You can readily see how futile the anchoring would be and leave one or more of these complications.

Many times in well selected cases, as we hope to show later, the operation is not a success, because individual conditions have not been thought out.

The Cause of Floating Kidney.-Longyear describes a cord-like band passing down from the lower pole of the kidney and separating the organ from the bowel, this structure is formed by the covering of the longitudinal fibre of the fibrous network which forms the framework of the fatty capsule, this band is attached to the posterior surface of the ascending colon behind the peritoneal reflection extending to the junction of the ilium-this writer claims that this nephrocolic attachment is the most important feature in the etiology of movable kidney.

The full cecum in its efforts to force the contents upward makes traction downward on the kidney because of this attachment. Hutchinson attributes frequency of movable kidney on the right side to the differ

ent anatomical relation between colon and kidney of the two sides. The splenic flexure lies on the top of the kidney, the descending colon beside it and both are firmly anchored by the peritoneum, the mesocolon and branches of the inferior mesenteric cross the kidney and keep it in position, while on the right side, the cecum lies just below the kidney, and at first the ascending colon runs to the inner side, later the colon is more in front of the kidney.

The hepatic flexure never anchors it in the way the splenic flexure does. On the front of the left kidney, especially fixed in its lower half is the fascia of Toldt, which is supposed to be formed from the fusion of two layers of perioneum originally belong ing to the descending colon, but on the right side there is no corresponding fascia.

In adult life additional causes account for floating kidney, such as repeated pregnancies, abdominal strain and rapid absorption of perirenal fat. The failure of the many operations so far devised is because of the great probability of the kidney again freeing itself from the restraints imposed upon its movements due to (1) the fact that the sutures usually applied tend to cut themselves out, because the whole weight of the kidney is brought to bear on them at a most favorable angle, and the sutures themselves are acting upon and tending to cut through tissues on the renal side which are possessed of little resistive power.

(2) The previous excursions of the kid

ney have hollowed out below it a cavity in the post-peritoneal connective tissue always ready to receive it should it again come loose, for by no operation ordinarily practiced is any attempt made to close this.

Treves, weighty opinion for the fixing of the kidney, is that it is not necessary in the great majority of cases, unless torsion symptoms have appeared, and then operation should be performed as soon as possible. He states, the underlying neurasthenia so common in movable kidney is best treated by the rest cure, as it often removes all the renal symptoms. He highly recommends a truss devised by himself, in which he claims in 95 per cent of his cases it proved absolutely efficient.

There are two classes of cases in which the question of operation is doubtful:

1. Movable kidney associated with a greater or less degree of enteroptosis, for where this is marked the fixation of the kidney is not likely to produce much if any benefit unless it is accompanied or followed by some attempt to raise the other organs which have also dropped, and that means important operations, the extent of which is no means certain, hence in cases it seems the most prudent course to pursue to ascertain what amount of benefit can be obtained by properly constructed and wellfitting corsets or pads before considering the question of operation.

2. The other class of cases is where the condition is accompanied by marked neurasthenia, and the general experience is, that in these cases not only may no benefit result, but the state of the patient may be made markedly and miserably worse.

In closing, my admonition is (except in torsion) look for other causes for your neurasthenia, than mere wandering kidney, for if you do not you not only do yourself an injury, but you will also injure the cause of

surgery.

DISCUSSION.

DR. GEORGE A. BOYLE: Although Dr. Becton mentioned this operation for movable kidney with appendectomy and oophorectomy as being such a simple one, I have done less of these operations than the other two. I am not as skilled along that line quite a number of cases, and among them two of toras some of the men I know, although I have had sion of the kidney. I anchored the kidney a number of years ago in such cases, and the result seemed to be perfect, yet in a number of cases the results relieved for the time being. It relieved the cause of have not been good, and the patients have only been

the trouble above the ears. I know the operation brings a man a good fee, and it is one in which the mortality is very slight under modern asepsis and cleanliness, and I believe it is an operation, considering the possibility of results, that will be continued. One reason is this: that so many of us, as Dr. Becton has mentioned, come out of college with

a high surgical temperature, and as it is one of the conditions that is so commonly met with, the younger practitioners will continue to do this work as well as the older ones.

