoroughly examined when reached through the loin 
 incision, and the organ was found to be perfectly normal 
 in contour, the mass being entirely separate from it. 
 
 Eecovery was ideal in every way, and patient left the 
 hospital at the end of five weeks. Abdominal support 
 applied and petrolatum oil prescribed. 
 
 September 29, 1908. Patient says: "Haven't an ache 
 or a pain, sleep well, have gained ten pounds. Took the 
 oil for two months, but have not needed it since, as the 
 bowels are perfectly regular." 
 
REPORTS OF CASES. 171 
 
 Examination showed the kidney in normal position; 
 could be forced down so that only the lower pole could 
 be palpated. 
 
 November 22, 1909. Dr. Jenne reports that she is fat, 
 has gained fifteen poimds, and is very well in every way. 
 
 Case 30. 
 
 Ideal result in a case complicated by intra-abdominal 
 surgery. 
 
 Female; aged 23; single; stenographer. Patient of Dr. 
 J. H. Sanderson. 
 
 March 5, 1908. Seeks relief for nearly constant back- 
 ache; "bearing down" in the abdomen; a "smarting" 
 sensation in the lower left side of the abdomen, near the 
 groin; increasingly severe dysmenorrhea for a year. Had 
 curettage twice — four years ago and one year ago — with 
 only temporary relief of the dysmenorrhea and no relief 
 of the other symptoms. Has lost flesh steadily for two 
 years — eleven pounds during the last six months. Nor- 
 mal weight, one hundred and thirty-five pounds; now 
 weighs one hundred and sixteen pounds. Bowels regu- 
 lar. Heart normal, 84; temperature normal. Urine 
 normal. Complexion muddy and skin rough. 
 
 Abdominal examination showed right kidney entirely 
 below the costal margin on deep inspiration; left kidney 
 in normal position; no abdominal tenderness, except just 
 above Poupart's ligament on the left side on deep 
 pressure. 
 
 Examination of pelvic organs obscured by fecal mass 
 in the sigmoid and rectum. Directions were given to 
 clear the colon by laxative and enema, and to return for 
 further examination. 
 
 March 9, 1908. Pelvic examination showed everything 
 
172 NEPHEOCOLOPTOSIS. 
 
 normal, excepting the left ovary, which was twice normal 
 size; very sensitive, bnt not adherent. 
 
 Diagnosis of nephrocoloptosis and left cystic ovary, 
 and operation advised. 
 
 April 28, 1908. Operation at Harper Hospital. Neph- 
 rocolopexy; abdominal section, with left oophorectomy. 
 Ovary large and cystic. Recovery ideal in every way. 
 In bed eighteen days. Applied abdominal supporter on 
 discharge from hospital. 
 
 July 8, 1909. Feels much better in every way. 
 
 October 16, 1909. Gained twenty-five jDounds; dys- 
 menorrhea better; bowels somewhat constipated, and has 
 been using the petrolatum oil and an occasional enema. 
 
 March 29, 1909. Has kept the weight as reported in 
 October. Bowels normal; no headache or "bearing 
 down;" endurance very good; marked improvement in 
 complexion and smoothness of skin. Kidney in normal 
 position and can not be brought down by posture. 
 
 September 19, 1909. Feels perfectly well, and asks 
 permission to discard the abdominal supporter, which 
 was granted. 
 
 Case 31. 
 
 A good anatomic result, with failure of symptomatic 
 cure because of conditions of apparent neurotic origin. 
 
 Female; aged 45; married; mother of two children, the 
 youngest 22 years old. Patient of Dr. S. P. Duffield, of 
 Dearborn. 
 
 March 30, 1908. Seeks relief for a feeling of pressure 
 in the abdomen and of distention at the vulva; frequent 
 abdominal pain, more frequently in the left side; gen- 
 eral weakness and neurasthenia, with hysterical tend- 
 ency; insomnia. Patient constantly talks of something 
 having ''broken" at the vulva, following a trachelor- 
 
EEPORTS OF CASES. 173 
 
 rliaiDliy by another surgeon two and a half years ago, 
 and appears to be liypocliondriacal on the subject. Men- 
 struation regular, but profuse at times. Heart normal, 
 90; temperature normal. Urine normal. 
 
 Abdominal examination in the left lateral decubitus 
 showed the right kidney entirely below the costal margin, 
 and abdominal tenderness in left epigastrium. 
 
 Vaginal examination showed ruptured perineum of 
 second degree and large hyperplastic uterus. Operation 
 recommended, though the peculiar neurotic element in 
 the case made the prognosis guarded. 
 
 May 28, 1908. Operation at Harper Hospital. Neph- 
 rocolopexy; perineorrhaphy; curettage. Recovery with- 
 out incident, though strength returned slowly after get- 
 ting up and mental condition was sluggish. Abdominal 
 supporter applied on discharge from hospital. 
 
 October 6, 1908. Pain and pressure in vulva gone, Init 
 thinks now she has ''broken something" in the kidney. 
 Examination showed kidney in normal position and not 
 sensitive. Gained in flesh, but says she sleeps badly. 
 
 February 17, 1909. Kidney in normal position; bowels 
 regular, and patient in good appearing condition, but 
 complains again of "something broken" in the vulva. 
 Was sent to the hospital and various examinations made, 
 with only negative results. 
 
 Case 32. 
 
 Operation on kidney having- pathologic surroundings 
 gives no relief of symptoms. 
 
 Female; aged 38; married; mother of one child 11 
 years old. 
 
 July 2, 1908. Seeks relief for frequent attacks of grip- 
 ing pain in abdomen, and nearly constant pain and 
 
174 NEPHROCOLOPTOSIS. 
 
 tenderness below the ribs on the right side; gradual loss 
 of flesh for three years (weighs one hundred and eight 
 pounds); extreme nervous irritability; insomnia; fre- 
 quent headaches; has menstruated but twice in the last 
 eight months (the last time slightly, in May). Torso 
 very narrow and the lower thoracic zone contracted. 
 Heart normal, 90; temperature normal. Urine normal. 
 
 Abdominal examination in dorsal position showed 
 right kidney entirely below the costal margin without 
 inspiratory effort. Impossible to replace the organ en- 
 tirely back into its normal position behind the costal 
 margin, the renal fossa being apparently filled or closed, 
 so that the kidney could be replaced only partially, and 
 would then drop back at once by its own weight. The 
 whole abdomen was sensitive to touch. 
 
 Vaginal examination showed pelvic organs normal, ex- 
 cepting the uterus, which was very small, and apparently 
 undergoing atrophy. Eadiograph of the colon to be 
 made. 
 
 July 4, 1908. Radiograph showed the cecum in the 
 bottom of the pelvis, and very large. The transverse 
 colon did not show at all. Operation advised, although 
 the difficulty of replacing the kidney normally should 
 have demanded treatment for a time and longer observa- 
 tion. The peculiar situation of the patient at the time 
 precluded this delay, and I therefore concluded to take 
 the chance of immediate operation. 
 
 July 7, 1908. Operation at Harper Hospital. Nephro- 
 colopexy. The nephro colic ligament was large, but it 
 was impossible to draw or push the kidney up into the 
 fossa far enough to secure it below the pole, and the 
 mistake was made of attaching that portion of it which 
 lay parallel with the convexity of the kidney, hoping 
 that its good volume would serve to hold sufficiently. 
 
EEPORTS OF CASES. 175 
 
 Recovery was without incident, and patient left the 
 hospital at the end of four weeks. Al)dominal supporter 
 applied and petrolatum oil prescribed. 
 
 November 7, 1908. The whole kidney can be felt lying- 
 close to the side where attached, and does not drop into 
 the abdomen, toward the navel, as before oioeration. 
 Patient's symptoms, however, she reports, are not re- 
 lieved. 
 
 December 31, 1909. Weighs one hundred and twelve 
 pounds; bowels regular; still has some pain in both sides 
 of abdomen, though gradually decreasing; sleeps very 
 much better; kidney still fixed, though entirely below 
 costal margin. 
 
 Case 33. 
 
 Good result, anatomically and symptomatically, three 
 months after operation. 
 
 Female; aged 30; married; mother of three children, 
 youngest 2 years old. Clinical patient. 
 
 September 26, 1909. Seeks relief for backache; ab- 
 dominal pain, located in both sides; frequent attacks of 
 nausea without emesis; gradual loss of weight and 
 strength, and resultant inability to work; constipation; 
 nervousness; insomnia. Heart, temperature, and urine 
 normal. 
 
 Abdominal examination showed right kidney entirely 
 below the costal margin; sensitiveness in left epigas- 
 trium. 
 
 Vaginal examination showed everything normal, ex- 
 cepting a uterus of normal size in third degree retro- 
 version, which was easily replaced, manually, with the 
 patient in the knee-chest position. 
 
 Diagnosis of nephrocoloptosis and retroversion, and 
 operation advised. 
 
176 NEPHROCOLOPTOSIS. 
 
 Sei^tember 30, 1908. Operation at Harper HosxDital. 
 Neplirocolopexy; Alexander's operation by the blnnt 
 hook method. Recovery uneventful. Abdominal sup- 
 porter applied and petrolatum oil prescribed on dis- 
 charge from hosi3ital. 
 
 December 25, 1908. Kidney in normal position and 
 not palpable in any position. Bowels regular by the use 
 of the oil once a day. Gaining in flesh and strength. 
 Patient not seen since. 
 
 Case 34. 
 
 Extreme neurasthenia. 
 
 Female; aged 42; married; mother of two children, the 
 youngest 6 years old. Patient of Dr. Thomas, of North 
 Branch, Mich. 
 
 November 1, 1908. Seeks relief for neurasthenia; con- 
 stant headache; progressive emaciation; almost constant 
 pain in abdomen, back, and thighs; alternating constipa- 
 tion and diarrhea; frequent micturition; insomnia — can 
 never sleep on the left side because of palpitation; says 
 she has always had the abdominal pains. Is a chronic 
 invalid, and unable to stand or walk but for a few min- 
 utes at a time. Had operation for cervical stenosis at 
 19. AVas badly lacerated at childbirth, and says she has 
 been "sewed up" three times for it. Heart normal, 100; 
 temperature normal. Urine normal. 
 
 Abdominal examination in the dorsal position showed 
 great sensitiveness all over, the especial points being at 
 the right of the navel and just below it on deep pressure; 
 the right kidne}^ entirely below the costal margin, with- 
 out effort- — not very movable in further descensus, and 
 easily replaced. 
 
 Vaginal examination showed a normal appearing peri- 
 neum, which on close inspection proved to be composed 
 
EEPORTS OF CASES. 
 
 177 
 
 of skin only, the onl}^ muscular portion intact being a 
 very small part of the sphincter ani; cervix uteri large, 
 cystic, eroded, and lacerated left laterally; uterus hyper- 
 plastic, normal position; appendages normal. 
 
 November 2, 1908. Radiograph showed ptosis of the 
 colon, as illustrated in Fig. 51. Diagnosis of right neph- 
 rocolo]3tosis, ruptured perineum of second degree, left 
 laceration of cervix uteri, and endometritis. Operation 
 advised. 
 
 Fig. 51. Case 34. 
 
 November 3, 1908. Operation at St. Mary's Hospital. 
 Nephrocolopexy; i^erineorrhaphy (split flap method and 
 buried No. 1 twenty-day catgut) ; trachelorrhaphy; cu- 
 rettage. The wound in the loin healed perfectly; the 
 perineal wound suppurated slightly, but careful atten- 
 tion ended in a perfect result. In bed five weeks, the 
 last two because of debility, and also a desire to benefit 
 the nervous system by rest and forced feeding. On dis- 
 charge from the hospital the alidominal supporter was 
 applied and i^etrolatum oil prescribed. 
 
 July 3, 1909. Has gained thirteen pounds, and feels 
 
178 NEPHEOCOLOPTOSIS. 
 
 better and stronger in every way. Still lias some ab- 
 dominal tenderness, and her nerve tone and endurance 
 are returning slowly. Bowels regular by the use of the 
 petrolatum oil once daily; kidney in normal position. 
 
 Case 35. 
 
 A case in point where a uric acid diathesis protracts 
 recovery and proves an important factor in post-opera- 
 tive treatment. Such cases should be recognized and re- 
 ceive adequate treatment before operation. Case also 
 remarkable for good anatomic result, notwithstanding 
 post-operative infection of wound — showing value of the 
 silver wire suture. 
 
 Female; aged 44; married; mother of one child, 9 years 
 old. 
 
 October 27, 1908. Seeks relief for pain and burning- 
 sensation in the stomach and bowels; palpitation of the 
 heart; sick headaches; meuorrhagia and menses of foul 
 odor; loss of flesh and streng-th. All symptoms came on 
 gradually during the last year. Complexion dark and 
 muddy and skin rough. Heart normal, 90; temperature 
 normal. Urine, specific gravity, 1,028; acid; loaded with 
 sediment composed of uric acid, urates, and epithelium. 
 No albumin or sugar. 
 
 Abdominal examination in the dorsal position showed 
 the right kidney entirely below the costal margin without 
 effort, and well down in the abdomen, near the navel, on 
 deep inspiration; easily replaced manually. Left kidney 
 not palpable in any position. 
 
 Vaginal examination showed a ruptured perineum of 
 second degree; normal uterus and cervix; the latter hav- 
 ing a mucous polyp of about an inch in length hanging 
 from it and passing into its attachment near the inner os. 
 Operation advised. 
 
EEPORTS OF CASES. 179 
 
 November 11, 1908. Operation at Harper Hospital. 
 Neplirocolopexy; perineorrhaphy; excision of polyp; and 
 curettage. A stormy convalescence followed, due large- 
 ly to the uric acid diathesis of the patient, and partly to 
 a mild infection of the wound in the loin following the 
 removal of the continuous subcutaneous silkwormgut 
 suture (the last used by me in these cases). 
 
 There was slight febrile action lasting for three days 
 following the infection of the wound, but after that the 
 temperature remained practically normal, or subnormal, 
 throughout. 
 
 A j)rominent symptom which continued for three 
 weeks was pain of a severe character, occurring fre- 
 quently in various parts of the body, legs, and arms. The 
 treatment was principally eliminative in character and 
 the use of acid, nitromur. dilut. and aspirin. In bed four 
 weeks. Discharged December 12, 1908, in good con- 
 dition and both wounds healed. 
 
 February 6, 1909. Wound in loin open and discharg- 
 ing slightly; on probing found silver wire suture had be- 
 come untwisted (silver shot not used in this case) and 
 was causing a mechanical irritation, and was removed. 
 Kidney in normal position. 
 
 March 7, 1909. Kidney in normal position and not 
 palpable. Bowels regular without medication. 
 
 October 25, 1909. Kidney in normal position and 
 bowels regular. Has gained six pounds since operation. 
 Troubled a good deal with rheumatic pains. Urine 
 turbid with urates. Prescribed acid, nitromur. dilut. 
 
 January 10, 1910. Has gained ten pounds since opera- 
 tion; kidney in normal position. 
 
180 NEPHEOCOLOPTOSIS. 
 
 Case 36. 
 
 Ideal anatomic and symptomatic result of fixation. 
 
 Female; aged 31; married; mother of seven children, 
 the youngest 1 year old. 
 
 November 25, 1908. Seeks relief for constant head- 
 ache; pain of both dull and griping character in the left 
 side of abdomen; constii^ation, the movements being pre- 
 ceded by cramps; loss of flesh and strength; menor- 
 rhagia; leucorrhea. Had lacerated cervix repaired six 
 months ago by another surgeon. Heart normal, 100; 
 temperature normal. Urine normal. 
 
 Abdominal examination showed a broad, flat abdomen, 
 with widely expanded lower thoracic zone; sensitive in 
 left epigastrium; right kidney completel}^ down in the 
 abdomen with patient in the left lateral decubitus. 
 
 Vaginal examination showed good perineum; repaired 
 cervix; large uterus, with soft fundus in third degree of 
 retroversion, easily replaced in the knee-chest position. 
 
 November 6, 1908. Radiograph made, but proved a 
 failure, owing to the rapid descent of the bismuth into 
 the descending colon, sigmoid, and rectum because of the 
 previous use of a cathartic. 
 
 November 28, 1908. Operation at Harper Hospital. 
 Nephrocolopexy; curettage; Alexander's operation. Re- 
 covery without incident. In bed eighteen da^^s. Ab- 
 dominal supporter applied and petrolatum oil prescribed 
 on discharge from hospital. 
 
 January 13, 1909. Bowels regular by use of the petro- 
 latum oil ; kidney and uterus in normal position. 
 
 February 22, 1909. Bowels regular by taking the oil 
 once a day; no more abdominal pains; no leucorrhea; 
 menstruates normally; kidney and uterus both in normal 
 position. 
 
EEPORTS OF CASES. 181 
 
 April 15, 1909. Bowels regular, without oil, and no 
 ''cramps;" kidney in normal position, with lower pole 
 just palpable with patient in left lateral decubitus and 
 deei^ inspiratory effort; gained ten pounds. 
 
 Case 37. 
 
 Remarkable immediate improvement following opera- 
 tion in a typical case showing extreme neurasthenia. 
 
 Female; aged 42; married eighteen years; mother of 
 one child 16 years old; menstrual history normal. Ee- 
 ferred to me by Dr. T. A. McGraw. 
 
 February 27, 1909. Seeks relief for neurasthenia; gen- 
 eral debility; malnutrition; dyspepsia; loss of memory, 
 etc. Thinks iniury in a railroad accident many years 
 ago caused a shock to the nervous system, and that the 
 present illness is due to it. Has lost thirty pounds in 
 five years. Spends most of her time lying down. Con- 
 stipation very troublesome, requiring daily medication 
 or enema. Mentality much impaired, being unable to 
 carry on a connected conversation. Has no hallucina- 
 tions. Sleeps little and never on the left side. Frequent 
 griping pain in bowels and mucus in stools. Most pain 
 in left side of abdomen. Has been in sanitariums and 
 health resorts for years, with no benefit, and has con- 
 sulted various kinds of specialists, from the neurologist 
 to the osteopath, without benefit. They all advised 
 change of scene and climate after unsuccessful periods of 
 treatment. The diagnosis was usually ''neurasthenia" 
 and "intestinal indigestion." 
 
 February 27, 1909. Examination made. Facial ex- 
 pression drawn and tired-looking; complexion muddy, al- 
 most to jaundice. Abdominal walls thick, flaccid, and 
 relaxed. Deep inspiration, dorsal position, right kidney 
 
182 
 
 NEPHROCOLOPTOSIS. 
 
 can be felt down to the umbilicus, and does not return 
 without manual assistance. With patient on the left side 
 and knees drawn up, the kidney is felt well in the median 
 line. Left kidney not displaced. Some tenderness at 
 McBurney's point — cecum and ascending colon — ^not the 
 appendix. (See Fig. 52 for position of appendix.) 
 
