Dr. L. Sexton, of New Orleans, La.: There is one suggestion that occurred to me in connection with this paper. Is it not possible the ensheathing callus had something to do with causing paralysis? The reason this suggests itself is that after a year the paralysis began to subside. Of course, massage was applied, and may have had something to de in causing the disappearance of the paralysis, but the ensheathing callus is usually absorbed within a year or a year and a half. This nerve might have been injured by a sharp transverse fracture and the paralysis produced in that way, or it might have been due to the traumatism alluded to.

Dr. Butler (closing): I do not know that I wish to discuss my paper any further. The paralysis in the case was the point I wished to bring out, and if the patient had not been an intelligent and honest man, I should have had more trouble than I did. He was a large, plethoric man, and subject to nervous troubles in general, hence I gave a guarded prognosis in the beginning. It was fortunate that he was an intelligent man and looked up these things himself. In the case that I reported in the Journal of the American Medical Association, it was a good while before normal function and use of the arm were brought about. I was very particular in this case, as I had some two or three cases of slight paralysis before, after fracture of the arm, also of the femur, in applying loose dressing. If I had applied a constricted dressing in this case, not only the man, but others interested, might possibly have said that the paralysis was due to too tight or constricted dressings from the start.

While I have had some little experience with the different kinds of splints, the best results I have had in cases of fractures of arms and legs have been where I made the splints myself, using splint-board material or anything I could get at hand.

NEW RAILWAY HOSPITAL. The new hospital for the Cotton Belt System at Texarkana, Ark., is now in operation. The surgeons, nurses, servants and 35 patients arrived by a special hospital train, November 22, and were at once installed in their new quarters.

THE INFLUENCE OF TRAUMA IN THE PRODUCTION OF MOVABLE KIDNEY.*

BY M. L. HARRIS, M. D., OF CHICAGO.

The influence of trauma in the production of movable kidney is a subject of special importance to the railway surgeon who is so frequently called on to decide whether or not a movable kidney in a given case is the result of a certain injury or accident. It is a common belief of the profession, as well as of the laity, that a movable kidney is frequently the result of an injury. Most writers on the subject assign to trauma an important place among the etiologic factors, but few of them indeed offer any evidence, such as the report in detail of cases, or of reasoning based on pathologic conditions found, in support of their statements. It is evident, therefore, that the statement has been passed on from one author to another without the subject receiving the careful attention which it deserves.

Before entering in detail into this phase of the question, it will be necessary to consider the etiology in general of movable kidney. It was early observed that the large majority of cases occurred in women, and as movable kidneys were first discovered in women with lax abdominal walls, the result of repeated childbirth, it was at once concluded that repeated pregnancies were the cause of movable kidneys. More extensive observations, however, gradually disclosed the fact that movable kidneys are much more common than at first supposed; that they frequently occur in the un

married and in those who have never borne children, and, furthermore, that the right kidney is affected much more frequently than the left. Notwithstanding these facts, repeated pregnancies is still given as the most important cause of movable kidney by almost all authors. Of 126 women examined in order, it was found that those in whom the kidneys were not palpable or abnormally movable-fifty-five in number-the average number of children born per woman was slightly greater than in those in whom movable kidneys were found-some seventy-one in number. Of 107

*Read at the tenth annual meeting American Academy of Railway Surgeons, Chicago, October 1, 2, 1903.

cases of movable kidney in women, from the author's records, forty were single and sixtyfive married, two not stated. Of the sixty-five married women twelve had never borne children; in other words, of 105 women with movable kidneys fifty-two had never been pregnant and fifty-three had borne one or more children. These facts show conclusively that pregnancy in itself is not a material factor in the production of movable kidney. That retrodisplacements and prolapse of the uterus and vagina with lacerations of the perineum are material factors in the production of movable kidney, as stated by some, is likewise disproved by the above facts.