I want to relate a case briefly to show how easily one may be deceived in regard to movable kidney. The case occurred two or three years ago. I was called to see an old lady, a Methodist minister's wife, passed 76. She was a walking skeleton, and the physician who called me in to see the case said he simply wanted me to see her. "I am not going to tell you what is the matter until you examine her," he said. I found what I thought was a freely movable kidney. It was of the right size and consistency, and I so told the doctor and the patient, and said that if she were twenty or thirty years younger I would not hesitate to anchor it; but on account of her age, and as it was not giving her much trouble we would let it alone. Two years after that they moved up to North Enid, and the old woman died. The undertaker and doctor asked me to accompany them and make a post-mortem examination. This we did and found an elongated gallbladder, but not a movable kidney. I did not have that tactus eruditus that we read about so frequently. This one case of what was thought to be a movable kidney proved to be an elongated gall-bladder at the post-mortem table. There was no trouble in locating it. I want to confess that we do not always know whether we have a movable kidney to deal with or not.

I

DR. W. B. DORSETT: I think Dr. Becton is right in some of the assertions he has made, and I think he is radically wrong in others. In the first place, the question arises in one's mind as to whether the etiological factors in a given case of neurasthenia are not due to a wandering kidney or ptosis of some other organ, or whether vice versa. know in my own experience I learned two lessons in two women who came to me, and whose cases I wanted to treat conservatively by using pads and bandages and trusses, but to no advantage whatever. They suffered from considerable discomfort. I refused operation. One of them, who had a great deal of pain, had a tumor which increased in size to a considerable extent. In this case Dr. Bransford Lewis had attempted to catheterize the ureter on one side and met with an obstruction and could not do it. I had to operate, and it was one of those tragical cases. When I got into the capsule and enucleated the kidney and brought it up, it was broken or had bursted, the urine flowing all over us, and we had simply an empty sac. I made an attempt to get the renal artery The condition present was possibly due to edema by which the renal artery was broken through and through. Imade two or three attempts to secure it, but finally put on three forceps and left them on. I did not try to put on a ligature because the distance between the kidney and aorta is very short. I left those forceps on. I did not sleep well the next night. When I went to the hospital at about 11 o'clock that night, the patient claimed that something had given away on that side. I afterwards found it was one of the forceps that was broken, but the other two happened to hold. But the patient lost much blood during the operation.

Another case was along the same line in which I refused to operate, and after some three months she became pregnant with this wandering kidney. She had a case of hydronephrosis and I had to remove the kidney. That case taught me a lesson, that some of these cases of wandering kidney should be anchored. The technic of abdominal surgery has not reached that degree of perfection where the ordinary surgeon in ordinary practice, that is, considering surgeons over the whole country, unless practicing in hospitals or at the centers of education,

and who are men of eminence, can anchor the transverse colon or a wandering spleen or a wandering kidney, but as Dr. Becton has said, and I am willing to agree with him, that the operation of anchoring a floating or wandering kidney is comparatively easy. There may be other conditions which need attention besides the movable kidney, and I would not condemn anchoring a kidney in toto. It is a good operation as far as it goes, but there are other things that can be done and are often done in connection with anchoring of the kidney.

Only about four months ago I had a patient come to me in whose case I made a diagnosis of wandering kidney. She was a fat individual. I did not take the precaution to catheterize the ureters to find out whether they were patent or not. I opened the abdomen with the intention of anchoring the kidney, and when I got there I found it was the spleen down in the pelvis. But we have these cases of ptosis of various organs, ptosis of the uterus, ovaries, etc., and these cases ought to be operated on if they have a wandering kidney. You have a wandering kidney in connection perhaps with a wandering ovary. The doctor takes the stand that all these ovaries are taken out. In this I cannot agree with him.

DR. BECTON: No, I did not say that, but that the practitioner goes in, anchors the kidney, and often removes a prolapsed ovary, that in reality should be anchored.

DR. DORSETT: That is not done by good gynecologists today. You anchor the ovary as well as the kidney.