 Vaginal examination showed ruptured perineum of 
 second degree, rectocele, and uterine hyperplasia. 
 
 February 28, 1909. X-ray (Fig. 52) showed the cecum 
 in the bottom of the pelvis as far as gravity could take 
 
 Fig. 52. Case 37. 
 
 it, and the transverse colon very low, causing sharp angu- 
 lation at the splenic flexure (cause of pain in this side). 
 Operation recommended. 
 
 March 4, 1909. Operation at Harper Hospital. Nepli- 
 rocolopexy; perineorrhaphy; curettage. In bed three 
 weeks. Recovery ideal in every way. 
 
 April 1, 1909. Discharged from hospital. 
 
 April 17, 1909. Bowels regular, without medication of 
 any kind since operation; feels well and is gaining in 
 flesh. Left for Atlantic City. 
 
EEPORTS OF CASES. 183 
 
 May 20, 1909. Returned from Atlantic City. Bowels 
 regular and appetite good; has no abdominal pain, and 
 has gained eighteen pounds. 
 
 July 30, 1909. Bowels regular; often walks two miles 
 a day without fatigue; sleeps well; has gained thirty-two 
 pounds since operation; mentality greatly improved, is 
 sprightly and vivacious, and enjoys life. On sending her 
 to Dr. Hickey for another x-ray, he was especially struck 
 with the greatly improved facial expression and mental 
 tone. Radiograph a poor one. (Dr. Hickey said I had 
 made her too fat for a good one.) 
 
 Case 38. 
 
 A common cause of ''nervous breakdown" in a young 
 subject, caused by a right nephrocoloptosis, cured by 
 operation. 
 
 Female; aged 25; single. 
 
 January 18, 1900. Seeks relief for neurasthenia; mal- 
 nutrition; debility; headaches; dizziness; nausea; flatu- 
 lence; "cramps" in the abdomen; sleeplessness; dysmen- 
 orrhea. Never can sleep on the left side, as it causes 
 palpitation of the heart. Bowels constipated, and re- 
 quire constant attention by medication and enema. 
 Heart and temperature normal. Urine normal. 
 
 Abdominal examination shows right kidney entirely 
 below costal margin. Left lateral position, with deep 
 inspiration, necessary to bring it down, when it remained 
 so until replaced manually. Vaginal examination nega- 
 tive. 
 
 Radiograph of the colon showed a moderate coloptosis 
 of the transverse section and a marked ptosis of the cecal 
 end of the gut. (Fig. 53.) Operation advised. 
 
 April 13, 1909. Operation at Harper Hospital. Neph- 
 
184 
 
 NEPHROCOLOPTOSIS. 
 
 rocolopexy; dilatation of the cervix uteri. Weight at 
 operation, ninety-four pounds; weight elune 7, 1909, one 
 hundred pounds; weight September 1, 1909, one hundred 
 
 Fig-. 53. Case 38. 
 
 and six pounds, when she reported bowels in perfect con- 
 dition; has discontinued the petrolatum oil. 
 
 December 12, 1909. Kidney in normal position. 
 Weight, one hundred and eight pounds. 
 
 Case 39. 
 
 A chronic invalid, having extreme neurasthenia and 
 malnutrition, cured by operation. 
 
 Female; aged 37; married; one child. 
 
 March 2, 1909. Seeks relief for neurasthenia, approach- 
 ing melancholia in spells of depression; nervous irritabil- 
 ity; dyspepsia; diarrhea; pain over whole abdomen, but 
 especially in left side; emaciation; muddy complexion. 
 Has passed the greater part of the past two years in sani- 
 tariums and health resorts, and has consulted various 
 specialists. Was treated by all of them for neurasthenia, 
 intestinal indigestion, and toxemia, and had all kinds of 
 
EEPORTS OF CASES. 
 
 185 
 
 examinations of blood and secretions made. Sleeps well, 
 which is unusual in these cases. Normal weight, one hun- 
 dred and twenty pounds; present weight, one hundred 
 and ten pounds. 
 
 Abdominal examination showed the right kidney en- 
 tirely below the costal margin while in the dorsal po- 
 sition, without respiratory effort, and sensitiveness in left 
 hypochondrium. Vaginal examination negative. 
 
 Fig. 54. Case 39. 
 
 March 5, 1909. Radiograph shows cecum and ascend- 
 ing colon nearly completely below McBurney's point, the 
 first half of the transverse colon very low in the pelvis, 
 and the distal portion in a position parallel to the de- 
 scending colon. (Fig. 54.) 
 
 May 6, 1909. Operation at Harper Hospital. Nephro- 
 colopexy. In l)ed eighteen days. Recovery without in- 
 cident. Abdominal supporter applied and petrolatum oil 
 prescribed on discharge from the hospital. 
 
 September 29, 1909. Reports great improvement in 
 every way. Gained ten pounds; complexion is clear; 
 bowel movements improving; rarely has diarrhea. Her 
 
186 
 
 NEPHEOCOLOPTOSIS. 
 
 family reports great improvement in the nervous irrita- 
 bility. Rarely has pain in the left side, and only occa- 
 sional attacks of indigestion. 
 
 December 20, 1909. Weighs one hundred and twenty- 
 five pounds, and is well in every respect; bowels regular; 
 kidney in normal position. 
 
 Case 40. 
 
 Dietl's crisis — typical case — cured by operation. 
 
 Female; aged 26; married two months. Was always 
 thin and dyspeptic, and bowels constipated. Patient of 
 Dr. C. G. Jennings. 
 
 Fig-. 55. Case 40. 
 
 Gastroptosis diagnosticated a year before and has 
 worn an abdominal support for it. Has had two attacks 
 of Dietl's crisis — one three weeks before marriage and 
 the other two weeks after that event. Had fever with 
 both attacks, which were also attended with much swell- 
 ing of the right kidney and surrounding structures, with 
 albumin, casts, and red blood cells in the urine, which 
 condition persisted for some time after the subsidence 
 of the acute symptoms. 
 
REPORTS OF CASES. 187 
 
 Patient sent to St. Mary's Hospital and pnt to bed 
 after the second attack, and kept under treatment, with 
 absohite rest, for four weeks, when, all indication and 
 symptoms of local irritation having subsided and the 
 urine cleared up, the operation of nephrocolopexy was 
 performed on June 12, 1909. A retroverted uterus was 
 restored by the Alexander operation at the same time. 
 Eecovery without incident. In bed four weeks. A 
 radiograph taken the day before operation (Fig. 55) 
 shows the result of great relaxation of the hepatocolic 
 ligament, the cecum, ascending colon, and much of the 
 transverse colon lying low in the pelvis. 
 
 August 20, 1909. Eeported in good condition. No 
 pain, bowels regular by using petrolatum oil, appetite 
 good, and increasing in weight. Kidney in normal po- 
 sition. 
 
 November 20, 1909. Reports from abroad, where she 
 went in September, that she is perfectly well and getting 
 fat. 
 
 Case 41. 
 
 Ideal rapid recovery and ideal anatomic result of 
 operation. 
 
 Female; aged 33; married, never pregnant. Patient of 
 Dr. F. J. Langlois, of Wyandotte, Mich. 
 
 January 21, 1909. Seeks relief for frequent attacks 
 of pain in the middle and right side of abdomen, and 
 also in the back of head and neck; "heartburn;'' severe 
 constipation — defecation often causes the occurrence of 
 the abdominal pain; frequent micturition, which also 
 seems to start the pain; menstruation irregular (three to 
 six weeks), very painful, free and clotted, and continues 
 for ten days; loss of flesh — twenty pounds in two years; 
 all symptoms have been gradual in commencement, and 
 
188 NEPHEOCOLOPTOSIS. 
 
 have been present for about two years. Heart normal, 
 84; temperature normal; urine normal. Weight now one 
 hundred and eighteen pounds. 
 
 Abdominal examination in dorsal decubitus shows 
 great tenderness in all of right side, but esiDecially in 
 right epigastrium; on deep inspiration right kidney is 
 forced down entirelj^ below the costal margin. Left kid- 
 ney not palpable. 
 
 Vaginal examination shows normal perineum; normal 
 cervix uteri containing a large cyst; uterus hyperplastic, 
 and in normal position and mobility. Operation advised. 
 
 June 23, 1909. Operation at Harper Hospital. Neph- 
 rocolopexy; curettage; removal of small intra-uterine 
 mucous polyp; scarification of cervix. 
 
 Eecovery without incident. In bed eighteen days. 
 Abdominal supporter applied and petrolatum oil pre- 
 scribed on discharge from hospital. 
 
 March 22, 1909. Defecation regular by the use of the 
 oil only; menstruation normal; gaining in weight; kidney 
 in normal position in any position. 
 
 April 26, 1909. Bowels regular with one dose of oil 
 daily; weight, one hundred and thirty-two pounds, and is 
 steadily gaining. Feels quite well, and says her endur- 
 ance returns slowly, but, as she tells of walking two and 
 a half miles the day before, whereas before operation 
 walking any distance was impossible, the "endurance" 
 can be put down as "very good." Has occasional pain 
 and a pulling sensation in and around the kidney and in 
 the scar. Rarely has pain in the back of the neck and 
 head. Kidney not j)alpable in any position. 
 
EEPORTS OF CASES. 189 
 
 Case 42. 
 
 Patient having had Dietl's crisis, mistaken for attacks 
 of appendicitis. Cured by operation. Rapid increase in 
 weight. 
 
 Female; aged 26; single; stenographer. 
 
 June 3, 1909. Seeks relief for pains in back and right 
 side of abdomen; loss of flesh — twenty-five pounds in ten 
 months; dysjDepsia; dysmenorrhea; severe constipation, 
 relieved only by high colonic flushing; neurasthenia and 
 loss of strength; inability to do her work. Says she had 
 two attacks of "appendicitis," one in August last, which 
 laid her up for six weeks, and another two months later, 
 wdiich lasted two weeks. In both attacks she referred 
 the seat of pain and swelling — which she said was 
 marked — high up in the right side, close to the costal 
 margin. Complexion muddy and skin rough. Heart and 
 temperature normal; urine normal, excepting for pres- 
 ence of amorphous urates. Weight, one hundred and ten 
 pounds. 
 
 Examination in dorsal decubitus shows no sensitive- 
 ness at McBurney's point, but a good deal above, close 
 to the ribs. Kidneys not palpable in this position. In 
 the left lateral decubitus the right kidney dropped low in 
 the abdomen on deep inspiration, and was easily replaced 
 manually. Left kidney not palpable. 
 
 Vaginal examination showed perineum and cervix nor- 
 mal; uterus hyperplastic and in the third degree retro- 
 version, and easily replaced in the knee-chest position. 
 
 The results of the examination convinced me that the 
 previous attacks of "appendicitis" were no doubt at- 
 tacks of Dietl's crisis. Operation advised. 
 
 June 29, 1909. Operation at Harper Hospital. Neph- 
 rocolopexy; curettage; Alexander's operation. Eecovery 
 
190 NEPHROCOLOPTOSIS. 
 
 witlioiit incident. In bed eighteen days. Abdominal 
 supporter applied and petrolatum oil prescribed on dis- 
 charge from hospital. 
 
 October 15, 1909. Kidney in normal position and can 
 not be brought down in either position. Uterus in 
 normal position. Is g-aining in weight, and the complex- 
 ion is clearing. 
 
 December 15, 1909. Kidney in normal position, and 
 stands the test of the left lateral position without appear- 
 ing at all below the costal margin. Patient says all sen- 
 sitiveness in the region of the kidney, which was so mani- 
 fest before operation, is entirely gone. Sometimes has 
 transient pain in the cecum, caused by gas (common 
 symptom for several months after operation). Bowels 
 are perfectly regular by the use of one daily dose of the 
 petrolatum oil; enema not necessary. Sleeps and eats 
 well. Weighs one hundred and thirty-one pounds, a 
 gain of twenty-one pounds since operation. Complexion 
 perfectly clear. . 
 
 Case 43. 
 
 Coloptosis without nephroptosis, cured of intestinal 
 symptoms by the operation of nephrocolopexy. (Radio- 
 graphed before and after operation.) 
 
 Female; aged 42; married; three children. 
 
 June 3, 1909. Seeks relief for constant pain in the left 
 side, above the hip, and in the loin, which she has had for 
 six months, and can not walk or work because of it. Ab- 
 dominal section one year before by myself for hematoma 
 of both ovaries. 
 
 Abdominal examination in both dorsal and lateral po- 
 sitions showed both kidneys normally placed. Muscles 
 in the left loin very rigid, and abdomen on same side dis- 
 tended and dull on percussion. Patient sent to the hos- 
 
EEPOETS or CASES. 
 
 191 
 
 pital, a cathartic given, and high enema used; examina- 
 tion made imder ether, which was negative in resnlt, ex- 
 cepting that it showed complete relaxation and normal 
 condition of the muscles of the loin. Patient was kept 
 in bed nnder constant observation for a week without 
 change in the pain, which was nearly constant. 
 
 June 29, 1909. Eadiograph made, showing large col- 
 lection of gas at splenic flexure and complete ptosis of 
 cecum. (Fig. 56.) 
 
 Fig-. 56. Case il 
 
 Fig-. 57. Case 4J 
 
 July 1, 1909. Operation at Harper Hospital. Nephro- 
 colopexy. Very long and loose nephrocolic ligament. 
 No pain in the left side after the opeiation. After three 
 weeks in bed and one week up, went home. Abdominal 
 supporter applied and petrolatum oil prescribed on dis- 
 charge from hospital. 
 
 July 28, 1909. Post-operative x-ray (Fig. 57) shows 
 elevation of cecum and a tendency to the correction of the 
 sag of the transverse colon. (See position of silver wire 
 suture. ) 
 
192 
 
 NEPHROCOLOPTOSIS. 
 
 October 3, 1909. Reports no pain and is improving in 
 every way. 
 
 November 1, 1909. Reports by letter that she has 
 gained ten pounds and is free from pain. 
 
 Case 44. 
 
 Coloptosis without nephroptosis. Intestinal symptoms 
 cured by operation. 
 
 Female; aged 30; single. Patient of Dr. C. G. Jennings. 
 
 Fig. 58. Case 44. 
 
 Fig. 59. Case 44. 
 
 July 7, 1909. Seeks relief for pain in stomach, com- 
 ing on about five hours after eating; severe constipation, 
 from which she has suffered nearly all her life — move- 
 ments containing much mucus; frequent attacks of pain 
 and sensitiveness in right side of abdomen; pain passing 
 from the navel to the rectum; neurasthenia and loss of 
 flesh, although she was never very strong or robust. 
 Gastroptosis diagnosticated by Dr. Jennings. Heart 
 normal, 105; temperature normal ; urine normal. AVeight, 
 one hundred pounds. 
 
REPORTS OF CASES. 193 
 
 Abdominal examination, in both dorsal and lateral po- 
 sitions, negative, excepting a very sensitive area around 
 McBurney's point. (Examine radiograph to determine 
 the viscera palpated at this point.) 
 
 Vaginal examination showed normal introitus, cervix, 
 and uterus. Behind, and at the sides of the fundus uteri, 
 two irregular, very sensitive masses, large as hen's eggs, 
 were palpated. 
 
 July 11, 1909. Eadiograph made (Fig. 58), which 
 shows a complete coloptosis, both the cecal end and the 
 proximal half of the transverse portion lying nearly as 
 low in the pelvis as gravity can take them. Eadiograph 
 of the stomach (Fig. 59) shows dilatation and moderate 
 ptosis. A diagnosis of coloj)tosis (without nephroptosis) 
 and bilateral ovarian cystoma was made and operation 
 advised. 
 
 July 15, 1909. Operation at Harper Hospital. Neph- 
 rocolopexy; abdominal section, with bilateral salpingo- 
 oophorectomy. Both ovaries contained large hemor- 
 rhagic cysts. During the operation the oozing from all 
 incised or punctured tissues was very protracted and 
 difficult to control. Both wounds healed perfectly, and 
 recovery until the fourteenth day was practically afebrile 
 and normal, excepting for rather more persistent pain 
 than usual in the left side of the abdomen. On July 24th 
 more pain was complained of, and there was a slight rise 
 of temperature. Examination showed tenderness in the 
 left groin and passing down the inside of the thigh for a 
 few inches; and a left phlebitis developed, which was of 
 a mild character and did not extend further downward. 
 The treatment consisted principally of the application of 
 lead and opium wash all the time, and the ice bag during 
 any rise of temperature. At the end of ten days the 
 symptoms had subsided, and patient was thinking of sit- 
 
194 NEPHROCOLOPTOSIS. 
 
 ting up, when the other side began to show similar symp- 
 toms and went through a little more severe course, the 
 affected veins reaching to the popliteal space. 
 
 This made a protracted convalescence, and the patient 
 was discharged September 11, 1909. 
 
 October 5, 1909. Has gained some in flesh and is be- 
 ginning to feel stronger. Bowels regular by the use of 
 the oil and a tablespoonful of wheat bran in a glass of hot 
 water once a day. Kidney in normal position. 
 
 Case 45. 
 
 Colonic ptosis causes intestinal toxemia and low febrile 
 action for years, with consequent progressive emaciation. 
 Cured by operation. 
 
 Female; aged 28; single; stenographer. 
 
 December 29, 1904. Seeks relief for dull and constant 
 pain in lower abdomen, which is increased by sitting at 
 the desk, or standing or walking for more than an hour 
 at a time; jDrogressive weakness and nervous exhaustion; 
 leucorrhea; loss of weight; feeling of feverishness; mucus 
 in bowel movements, which are regular, although fre- 
 quently of a diarrheal character. Heart normal, 100; 
 temperature, 99°; lungs normal; urine normal, excepting 
 for presence of amorphous urates. 
 
 Abdominal examination in dorsal decubitus showed 
 sensitiveness at McBurney's point; right kidney entirely 
 below the costal margin on deep inspiration, very mov- 
 able and easily replaced manually. Left kidney was not 
 palpable in either position. 
 
 Vaginal examination negative. 
 
 Diagnosis of nephrocoloptosis, with consequent catarrh 
 of the colon. 
 
 Silk elastic abdominal band, with large abdominal pad. 
 
EEPORTS OF CASES. 195 
 
 applied, and Enssell's emulsion prescribed, with direc- 
 tions to flush the colon with normal salt solution twice a 
 week. 
 
