—The symptoms vary from vague discomfort to agonizing pain. Ordinarily they include dragging sensation in the abdomen, with indefinable discomfort, a feeling of weakness, sometimes radiating down the legs and across the back, these symptoms frequently accompanied by dyspnea, flatulence, constipation, and frequency of urination, all of which may be intensified by increased activity. In the more severe forms we find abdominal tenderness, severe pain and vomiting, with collapse and the occurrence of peculiar crises, sometimes of intense agony, which may occur gradually or suddenly, ceasing in the same fashion. Not one of these symptoms is pathognomonic of movable kidney, nor can they be with certainty attributed to it until the suspicion is confirmed by physical examination. The severe crises are described as coming on with intense pain, nausea, vomiting, collapse, chills, and sometimes considerable temperature, especially in hysterical subjects. Osler and Atlee think that too much stress has been laid upon the condition, especially after the patient’s realization of it, the severer symptoms often dating from the first knowledge of the facts. Obviously, temporary hydronephrosis may be caused by temporary obstruction in the ureter, from displacement, while temporary venous obstruction may cause pain in a different way. Actual alimentary disturbances are very closely simulated, and sometimes it is difficult to distinguish between a movable kidney on the right side and a chronic appendicitis.
A great deal of attention has of late been given to nephroptosis and to the effects of enteroptosis, and their production. The peculiar crises were long ago described by Dittel, and include sometimes a feeling of suffocation, with a desire to loosen and remove clothing, when, after lying down, the kidney resumes its position. When after urination relief quickly follows, there is much to suggest kinking of the ureter and distention of the renal pelvis. Much less frequent features are jaundice, from contraction of adjacent viscera, and persistent nausea from the same result, or hematuria from a disturbed circulation. The more marked forms in women are usually accompanied by certain neurotic features, which give them a feature to which they are not properly entitled, while the entire digestive process and the vasomotor innervation of the viscera seem more or less disturbed, with consequent toxemia.
The actual indication of floating kidney is its discovery by palpation, the degree of displacement being in some cases quite noticeable; thus it may cross the middle line, or may be felt even in the pelvis. In the female the kidney should lie above the twelfth rib, posteriorly, and above the costochondral border of the eighth rib anteriorly, and, therefore, not be easily palpated during respiration. This statement is somewhat at variance with some of those contained in the text-books on anatomy, the diagrams being all made from male cadavers. It is of importance not merely in locating the organs, but in fastening them in place, as all methods thus far devised leave much to be desired in complete replacement. A kidney prolapsed only to the waist-line can scarcely be sutured to the loin without displacing it even farther backward. On the other hand, the kidney which lies near the brim of the pelvis rarely causes acute symptoms, because, supported from below, it enjoys accommodation of its ureter to its abnormal relations, so that hydronephrosis rarely occurs. The truth is that in most aggravated cases of nephroptosis nearly all the viscera have been displaced downward, and Ingall’s suggestion to fasten in place at one and the same time the kidney, the liver, the spleen, the stomach, and the transverse colon is well founded, although difficult to carry into effect.
Treatment.
—Fixation of an abnormally mobile kidney is indicated in every case where its displacement causes unpleasant symptoms, yet simple as it is in theory it is neither easy nor always successful in practice. To completely restore the kidney to place is to fasten it higher than the natural routes easily permit, and requires either resection of a rib or fixation of the kidney to one of the lower ribs, a method which has been recommended and practised by some operators. Because of the disappointment so often resulting from these operations conservative practitioners have felt that by pressure from below, as by an abdominal binder with a suitably placed pad, the kidney could be so pushed upward and held as to be made comfortable. This may at least be tried in the milder cases. The supports should never be put in place until the patient is on her back and completely undressed. This method of external support failing or proving unsatisfactory, the surgeon may choose from many different methods the peculiar plan for nephropexy or kidney fixation which he will adopt.
Fig. 636
Nephropexy. Method by sutures passed through both kidney and capsule. (Hartmann.)
Nephropexy.
—These methods all have in common the intent to produce adhesions between the kidney and its normal environment, by which it shall be held in or near its proper place and prevented from dropping. The kidney more than any other organ is held in a cushion of fat, and it becomes a question to what extent this mass of surrounding fat shall be removed. To take it all away considerably complicates the procedure; to leave it is to not furnish the firmest possible surroundings for the purpose. The patient should be placed either flat upon the abdomen or turned well over on the side opposite that to be operated, a cushion or bolster being usually placed beneath the abdomen and loin in such a way as to push upward and into prominence the side to be attacked. The incision employed may be parallel to the spine, about three inches away from it, and carried down to the tissues outside the quadratus lumborum and other spinal muscles. Most operators prefer an oblique incision, made between the lower rib and the upper margin of the pelvis, its centre about four inches from the spine, extending in either direction two inches or more, in order to afford sufficient access. It is carried down until the abdominal aponeurosis and muscles are exposed. These are then divided and the perirenal fat, which is sometimes excessive in amount, is exposed. The deep opening should now be stretched to a size to permit the introduction of a hand, and exploration made for the identification and retraction of the kidney. Much aid may be afforded in this effort by the use of the other hand upon the outside of the patient’s abdomen, which should all have been protected and sterilized to permit such free manipulation. Sometimes it is easy to find such a kidney, at other times and in persons of certain build it is a difficult matter. It lies behind the peritoneum, and this should never be opened during the effort. More or less of the perirenal fat may be cleared away. The more or less elusive kidney being identified, it should be seized with tenaculum forceps, which should secure only its capsule and not injure its substance. With these it is drawn up at least to the wound, or in some methods, it is withdrawn through it and delivered upon the surface of the body. If sutures alone are to be depended upon they may be placed after any one of a number of different methods. The older method was to place the kidney as nearly as possible in its normal relations and then unite the deep margins of the wound to the capsule, and perhaps the cortex of the kidney, by a series of two or three sutures on either side, either of chromic gut or of silk. The theoretical objections which prevail against passing sutures through the renal cortex are hardly well founded, and stitches may be so placed, if desired, but they should not be drawn too tightly ([Fig. 636]).