DR. A. L. BLESH: When we consider that the kidney, after forming but one and the least offensive link in a chain of pathological sequences, has been anchored thousands of times unnecessarily just as the ovary was formerly assailed under the impetus imparted by the Battey normal oophorectomy, it has become high time for just such a paper as this. Fortunately it is generally, so far as life is concerned, a safe operation even in the hands of the budding surgical tryo. Floating kidney has unjustly borne the blame as the causative factor of neurasthenia and as such has for some time borne the brunt of surgical attack to relieve this protean manifestation. Gentlemen, personally I do not believe that any surgical operation will, per se, cure neurasthenia. In other words neurasthenia is not necessarily or essentially a surgical disease, if indeed it can truly be called a disease at all. The first therapeutic desideratum for the neurasthenic patient is rest. If not a too severe surgical operation provides for the patient this rest, then incidentally it may become a factor in the cure-if it does this without in turn at the same time adding another burden to that already carried. It must never be forgotten that energy is also consumed in recovering from a surgical operation. According to the latest researches of the internists neurasthenia is a distinctive functional entity which very rarely indeed rests upon any part of a surgical basis. In so far only as a surgical condition contributes to the causation should surgery be considered-the neurasthenic should have surgery just as the victim of insanity, of epilepsy should have it-i.e. when they have a surgical lesion and then it should be applied for the relief of that particular surgical lesion and not because the patient is insane or an epileptic or a neurasthenic. For instance if a floating kidney in a neurasthenic or a normal individual, by axial rotation causes torsion on the ureter and this excites the kidney colic, the Dittl's crisis, it should be fixed and it should be fixed right. Every experienced operator will agree with me in this statement too that because it can always be so easily done, it is many times the opera

tion of election by the inexperienced. A floating kidney that by kinking of the ureter has given rise to crises only occasionally, will if fixed in rotation become the source of permanent kidney block and thus lead to permanent structural damage. I think even the essayist will herein agree with me. Faulty anchorage may therefore lead to an intensification and a perpetuation of the symptomatology and pathology. It is well that we balance carefully in our minds when we find a floating kidney, whether or not that particular kidney is or is not suited for anchorage, that is whether it plays a sufficient part in the chain of sequences to warrant anchoring and if so to see to it that the operation is properly done.

More often upon careful enquiry we will find that it is a co-sufferer with the colon in an embryological rotation and fusion failure on the part of the colon -the cecum mobile. Here if the kidney alone is fixed it will be but a question of time until the free ascending colon and cecum will again drag it down -hence the all too many recurrences which plague the incautious operator. Anchoring of such kidneys may go on until the crack of doom and the unfortunate patients will be the same-perhaps worse neurasthenics than they were before operation and surgery will justly come into disrepute.

Again we may be dealing with a splanchnoptosis involving the entire abdominal viscera-a condition not amenable to surgery at all much less to patch work surgery. Here nature in the very fact of her having loosened all attachments-by the very completeness of the fall-has done all she can and more than we can do to ameliorate suffering. Here all the natural points of anchorage have let go, the

stomach, liver, spleen, transverse colon with its two lateral points of fixation, kidneys, uterus, ovaries, all have fallen-what can you do surgically? In order to relieve kinking just bear in mind that nature has loosened all the supports. These things must be borne in mind if we would do our duty to our patients.

All that these patients now suffer from is due to ligamentous tug.

Again, the congenital factor must be considered. It is interesting to note that in the acquired types of long standing Nature has imitated the physical conformation recognized as congenital, hence it must be conservative in character. Let us not be so keen to do surgery that we submit these patients to a useless operation, thus often making their condition worse and bringing our art into deserved disrepute.

DR. BECTON (closing): I do not think any one has materially disagreed with me. The point I want to bring out is this: a slight discomfort is no indication for anchoring a kidney. When you anchor simply a floating kidney and do nothing else, if you do not look beyond that for the cause of the neurasthenia, you will disappoint the patient. These people come to us for operation, they risk their lives on the operating table, and expect a result. If they do not get that result, then you get them in worse shape than you found them in the first place I recall a woman who said she had to have her kidney anchored. Night and day she thought of it. The kidney was lower than it should be. I operated and anchored her kidney to relieve her mind, and she has been happy ever since.

use are sterile:

Censor, C. B. Francisco, M. D. Secretary, Paul V. Woolley, M.D.

ISTORY.-Case came to my office this p.m., and I have had no time to work up the clinical picture as desired, but knowing the practice of this society, I have asked her to come here and let us discuss her case.