 November 9, 1905. Pulse, 100; temperature, 99.2°. Has 
 worn the abdominal supporter with a good deal of relief, 
 and can work better and be on her feet longer with it. 
 Still has the abdominal pain, very severe at times; is 
 very thin, and feels exhausted all the time. Operation 
 advised. 
 
 September 10, 1909. Married four years, and has a 
 child two and a half years old. Says she felt perfectly 
 well for six months before the child was born, having 
 none of the old abdominal pains; felt strong, and gained 
 in flesh (caused by the enlarging uterus pushing up the 
 colon into its normal position, and thus removing the 
 strain from the kidney and duodenum). Kidney in com- 
 plete ptosis and all the old symptoms have returned, and 
 the loss of flesh and strength is at about the limit. Pa- 
 tient emaciated. Pulse, 105; temperature normal; urine 
 normal. Operation strongly advised. 
 
 September 15, 1909. Operation at Harper Hospital. 
 Nephrocolopexy. Eecovery ideal in every respect. Ab- 
 dominal supporter, with the truss attachment, applied 
 and petrolatum oil prescribed on discharge from hospital. 
 
 December 1, 1909. Has gained five pounds since opera- 
 tion; has good appetite and digestion; pain has entirely 
 left the abdomen; bowels regular. Kidney in normal 
 position. 
 
 Case 46. 
 
 Case having nephrogastrocoloptosis. 
 
 Female; aged 33; single; stenographer. Patient of Dr. 
 C. G. Jennings. 
 
 June 30, 1909. Seeks relief for frequent attacks of 
 
196 
 
 NEPHROCOLOPTOSIS. 
 
 pain in the abdomen and a constant sensation of burning 
 in the abdomen and sides; indigestion; insomnia; can not 
 sleep on the left side at all because it causes a sensation 
 of tension and fullness, and palpitation; constipation; 
 painful and irregular menstruation; loss of flesh. Had 
 ulcer of the stomach at 14. Heart normal, 88; tempera- 
 ture normal; urine normal, except for a sediment of 
 amorphous urates. Weight, eighty-seven pounds. Nar- 
 row thorax. 
 
 Fig. 60. Case 46. 
 
 Abdominal examination in dorsal position showed 
 right kidney entirely below costal margin without effort, 
 and when on the left side it dropped somewhat to the 
 left of the navel. 
 
 Vaginal examination negative. 
 
 July 6, 1909. Eadiograph made, showing entire ptosis 
 of ascending and half of transverse colon (Fig. 60), and 
 the stomach reaching into the pelvis also. Operation ad- 
 vised. Abdominal supporter applied and petrolatum oil 
 prescribed pending time of operation, which was un- 
 certain. 
 
REPORTS OF CASES. 197 
 
 September 10, 1909. Abdominal supporter has given a 
 good deal of relief in adding to her strength and endur- 
 ance, and the oil causes better action of the bowels, but 
 the pain and burning in the abdomen continue, and the 
 operation is therefore decided on. 
 
 September 15, 1909. Operation at Harper Hospital. 
 Nephrocolopexy; curettage. Eecovery without incident. 
 In bed eighteen days. 
 
 November 29, 1909. Weighs ninety-three pounds (gain 
 of six pounds) ; bowels regular by use of the oil and oc- 
 casionally of the enema also; no pain in the left side. 
 Kidney in normal position. 
 
 Case 47. 
 
 A very typical case illustrative of the obscurity and 
 vagueness of the symptomatology of a coloptosis and gas- 
 troptosis, with very little nephroptosis. After years of 
 invalidism cured by operation. 
 
 Female; aged .31; married four and a half years; never 
 pregnant. 
 
 September 26, 1905. Seeks relief for frequently recur- 
 ring pain in right side of abdomen, often very severe; 
 pain in the pit of the stomach after eating; chronic diar- 
 rhea — four or five movements every morning; great loss 
 of flesh — twenty-five pounds in three years. Looks weak 
 and anemic. Says she has "spells," which commence 
 with chills, diarrhea, severe vomiting of bile, and high 
 temperature — often 104° — in which she is very nervous 
 and hysterical. Heart normal, 110; temperature, 99 1/2°; 
 urine normal. 
 
 Examination in both dorsal and lateral positions was 
 negative, excepting for sensitive area around McBurney's 
 point. ISTeither kidney could be palpated. 
 
198 NEPHROCOLOPTOSIS. 
 
 Vaginal examination showed normal conditions, ex- 
 cepting the uterns, which was found to be in a second de- 
 gree retroversion — mobile and easily replaced in the 
 knee-chest position. 
 
 A diagnosis was made of chronic diarrhea and intes- 
 tinal toxemia; retroversion of the uterus. Medicinal and 
 dietetic treatment for the intestinal conditions were be- 
 gun at once and continued for a year and a half, with 
 varying results. I note that during this time her tem- 
 perature rarely registered below 99°. She gave a better 
 report from a medication in which arsenite of copper 
 was used and large doses of creosote were given, and 
 colonic flushing with normal salt solution used. I did not 
 see her again for a period of over three years, 
 
 July 30, 1909. Has a baby two and a half years old, 
 and says that while carrying the child she felt perfectly 
 well, having no chills or fever or diarrhea during the 
 time (caused by the growing uterus pushing the colon up 
 in normal position, and thus relieving the strain on the 
 kidney and duodenum). The old symptoms began to re- 
 turn when the child was six months old, and have con- 
 tinued to increase in severity since. Has frequent pas- 
 sages, tenesmus, bearing down, etc., and much mucus in 
 the stools. Has lost thirty-two i3ounds in two years, and 
 is thinner than she ever was. 
 
 Abdominal examination in the left lateral position, with 
 respiratory effort, was successful at this time in bringing 
 the right kidney down — only about half of the organ pal- 
 pable below the costal margin. Left kidney not palpable. 
 Sensitive area in the epigastrium and down to navel. 
 
 Vaginal examination showed a ruptured perineum of 
 second degree; rectocele; normal cervix; uterus in third 
 degree retroversion — easily replaced in knee-chest po- 
 sition. 
 
REPORTS OF CASES. 
 
 199 
 
 August 2, 1909. Radiograph made, showing the 
 stomach with the greater curvature three inches below 
 the navel and the colon well down in the pelvis, the cecum 
 being six inches below McBurney's point. (Figs. 61, 62.) 
 
 My abdominal supporter applied and petrolatum oil 
 and creosote prescribed. Operation advised. 
 
 September 10, 1909. Patient reports less abdominal 
 pain while wearing the band, and that it gives her a 
 stronger and better feeling. Diarrhea less severe. 
 
 Fig. 61. Case 47. 
 
 Fig. 62. Case 47. 
 
 September 25, 1909. Operation at Harper Hospital. 
 Nephrocolopexy; perineorrhaphy; Alexander's operation. 
 Recovery without incident until the beginning of the 
 third week, when she had several attacks of the "spells" 
 previously mentioned, which always occurred at night 
 during sleep and resembled petit mal. In bed three 
 weeks. Discharged from hospital October 27, 1909. 
 
 November 27, 1909. Has not had any diarrhea since 
 leaving the hospital; bowels regular; takes one dose of 
 the oil daily; gaining in flesh rapidly — about ten pounds; 
 
200 NEPHROCOLOPTOSIS. 
 
 good appetite and digestion; sleeps well; no more 
 ' ' spells. ' ' 
 
 March 10, 1910. Bowels continue normal. Has gained 
 fifteen pounds. 
 
 Case 48. 
 
 A typical illustration of the progressive nature of the 
 colonic ptosis in a case under observation three years, 
 showing no colonic manifestations in its earlier liistory, 
 but developing later because of increasing distention and 
 angulation of the bowel. 
 
 Female; aged 22; married; two children, the youngest 
 1 year old. Patient of Dr. D. J. Jones. 
 
 September 28, 1906. Seeks relief for increasing weak- 
 ness; loss of flesh and nervous exhaustion; pain in the 
 back of head and in lower left abdomen, which she has 
 had for several years. Is still nursing her child, but has 
 irregular, painful periods. Defecation regular and has 
 no mucus in stools; no leucorrhea. Heart normal, 86; 
 temperature normal; urine normal. 
 
 Abdominal examination in dorsal position shows right 
 kidney entirely below the costal margin without effort; 
 left kidney not palpable; no marked abdominal ten- 
 derness. 
 
 Vaginal examination shows normal perineum; erosion 
 and cysts of cervix and slight laceration of right side; 
 hyperplastic uterus in normal position and mobility; ap- 
 pendages normal; right ovary prolapsed. Applied ab- 
 dominal supporter, scarified cervix, and prescribed tonic. 
 
 October 29, 1906. Headaches no better; backache bet- 
 ter. Sent her to oculist, who prescribed glasses for eye 
 strain, thinking the presence of astigmatism the cause of 
 the headache. 
 
 February 25, 1907. Headaches better. 
 
REPOETS OF CASES. 201 
 
 August 2, 1909. For tile past two years has been suf- 
 fering more or less with the pain in the left side, which 
 is now much worse. Is weak and anemic ; has indigestion 
 and constipation, and notices much mucus and sometimes 
 blood in the stools. Has not worn the supporter for over 
 a year. 
 
 On examination the right kidney was found quite loose 
 in the abdomen, and also much sensitiveness in left side 
 above the hip. The pelvic conditions were much the 
 same as on the previous examination, excepting a more 
 hyperplastic condition of the uterus. Operation advised. 
 
 September 27, 1909. Operation at Harper Hospital. 
 Nephrocolopexy; curettage; trachelorrhaphy. Convales- 
 cence good. In bed eighteen days. Abdominal sup- 
 porter applied on discharge from the hospital. 
 
 November 26. Bowels regular by the use of the oil. 
 Fears dislodgment of kidney, as she has had a severe 
 bronchitis and coughed much and violently. Examina- 
 tion showed the kidney in good position, though the 
 lower pole could be palpated in the left lateral position. 
 
 January 10, 1910. Increasing in weight. 
 
 Case 49. 
 
 A good example of a case of coloptosis without nephro- 
 ptosis, with the usual history of obscure symptoms and 
 nondiagnosis — later diagnosis by radiography. Opera- 
 tion and cure. 
 
 Female; aged 29; housemaid; single. 
 
 December 4, 1908. Seeks relief for pains in back, head, 
 hips, and abdomen, which she has had, gradually increas- 
 ing, for two years; frequent attacks of palpitation, with 
 sudden awakening at night; constant constipation, requir- 
 ing use of laxatives and enemas; nervousness and tremor; 
 
202 
 
 NEPHROCOLOPTOSIS. 
 
 irregular painful menstruation; leucorrhea for several 
 years. Has had a small goiter since she matured, but 
 never had exophthalmus, and none now in evidence. 
 Heart normal, 82; temperature normal; urine normal. 
 
 Abdominal examination in both dorsal and lateral po- 
 sitions negative, excepting for sensitiveness to pressure 
 at McBurney's point and just below the navel. 
 
 Vaginal examination negative, excepting for a some- 
 what hyperplastic, retro verted, and flexed uterus, which 
 
 Pig-. 63. Case 49. 
 
 was freely mobile and easily replaced in the knee-chest 
 position. Operation advised. 
 
 December 8, 1908. Operation at Harper Hospital. 
 Curettage; Alexander's operation. In bed fourteen days. 
 Good recovery. On discharge prescribed petrolatum oil 
 for the constipation. 
 
 February 26, 1909. Still somewhat constipated, and 
 needs the enema occasionally to assist the oil in its 
 action. Sleeps better, and has no palpitation. Uterus 
 in normal position. 
 
EEPORTS OF CASES. 203 
 
 April 6, 1909. Heavy, bearing-down sensation in the 
 abdomen; constipation more troublesome. 
 
 June 5, 1909. Complains of a "dragging" in the ab- 
 domen. Uterus in good position. 
 
 September 17, 1909. Pain in back and across ab- 
 domen; very constipated; oil and enema often fail to 
 empty the bowel, showing that the fecal matter does not 
 reach the descending colon. 
 
 September 2-4, 1909. Radiograph (Fig. 63) shows the 
 cecum in the bottom of the pelvis and the transverse 
 colon greatly prolapsed, indicating a sharj) angulation at 
 the splenic flexure. Operation advised. 
 
 October 2, 1909. Operation at Harper Hospital. Neph- 
 rocolopexy. Good recovery. In bed eighteen days. Dis- 
 charged October 20, 1909. Abdominal supporter applied 
 and the use of the oil continued as before operation. On 
 discharge weighed one hundred and thirteen pounds. 
 
 November 30, 1909. Weighs one hundred and twenty- 
 one pounds. Bowels regular by the use of the oil alone. 
 Abdominal pain relieved. 
 
 February 5, 1910. Is perfectly well; has gone back to 
 work. 
 
 Case 50. 
 
 Case of gastrocoloptosis without nephroptosis. Symp- 
 toms of an obscure character. Diagnosis made by radio- 
 graph. Operation restores normal nutrition and regu- 
 lates colonic function. 
 
 Female; aged 56; single. Patient of Dr. E. T. Tappey. 
 
 Patient treated for about two years for displacements 
 of uterus and ovaries, but since the menopause, at 50, 
 these conditions had not demanded much attention. 
 
 April 20, 1908. Seeks relief for insomnia; loss of flesh 
 — forty pounds in three years; progressively increasing 
 
204 
 
 NEPHEOCOLOPTOSIS. 
 
 nervous irritability and depression; fears loss of mind 
 (and looks it). Face drawn and distressed; complexion 
 muddy; bowels very constipated and movements attended 
 with pain in the abdomen. Mucli pain in the left side 
 over the hip — especially at night when lying — and often 
 has severe cramps of the muscles of the thigh of this 
 side. 
 
 Repeated examinations in various positions showed 
 both kidneys to be normally placed and no other ab- 
 
 Fig-. 64. Case 50. 
 
 Case 50. 
 
 dominal or joelvic trouble. Radiograph June 20, 1909, of 
 stomach, and June 21 of colon (Figs. 64, 65) showed a 
 gastrocoloptosis of exaggerated type. 
 
 July 10, 1909. Applied my abdominal band and pre- 
 scribed petrolatum oil. 
 
 September 16, 1909. Reports some improvement in 
 sleeping and bowel movements; still has abdominal pain, 
 though less severe. Has gained three pounds since put- 
 ting on the supporter, and says it gives her greater en- 
 durance. Operation advised. 
 
EEPOETS OF CASES. 205 
 
 October 15, 1909. Operation at Harper Hospital. 
 Neplirocolopexy. Eecovery without incident. In bed 
 twenty-one days, and during the last fourteen days slept 
 well, had very little abdominal pain, and not any of the 
 muscular cramps. The usual daily enema of salt solution 
 caused the old severe pain in the rectum, but when pre- 
 ceded the night before by an enema of 4 ounces of warm 
 olive oil (retained), the action of the bowels by the enema 
 of saline was natural and painless. 
 
 December 4, 1909. Has gained ten pounds since leav- 
 ing the hospital; gaining in strength, and sleeps well. 
 The bowels move nearly in a normal manner by the use 
 of the petrolatum oil, but about twice a week there seems 
 to be the same accumulation — apparently above the sig- 
 moid — which is dislodged by the use of an enema to 
 overflow of an alkaline starch solution (sod. bicarb. 3j to 
 Oj). This acts very kindly on the irritable bowel, which 
 often seems to be the active etiologic factor in the in- 
 somnia of these cases, and in this instance it proves of 
 especial value, giving a good night after its use and leav- 
 ing the bowel quiescent and free from j)ain. 
 
 Case 51. 
 
 Female; aged 35; single; housemaid. 
 
 October 14, 1909. Seeks relief for severe dyspepsia; 
 catarrh of the bowel; great constipation; backache; in- 
 somnia. 
 
 Had an operation, per vaginam, for uterine adhesions 
 by another surgeon six months ago. Operation was fol- 
 lowed by infection and she was in bed two months with 
 it. Heart normal, 80; temperature normal; urine normal. 
 
 Abdominal examination in the dorsal position was neg- 
 ative, but in the left lateral position the right kidney 
 
206 NEPHEOCOLOPTOSIS. 
 
 dropped entirely below the costal margin. Left kidney 
 in normal position and not palpable in either position. 
 
 Vaginal examination negative. 
 
 Operation advised. 
 
 November 9, 1909. Operation at Harper Hospital. 
 Nephrocolopexy. Eecovery without incident. In bed 
 eighteen days. Abdominal supporter applied and petro- 
 latum oil prescribed on discharge from the hospital. 
 
 Case not seen since discharged from the hospital. 
 
 Case 52. 
 
 Operation for coloptosis without nephroptosis. Dilata- 
 tion of cecum the cause of symptomatology simulating 
 that of appendicitis. 
 
 Female; aged 19; single; housemaid. Ward patient at 
 Harper Hospital. 
 
 December 11, 1909. Referred to me by Dr. C. G. Jen- 
 nings. Was sent to the hospital three days before by 
 an outside physician for treatment for an attack sup- 
 posedly of appendicitis. Patient said she had had three 
 previous attacks similar to this, the first occurring four 
 years ago, which kept her in bed for five weeks; one two 
 years ago, and one six months afterward, the last two 
 each of about three weeks' duration. Said she had chills 
 and fever with them, and is certain she is feeling the same 
 symptoms with this attack. Her record showed normal 
 pulse and temperature, and normal urine. A blood ex- 
 amination had been made, which reported no leuko- 
 cytosis, but a marked lymphocytosis. Has had severe 
 constipation for four years, necessitating the habitual use 
 of enemas and cathartics. Menstruation irregular, and 
 of but four hours^ duration each month. Has no history 
 of any pelvic trouble, and no loss of flesh. Complains of 
 
EEPOETS OF CASES. 
 
 207 
 
 a stiuging or smarting pain in the right side of the ab- 
 domen, which she has had ahnost constantly since the 
 first attack of "appendicitis" four years ago. For the 
 last five days has had severe pain in the same region, with 
 great sensitiveness. No nansea; bowels constipated. 
 
 Examination in both dorsal and lateral positions failed 
 to bring down either kidney, but great sensitiveness was 
 shown on palpation at McBurney's jDoint, and below on 
 that side of the abdomen, which was dull on percussion. 
 
 Fig. 66. Case 52. 
 
 The slightest touch caused the patient to cry out, but the 
 board-like feel of muscular tension was absent, especially 
 when the patient's attention was attracted away from the 
 point. 
 
 Vaginal examination was attempted, but failed because 
 of the complete filling of the lower pelvic cavity with 
 fecal matter. Petrolatum oil |ss twice daily, and a saline 
 enema morning and evening, were ordered, and the vagi- 
 nal examination deferred for three days. 
 