Another commonly stated cause of movable kidney is rapid absorption of the perirenal fat, but there are no facts in support of this statement. On the contrary, clinical experience, as well as observations at the operating table and in the dead-house, are opposed to it. Such a cause should be equally operative in both sexes, but we know how rare the affection is in man as compared to women. The condition is not observed to follow acute wasting diseases, nor is it more common in emaciated subjects. While in some cases the amount of perirenal fat found at operation is small, in others it is abundant, and in the dead-house a small amount of perirenal fat is frequently found without a movable kidney. Movable kidneys are so frequently found in young women who have never been pregnant; whose pelvic organs are normal; whose abdominal walls are firm and, therefore, no diminution of intraabdominal tension present; who are not emaciated and who have never received any material injury; that all who have given the matter any serious thought and study have been compelled to seek other causes for the condition. The more the subject is studied the more it becomes evident that those in whom movable kidneys are found are defective in bodily form, that they deviate in some particular from the highest normal type.

Thus the investigations of Wolkow and Delitzin show deviations in the anatomic configuration of the posterior abdominal wall. The paravertebral niches in which the kidneys lie and which in the normal well-built individual are deep and show a distinct pear- or funnel

shape, are shallow and of cylindrical shape in those with movable kidneys, thus favoring displacement of these organs. Albarran, ranks movable kidneys with the bodily stigmata of degeneracy, and Stiller finds them associated with dilatation of the stomach and a loose tenth rib, which he likewise considers a sign of degeneracy. Becker and Lenhoff2 found that the least abdominal circumference was much smaller in proportion to the body length in those with movable kidneys than in normal individuals, and the author in a paper3 read before the American Surgical Association in 1901 demonstrated by a series of careful measurements of the body form that there was a distinst relative contraction or diminution in the capacity of the middle zone of the body in all individuals with movable kidneys. For the method and details of measurements I refer to my article above mentioned. Of 107 cases of movable kidney that I measured in this manner, all showed in a greater or lesser degree the characteristic contraction of the mid zone of the body. This diminution of the size of this body zone necessarily produces a downward displacement of the organs normally contained therein, and the right kidney, owing to the large non-compressible liver above it, is more affected than the left. It is this depression of the kidneys, particularly the right, together with the shallower paravertebral renal niches of Wolkow and Delitzin, that forms the chief predisposing factors in the production of movable kidney. The mere fact that the kidney is crowded lower than it should be does not in itself produce an abnormally movable organ. There are other factors at work. The lower, plane of the mid zone corresponds to the lower border of the costal arch, and usually touches the anterior extremities of the tenth, eleventh and twelfth ribs. In all flexion movements of the body, whether lateral or antero-posterior, in all muscular efforts, such as lifting, straining, coughing, sneezing, etc., in which the lower ribs are adducted, this plane becomes the point of greatest constriction of the body. In individuals with what may be termed normal body forms, the major portion of the kidney lies above this line of constriction, and hence when this plane of the body is narrowed by any of

the acts above mentioned, the tendency is not to depress the kidney, but rather to compress it and hold it up, while, on the other hand, in those individuals with contracted mid zones in whom the kidneys are crowded lower than normal, the line of constriction lies above the major portion of the kidney, and, consequently, all acts producing narrowing of this plane tend to depress that organ. The constant repetition of these acts operating to depress the kidney, gradually leads to a stretching and elongation and loosening of the fascia and tissues tending to hold this organ in place, thus developing a movable kidney. If the above statements be correct, then it follows that every woman with the characteristic body form ought to have a movable kidney.

All the cases of movable kidney which I measured and examined showed a contraction of the mid zone of the body, and, while I am fully aware of the dangers of generalizing from a few cases, still, as the effects here referred to are the result of well-defined causes, the deduction appears justifiable that all women with contracted mid zones develop movable kidneys of greater or less degree. The causes of the contracted mid zone and the age at which the characteristic body form develops are questions of great practical interest, but a discussion of these here would lead us too far from the question at issue.

With these preliminary remarks on the etiology in general, we may proceed to a consideration of the influence of trauma in the production of movable kidney.