This lady is 34 years of age. Seventeen years ago I delivered her, performing version. She has had six children; three are living. Three were born at eight months. The first child was interfered with, she thought, by a shock of lightning. She now has a child six years old, but had symptoms at eight months similar to former miscarriage, but this child went to full term. Patient has worked hard the past three years. During that time has had several falling (?) spells. First, six years ago at the death of her husband. Second, was one year ago. Last December another, one in March, and one on the 1st of July. On the 1st of July her illness put her to bed for fourteen weeks. Discharged pus four times from the bowel. (I have never seen any of these discharges). I saw her after she was in the hospital for some time, when she was running a septic temperature; had some pain over the abdomen, principally in the left hypochondrium. Patient was operated on four weeks ago. Found no evidence of pus cavities, but we did find adhesions of the descending colon, and adhesions posterior to the uterus, and cystic degeneration of the left ovary and tube. I have not brought this patient here for consideration of this. She has made an excellent recovery, gaining flesh rapidly. Before operation she had a rapid pulse, and this is the condition for which I bring her here. Her pulse at times has been 160, and is always very rapid. I put her on treatment for two or three weeks, and she improved materially so far as rapidity and volume of the pulse are concerned. It seems to me the skin and complexion shows a somewhat hyperemic condition, and mild cyanosis, perhaps due to the condition of the circulation. We have examined her several times and have not fully determined the condition. I bring her here to have some

of these eminent physicians examine her, and learn what they have to say. She has a slight goitre; that may have something to do with her condition.

DISCUSSION.

DR. FROEHLING: This is a plain case of exophthalmic goitre. The exophthalmus is not predominant, but it is there. She has a goitre. The pulse is 160 at present, the heart is enlarged. There is a decided systolic murmur at the apex. This to me seems to be only functional, as far as murmurs are concerned, and not organic. The heart is enlarged, and probably the heart muscles are dilated, and not hypertrophied. The woman is still in a weak condition. Should this heart enlargement continue, this lady will soon be in a bad shape. The rest in bed after operation has done her good, and the good feeding inaugurated in the treatment by Dr. Crowell has also done much good. This woman should be put in bed until this heart returns to normal size. Surgical extirpation of that goitre might be considered. I do not believe in operating every case of exopthalmic goitre, but I would give first internal treatment, and then if that does not work, resort to surgery. To my mind, this is a plain case of exophthalmic goitre.

DR. ZWART: Dr. Froehling has put it well and clearly. The clear and distinct heart sounds that are accompanied by murmurs, the low blood tension, and the difficulty to feel the pulse at the wrist seems to be positive diagnostic conditions. It is difficult in goitre to count the pulse; I do not know why. With the heart sounds clear, you will find it hard, and so it is with her. I feel something must be done with this woman quickly, and I think it is one of these cases of goitre which will derive much benefit from small doses of a good preparation of digitalis. I do not mean to give it in doses equivalent to 5 to 10 drops of the tincture, but doses equivalent to 2 to 3 drops of the tincture continued over some time. would be unwise to give large doses. Nervous symptoms here are not marked, but there is that stare one gets when you first call her attention, which is one of the first things noted in exophthalmic goitre. I think there is no question but what this is purely a case of exophthalmic goitre.

It

DR. SOPHIAN: I agree with the gentlemen who have discussed this case. From a standpoint of differential diagnosis, we first wish to know whether the rapidity is due to organic heart trouble. Examination rules this out. There is no dyspnea or any. thing to make us think of that. A pulse of 160 without dyspnea is uncommon, and that rules out the heart trouble. You must think of functional neuroses, and first, hysteria. This is not hysteria. Then it comes down to the two conditions which cause tachycardia, and these are paroxysmal, or a Graves's disease. Everything points to Graves's disease. She

has a goitre, exophthalmus, velvety skin, and the whole picture here is that of exophthalmic goitre. Now, in regard to treatment: I have seen many of these cases in the hospitals, and first comes rest. And then, I have noticed these cases respond best to gland extracts, thyro-globulin, thyroid gland extract, etc. In my own family I treated a case with thyro-globulin with good results. This was a matter of interest to me, and may be worth something here.

DR. ROBINSON: This condition is of interest, because it simulates neurasthenia. The nervous conditions are those of the irritable weakness of the nervous system. These patients are irritably mentally and physically. They often have exaggerated reflexes, fatigue, and irritability. I have seen a number of these cases with enlargement not extensive, without exophthalmus being marked, being diagnosed as neurasthenia. The treatment giving improvement, or definite results, is the hydrobromate of quinin. The important thing above all of course, is rest in bed. The hydrobromate is given in five grain doses every three hours with ergotin.