 December 14, 1909. Vaginal examination was nega- 
 
208 NEPHEOCOLOPTOSIS. 
 
 tive, exceijting that it showed the presence of an infantile 
 nterns. Abdominal examination was again made, when 
 the sensitiveness at McBurney 's point was found to have 
 disapj)eared completely, and only a slightly sensitive 
 area, low in the inguinal region, was found. Eadiograph 
 ordered. 
 
 December 15, 1909. The radiograph — an unusual one, 
 showing the entire large intestine (Fig. 66) — revealed the 
 trouble. A moderate relaxation of the hepatocolic liga- 
 ment is shown, with descent of the cecum into the pelvis. 
 The cecum is seen to be much elongated and dilated, 
 which is the condition that has no doubt been causing the 
 constant smarting pain, and when acutely distended, as a 
 result of impaction farther along in the large intestine, 
 gave rise to the acute symptoms which were thought to be 
 caused by apj)endicitis. 
 
 Operation of nephrocolopexy was advised, and the con- 
 dition explained to the patient, who insisted also on ab- 
 dominal section and the examination of the appendix. 
 
 December 18, 1909. Operation. Nephrocolopexy and 
 appendectomy. The nephrocolic ligament was long and 
 lax, as previously noted in similar cases. The appendix 
 was found easily, through a median incision, to be en- 
 tirely normal, free from any signs of irritation or de- 
 formity, and its lumen pervious. As it was of very large 
 size, being about six inches in length, and thus a possible 
 menace to her future health, it was removed. 
 
 Recovery without incident. Patient not seen since dis- 
 charge, January 10, 1910. 
 
 Case 53. 
 
 Complete nephrogastrocoloptosis in a male patient. 
 
 Male; aged 26; single; clerk. Patient of Dr. C. G. Jen- 
 nings. Had been treated by a well-known gastro-enter- 
 
REPORTS OF CASES. 
 
 209 
 
 ologist for two years and was wearing' an abdominal 
 band, wliicli be reported bad benefited bim. 
 
 December 8, 1909. Seeks relief for nervonsness; lack 
 of ability to concentrate bis tbougbts; a severe constipa- 
 tion, wbicb be bas bad for several years. Says be bas no 
 abdominal pain, sleeps well, and bas not lost flesb. Body 
 of tbin babit, well developed; cbest broad and of good 
 capacity. Heart, temperatnre, and nrine normal. 
 
 Abdominal examination in tbe dorsal position sbowed 
 
 Fig-. 67. Case 53. 
 
 Fig. 68. Case 53. 
 
 tbe rigbt kidney entirely below tbe costal margin witbont 
 inspiratory effort. In tbe left lateral position tbe kidney 
 conld be palpated nnder tbe navel. No abdominal sensi- 
 tiveness was fonnd, excepting in tbe palpated dropped 
 kidney. 
 
 Radiograpbs of stomacb and large intestine sbowed 
 extensive displacement of botb organs and dilatation of 
 cecum and stomacb. (Figs. 67, 68.) Tbe angulation of 
 tbe bowel at tbe splenic flexure is sbown unusuall}^ well, 
 tbe descending colon passing down close bebind tbe as- 
 cending portion of tbe transverse colon; tbe two ligbt 
 
210 NEPHEOCOLOPTOSIS. 
 
 spots indicating collections of gas at eitlier side of the 
 angulation. The showing would indicate complete re- 
 laxation of the hepatocolic ligament. Operation advised. 
 January 17, 1910. Operation at Harper Hospital. 
 Nephrocolopexy. Ideal recovery. 
 
 Case 54. 
 Nephrogastrocoloptosis, in which a gastro-enterostomy 
 was previously made because of duodenal occlusion. 
 
 Female; aged 42; married; no children. 
 
 November 9, 1909. Seeks relief for profound neuras- 
 thenia; headaches of a joaroxysmal, violent character; 
 melancholia; hysteria; flatulence; dyspepsia; pain in left 
 hypochondrium ; constipation and mucus in stools. Had 
 the operation of gastro-enterostomy made eight years ago 
 for gastroptosis, with partial occlusion of the pylorus, 
 which was followed by some relief and gain in flesh. The 
 last two years, however, she reports a steady loss of flesh 
 and increase of nervous symptoms. Weight, eighty-nine 
 pounds. Pulse slightly irregular, 100; heart normal; 
 temperature 98°; urine normal. 
 
 Abdominal examination in dorsal position showed well- 
 formed thorax, thin and relaxed abdominal walls, sensi- 
 tiveness in right loin at McBurney's point. In the left 
 lateral position the right kidney was brought completely 
 below the costal margin on deep inspiration, and passed 
 back into the renal fossa when released. 
 
 Vaginal examination was negative. 
 
 November 17, 1909. Radiograph of the colon was made 
 (Fig. 69), showing complete relaxation of the hepatocolic 
 ligament and descent of the gut into the pelvis. The sen- 
 sitiveness noted, on examination, at the McBurney point 
 is shown by the radiograph to be located in the dropped 
 splenic flexure, or an angulation of the ascending colon — 
 
REPORTS OF CASES. 211 
 
 the entire cecum and appendix being below this point in 
 the bottom of the pelvis. With this position of the bowel, 
 a sharp angulation at the splenic flexure would be inevit- 
 able, and the constipation and mucus stools explained. 
 Operation of nephrocolopexy advised. 
 
 January 25, 1910. Operation at Harper Hospital. Re- 
 covery uneventful. 
 
 Fig-. 69. Case 54. 
 
 February 22, 1910. Discharged from hospital, wearing 
 abdominal supporter and taking i^etrolatum oil. 
 
 March 30, 1910. Reports from Atlantic City she has 
 gained six pounds. 
 
 Case 55. 
 
 Frequent child-bearing* causes characteristic symptoms 
 of nephrocoloptosis to remain in abeyance. Needle 
 wound of hilum of kidney causes temporary urinary 
 fistula. 
 
 Female; aged 36; married; seven children in twelve 
 years; patient of Dr. B. R. Shurly. 
 
 Seeks relief for loss of flesh — one hundred and forty 
 pounds to one hundred and thirty pounds ; frequent head- 
 
212 NEPHROCOLOPTOSIS. 
 
 aches; backache; leucorrhea; weakness and nervous ex- 
 haustion. Bowel movements always regular. Heart, 
 temperature, and urine normal. Says all symptoms have 
 increased gradually since the birth of the last child, two 
 years ago. 
 
 Examination in the dorsal position showed thorax 
 broad and flat; no abdominal tenderness; right kidney 
 found at the navel without deep inspiratory effort; 
 left kidney not displaced. Vaginal examination showed 
 ruptured perineum of second degree; extensive bilateral 
 laceration of cervix; endometritis. Operation advised. 
 
 February 11, 1910. Operation at Harper Hospital. 
 Right nephrocolopexy; perineorrhaphy; trachelorrhaphy; 
 curettage. Recover}^ uneventful until the twelfth day, 
 when pain and tension in the well-healed wound in the 
 loin was complained of. A small incision was made and 
 a drainage tube inserted, from which urine escaped in 
 considerable quantity for one month, when it gradually 
 ceased, and the tube was removed. 
 
 April 7, 1910. Wound healed, and kidney in good 
 position. 
 
 This accident was undoubtedl}^ caused by a needle 
 wound of the renal pelvis, which, with a very mobile kid- 
 ney turned sideways to the wound, would bring it close 
 enough to be punctured by a deep needle insertion. The 
 occurrence should warn the operator against the unneces- 
 sarily deep insertion of sutures in this operation. 
 
 Case 56. 
 
 Appendectomy advised by several physicians because 
 of pain at McBurney's point, caused by distention of the 
 cecum and ascending colon — a characteristic symptom of 
 coloptosis. 
 
 Female; aged 27; single; housemaid. Seeks relief for 
 loss of flesh — one hundred and thirty pounds to one hun- 
 
EEPORTS OF CASES. 213 
 
 dred and thirteen pounds; pain in right side of abdomen, 
 which is intensified by wallving or standing. Heart, tem- 
 perature, and urine normal. 
 
 Examination in the dorsal position showed sensitive- 
 ness at McBurney's point, Ijut nothing more. In the left 
 lateral position, deep respiratory effort brought the right 
 kidney down very low in the abdomen, where it could be 
 moved about at will. The left kidney could not be 
 brought down. Vaginal examination negative. Opera- 
 tion of nephrocolopexy advised. 
 
 February 12, 1910. Operation at Providence Hospital. 
 Recoverv uneventful. 
 

 
 
 
 Summary of the Foreg-oing Reports of Cases, 
 
 on All of 
 
 
 
 
 Marr'd 
 
 
 
 
 
 
 Suture mate- 
 
 
 
 
 Chil- 
 
 Diagnosis 
 
 Date of 
 
 Additional 
 
 rial used in 
 
 No. 
 
 Sex 
 
 Age 
 
 or 
 
 single 
 
 dren 
 
 operation 
 
 operations 
 
 nephro- 
 colopexy 
 
 1 
 
 F 
 
 26 
 
 M 
 
 1 
 
 Right nephrocoloptosis ; 
 retro versio uteri; lacer- 
 ated cervix 
 
 Jan. 
 
 8, 1906 
 
 Alexander's opera- 
 tion; trachelorrha- 
 phy 
 
 20-day catgut 
 
 2 
 
 F 
 
 26 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 cervical stenosis 
 
 Jan. 
 
 13, 1906 
 
 Dilatation cervix 
 
 Same 
 
 3 
 
 F 
 
 27 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 ruptured perineum; 
 hemorrhoids 
 
 Feb. 
 
 15, 1906 
 
 Perineorrhaphy; 
 Whitehead's opera- 
 tion 
 
 Same 
 
 4 
 
 F 
 
 34 
 
 S 
 
 
 
 Right nephrocoloptosis 
 
 March 
 
 10, 1906 
 
 None 
 
 Same 
 
 5 
 
 F 
 
 28 
 
 s 
 
 
 
 Same 
 
 March 
 
 12, 1906 
 
 None 
 
 Same 
 
 6 
 
 F 
 
 29 
 
 s 
 
 
 
 Same 
 
 March 
 
 17, 1906 
 
 None 
 
 Same 
 
 7 
 
 F 
 
 31 
 
 M 
 
 1 
 
 Right nephrocoloptosis ; 
 cicatricial stenosis os 
 uteri 
 
 June 
 
 2, 1906 
 
 Incision; dilatation 
 OS uteri 
 
 Same 
 
 8 
 
 F 
 
 54 
 
 M 
 
 10 
 
 Right nephrocoloptosis ; 
 varices ; ruptured peri- 
 neum; lacerated cer- 
 vix 
 
 June 
 
 6, 1906 
 
 Perineorrhaphy ; 
 trachelorrhaphy; 
 curettage ; abla- 
 tion of varices 
 
 Same 
 
 9 
 
 F 
 
 27 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 endometritis 
 
 July 
 
 6, 1906 
 
 Curettage 
 
 Same 
 
 10 
 
 F 
 
 29 
 
 M 
 
 
 
 Right nephrocoloptosis; 
 adhesions 
 
 Sept. 
 
 19, 1906 
 
 Exploratory abdomi- 
 nal section 
 
 Same 
 
 11 
 
 F 
 
 19 
 
 S 
 
 
 
 Coloptosis (without 
 nephroptosis) ; uterine 
 polyp 
 
 Sept. 
 
 28, 1906 
 
 Curettage; extirpa- 
 tion of polyp 
 
 Same 
 
 12 
 
 F 
 
 42 
 
 M 
 
 
 
 Right nephrocoloptosis 
 
 Oct. 
 
 5, 1906 
 
 None 
 
 Same 
 
 13 
 
 F 
 
 32 
 
 M 
 
 3 
 
 Right nephrocoloptosis; 
 lacerated cervix; 
 endometritis 
 
 Oct. 
 
 18, 1906 
 
 Trachelorrhaphy : cu- 
 rettage 
 
 Same 
 
 14 
 
 F 
 
 40 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 endometritis 
 
 Oct. 
 
 20, 1906 
 
 Curettage 
 
 20-day catgut 
 silkworm 
 gut in skin 
 
 15 
 
 F 
 
 42 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 uterine myoma; adher- 
 ent appendix: retro- 
 version 
 
 April 
 
 3, 1907 
 
 Abdominal section; 
 myoToectomy; ap- 
 pendectomy; Alex- 
 ander's operation 
 
 20-day catgut ; 
 silver wire; 
 silkworm 
 gut in skin 
 
 16 
 
 F 
 
 41 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 uterine myoma; hydro- 
 salpinx: appendicitis 
 
 April 
 
 16, 1907 
 
 Abdominal section; 
 myomectomy; sal- 
 pingo-oophorec- 
 tomy; appendec- 
 tomy 
 
 Same 
 
 17 
 
 F 
 
 66 
 
 M 
 
 3 
 
 Right nephrocoloptosis; 
 cholelithiasis 
 
 May 
 
 14, 1907 
 
 Abdominal section; 
 cholecystostomy 
 
 .^ame 
 
 18 
 
 F 
 
 26 
 
 M 
 
 
 
 Right nephrocoloptosis 
 
 May 
 
 18, 1907 
 
 None 
 
 Same 
 
 19 
 
 F 
 
 41 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 endometritis; uterine 
 myoma 
 
 May 
 
 20, 1907 
 
 Abdominal section; 
 myomectomy; 
 curettage 
 
 Same 
 
 20 
 
 F 
 
 28 
 
 S 
 
 
 
 Right nephrocoloptosis ; 
 endometritis 
 
 May 
 
 29, 1907 
 
 Curettage 
 
 Same 
 
 21 
 
 F 
 
 31 
 
 s 
 
 
 
 Right nephrocoloptosis; 
 hematocystic ovaries 
 
 June 
 
 21, 1907 
 
 Abdominal section; 
 bilateral oophorec- 
 tomy; curettage 
 
 Same 
 
 22 
 
 F 
 
 36 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 lacerated cervix; rup- 
 tured perineum 
 
 June 
 
 24, 1907 
 
 Trachelorrhaphy; 
 perineorrhaphy 
 
 Same 
 
 23 
 
 F 
 
 23 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 retroversion; endome- 
 tritis 
 
 June 
 
 29, 1907 
 
 Alexander's opera- 
 tion; curettage 
 
 Same 
 
 24 
 
 F 
 
 30 
 
 M 
 
 
 
 Right nephrocoloptosis; 
 endometritis 
 
 July 
 
 5, 1907 
 
 Curettage 
 
 Same 
 
 25 
 
 F 
 
 30 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 retroversion; endome- 
 tritis 
 
 Sept. 
 
 20, 1907 
 
 Alexander's opera- 
 tion; curettage 
 
 Same 
 
 26 
 
 F 
 
 41 
 
 M 
 
 4 
 
 Right nephrocoloptosis 
 
 Sept. 
 
 23, 1907 
 
 None 
 
 Same 
 
 1 Child born since operation; organs remain in normal position. 
 
 2 Fall after operation caused partial displacement of kidney; did not prevent good results. 
 
 3 Last report states "occasional constipation." 
 
 i Failure to improve symptoms due to neurotic tendency. 
 
 5 First case of operation on case of coloptosis without nephroptosis: severe constipation cured. 
 
 214 
 
Which the Operation of Nephrocolopexy was Performed. 
 
 
 1 
 
 RESULTS 
 
 
 
 
 Bed T.at.e 1 
 
 
 
 
 
 No. 
 
 convales- 
 cence 
 
 convales- 
 cence 
 
 Position of kidney 
 
 Defecation 
 
 Weight 
 
 Nervous 
 symptoms 
 
 Abdominal 
 pain 
 
 1 
 
 Afebrile 
 
 Good 
 
 Normal ; not palpable 
 
 Normal 
 
 Increased 
 
 Much im- 
 proved 
 
 Entirely re- 
 lievedi 
 
 2 
 
 Same 
 
 Same 
 
 Same 
 
 Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 
 10 pounds 
 
 j 
 
 
 3 
 
 Same 
 
 Inter- 
 rupted 
 by acci- 
 dent 
 
 Two-thirds palpable Same 
 below costal mar- 
 gin 
 
 Increased 
 21 pounds 
 
 Same 
 
 Same 2 
 
 4 
 
 Septic 
 
 Not good 
 
 Reported prolapsed Not known 
 
 Not known ' 
 
 Not known 
 
 No report 
 
 5 
 
 Afebrile Good 
 
 Normal: not palpable 
 
 Normal 
 
 Slight increase 
 
 Improved 
 
 Improved 
 
 6 
 
 Same Same 
 
 Same 
 
 Same 
 
 No report 
 
 Same 
 
 Same 
 
 7 
 
 Same Same 
 
 Lower pole barely 
 
 Same 
 
 Increased 
 
 Much im- 
 
 Entirely re- 
 
 
 ■ 
 
 palpable below 
 
 
 15 pounds 
 
 proved 
 
 lieved 
 
 
 1 
 
 costal margin 
 
 
 
 
 
 8 
 
 Slow; Slow 
 
 Same 
 
 Same 
 
 Increased 
 
 Improved 
 
 Same 
 
 
 good as 
 
 
 
 
 10 pounds 
 
 
 
 
 to neph- 
 
 
 
 
 
 
 
 
 roco- 
 
 
 
 
 
 
 
 9 
 
 lopexy 
 Afebrile Good 
 
 Normal; not palpable 
 
 Same 
 
 Increased 
 
 Much im- 
 
 Same3 
 
 
 
 
 
 
 12 pounds 
 
 proved 
 
 
 10 
 
 Same 
 
 Slow ow- 
 ing to 
 nausea 
 
 Same 
 
 Same 
 
 No increase 
 
 No improve- 
 ment 
 
 Improved* 
 
 11 
 
 Same 
 
 Good 
 
 Was not displaced 
 
 Same 
 
 Increased 
 
 Much im- 
 
 Occasional 
 
 
 
 
 15 pounds 
 
 proved 
 
 pain in 
 cecum due 
 
 
 
 
 
 
 to gaS''' 
 
 12 Same Same 
 
 Normal 
 
 Nearly normaMncreased 
 
 Same 
 
 Entirely re- 
 
 
 
 
 22 pounds 
 
 
 lieved 6 
 
 13 Same 
 
 Slow 
 
 Lower pole barely 
 palpable below ribs 
 
 Normal 
 
 Slight increase 
 
 Slightly im- 
 proved 
 
 Improved 7 
 
 14 Good ex- Same 
 
 Normal; not palpable Same 
 
 Increased 
 
 Much im- 
 
 Entirely dis- 
 
 cept for 
 
 
 20 pounds 
 
 proved 
 
 appeared 8 
 
 urinary 
 
 
 
 
 
 fistula 
 
 
 
 
 
 15 Good ex- Good 
 
 Same i Normal: uses 
 
 Increased 
 
 Same 
 
 Same 
 
 cept 
 
 oil occasion- 
 
 10 pounds 
 
 
 
 pleurisj- 
 
 
 ally 
 
 
 
 
 10th day 
 
 
 
 
 
 
 16 Good Slow 
 
 Same 
 
 Same 
 
 Increased 
 
 Same 
 
 Only occa- 
 
 after 
 
 
 
 18 pounds 
 
 
 sional pain 
 
 10th ! 
 