The question may be considered from two standpoints: the histopathologic and the clinical. During the past three years the author has made it a practice to open the peritoneal cavity in operating on movable kidneys. A muscle-splitting incision is made in the anterolateral junction of the abdominal wall, which affords not only free access to the perirenal space and kidney, but also permits a ready examination of the region intraperitoneally by simply incising the lateral fold of peritoneum. Through this incision one may examine on the right side of the anterior surface of the kidney through the peritoneum covering it; the range and direction of greatest mobility of the kidney; the ascending and transverse colon; the

num.

hepatic flexure; the cecum and appendix; the duodenum; the major portion of the liver with the gall bladder and bile tracts. An examination of this kind gives one a very much better idea of the changes which take place in the tissues which surround and hold in place the kidney than can possibly be obtained through the usual posterior incision. One always finds the perirenal fascia elongated. This fascia is distinct and separable from the peritoneum laterally, but becomes more intimately attached to or blended with the the peritoneum ventrad of the kidney proper, from which it is separated by the perirenal fat, variable in amount. The fascia becomes more intimately attached to the kidney at the hilus, where it spreads out over the renal vessels, and on the right side passes dorsad of the duodenum, where it again becomes separated from the peritoneum, which passes ventrad of the duodeThis fascia with the peritoneum, as already stated, is elongated and can easily be picked up in loose folds, in fact, it forms a veritable pouch, or sac-like covering, varying, of course, in size, in which the kidney moves. The perirenal fat and its attachment posteriorly is so loose as to offer practically no resistance to the mobility of the kidney. The hepatic flexure and transverse colon adjoining descend, so that the pouch in which the kidney moves always lies above the colon. This is not the case on the left side, as here the pouch is usually formed beneath the splenic end of the transverse colon and internal to the descending colon. The attachments of the duodenum become lengthened, so that this portion of the intestine is often very freely movable. In a case operated on recently the descending portion of the duodenum could easily be drawn out into the lateral incision. The liver is often abnormally movable, and at times quite so. Usually its anterior border descends the most, but occasionally the posterior border descends and tilts the superior pole of the kidney forward. The renal vessels become elongated, attaining a length at times of 8 cm. (Hepburn), or even 13 cm. (Legueu). When the perirenal tissues become considerably loosened and the pouch formation well marked, the kidney is very freely movable, and might almost be classed as an intra-abdominal organ, yet the

author has never seen anything that approached what might be called a genuine mesonephron.

An examination of the changes above mentioned makes it very evident that they are of slow development, as it is certainly impossible to elongate fascia and blood vessels and form distinct loose pouches suddenly. Based on these facts alone many excellent observers doubt the possibility of a sudden or acute origin of a movable kidney. Sulzer says: "I believe that without the acceptance of a particular abnormal body condition a movable kidney can never be the immediate result of trauma." Keller is also of the opinion that this condition can not be produced suddenly, but requires a considerable time for its development, and that, therefore, a kidney with a distinct range of motion discovered immediately or soon after the receipt of an injury must have been movable before, and its mobility can not thus have been caused by the injury. Büdinger says, concerning the traumatic origin of movable kidney: "A sudden marked dislocation presupposes an extensive loosening of the kidney, and not only that, but a space below the kidney with a considerable change in the relations of the peritoneum." Sterns says: "In the majority of the cases so far there occurred not a mobilization of a normally fixed kidney, but a dislocation of an already movable or incompletely fixed organ."

When we turn to the clinical aspect of the subject, we find the evidence presented requires the most careful analysis, as the possibilities of error are very great. Most of the opinions expressed are based on two classes of cases. In the first class a movable kidney is discovered on examination. The patient states that at some time more or less remote a fall or accident of some kind was experienced. The conclusion is immediately reached that the movable kidney is due to the accident. In the second class the same conclusion is reached based on the facts that a patient examined soon after an accident is found to have a movable kidney. The conclusion in neither of these cases is justified by the evidence. In the first case there is usually no relation shown between the nature of the injury and the supposed effect, and no continuity of the symptoms from the time of the injury to that of the discovery of the mov

able kidney. In the second case the discovery of a kidney with a distinct range of motion immediately or soon after an accident is positive evidence that it existed before, as it certainly takes time to develop a movable kidney. In a third class of cases we find the history something as follows: A person whom the physician knows personally to have been in good health meets an accident involving, perhaps, the region of the kidney. On examination soon after the physician discovers a bruise or contusion of the side with tenderness, and a movable kidney. It would seem here that the injury was certainly the cause of the movable kidney, but the error in the conclusion is due to an error in the premises. Because a person was in good health previous to an accident is no evidence that a movable kidney was not present, as it is a common experience of the examining room to find movable kidneys, the presence of which was not only unknown or unsuspected, but which gave rise to no symptoms whatever.