DR. S. GROVER BURNETT: I have long lost my patience (in more ways than one) in trying to medicinally treat Graves's disease. We had just as well recognize from the first that the primary cause of Graves's disease is in the central nervous system and not in thyroid gland as we have tried to make ourselves believe in the past. The common exciting cause is shock, powerful depressing emotions or prolonged mental or nervous strain. In health the nervous tissue depends on a thyroid secretion for physiologic nourishment and the performance of natural functions. Under the influence of the damaged cell chemistry and resulting damaged function caused by shock or its mischief making equivalent, great demand is made on the thyroid gland by the nerve cells. In unstable persons with non-resisting tissues the thyroid secretory inhibition gives way to gland hyperactivity. So with the impetus given to the thyroid activity by the demand of the overtaxed nerve cells and the inability of the gland to hold hypersecretion in abeyance, it goes on enlarging and deluging the system with its secretion till it causes the usual symptoms due to systemic poisoning: while the symptom picture is one of poisoning by the hypergland secretion, the gland is primarily whipped

into activity by the primary disturbance in the nerve

centers.

For this reason we instinctively treat our patients by putting them to bed for the sole purpose of resting the nerve centers, lessening their activity, thereby hoping to lessen the demand for greater thyroid activity without knowing fundamentally the indications for the treatment; but when the thyroid gland assumes a hyperactivity in certain unstable individuals it seems to lose self control, takes on an intraglandular pathology and continues a pernicious cycle from the activity of the stimulating demands of repair to a functional destruction from self poisoning. It is rare that medicinal treatment does much good. Of late years I early advise surgery. By getting rid of the secondary gland hyperactivity the systemic poisoning stops and the disagreeable symptoms disappear. This accomplished, the primary central nervous disturbance is easily cared for and the patient's future is worth while.

DR. CROWELL, (closing): I am very much obliged to the gentlemen for examining the case, and for the lucid discussion. I did not bring her here because it was so intricate, and indefinite and unprecedented, but to show the interest of the case. I think it is interesting, and I think with further consideration it might be discussed profitably, and further in regard to certain manifestations in the case, and some deductions made as to the exact condition. In regard to this woman being irritable, she is one of the most amiable and lovable characters I have ever met. Not irritable, but is happy and genial. She was in bed fourteen weeks prior to the operation, with the idea she had a septic condition and for the great portion of this time her diet had been restricted to such a degree the woman was starving. Upon forced feeding, milk, eggs, etc., in addition to her regular diet, she made improvement rapidly. The pulse irregular and rapid, and some temperature, localized tenderness, all improved. Following the operation she has continued to improve, until in the last few days, today for the first time, she has reported she has swelling of the feet. I believe there is in this case an organic condition besides the effect of the thyroid gland upon the rapidity of the pulse. I think we have here an organic condition. I put her on digitalis and she seemed to improve, and now I have been contemplating thyroid extract, or thyro-globulin.

P

ATIENT, age 40, male. Had all diseases of childhood. Father died at 42 of pulmonary tuberculosis. Moth

er died of sarcoma of uterus; no brothers or sisters. Had sciatic rheumatism at 12 years of age. Has had gonorrhea with arthritis following. Had sore tongue seven years ago and was examined by Dr. Murphy, who made a diagnosis of syphilis. Never had a sore except on the tongue. In December, 1909, pains started between 6th and 8th dorsal vertebrae. Three months before I saw him he was examined by Dr. Hall who assured him he had no syphilis. In May, 1910, I saw him again and he was completely paralyzed from the hips down, and had retention of

urine and feces. Had complete paralysis, both of sensation and motion. Mentally clear. Was sent to a hospital for a skiagraph of back and lungs. Lungs showed numerous deposits both in apex, and in different lobes. The bodies of the vertebrae at that time showed, according to the X-ray, more or less thickening, and some breaking down. For three weeks was completely paralyzed, leaving the hospital in a wheel chair. Under three months specific treatment he got better, went to Silver City, N. M., and took treatment for tuberculosis and gained in weight after five months, but still had pain in back. turning to me I saw him again with symptoms of locomotor ataxia, except Argyle

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