 
 
 
 
 
 day i 
 
 
 
 
 
 
 17 Afebrile |Good 
 
 Same 
 
 Normal 
 
 Increased 
 
 Same 
 
 Entirely re- 
 
 
 
 20 pounds 
 
 
 lieved 
 
 18 iSIow duel Same 
 
 Same Same 
 
 Increased 
 
 Same 
 
 Same9 
 
 to phle- 
 
 
 
 8 pounds 
 
 
 
 bitis in 
 
 left leg 
 
 19 Afebrile 
 
 
 
 
 
 
 Same 
 
 Lower pole barely Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 palpable in left 
 
 26 pounds 
 
 
 
 
 
 lateral position 
 
 
 
 
 20 
 
 Same 
 
 Same 
 
 Normal; not palpable ^Same 
 
 Increased 
 
 15 pounds 
 Increased 
 
 Same 
 
 Same 
 
 21 
 
 Same 
 
 Same 
 
 Same 
 
 Same 
 
 Same 
 
 Same 
 
 
 
 
 
 
 considerably 
 
 
 
 22 
 
 Slow; 
 good as 
 to neph- 
 roco- 
 lopexy 
 
 Same 
 
 Same 
 
 Same 
 
 No report 
 
 Much im- 
 proved 
 
 Same 
 
 23 
 
 Afebrile 
 
 Same 
 
 Lower pole barely 
 palpable 
 
 Same 
 
 No report 
 
 Improved 
 
 Same 
 
 24 
 
 Same 
 
 Same 
 
 Normal ; not palpable 
 
 Same 
 
 Increased 
 18 pounds 
 
 Much im- 
 proved 
 
 Same 
 
 25 
 
 Same 
 
 Same 
 
 Lower pole barely 
 palpable 
 
 Same 
 
 Increased 
 15 pounds 
 
 Same 
 
 Same 
 
 26 
 
 Septic 
 
 Slow 
 
 Normal; not palpable 
 
 Same 
 
 Increased 
 35 pounds 
 
 Same 
 
 Same 
 
 6 Had chronic diarrhea ; now reports she has to use an occasional enema. 
 
 7 Very neurotic and of a uric acid diathesis. 
 
 8 Urinary fistula occurred in wound; entirely healed in three months. 
 
 9 Wound healed perfectly; phlebitis only in left leg. 
 
 215 
 
Summary of the Foregoing Reports of Cases, on All of 
 
 
 
 
 
 
 
 
 
 
 Suture mate- 
 
 
 
 
 Marr'd 
 
 Chil- 
 
 Diagnosis 
 
 Date of 
 
 Additional 
 
 rial used in 
 
 No. 
 
 Sex 
 
 Age 
 
 or 
 
 single 
 
 dren 
 
 operation 
 
 operations 
 
 nephro- 
 
 
 
 
 
 
 
 
 
 colopexy 
 
 27 
 
 F 
 
 57 
 
 M 
 
 5 
 
 Right nephrocoloptosis ; 
 retroversion; endome- 
 tritis 
 
 Oct. 
 
 12, 1907 
 
 Alexander's opera- 
 tion; curettage 
 
 20-day catgut; 
 silver wire; 
 silkworm 
 gut in skin 
 
 28 
 
 F 
 
 47 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 
 Dec. 
 
 31, 1907 
 
 None 
 
 Same 
 
 29 
 
 F 
 
 31 
 
 M 
 
 3 
 
 Right nephrocoloptosis; 
 ruptured perineum; 
 retroversion 
 
 April 
 
 17, 1908 
 
 Perineorrhaphy; 
 Alexander's opera- 
 tion 
 
 Same 
 
 30 
 
 F 
 
 23 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 left cystic ovary 
 
 April 
 
 28, 1908 
 
 Abdominal section; 
 left oophorectomy 
 
 Same 
 
 31 
 
 F 
 
 45 
 
 M 
 
 2 
 
 Right nephrocoloptosis; 
 ruptured perineum; 
 endometritis 
 
 May 
 
 28, 1908 
 
 Perineorrhaphy; 
 curettage 
 
 Same 
 
 32 
 
 F 
 
 38 
 
 M 
 
 1 
 
 Right nephrocoloptosis 
 
 July 
 
 7, 1908 
 
 None 
 
 Same 
 
 33 
 
 F 
 
 30 
 
 M 
 
 3 
 
 Right nephrocoloptosis; 
 retroversion 
 
 Sept. 
 
 30, 1908 
 
 Alexander's opera- 
 tion 
 
 Same 
 
 34 
 
 F 
 
 42 
 
 M 
 
 2 
 
 Right nephrocoloptosis; 
 ruptured perineum ; 
 lacerated cervix; en- 
 dometritis 
 
 Nov. 
 
 3, 1908 
 
 Perineorrhaphy ; 
 trachelorrhaphy ; 
 curettage 
 
 Same 
 
 35 
 
 F 
 
 44 
 
 M 
 
 1 
 
 Right nephrocoloptosis ; 
 ruptured perineum; 
 uterine polyp 
 
 Nov. 
 
 11, 1908 
 
 Perineorrhaphy ; 
 excision of polyp 
 
 Same 
 
 36 
 
 F 
 
 31 
 
 M 
 
 7 
 
 Right nephrocoloptosis; 
 retroversion; endome- 
 tritis 
 
 Nov. 
 
 28, 1908 
 
 Alexander's opera- 
 tion; curettage 
 
 20-day catgut; 
 silver wire; 
 buried sub- 
 cutaneous 
 catgut 
 
 37 
 
 F 
 
 42 
 
 M 
 
 1 
 
 Right nephrocoloptosis; 
 ruptured perineum; 
 endometritis 
 
 March 
 
 4, 1909 
 
 Perineorrhaphy ; 
 curettage 
 
 Same 
 
 38 
 
 F 
 
 25 
 
 S 
 
 
 
 Right nephrocoloptosis 
 
 April 
 
 13, 1909 
 
 Dilatation cervix 
 
 Same 
 
 39 
 
 F 
 
 26 
 
 M 
 
 
 
 Right nephrocoloptosis; 
 retroversion 
 
 June 
 
 12, 1909 
 
 Alexander's operation 
 
 Same 
 
 40 
 
 F 
 
 33 
 
 M 
 
 
 
 Right nephrocoloptosis; 
 endometritis 
 
 June 
 
 23, 1909 
 
 Curettage 
 
 Same 
 
 41 
 
 F 
 
 26 
 
 S 
 
 
 
 Right nephrocoloptosis; 
 retroversion; endome- 
 tritis 
 
 June 
 
 29, 1909 
 
 Alexander's opera- 
 tion; curettage 
 
 Same 
 
 42 
 
 F 
 
 42 
 
 M 
 
 3 
 
 Coloptosis (without 
 nephroptosis) 
 
 July 
 
 1, 1909 
 
 None 
 
 Same 
 
 43 
 
 F 
 
 30 
 
 S 
 
 
 
 Coloptosis (without 
 nephroptosis) ; cystic 
 ovaries 
 
 July 
 
 15, 1909 
 
 Abdominal section; 
 bilaterial salpingo- 
 oophorectomy 
 
 Same 
 
 44 
 
 F 
 
 28 
 
 S 
 
 
 
 Right nephrocoloptosis 
 
 Sept. 
 
 15, 1909 
 
 None 
 
 Same 
 
 45 
 
 F 
 
 33 
 
 S 
 
 
 
 Right nephrogastrocolo- 
 ptosis; endometritis 
 
 Sept. 
 
 15, 1909 
 
 Curettage 
 
 Same 
 
 46 
 
 F 
 
 31 
 
 M 
 
 
 
 Right nephrogastrocolo- 
 ptosis; ruptured peri- 
 neum; retroversion 
 
 Sept. 
 
 25, 1909 
 
 Perineorrhaphy; 
 Alexander's opera- 
 tion 
 
 Same 
 
 47 
 
 F 
 
 22 
 
 M 
 
 2 
 
 Right nephrocoloptosis; 
 lacerated cervix; en- 
 dometritis 
 
 Sept. 
 
 27, 190;j 
 
 Trachelorrhaphy ; 
 curettage 
 
 Same 
 
 48 
 
 F 
 
 37 
 
 M 
 
 1 
 
 Right nephrocoloptosis 
 
 Sept. 
 
 29, 1909 
 
 None 
 
 Same 
 
 49 
 
 F 
 
 29 
 
 S 
 
 
 
 Coloptosis (without 
 nephroptosis) 
 
 Oct. 
 
 2, 1909 
 
 None 
 
 Same 
 
 50 
 
 F 
 
 56 
 
 S 
 
 
 
 Gastrocoloptosis (with- 
 out nephroptosis) 
 
 Oct. 
 
 15, 1909 
 
 None 
 
 Same 
 
 ai 
 
 F 
 
 35 
 
 s 
 
 
 
 Right nephrocoloptosis 
 
 Nov. 
 
 9, 1909 
 
 None 
 
 Same 
 
 52 
 
 F 
 
 19 
 
 s 
 
 
 
 Coloptosis (without 
 nephroptosis) 
 
 Dec. 
 
 18, 1909 
 
 Abdominal section; 
 appendectomy 
 
 Same 
 
 53 
 
 M 
 
 26 
 
 s 
 
 
 
 Right nephrogastrocolo- 
 ptosis 
 
 Jan. 
 
 17, 1910 
 
 None 
 
 Same 
 
 54 
 
 F 
 
 42 
 
 M 
 
 
 
 Right nephrocoloptosis 
 
 Jan. 
 
 25, 1910 
 
 None 
 
 Same 
 
 55 
 
 F 
 
 36 
 
 M 
 
 7 
 
 Right nephrocoloptosis; 
 ruptured perineum; 
 lacerated cervix; en- 
 dometritis 
 
 Feb. 
 
 11, 1910 
 
 Perineorrhaphy ; 
 trachelorrhaphy; 
 curettage 
 
 Same 
 
 56 
 
 F 
 
 27 
 
 s 
 
 
 
 Right nephrocoloptosis 
 
 Feb. 
 
 12, 1910 
 
 None 
 
 Same 
 
 10 Sleeps very much better. 
 
 11 The last case in which the external cutaneous. suture was used. 
 
 216 
 
Which the Operation of Nephrocolopexy was Performed. 
 
 I Bed 
 No. convales- 
 cence 
 
 Late 
 convales- 
 cence 
 
 RESULTS 
 
 Position of kidney 
 
 Defecation 
 
 Weight 
 
 Nervous 
 symptoms 
 
 Abdominal 
 pain 
 
 27 
 
 Septic 
 
 Slow 
 
 Normal; not palpable 
 
 Normal 
 
 Increased Much im- Entirely 
 
 25 pounds proved relieved 
 
 28 
 
 Afebrile 
 
 Good 
 
 No report 
 
 No report 
 
 No report 
 
 Improved 
 
 No report 
 
 29 Same 
 
 Same 
 
 Lower pole barely Normal 
 
 Increased 
 
 Much im- 
 
 Entirely re- 
 
 
 
 palpable 
 
 15 pounds 
 
 proved 
 
 lieved 
 
 30 Same 
 
 Same 
 
 Normal; not palpable Same 
 
 Increased 
 25 pounds 
 
 Same 
 
 Same 
 
 31 Same 
 
 I 
 
 Same 
 
 Same Same 
 
 Increased 
 
 Little im- 
 provement 
 
 Same 
 
 32 Same 
 
 Same 
 
 Entire kidney palpa- Same 
 
 Increased 
 
 Improved 
 
 Still some in 
 
 . 
 
 
 ble, but not mova- 
 
 4 pounds 
 
 
 both sides, 
 
 
 
 ble 
 
 
 
 but less 
 severe 10 
 
 33 Same 
 
 Same 
 
 Normal; not palpable Same 
 
 Increased 
 
 Same 
 
 Relieved 
 
 34 Same 
 
 Slow 
 
 Same Same 
 
 Increased 
 13 pounds 
 
 Much im- 
 proved 
 
 Improving 
 
 35 Septic 
 
 Same 
 
 Same Same 
 
 Increased 
 13 pounds 
 
 Improving 
 
 Saraeii 
 
 36 Afebrile 
 
 Good 
 
 Lower pole palpable Same 
 
 Increased 
 
 Much im- 
 
 Entirely re- 
 
 
 
 
 I 
 
 10 pounds 
 
 proved 
 
 lieved 
 
 37 
 
 Same 
 
 Same 
 
 Normal; not palpable Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 
 
 32 pounds 
 
 
 
 38 
 
 Same 
 
 Same 
 
 Same 
 
 Same 
 
 Increased 
 14 pounds 
 
 Same 
 
 Same 
 
 39 Same 
 
 Same 
 
 Same 
 
 Same 
 
 Much in- 
 creased 
 
 Same 
 
 Same 
 
 40 Same 
 
 Same 
 
 Same Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 i 
 
 14 pounds 
 
 
 
 41 
 
 Same 
 
 Same 
 
 Same ^Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 
 
 21 pounds 
 
 
 
 42 
 
 Same 
 
 Same 
 
 Not displaced 
 
 Same 
 
 Increased 
 
 10 pounds 
 Increasing 
 
 Same 
 
 Same 
 
 43 Febrile 
 
 Slow 
 
 Normal; not palpable Same 
 
 Improving 
 
 Improving 12 
 
 due to 
 
 
 
 
 
 
 bilateral 
 
 
 
 
 
 
 phlebi- 
 
 
 
 
 
 
 tis 
 
 
 
 
 
 
 44 .Afebrile 
 
 Good 
 
 Same Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 1 
 
 5 pounds 
 
 
 
 45 
 
 Same 
 
 Same 
 
 Same ;Improving by 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 
 use of oil 
 
 6 pounds 
 
 
 
 
 
 
 
 and enema 
 
 
 
 
 
 
 
 
 occasionally 
 
 
 
 
 46 
 
 Same 
 
 Same 
 
 Same Normal 
 
 Increased 
 10 pounds 
 
 Much im- 
 proved 
 
 Entirely re- 
 lieved 
 
 47 
 
 Same 
 
 Same 
 
 Lower pole palpable iSame 
 
 Increasing 
 
 Improving 
 
 Same 
 
 48 iSame 
 
 Same 
 
 Normal; not palpable Same 
 
 Increased 
 
 Same 
 
 Same 
 
 
 
 
 
 15 pounds 
 
 
 
 49 iSame 
 
 i 
 
 Same 
 
 Not displaced 
 
 Same 
 
 Increased 
 8 pounds 
 
 Same 
 
 Same 
 
 50 |Same 
 
 Same 
 
 Same 
 
 Improving 
 
 Increased 
 10 pounds 
 
 Same 
 
 Improving 
 
 51 jSame 
 
 Same 
 
 No report No report 
 
 No report 
 
 No report 
 
 No report 
 
 52 Same 
 
 Same 
 
 Not displaced Same 
 
 Same 
 
 Same 
 
 Samel 3 
 
 53 [Same 
 
 Same 
 
 Normal; not palpable Improving by 
 use of oil 
 
 Gaining rap- 
 idly 
 
 Improving 
 
 Relieved 
 
 54 
 
 Same 
 
 Same 
 
 Same Normal 
 
 Increased 6 
 pounds 
 
 Same 
 
 Improving 
 
 55 
 
 Same 
 
 Slow 
 
 Lower pole palpable Same 
 
 No increase 
 
 No report 
 
 No report 
 
 56 
 
 Same 
 
 Good 
 
 Normal; not palpable |Same 
 
 1 
 
 Increased 2 
 pounds 
 
 Improving 
 
 Improving 
 
 12 Wounds healed perfectly by first intention. 
 
 13 Appendix not diseased, but removed because of its great size. 
 
 217 
 
218 NEPHEOCOLOPTOSIS. 
 
 Analysis of the Summary of Reports of Cases. 
 
 Number of cases of operation of nephrocolopexy since Jan- 
 uary 8, 1905 56 
 
 Cases In which additional operations were made 38 
 
 Mortality None 
 
 Results. 
 Position of the kidney: 
 
 Normal (not palpable in any position) 36 
 
 Slightly movable (only lower pole palpable in any po- 
 sition) 10 
 
 Loosely fixed (not floating) 2 
 
 Entire failure of fixation (failure due to sepsis) 1 
 
 Cases of coloptosis (in which the kidney was not dis- 
 lodged ) 6 
 
 Not reported 1 
 
 Regulation of the movements of the bowels: 
 
 Normal (without medication, excepting the use of pet- 
 rolatum oil) 48 
 
 Improved 5 
 
 Not reported 3 
 
 Effect on nutrition as shown by body weight: 
 
 Increase of from two to thirty-five pounds 38 
 
 Increase ( amount not stated ) 8 
 
 No increase 2 
 
 Not reported 8 
 
 Effect on the nervous system: 
 
 Much improved 31 
 
 Slightly improved and improving 20 
 
 Not improved 1 
 
 Not reported 4 
 
 Effect on abdominal pain: 
 
 Entirely relieved 35 
 
 Partially relieved and improving 16 
 
 Not reported 5 
 
 The most notable and significant immediate better- 
 ments are improved nutrition, as shown by increase of 
 body weight — which, in some cases, is very rapid — and 
 relief from colonic catarrh, constipation, and the general 
 symptoms of colonic irritability, as shown by the regula- 
 tion of the natural movements of the bowels. 
 
 Jnst what is accomplished by the fixation of the bowel 
 that leads to the remarkable improvement in the action 
 of the colon has been an interesting study. Until post- 
 operative radiographs were made the author attributed 
 the improvements entirelj^ to the elevation of the cecum 
 
EEPORTS OF CASES. 219 
 
 and ascending colon, bnt, as the radiograplis— even in the 
 best cases of recovery — indicate too little change in this 
 respect to be counted on as the only positive factor, he 
 has come to the conclusion that the improvement is 
 largely due to the immobilization of the gut, caused by 
 the fixation, which acts as a substitute for the relaxed and 
 deficient or absent hepatocolic ligament. The reverse 
 peristalsis, alternating with the forward peristalsis, pro- 
 ducing the churning' action of this part of the colon, is 
 probably facilitated by the fixation, as well as the passage 
 of the contents of the bowel over the hepatic flexure. 
 The benefit to nutrition is attributed to the removal of 
 the traction on the duodenum as well as to the resumption 
 of the normal action of the cecum. The neurasthenia dis- 
 appears more slowly, but does so surely as the nutrition 
 continues to improve. 
 