Sulzer says in regard to the relation of injury to movable kidney: "However, one must be very careful in judging of these relations, for on the one hand we know from other diseases how readily people in general refer their troubles to a particular injury, and on the other hand, we shall see later that on the occasion of a fall, exertion, etc., a movable kidney which is already present may suddenly present severe so-called strangulation symptoms, and thus become first known to the patient or physician after it has existed without symptoms for symptoms months or years." Güterbock says: "The pain in a movable kidney which was discovered immediately after an accident is not the slightest proof of any connection between the accident and the movable kidney, nor are all other subjective symptoms any proof, so long as it can not be demonstrated with unequivocal certainty that the kidney was not movable before that time." Just why one individual with movable kidney should have no symptoms whatever of the condition, while another with even a less marked case should suffer great annoyance and discomfort is not always easy to explain.

It is a common observation that a person with a movable kidney not giving rise to any discomfort will suddenly develop symptoms

after a slight accident, such as a fall or an unusual muscular effort, after a nervous shock or mental depression. Sometimes the mere knowledge that the condition is present gives rise to symptoms. On the other hand, the author saw a woman who was suffering considerable pain and discomfort in the right side from a movable kidney, which she herself discovered, but supposed was a cancer. The symptoms all disappeared when assured it was not a cancer, but simply a movable kidney. She remained free from further annoyance for several years. Another person may complain of symptoms only when the nervous system or general health is below par.

It will thus be seen that one must be extremely careful in attributing the cause of movable kidney to an event, simply because it is coincident with the development of symptoms. One will search the literature in vain for a satisfactory case in which a movable kidney was found soon after an injury, and in which the absence of the condition had been previously demonstrated by examination.

At this point it is necessary to distinguish between a displaced kidney and a movable one. No one familiar with injuries will doubt for an instant the possibility of suddenly displacing a normal kidney by violence. Such cases, however, are very rare. They have usually followed severe crushing injuries affecting the region of the kidney. The perirenal tissues are always more or less lacerated, the peritoneum frequently torn, and at times when the displacement has been great, the renal vessels themselves have been completely severed. The kidney may also be displaced more slowly by a hemorrhage into the perirenal fat. Subcutaneous injuries of the kidney and perirenal tissues are by no means uncommon. Rieses has just reported 491 cases from the literature. In many of these there was hemorrhage into the perirenal space with more or less displacement of the kidney. One might suppose that with absorption of the blood in these cases the kidney might remain movable. While such a result may be possible, it is by no means the rule. On the contrary, it is the rare exception, for with the absorption of the blood and organization of part of the blood clot, new connective tissue is formed, which may fix the

kidney even more firmly than it was before, but its location may be slightly altered. Although Güterbock" is of the opinion that such perirenal hemorrhages may be the starting point of movable kidneys, he was unable to present any cases in support of his opinion. The case of Peyrot which he quotes was not a case of movable kidney, but of a kidney found somewhat displaced by blood clot at operation two months after a fall. Sterns, in discussing this phase of the question, says that so far he has "never been able to find a single case of perirenal hemorrhage or traumatic peudohydronephrosis in which later a movable kidney was demonstrated." As bearing on this question I present the following case which I observed a short time ago:

Mrs. K., aged 40 years. In a car accident she received a severe direct injury to the left side of the body, in which the left tenth rib was fractured. A large swelling, hematoma, developed about the left kidney, accompanied by hematuria. The swelling was very painful and she was confined to her bed for several weeks. The swelling was some months in disappearing, and a year after the accident the left. kidney was still somewhat enlarged, tender and movable. She also had a very movable right kidney, which had existed for a long time.

Admitting, then, that a movable kidney may have its origin in a perirenal hemorrhage of sufficient size to partially displace that organ and loosen up its fatty and fibrous capsules, still it must be acknowledged, judging from the lack of recorded cases, that such an origin is extremely rare indeed.

The class of cases, however, which most frequently comes before the railroad surgeon is of another kind. Of course, many cases of severe and serious injuries are encountered in railroad surgery, but those in which movable kidney is alleged to have resulted are usually not of the severer kind. The most frequent accidents are falls while alighting from or attempting to board cars; jars and general concussion from collisions, or by reason of the cars jumping the track, etc. In the majority of cases the movable kidney has not been discovered for some weeks or months after the accident, when the case has been worked up by the personal injury lawyer and doctor. The in