 The operation, as performed by the author, is quite a 
 simple procedure when once the technic is mastered, and, 
 as is seen by the foregoing report, is practically free from 
 danger to life. It being made with a minimum dissec- 
 tion and mutilation of the parts consistent with the object 
 to be attained (the fixation of the nephrocolic ligament), 
 the shock is comparatively nil, and the pain following 
 not of a severe character and of but a few hours' dura- 
 tion. Its usefulness in restoring the normal colonic func- 
 tion in cases of nephrocoloptosis led the author to em- 
 ploy it also in the cases above reported of coloptosis only. 
 While they are of a very limited number on which to base 
 any conclusive deductions, the beneficial results have 
 been so immediate and positive that the outlook for its 
 usefulness in cases of colonic ptosis attended with 
 catarrh, constipation, or diarrhea would seem very good, 
 and warrant its farther application in all such cases as a 
 safe and efficient remedy. 
 
220 NEPHROCOLOPTOSIS. 
 
 Cases Not Yet Come to Operation. 
 
 The following report of cases wliicli have not yet come 
 to operation is given for the purpose of illustrating valu- 
 able points relating to the text, and especially to show the 
 diagnostic jDossibilities of the radiograph, its value being 
 strikingly illustrated in some of the cases of obscure 
 symptomatology. 
 
 Case A. 
 
 Enormous dilatation of cecum and transverse colon, 
 with complete nephrocoloptosis. 
 
 Female; aged 25; married one year; never pregnant. 
 Patient of Dr. C. G. Jennings. 
 
 October 15, 1908. Seeks relief for neurasthenia; pro- 
 gressive loss of flesh — fifteen pounds in a year; lack of 
 endurance; flatulence; dyspepsia; backache; leucorrhea; 
 menorrhagia. The mother of this patient had a floating 
 kidney all of her adult life, but otherwise the family his- 
 tory was good. Figure good and thorax not of the bar- 
 rel-shape type. Heart normal; pulse, 100; temperature, 
 98° ; urine normal. 
 
 Abdominal examination in the dorsal decubitus showed 
 thin abdominal walls; sensitiveness at McBurney's point 
 and in the right inguinal region; on deep inspiratory 
 effort the right kidney was brought entirely below the 
 costal margin. In the left lateral position the kidney 
 dropped below the navel. The left kidney could not be 
 palpated in any position. 
 
 Vaginal examination showed vagina and cervix normal, 
 uterine bod}^ larger than normal, and continuous with it 
 on the right side a very sensitive tumor, which apparently 
 consisted of the fallopian tube and ovary of that side in a 
 condition of acute congestion. The pelvic condition was 
 
EEPOETS OF CASES. 
 
 221 
 
 treated by local aiitiplilogistics and disappeared entirely 
 in about six weeks. 
 
 November 23, 11)08. A radiograph showed very ex- 
 tensive coloptosis (Fig. 70) and dilatation of the cecum 
 and first half of the transverse colon. The a])dominal 
 
 Fig-. 70. Case A. 
 
 supporter was then applied and the operation of nepliro- 
 colopexy advised. Considerable relief followed the use 
 of the supporter — so much so that the patient still defers 
 the operation. 
 
 Case B. 
 Complete nephrocoloptosis. 
 
 Female; aged 32; single; teacher. Patient of Dr. P. M. 
 Hickey. 
 
 January 23, 1909. Seeks relief for pain in left side of 
 abdomen; flatulence; severe constipation (for five years); 
 progressive emaciation and debility; enlarged lymphatic 
 glands in the neck were present, which were suspected to 
 be tuberculous. Heart normal; temperature normal; 
 pulse, 80; urine normal. Thorax narrow and barrel- 
 shaped. 
 
222 
 
 NEPHEOCOLOPTOSIS. 
 
 Abdominal examination in dorsal ]Dosition showed tym- 
 joanitic fullness and sensitiveness in left side; sensitive- 
 ness at and below McBurney's point; the right kidney 
 lying loose near the navel, and could be replaced manu- 
 ally up into the renal fossa. The left kidney could not 
 be palpated in any position. 
 
 January 25, 1909. A radiograph of the large intestine 
 (Fig. 71) showed the result of complete relaxation of the 
 hepatocolic ligament in the descent of the cecum and 
 
 Fig-. 71. Case B. 
 
 transverse colon into the pelvis as far as gravity and the 
 firmly attached splenocolic ligament would permit. The 
 radiograph also shows dilatation of the cecum, and illus- 
 trates well the position of the dropped transverse colon, 
 with its sag to the left, ascending left half, and conse- 
 quent formation of an acute angle at its junction with the 
 descending colon to cause the sharp obstructive angula- 
 tion at the splenic flexure. The latter condition explains 
 the cause of the tympanites and pain complained of in 
 the left side of the abdomen, which is a characteristic 
 symptom in cases of complete colonic ptosis. 
 
REPORTS OF CASES. 
 
 223 
 
 Operation of neplirocolopexy was advised, and arrange- 
 ments made for tlie operation, but the date deferred from 
 time to time because of slight activity manifested in the 
 cervical lymphatic glands, and at last given up because 
 of the development of pulmonary tuberculosis. 
 
 Case C. 
 
 Right nephrocoloptosis. Enormous cecum. Notable as 
 showing" no descent of hepatic flexure. 
 
 Female; aged 26; married; no children. Eef erred to 
 me by Dr. L. Breisacher. 
 
 Fig-. 72. Case C. 
 
 January 25, 1909. Seeks relief for excessive nervous- 
 ness; emaciation; headaches; nausea; frequent attacks 
 of itching over the entire body; constipated bowels; gen- 
 eral debility. Can walk but little, and spends much of 
 her time on the couch. Heart, temperature, and urine 
 normal. 
 
 Examination in the dorsal position showed a narrow, 
 barrel-shaped thorax, with rather full abdomen and poor 
 
224 NEPHROCOLOPTOSIS. 
 
 muscular development; sensitiveness over McBurney's 
 point was marked, and a lesser sensitive point found deep 
 in the pelvis on the left side. Neither kidney could be 
 palpated in that position. In the left lateral joosition the 
 right kidney was forced below the costal margin by the 
 inspiratory effort, and was freely movable in the region 
 of the navel. The left kidney could not be palpated in 
 either position. 
 
 Vaginal examination was negative. 
 
 June 29, 1909. A radiograph (Fig. 72) showed an 
 enormously distended and elongated cecum and a 
 dropped transverse colon, producing the characteristic 
 sjDlenic acute angle. This radiograph differs from all the 
 others here shown in that there is little, if any, dropping 
 of the hepatic flexure indicated, and is the only case of 
 coloptosis which I have ever met with that did not have 
 this feature. It seems to be a case similar to those de- 
 scribed by Lane, in which he advises complete extirpa- 
 tion of the colon. 
 
 The operation of nephrocolopexy was advised. 
 
 Case D. 
 
 Severe paroxysmal headaches caused by complete 
 nephrocoloptosis. 
 
 Female; aged 30; married; two children. Patient of 
 Dr. Bel anger. 
 
 January 26, 1909. Seeks relief for almost constant 
 headache, which at times becomes agonizing, especially 
 caused by unusual muscular effort or mental disturbance; 
 constant pain in the lower part of the abdomen; severe 
 morning headache; much mucus in stools, which are regu- 
 lar, but often loose, and attended with pain in the abdo- 
 men; pain in the abdomen also caused by the act of mic- 
 
REPORTS OF CASES. 
 
 225 
 
 turition, which is not frequent nor prodnctive of ureteral 
 or vesical pain; progressive loss of flesh. Heart normal; 
 Ionise, 75; temperature, 98°. Urine — specific gravity, 
 1,008; alkaline; turbid with urates. 
 
 Abdominal examination in dorsal decubitus showed a 
 narrow lower thorax; flat, flaccid abdomen, sensitive 
 across the entire lower half; otherwise negative, even the 
 inspiratory effort failing to dislodge either kidney. In 
 the left lateral decubitus, deep inspiration forced the 
 
 Fij 
 
 Case D. 
 
 right kidney quickly and entirely below the costal margin, 
 where it remained until replaced manually. The left kid- 
 ney could not be palpated in any position. 
 
 Vaginal examination negative, excepting showing 
 cervical endometritis. 
 
 At the conclusion of the examination the patient was 
 seized with one of the characteristic paroxysms of pain 
 in the head of which she had spoken, and was completely 
 prostrated by it for half an hour, holding the head firmly 
 in both hands and pressing the forehead against the 
 
226 NEPHROCOLOPTOSIS. 
 
 coucli while kneeling on the floor. She did not cry out, 
 but moaned, and seemed in great agony. 
 
 January 28, 1909. A radiograph (Fig. 73) showed 
 complete colonic ptosis, with occlusion at the splenic flex- 
 ure and dilatation of the entire gut, the condition explain- 
 ing the cause of the constant pain in the lower abdomen. 
 
 Nephrocolopexy was advised, but the patient did not 
 return, and the farther history of this interesting case is 
 unknown to me. 
 
 Case E. 
 
 Cecal distention mistaken for appendicitis for several 
 years. 
 
 Female; aged 50; married; never pregnant. 
 
 First treated this patient iq 1893, when she gave a his- 
 tory of an old tubal infection, and was then having en- 
 dometritis, and occasional attacks of pain in the right 
 side of the abdomen, the latter thought to be caused by 
 appendiceal irritation of some kind. The author treated 
 her for these attacks, which were never attended with 
 rise of temperature or acceleration of pulse, for ten years 
 following, during which time appendectomy was pro- 
 posed several times and refused. Each attack was sup- 
 posed to be fraught with danger of a genuine appendi- 
 citis, and the patient was advised to have the appendix 
 removed between attacks. With my present knowledge 
 of the symi^tomatology of colonic ptosis and the diagnos- 
 tic technic as applied to nephroj)tosis, this patient would 
 not have passed all of these 3^ears, having attacks of pain 
 at the McBurney point, without the discovery of the fact 
 that the appendix was far from this supposed area of 
 its location, and that the sensitive spot was really in the 
 distended ascending colon and cecum, or possibly in the 
 angulation caused by the dropping of the hepatic flexure. 
 
EEPORTS OF CASES. 
 
 227 
 
 This case is a good illustration of many similar ones 
 having supposed mild attacks of appendicitis, operated 
 on as such, and perfectly normal appendices removed. 
 
 The patient was lost sight of for a number of years, 
 and returned January 27, 1909, complaining of the same 
 old pain in the side, and giving a history of having had 
 gastric irritability and nausea for several months. 
 
 Abdominal examination in the left lateral position. 
 
 Fig. 74. Case E. 
 
 with inspiratory effort, brought the right kidney well 
 down into the abdomen. The left kidney could not be 
 dislodged in any position. 
 
 January 29, 1909. A radiograph (Fig. 74) showed a 
 nearly complete coloptosis, and located the position of 
 the appendix much nearer the uterus than at McBurney's 
 point. 
 
 Operation was advised, but has not yet been decided on 
 by the patient. 
 
228 
 
 NEPHROCOLOPTOSIS. 
 
 Case F. 
 
 Great dilatation of cecum and transverse colon, the 
 latter at the splenic flexure. 
 
 Female; aged 37; married; mother of four children. 
 
 February 13, 1909. Seeks relief for a burning sensa- 
 tion over the entire abdomen; quite constant pain in the 
 left side above the hip; dryness of the mouth; alternating- 
 constipation and diarrhea; loss of flesh and strength. 
 Heart, temperature, and urine normal. 
 
 Case F. 
 
 Abdominal examination in the dorsal position showed 
 a broad, roomy lower thorax; thin, flat abdomen; sensi- 
 tiveness over McBurney's point. Neither Ividney pal- 
 pable. 
 
 In the left lateral position the right kidney was brought 
 down entirely below the costal margin by inspiratory 
 effort. The left kidne}^ could not be dislodged. 
 
 Vaginal examination was negative. 
 
 February 15, 1909. A radiograph (Fig. 75) showed a 
 comiDletely dropped colon; dilated cecum, with its lower 
 
REPORTS OF CASES. 229 
 
 end lying in the bottom of the pelvis, indicating the po- 
 sition of the appendix at this point; dilated transverse 
 colon at its partial occlusion at the splenic flexure. The 
 angulation at the splenic flexure is doubtless the cause of 
 the pain above the hip, and the burning sensation across 
 the abdomen results from the process of dilatation which 
 the gut is constantly undergoing because of its inability 
 to force its contents normally over this angulation. 
 Operation advised. 
 
 Case G. 
 
 A life sacrificed to a wrong diagnosis. 
 
 Female; aged 36; married; no children; factory hand. 
 
 April 21, 1909. Seeks relief for pain in the left side 
 of the abdomen above the hips; constipation; weakness 
 and continued loss of flesh — one hundred and thirty-six 
 pounds to one hundred and twelve pounds in three years. 
 Is very nervous and can work but about half the time, 
 and often has to leave her work because of exhaustion 
 and pain in the side. Has large frame, broad chest and 
 abdomen. Heart and temperature normal; urine high 
 specific gravity and full of urates. 
 
 Abdominal examination in the dorsal position showed 
 sensitive areas in the left epigastrium and right lumbar 
 regions. Neither kidney could be forced below the costal 
 margin by deep inspiration while in this position, but in 
 the left lateral position the insjnratory effort brought the 
 right kidney entirely below, where it could he felt lying- 
 loose, and in the right lateral position the left kidney was 
 brought partly below the costal margin in a similar 
 manner. 
 
 Vaginal examination showed a mobile retroversion of 
 the third degree, which was easih^ replaced; normal 
 aclnexa. 
 
230 
 
 NEPHEOCOLOPTOSIS. 
 
 April 24, 1909. A radiograph (Fig. 76) showed the 
 complete ptosis of the bowel. 
 
 Operation of bilateral nephrocolopexy and Alexander's 
 
 Fig. 76. Case G. 
 
 operation advised, and hospital arrangements made, bnt 
 the patient songiit other advice, and died of pneumonia 
 following an abdominal section three weeks later. 
 
 Case H. 
 
 Complete gastrocoloptosis, with moderate nephroptosis. 
 
 Female; aged 29; married; mother of three children. 
 
 June 25, 1909. Seeks relief for neurasthenia; progres- 
 sive emaciation; pain in the abdomen and ''bearing- 
 down;" constipation; backache; dj^spepsia; nausea. Be- 
 sides bearing her children, during the last seven years 
 she has had a stormy operative career — appendectomy at 
 one time, curettage and perineorrhaphy at another, and 
 an abdominal section for adhesions at last. A tubal in- 
 fection a year ago still further complicated the pathology. 
 
REPOKTS or CASES. 
 
 231 
 
 Has had a daily rise of temperature of from one-lialf to 
 two degrees during the last three years. Heart normal; 
 pulse, 110; temperature, 99.2°; urine normal. 
 
 Abdominal examination in the dorsal position showed 
 a roomy, broad thorax; sensitiveness over the whole ab- 
 domen, but especially at McBurney's point, and in the 
 median line below the navel. Neither kidney palpable 
 in this position. In the left lateral position the right kid- 
 
 Fig-. 77. Case H. 
 
 Fig-. 78. Case H. 
 
 ney became entirely palpable below the costal margin, 
 being dislodged by inspiratory eifort. The left kidney 
 could not be brought down. 
 
 Vaginal examination showed a lacerated cervix; 
 normal uterus; slightly enlarged and adherent right fal- 
 lopian tube. 
 
 January 29, 1909. Eadiographs of stomach and colon 
 (Figs. 77, 78) showed extensive displacement in both in- 
 stances. A more complete prolapse of the hepatic flex- 
 ure, as a result of relaxation of the hepatocolic ligament, 
 is rarely seen. The appendix, if one were present, would 
 
232 NEPHKOCOLOPTOSIS. 
 
 be lying in the median line, against the uterus or bladder. 
 What value would the usual diagnostic sign of pain and 
 tenderness at McBurney's point have in a case of this 
 kind if attacked with appendicitis? On the other hand, 
 how misleading is this sign when applied to these cases, 
 almost all of which have both pain and sensitiveness in 
 this region, caused by the distended cecal end of the gut. 
 Note the distention in this case of the hepatic flexure, 
 which lies at and below McBurney's point. 
 
 An abdominal supporter was applied, but it caused 
 nausea each time that it was worn for more than an hour, 
 so that its use was discontinued after a number of per- 
 sistent trials. Adhesions are doubtless present, as a re- 
 sult of the tubal inflammation, and the stomach and colon 
 probably bound fast in their present positions by adher- 
 ent omentum. 
 
 The operations considered necessary in this case are 
 trachelorrhaphy, curettage, abdominal section, with the 
 removal of the utering appendages and breaking up of 
 adhesions, and nephrocolopexy. The patient is now con- 
 sidering such a proposition. 
 
 Case I. 
 
 Enormously dilated cecum and complete gastrocolo- 
 ptosis without nephroptosis. 
 
 Female; aged 33; married; mother of two children. 
 Patient of Dr. C. Gf. Jennings. 
 
 February, 1906. I restored a completely retroverted 
 uterus by the Alexander operation, and at the same time 
 performed trachelorrhaj^hy and perineorrhaphy. Since 
 that time her second child was born, the uterus and re- 
 paired parts remaining intact thereafter. 
 
 July 12, 1909. The patient returned, complaining of 
 
EEPORTS OF CASES. 
 
 233 
 
 frequent headaches and bilious attacks, and soreness in 
 the right side of the abdomen; neurasthenia; dyspepsia, 
 and loss of flesh. 
 
 Abdominal examination in l)otli dorsal and lateral po- 
 sitions failed to dislodge either kidney, but, the symp- 
 toms being characteristic of colonic or gastric ptosis, a 
 radiograph was ordered taken. 
 
 January 14, 1909. Eadiographs of stomach and colon 
 (Figs. 79, 80) showed extensive gastrocoloptosis, and in- 
 
 Fig. 79. Case I. 
 
 Fig. SO. Case I. 
 
 dicated clearly the cause of the symptomatology. Here 
 was a case having a weak or relaxed hepatocolic liga- 
 ment, allowing the hepatic flexure to drop to a point be- 
 low the level of the navel, and having a long nephrocolic 
 ligament, which prevented the usual renal displacements. 
 The cecum is seen to be ninch enlarged, its distention be- 
 ing doubtless the cause of the pain in this side of the 
 abdomen. The cecal distention is the natural sequence 
 following the angulation at both the hepatic and splenic 
 flexures, more especially of the latter, which is always 
 the most acute, and, being firmly fixed in its position, the 
 
234 
 
 NEPHKOCOLOPTOSIS. 
 
 backing up of fecal contents is iisnally from this 
 point. 
 
 Operation of neplirocolopexy was advised, but lias been 
 deferred. 
 
 Case J. 
 
 Extensive coloptosis without nephroptosis, causing 
 malnutrition and emaciation. 
 
 Female ; aged 30 ; single. Patient of Dr. C. Gr. Jennings. 
 
 July 30, 1909. Seeks relief for gradually increasing 
 
 debility, neurasthenia, anemia, and loss of flesh. Has lost 
 
 Fig. 81. Case J. 
 
 Fig-. 82. Case J. 
 
 thirty pounds. "Weighed one hundred and forty-five 
 pounds at twenty years of age and now weighs one hun- 
 dred and fifteen pounds. Sleeps well on either side, and 
 complains of no indigestion or flatulence, and bowels are 
 regular. Menstrual periods are regular, and no symp- 
 toms of pelvic disease. Good figure and broad lower 
 thorax. Heart, temperature, and urine normal. 
 
 Abdominal examination in both positions was negative, 
 excepting for sensitiveness at McBurney's point. 
 
EEPOETS OF CASES. 235 
 
 August 2, 1909. Eadiographs of stomacli and colon 
 (Figs. 81, 82) showed dilatation of the stomach and ex- 
 tensive ptosis of the colon. The relaxation of the hepato- 
 colic ligament is apparently complete, allowing the cecal 
 end of the bowel to descend into the bottom of the pelvis. 
 A long nephrocolic ligament would, no doubt, be found 
 in this case to account for the kidney remaining in place. 
 
 Operation was advised, but, as the patient was just 
 starting for a foreign trip, she was fitted with an ab- 
 dominal supporter and the operation deferred. 
 
 February .2, 1910. Reports much relief of all symp- 
 toms, and is still wearing the supporter. Nutrition about 
 the same. 
 
 Case K. 
 
 Nephrocoloptosis in its incipiency in a young patient, 
 pregnant three months. 
 
 Female; aged 25; married; never before pregnant. 
 Patient of Dr. H. E. Shaver, of Bonnie City, Mich. 
 
 October 18, 1909. Seeks relief for frequent attacks of 
 pain across the abdomen, which is worse on the left side, 
 above the hip, where it commences, and afterward ex- 
 tends downward to the bladder; alternate severe consti- 
 pation and diarrhea; frequent micturition, both night and 
 day; inability to sleep, excepting on the right side (says 
 any other position causes a choking sensation) ; much 
 flatulence ; loss of weight — from one hundred and twenty- 
 two to one hundred and twelve pounds. Says these man- 
 ifestations have come on gradually during the last two 
 years, and are all increasing in severity and persistence. 
 Menstruation always very irregular and infrequent, and 
 frequently passes over one, two, or three periods; none 
 since July 13 last; no nausea. Had "inflammation of the 
 
236 
 
 NEPHEOCOLOPTOSIS. 
 
 bowels" at 15, wliicli confiiied lier to bed for six weeks. 
 Heart and temperature normal ; urine slightly turbid with 
 urates, otherwise normal. 
 
 Abdominal examination in the dorsal position showed 
 broad and roomy lower thorax, tenderness at McBurne3^'s 
 point, and rather a fall abdomen, with good muscular de- 
 velopment. The inspiratory effort failed to dislodge 
 either kidney in this position. In the left lateral position 
 the inspirator}^ effort brought the right kidney down to 
 
 Fig. S3. Case K. 
 
 84. Case K. 
 
 the paliDating hand to the extent of two-thirds of its vol- 
 ume below the costal margin. The left kidney could not 
 be palpated in either j^osition. 
 
 Vaginal examination showed a normal introitus; soft 
 cervix, which was purple in color; body of uterus soft and 
 enlarged, reaching a i^oint two inches below the navel. 
 
 The patient was, no doubt, pregnant, which would pre- 
 clude any immediate surgical work, but, after conferring 
 with Dr. Hickey regarding the possible danger of the 
 x-ray to the conception, radiographs were made of both 
 
REPOETS OF CASES. 237 
 
 stomach and colon. (Figs. 83, 84.) These show a mod- 
 erate displacement of both organs. The position of the 
 transverse colon, with its sag to tlie left and the sharp 
 angle at the splenic flexnre, explains the cause of the jDain 
 in the left side. 
 
 The case illustrates one of ptosis in comparative in- 
 cipienc}^, and one in which results from operation sliould 
 be of the best to be obtained in this class of cases, as the 
 gut has not yet become chronically distended. The 
 stomach has not become much dilated, and will, no doubt, 
 return to its normal position after the strain on the 
 duodenum has been relieved by raising and fixing the 
 cecal end of the bowel. 
 
 The patient was advised to return for operation after 
 confinement and the weaning of the baby. She was as- 
 sured that tlie symptoms resulting from the displace- 
 ments would decrease as the pregnancy progressed, as the 
 enlarging uterus would push up tlie bowel, and thus re- 
 move the strain from the kidney and duodenum as well 
 as round out the angle of tlie gut at the splenic flexure. 
 
 Case L. 
 
 Enormous dilatation of cecum and transverse colon due 
 to angulation; occlusion at the splenic flexure. 
 
 Female; aged 28; factory hand. 
 
 December 28, 1908. Seeks relief for pain in right side 
 of abdomen and back on the same side; severe headaches, 
 which cause nausea, the attacks frequentl}" interfering 
 with her work ; irregular and painful menstruation ; grad- 
 ual loss of flesh and strength; constipation and flatulence 
 (gas has foul odor). Symptoms have been gradually in- 
 creasing for ten years. Has been treated by many physi- 
 cians for all kinds of digestive and nervous disorders. 
 Heart normal; pulse, 68; temperature and urine normal. 
 
238 
 
 NEPHEOCOLOPTOSIS. 
 
 Abdominal examination in the dorsal position showed 
 a broad, roomy lower thorax; flat abdomen; good muscn- 
 lar development; right kidney palpated in the region of 
 the umbilicns without inspiratory effort, and easily re- 
 placed up behind the costal margin; no abdominal sensi- 
 tiveness. 
 
 Vaginal examination negative. 
 
 Fig. S5. Case L. 
 
 January 10, 1909. A radiograph of the colon (Fig. 85) 
 showed moderate coloptosis and great dilatation of the 
 gut; the latter, no doubt, due to the acute angulation at 
 the splenic flexure, caused by the complete downward 
 drag of the left end of the transverse colon on the phreno- 
 colic ligament. 
 
 Abdominal supporter applied, petrolatum oil pre- 
 scribed, and operation advised. 
 
 February 11, 1909. Reports partial relief of symp- 
 toms. Operation deferred. 
 
REPORTS OF CASES. 
 
 239 
 
 Case M. 
 
 Dietl's crisis. 
 
 Female; aged 44; single. Patient of Dr. B. R. Sliuriy. 
 (See record of the case in the chapter on symptoma- 
 tology.) 
 
 Fig. 86. Case M. 
 Bowel sketched by following 
 shadow. 
 
 The radiograph (retouched by the artist) shows a very 
 narrow thorax of the barrel-shaped type. (Fig. 86.) 
 Operation advised, but deferred. 
 
240 
 
 NEPHROCOLOPTOSIS. 
 
 Addendum. 
 
 A typical, unfavorable, anotomic, and symptomatic re- 
 sult following- the old operation of nephropexy, confirm- 
 ing theory illustrated by Fig. 28. 
 
 This case, having had symptoms gradually increasing 
 in severity after a nephropexy made three years previous, 
 came to operation as the book was going to press. The 
 kidney was found fixed to the muscles of the loin, about 
 two-thirds of the organ being below the costal margin. 
 
 Fig. 87. 
 
 Gerota's capsule was in cicatricial union with the trans- 
 versalis fascia. A portion of the fatty capsule was found 
 below the lower pole of the kidney, to which it was at- 
 tached by a few filaments, the most of it passing down- 
 ward to the colon. This was raised up and sewed into the 
 opening in the transversalis fascia, hoping thus to retain 
 the elevation and cause the fixation of the cecum, the de- 
 scent of which had resulted in increased severity of symp- 
 toms. 
 
EEPOKTS OF CASES. 
 
 241 
 
 Fig. 87 is an x-ray giving a graphic illustration of the 
 resultant complete coloptosis following the old operation 
 of nephroioex}^, in wliich the fatty capsule was stripped 
 away from the kidney, allowing the cecal end of the 
 gut to drop comjiletely into the pelvic cavity. 
 
 Fig-. 88. 
 
 Fig. 88 is a somewhat enlarged radiograph of the same 
 case as shown in Fig. 87, taken with the patient in the 
 recumbent position. Note the higher position of the 
 cecum and the separation of tlie lower part of the loop 
 of the transverse colon, caused by the elevation of the 
 cecum. 
 
 This picture shows why the patient was most comfort- 
 able while recumbent and why she had passed much of 
 her time in bed during the last three vears. 
 
REFEEENCES. 
 
 Alton, R. W., 145 
 Belanger, J. A., 224 
 Billington, Wm., 28 
 Blodgett, Wm. M., 15, 82 
 Breisacher, L., 223 
 Burley, D. H., 160 
 Burr, C. B., 15, 55 
 Cadieux, H. W., 136 
 Gary, Hugh, 143 
 Conner, Sarah, 168 
 Duffield, S. P., 172 
 Gerota, 39 
 Glautenay, 39 
 Gleanard, 7, 50 
 Gray, 25 
 
 Hickey, P. M., 15, 72 
 Huson, Florence, 131 
 Inglis, David, 154 
 Jenne, B. H., 169 
 Jennings, C. G., 155 
 
 Jones, D. J., 200 
 Kelly-Noble, 25 
 Langlois, F. J., 187 
 Loucks, R. E., 157 
 McGraw, T. A., 181 
 Mann, F. W., 146 
 Newman, F. L., 139 
 Potter, G. E., 137 
 Reed, C. A. L., 28 
 Sanderson, J. H., 171 
 Shaver, H. E., 235 
 Sherrill, E. S., 140 
 Shurly, B. R., 60 
 Small, Sidney, 153 
 Suckling, C. W., 13, 15 
 Tappey, E. T., 203 
 Thomas, O. J., 176 
 Vernier, Jean A., 163 
 Weir-Mitchell, 9 
 Zuckerkandl, 39 
 
 213 
 
INDEX. 
 
 Abdominal massage, 86 
 
 pad and adhesive plaster, 98, 122 
 ptosis, orthopedic considerations 
 in, 82 
 orthopedic treatment in, 81, 82 
 supporter, Longyear's, 94 
 
 Long-year's, adjustment of, 97, 
 
 98 
 Longyear's elastic, 94 
 Longyear's, in mechanical 
 
 treatment, 94 
 Longyear's, posture in adjust- 
 ing, 96 
 Acid, uric, diathesis in medical 
 
 treatment, 87 
 Adhesive plaster. See Abdominal 
 
 pad and adhesive plaster. 
 Adhesive plaster, pad and, in 
 
 mechanical treatment, 98 
 After-treatment in nephrocolopexy, 
 
 122 
 Analysis of summary of reports of 
 
 cases, 218 
 Anatomic relations of kidneys, 22 
 Anatomy, 21 
 
 diagrams illustrating, 22, 23, 24 
 Anesthesia in nephrocolopexy, 103 
 
 method of, 103 
 Angulation, colonic, in nephro- 
 coloptosis, 51, 54 
 colic caused by, 55 
 of colon, 27. 31, 51, 54 
 of duodenum, 27, 31, 51, 53 
 of large intestine, 51, 54 
 Antiseptics, intestinal, in medical 
 
 treatment, 90 
 Apparatus necessary for Rontgen 
 
 ray, 73 
 Appendicitis, differential diagnosis 
 of, 77 
 errors in diagnosis of, 97, 163, 
 
 189, 213 
 pain in cecum simulating, 54, 
 163, 189, 213 
 Appendix, McBurney's point of no 
 value in locating, in colo- 
 ptosis, 182, 193, 199, 203 
 Appliances in mechanical treat- 
 ment, 92 
 
 Ascending colon, 44 
 
 attachment of, to kidney by 
 nephrocolic ligament, 29, 30, 
 31 
 
 BiSiSiUTH, subcarbonate of, in 
 Rontgen ray, 73 
 subnitrate of, in Rontgen ray, 73 
 
 Bowels, regulation of. See Defe- 
 cation. 
 
 Bowels, regulation of, after neph- 
 rocolopexy, 126 
 
 Bran in constipation, 90 
 in medical treatment, 90 
 
 Breathing exercises in prophy- 
 laxis, 81 
 
 Camppior stupe in topical treat- 
 ment, 91 
 Capsule, fatty, forming nephro- 
 colic ligament, 25, 29 
 fibrous, 25 
 Gerota's, 38, 92, 107 
 location of Gerota's, important 
 in nephrocolopexy, 107 
 Cases, analysis of summary of re- 
 ports of, 218 
 histories of, valuable in diag- 
 nosis, 64 
 radiographs of. 151-241 
 reports of nonoperative, 220 
 of operative, 130 
 of nephrocolopexy, 130 
 summary of reports of, of 
 
 nephrocolopexy, 214 
 value of histories of, in diag- 
 nosis, 64 
 Catarrh, colonic, in nephrocolo- 
 ptosis, 55 
 mucus in stool indication of 
 
 colonic, 55 
 of colon, treatment of, 87 
 Cathartics in medical treatment, 
 87 
 lubricants rather than, in medi- 
 cal treatment, 88 
 to be avoided, 87 
 Cause, body shape secondary, of 
 nephroptosis, 52 
 
 245 
 
246 
 
 INDEX 
 
 Cause — cont'd. 
 
 hereditary laxity of restraining 
 tissues primary, of nephro- 
 coloptosis, 49 
 
 of rigiit side nepliroptosis, 52 
 Cecal pain, appendicitis simu- 
 lated by, 163, 189, 213 
 Cecum, 44, 51 
 
 churning action of, 219 
 
 dilatation of, 59, 226, 228, 232 
 
 displacement of, leads to faulty 
 diagnosis, 54 
 
 pain in, simulating appendicitis, 
 54,' 163, 189, 213 
 
 palpation of, 54 
 
 spastic contraction of, 54. 58 
 Children, importance of prophy- 
 lactic treatment in, 81, 82 
 
 nephroptosis in, 13, 86 
 
 orthopedic treatment in, 81, 82 
 
 prophylactic treatment in, 81, 82 
 Colic caused by colonic angula- 
 tion, 55 
 by nephrocoloptOiSis, 55 
 
 in colon, 55 
 Colon, 26, 2v, 30, 31 
 
 angulation of, 27, 31, 51, 54 
 
 ascending, 44 
 
 attaching kidney by nephrocolic 
 ligament to, 29, 30, 31 
 
 catarrh of, 55 
 
 colic in, 55 
 
 descending, 44 
 
 displacement of, 27, 30, 44 
 
 fixation of, of first importance 
 in operative treatment, 100 
 
 fiexures of, 42 
 
 hepatic flexure of, 42 
 
 ligaments of, 43 
 
 mucus in stool indication of 
 catarrh of, 55 
 
 ptosis of, 27, 30, 34 
 
 regulation of function of, 85, 126 
 
 results of fixation of, 218 
 
 sigmoid flexure of, 42 
 
 splenic flexure of, 42 
 
 stasis of contents of, 85 
 
 transverse, 44 
 
 treatment of catarrh of, 87 
 Colonic angulation, colic caused 
 by, 55 
 in nephrocoloptosis, 51, 54 
 
 catarrh in nephrocoloptosis, 55 
 
 catarrh, mucus in stool indica- 
 tion of, 55 
 
 function. See Defecation. 
 
 normal, function important in 
 prophylactic treatment, 85 
 
 pain in nephrocoloptosis, 54 
 
 Colonic — cont'd. 
 
 ptosis, intra-abdominal fat to 
 
 prevent, 87 
 stasis, toxemia caused by, 55, 
 194 
 Coloptosis, 27, 30, 44 
 
 causing nephroptosis, 7, 50 
 diagnosis of, by inflation, 69 
 
 by x-ray, 70 
 McBurney's point of no value in 
 locating appendix in, 182, 
 193. 199, 203 
 nephroptosis result of, 7, 50 
 olive oil in, 90 
 petrolatum oil in, 88, 126 
 symptoms relieved by nephro- 
 
 colopexy, 143, 219 
 without nephroptosis, cause of, 
 52 
 diagnosis diflScult in, 65 
 nephrocolopexy in, 10, 143, 
 190, 192, 201, 206 
 Compression of ureter in nephro- 
 ptosis, 126 
 Constipation, 12 
 bran in, 90 
 
 cause of ptosis, 51, 86 
 caused by nephrocoloptosis, 55, 
 
 58 
 cured by nephrocolopexy, 10, 
 
 143, 190, 192, 201, 206 
 fecal impaction in, 56 
 in mental disorders, 56 
 olive oil in, 90 
 persistent in nephrocoloptosis, 
 
 58 
 petrolatum oil in. 88, 126 
 treatment of, 87 
 Contraction, spastic, of cecum, 
 
 54, 58 
 Corsets, 93 
 Crisis. See Dietl's crisis. 
 
 Decubitus, physical examination 
 in nephroptosis in dorsal, 
 66, 67 
 in lateral, 66. 67 
 Defecation, physician's duty in 
 regulation of, 86 
 regulation of, 85, 126 
 Descending colon, 44 
 
 kidney, traction on duodenum 
 by, 46 
 Descensus, course of, 50 
 Diagnosis, 64, 70 
 
 correct, necessary. 64 
 differential, 76 
 
 of appendicitis, 77 
 
 of nephrocoloptosis, 76 
 
INDEX 
 
 247 
 
 Diagnosis — cont'd. 
 
 difficult in coloptosis without 
 
 nephroptosis, 65 
 displacement of cecum leads to 
 
 faulty, 54 
 errors in, of appendicitis, 97, 
 
 163, 189, 213 
 histories of cases valuable in, 64 
 importance of early, 11 
 of coloptosis by inflation, 69 
 
 by x-ray, 70 
 of nephrocoloptoisis, 64 
 physical, 65 
 
 teaching of imperfect, 64 
 value of histories of cases in, 64 
 
 of symptoms in, 64 
 x-ray in, 64, 70 
 Diarrhea caused by nephrocolo- 
 ptosis, 58 
 in nephrocoloptosis, 58 
 Diathesis, uric acid, in medical 
 
 treatment, 87 
 Dietl's crisis, 11, 59 
 cases of, 61, 151, 186 
 in nephrocoloptosis, 11. 59, 61. 
 
 151, 186 
 jaundice in, 60 
 
 preceding nephrocolopexy, 102 
 simulating peritonitis, 60, 189 
 treatment of, 91 
 tympanites in, 60 
 uncertainty of attacks of, 11 
 Dilatation of cecum, 59, 226, 228, 
 
 232 
 Displacement of colon, 27, 30, 44 
 of kidneys, 27, 30, 48 
 of kidneys affecting morbid 
 mentality, 58 
 Dissection to demonstrate nephro- 
 
 colic ligament, 32 
 Divisions of large intestine, 43 
 Duodenum, 45 
 
 angulation of, 27, 31, 51, 53 
 fixed position of, important in 
 
 pathology, 45 
 suspensory muscle of, 26, 31, 45 
 traction on, by descending kid- 
 ney, 46 
 
 Electric pad in topical treatment. 
 
 91 
 Eliminatives in medical treat- 
 ment, 87 
 Enema, uses of, 89 
 
 medical treatment in, 89 
 Enteroptosis, 7 
 Etiology, 48 
 
 nephrocolic ligament principal 
 factor in, 7, 50 
 
 Etiology — cont'd. 
 
 of nephroptosis, 48 
 Examination, physical, in nephro- 
 ptosis in dorsal decubitus, 
 66, 67 
 in lateral decubitus, 66, 67 
 technic of, of gastro-intestinal 
 tract by Rontgen ray, 72 
 Examinations, percentage of neph- 
 roptosis in gynecologic, 14 
 
 Facial expression in nephrocolo- 
 ptosis, 58 
 Fascia, perirenal. See Gerota'is 
 capsule, 
 transversalis, 107 
 Fat, intra-abdominal, to prevent 
 colonic ptosis, 87 
 to prevent nephrocoloptosis, 87 
 Fatty capsule forming nephrocolic 
 
 ligament, 25, 29 
 Fecal impaction in constipation. 
 
 56 
 Fibrous capsule, 25 
 Fixation, adaptability of nephro- 
 colic ligament to, 101 
 of colon of first importance in 
 operative treatment, 100 
 results of, 218 
 of kidney, effect of, on ureter, 
 126 
 results of, 126 
 Flexures of colon, 42 
 hepatic, 42 
 sigmoid, 42 
 splenic, 42 
 Floating kidney. See Nephropto- 
 sis. 
 Forceps-hook. Longyear's, 106 
 Function of colon, regulation of, 
 85, 126 
 
 Gastro-ixtestinal tract, technic of 
 examination of, by Rontgen 
 ray, 72 
 
 Gastroptosis, 8. 199, 204, 209, 231, 
 233, 234. 237 
 
 Gerota's capsule, 38, 92, 107 
 
 location of. important in neph- 
 rocolopexy, 107 
 
 Gynecologic examinations, p e r- 
 centage of nephroptosis in. 
 14 
 
 Heat in topical treatment, 91 
 Hepatic flexure of colon, 42 
 Hepatocolic ligament, 23, 24, 43, 
 51, 52 
 absence of, 43 
 
248 
 
 INDEX 
 
 Hepatoduodenal ligament, 27,31,52 
 Hepatoptosis, 8 
 
 Histories of cases valuable in 
 diagnosis, 64 
 
 Impaction, fecal, in constipation, 
 
 56 
 Incision, location of, in nephro- 
 
 colopexy, 107 
 Inflation, diagnosis of coloptosis 
 
 by, 69 
 Instruments used in nephrocolo- 
 
 pexy, 104 
 Intestinal antiseptics, 90 
 in medical treatment, 90 
 paresis, physostigmin sulphate 
 m, 62, 91 
 Intestine, large, 42 
 angulation of, 51, 54 
 description of, 42 
 divisions of, 43 
 Intra-abdominal fat to prevent 
 colonic ptosis, 87 
 
 Jaundice in Dietl's crisis, 60 
 caused by neplirocoloptosis, 54, 
 60, 61 
 
 Kidney, anomalous, 25 
 
 attaching, by nephrocolic liga- 
 ment to colon, 29, 30, 31 
 
 capsule of, 25, 29 
 
 displacement of, 27, 30, 48 
 
 affecting morbid mentality, 58 
 
 effect of fixation of, on ureter, 
 126 
 
 elevator, Longyear's, 103 
 used in nephrocolopexy, 103 
 
 floating. See Nephroptosis. 
 
 moi'bid mentality induced by 
 displaced, 58 
 
 palpation of, 66 
 
 posture in palpation of, 65 
 
 prolapse of, in childhood, 13, 86 
 
 ptosis of, 27, 30, 48 
 
 results of fixation of, 126 
 
 traction on duodenum by de- 
 scending, 46 
 Kidneys, 24 
 
 anatomic relations of, with 
 other organs and tissues, 22, 
 23, 24 
 
 Ligament, hepatocolic, 23, 24, 43, 
 51, 52 
 absence of, 43 
 hepatoduodenal, 27, 31 
 nephrocolic, 23, 24, 26, 27, 29, 
 31, 32 
 
 Ligament, nephrocolic — cont'd. 
 
 adaptability of, to fixation, 
 
 101 
 attaching kidney by, to colon, 
 
 29 30 31 
 description of, 29, 32 
 discovery of, 7, 9, 143 
 dissection to demonstrate, 32 
 fatty capsule forming, 25, 29 
 knowledge of, assists me- 
 chanical treatment, 92 
 principal factor in etiology of 
 
 nephroptosis, 7, 50 
 relation's of, 32 
 phrenocolic, 23, 24, 43, 51 
 always present, 51 
 utilization of Longyear's, by 
 Reed, 28 
 Ligaments of colon, 43 
 Longyear's abdominal supporter, 
 94 
 in mechanical treatment, 94 
 forceps-hook, 106 
 kidney elevator, 103 
 ligament, utilization of, by Reed, 
 
 28 
 operation of nephrocolopexy, 102 
 Lubricants rather than cathartics 
 in medical treatment, 88 
 
 McBukney's point, 76 
 
 of no value in locating appendix 
 in coloptosis, 182, 193, 199, 
 203 
 
 Malnutrition caused by nephro- 
 coloptosis, 54 
 
 Massage, abdominal, 86 
 
 Mechanical supports for ptosis, 92 
 
 Mechanical treatment. See Treat- 
 ment, mechanical. 
 
 Mechanical treatment, knowledge 
 of nephrocolic ligament as- 
 sists, 92 
 
 Medical treatment. See Treat- 
 ment, medical. 
 
 Mental disorders caused by neph- 
 rocoloptosis, 15, 55, 56 
 by ptosis, 15, 56 
 constipation in, 56 
 nephroptosis in, 15, 56 
 
 Mentality, morbid, induced by dis- 
 placed kidney, 58 
 
 Mucus in stool indication of co- 
 lonic catarrh, 55 
 
 Muscle, suspensory, of duodenum,' 
 
 26, 31, 45 
 
 Nepheocolic ligament, 23, 24, 26, 
 
 27, 29, 31, 32 
 
INDEX 
 
 249 
 
 Nephrocolic ligament — cont'd, 
 adaptability of, to fixation, 101 
 attaching kidney by, to colon, 
 
 29, 30, 31 
 description of, 29, 32 
 discovery of, 7, 9, 143 
 dissection to demonstrate, 32 
 fatty capsule forming, 25, 29 
 knowledge of, assists mechan- 
 ical treatment, 92 
 principal factor in etiology of 
 nephroptosis, 7, 50 
 
 relations of, 32 
 
 m, 
 
 Nephrocolopexy, anesthesia 
 103 
 after-treatment in, 122 
 constipation cured by, 10, 143, 
 
 190, 192, 201, 206 
 coloptosis symptoms relieved by, 
 
 143, 219 
 Dietl's crisis preceding, 102 
 in coloptosis without nephro- 
 ptosis, 10, 143, 190, 192, 201, 
 206 
 instruments used in, 104 
 kidney elevator used in, 103 
 location of Gerota's capsule im- 
 portant in, 107 
 of incision in, 107 
 Longyear's operation of, 102 
 operative treatment in, 102 
 pad and plaster support after, 
 
 122, 127 
 preparatory treatment in, 102 
 regulation of bowels after, 126 
 reports of cases of, 130 
 
 summary of, 214 
 vomiting after, 103, 122 
 Nephrocoloptosis, colic caused by, 
 55 
 colonic angulation in, 51, 54 
 catarrh in, 55 
 pain in, 54 
 constipation caused by, 55, 58 
 
 persistent in, 58 
 diagnosis of, 64 
 diarrhea caused by, 55, 58 
 differential diagnosis of, 76 
 facial expression in, 58 
 factors necessary to cause, 50 
 hereditary laxity of restraining 
 tissues primary cause of, 49 
 intra-abdominal fat to prevent, 
 
 87 
 jaundice caused by, 54, 60, 61 
 malnutrition caused by, 54 
 mental disorders caused by, 15, 
 
 55, 56 
 nervous symptoms of, 55, 56 
 
 Nephrocoloptosis — cont'd, 
 neurasthenia caused by, 55 
 organs involved in, 26, 27, 30, 31 
 prevalence of, 13 
 reason for the term, 7 
 symptomatology of, 53 
 tachycardia caused by, 55 
 toxemia caused by, 55 
 treatment of, 79 
 Nephroenteroptic, psychopathic, 
 
 symptomatology, 56 
 Nephropexy, failure of, in opera- 
 tive treatment, 99 
 Nephroptosis, body shape second- 
 ary cause of, 52 
 cause of coloptosis without, 52 
 
 of right side, 52 
 coloptosis causing, 7, 50 
 compression of ureter in, 126 
 diagnosis difficult in coloptosis 
 
 without, 65 
 Dietl's crisis in, 11, 59, 61, 151, 
 
 186 
 etiology of, 48 
 in children, 13, 86 
 in mental disorders, 15, 56 
 nephrocolic ligament principal 
 factor in etiology of, 7, 50 
 physical examination in, in dor- 
 sal decubitus, 66, 67 
 in lateral decubitus, 66, 67 
 percentage of, in gynecologic ex- 
 aminations, 14 
 result of coloptosis, 7, 50 
 torsion of pedicle in, 63 
 Nervous symptoms of nephrocolo- 
 ptosis, 55, 56 
 Neurasthenia, 55 
 
 caused by nephrocoloptosis, 55 
 Neuroses, toxemia a causative fac- 
 tor in psychoses and, 56 
 Nonoperative cases, reports of, 
 220 
 
 Oil, olive, in coloptosis, 90 
 in constipation, 90 
 petrolatum, in coloptosis, 88, 126 
 in constipation, 88, 126 
 Oils in medical treatment, 88, 90 
 Olive oil in coloptosis, 90 
 
 in constipation, 90 
 Operation, Longyear's, of nephro- 
 colopexy, 102 
 medical treatment preparatory 
 
 to. 102 
 vomiting after, 103, 122 
 Operative cases, reports of, 130 
 Operative treatment. See Treat- 
 ment, operative. 
 
J50 
 
 INDEX 
 
 Organs, replacement of, in me- 
 chanical treatment, 91 
 Orthopedic considerations in ab- 
 dominal ptosis, 82 
 treatment in alDdominal ptosis, 
 81, 82 
 in children, 81, 82 
 Orthopedics in prophylactic treat- 
 ment, 82 
 
 Pad. See Abdominal pad and ad- 
 hesive plaster. 
 Pad and adhesive plaster in me- 
 chanical treatment, 98 
 and plaster support after neph- 
 
 rocolopexy, 122, 127 
 electrical, in topical treatment, 
 91 
 Pain, colonic, in nephrocoloptosis, 
 54 
 in cecum simulating appendi- 
 citis, 54 
 Palpation of cecum, 54 
 of kidney, 66 
 posture in, of kidney, 65 
 Paresis, physostigmin sulphate in 
 
 intestinal, 62, 91 
 Pathology, 21 
 
 fixed position of duodenum im- 
 portant in, 45 
 Pedicle, torsion of, in nephro- 
 ptosis, 63 
 Perirenal fascia. See Gerota's cap- 
 sule. 
 Peritonitis, Dietl's crisis simu- 
 lating, 60, 189 
 Petrolatum oil in coloptosis, 88, 
 126 
 in constipation, 88, 126 
 Phrenocolic ligament, 23, 24, 43, 51 
 
 always present, 51 
 Physical examination in nephro- 
 ptosis in dorsal decubitus, 
 66, 67 
 in lateral decubitus, 66. 67 
 Physician, duty of, in prophy- 
 laxis, 86 
 Physostigmin sulphate in intes- 
 tinal paresis, 62, 91 
 in medical treatment, 91 
 Post-operative treatment, 122 
 
 Weir-Mitchell. 9 
 Posture, faulty, a factor in ptosis, 
 82 
 in adjusting abdominal sup- 
 porter, 96 
 in palpation of kidney, 65 
 Preparatory treatment in nephro- 
 colopexy, 102 
 
 Prevalence of nephrocoloptosis, 13 
 Prolapse of kidney in childhood, 
 
 13, 86 
 Prophylactic treatment, 80 
 breathing exercises in, 81 
 duty of physician in, 86 
 importance of, in children, 81, 
 82 
 Psychopathic nephroenteroptic 
 
 symptomatology, 56 
 Psychoses, toxemia a causative fac- 
 tor in, and neuroses, 56 
 Ptosis, constipation cause of, 51, 
 86 
 faulty posture a factor in, 82 
 intra-abdominal fat to prevent 
 
 colonic, 87 
 mechanical supports for, 92 
 mental disorders caused by, 15, 
 
 56 
 of colon, 27, 30, 34 
 of kidney, 27, 30, 48 
 orthopedic , treatment in ab- 
 dominal, 81, 82 
 
 Radiographs, directions for pre- 
 paring patients for, 71, 74 
 of cases, 151-241 
 Replacement of organs in me- 
 chanical treatment, 91 
 Reports of cases. See Cases. 
 Rontgen ray, apparatus necessary 
 for, 73 
 powerful modern, equipment 
 
 necessary, 75 
 subcarbonate of bismuth in, 73 
 subnitrate of bismuth in, 73 
 technic of examination of gas- 
 
 tro-intestinal tract by, 72 
 zirconium oxide in, 74 
 
 Sigmoid flexure of colon, 42 
 
 Spastic contraction of cecum, 54, 
 58 
 
 Splanchnoptosis, 7 
 
 Splenic flexure of colon, 42 
 
 Stasis of contents of colon, 85 
 toxemia caused by colonic, 55, 
 194 
 
 Stomach, 46 
 
 Stool, mucus in, indication of 
 catarrh of colon, 55 
 
 Stupe, camphor, in topical treat- 
 ment, 91 
 
 Subcarbonate of bismuth in 
 Rontgen ray, 73 
 
 Subnitrate of bismuth in 
 Rontgen ray, 73 
 
 Summary of reports of cases, 214 
 
IXDEX 
 
 251 
 
 Support, pad and plaster, after 
 
 nephrocolopexy, 122, 127 
 Supporter, abdominal. See Ab- 
 dominal supporter. 
 Supports, mechanical, for ptosis, 
 
 92 
 Suspensory muscle of duodenum, 
 
 26, 31, 45 
 Symptomatology, 53 
 of nephrocoloptosis, 53 
 psychopatbic nephroenteroptic, 
 56 
 Symptoms, coloptosis, relieved by 
 nephrocolopexy, 143, 219 
 nervous, of nephrocoloptosis, 55, 
 
 56 
 value of, in diagnosis, 64 
 
 Tachycardia caused by nephro- 
 coloptosis, 55 
 Topical treatment. See Treat- 
 
 ment, topica!. 
 Torsion of pedicle in nephro- 
 ptosis, 63 
 Toxemia a causative factor in 
 psychoses and neuroses, 56 
 caused by colonic stasis, 55, 194 
 by nephrocoloptosis, 55 
 Transversalis fascia, 107 
 Transverse colon, 44 
 Treatment, 79 
 
 breathing exercises in prophy- 
 lactic, 81 
 duty of physician in prophy- 
 lactic, 86 
 importance of prophylactic, in 
 
 children, 81, 82 
 knowledge of nephrocolic liga- 
 ment assists mechanical, 92 
 of catarrh of colon, 87 
 of constipation, 87 
 of Dietl's crisis, 91 
 of nephrocoloptosis, 79 
 mechanical, 91 
 appliances in, 92 
 elastic abdominal supporter 
 
 in, 94 
 Longyear's abdominal sup- 
 porter in, 94 
 orthopedic, 81, 82 
 pad and adhesive plaster in, 
 
 98 
 replacement of organs, 91 
 medical, 87 
 bran in, 90 
 cathartics in, 87 
 
 Treatment, medical — cont'd. 
 
 eliminatives in, 87 
 
 in enema, 89 
 
 intestinal antiseptics in, 90 
 
 lubricants rather than cathar- 
 tics in, 88 
 
 oils in, 88, 90 
 
 physostigmin sulphate in, 91 
 
 preparatory to operation, 102 
 
 uric acid diathesis in, 87 
 operative, 99 
 
 failure of nephropexy in, 99 
 
 fixation of colon of first im- 
 portance in, 100 
 
 in nephrocolopexy, 102 
 orthopedic, in abdominal ptosis, 
 81, 82 
 
 in children, 81, 82 
 post-operative, 122 
 
 Weir-Mitchell, 9 
 preparatory, in nephrocolopexy, 
 
 102 
 prophylactic, 80 
 
 duty of physician in, 86 
 
 in children, 81, 82 
 
 normal colonic function im- 
 portant in, 85 
 
 orthopedics in, 82 
 topical, 91 
 
 camphor stupe in, 91 
 
 electric pad in, 91 
 
 heat in, 91 
 
 hot water bag in, 91 
 
 working basis for, 8 
 Tympanites in Dietl's crisis, 60 
 
 Uric acid diathesis in medical 
 treatment, 87 
 
 Ureter, compression of, in nephro- 
 ptosis, 126 
 effect of fixation of kidneys on. 
 126 
 
 Vomiting after nephrocolopexy, 
 103, 122 
 
 Water bag, hot, in topical treat- 
 ment, 91 
 
 Weir-Mitchell post-operative treat- 
 ment, 9 
 
 X-RAY in diagnosis, 64, 70 
 
 diagnosis of coloptosis by, 70 
 
 ZiRCOjSfii'M oxide in Rontgen ray, 
 74 
 

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